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'i 11 i- i KAkA ii^AL 
 
 E PHYSICIAN 
 
 NCYCLOPHni\ UP MEDICINE: 
 
 A (rtiifl. H fUMkold 
 
 MAN AG KM .'ISEASE; 
 
 • - th4 History. i ■ . ■ i ■ .itptoms of all 
 
 .ASKS OF MF.v , :ir,l>i N 
 
 HE CAKK Ol' : UK SiCK. 
 
 Pull 
 
 ii.n (or ,'" .i/'i'.'ii' 
 
 Wounds, li^j^.ivil:.^ I'Uibui^S, *yi. 
 
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 Hlil-FIlfLO, A.M. 
 
 {.fnhtna h 
 
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 ami lilHStrriUU by n\i>u'r>>ui i';,< i-.-i .//' a iuperb thuiacter, colour:. , sr 
 
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 1 n rUBLfSUI N 
 
 v.,i.'i-,LI H, ONTARIO. 
 
THE PRACTICAL 
 
 HOME PHYSICIAN 
 
 AND 
 
 ENCYCLOPEDIA OF MEDICINE: 
 
 A Guide for the Household 
 
 MANAGEMENT OF DISEASE; 
 
 Giving the History, Cause, means of Prevention, and Symptoms of all 
 
 DISEASES OF MEN, WOMEN AND CHILDREN 
 
 And Most Approved Methods of Treatment, with plain instructions, for 
 
 THE CARE OF THE SICK. 
 
 Full and accurate Directions for treating 
 
 WOUNDS, INJURIES, POISONS, &c. 
 
 Free from technical terms and phrases, and written in plain English, by men %vho have 
 had great experience, and are acknowledged authorities in their various Departments. 
 
 Also a concise account of the 
 
 STRUCTURE AND FUNCTIONS OF THE HUMAN BODY, 
 HYGIENE AND RULES OF HEALTH. 
 
 WRITTEN BY 
 
 HENRY M. LYMAN, A.M., M.D. 
 CHRISTIAN FliNGER, A.M., M.D. 
 
 H. WEBSTER JONES, A.M., M.D. 
 W. T. BELFIELD, A.M., M.D. 
 
 Embellished and Illustrated by numerous Plates of a superb character, coloured after 
 
 nature, and other fine Engravings. 
 
 Wilh valuable inform-ition on Draining, Droitming Emerf^cncies, etc., os furnished by the 
 Ontario Board oj Health (copied "unth permission). 
 
 THE WORLD PUBLISHING CO, 
 GUELPH, ONTARIO. 
 
PUBIylSHE^RS' PRE:FA<3E;. 
 
 The publishers, in undertaking the preparation of this work, 
 realized to the fullest extent the great importance of its production 
 in a careful and thorough manner. To accomplish this it was nec- 
 essary to place its authorship far above the meres i^ suspicion of 
 weakness or inefficiency. 
 
 It was a matter of no small difficulty to secure as authors 
 four physicians standing at the head of their profession : firstly, as 
 eminently successful practitioners; secondly, as lecturers highly 
 appreciated in the foremost schools of the land ; thirdly, as medical 
 writers of marked erudition ; and fourthly- s specialists of deep 
 investigation and large experience. 
 
 They have labored indefatigably, and have harmonized their 
 efforts to produce a work, practical, thorough and complete. 
 They have given to the public unreservedly the knowledge which 
 long experience has taught them. We can state with confidence, 
 that they have not been selfishly actuated by financial remunera- 
 tion only, but in£,pired by a spirit of philanthropy, by a generous 
 desire to benefit mankind, they have written for the good of the 
 people. There are many works which are of incalculable value 
 to the physician, who is learned in all the technicalities of his 
 profession ; yet most of them are but sealed letters in the hands of 
 the multitude. The authors have departed from the ordinary 
 path of scientific writers, and have given us this matter in plain 
 language, and as free as possible from medical or technical terms. 
 
 The publishers would further state, that although an im- 
 mense^ amount of money has been expended in preparing this 
 work, yet they owe a debt of endless gratitude to the authors, 
 for giving to the public such rich and successful experience in 
 so practical a form as is contained in the succeeding pages. 
 
 IX 
 
'^N, 
 
 
 V^, 
 
 II 
 
 i' 
 
 
grmmamasL 
 
 u 
 
 3LUTHORS' preface;. 
 
 :' In preparing this work, the authors have endeavored to accom- 
 'jpli|h two objects : 
 
 V First, to furnish such practical information as may be service- 
 able to those who, from force of circumstances, cannot procure the 
 Jpersonal attendance of a medical adviser. 
 
 I Second and chiefly, to convey a general idea of the nature of 
 
 kiiscase and the principles of "ireatment ; to present an outline of 
 
 j rational and scientific medicine. It is highly desirable that the 
 
 , ?|)ublic should learn to appreciate the true position of the scientific 
 
 '^'physician ; to recognize not only what he is able to accomplish, 
 
 but also what he can not do. In the care of the body it is pre- 
 
 reminently true that an ounce of prevention is worth a pound of 
 
 l^cu^'e. The most valuable and tangible services of the physician 
 
 jJK rendered in his capacity of medical adviser ; his chief duty is 
 
 fj- and should be the prevention rather than the cure of disease. 
 
 \ This fact has guided the authors in writing these pages. While 
 
 they have in every case presented the most approved treatpient for 
 
 the various diseases which afflict so large a portion of humanity, 
 
 they have especially endeavored to furnish such information as may 
 
 protect against the attacks of these diseases. 
 
 The authors feel that in this attempt to popularize medical 
 science, they are rendering a service to their professional brethren 
 
 as well as to the public at large. A little knowledge is a dan- 
 
 xi 
 
 «J' 
 
->/ 
 
 u 
 
 XII 
 
 authors' preface. 
 
 
 gerous thing for a patient to possess ; it makes him the pre^ 
 and plunder of every advertising quack. The more intelligent a 
 patient becomes, the more he appreciates the absurdity of remedies 
 advertised to cure any one of forty different and distinct complaints. 
 He realizes that medicine is not magic nor sleight-of-hand, but an 
 art founded on a science, and that the best expositor of medicine 
 is the scientific physician. 
 
INDEX 
 
 TO 
 
 SBNEI^TIIj DIYI3I@N^. 
 
 Pagj 
 CONSTITUTIONAL DISEASES 21 
 
 DISEASES OF THE THROAT AND CHEST 117 
 
 DISEASES OF THE ORGANS OF CIRCULATION... 101 
 
 DISEASES OF THE DIGESTIVE ORGANS 170 
 
 DISEASES OF THE INTESTINES 211 
 
 DISEASES OF THE NERVOJS SYSTEM 289 
 
 DISEASES OF THE SKIN 305 
 
 VENEREAL OR PRIVATE DISEASES 471 
 
 DISEASES OF THE EVE AND EAR S43 
 
 SURGICAL DISEASES 045 
 
 POISONS AND THEIR ANTIDOTES 863 
 
 DISEASES OF WOMEN AND CHILDREN 871 
 
 ANATOMY AND PHYSIOLOGY ,..\ 1043 
 
 HYGIENE 1069 
 
 MEDICINES AND MEDICINAL PLANTS 1070 
 
\ 
 
TABLE OF CONTENTS 
 
 CONSTITUTIONAL DISEASES. 
 
 Remarks: Specific Fevers— Eruptive Fevers.— Small-Pox : Stage of invasion. 
 Stage of^uption. cause, treatment. — Varioloid — Vaccination — Chicken Pox; 
 SymptomaTnUl^ment.— Scarlet Fever: cause, symptoms, stage of disquamation. 
 Scarlatina Mali^ui or Maligfnant Scarlet Fever : treatment. — Measles : stage of dis- 
 .quamation; treatment. — Roseola: Tables exhibiting the difference between Small-Pox, 
 Scarlet Fever and Measles. — Diphtheria: symptoms, cause, treatment. — Typhoid 
 Fever : symptoms, cause, treatment — Typhus Fever: symptoms, treatment. — Relap- 
 sing Fever : cause. — The Malarial Fevers : symptoms, cold stage, hot stage, cause, 
 treatment. — Pernicious Intermittent Fever : symptoms, cause, treatment.- Remittent 
 Fever : symptoms. — Yellow Fever : symptoms, treatment. — Cholera : symptoms, 
 cause, treatment. — Rheumatism— Acute Articular Rheumatism : symptoms, cause, 
 treatment. — Chronic Rheumatism : treatment. — Muscular Rheumatism : symptoms. — 
 Gout : symptoms, cause, treatment. — Rheumatic Gout : treatment. — Scurvy : symptoms, 
 treatment. — Purpura Hemorrhagica Page 21. 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 Affections of the Larynx, — Catarrh of the Larynx : symptoms, treatment. — 
 Tumors of the Larynx : symptoms, treatment. — Affections of the Lungs.— Pleurisy : 
 symptoms, treatment. — Empyema.— Pneumonia : symptoms. — Bronchitis: symptoms, 
 treatment. — Chronic Bronchitis : symptoms, treatment. — Emphysema : symptoms, 
 treatment. — Asthma : symptoms, treatment. — Consumption: symptoms, cause, tru it- 
 ment Page 117. 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 DISEASES OF THE HEART. 
 
 PerecTarditis : symptoms, cause, treatment— Endocarditis. — Heart Disease: symp- 
 toms, treatment.— Organic Disease of the Heart : treatment, — Exophthalmic Goitre 
 Palpitation of the Heart. -Angenia Pectoris.— Aneurism of the Aorta : symptoms. 
 
 XV. Page 161. 
 
XVI. 
 
 TABLE OF CONTENTS. 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Sore Throat.— Pharyngitis.— Chronic Pharyngitis: treatment.— Quinsy: treat- 
 ment. — Mumps : symptoms, treatment. — Diseases of the Stomach. — Inflammation : 
 treatment. — Ulcer of the Stomach : symptoms, cause, treatment. — Dyspepsia : treat- 
 ment. — Chronic Indigestion: symptoms, cause, treatment.— Heartburn.— Dilitation 
 of the Stomach : symptoms, reatment. — Pain in the Stomach.— Gastrodynia : 
 symptoms, treatment. — Cancer of the Stomach : symptoms, treatment, Page 179. 
 
 
 DISEASES OF THE INTESTINES. 
 
 Diarrhoea: symptoms, treatment — Dysentery: symptoms, cause, treatment. — 
 Epidemic Dysentery.— Chronic Dysentery. —Constipation : treatment. — Colic : treat- 
 ment. — Bilious Colic : treatment. — Lead Colic : symptoms, treatment. — Uterine Colic: 
 treatment— Passage of Gall Stone: treatment. — Inflammation of the Bowels.— 
 Peritonitis: symptoms, cause, treatment. — Chronic Peritonitis: symptoms. — Inflam- 
 mation of the Bowels : symptoms, treatment. — Intestinal Worms : treatment —^Thread 
 Worms: treatment. — Tape Worms: symptoms, treatment. — Trichinae Spiralis: 
 treatment.— Guinea Worm. — Filara Sanguinis Hominis. — Dropsy : causes, treatment. 
 —Dropsy of the Chest. — Dropsy of the Brain : symptoms, treatment.— Chronic 
 Dropsy of the Erain : treatment. 
 
 DISEASES OF THE LIVER. 
 
 Acute Inflammation of the Liver: treatment.— Abscess of the Liver: symptoms, 
 treatment. — Chronic Inflammation of the Liver : symptom.s, treatment. — Gin Liver 
 (Cirrhosis of the Liver) : symptoms, cause, treatment. — Hydatit Tumors of the Liver : 
 symptoms, treatment. — Jaundice: cause, symptoms, treatment. 
 
 DISEASES OF THE KIDNEYS. 
 
 Inflammation of the Kidneys. — Bright's Disease. — Acute Bright's Disease : symp- 
 toms, treatment. — Chronic Bright's Disease: symptoms, treatment.— Gravel: treat- 
 ment. — Stone in the Bladder: symptoms, treatment. — Sugar in the Urine (Diabetes): 
 symptoms, cause, treatment. — Diabetes Insipidus : symptoms, cause, treatment. — 
 Addison's Disease : treatment, ., Page 211. 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Inflammation of the Brain : treatment.— Chronic Meningitis. — Tuberculous 
 Meningfitis. — Spinal Meningitis : symptoms. — Cerebro Spinal Meningitis : symptoms, 
 treatment. — Apoplexy : symptoms, cause, treatment. — Falling Sickness (Epilepsy) : 
 symptoms, cause, treatment,— Catalepsy, St. Vitus' Dance (Chorea). — Acute Chorea: 
 treatment. — Lock Jaw: symptoms, treatment. — Hydrophobia: treatment.— AlcohoN 
 ism : treatment.— Delirium Tremens : symptoms, treatment,— Neuralgia : treatment 
 
TABLE OF CONTENTS. 
 
 xvii 
 
 —Intercostal Nearal8:ta.— Sciatica.— Headache : treatment.— Diziiness (Vertigo).— 
 Locomotor Ataxie : symptoms, cause, treatment.— Wasting Palsy: treatment. — Par- 
 alysis. — Hemiplegfia : symptoms. — Paraplegia: symptoms. — Facial Paralysis : symp. 
 toms —Infantile Paralysis.— General Paralysis of the Insane.— Shaking Palsy.— 
 Writers' Cramp: treatment of.— Paralysis.— Nerrous Exhaustion: treatment.— 
 Sunstroke : treatment. — Whooping Cough ; treatment Page 289. 
 
 DISEASES OF THE SKIN. 
 
 Pimples (acne) : cause, treatment. — Dandruff : treatment. — iitii : (Scabbies) : 
 symptoms, treatment. — Salt Rheum (Eczama) : cause, treatment. — Dry Tetter (Psorisis): 
 treatment. — Ringfworm : treatment. — Favus : treatment. — Liver Spots : treatment. — 
 Fever Blister: treatment. — Barbers' Itch (Sycosis) : treatment. Baldness : treatment. 
 — Hair Dyes : numerous receipts for restoring the hair. — ''.rysipelas : treatment. — 
 Redness (Erythema) : treatment. — Nettle Rash (Urticaria) : treatment. — .^upus: treat- 
 ment. — Malluscum: treatment. — Impetigo: treatment. — Ecthyma: treatment. — 
 Lichen : treatment. — Fish Skin Disease : treatment. — Leprosy : cause, symptoms, 
 treatment. — Barbadoes Leg : treatment. Pemphigus : treatmei ;. — Prurigo : treat- 
 ment. —Itching (Pruritus). — Condylomata — Sweat Rash (Miliaria) : treatment. — Pie- 
 bald Skin. — Pityriasis: treatment -Rupia: treatment. — Seborrhea: treatment. — 
 Inflammation of the Skin. — Freckles: treatment. — Lice: treatment. — Corns: treat- 
 ment. — Mothers' Marks. — Medicinal Rashes. — The Nails : treatment. — Diet in Dis- 
 eases of the Skin. — Keloid : treatment.— Fatty Tiunors : treatment Page 365. 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 Pox (Syphilis): symptoms.— Secondary Syphilis: treatment. — Treatment of 
 primaty sore or Chancre. — Soft Chancre (Venereal Ulcer).— Bubo : treatment. — 
 Clap (GonorrhcEa) : symptoms, treatment. — Gleet : treatment. — Impotence. — Sterility 
 in the Male. — Seminal Emissions (Spermatorrhoea) : symptoms, cause, treatment 
 
 Page 471. 
 
 DISEASES OF THE EYE AND EAR. 
 
 Diseases of the Eye.— Color-BIindness.— Core of the Eyes in Childhood.— Weak 
 Sight,— Foreign Bodies in the Ej ?.—Short-Sightedness.— Far-Sight.— Squinting.— 
 The selection of Spectacles.— Inflammation of the Eye (Conjunctivis) : symptoms, 
 treatment. — Purulent Inflammation of the Eyes : symptoms, treatment. — Gonorrhoeal 
 Inflammation of the Eyes : symptoms, treatment. — Granular Lids : symptoms, treat- 
 ment. — Inversion of the EyeUds : treatment.— Inflammation of the Cornea : symptoms, 
 treatment.— Ulcers of the Cornea: treatment. — Inflammation of the Iris (Iritis): 
 symptoms, treatment.— Cataract : causes:— Congenital Cataract : treatment.— Injuries 
 of the Eye : treatment.— Injuries of the Eyelids : treatment. — Inflammation around 
 the Eyelashes : treatment.— Stye : treatment.— Tumors of the Eyelids : treatment. — 
 Inflammation of the Tear Duct: symptoms, treatment.— Artificial Eyes. — Instructions 
 for persons wearing an Artificial Eye.— Diseases of the Ear.— Foreign Bodies in 
 the Ear: treatment. — Wax in the Ear: symptoms, treat ment.— Running from the 
 
XVlIt 
 
 TABLE OF CONTENTS. 
 
 Ear. — Inflammatioii of the Drum of the Ear: symptoms, treatment. Injuries to the 
 Dram of the Ear. — Catarrh of the Middle Ear : symptoms, treatment, — Nervous Deaf- 
 neia : symptoms, treatment. — Earache : treatment. — Polyp of the Ear : symptoms, 
 treatment. — Gfannlations in the Ear : treatment. — Eczema of the Ear : treatment. 
 
 Page 543. 
 
 If;- 
 
 r 
 
 SURGICAL DISEASES. 
 
 Boil (Furuncle): treatment.— Carbuncle : treatment. — Felon: treatment. — Ulcers 
 of the Ltg : treatment.— Hare-lip.- - Cancer of the Lip : treatment.— Polyp of the Nose : 
 treatment.— Mortification of the Jaw. — Tumors of the Mouth. — Tongue-tic— Cancer 
 of the Tongue.— Enlargfement of the Tonsils : treatment. — Enlargement of the Uvula. 
 — Foreig^n Bodies in the Throat.— Stricture of the Gullet : treatment.— Goitre : treat- 
 ment—Tumors of the Neck: treatment. — Wry Neck : treatment.— Weeping Sinew: 
 treatment.— Housemaid's Knee : treatment.— Wounds.— Bleeding from the Nose- 
 Bleeding from the Mouth.— Bleeding from the Bowels: treatment.— Bleeding 
 from the Urinary Organs. — Fainting: symptoms, treatment. — Treatment of Wounds. 
 — Ptmctured Wounds : treatment.— Gunshot Wounds : treatment of gunshot wounds. 
 — Shock: symptoms, treatment. — Poisoned Wounds: treatment.- Bites and Stings 
 of Insects: treatment. — Snake Bites: treatment. — Broken Bones (Fractures): 
 symptoms. — General Treatment of Fractures.— Setting of a Broken Bone. - 
 Dressmg of Fractures. — Bandages. — Results of Fractures. — Blood Poisoning 
 (Pyaemia): symptoms, treatment.— Erysipelas: treatment.— Fracture of the Skull: 
 symptoms, treatment.— Inflammation of the Brain: symptoms, treatment.— Frac- 
 tures of the Lower Jaw : symptoms, treatment. — Fractures of the Upper Jaw. 
 — Fracture of the Nose: treatment.— Fracture of the Collar-Bone: treatment. 
 Fracture of the Shoulder-Blade. —Fractures of the Arm-Bone (Humerus): treat- 
 ment.— Fractures of the Fore-Arm: treatment.— Fracture at the middle of the 
 Fore-Arm: treatment —Fracture of the Fore-Arm near the wrist: treatment. 
 — Fractures of the Hand: treatment. — Fractures of the Fingers: treatment. 
 — Fractiu% of the Ribs: treatment — Fractures of the Spine: treatment.— 
 Fractures of the Hips: treatment. — Fractures of the Thigh-Bone: signs, treatment. — 
 Fractures of the Neck of the Thigh-Bone : treatment —Fractures just above the 
 Knee: signs, treatment.— Fractures of the Knee-pan: signs, treatment. — Fracfure of 
 the Leg.— Fractures of the Fibula: treatment.— Fractures ot the Tibia: treatment — 
 Fractures of both Bones of the Leg : treatment, — Treatment of Compound Fractures. 
 — Fractures of the Bones of the Foot: treatment.— Non-union of Bones after 
 Fractures: treatment.— Dislocations.— Symptoms of Dislocations. — Treatment of 
 Dislocations. — Dislocation of the Lower Jaw: symptoms, treatment.— Disloca- 
 tion of the Collar-Bone : treatment — Dislocation of the Shoulder-Blade. — 
 Dislocation of the Shoulder : signs, featment. — Dislocations of the Elbow : signs, 
 treatment. — Dislocations of the Wrist : signs, treatment. — Dislocations of the Thumb : 
 signs, treatment.— Dislocations of the Fingers. — Dislocation of the Vertebrae: signs, 
 treatment.— Dislocation of the Hip.— Displacement upon the Back of Hip-Bone : 
 treatment. — Dislocation of the Knee-pan, signs, treatment. — Dislocation of the Car- 
 tilages of the Knee Joint: signs, treatment. — Dislocation of the Knee Joint: signs, 
 treatment.— Dislocation of the Ankle : signs, treatment.— Dislocation of the Bonos of 
 the Foot: treatment.— Dislocation of the Toes — Rupture (Hernia): treatment, 
 symptoms. — Sprains: treatment. — Bruises: treatment. — Bums and Scalds. — Diseases 
 of the Teeth.— Toothache : treatment, Page 645. 
 
TABLE OF CONTENTS. 
 
 XIX. 
 
 POISONS AND THEIR ANTIDOTES. 
 
 PoiMMu which occur in food.— Copper poisoning from food.— Poisona in Sngar. 
 —Poisoning from Colored fabrics.— Poisoning from Cosmetics.— Poisoning from 
 Insect Powders.— Poisoning from Meats, Fish and Cheese : treatment.— Poisoning 
 by Medicine and Chemicals, Page 853. 
 
 SMOTHERING : 
 
 Treatment. — Howard's Method of Reviving the Drowned: after treatment, practical 
 suggestions. 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 General Remarks. — Hygiene of Puberty: care during the monthly changes. — 
 When Puberty is Delayed.— Dysmenorrhoea: causes, treatment— Marriage.— Preg- 
 nancy.— Diseases of Pregnancy: treatment.— Hygiene of Pregnancy.— Accidents of 
 Pregnancy: causes, symptoms, treatment, prevention. —Placenta Praevia: symptoms, 
 treatment.— Duration of Pregnancy.— To calculate the Time of Confinement.— Con- 
 finement— Attention to the Child.— Care of the Mother after I>bor.— Lactation.— 
 The Relation between Lactation and the Sexual Functions.— Hygiene of Lactation. 
 —The Selection of a Wet Nurse.— Care of the Infant.— Food. —Teething.— Wean- 
 ing.— Diseases of Child-Bed.— Child-Bed Fever : symptoms, causes. — Puerperal Con- 
 vulsions,— Milk-Leg. 
 
 Diseases of Women.— Diseases of the Vulva : symptoms, causes, treatment. — 
 Abscess in the Vulva : symptoms, treatment. — Eczemaof the Vulva: symptoms, treat- 
 ment.— Pruritus (Itching) of the Vulva : causes, treatment. — Excessive Sensitiveness 
 of the Vulva; treatment. 
 
 Diseases of the Womb. — Inflammation : causes, symptoms, treatment. — Chronic 
 Inflammation of the Womb : symptoms, treatment.— Chronic Enlargement of the 
 Womb: causes, treatment. — Peri-Uterine Inflammation: causes, treatment, symp- 
 toms. — Displacement of the Womb : causes.— Falling of the Womb (Prolapsus) : 
 symptoms, treatment. — Flexions: symptoms, treatment.— Tumors of the Uterus: 
 symptoms, treatment. — Polyps: causes, symptoms, treatment. — Cancer of the Uterus: 
 causes, symptoms, treatment. 
 
 Diseases of the Ovaries : treatment. — Ovarian Tumors : causes, treatment, symp- 
 toms. — Sterility. 
 
 Diseases of Infants.— Indigestion.— Disorders of the Bowels. — Diarrhoea- 
 Summer Complaints. — Constipation. — Croup: treatment, symptoms, causes. — Influ- 
 enza : treatment. — Convulsions : treatment, Page 871. 
 
 ANATOMY AND PHYSIOLOGY. 
 
 The Skeleton.— The Spine.— The Head.— The Chest.— The Upper Extremity. 
 —The Joints. —The Muscles.— The Nervous System, Page 1043. 
 
 .im" 
 
!•( 
 
 XX. TABLE OF CONTENTS. 
 
 HYGIENE. 
 
 Clothing.— Exercise.— Ventilation.— Quantity of Food.— Niunerons Tables in 
 connection with same. — ^Analysis of Milk, Rye, Rice, Potatoes, and other kinds of 
 Food Page 1059. 
 
 CARE OF THE SICK. 
 
 Cleanliness. — Pure Air.— Water. — Temperature.— Ventilation. — Disinfection. — 
 Proper Bedding.— Isolation.— Food for the Sick — Chicken Broth.— Mutton Broth.— 
 Gruels.— Jellies.— Iceland Moss.— Irish Moss.— Tapioca.— Rice Page 1607. 
 
 MEDICINAL PLANTS. 
 
 Illustrated by 64 Coloured Plates, and they and all other important medical plants 
 fully described, with directions for use Poge 1076. 
 
 ADMINISTRATION OF MEDICINE. 
 
 List of Medicines and Doses for Adults. — Preparation of Medicines, Infusions, 
 Decoctions, Extracts, etc., Page 1088. 
 
CONSTITUTIONAL DISEASES. 
 
 REMARKS. 
 
 Many of the diseases which will be discussed in these pages 
 affect primarily and chiefly a certain limited part of the body, the 
 remainder of the organism either escaping all disease or merely 
 suffering in sympathy with the affected part. A familiar example 
 is the ordinary felon. Such affections are classed as local diseases. 
 In distinction from these, there are numerous diseases which seem 
 to affect no one part of the body more than others, but which 
 cause serious interference with the entire organism and all its func- 
 tions. Such affections, of which intermittent fever, or" ague," is a 
 familiar instance, will be described under the name of Constitutional 
 Diseases in the present section. 
 
 Among the most important and frequent of constitutional dis- 
 eases are the infectious diseases, including the familiar fevers. 
 Indeed, most of the infectious diseases induce in the subject of 
 them a considerable degree of fever; though it cannot be, in gen- 
 eral, stated that the converse of this proposition is true — that the 
 fevers are necessarily infectious. 
 
 SPECIFIC FEVERS. 
 
 The word fever is applied to a certain group of symptoms, the 
 most prominent of which consists in an increased heat of the body. 
 Yet there are also other characteristics which are usually associated 
 in all of the diseases designated as fevers. The most common 
 
 21 
 
w 
 
 22 
 
 CONSTITUTIONAL DISEASES. 
 
 
 characteristics are a premonitory stage (technically called the period 
 of incubation), during which there may be no other symptom of 
 disease than general lassitude and indisposition on the part of the 
 patient. Then follows a more or less pronounced c/till, which may 
 be so violent as to shake the entire body of the victim, or may, on 
 the other hand, consist merely in a sense of coldness. With this 
 occurs the characteristic rise of temperature, the fever, accom- 
 panied by thirst, diyness of the skin, increased force and frequency 
 of the heart beat, and usually by pain in the head, back and limbs. 
 All these symptoms may «)ccur after a wound or injury, in which 
 case the disease may still be called a fever — a surgical or ivotiud 
 fever. But there are also numerous instances in which the group 
 of symptoms characteristic of fever occurs without any injury or 
 wound, indeed without any local cause in any part of the body; 
 these are termed the essential fevers. It is found, furthermore, 
 that while all cases of essential fever present the features already 
 indicated as characteristic of fever, yet they differ among themselves 
 as to the details of the disease: as to the duration of the premoni- 
 tory stage, the violence of the chill, the degree of increased body 
 heat, the duration of the fever, the seat of the pain, the effect upon 
 the various functions — heart, brain and skin, for example. Hence, 
 while all of these fevers have certain features in common, yet they 
 differ one from another in other characteristics, so that we recog- 
 nize numerous distinct diseases, all denominated fevers because in- 
 cluding a marked increase of body heat, and yet designated by 
 special names because evidently due to different causes. These 
 are the specific fevers — scarlet fever, small-pox and measles, for 
 example. The specific fevers are all infectious. By this statement 
 it is not meant that the disease is necessarily communicated from 
 one individual to another — for the word contagious is used to indi- 
 cate transmission from one person to another. When we say that 
 a disease is infectious, we mean that it is due to the entrance into 
 the body of some external agent, in some instances certainly a 
 minute organism. Most of the infectious diseases are, it is true, 
 contagious also ; that is to say, the agents which have induced the 
 disease in one individual, readily escape from his body into those 
 persons with whom he may come in contact — as is familiarly illus- 
 trated to us in small-pox. On the other hand, there are infectious 
 diseases — that is, diseases induced by the presence of foreign agents 
 (organisms) in the body, which do not seem capable of transmis- 
 
SPECIFIC FKVERS. 
 
 23 
 
 sion from one to another, but can be contracted only in certain 
 regions. Intermittent fever, or ague, for instance, is, so far as we 
 know, never communicated from one person to another, but can be 
 acquired only in certain so-called malarial districts; yet intermit- 
 tent fever is eminently infectious, though not contagious. With 
 regard to three of the specific fevers, it has been already demon- 
 strated that the cause is a mi-roscopic organism, a plant, which 
 finds access to the body through the lungs or skin, and by its 
 growth within the human organism, occasions the derangement of 
 function which we know as fever. We have every reason to believe 
 that the same general cause underlies all of the specific fevers — 
 that each is due to a definite and special agent, and that this agent 
 is a vegetable organism. 
 
 It is customary to discuss the various specific fevers under 
 different categories. Thus, those which are distinguished by the 
 unbroken continuance of fever — the absence of intermission — arc 
 designated continued fevers; such are typhus and typhoid fever. 
 Then, again, there are fevers distinguished by the intermittent char- 
 acter of the temperature — a day or two of fever being followed by 
 a similar period of natural body heat, that is, absence of fever. 
 These are known as periodical fevers, among which are intermit- 
 tent, remitten and yellow fevers. Still a third class is distin- 
 guished by the occurrence of eruptions on the skin, and are hence 
 designated eruptive fevers. The most familiar examples of this 
 class are small-pox, scarlet fever, measles. 
 
 ESUPTIVE FEVEBS. 
 
 Each of the eruptive fevers is characterized by the develop- 
 ment of a rash on the skin, by which it may be distinguished from 
 the other fevers of its class. There are, it is true, other features — 
 the duration of the incubative period, the degree of fever, the 
 duration of the disease, the location of the pain, etc. For con- 
 venience of description, it may be said in advance that the course 
 of any eruptive fever is best described in three periods or stages. 
 First, the stage of invasion, beginning with the first manifestations 
 of ill-health, and terminating with the first appearance of the erup- 
 
I, 
 
 24 
 
 CONSTITUTIONAL DISEASES. 
 
 tion; second, the stage of eruption, which succeeds the former and 
 endures until the eruption disappears; third, the stage of desqua- 
 mation during which the skin recovers its natural condition. In 
 distinguishing between the various eruptive fevers, especially in 
 children, it is particularly important to note the duration of the 
 stage of incubation and the time of the appearance of the eruption. 
 
 Small-Pox. 
 
 Within the past eighty years the entire relation of this disease 
 to the human family has undergone a complete revolution. It is 
 no longer the dread and scourge of nations, but a comparatively 
 infrequent and harmless visitor, and we may confidently hope that 
 when it shall be possible to confer upon all the benefits of vaccin- 
 ation we may completely eradicate the disease from the human 
 species. It is interesting to note that the number of cases of 
 small-pox in civilized communities has been diminished, not by 
 any decrease in the severity of the disease, but simply because we 
 have acquired, through vaccination, the power to resist its attacks. 
 For among the tribes which have not employed vaccination small- 
 pox is as destructive to-day as it was in Europe before the time of 
 Jenncr; at that time 50,000 persons are said to have died of this 
 disease in England alone. In 1837 small-pox attacked the Mandan 
 Indians ; within a year only twenty-seven individuals remained out 
 of the population of 1 50,000. In consequence of the general intro 
 duction of vaccination, small-pox has not only ceased to be the 
 most formidable of the plagues that afflict humanity, but has even 
 become one of the rarer of the infectious diseases. Even among 
 the unvaccinated, the disease is not so fatal as in former years, the 
 mortality now being only about one case in seven or eight. Yet in 
 consequence of the gravity and evil after-effects of the disease, as 
 well as of its contagiousness, it is important that every case should 
 be early recognized; for which reason a somewhat minute description 
 will be given. 
 
 Stage of Invasion. — The disease usually begins with a chill, 
 and is distinguished from the other eruptive fevers by the extreme 
 violence of this chill ; in some cases a series of chills recur in the 
 
SMALI,-POX. 
 
 as 
 
 course of a few hours. This chill, which marks the beginning of 
 the fever, usually occurs about ten or twelve days after exposure to 
 contagion. Previous to the chill, there may have been some lassi- 
 tude, languor, and perhaps wandering pains in different parts of the 
 body, especially in the abdomen, the small of the back, and the 
 head. The beginning of the fever is also usually accompanied by 
 nausea and vomiting ; the tongue is coated, the bowels usually con- 
 stipated. In children, convulsions are a common occurrence ; in 
 adults, delirium is not infrequent. There may be also various addi- 
 tional symptoms, such as retention of urine and partial loss of power 
 in the limbs. On the other hand, the symptoms may be so mild as 
 to attract no special attention. The severity of the subsequent 
 fever, and the extent of the eruption are usually proportional to the 
 severity of these symptoms in the stage of invasion. In these 
 cases, in which the patient feels but slightly indisposed before the 
 appearance of the eruption, he may not be compelled to keep his 
 bed any time during the attack ; while there are cases in which the 
 onset is so overwhelming that the patient dies before the eruption 
 has had time for complete development. On the third day after 
 the chill, usually — sometimes on the second, fourth, or even sixth 
 day — an eruption begins to appear, marking the beginning of the 
 
 Stfige of Eruption, — A most striking feature, which marks 
 very accurately the beginning of the eruption, is the cessation of 
 fever, which may have been quite intense for two or three days 
 previously. At the same time that the fever ceases, the symptoms 
 usually improve : the pains are less severe, the mental disturbances, 
 if present — delirium, convulsions, etc., — often cease, and the patient 
 is more comfortable. 
 
 The rash usually appears first upon the face, especially around 
 the mouth and on the chin; at nearly the same time the neck and 
 wrists are affected, then the breast and arms. The extension of 
 the rash over the entire body usually requires two or three days, so 
 that six or seven days may elapse after the initial chill before the 
 entire eruption has appeared. The rash at first takes the form of 
 small red spots, sometimes exhibiting a purplish tint; the center of 
 these spots becomes hard and somewhat elevated, the rash resem- 
 bling at this period somewhat the complete eruption of measles — a 
 resemblance which has occasioned serious errors in diagnosis. At 
 this time even the inexperienced can usually recognize the nature 
 
26 
 
 CONSTITI'TIONAI, DISEASES. 
 
 of the malady; for the eruption on the wrists feels very much like 
 small shot under the skin. Within twenty-four hours it will be 
 noticed that the tops of these little bodies constituting the rash 
 are filled with a clear watery liquid, this change usually occurring 
 first in that part of the rash which first appeared, that is, on the 
 face, wrists and neck. During the next two days these little drops 
 of watery fluid increase in size so as to become an eighth of an inch 
 or more in diameter; but it is not until the fifth day of the eruption 
 that the characteristic appearance — the feature which distinguishes 
 the small-pox rash from all others — is visible — the depression in 
 the center. The top of the vesicle, as the little collection of watery 
 fluid is called, is nearly flat except that its middle is drawn down- 
 ward, making an appearance resembling that of the navel; it i^ 
 hence technically termed utndi/ieated. This is, as has been said, the 
 most characteristic feature of the small-pox eruption, and the one 
 which is relied upon for a decision in doubtful cases. In most 
 instances, it is true, the experienced physician can gi\e a positive 
 opinion so soon as the shot-like rash appears upon the wrists; indeed 
 he may be confident even previous to this time, from the history of 
 the case, that it will prove to be small-pox. Yet there are instances, 
 in which the attack is very light, the patient does not feel anything 
 more than a slight indisposition — and perhaps even attends to his 
 avocation — in which the rash consists merely of a few scattered 
 spots. In such cases a positive opinion can rarely be given until 
 this peculiar feature, the umbilication of the vesicles appears. So, 
 too, there may be at times doubt as to whether the disease is small- 
 pox or chicken-pox, for in the latter disease large vesicles resembling 
 those of small-pox, but not umbilicated, are observed. 
 
 If the case be severe and the eruption very profuse, many of 
 these vt icles may coalesce, running together so as to form blisters 
 of considerable size. Yet even here the characteristic umbilication 
 can usually be observed. Up to this time the vesicles have, been 
 clear and transparent, containing only a watery fluid; but about the 
 sixth day after the first appearance of the first eruption, this watery 
 fluid contained in the vesicles becomes turbid and white — that is, 
 sttppnration occurs. The vesicles, or pocks, as they may now be 
 called, become distended with fluid, the central depression or 
 umbilication disappears, and the pocks become pointed. At the 
 same time the patient, who has been for several days nearly or quite 
 
SMAl.L-l'OX. 
 
 V 
 
 free from fever, becomes again the subject of a fever equal ur 
 exceeding that with which the attack was ushered in. 
 
 Before referring in detail to this secondary fever, it should be 
 remarked that the eruption is not limited to the skin. For, simul- 
 'taneously with its appearance on the cutaneous surface, it may 
 be seen also, though to a less extent, on the mucous surface of 
 the moMth and throat. In these places it does not, it is true, exhibit 
 exactly the same appearance as on the skin ; the spots are sur- 
 rounded by a whitish area, and do not exhibit the entire course — 
 the change into vesicle and pock already 'described. Instead of 
 this, there not infrequently occur minute ulcers, even while the 
 rash on the skin is still in the vesicular stage. In many cases the 
 eruption is not limited to the mouth and throat, but may extend 
 also down the wind-pipe to the lungs ; in these instances the breath 
 is usually extremely offensivi So, too, the other mucous mem- 
 branes may become the seat of the disease ; thjit of the eye — called 
 the conjunctiva — not infrequently surfcring from the appearance of 
 several pocks ; indeed, the ulceration consequent upon these pocks 
 may destroy the eyesight by rendering the front of the eye white 
 and opaque. So, too, the mucous membrane of the genital organs, 
 especially in women, may become the seat of the small-pox erup- 
 tion. The most dangerous complication arising in connection with 
 the mucous membranes is the swelling of the larynx, whereby the 
 air admitted to the lungs is greatly diminished in quantity, and 
 sufifocation may be imminent. 
 
 The secondary, or suppurative fever, begins, as already indi- 
 cated, with the change in the character of the fluid filling the ves- 
 icles, usually about the sixth day after the appearance of the eruption. 
 The intensity of this fever is usually proportional to the extent of 
 the eruption, being insignificant when there are but a few scattered 
 pocks, but very severe in the cases where the vesicles have coalesced 
 into blisters — the so-called confluent variety. The general surface 
 of the skin now gives indication of inflammatory action ; the spaces 
 between the pox are red ; there is often swelling of the eyelids, and 
 of the face, perhaps also of the hands and feet. This latter feature, 
 by the way, is a welcome sign, since it is the general experience 
 that cases of confluent small-pox, in which no such swelling occurs, 
 rarely recover. The skin is not only red and swollen, but also 
 painful ; the mouth and throat are sore from the presence of the 
 pocks, and a considerable quantity of mucus — so-called salivation — 
 
28 
 
 CONSTITUTIONAL DISEASES. 
 
 is often observed. In severe cases, the symptoms already referred 
 to as possible during the stage of invasion are frequently noted — 
 delirium, convulsions, and partial loss of power in the limbs. 
 
 Oa the sev .th, eighth or ninth days of the disease the pocks 
 or pujtules become converted into scabs ; they break, and their 
 contents dry and harden into crusts. Those parts of the skin 
 which have been thickly studded with pocks may be now almost 
 entirely concealed by the mass of scabs, so that the face may look 
 as if covered with a mask. Meanwhile the skin exhales a charac- 
 teristic, extremely unpleasant odor. The repulsive appearance of 
 the skin covered w ith crusts taken in connection with this sickening 
 odor, combine to render small-pox one of the most loathsome dis- 
 eases with which we are acquainted. However, in most cases the 
 patient's general condition begins to improve so soon as the scab- 
 bing commences; the fever subsides, the appetite usually improves, 
 and the distressing mental symptoms may also cease, so that the 
 convalecsence of the patient may be said to begin with the com- 
 mencement of the scabbing. In severer cases, however, the 
 oHtient's condition remains serious for some days yet. The fever 
 persists ; there is considerable annoyance from the ulcers left by 
 the broken pockb, for it may be expected that the site of each pus- 
 tule which has broken and discharged its contents, will be an ulcer, 
 the depth and extent of which varies with the size of the previous 
 pustule. It is these ulcers in which the unsightly scars or " pock- 
 marks " originate. 
 
 An attack of small-pox, therefore, usually lasts, in those who 
 recover from it, about three weeks, recovery being complete about 
 four or five weeks after exposure to contagion ; that is, after twelve 
 days of incubation there are thiee of invasion, five to seven for the 
 eruption, four or five for the scabbing process, and six to ten for 
 the removal of the scabs and the healing of the ulcers. These 
 various periods, and hence the entire duration of the disease, may 
 vary somewhat, but the time already indicated may be considered 
 a fair average. The discolored spots marking the sites of the pocks 
 may be visible for several weeks subsequent to recovery, especI.^.Uy 
 when the skin becomes cold. In many of these spots pitting occurs ; 
 in some the skin gradually assumes its natural appearance. 
 
 Severi.i accidents may unfavorably complicate the course of 
 small-pox. The various mucous membranes may be permanently 
 somewhat affected by the eruptions ; many months may elapse 
 
SMALL-POX. 
 
 29 
 
 before the voice, for instance, is entirely recovered. So, too, bron- 
 chitis, and even pneumonia (inflammation of the lungs) sometimes 
 occur. The skin of the face and body is frequently affected with 
 erysipelas ; vision is sometimes seriously impaired, or even entirely 
 lost. The mnammation may extend from the throat into the ears, 
 and thus result in deafness. A serious disease of the kidney may 
 supervene, and female weaknesses sometimes date from an attack 
 of small-pox. 
 
 Such is the course of ordinary small-pox, yet cases occur in 
 which, either from the depraved condition of the patient's consti- 
 tution at the time of exposure, or fnim the reception of an unusually 
 large amount of the contagious matter, the disease exhibits a far 
 more violent course, and is termed malignant small-pox. In such 
 cases the vessels contain, not a thin watery fluid, but a reddish, 
 bloody liquid ; there may be even extravasations of blood (black 
 and blue spots) into the skin in different parts of the body. These 
 cases are sometimes called hemorrhagic small-pox. The general 
 condition of the patient indicates from the start a fatal termination, 
 which usually occurs within a week. The individual is commonly 
 delirious or maniacal, completely prostrated, and succumbs before 
 the formation of pocks is complete. 
 
 Cause. — There is, unquestionably, a specific poison or virus, 
 the entrance of which into the body occasions this disease, though 
 this virus has not as yet been isolated. So far as we are aware, the 
 disease is never contracted except by exposure, direct or indirect, to 
 the emanations of a previous subject of the disease. Many cases, it 
 is true, are known in which it seems impossible to trace the connec- 
 tion with other patients suffering from small-pox, since individuals 
 who have not consciously appror.ched even a dwelling of a small-pox 
 patient are stricken with the disease. But it is also known that very 
 slight and indirect exposure is sufficient to convey the specific virus. 
 It is not necessary to touch an individual already afflicted, nor even 
 to approach his sick room. It may suffice merely to touch a gar- 
 ment which has once, even years before, enveloped the person of a 
 small-pox patient, or which has hung in his vicinity. Indeed, it is 
 impossible to trace all the possible ways in which contagion may be 
 conveyed from one case of small-pox to another individual. In large 
 cities a contagion most frequently occurs by passing afflicted indi- 
 viduals on the street, by riding in the same street car or carriage, 
 
i 
 
 1 
 
 I 
 
 f 
 
 30 
 
 CONSTITUTIONAL DISEASES. 
 
 even after the small-piox patient has left the vehicle. The disease 
 may be probably communicated at any time, and during all stages of 
 its progress, but it is especially contagious during the period of scab- 
 bing and drying. Even after the surface of the skin is entirely 
 healed, the patient should not for a time mingle with other individu- 
 als. The body of one who has died from small-pox is a fruitful 
 source of contagion, since instances enough are on record in which 
 individuals have contracted the disease by simply gazing upon the 
 face of the dead. 
 
 The susceptibility to small-pox, as to all other known infectious 
 diseases, varies extremely in different individuals in different races, 
 and under the influence of conditions which are as yet unknown. 
 Some persons are, as is well known, insusceptible to the disease as 
 well as to vaccination ; others, again, have had small-pox twice, or 
 even three times. The African and the Indian races are far 
 more susceptible to its ravages than are the whites. Then, again, 
 at intervals of a few years, the general susceptibility of the com- 
 munity seems to be increased so that cases of small-pox become far 
 more numerous than usual. 
 
 A point of i.-.nsiderable interest is the fact that the child in 
 the womb may experience the disease with its mother, and thereby 
 acquire, before birth, the usual immunity conferred by one attack of 
 small-pox. In most cases of small-pox in pregnant women abor- 
 tion or miscarriage occurs ; yet instances enough are on record in 
 which healthy children have been born, exhibiting the characteristic 
 pitting of small-pox, and possessing no susceptibility to the disease 
 or to vaccination. In other cases again, in which a pregnant 
 woman has small-pox, the foetus in the womb escapes entirely, 
 while the most singular fact is that the foetus may experience the 
 disease, while the mother, through whom the exposure was effected, 
 escapes, either because of a previous attack or because protected 
 by vaccination. 
 
 While there is no reason for believing that an attack of small- 
 pox can be or ever has been shortened, or " aborted," by artificial 
 means, yet there is a prevalent belief among physicians that this 
 process occurs during certain epidemics of small-pox. That is to 
 say, cases have been known in which individuals presented all the 
 symptoms indicating the invasion of small-pox, and yet no eruption 
 occurred ; yet such individuals are thereafter insusceptible to small- 
 pox and to vaccination alike. 
 
SMALL-POX. 
 
 3J 
 
 The mortality from small-pox varies, like the susceptibility to 
 it, with the age of the patient, and with certain unknown conditions 
 of atmosphere or soil which favor the occurrence of epidemics. 
 The average among scattered cases — the so-called sporadic cases — 
 is probably not greater than one in nine or ten; yet in epidemics 
 and in communities where vaccination has not been extensively 
 practiced, the mortality may reach a much larger figure. A fatal 
 result occurs more frequently in the second week of the disease 
 than at other times; thus Gregory found that of i68 fatal cases 
 death occurred in ninety-nine during the second week, in thirty-two 
 during the first, in twenty-one during the third, in nine during the 
 fourth and in seven during the fifth week. Generally speaking, 
 the danger may be said to be indicated by the extent of the 
 eruption. 
 
 Tf'^atinent, — There is as yet no means known whereby 
 an att- of small-pox can be cut short or in any other way 
 interfered with ; the disease once established, must run its 
 course. Yet small-pox, like the other eruptive fevers and 
 infectious diseases generally, is self-limited. The patient is 
 sure of a cure if he can only manage to survive until the natural 
 termination of the disease occurs. The object of treatment, there- 
 fore, is simply to sustain and assist the afflicted individual ; to sup- 
 port his strength, allay so far as possible the fever and other annoy- 
 ing symptoms of the disease. One of the first requisites, therefore, 
 consists in good nursing and hygiene. The comfort and welfare of 
 the patient alike will be promoted by a free supply of fresh air; his 
 fever will be diminished and his pains assuaged by warm baths, or 
 where this is impracticable, by frequent sponging with warm water; 
 his thirst may be quenched by the use of cold drinks, ice water, lem- 
 onade or effervescing drinks. Persistent vomiting is a troublesome 
 symptom to treat, but may be often controlled by permitting the 
 patient to hold pieces of ice in the mouth until melted, or by admin- 
 istering equal parts of lime-water and milk, say a tablespoonful 
 every two hours. If there be a tendency to constipation, a saline 
 laxative, such as the citrate of magnesia, may be employed; at the 
 same time a teaspoonful of sweet spirits of nitre may be given four 
 or five times a day. If the mouth and throat be sore they may be 
 frequently washed and gargled with a solution of the chlorate of 
 potash — one drachm to the ounce of water. If vesicles form in the 
 
32 
 
 CONSTITUTIONAL DISEASES. 
 
 ■: 
 
 IM 
 
 
 
 ,. 
 
 eyes, also, extreme care should be taken to secure perfect cleanliness 
 by frequent washings with simple water ; yet this complication, 
 because capable of such serious results, should always be entrusted 
 to the care of the physician. 
 
 One of the most important indications in most cases of small 
 pox is the necessity for the employment of nourishing, easily-digested 
 food. The patient has, of course, little or no appetite, and his diges- 
 tion is further impaired by nausea, and perhaps by the soreness 
 of his mouth and throat, during the primary fever — the stage of in- 
 vasion. Reliance may be placed upon miUc, broths, and similar sick- 
 room fare; but during the second week certainly it will be neces- 
 sary, in the vast majority of cases, to employ alcoholic stimulants 
 in some shape; whisky-punch is perhaps the best form. 
 
 The most important object of treatment, though one which 
 cannot always be successfully accomplished, is the avoidance 
 of scars or " pitting. " It is scarcely necessary to mention all of 
 the plans which have been devised for the accomplishment of this 
 end; the fact that so many have been recommended, indicates 
 that none can always be relied upon for success. In the writer's 
 experience, the best plan consists in touching the largest vesicles 
 with a pointed stick of the nitrate of silver (lunar caustic) on the 
 second day of their appearance; then poultices of linseed meal or 
 bread and milk may be applied over the entire face for four or five 
 days, until the vesicles have become umbilicated; then collodion, 
 mixed with one-twentie'Ji part of glycerine, may be applied to the 
 vesicles by means of a camel's hair brush, so thick as to make an arti- 
 ficial skin. This may be renewed every day or two. 
 
 While we endeavor faithfully to discharge our duty to the 
 patient himself, we may not forget the interests of others. It is 
 scarcely necessary to remark that the individual should be isolated 
 so far as possible from others, especially that no children should be 
 permitted to run any risk of contracting the disease. At the very 
 first manifestation of small-pox, every one who has been or can be 
 exposed to the contagion, should be at once vaccinated; for since 
 the stage of incubation of the vaccine matter is several days shorter 
 than that of the small-pox virus, it is possible, by immediate vac- 
 cination, to escape the small-pox, even after exposure; and even if 
 the vaccination be performed too late to prevent the attack of 
 small-pox, the disease will be nevertheless less severe than would 
 otherwise have been the case. 
 
 \ 
 
 
VARIOLOID. 
 
 33 
 
 Then, again, it must not be forgotten that the patient is capa- 
 ble of communicating the disease even during his convalescence — 
 indeed, after the skin is entirely healed ; and that all the articles of 
 whatever nature present in the room during his illness may also 
 convey the disease after months have elapsed. The patient should, 
 therefore, never be allowed to come into contact with any person 
 until a week or so after the scabs have all fallen off and the surface 
 is entirely healed ; not until he has by repeated fumigations and 
 disinf :tion destroyed, so far as may be, all the effluvia emanating 
 from his person. As for the bedding and body linen, the most 
 effectual method of disinfection is by burning them ; if this be 
 impossible, they, as well as the carpets and furniture of the room, 
 should be disinfected by the use of bromine, as will be described 
 under tiie head of " Disinfection. " 
 
 Varioloid. 
 
 Varioloid, or modified small -pox, is a name used to indicate the 
 disease either as it occurs in those who have been previously vac- 
 cinated, or as it occurs as the result of direct and intentional inocu- 
 lation from a patient suffering with small -pox. Since, in these 
 latter days, the latter practice has been discontinued, the term 
 varioloid now designates small-pox as modified by previous vacci- 
 nation. It is, of course, essentially small-pox — presents the same 
 features, though in a less intense degree. It is rarely fatal, and 
 usually occasions the individual comparatively little indisposition. 
 The vesicles are usually few in number, widely scattered; the fever 
 IS slight, the chills and pains far less severe. Indeed, many a 
 patient with varioloid is astounded to learn from his physician that 
 he has small -pox. Yet, while the individual himself suffers so little 
 inconvenience, he is just as dangerous to others as the most 
 malignant case of small -pox; he should, therefore, observe the 
 same precautions for the protection of others as if he were himself 
 seriously ill. It is probable that much of the promiscuous dissemi- 
 nation of small-pox in our large cities is accomplished, in great 
 measure, by these cases of varioloid, since many such individuals 
 find it unnecessary to interrupt their usual avocations. 
 
 3 
 
 ■H 
 
i:i 
 
 I 
 
 I!'! 
 
 : 
 
 ; 
 
 ^n 
 
 34 
 
 CONSTITUTIONAL DISEASES. 
 
 Vaccination. 
 
 It had been for centuries known in t>e Orient that the seventy 
 of small-pox was much diminished by the actual transfer of the 
 specific virus from one patient to another ; that individuals so inocu- 
 lated sufifered less severely from the ravages of the disease than those 
 who acquired it in the usual way of exposure. This practice of in- 
 oculation had been long and extensively employed in Turkey, when 
 in 1718, an English lady, Lady Mary Wortley Montague, visiting 
 Constantinople, became personally convinced of the value of this 
 measure. She had the courage to submit her own son to inocula- 
 tion, and was the means of introducing the practice into England, 
 whence it spread over various parts of the Continent. It might be 
 proper to add, though not exactly pertinent to the present topic, 
 that the same principle — inoculation from a diseased to a healthy 
 animal — has been since, and still is, extensively employed to 
 diminish the ravages of certain diseases which afflict domestic 
 animals. In the latter half of the same century, Edward Jenner, 
 an English physician, arrived at a most important discovery on the 
 same subject. It had long been reported among the peasantry that 
 individuals who had contracted from cows a certain pustular disease 
 — cow-pox — remained ever after insusceptible to small-pox. Jen- 
 ner investigated by a series of observations extending over twenty 
 years the actual facts in the case. He found that the pustular dis- 
 ease to which cows are subject could be communicated to man by 
 simple contact ; that the result was the production of a few vesicles 
 resembling those of small-pox, and that individuals so inoculated 
 resisted all attempts at inoculation with the virus of small-pox. In 
 1798, Jenner published this discovery to the world, and commenced 
 public demonstrations of the truth of his conclusion. His discovery 
 was bitterly contested and ridiculed, as discoveries have always 
 been, and will continue to be, in conservative England. The prac- 
 tice, however, was soon extensively tried in other countries ; vac- 
 cination was first performed in America and in Austria, in 1799. 
 Even before Jenner's death, sufficient evidence had accumulated to 
 convince the world that his was the greatest and most valuable dis- 
 covc- iri that time recorded in the annals of medicine. " The 
 frun. ' . .? s\.nscendantly important discovery have been the 
 s; 1.; c\ t,>! jKalculable number of lives, which would otherwise 
 have bccii i"^-.. ./ed by one of the most loathsome of diseases, and 
 
VACCINATION. 
 
 35 
 
 the prevntion, to an extent which cannot be computed, of the dis- 
 figurement and other distressing effects which small-pox is apt to 
 produce, when it does not prove fatal. Of all the benefactors who 
 have ever lived, no one has conferred on mankind such immense, 
 palpable and timelasting benefits. " — Flint. The investigations of 
 the present century have shown that Jenner's belief of the identity 
 of small-pox in the human subject and in the cow, was correct ; 
 furthermore, that horses and sheep are subject to essentially the 
 same disease, which may be communicated from one species to the 
 other, or to man. The facts, as at present ascertained, are that 
 inoculation of the cow vi^ith small-pox virus produces in that animal 
 a modified form of small-pox, and that the inoculation of the human 
 subject again from such an animal produces a modified small-pox — 
 that is, vaccination. As to the importance and value of vaccination, 
 there can be and is no question whatsoever ; there are, it is true, 
 certain fanatics in England who decry the practice, because instances 
 occur in which the vaccination of one • /idual from another has 
 resulted in the transfer, not only of tne vaccine material, but also 
 of a contagious disease. It should be remarked that, while such an 
 occurrence is possible, while indeed several well authenticated 
 instances are reported and acknowledged, yet this occurrence is so 
 rare as to be almost without significance ; thus, Auspitz reports that 
 only two instances of such transfer of contagious disease occurred 
 in 12,000,000 of vaccinations performed in Germany. It is further 
 evident that the exercise of proper care on the part of the physician 
 in the selection of the subject from whom he takes his vaccine 
 matter would obviate the danger ; and, furthermore, that there can 
 be no possibility of such transfer when the material is obtained 
 directly from the cow. There are, it is true, certain disadvantages 
 in the employment of animal virus ; the sore produced is usually 
 more severe and painful than that produced by human virus. On 
 the whole, the most desirable material is, doubtless, that obtained 
 by one or two transmissions from the cow, through healthy human 
 subjects. 
 
 Vaccination may be performed either with the fresh matter 
 or with the same after it has dried, or, finally, with the scab from 
 the arm of the human subject or from the udder of a cow. The 
 matter, technically called lymph, may be taken from the vesicles 
 from the fifth to the eighth or ninth day after vaccination. The 
 lymph is usually kept on ivory points, or in quills ; but, treated in 
 
I 
 
 i > 
 
 ^it 
 
 36 
 
 CONSTITUTIONAL DISEASES. 
 
 this way, the lymph, as well as the scab from the arm, lose their 
 specific power in a month or so. In order to preserve this power, 
 the lymph has been drawn into capillary tubes and then sealed ; it 
 has also been preserved by admixture with glycerine and water. 
 The best, because the surest, method consists in transferring the 
 lymph directly from one arm to another; in this way, too, it is 
 possible to inspect the source and to avoid the transfer of any con- 
 tagious disease. For the introduction into the system, several 
 methods have been used; the exact manner is not important, since 
 the object is to introduce the material under the skin without draw- 
 ing blood enough to flow. One way is to make a series of shallow 
 scratches, linear and transverse, with a lancet previously dipped in 
 the lymph ; or, such scratches can be made with a clean lancet, and 
 a paste made of the scab can be rubbed over the surface. Another 
 way is to introduce the point of the lancet, \\Q\d parallel ivith the 
 arm, just far enough to deposit a particle of the lymph, or scab, 
 under the skin, but not far enough to provoke a flow of blood. The 
 position usually selected — on the outside of the arm — is preferable 
 for many reasons; not the least of which is the facility afforded for 
 subsequent inspection of the scar in after years. It is desirable to 
 vaccinate at two or three points so as to afibrd a greater chance for 
 success. The age at which vaccination should be first performed 
 may, of course, vary somewhat with circumstances. If the child 
 be in good health, the vaccination may be made in the third month 
 of life ; if there be especial danger of exposure to small-pox, the 
 vaccination may be made even earlier; under these conditions, too, 
 slight indisposition on the part of the child should not be per- 
 mitted to postpone this act of protection. The period during 
 which a single vaccination aff"ords protection against small-pox 
 varies extremely. Instances are known in which, after a single 
 successful vaccination in early life, the individual has remained in- 
 susceptible to the disease, as well as to subsequent vaccination ; 
 on the other hand, cases are known in which small-pox has been 
 contracted within three or four years after vaccination. Generally 
 speaking, it may be advisable to attempt a revaccination at periods 
 not greater than five years ; in cases of unusual exposure to small- 
 pox — as during epidemics of this disease — this period may be 
 abbreviated. Some physicians submit themselves to vaccination 
 every year, usually without success, though occasionally the vac- 
 cination will quite unexpectedly " take. " It is evident that notk- 
 
VACCINATION. 
 
 37 
 
 ing is to be lost, though much may be gained, by vaccination at 
 comparatively short periods. It is also important that the vaccin- 
 ation should be intrusted to a competent person. Although so 
 simple an operation, it requires, nevertheless, considerable skill to 
 insert the material under the skin without causing the flow of so 
 much blood as to wash away the lymph. Then, ag;tin, the quality 
 of the virus is all important, and should be vouched for by a relia- 
 ble person. Much of the dissatisfaction consequent upon vaccina- 
 tion, doubtless, results from the fact either that the operation was 
 improperly performed, or that the material used was not of the 
 proper quality. 
 
 " On the third day after vaccination (the operation being 
 usually performed on the arm near the insertion of the deltoid 
 muscle) red points, slightly elevated — that is, small papules — are 
 apparent at the spots where the vaccine virus was inserted. On 
 the fourth day the papules are more developed and reddened. 
 On the fifth day vesicles are discovered. The vesicles increase, 
 presenting an umbilicated appearance, and on the eighth day they 
 attain their full development, being elevated from two to three 
 lines, and measuring one-third of an inch in diameter. The 
 vesicles, like those of small-pox, are multilocular (flattened at the 
 summits), and contain a transparent viscid liquid, called the vaccine 
 lymph. On the seventh or eighth day a red areola is apparent, 
 extending from one to three inches around the pocks, increasing in 
 redness until the ninth or tenth day, and the contents of the vesi- 
 cles become more or less purulent. At this time there is usually 
 slight fever, with some local pain and itching ; the vessels of the 
 arm become swollen, and the glands in the arm-pit may become 
 enlarged and tender. On the tenth or eleventh day the fever 
 subsides, and the redness around the pocks diminishes. A dark 
 spot soon appears on the center, and gradually extends over the 
 whole of the pocks. The pustules dry up, and by the fifteenth 
 day they are converted into black, hard scabs, which fall off, 
 usually, by the twenty-fifth day from the date of the vaccination. 
 During the progress of the vaccine affection, vesicles, having the 
 distinctive characters of cow-pox, have sometimes been observed 
 on other parts of the body. It is probable that these are caused 
 by the patient scratching the vesicles on the arm, and carrying 
 thereto lymph containing the virus, on the finger nails, to parts 
 where, owing to abrasions of the skin, self-vaccination is the result. 
 
38 
 
 CONSTITUTIONAL DISEASES. 
 
 Experiments show that between the fourth and the ninth or tenth 
 day, the characteristic vesicles may be multiplied at will, by 
 rcvaccinating with lymph from the vesicles produced by the 
 primary vaccination. Permanent scars denote the situation of 
 the vaccine pocks. The scar, provided the vesicles have pursued 
 a regular course, and subsequent ulceration has not occurred, is 
 characteristic, presenting a series of depressions, or pits, each of 
 which represents the site of one of the cells composing a vaccine 
 vesicle. " — Flint. 
 
 Several of these features are important, as indicating a success- 
 ful vaccination, and constitute a permanent record of the operation. 
 Thus, on the fourth day, there should be a small, red elevation; 
 this should become a vesicle on the fifth day and depressed in the 
 center — Mmbilicatcd — on the tenth or eleventh day. The scabs 
 should not fall off before the eighteenth or twentieth day. The 
 separation of the scar into compartments is also an important 
 feature. There is a prevalent belief among physicians, supported 
 by certain observations, that the security against small-pox is 
 increased by several inoculations at the same time; in other words, 
 that the protection increases with the number of the vesicles formed 
 up to four or five. Simon reports that of nearly 6,ooo cases of 
 small-pox contracted after vaccination, the mortality among those 
 who asserted that they had been vaccinated, but who could exhibit 
 no scar, was 21^ per cent.; among those with one scar, 71^^ per 
 cent.; among those with two scars, 4 per cent.; among those 
 with three scars, i ^ per cent. ; among those with four or more 
 scars, ^' per cent. It is a prevalent belief among physicians 
 that vaccination affords briefer security against small-pox now- 
 adays than was the case eighty years ago; and it is supposed 
 that the explanation of the fact lies in the general use o{ Iminanised 
 virus — that is, virus which has passed through several human sub- 
 jects since leaving the cow, and has been thereby somewhat weak- 
 ened. This belief has led to a general employment of animal virus, 
 and the establishment of numerous depots for this material. That 
 vaccination should become the universal practice is unquestionable; 
 though there may be individuals who, though unvaccinated, have 
 never contracted small-pox, yet there are also individuals who 
 escape cholera and yellow fever. The security of a few does not 
 alter the fact that the vast majority are susceptible, and that protec- 
 tion is afforded by vaccination. 
 
CHICKEN-POX. 
 
 3> 
 
 Chioken-Pox. 
 
 This disease, technically known as varicella, is somewhat insifj- 
 nificant, because rarely, if ever, fatal. It is confined almost entirely 
 to children, though cases are known in which adults also are affected. 
 It is a highly infectious disease, and presumably spreads only by 
 contagion. » 
 
 Symptoms, — The appearance of the eruption is generally pre- 
 ceded by slight constitutional disturbance for about twenty-four 
 hours. There is some fever ; possibly nausea and vomiting. The 
 rash usually appears first on the body, and afterwards on the face and 
 head. It is well characterized from the eruption of small-pox, by the 
 fact that it is from the first composed of vesicles (blisters), and not 
 of hard />apules (p'wiples). On the fifth or sixth day the vesicles 
 begin to dry ; b / this time they may be as large as small peas, and 
 are surrounded )y a broad red margin. They soon scab and fall off, 
 rarely leaving scars. Not infrequently a second crop of vesicles 
 appears during the first three days. 
 
 Treatment, — The indisposition attending this disease is so 
 slight as to require nothing more than the simplest home treatment; 
 a saline laxative, such as the citrate of magnesia, occasional spong- 
 ing and light diet will fulfill all requirements. It is desirable to iso- 
 late the child, so as to protect other children. 
 
 The only point of special interest in connection with chicken-pox 
 is the possibility of confusion with small-nox. This mistake is often 
 made, sometimes even by physicians, who unguardedly give an opin- 
 ion before the characteristics of the respective diseases become mani- 
 fest. Two points may be recognized by the non-professional : in 
 small-pox the rash begins as hard papules, and become vesicles only 
 after the lapse of several days ; in chicken-pox the rash consists of 
 vesicles from the outset. In small-pox the vesicles exhibit the char- 
 acteristic umbilication, which is wanting in chicken-pox. 
 
40 
 
 CONSTITUTIONAL DISEASES. 
 
 Scarlet Fever. 
 
 This disease, technically called scarlatina, is distinguished by 
 a great diversity of symptoms as well as by varying degrees of 
 severity. The mildest form is comparatively trivial in its effects 
 upon the individual, while its severest form is one of the most 
 destructive diseases with which we are acquainted. Physicians 
 generally distinguish for convenience three varieties of the disease, 
 according to the degree of severity, and to the amount of compli- 
 cation in the throat. These varieties are called scarlatina simplex, 
 scarlatina anginosa, and scarlatina maligna. It must be under- 
 stood, however, that these are not distinct diseases, but merely 
 convenient terms for the designation of different manifestations of 
 the same disease. 
 
 Cnnse, — Scarlatina, like the other infectious diseases, is due 
 to a specific virus or poison, as to the exact nature of which we are 
 not yet informed. Like the other infectious diseases, it seems to 
 arise only by communication from individuals who are already 
 afflicted. Some cases, it is true, cannot be traced to contagion, 
 but seem to arise quite spontaneously, without previous exposure 
 to the disease; but it must be remembered that scarlet fever, like 
 small-pox, can be communicated by articles of clothing or of furni- 
 ture which have once been impregnated with the virus. Yet it by 
 no means follows that exposure to the contagion will induce the dis- 
 ease. This general principle is applicable, of course, to all infectious 
 diseases. There must be not only exposure to contagion, but also 
 a certain susceptibility on the part of the exposed individual, in 
 order that the disease may be developed. Yet tiio susceptibility 
 to scarlet fever seems to be less general than in any other of the 
 infectious diseases ; for it is no uncommon obpcivrtion that several 
 of the children, even in the same family, who are exposed at the 
 same time to the scarlet fever contagion, escape the disease. Indeed, 
 it is even observed that while one child in a family suffers from the 
 disease, others living in the same house during the entire illness of 
 the first, escape completely. Such facts as these have caused some 
 physicians to doubt the contagiousness of scarlet fever. But it 
 must be remembered that there is precisely the same ground for 
 doubting the contagiousness of any other infectious disease, since 
 
SCARLET FEVER. 
 
 41 
 
 similar facts, not perhaps so numerous, can be adduced in regard to 
 each. The specific virus of scarlatina, like that of certain other 
 infectious diseases, retains its power of inducing the disease for 
 nionths, and may be transferred in the clothes of the attendants or 
 visitors. 
 
 The disease rarely occurs twice in the same individual, although 
 such repetition is more frequent in the case of scarlet fever than of 
 most of the other infectious diseases ; instances are known in which 
 the .same individual has suffered even three times from scarlet fever. 
 The disease occurs most frequently in the third and fourth years of 
 life; the susceptibility to it seems to decrease rapidly after the fifth 
 year, and almost subsides in adult life, During the first and second 
 years also the susceptibility seems to be slight, for cases in children 
 of that age are certainly rare. Instances are reported in which the 
 fu?tus has contracted the disease before birth, though such cases are 
 certainly far less numerous than the analogous ones of small-pox. 
 
 fhfmpfoiHH, — The period of incubation, so called — that is, the 
 interval between exposure and the first manifestation of the dis- 
 ease — is shorter in scarlet fever than in most of the eruptive fevers. 
 It is usually stated at two to five days, though it seems to vary be- 
 tween one and six days. At this interval, after exposure there com- 
 monly occurs a pronounced chill, which may, however, be absent. 
 Another symptom is usually vomiting, a symptom rarely absent in 
 children. The child in many cases complains of soreness of the 
 throat and pain upon swallowing, though it is a by no means con- 
 stant symptom. When it does occur there is usually also consider- 
 able reddening of the inside of the throat, and swelling of the 
 glands at the angle of the jaw. The other symptoms vary with 
 the intensity of the attack. In some there is intense fever, head- 
 ache and general prostration, perhaps even delirium; on the other 
 hand, there may be no indication of constitutional affection except 
 slight fever. 
 
 This stage of invasion usually lasts only twenty-four or, at 
 most, forty-eight hours. On the second day there appears, usually 
 first on the body and limbs, rapidly extending over the entire sur- 
 face, a brilliant scarlet rash. While this is the usual order of its 
 occurrence, it sometimes happens that the rash will be first percep- 
 tible on the face and neck. It consists at first of minute red specks 
 or dots, which soon run together, forming irregular shaped patches; 
 
42 
 
 CONSTITUTIONAL DISEASES. 
 
 'lilt 
 
 yet even in these patches it can be seen, upon close inspection, that 
 the redness is not uniform and continuous, but is made up of a 
 mass of minute points of a deep red color, while the intervening 
 skin is tin^jed less intensely red. The color disappears upon press- 
 ure with the finger, and white lines may be made by drawing a 
 pencil or a finger-nail over the surface. The redness is usually 
 most intense and persistent on those parts where the skin is espe- 
 cially thin and delicate — along the inner surface of the arms and 
 legs and at the elbow. In some instances the entire surface is con- 
 tinuously red, producing the appearance which has been likened to 
 that of a boiled lobster. The surface is usually smooth, but may 
 cause a feeling of minute elevations. Sometimes very small watery 
 blisters may be scattered over the skin. 
 
 The patient is usually annoyed by a general itching sensation 
 which may amount even to positive pain; the skin is somewhat 
 swollen, a condition which becomes evident when the patient 
 attempts to close the hands, or places the feet upon the floor. Just 
 as there are great differences in the intensity of the skin eruptions 
 so the soreness of the throat may vary extremely; at times the 
 entire difficulty seems to be concentrated in the throat. In all cases, 
 probably, there is more or less swelling of the tonsils, and usually a 
 whitish deposit upon their surface; in the severer cases the swelling 
 in the throat becomes so great as to prevent the patient from swal- 
 lowing anything but liquids, and even to interfere seriously with 
 breathing, so that the voice acquires a nasal twang. Sometimes 
 there is an escape of blood into and on the surface of the throat. 
 
 The tongue usually presents certain characteristic appearances 
 in scarlet fever; it is often sprinkled over with projecting red points, 
 looking as if it had been Jested with red sand. Later the coating 
 of the tongue is cast off, leaving its surface clean and red, the points 
 above described now projecting so as to resemble the appearance of 
 a strawberry; hence the name strawberry tongue, an appearance 
 quite characteristic of this disease. 
 
 In scarlet fever the appearance of the eruption is not accom- 
 panied as in small- pox by a cessation of the fever; on the contrary 
 the constitutional symptoms are often increased; the degree of fever 
 is more intense during the eruptive stage of scarlet fever than in 
 any of the other eruptive fevers. During this stage, too, the most 
 serious mental and constitutional symptoms occur; delirium is usual, 
 
 
SCARLET FEVER. 
 
 43 
 
 and convulsions (in children) very common; hence the greatest care 
 is required on the part of the attendants, since patients not in- 
 frequently injure themselves, even precipitate themselves from 
 windows during such delirium. 
 
 The eruption ordinarily lasts four to six days, though here, too, 
 variations occur. Of fifty-four cases reported by Jenner, the rash 
 disappeared on the fifth day of the disease in one case; in three 
 cases on the sixth day; in five cases on the seventh day; in thirteen 
 cases on the eighth day; in twelve cases on the ninth day; in eight 
 on the tenth; in four on the eleventh, and in two on the thirteenth, 
 fourteenth and sixteenth day respectively. 
 
 Staffs of Desqiifimntion. — About the sixth day the rash be- 
 gins to fade, and in the succeeding days the surface of the skin is 
 cast oiT in the shape of scales, usually of small size, like bran, 
 though some times in large pieces; indeed the entire skin of a finger 
 of a hand may be cast off entire like the finger of a glove. This 
 desquamation may last from six to twelve days, or may not be 
 finished for several weeks. 
 
 Such is the history of an ordinary mild case of scarlet fever 
 without complications; yet a large number of cases, whether mild or 
 severe during the original disease, are accompanied by complica- 
 tions which are often more serious in the permanence of their effects 
 than any feature of the disease itself. Among these complications 
 are serious affections of the throat. These are so common that one 
 variety of the disease has been accordingly named scarlatina 
 anginosa. In these cases (which are probably sometimes considered 
 diphtheria) the swelling and ulceration in the throat and the conse- 
 quent interference with respiration are so great as to concentrate 
 the attention upon this part of the body. The rash is usually slight, 
 and maybe overlooked. The tonsils become enormously enlarged, 
 ulcerated, covered with a brown film or false membrane, and often 
 produce a great amount of matter; in these cases the glands around 
 the angle of the jaw are greatly enlarged and sometimes become 
 abcesses, which either break spontaneously or are opened. Another 
 complication, especially apt to occur in these cases of severe sore 
 throat, is deafness, partial or complete. The reason for this lie.-) in 
 the fact that the cavity of the ear is connected with the throat by 
 means of a bony channel called the eustachian tube. The inflamma- 
 tion may, and frequently does, spread from the throat into and 
 
44 
 
 CONSTITUTIONAL DISEASES. 
 
 through this tube into the middle ear ; the result is the formation 
 of matter — an abscess — in the ear and the consequent loss of hear- 
 ing. In some cases there may be recovery of a certain amount of 
 hearing even after suppuration has occurred in the ear. Some- 
 times the local disease in the throat is so violent as to cause exten- 
 sive mortification of these structures, — sloughing — and this may 
 extend even to the mouth. Then, again, a severe inflammation of 
 the larynx (the upper part of the windpipe) may cause speedy 
 death. Sometimes, too, the membrane surrounding the brain, and 
 even this organ itself, becomes inflamed, resulting in more or less 
 permanent derangements of the mental functions. From the same 
 cause paralysis of the face or of the limbs may follow. Sometimes, 
 too, affections of the eyes, resulting in serious impairment of vision, 
 are observed. 
 
 But one of the most frequent and serious complications of scar- 
 let fever is inflammation of the kidneys. It would seem, indeed, 
 that this should be regarded almost as an essential part of the dis- 
 ease, though in a considerable number of cases the kidneys resume 
 their natural state soon after the fever subsides. The complication 
 with inflammation of the kidneys is indicated by swelling of the skin 
 — dropsy — usually first noticed under the eyes, and then spreading 
 over the face, trunk, and extremities. A certain amount of dropsy 
 is a usual feature in all but the mildest cases of scarlet fever, and it 
 is often one of the last symptoms to disappear. But a dropsy which 
 persists for some time after recovery usually indicates serious inflam- 
 mation of the kidneys. This inflammation may exist without 
 noticeable dropsy, and can be, under these circumstances, detected 
 only by an examination of the urine, microscopical as well as chem- 
 ical. In every case of scarlet fever the physician should acquaint 
 himself by frequent examination of the urine as to the condition of 
 the kidneys ; for, though everything else may go on well, the 
 patient may succumb to this kidney disease even at a time when 
 convalescence seems at hand. In every case in which, after the 
 appearance of the eruption, the patient has repeated convulsions, or 
 lies stupid and unconscious, the condition of the kidneys may afford 
 a key to the situation. 
 
SCARLATINA MALIGNA, OR MALIGNANT SCARLET FEVER. 
 
 45 
 
 Scarlatina Maligna, or Malignant Scarlet Fever. 
 
 Under this name is designated an affection which oftentimes 
 exhibits none of the features of scarlet fever, but is recognized as 
 such by its occurrence among children during an epidemic of the 
 disease. The patient seems simply overwhelmed by some acute 
 poisoning ; lies prostrate, perhaps unconscious, with cold extremi- 
 ties. There is usually no fever ; death commonly occurs in a few 
 hours, before the appearance of an eruption or other characteristic 
 features of scarlet fever. 
 
 Then, again, there are cases in which the throat affection and 
 the general appearance and history of the patient indicate that the 
 disease is scarlet fever, although the characteristic rash may not 
 appear ; and there are still others in which the rash may be insig- 
 nificant in quantity, while the skin is reddened in patches by the 
 escape of blood into its structure. 
 
 One characteristic feature of scarlet fever, as distinguished from 
 all other eruptive diseases, is the rash ; after this has been seen a 
 few times it is usually easy of recognition subsequently. Scarlet 
 fever is especially apt to be mistaken for measles ; several points of 
 distinction will be mentioned subsequently, and it will suffice here to 
 call attention to a few items: the brevity of the stage of invasion (one 
 or two days prior to the appearance of the eruption); the intensity of 
 the fever ; the appearance of the throat difficulty before the rash on 
 the skin becomes visible, and the persistence of the fever after the rash 
 has appeared. The difficulties in recognizing the disease occur in 
 those mild cases in which the eruption is very slight without any 
 soreness of the throat ; also in those instances (scarlatina anginosa) 
 in which there is little or no eruption, but severe affection of the 
 throat. In some of these cases even the experienced physician may 
 be compelled to decide by the surroundings of the patient — the 
 prevalence of an epidemic of scarlet fever, for instance. 
 
 Treatment. — With our present means we have no power to 
 cut short scarlet fever any more than the other infectious diseases. 
 The remark made as to the treatment of one holds good for them 
 all : that the object is to support and guard the patient from the 
 ravages of the disease. In ordinary mild cases ot scarlet fever no 
 formal treatment is necessary f the child should be sponged or 
 
u 
 
 ! 
 
 'i 
 
 iii 
 
 46 
 
 CONSTITUTIONAL DISEASES. 
 
 'H 
 
 immersed in a hot bath several times daily, half a teaspoonful of 
 sweet spirits of nitre may be given every four hours (if the child 
 be three or more years old) ; if there be constipation a saline 
 laxative may be given. 
 
 One of the troublesome features is the management of the 
 throat affection. Fortunately, this feature is absent in many cases 
 except in a slight degree ; for these the old remedy of muriatic acid 
 and honey in equal parts as a gargle (diluted with water) may suf- 
 fice. In severer cases it becomes necessary to cleanse the throat 
 several times a day with camel's hair brushes or similar instruments. 
 After gargling with water or with a solution of carbolic acid (one 
 part to twenty of water) the brush may be swept over the grayish 
 or brown surfaces, removing ar.j ^articles that may be easily 
 detached ; after this a clean brush i' ..ipped into a solution of 
 nitrate of silver (twenty grains to the . jncc of water) and the 
 ulcerated parts of the throat are penciled wiui this. These throat 
 cases, too, are often benefited by the application of cold cloths, fre- 
 quently changed, to the neck. 
 
 If the fever be very high and mental symptoms prominent, great 
 advantage will often be derived from the wet pack. For this pur- 
 pose a sheet may be wrung out of water having a temperature of 
 70 degrees F. The patient, divested of all clothing, is wmpped in 
 this sheet, and covered with several blankets. In the course of half 
 an hour or so, the individual is usually perspiring freely, and feels 
 greatly refreshed, and often enjoys tranquilizing sleep. This 
 measure may be executed two or three times daily ; there is no 
 danger of" driving in the rash," according to the popular prejudice. 
 
 In the severer cases, whether complicated by affections of the 
 throat or not, an important feature of the treatment is the administra- 
 tion of light and nutritious food. The usual fare — milk, eggs and broth 
 — must be in such cases supplemented by alcoholics in some form, 
 egg nog or milk punch. To the same end it is advisable to admin- 
 ister quinine regularly ; for a child of three years the dose may be 
 one-half to one grain four times a day. 
 
 Another indication for treatment in scarlet fever is the itching 
 which so often annoys the patient. A popular, though not espe- 
 cially desirable, remedy consists in lubricating the skin with lard ; a 
 preferable substitute is a solution of glycerine, either in simple water 
 or in rose or cologne water — one part of glycerine to four of rose 
 water. 
 
 If 
 
MEASLES. 
 
 47 
 
 In cases of mental disturbance — stupor, delirium and convul- 
 sions — the source of the difficulty is often the failure of the kidneys 
 to discharge their functions properly. In such instances the greatest 
 hope of relief lies in brisk purging and in the wet pack. 
 
 There are cases, too, in which there is no evidence of inflam- 
 mation of the kidneys until after the peeling off — desquamation — has 
 begun, so that dropsy may become apparent a week or two after the 
 crisis of the disease has passed. This must not, however, be con- 
 sidered as an indication that the patient has taken " a fresh cold," 
 for it is usually a portion of the disease itself. 
 
 Measles. 
 
 The disease, also known as morbilli and rubeola, is of far less 
 importance, with regard to the immediate danger to life, than either 
 small-pox or scarlet fever ; and yet there so often follow in the train 
 of measles complications which may have a permanent effect upon 
 the health and vigor of the individual, that the disease is, neverthe- 
 less, one of considerable importance. Moreover, it is important to 
 be able to recognize measles because of the similarity of this disease 
 with scarlet fever, and the consequent possibility of mistaking one 
 for the other. 
 
 The period of incubation — the interval between exposure and 
 the onset of the symptoms — is from ten to fifteen days; then occurs 
 the stage of invasion. The onset of the disease resembles a severe 
 cold or an attack of influenza. The individual sneezes repeatedly, 
 and there is an acrid discharge from the nostrils ; the eyes are also 
 usually inflamed, red and watery. There is, also, soreness of the 
 throat, hoarseness, and a dry, painful cough. At the same time 
 there is usually a chilly sensation, perhaps shivering, but rarely a 
 distinct and pronounced chill. Then begins a fever, usually less 
 intense than that of scarlet fever ; the appetite is impaired; nausea 
 and vomiting may occur ; there are wandering pains in various 
 parts of the body, especially in the head and limbs ; there is gen- 
 eral debility and languor. In children more marked symptoms, 
 such as convulsions and bleeding at the nose, may occur ; some- 
 times, too, the disease is ushered in with an attack of false croup. 
 
 t 
 
<i 
 
 ilf 
 
 'it' ' 
 
 4 
 
 ^ % 
 
 48 
 
 CONSTITUTIONAL DISEASES. 
 
 After a time, which varies somewhat, though averaging about four 
 days from the beginning of the symptoms, there occurs the siag-e of 
 eruption. The rash is usually first seen on the forehead and tem- 
 ples, rapidly spreading over the face and neck. Within forty-eight 
 hours the entire body and extremities are covered. It will be 
 noticed, therefore, that the spread of the rash in measles is less 
 rapid than in scarlet fever or small-pox. 
 
 The rash begins with minute red specks similar to those of the 
 scarlatinal rash, except that the color is a less intense red; the rash 
 of measles, moreover, is usually arranged in somewhat crescentic 
 patches. The specks at this stage resemble the pimples of small- 
 pox before the formistion of vesicles, but they do not give that 
 shot-like sensation to the finger; they are more like flea bites. • 
 The eruption is often attended, like that of scarlet fever, with con- 
 siderable itching, and there may ''" some swelling of the skin, 
 especially on the face. Som .tirucr. a few vesicles may be observed 
 among the dark red patches. The fever continues until about the 
 fourth day after the appearance r *" the : ■ i^, when both fever and 
 eruption gradually disappear. The rash begins to fade where it 
 began to appear — on the face. 
 
 Most of the symptoms which were present before the appear- 
 ance of the rash — the inflammation and discharge from the eyes, 
 nose and throat — continue during the eruption. 
 
 Stage of Deaqmrniatioti. — The fading of the eruption and 
 the scaling of the skin occupy ordinarily four to eight days. The 
 skin does not peel off to the same extent as in scarlet fever, the 
 scales being always small and not patches. The fever which has 
 persisted during the eruption now begins to decline, though the 
 cough and inflammation in the eyes may continue for some days 
 subsequently. 
 
 Such is the history of an ordinary case of measles; there arc 
 several variations from this type, and several complications may 
 aggravate the gravity of the disease. The affections of the eyes, 
 nose and bronchial tubes, though quite characteristic of this disease, 
 are sometimes wanting; and there are cases which are unmistakably 
 measles, though the peculiar rash is but imperfectly developed. 
 Sometimes, too, severe cases of measles, like those of scarlet fever, 
 are characterized by the escape of blood from the blood-vessels into 
 the skin, making diffuse dark-red patches. 
 
ROSEOLA. 
 
 49 
 
 Among the complications which often follow measles are ob- 
 stinate affections of the eye and of the larynx, and severe inflam- 
 mation of the lungs; somewhat less frequently there occur attacks 
 of diphtheria and true croup. A possible complication also is deaf- 
 ness, originating in the same way as was described in connection 
 with scarlet fever. 
 
 The more important points distinguishing this disease from 
 scarlet fever and small-pox are the length of the period of incuba- 
 tion, the long interval after the first symptoms before the rash ap- 
 pears, the affection of the eyes, nose and air passages, the appear- 
 ance of the eruption first on the face and its gradual extension 
 over the body, the dark-red color of the rash and its arrangement 
 in circular or crescent-shaped patches. Until the appearance of the 
 rash it is impossible to decide definitely upon the nature of the 
 complaint, and hence in those exceptional cases in which the rash 
 does not appear a definite diagnosis is almost impossible. 
 
 Treatment, — The directions already given for the treatment 
 of mild cases of scarlet fever apply equally well to .measles, except 
 that in the latter complaint there is rarely any necessity for local 
 treatment of the throat. S metimes it becomes necessary to make 
 cold applications to the eyes, or to administer a few drops of pare- 
 goric for the cough. The usual indications for treatment consist 
 in the complications already described. Only one requires especial 
 notice here — the tendency to consumption, which seems to be con- 
 ferred in some cases of this disease. This should be borne in mind 
 in the after-treatment of measles. 
 
 Boseola. 
 
 This affection, sometimes called false measles, is a rM'^ease of no 
 gravity, but possessing a certain importance, because it is necessary 
 to avoid confounding it with scarlet fever or measles. 
 
 In most cases a certain amount of constitutional disturbance — 
 headache, loss of appetite, sometimes nausea and vomiting, a slight 
 chill and some fever, precede for a day or two the eruption. This 
 appears finally as rose-colored spots, which are not raised into pim- 
 ples, but disappear temporarily upon pressure. It appears upon 
 the trunk more commonly than upon the face, and usually lasts not 
 
 4 
 
'C;« 
 
 50 
 
 CONSTITUTIONAL DISEASES. 
 
 ' i| 
 
 more than two days. It is readily distinguished from scarlet fever 
 and measles by the absence of the throat affection in the one case 
 and of the inflammation in the eyes and nose in the other case; 
 moreover, the rash is easily distinguishable from those of the two 
 diseases named; it requires no treatment. 
 
 Table exhibiting the differences between small-pox, scarlet 
 fever and measles. 
 
 Measles. 
 
 Scarlet Fever. 
 
 Small-pox. 
 
 The period which elapses be- The period between exposure The period between exposure to 
 
 tween exposure to contagion and to contagion and the beginning of contagion and the beginning of 
 
 the beginning of the disease is the disease is variable, often three the disease may vary from five to 
 
 oiually teven \o fourteen days. to six days, but may be several twenty days, and usually about 
 
 weeks. ten days. 
 
 Fever is moderate ; it does not Kever is intense ; continues The fever is usually high ; it 
 
 decrease, but often i«fr/a*« when without interruption after the erup- subdues when the rash appears, 
 
 the eruption appears. tion appears. 
 
 The eruption makes its appear- The rash makes its appearance The eruption makes its appear- 
 ance on the fourth day, first on on the secouii day, first on the ance on the third or fourth day, 
 the y<»r^ and neck; it spreads m-ck ami chest: .spreads over hQin^ fiT%\ seen around the mouth 
 gradually for two days over the the entire body rapidly in eight and on the forehead. 
 rest of the body. to ten hours. 
 
 The eruption appears as cres- 
 cent-shaped patches, the inter- 
 vening skin being healthy. 
 
 The rash lasts ^ve days, at the 
 end of which time the skin peels 
 off in very Jine scales. 
 
 The tongue is coated and red at 
 the edges. 
 
 Kunning of the eyes and nose 
 «0j bronchitis are usually pret- 
 
 Sort throat is very rare. 
 The mind is not affected. 
 
 There is no secondary fever ; 
 (hat is, after the first fever has 
 subsided, which happens during 
 'the second or third day after the 
 appearance of the rash, no 
 further fever occurs. 
 
 Measles is often followed by 
 chronic bronchitis, consumption 
 and inflammation of the eyes. 
 
 The rash is spread uniformly The rash consists at first of 
 
 over the skin, without intervening pimples which become a day 
 
 patches of healthy skin. later watery blisters. Finally 
 
 these blisters become white, and 
 
 The eruption lasts six or seven a""e dr.iwn in at the center— ««i- 
 
 days, when it begins to peal off bilicated. 
 in large Jlakes, 
 
 The tongue is heavily coated 
 and often swollen. 
 
 The tongue is covered with 
 numerous fine red points, which 
 give it the name "strawberry 
 tongue." 
 
 There is rarely any noticeable There is no running at the eyes 
 bronchitis or running of the eyes or nose, and not often bronchitis. 
 and nose. 
 
 Sore throat is always present. 
 
 The mind is usually affected ; 
 there may be delirium and con- 
 vulsions. 
 
 There is no secondary fever 
 
 Sore throat is often present, but 
 not so marked as in scarlet fever. 
 
 The mind is often affected ; de- 
 lirium and convulsions may occur. 
 
 Secondary fever always ap- 
 pears after the rash has been visi- 
 ble for several days. 
 
 Scarlet fever is often followed 
 
 by Bright s disease, dropsy, in- Small-pox is not usually fol— 
 
 flammation of the eyes, deafness, lowed by other diseases, though 
 
 and enlargement of the glands the pocks may result in serious 
 
 about the throat ; sometimes by damage to the eyesight, as well as 
 
 paralysis. cause unsightly scars on the skin. 
 
DIIMiTHKklA. 
 
 51 
 
 Diphtheria. 
 
 One of the most frequent and important affections, next to 
 the essential fevers, is diphtheria. This disease prevails often as 
 an epidemic, and in the intervals between these epidemics is always 
 more or less prevalent. Unlike many of the infectious diseases, it 
 seems to be independent of ordinary hygienic regulations — attacks 
 all classes of the community, and at all times of the year. It is 
 supposed that Washington and the Empress Josephine were among 
 its victims during epidemics. 
 
 While the disease thus may occur quite unexpectedly, yet it is 
 equally certain that a large number, if not the majority, of cases des- 
 ignated diphtheria by some physicians, as well as the non-profes- 
 sional, have no right whatsoever to that name. For diphtheria is a 
 general, a constitutional affection, usually manifesting itself, it is 
 true, by inflammation in the throat, among other symptoms, but by 
 no means comprised in a local inflammation, whether in the throat 
 or elsewhere. The numerous cases in which the throat is red and 
 sore, and perhaps a few whitish points are visible on the tonsils — 
 such cases are not necessarily diphtheria, and in fact have rarely any 
 of the characteristic signs of diphtheria. There may be, it is true, 
 mild cases of the disease, in which the constitutional symptoms are 
 not sufficiently severe to invalid the patient completely ; yet in most 
 instances, even when the local disturbances in the throat are not 
 severe, the patient is nevertheless unquestionably ill. 
 
 Symptoms, — The symptoms of diphtheria, while agreeing in 
 most essentials, present wide diversities in the degree of those feat- 
 ures. One of these differences occurs in the development of the 
 disease. Sometimes the onset is very rapid and acute ; the patient 
 suffers a severe chill, followed at once by a high fever. In other 
 cases, again, the commencement is gradual and insidious ; the pa- 
 tient complains for some days or a week of vague and indefinite 
 illness, perhaps even without alluding to any unusual soreness in the 
 throat. It may even happen that the discovery of the throat affec- 
 tion is made accidentally, especially in the case of children. The 
 consideration of the symptoms may be, for convenience, divided into 
 those which affect the system generally, and those which are asso 
 elated immediately with the inflammation in the throat. 
 
52 
 
 CONSTITLTIONAI. DISEASES. 
 
 The sensibility of the throat would seem to be somewhat dim- 
 inished in this disease, since there is rarely so much pain and sore- 
 ness as would seem inseparable from the extreme swelling and 
 inflammation that are seen actually to exist. A point which should 
 never be forgotten in hou.sehold practice is to inspect the throat 
 whenever an individual is suffering from any indefinite ailment; if 
 this were a more general practice, mothers would often be spared 
 the surprise and chagrin which occurs when, upon the first visit of 
 the physician, he discovers in the throat of the child, who may 
 have been ill several days, a thick, white coating of diphtheritic 
 membrane. The act of swallowing is sometimes accompanied with 
 considerable pain, but not necessarily so, even though the throat 
 be considerably inflamed. Another symptom which may be pres- 
 ent early in the disease is a paralysis of certain muscles concerned 
 in swallowing, so that this act is but imperfectly performed ; as a 
 result fluids return through the nostrils. In these cases there may 
 also be an acrid discharge from the nose, causing soreness of the 
 adjacent parts of the skin. Then, again, the simple mechanical 
 effect of the swelling in the throat may interfere seriously with 
 swallowing, and even breathing. 
 
 Although the local affection is usually manifested first, and 
 chiefly in the throat, yet it is not necessarily limited to this part of 
 the body, but may extend also into the larynx. Under these cir- 
 cumstances, the symptoms of true croup are added to those of 
 diphtheria. Weakness of the voice, a peculiar character of the 
 tone, difficult, labored and audible respiration, with the character- 
 istic " croupy " cough, mark the spread of the disease to the larynx. 
 This, however, is not an extremely common complication ; many 
 symptoms indicating difficult respiration may be caused by the 
 swelling in the throat, without any interference with the larynx. 
 For diphtheria proper is entirely distinct from croup in the location 
 of the throat inflammation, as well as in its essential nature. 
 
 As has been said, there are mild cases in which the patient is 
 scarcely compelled to take his bed ; yet the gravity of the case is 
 not always indicated by its severity at the outset. There is not 
 usually so high a grade of fever as characterizes scarlet fever ; at 
 times, indeed, the skin seems only naturally warm to the hand. 
 An occasional symptom is the rupture of small blood vessels, caus- 
 ing reddish spots on the skin ; a similar rupture in the vessels of 
 the nose accounts for the bleeding from the nostrils which is some- 
 
DIMITIIKKIA. 
 
 53 
 
 times observed. There is no skin eruption characteristic of diph- 
 theria, although various forms of rash not infrequently occur during 
 the course of the disease. 
 
 The digestion is quite deranged, even before the swelling of the 
 throat makes swallowing difficult. This derangement of digestion 
 is indicated, as in other constitutional diseases, by loss of appetite, 
 coating' of the tongue, often vomiting. This is a symptom of con- 
 siderable practical importance and gravity, for it interferes seriously 
 with the success of efforts for sustaining the patient's strength, and 
 in probably no other disease is his strength so soon exhausted as in 
 diphtheria. The mind is not usually affected unless the case termi- 
 nate fatally. In children, it is true, convulsions occur, as they may 
 from other causes, even when slight. Dropsy, so frequent in scar- 
 latina, is an unusual symptom of diphtheria. 
 
 The disease may last one to two weeks, before the patient 
 begins to convalesce. Fatal cases may, of course, terminate much 
 sooner. There is a malignant form of diphtheria which, like 
 malignant scarlet fever, may destroy the patient's life before the 
 characteristic symptoms of the disease are manifested. Yet diph- 
 theria is by no means over when the patient begins to convalesce, 
 since some of the numerous complications may seriously impair his 
 health for months subsequently. 
 
 Perhaps no other of the infectious diseases brings in its train 
 such a number and variety of complications as diphtheria. First 
 of all is the paralysis of the muscles concerned in swallowing and 
 in articulation. These muscles may not be affected until the severer 
 symptoms of the disease have subsided; and they may recover their 
 power within a few weeks; so long as the difficulty endures, there 
 uill be difficulty in swallowing; and fatal accidents have been known 
 to occur from this very cause — the food passing into the windpipe 
 and causing strangulation. Sometimes it is even necessary to feed 
 the patient through a stomach-tube. The paralysis may also affect 
 other muscles than those engaged in swallowing; the muscles of the 
 eye arc occasionally affected, the iris being paralyzed so as to keep 
 the pupils dilated. The result is that the patient is unable to read 
 ordinary print, becomes, in fact, far-sighted; then again the arms or 
 legs — often the latter — may exhibit partial or complete paralysis. 
 There may be impairment of sensation also, as well as of motion; 
 that is the power of feeling may be partly or completely lost. This 
 loss is usually limited to a portion of the face; or there may be loss 
 
^ '4 
 
 I 
 
 
 'I 
 1 
 
 !;- 
 1 1 
 
 54 
 
 coNsrnurioNAi. diseases. 
 
 ( f power to perceive light; there may be also a change in direction 
 of one or both eyes — the individual is, in other words, cross-eyed. 
 So, too, the muscles concerned in breathing may become paralyzed, 
 giving rise to difficulty in the performance of this act, and even 
 causing danger from the failure to breathe. There may be also 
 impairment of the muscles concerned in the evacuation of the 
 bowels and bladder; also impairment of sexual power and instinct. 
 The characteristic feature of diphtheria, by which alone we are 
 enabled to express a positive opinion as to its nature, is the pe- 
 culiarity of the local inflammation; this, it is true, is usually found in 
 the throat, but not necessarily so, since we recognize as diphtheria 
 cases in which the same local inflammation is found on other mucous 
 membranes, those of the intestine and of the female genital organs 
 especially. As seen in the throat, the first appearance is usually 
 redness accompanied by swelling of the tonsils; the surface of 
 these is soon covered with a thin grayish substance, which, in the 
 course of a day or two, is much increased in thickness and becomes 
 white or ash-colored. This substance — the diphtheritic membrane 
 — varies much in its extent and location. In bad cases it forms an 
 almost unbroken sheet over the tonsils and perhaps on the back of 
 the throat as well; but in most instances it appears merely in small 
 patches scattered over the tonsils and back part of the mouth and 
 pharynx. The gray membrane is surrounded by an intensely red 
 area. When these gray patches are detached there appears to be a 
 bright red surface with numerous bleeding points. Furthermore, 
 the detachment of one layer may be followed by the formation of a 
 second and even of a third membrane on the same spot. In this 
 characteristic — the bleeding surface upon gentle removal of the 
 membrane — is found one of the characteristics of the diphtheritic 
 as distinguished from other gray patches in the throat. It is no 
 uncommon thing to find, even in healthy throats, and especially in 
 those subject to a little catarrh, grayish white spots, particularly on 
 the surface of the tonsils. These should not be mistaken for diph- 
 theritic membrane; they are not surrounded by the intensely red 
 area, they do not cling to the surface with the same tenacity, nor 
 do they leave when detached a bleeding surface. These are the 
 cases which are so often miscalled diphtheri \. 
 
 The true diphtheria is usually accompanied by swelling of the 
 glands at the angle of the jaw; this swelling may subside with the 
 affection in the throat, or may result in the formation of abscesses. 
 
 1! 
 
DIPHTIII'KIA. 
 
 ss 
 
 CftHHi'. — Like the other infectious diseases, diphtheria is due to 
 a specific virus or poison; that it is eminently comnuinicabie, admits 
 of no doubt, though it stems, with our present knowledge, that it 
 may also originate without previous exposure of the individual to a 
 patient suffering from the disease. The malignant form of diphtheria 
 occurs especially as an epidemic. It is an interesting fact, that these 
 epi •'•s were unknown in America between 1771 and 1856, while 
 sin ..s latter date they have frequently visited all parts of our land. 
 Such an epidemic is often restricted to a particular section of country; 
 it may even prevail on one bank of a stream, while the other side 
 escapes unvisited. The greatest susceptibility to the disease appears 
 to be childhood, between three and twelve years especially ; yet 
 people of all ages are susceptible to a greater or less extent. 
 
 The chances for recovery from diphtheria vary extremely with 
 many circumstances. The scattered, so-called sporadic, cases are 
 attended with far less mortality than the average epidemic. One of 
 the dangers is from an extension of the inflammation to the larynx; 
 such cases usually terminate fatally. A second peril is from exhaus- 
 tion ; in some instances, as has been already narrated, death occars 
 witl' 1 day or two, before the local effects of the disease have been 
 m; ed in the throat. Such cases evidently die overwhelmed 
 
 witn ....e violence of the poison; and many other instances occur in 
 which the patient, though resisting for days the onset of the disease, 
 finally succumbs before the condition of his throat is such as to im- 
 peril life. A third danger is one which cannot be foreseen, and 
 scarcely explained, that is sudden fainting, from which the patient 
 cannot be aroused ; this has repeatedly occurred in individuals who 
 were apparently convalescent, but who, upon some unusual effort, 
 even getting out of bed, have swooned and died. In view of this 
 fact, it is important to use especial care during the convalescence 
 from diphtheria, particularly in those who have suffered from severe 
 attacks. If death occurs from simple exhaustion, it is apt to happen 
 during the second week of the disease. 
 
 Treatment. — The treatment of diphtheria resolves itself into 
 two chief aims: general treatment, that is the support of the 
 patient's strength; and local measures, to subdue and restrain the 
 inflammation in the throat. For this latter purpose, measures vary 
 according to the severity of the inflammation and to the effect upon 
 the throat. It will rarely be advisable to use strong caustics; in 
 
M I 
 
 ii3 
 
 I 
 
 56 
 
 CONSTITUTIONAL DISEASES. 
 
 most cases a gargle of some antiseptic properties will besc answer 
 the purpose. One of the best of them is the following : 
 
 Hyposulphite of soda, - - Three ounces. 
 
 Glycerine, . _ . _ Two ounces. 
 
 Water, ----- Six ounces. 
 
 Half an ounce of this solution may be placed in a glass of water 
 and used as a gargle at short intervals. If the patient be a child 
 too young to gargle, this solution may be applied directly to the 
 throat by means of a camel's hair brush. Much comfort and benefit 
 will also be derived from permitting the patient to hold pieces of 
 ice in the mouth until dissolved. Instead of the above solution, 
 the familiar mixture of muriatic acid and honey in equal parts; 
 lime water; carbolic acid (one part to twenty of water), may all 
 be employed. If there be much difficulty in breathing, relief will 
 be obtained by saturating the atmosphere of the room with steam; 
 or a tent may be made out of a sheet and placed around the bed; 
 a kettle of boiling water may be made to discharge its steam into 
 this tent, and thus accomplish the desired object. Cloths wrung 
 out in hot water may also be applied to the neck. 
 
 Yet the greater reliance must be placed upon the constitutional 
 treatment, for which alcohol in some form is absolutely indispens- 
 able. There is but little danger of intoxicating the patient. Half 
 an ounce of brandy may be given every hour to a patient twelve or 
 thirteen years old, with the best results, if the case be one of 
 extreme exhaustion. Another important agent is quinine, a grain 
 of which may be administered in the whisky or brandy every hour 
 r>r two during the day. If the patient be very young, say three 
 or four years old, half a teaspoonful of brandy and a quarter of a 
 grain of quinine would be a sufficient dose. Sometimes consider- 
 able difficulty is experienced in persuading the patient to take 
 nourishment. The danger from this must be recognized and neces- 
 sary measures employed to meet the requirements of the case. 
 
 In cases where the larynx is obstructed by the formation of 
 false membrane, the outlook is extremely serious; yet, even in 
 these, it is sometimes possible to save the life apparently lost, by 
 making an opening into the windpipe — an operation technically 
 called tracheotomy — whereby the imminent danger, suflfocation, is 
 averted. This fact is mentioned here, not because the operation 
 should ever be undertaken by other than a skillful surgeon, but 
 simply to emphasize the value of tracheotomy in proper cases. There 
 
 t^TM 
 
tVphoid fever. 
 
 57 
 
 esc answer 
 
 are, it is true, instances in which the patient must eventually die of 
 exhaustion, and the result could not be averted by the simple ad- 
 mission of air to the lungs. Yet it is equally true that there are 
 many iii:3tances where death occurs from suffocation, and in which 
 a timely performance of tracheotomy would undoubtedly have 
 saved life, as it has done in numerous other instances. The diffi- 
 culty lies in the fact that parents obstinately refuse to listen to any 
 suggestion for the use of the knife until it becomes evident that the 
 child must die, and then the operation is, of course, too late; and 
 there is no doubt that the responsibility for many a child's death 
 rests upon the unreasoning dread and prejudice of the parent against 
 an operation. 
 
 Typhoid Fever. 
 
 The onset of typhoid fever, unlike that of the eruptive fevers 
 and of most infectious diseases, is gradual and insidious. In a large 
 number of cases, patients are unable to fix definitely the date at 
 which their ailment commenced, since the beginning of the disease 
 is so imperceptible. It is, therefore, impossible to say just how 
 long the stage of incubation endures, though the average seems to 
 be from three to ten days. 
 
 During this premonitory stage the patient, while usually able 
 to continue his avocation, is nevertheless not in his usual state of 
 health. He experienceschilly sensations, shivering, perhapseven pro- 
 nouncedchillsoccurringatirregularintervals, perhaps often repeated 
 At the same time he suffers from headache, usually in the forehead, 
 his mental faculties seem enfeebled, he is unable to concentrate his 
 attention with the usual vigor, and feels generally prostrated and 
 languid. Impairment of appetite, nausea, and even vomiting are 
 not unusual symptoms. There is usually a tendency to diarrhea, 
 which is aggravated if the patient incautiously takes a laxative. A 
 frequent symptom is bleeding at the nose without apparent cause. 
 After these symptoms have endured perhaps a week, the individual 
 is compelled to give up his occupation and take to his bed. 
 
 The recognition of typhoid fever depends not so much upon 
 any one special symptom as upon the grouping of numerous 
 features after a certain arrangement. It is therefore desirable, in 
 
58 
 
 CONSTITUTIONAL DISEASES. 
 
 :l 
 
 >•; 
 
 discussing the symptoms of the disease, to refer in detai! to the 
 changes presented by different parts of the system. 
 
 Symptoms. — During the first few days there is no especial 
 change in the countenance, unless it be a persistent, dull red flush- 
 ing of face. As the disease progresses, usually by the time the 
 patient take to his bed, there is an unusual lack of expression, a 
 degree of h^tlessness and even of stupidity, which attracts atten- 
 tion. There are cases, indeed, in which the severity of the attack 
 seems to be expended upon the nervous system, so that one is 
 inclined to overlook the other symptoms in the evidence of mental 
 derangement. In such cases the patient, even before taking to his 
 bed, may seem half deranged, taking no notice of questions until 
 repeatedly addressed to him, and then muttering incoherent replies. 
 The skin is usually somewhat reddened, especially on the face; and 
 this redness, while disappearing upon pressure of the finger, returns 
 in a sluggish way never observed -luring health. This same appear- 
 ance of the skin may be found, also, upon the abdomen and upon 
 the arms, indicating a feebleness of the circulation. 
 
 During the first week in bed the patient, if not too stupid and 
 listless, complains of a dull, aching pain in the head. His com- 
 plaints become less frequent toward the beginning of the second 
 week, probably not because the pain is less severe, but because the 
 patient's ability to perceive pain is less acute. For about the begin- 
 ning of the second week the symptoms of mental derangement 
 usually become prominent ; in the majority of cases delirium occurs 
 — not the violent, active delirium which we are accustomed to asso- 
 ciate with that name, but a low, muttering delirium quite in accord 
 with the physical debility of the patient. The first evidence of this 
 is often given by the patient upon awakening from sleep ; he is evi- 
 dently confused, cannot recall where he is, and answers questions 
 incoherently. At a later period he talks constantly in a low, feeble 
 tone, usually repeating frequently that he wants to go home, and 
 often accompanying this wish by feeble efforts to get out of bed. 
 No mental restraint is possible, since so soon as one effort to rise 
 has been defeated the patient makes another attempt. If not care- 
 fully watched, the individual will leave his bed, if physically able to 
 do so, walk out of the house, usually in his night clothes, and may 
 even wander a considerable distance away until he falls exhausted. 
 There is no apparent coherence of ideas ; the patient's thoughts 
 
TYPHOID FEVEK. 
 
 59 
 
 seem merely a succession of dreams which have no relation to his 
 actual condition. There are exceptions to this type of delirium, in 
 which the patient is active and boisterous, shouts, makes forcible 
 efforts to rise, and may even display a belligerent spirit for his 
 attendants, requiring forcible restraint. Then again his delirium, 
 instead of being a mere succession of disjointed ideas, may take the 
 shape of a fixed delusion, the patient imagining himself extremely 
 rich or powerful. It is usually the case that, while the patient talks 
 somewhat coherently, he has no idea of the meaning of his words, 
 on which account no reliance can be placed upon his answers. This 
 fact should be borne in mind, in endeavoring to elicit information 
 from the patient as to his own feelings of pain, etc. In exceptional 
 cases there may be no evidence of delirium throughout the entire 
 illness, though the patient even then rarely has, after convalescence, 
 any distinct recollection of what occurred during his sickness. 
 
 Associated with the delirium is an utter indifiference to every- 
 thing in the shape of physical comfort and welfare. The patient 
 asks for nothing to eat or drink, though the mouth may be dry and 
 parched and the unfortunate person be constantly endeavoring to 
 moisten his Hps with his tongue; flies are allowed to creep over his 
 face without any indication of annoyance on his part; he will lie 
 listlessly in one position in the bed until the skin becomes sore. In 
 grave cases it often happens that the patient will evacuate the bowels 
 and bladder in the bed, apparently from simple indifference. Sight 
 and hearing are usually impaired; at any rate, light and noise of 
 unusual intensity are required to attract even the slightest attention. 
 One of the features of this disease, which must never be forgotten in 
 its treatment, is the patient's inability to sleep. During the first few 
 days, before his mind becomes benumbed, he usually complains of 
 this exhausting lack of sleep; but later he is as indifferent to this as 
 to everything else, and lies in a condition which may seem to the 
 bystander sleep, but which is practically a condition of wakefulness. 
 He is easily aroused, but lapses at once into this semi-unconscious 
 state. Doubtless this lack of sleep contributed largely to the 
 exhaustion which constitutes one of the greatest dangers. One 
 of the features of this condition is a twitching of the tendons or 
 "sinews," in the wrist especially, though there may be a similar 
 appearance in the muscles of the face and limbs. In grave cases 
 there may be general convulsions, which usually shortly precede 
 death. 
 
6o 
 
 CONSTITUTIONAL DISEASES. 
 
 There is usually no appetite; indeed, the patient can sometimes 
 be fed only by force; yet in exceptional cases food is readily taken 
 throughout the entire illness. Thirst seems always prominent as a 
 symptom ; even when the patient's mind is so blunted that he does 
 not ask for a drink, he may take it with avidity when administered. 
 
 The teeth become covered during the second week with dark 
 brown or black matter, called sordes ; this is especially abundant in 
 unusually severe cases ; the gums may be swollen, and bleed readily 
 upon pressure ; the tongue presents characteristic appearances. At 
 the beginning, that is, before the patient assumed the recumbent 
 posture, the tongue is heavily coated white, ellow or brown, and 
 indicates an unusual lack of moisture. During the first week of 
 the disease proper, the surface of the tongue usually becomes brown, 
 hard, dry and glazed; it seems divided into small sections, like 
 mosaic work, and may be deeply cracked. When asked to pro- 
 trude the tongue, even in the early stage of the affection, the patient 
 complies with apparent difficulty, the tongue refuses prompt obedi- 
 ence, and when finally protruded is very tremulous. Having put 
 out his tongue, the patient sometimes forgets to withdraw it until 
 reminded of it — another indication of the tardy and uncertain 
 character of his mental acts. 
 
 Another usual symptom is diarrhea ; the stools are usually 
 very thin, watery and of a yellow color, though these characters are 
 not invariable or necessary. The abdomen usually becomes some- 
 what distended with gas, and a gurgling sensation may be felt by 
 pressure with the hand just above the right groin. In the earlier 
 weeks of the disease, pressure upon this spot often causes the patient 
 to wince ; indeed, there may be tenderness over a considerable part 
 of the abdomen. This is to be explained by the fact that typhoid 
 fever usually causes ulceration in the intestine just at that point 
 which lies in the right groin. This ulceration explains several of 
 the unfortunately frequent and dangerous incidents of the disease. 
 The first of these is hemorrhage from the bowels. This may occur 
 at any time in the latter part of the disease, and even during con- 
 valescence. Without any warning or premonitory pain the patient 
 passes a large quantity of blood from the bowels, the hemorrhage 
 sometimes continuing until the individual faints. Notwithstanding 
 the alarming appearance from this accident, the result is not 
 necessarily fatal. Another and almost invariably fatal result of this 
 ulceration in the bowels, vi perfc-ation of the intestine ; that is, the 
 
 ii Ml 
 
TYPHOID FEVER. 
 
 6l 
 
 ulceration extends through the wall of the intestine, permitting the 
 contents to escape into the abdominal cavity. The result is a fatal 
 inflammation of this cavity, termed peritonitis. This accident, too, 
 may occur without especial cause or warning, at any time during 
 or after the third week ; it sometimes happens while the patient 'S "^ 
 convalescent. 
 
 During many cases of typhoid fever an eruption is observed on 
 the .skin of the abdomen and chest, sometimes also on the back ; 
 this rash consists of a few scattered red pimples, an eighth of an , 
 inch or less in diameter. This eruption, if it appear at all, becomes 
 visible during the second week. In this, as in other severe affec- 
 tions, there are often observed minute watery blisters scattered over 
 the neck and chest particularly. The p-^tient not infrequently has 
 a short dry cough, and may even raise a iittle mucus. An occa- 
 sional complication usually involving a fatal result is an inflamma- 
 tion of the lungs, pneumonia. 
 
 Cause, — Typhoid fever is another of the infectious diseases 
 which is to be ascribed to a specific virus or poison. Yet the 
 present state of our knowledge would indicate that the disease is 
 not directly communicated by contact of the sick with the well / 
 individual. The disease seems capable of manifesting itself with- 
 out previous exposure to this disease ; yet it is unquestionable that 
 the excretions — the stools — of a typhoid fever patient may be the 
 means of disseminating the disease among healthy people. The , 
 contagion is conveyed in the water of well? and cisterns, as has ( 
 been amply demonstrated by observations upon the German and 
 Austrian soldiery, as well as by cases in civil life. City physicians 
 are well aware that typhoid fever is specially apt to occur in those 
 dwellings in which, however elegant the general appointments, the 
 sewerage is defective, as indicated by the odor from the traps. 
 
 Typhoid fever, while occurring during all seasons of the year, is 
 especially frequent in the fall, at which time it may amount almost 
 to an epidemic. The average mortality varies extremely, being 
 of course greater during epidemics; at these times there may be 
 one fat.il result in three or four. At other times, however, the 
 avcra<^fc mortality is rarely more than one in six or seven. 
 
 Ti'cntment, — ^The object here, as in other infectious diseases, 
 is simply to assist the patient to bear the ravages of the disease; 
 hence the chief measures will consist in such food, medicine and 
 
62 
 
 CONSTITUTIONAL DISEASES. 
 
 1 4 ■' 
 
 I 
 
 I'M 
 
 im 
 
 1 
 
 m 
 
 m 
 
 ;ii 
 
 I 
 
 M 
 
 i 
 
 I 
 
 A 
 
 hygienic arrangements as will conduce to the preservation of the 
 patient's energies. It is impossible to cut short the disease. 
 
 Nowhere in medicine is there more imperative demand for 
 £^0od nursing. This constitutes indeed the most important part of 
 the treatment of typhoid fever. It is not necessary to repeat in 
 detail directions which have been already several times given as to the 
 managementof other fevers; it is sufficient to say, in brief, that fresh 
 air, frequent lukewarm baths, or the use of the wet pack every day, 
 when the fever is high, an abundance of nourishing food — liquid 
 food — with a liberal allowance of alcoholic stimulants. In the early 
 weeks of the disease the headache may be so severe as to require 
 treatment. This may be relieved by the application of ice water, 
 alcohol and water, or cologne water to the head, or by the use of 
 the ice cap. It will gencr.ilybe found advisable to shave the head 
 so soon as the disease is definitely recognized as typhoid fever. In 
 order to break up the distressing inability to sleep, it will be desir- 
 able to give an opiate, say 20 drops of laudanum. The diarrhea 
 requires no checking unless the stools are extremely thin and 
 watery, and are passed more than four times a day. In this case 
 we may administer ten drops of laudanum every four hours for one 
 day. It is not advisable for the non-professional to attempt to 
 control the bowels, since the source of great danger lies in the in- 
 testines, and the peril may be aggravated rather than diminished 
 by the remedies used. Instead of laudanum, ten drops of the oil of 
 turpentine maybe administered in a teaspconful of simple mucilage 
 four times a day. The energy of the household can be better 
 directed to the preparation of the diet. One thing should never be 
 forgotten, that no solid food should be given to a typhoid fever 
 patient until his convalescence is complete ; for the passage of 
 undigested particles along the intestine may not only aggravate 
 the ulceration, but also provoke hemorrhage or perforation of the 
 intestine — those especially dreaded accidents. As early as the 
 second week it will be necessary, in the greater number of cases, to 
 administer wine or whisky, which may be best given in the shape 
 of milk punch. If the pain and distension of the abdomen arc 
 considerable, benefit maybe derived from the use of flannels wrung 
 out in hot water and sprinkled with turpentine over the abdomen. 
 So long as the patient's mental condition permits, pieces of ice may 
 be held in the rnouth, and after that cold drinks may be administered. 
 Care should be taken to keep the mouth and teeth free from sordes. 
 
TYPHUS FEVER. 
 
 63 
 
 During the 'nvalesence from typhoid fever, especial care must 
 be taken to avoid violent efifort, since such effort favors perforation 
 of the intestine and hemorrhage — accidents which have been known 
 to happen weeks after the symptoms of the fever had subsided. ' 
 The patient should be taken into the open air early and often, but 
 not permitted to walk or strain in any way until he has recovered a 
 fair degree of strength. 
 
 
 lapc 
 arc 
 
 may 
 
 MTd. 
 
 •des. 
 
 Typhus Pever. 
 
 This disease presents an extreme similarity to the one just de- 
 scribed — typhoid — as is indicated by the respective names. Indeed, 
 it was for a long time uncertain whether they were really two sepa- 
 rate and distinct diseases, or were merely two manifestations of the 
 same disease. The question, however, has long since been decided, 
 not only by a closer study of the appearance of the disease, but 
 also by the evidence that they occur under different circumstances 
 and from different causes. Typhoid fever occurs, as has been stated, 
 not only as epidemics, but also in sporadic or scattered cases, which 
 may occur in any class of society, and among individuals whose 
 hygienic surroundings are good. Typhus fever, on the other hand, 
 is almost always traceable to the accumulation of the effluvia from 
 human bodies, especially w"hen closely crowded. It occurs in the 
 crowded and filthy quarters of towns, in ill-kept jails, on board 
 ships, and in military camps. It is especially frequent in the winter, 
 because during this season people are more closely crowded in these 
 locations, and spend a greater number of hours per day in the close 
 and foul air of their dwellings. So common, indeed almost ex- 
 clusive, is the origin of this disease in crowded quarters, that it is 
 variously termed ship fever, jail fever, and camp fever. In our 
 country it is usually confined to the large cities on the sea coast, to 
 which it is brought by ships, especially by the emigrant vessels 
 arriving from Ireland. This is well illustrated in an epidemic which 
 occurred in the years 1861-5, •" New York city. A committee of 
 the Medical Board of Bellcvue Hospital, appointed to investigate 
 the origin of the disease, ascertained that the first case observed 
 was that of a child who had come from Ireland to this country two 
 weeks before the development of the disease. From this child the 
 fever attacked other individuals in the same tenement house and in 
 an adjoining building, so that sixteen cases of the disease occurred 
 
9R1 
 
 '', 
 
 64 
 
 tONST.TUTIONAL DISEASES. 
 
 in the two houses within three months. During the two succeeding 
 years the cases of typhus fever which were received into Bellevue 
 Hospital came almost entirely from these houses and their immediate 
 vicinity. 
 
 Unlike typhoid fever, the disease under discussion is eminently 
 contagious. While typhoid fever seems to be communicated through 
 the discharges of the patient, and by the use of infected drinking 
 water, it is by no . means established that it is ever acquired by 
 simple contact with a sufferer from the disease ; typhus fever, on 
 the other hand, is readily communicated by simple presence in the 
 patient's room. This was well illustrated in Bellevue Hospital, 
 during the epidemic to which reference has already been made. At 
 this time there were in the hospital twenty-two resident medical 
 officers, of whom fifteen were attacked by typhus fever ; ten of these 
 fifteen acquired the disease while performing medical duty in the 
 fever wards, two others while taking care of an associate who had 
 contracted the disease. Quite a number of the hospital attendants, 
 and of patients admitted to the hospital for other complaints, also 
 contracted the disease. Yet immediate contact with a patient seems 
 to be necessary, and even then the danger of contagion is much dim- 
 inished if the room be well-aired and ventilated. 
 
 Symptoms* — The stage of incubation seems to be somewhat 
 shorter than that of typhoid fever, and the patients are usually com- 
 pelled to take to bed within two or three days after the manifesta- 
 tion of the first symptoms. During this time the appearance and 
 history of the case are essentially the same as in typhoid fever, with 
 the exception of one feature : the signs of intestinal difficulty — 
 diarrhea, pain, tenderness, and swelling of the abdomen — are 
 usually absent. The countenance usually exhibits the same features 
 as in typhoid, except that mental activity is arrested earlier in the 
 disease, and hence the dull, listless expression is earlier exhibited. 
 The delirium and prostration are manifested earlier, as a rule, than 
 in typhoid fever. The tongue presents less frequently the brown, 
 glazed, fissure appearance characteristic of typhoid, but is more 
 commonly covered vith a thick black coating. The symptoms 
 indicating inflammation of the bowels, characteristic of typhoid 
 fever, are usually absent in typhus ; hemorrhage from the bowels 
 and perforation of the intestines are accordingly rare events. 
 
RELAPSING FEVER. 
 
 6$ 
 
 The skin, too, usually presents a marked difiterence between the 
 two diseases. An eruption very similar indeed to that of typhoid, 
 but more profuse and generally distributed, is, in the great majority 
 of cases, present at some period in every case of typhus fever. The 
 spots, too, are not raised as in typhoid fever, but are simple dis- 
 colorations of the skin which cannot be distinguished by the finger 
 from the surrounding skin ; they are smaller than the papules of 
 typhoid, do not come and go as in the case of the latter, and 
 sometimes terminate in small hemorrhages. 
 
 Typhus fever is usually of shorter duration than typhoid, the 
 average period being fourteen to sixteen days. It attacks adults 
 more frequently than children, though the latter are by no means 
 exempt. 
 
 Treatment, — The general principles recommended for the 
 treatment of typhoid fever are applicable also to this allied affection, 
 yet one feature, important as it is in the treatment of typhoid, is 
 absolutely essential in all cases of typhus fever, and that is fresh air. 
 The accumulated experi' nee in hospitals, camps and jails shows 
 that the mortality is immensely reduced by treating these cases in 
 open air, tents, or sheds, the other essential remaining essentially 
 the same. During the New York epidemic, already referred to, the 
 average mortality in the hospital wards was one case in six, while 
 in the tents on Blackwell's Island it was but one case in seventeen. 
 
 Relapsing Fever. 
 
 This disease occurs comparatively rarely in this country, but is a 
 familiar visitor in Europe and in Asia. The cases that are seen in the 
 United States are generally importations from abroad. Like typhus 
 fever, it occurs especially in overcrowded districts and houses, and 
 is a so frequent accompaniment of famine in Ireland that it has 
 been called " famine fever. " 
 
 The onset of the disease is usually abrupt ; there appears to be 
 no stage of incubation. The patient, previously in good health, 
 suddenly experiences a chill, followed at once by intense fever. 
 Nausea and vomiting are frequently present, and the patient is occa- 
 sionally jaundiced. The extreme prostration and the abdominal 
 
 s 
 
66 
 
 CONSTITUTIONAL DISEASES. 
 
 symptoms characteristic of typhoid and typhus fever are absent ; so, 
 too, the mental disturbances usual in these other diseases are not 
 observed. 
 
 The most marked feature of this disease is the one indicated 
 by its name — the relapses. The fever lasts at first from five to 
 seven days, at the end of which time the patient apparently 
 recovers, and may even resume his avocation. At the end of 
 another seven days, however, a second attack follows, identical in 
 all essentials with the first; sometimes after another interval of free- 
 dom from fever, a third attack similar to the preceding occurs. 
 The features of the disease may vary somewhat; the duration of the 
 febrile stage may vary from three to ten days, and the intermission 
 between the febrile attacks may likewise vary. It may also happen 
 that the interval between the attacks is not a perfect cessation of 
 the fever, but merely a fever of diminished intensity. 
 
 Cause, — In every case of this disease which has been carefully 
 investigated, whether in Europe or in India, there has been found a 
 microscopic organism of spiral form, and exhibiting active move- 
 ment. These organisms — technically called ^at^^r^'a, a species of 
 vegetable — are found in immense numbers in the blood of these 
 patients during the febrile attack. It is all but established that the 
 disease is due to the presence of these organisms in the patient's 
 blood. 
 
 The Malarial Fevers. 
 
 The so-called malarial fevers are all distinguished by a certain 
 variation in the degree of the fever at dif/erent periods of its con- 
 tinuance. They all occur in certain well-defined, often extensive, 
 regions of country, and are most abundant during certain seasons of 
 the year. 
 
 Intermittent Fever. 
 
 Intermittent fever is marked by the occurrence of febrile 
 attacks at regular intervals, and by the freedom from fever between 
 the attacks; hence the distinguishing name, "intermittent." This 
 
INTERMITTENT FEVER. 
 
 67 
 
 disease receives various popular names in different sections of the 
 country, among them "fever and ague," "chills and fever," 
 "swamp fever," "shakes," "Panama fever," etc., though in 
 different sections of the country the intensity and persistency of the 
 fever vary, yet its essential features remain unchanged in all. 
 
 Symptoms, — The attack is usually sudden, a chill occurring 
 in an individual who had previously exhibited no sign of ill health. 
 In other cases there are certain premonitory symptoms for several 
 days or a week previous to the chill. These previous symptoms are 
 not especially characteristic nor indicative of any particular disease; 
 they consist chiefly of languor, indisposition for effort, loss of appe- 
 tite, pains in the head and limbs; perhaps this latter is the most 
 frequent and characteristic spmptom, the patient sometimes com- 
 plaining that " the marrow of the bones aches. " 
 
 The febrile attack may be for convenience divided into three 
 stages — the cold, the hot, and the sweating stage. 
 
 Cold Stage, — The first pronounced manifestation of the dis- 
 ease consists in a sense of chilliness, often beginning in the small of 
 the back and thence extending throughout the body. Sometimes 
 there is nothing more than this simple sensation of coldness; but in 
 the majority of instances there is a decided chill, accompanied by 
 violent muscular tremors, causing the patient's teeth to chatter, his 
 entire body to tremble, and often making the bedstead rattle. 
 During this chill there may be a bristling of the hairs on the skin, 
 the appearance familiarly known as " goose skin." During this 
 stage the appearance of the patient would indicate that his body 
 was extremely cold; and that the patient has this impression is 
 shown by the eagerness with which he envelopes himself in blankets 
 and hugs the fire. Yet the fact is that during the chill the heat of 
 the body is very materially increased, as is shown by placing the 
 thermometer under the tongue or in the arm-pit; yet at the same 
 time the extremities may actually show a lower temperature than 
 that of health. During this time the patient is extremely wretched, 
 the countenance pale and anxious, the general surface of the body 
 pallid or livid; the patient sighs and groans, and often shows an 
 unusual degree of irritability. 
 
 The cold stage may last from a few moments to several hours, 
 averaging perhaps half an hour; occasionally the shiverings and 
 sensations of coldness are so slight as scarcely to attract attention. 
 
68 
 
 CONSTITUTIONAL DISEASES. 
 
 '> ij 
 
 ■rJ 
 
 In these instances some other unusual condition may take the place 
 of the ordinary health; thus the patient may be extremely nervous 
 and peevish, or very drowsy and stupid. In children the cold stage 
 may be accompanied by convulsions. 
 
 Hot Stage. — After the chilly sensations have ceased there 
 occurs a transition to the opposite condition, sometimes abrupt, 
 but commonly gradual. The chilly sensation is alternated with 
 flushings of heat, until finally a decided fever is developed. The 
 skin becomes extremely hot, the face flushed and the headache is 
 intense. Thirst is usually a marked symptom. This stage may 
 last from one to ten or twelve hours. 
 
 Sooner or later the fever ceases and the patient becomes bathed 
 in profuse perspiration; the annoying symptoms, headache, thirst, 
 etc., disappear; the body heat actually returns to the natural stand- 
 ard as shown by the thermometer. The patient usually falls into 
 a refreshing slumber, from which he awakens without any symptoms 
 of the disease, but still exhausted by its efiects. For a period which 
 varies with different types of the disease the individual now remains 
 free from the active symptoms, though still conscious that he is not 
 enjoying his usual health and strength. This consciousness is real- 
 ized in a few days by a return of the original symptoms. Various 
 types of the disease are recognized according to the number of days 
 which intervene between the ferbile attacks. There are accordingly 
 three usual types of intermittent fever. In the one the fever called 
 the " paroxysm," occurs daily, and the type is accordingly called 
 quotidian; in the second type the paroxysm occurs every other 
 day — the tertian type; in the third variety the chill and fever recur 
 on the third day subsequent to the first attack — the so-called quartam 
 type. These different varieties differ one from another chiefly in the 
 intervals, and not in the features of the paroxysm itself. The ma- 
 jority of cases are of the quotidian type, the paroxysm occurring 
 everyday. Next in frequency comes the tertian variety. The other 
 types are far less common, though instances are known in which the 
 paroxysm recurs on the fifth, sixth, seventh and eighth day. Then 
 again, there are cases in which one of the ordinary types is dupli- 
 cated, two sets of paroxysms being manifested by the same patient. 
 The commonest of these is called the double quotidian, in which 
 two chills occur each day. Another variety is the double tertian, 
 in which the paroxysm occurs every day, but the attacks on sue- 
 
INTERMITTENT FEVER. 
 
 cessive clays occur at different hours, and may differ in other ways, 
 while those on alternate days correspond in all respects, the hour 
 included. So there may be numerous other combinations in which 
 the chills occur after other types than those mentioned. 
 
 The onset of the attack may happen at any hour of the day 
 or ni"ht, though rarely beginning at night. In the majority of 
 cases the paroxysms begins in the morning, and are usually repeated 
 after the regular interval at almost precisely the same hour of the 
 dav. In other cases the paroxysm occurs later on succeeding days, 
 thi' interval elapsing remaining the same, but the date of commence- 
 ment being gradually retarded, the chill occurring half an hour or an 
 hour later on succeeding days. So, too, the paroxysms may occur 
 earlier on successive days, anticipating half an hour or an hour. If 
 this departure from the ordinary type occurs after the disease has 
 existed for some time, it is generally an indication that the end of 
 the disease is approaching. " , 
 
 The duration of intermittent fever is not a definite time, as is 
 the case with the eruptive fevers, but maybe indefinitely extended. 
 It does, sometimes, cease spontaneously, but, on the other hand, 
 may be continued for weeks and months. So, too, a single attack 
 docs not secure immunity against subsequent relapses — another 
 point of diiTerence and distinction from the eruptive fevers. Indeed 
 it seems that one attack of intermittent fever predisposes to subse- 
 quent ones, and that an individual who has once suffered from 
 the disease, may have a relapse months or years after removing 
 from the malarial district. For some time after the striking symp- 
 toms of the disease have ceased, the thermometer will show a certain 
 increase in the body heat at the time when the paroxysm would 
 otherwise have been expected. During the intermissions between 
 the attack the conditions of different patients vary extremely ; some 
 individuals seem comparatively well, appetite and digestion are 
 go"(l. ' ' in >)thers, during the entire intermission, the patient 
 uplains of debility and prostration. 
 
 Many \ riations from these, the classical types of intermittent 
 fever, may cur. First among these may be mentioned the so- 
 cal' d "dumb ague" — attacks in which the chill is absent or 
 ol lire, while the other symptoms are apparent. Sometimes only 
 a chill or a fever, or a nrofuse perspiration, constitutes the entire 
 attack, the other features being lacking ; yet this solitary symptom 
 — chill or fever or sweat — recurs daily, or every other day, at the 
 
70 
 
 CONSTITUTIONAL DISEASES. 
 
 I 
 
 S 
 
 same hour, indicating the malaiial origin of the disease. These 
 cases may present the usual symptoms, aside from the paroxysm 
 itself, — that is, the prostration and debility may be well marked. 
 Another variety of malarial poisoning consists in the regular recur- 
 rence of pain in some part of the body. Perhaps the commonest 
 form is what is popularly known as " brow ague," in which the pain 
 is located in the forehead. In other instances neuralgia occurs in 
 the face or the arm, or in the chest. The regular return of such a 
 pain should lead one to suspect that the difficulty is of malarial 
 origin, and should be treated accordingly. Still, again, there may 
 be other local affections, such as dysentery and cough, which recur 
 at the same intervals as an ordinary malarial paroxysm, and yield 
 readily to the 3anie treatment — quinine — while resisting measures 
 usually adapted for the relief of these complaints. 
 
 The complication which is met with especial frequency in indi- 
 viduals who have long been subject to malarial difficulties, particu- 
 larly those who have long resided in malarial aistri'^ts, is what is 
 popularly known as " ague cake. " This consists in an enlargement 
 and hardening of the spleen, in consequence of which this organ 
 can readily be felt under the ribs at tl e left side of the abdomen, 
 and may, indeed, be so increased in size as i - occupy a considerable 
 portion of the abdominal cavity. This affection rarely occurs, 
 except as has been already stated, in the obstinate chronic cases of 
 individuals who have been long subject to malarial influence, and 
 have employed only unsatisfactory methods of treatment. Yet 
 there are many of these long- continued cases in which no pro- 
 nounced "ague cake" occurs; yet a slight enlargement of the 
 spleen, perceptible only upon close examination, may occur in any 
 case of the disease. 
 
 One of the noticeable features of malarial influence, rarely 
 absent in cases which have been protracted a considerable time, is 
 marke'J aucemia — that is, a deficiency of the red globules of the 
 blood in consequence of which the skin loses its natural reddish 
 tint, and acquires a pallid, even ghastly, appearance. This pallor 
 usually exhibits a certain tinge of yellow, so that the skin may be, 
 in many cases, aptly called straw-color. This pallor may persist 
 long after the paroxysms themselves have ceased ; such individuals 
 frequently suffer, also, from dropsy, as the result of the depraved 
 condition of the blood. 
 
INTERMITTENT FEVER. 
 
 71 
 
 Cause, — The malarial fevers, and ail the other manifestations 
 of malarial influence, are due to a specific virus — a miasm, which is 
 presumably like the virus of other infectious diseases, a vegetable 
 organ'>"n. This miasm is generated particularly in marshy locali- 
 ties, though it is not confined to such districts. It is developed 
 only in warm climates, never at a temperature lower than sixty 
 degrees Fahrenheit. The activity of the virus is arrested if the 
 temperature sinks to the freezing point. It is most frequently 
 found and in the most virulent form, in the neighborhood of dense 
 foliage, districts which have long been known as malarial have lost 
 the power to produce this miasm after the forests have been cut 
 down. This malarial influence can be transported by winds to a 
 considerable distance <"rom its source, and may hence appear in 
 regions not usually malarial. This miasm is also produced in pre- 
 viously healthy localities by turning up the soil, by breaking prairie 
 and by laying out roads. 
 
 This malarial poison is generated only during the hot months ; 
 hence it happens that cases of malarial disease are most frequent in 
 the summe.- and autumn. It is more abundant in the air by night 
 than by day, whence the chances for contracting it are greater 
 during exposure to night air. The air near the surface of the earth 
 is more highly charged than that which lies seme distance above ; 
 hence it may happen that individuals living in ihe upper stories of 
 a house escape infection, while those sleeping in ihe lower part of 
 the same building contract the disease. Another peculiarity lies in 
 the fact, that tne period during which the virus may lie dormaiit in 
 the system is not only indefi:>ite, but may extend over months, per- 
 haps even years; as a result of this, individuals may exhibit the 
 disease lung after they have ceased to be exposed to it. 
 
 Treutinent. — For the cure of intermittent fever there is, as 
 all know, one remedy which can be relied upon, and several others 
 which rarely fail — in the various substances found in Peruvian 
 bark, particularly quinine and similar alkaloids. In ths, last few 
 years several other extracts of Peruvian bark have been made — 
 cinchonia, cinchonidia among them — which seem to possess the 
 same properLif's as quinine, though in a less degree ; and they pos- 
 sess for many people an extreme advantage, in that they are far less 
 expensive than that costly drug. 
 
mi 
 
 m 
 
 
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 ■' III f 
 
 'hi ? 1 
 
 •k. 
 
 5 ■II 
 
 72 
 
 CONSTITUTIONAL DISEASES. 
 
 To cure intermittent fever, then, one needs quinine, and that 
 only. It was formerly the custom to " prepare " the patient, as it 
 was called, for the use of the quinine by giving him several days 
 treatment with cathartics, emetics or other medicines. Such pre- 
 paratory treatment is, however, unnecessary. The drug may be 
 administered at once, and can be relied upon to stop the paroxysm. 
 Yet it is true that medicines given during the chill, or fever imme- 
 diately following it, are not apt to be absorbed from the stomach ; 
 hence it is advisable to postpone the administration of drugs at 
 least until the sweating stage begins. 
 
 During the chill the patient may be comforted, as well as bene- 
 fited, by external warmth, such as wrapping in blankets, by the 
 application of hot bottles to the feet, and by hot drinks. During the 
 fever the body heat may be palliated by the use of cold water, or 
 of some of the mineral waters, if convenient. When the sweating 
 stage is fairly begun, the quinine or its equivalent may be admin- 
 istered. Many plans have been proposed for the administration of 
 quinine in intermittent fever. The general principle should be ob- 
 served that the drug proves most effective when given at the shortest 
 possible interval after the paroxysm. If it be administered during 
 the sweating stage, the probabilities for preventing the next parox- 
 ysm are greater than if the administration of the drug be delayed. 
 As to doses, the usual plan is to give an amount which will produce 
 at once evidence of the constitutional effects of quinine — evidence 
 which is indicated by ringing of the ears. For an adult the quan- 
 tity necessary to produce this effect varies from ten to twenty grains. 
 This may be administered in one dose, but can be preferably given 
 in several smaller doses, which shall be taken before the next par- 
 oxysm begins. This plan has the advantage that no more of the 
 drug need be given than is necessary to produce ringing in the ears. 
 It is, therefore, advised that an adult take five grains of the drug as 
 soon as the sweating stage has begun, and that this dose be repeated, 
 at intervals of three or four hours, once, twice or three times. By 
 this time the effects of the drug will be manifested in the ringing in 
 the patient's ears. If the chills have been recurring daily, it is quite 
 possible that a paroxysm will occur on the first day after the quinine 
 has been taken, though this paroxysm will probably be less severe 
 than usual. If the disease has been of the tertian type (the chills 
 occurring on alternate days), it is probable that no chill will occur if 
 the quinine be administered as above directed. Others recommend 
 
 11! 
 
 i'll 
 
INTERMITTENT FEVER. 
 
 73 
 
 that one grain of the drug be given every hour until about fifteen 
 grains have been taken. This plan has no particular advantage over 
 the former, though usually successful. 
 
 As to the manner in whic^ .^uinine should be administered, there 
 is a diversity of tastes : "^ ..netimes it becomes necessary to devise 
 especial means, since there are individuals who seem unable to en- 
 dure, without great physical distress, saturation of the system with 
 quinine. The usual method, and one which answers the purpose in 
 the vast majority of instances, is simply to dissolve the drug in 
 acidulated water. The following formula can be used : 
 
 Sulphate of quinine - - 20 grains. 
 
 Dilute sulphuric acid - - 20 drops. 
 
 Syrup of orange peel - - Half an ounce. 
 
 Water to make - - - 2 ounces. 
 
 A tablespoonful of this can be taken and repeated as above di- 
 rected. One of the great disadvantages in the use of quinine is 
 its extremely bitter taste. This can be evaded in various ways — by 
 the use of the gelatine wafers, which are softened with water and 
 then wrapped carefully around the powder, making a mass which 
 can be swallowed without permitting the quinine to reach the sur- 
 face of the mouth ; or the drug can oe taken in the shape of sugar- 
 coated pills, the only objection to which is, that they are unreliable 
 unless fresh. The drug may also be given to advantage in empty 
 capsules, which may be procured at the druggists, into which the 
 powder can be poured, and which can then be completely closed 
 and swallowed. Though we rely upon the quinine administered 
 during the first day or two to stop the manifestations of the chill 
 and fever, yet it is not asserted that the malarial influence is thereby 
 abolished ; indeed, we know, as already stated, that although the 
 patient is apparently free from fever after the paroxys ceases, yet 
 there is a certain increase of his bodily temperature for many days 
 after the apparent cessation of the difficulty. Hence it is desirable 
 to continue the quinine in small doses — say four or five grains daily 
 — for several weeks. If the pitient be unable to endure quinine, 
 (which sometimes causes most unpleasant and annoying headaches 
 and feeling of general prostration) any one of several other reme- 
 dies may be employed with reasonable prospect of success. The 
 sulphate of cinchonia usually produces less violent head symptons 
 than quinine itself. If this remedy be also objectionable, and no 
 other preparation of Peruvian bark be employed, recourse may be 
 
74 
 
 CONSTITL TIONAL DISEASES. 
 
 
 i i ' ;■ 
 
 m 
 
 had to arsenic, which is almost as efficacious as quinine itself. It 
 may best administered in the compound known as " Fowler's Solu- 
 tion," which may be given to an adult in doses of six to ten drops 
 three times a day in water. 
 
 A most important item in the treatment of those who have had 
 malarial difficulty for any considerable time, is the administration 
 of iron, for these patients have suffered serious depreciation of the 
 blood through the loss of the red-blood globules — a loss indicated 
 by their intense pallor. For such cases, quinine alone is impotent 
 to restore health, but the addition of iron insures success. So, too, 
 the dropsy, which not infrequently follows long exposure to mala- 
 rial influence, will be best remedied by the administration of iron 
 rather than by any measures addressed directly to the treatment of 
 dropsy; for this dropsy depends not upon any disease of the kid- 
 neys or heart, as is often the case with dropsy, but merely upon 
 the impoverishment of the blood, which is remedied by the use of 
 iron; in this way, therefore, we may remove, not only the anaemia, 
 but also the accompanying dropsy. A good formula for this pur- 
 pose is the following: 
 
 Sulphate of quinine - - - - 20 grains. 
 
 Pill of carbonate of iron - - - 60 grains. 
 Mix and divide into 20 pills. Take one after each meal. 
 
 Pernicious Intermittent Fever. 
 
 The ordinary intermittent fever, just described, is rarely attended 
 with any immediate danger to life; if there be ultimately any serious 
 effects from the disease, those effects are traceable rather to the im- 
 poverishment of the blood and the enlargement of the spleen, than 
 to the immediate features of the disease. But there are forms of 
 malarial disease which occur in the same districts wh re the ordinary 
 intermittent fever is experienced, that arc distinguished by the over- 
 whelming violence of their onset, which sometimes prove fatal 
 within a few hours. These forms are variously designated as prr- 
 nicioHs, maligiiant and congestive. In the South and West this 
 variety is commonly termed congestive chills. This pernicious form 
 of the disease occurs at certain periods in malarial regions, particu- 
 
 I 
 
PERNICIOUS INTERMITTENT FEVER, 
 
 75 
 
 larly in the lower portion of the Mississippi valley and in some parts 
 of the banks of the great lakes. 
 
 It is extremely important to be able to recognize the malig- 
 nant character of this disease, more especially since it may be 
 developed in the course of a simple intermittent fever; that is, after 
 the patient has had one or more paroxysms of the ordinary variety. 
 For if anything can be done, it must be done early. It is said that 
 in the cases of ordinary intermittent, which gradually develop a 
 malignant character, the different features of the paroxysms are not 
 plainly marked ; that is, the cold stage is not accompanied by any 
 pronounced chill, nor the hot stage with so much fever. Indeed, 
 the patient may pursue his avocation in the intervals between the 
 paroxysms, and be thrown entirely off his guard, until the malig- 
 nant character of the disease suddenly manifests itself. 
 
 Symptoms, — The symptoms of this affection vary within wide 
 limits. Unlike the ordinary intermittent, the first paroxysm of the 
 pernicious variety may occur in the night, as well as by day; or, as 
 has been remarked, the malignant feature of the paroxysm may be 
 unexpectedly developed after the patient has had several paroxysms 
 of the ordinary variety. Then the skin suddenly becomes extremely 
 pale and shrunken ; there is usually a cold, clammy perspiration ; the 
 countenance betrays extreme anxiety, which is indicated also by 
 the nervous restlessness of the patient. In the worst cases, the mind 
 is at once affected; the patient becomes either unconscious, and lies 
 in a state of stupor, or he becomes wildly delirious, has convulsions, 
 and then passes into a state of unconsciousness. In this state the 
 breathing is slow and snoring — stertorous, as it is technically 
 called. If the patient retain consciousness, he complains of intense 
 thirst and a sensation of extreme internal heat, though his skin, par- 
 ticularly that of the extremities, is cold and corpse-like. Usually 
 there is violent vomiting and purging, the matter discharged being 
 thin, watery and often tinged with blood. The malignant paroxysm 
 does not always present the same stages of the ordinary attack. It 
 may be that after this profound chill a febrile reaction will occur, 
 in which case the fever is apt to be intense. Oftener, however, the 
 reaction from the cold stage is but partial ; the patient's skin and 
 extremities become warmer, and he lies in a state of profound pros- 
 tration, without developing the usual symptoms of the hot stage. In 
 a large number of cases, indeed, death occurs either during the 
 
76 
 
 CONSTITUTIONAL DISEASE). 
 
 l-llr 
 
 :t. 
 
 cold stage, or before the febrile reaction has been completely estab- 
 lished. If he survive the first six or eight hours, the chances for 
 life depend largely upon the probabilities of escaping subsequent 
 paroxysms. In some cases, especially if proper treatment be 
 promptly employed, but one such paroxysm occurs; if subsequent 
 attacks are experienced, they resemble more the ordinary simple 
 intermittent paroxysms. If a second malignant attack follow, as it 
 may on the succeeding day, the chances of the exhausted patient 
 for surviving are correspondingly diminished, and a third attack is 
 almost invariably fatal. 
 
 Cause, — So far as we are at present aware, the pernicious or 
 malignant form of intermittent fever differs from the ordinary simple 
 variety in intensity rather than in kind. The same difference is 
 familiar to us in other infectious diseases ; thus we recognize a 
 malignant form of scarlet fever in which the patient is overwhelmed 
 in a few hours by the violence of the attack, though he may have 
 contracted the disease from an individual suffering with the ordinary 
 form of scarlatina. So, too, we recognize a malignant form of small- 
 pox, which may be contracted by contagion from simple small-pox. 
 Inasmuch as pernicious intermittent fever occurs in the same locali- 
 ties as the simple \'ariety, and since it often begins apparently as a 
 simple intermittent fever, and its features are merely those of the 
 simple variety intensified, it seems but reasonable to assume that 
 the pernicious variety of intermittent fever is merely a more intense 
 exhibition of the ordinary intermittent virus. 
 
 Treatment, — As already indicated, the treatment of perni- 
 cious intermittent fever is a matter of vital importance, since without 
 it, a very considerable majority of the cases would doubtless prove 
 fatal ; as it is, the mortality is probably not greater than one case in 
 eight. 
 
 Much can be done in the way of preventing pernicious fever by 
 interrupting the paroxysms before they assume the malignant chai- 
 acter. During tie seasons when malignant cases are prevalent, no 
 time should be lost in arresting every case of intermittent fever, no 
 matter how simple and light the attack may seem. When the features 
 of the pernicious attack are developed there are two objects to be ac- 
 complished by treitment: one, tobrii»gthe patient under the influence 
 of quinine as soon as possible; the other, to induce reaction from the 
 chill. The latter, it is evident, requires immediate attention ; it is 
 
PERNICIOUS INTERMITTENT FEVER. 
 
 17 
 
 *-A 
 
 useless to attempt the administration of quinine while the patient 
 lies in a state of profound collapse, which usually characterizes the 
 cold stage ; for medicines introduced into the stomach will not be 
 absorbed, and even if inserted under the skin by means of a small 
 syringe, the circulation is so feeble that but little effect could be 
 hoped for. The measures best adapted for promoting reaction vary 
 somewhat with the features of the case, but always include stimula- 
 tion of the skin and of the circulation. Heat may be applied best 
 of all by putting the patient bodily into a hot bath ; if this be 
 impracticable, hot bottles or flat-irons may be applied to the feet and 
 along the spine. The skin of the trunk and its extremities may be 
 vigorously rubbed with alcohol or brandy containing a little red 
 pepper ; if there be much vomiting or purging, a mustard plaster 
 should be applied over the stomach, or indeed over the entire 
 abdomen. In all such cases it is to be remembered that mustard 
 blisters, and although blisters would probably not be formed so long 
 as the patient remains in the collapsed state, yet it must not be for- 
 gotten, in the excitement of the moment, that the plasters should be 
 removed when the patient reacts from the chill. These measures 
 will also serve to stimulate the circulation, which is one of the 
 objects of the treatment ; this can be furthered by the administra- 
 tion of alcoholic stimulants in some form — brandy or whisky may 
 be given; hartshorn may be applied to the nostrils ; if a physician 
 be in attendance, he will doubtless inject ether or alcohol under the 
 skin. If the mental symptoms have been prominent from the 
 beginning, especially if the patient have been unconscious an J 
 stupid, a full dose of calomel — say five grains — may be given at 
 once. It was in just these cases that the old practice of bleeding 
 from the arm celebrated its triumphs ; yet in the revulsion which 
 has followed the abuse of that practice of bleeding, medical men 
 would to-day scarcely practice or advise this measure. So soon as the 
 signs of returning heat and strength are manifested, it is desirable to 
 avoid pushing the stimulation, since the result will be to intensify 
 the fever that usually follows. 
 
 The second object of treatment is to bring the patient under the 
 influence of quinine, with the hope of preventing a repetition of the 
 chill, which would otherwise occur on the succeeding day. Five to 
 ten grains of quinine should be given at once and repeated every 
 three hours until the usual evidences of its effects — roaring in the 
 ears — occur. In these cases there should be no trifling with any of 
 
78 
 
 CONSTITUTIONAL DISEASES. 
 
 the usual substitutes for quinine, though these may answer well 
 enough the simple intermittent, for it should be remembered that 
 unless the patient can be saturated with this drug at once, he will 
 probably succumb to an attack on the succeeding day. Promptness 
 and boldness are indispensable for the successful treatment of this 
 malignant disease ; yet it must be borne in mind, that it is possible to 
 do damage by excess of quinine, as has been shown by the induction 
 of long-continued or permanent deafness and blindness. 
 
 In addition to the free use of quinine, it may be well to keep 
 the patient in bed for the next two or three days, especially during 
 the hours when a recurrence of the paroxysm may be expected. 
 During these hours the patient should be kept warm by artificial 
 heat — hot bottles and similar measures — and by hot drinks. A dose 
 of laudanum, say twenty drops, will be also efficient. 
 
 Remittent Fever. 
 
 \^' 
 
 This disease may be, and by some is, regarded rather as a 
 modification of intermittent than as a distinct disease ; yet, while evi- 
 dently due to the same cause and occurring under the same circum- 
 stances, they present so many distinctive features as to justify their 
 recognition as two distinct diseases. 
 
 Remittent fever is also and more popularly designated bilious 
 fever, or bilious remittent. 
 
 Syiuptoins. — The disease usually begins quite abruptly, with- 
 out any warning in the shape of previous indisposition on the part 
 of the patient ; yet there are instances in which the usual premoni- 
 tory symptoms of malarial fever are present. The paroxysm begins 
 with a chill, more or less marked. This chill, like that of simple 
 intermittent fever, usually occurs in the early part of the day, and 
 not at night. After the chill occurs the usual fever, which does not 
 subside ordinarily in six or eight hours, as is the case with simple 
 intermittent fever, but continues twelve, twenty-four, or even forty- 
 eight hours. At the end of this time — usually during the night — 
 there is a marked decrease in the intensity of the fever ; the skin 
 becomes moist, the pains subside, and the patient usually obtains 
 repose. This aspect of the case differs, however, from the same 
 stage of intermittent fever, in that the fever in remittent does not 
 entirely subside. There is, in other words, no complete disappear- 
 
 \ 
 
REMITTENT FEVER. 
 
 79 
 
 ance of the fever, although it is so much decreased as to render the 
 patient quite comfortable. In the one case there is complete inter- 
 mission of the fever, in the other only a remission, hence the dififer- 
 encc in the names. After a remission lasting from two or three 
 hours to one or two days, a second paroxysm occurs. In this 
 second attack the chill may be less severe than in the first, or even 
 be entirely absent ; the fever is, however, renewed with as much or 
 more intensity than at the first attack. Thus a series of paroxysms 
 may follow, separated by intervals or remissions of irregular dura- 
 tion. After a time these remissions become less marked, so that 
 the fever finally assumes the continuous form. This fever lasts two 
 or three weeks, at the end of which time it often assumes the form 
 of simple intermittent, or it terminates in a condition, to be presently 
 described, called typho-malarial fever. 
 
 Remittent fever presents marked evidences of constitutional dis- 
 turbances ; nausea and vomiting are almost invariably present, and 
 are frequently prominent symptoms. The matters ejected from the 
 stomach are of a greenish or yellowish color ; there is usually much 
 pain and uneasiness over the region of the stomach, and consider- 
 able tenderness, on pressure, at the same spot. Jaundice is a not 
 infrequent symptom. 
 
 The name typho-malarial fever is applied to a condition which 
 is often the continuation of the remittent fever. The remissions 
 become less marked, the fever, therefore, moic continuous ; while 
 at the same time the patient's general condition acquires a similarity 
 to that presented by typhoid fever. There is, however, no reason 
 for believing that the specific virus of typhoid fever is present in 
 these cases ; indeed, we know that the inflammation and ulceration 
 of the intestine, so characteristic of typhoid fever, are lacking in the 
 so-called typho-malarial fevers. The symptoms so common in 
 typhoid fever — the general prostration, impairment of mental func- 
 tion, delirium, stupor, physical debility — are found in several condi- 
 tions which are not typhoid fever, but which are usually designated 
 by a name indicating this resemblance to typhoid. Thus we speak 
 of a typhoid pneumonia, by which we mean not that the patient has 
 typhoid fever and pneumonia together, but that he is suffering from 
 pneumonia (inflammation of the lungs), and has sunk into a state of 
 nervous prostration and physical exhaustion which is so commonly 
 observed in typhoid fever. So when we say that the patient has 
 typho-malarial fever, we mean not that he has both typhoid and 
 
80 
 
 CONSTITUTIONA L DISEASES. 
 
 'J'i 
 
 ■'|| 
 
 ilf ■! 
 
 ri' 
 
 malarial fevers, but that he is suffering from malaria poisoning, and 
 at the same time has sunk '"nto an exhausted condition similar to that 
 which is usually found during typhoid fever. It is, of course, pos- 
 sible that an individual should be affected by the one virus while 
 still suffering from the other, and thus become compelled to endure 
 the ill effects of both at the same time ; yet such is not necessarily 
 the case in typho-malarial fever. 
 
 As already indicated, the symptoms of typho-malarial fever 
 present some of the characteristics of typhoid fever, as well as of 
 malarial poisoning ; the fever no longer presents remission, but has 
 become continuous ; the mind previously clear is now affected ; there 
 is active delirium or passive stupor; the face is dark and flushed, the 
 head hot, the skin dry and harsh, the tongue brown, heavily coated 
 and deeply fissured ; the teeth are often covered with sordes. This 
 change of remittent into typho-malarial fever is apt to occur during 
 the second week of the disease, and can probably always be averted 
 by proper care and treatment during the first week. This treatment 
 consists, like that for all forms of malarial poisoning, first and chiefly 
 in the use of quinine or its equivalent. If this be promptly done by 
 the method already indicated in speaking of simple intermittent fever. 
 it is reasonably certain that the disastrous terminations of the disease 
 can be avoided. Before the use of quinine, remittent fever was a 
 formidable disease, of which Charles the Fifth, James the First, and 
 Oliver Cromwell urc jaid to have died. Even after the develop- 
 ment of unfavorable symptoms of the disease, such as the disappear- 
 ance of the remission, and the appearance of the typhoid symptoms, 
 the chief reliance in treatment must still be upon quinine ; it would 
 be well to administer five grains of this drug every four hours, until 
 the characteristic effects are produced upon the ears. If the typhoid 
 symptoms are so prominent as to demand attention, they must be 
 treated after the manner described in discussing typhoid fever. 
 
 Physicians recognize also a disease known as pernicious remit- 
 tent fever, also called malignant and congestive. This bears to 
 simple remittent fever the same relation already described as exist- 
 ing between simple intermittent and pernicious intermittent fever. 
 The pernicious remittent fever is simply a more intense attack ; in the 
 severe cases death may occur during the initial chill, before, there- 
 fore, any remission has occurred. 
 
 Remittent fever, when early recognized and properly treated, is 
 not a a very formidable disease; under circumstances where it is 
 
YELLOW FEVER. 
 
 8i 
 
 impossible to procure quinine in sufficient quantities, the disease is 
 often fatal. Hence it has acquired a reputation for malignity in those 
 rc<nons where treatment is of necessity unsatisfactory, and is dreaded 
 in various parts of the world under various names — African fever, 
 iiint,^lo fever, Hungarian fever, and during our late war, Chicka- 
 honiiny fever. 
 
 Yellow Fever. 
 
 This dread disease has been known by numerous names at dif- 
 ferent times, and in different parts of the world; yet in the United 
 States, which has acquired an unfortunately intimate acquaintance 
 with the disease in the last two decades, the name, " yellow fever," 
 is universally employed. It is a little remarkable that this name, 
 derived from the yellowish tint of the skin during the disease, is by 
 no means always applicable, since this tint is sometimes absent. 
 
 \ellow fever is a perfectly typical ;;/rt/rtr/rt/ disease. It occurs 
 in certain limited districts where the following combination of cir- 
 cumstances prevail: First, continuous high temperature, about eighty 
 de'^rccs for one or two months; second, excessive moisture in the 
 atmosphere; third, vicinity to the ocean or to a large river empty- 
 ing into it; fourth, vegetable matter in a state of decomposition. 
 This latter feature may be furnished by the offal of the cities, or by 
 the upturning of the soil of the country. Yet many quarters of the 
 "lobe, presenting just this combination of conditions, are never vis- 
 ited by yellow fever. Yellow fever prevails only during certain of 
 the warmer months, and occurs as an epidemic at intervals of a few 
 years; it is then evidently due to a miasm, as to the nature of 
 which we have, as yet, no positive information, though from anal- 
 ogy we may be reasonably certain that this miasm, like that of cer- 
 tain other diseases, is a microscopic vegetable organism. 
 
 All the places which have ever been visited by yellow fever, 
 within the history of medicine, are situated upon or near the Atlan- 
 tic sea coast. The disease has never been known to visit the Pa- 
 cific coast of either Asia or America; nor has it ever been seen in the 
 interior towns of any continent, which were not situated upon large 
 rivers emptying into the sea. It occurs as an epidemic most frequently 
 upon those parts of the western coast of Africa and the eastern 
 
 6 
 
82 
 
 CONSTITUTIONAL DISEASES. 
 
 I lit 
 
 )!!' 
 
 " i ■. 
 
 coast of America, situated south of the thirtieth parallel of north 
 latitude. The Guinea coast is almost constantly devastated by the 
 disease; the West Indies, Central America, and the border of the 
 Gulf of Mexico, are rarely entirely free from it. The most destruc- 
 tive epidemics of yellow fever have occurred in New Orleans, 
 where it appears almost every year; in Shrevcport, Louisiana, and 
 in Memphis, Tennessee, in 1873, and again in Memphis in 1878. 
 
 SffniptOiiiH. — The onset of yellow fever is generally very 
 abrupt, though in the majority of cases it may be preceded for a 
 few days by a general indisposition, languor, wandering pains and 
 occasional shiverings. The attack its(.lf is ushered in by a chill of 
 moderate violence, after which follows fever. Both the intensity 
 and duration of this fever vary considerably; in many cases the 
 heat of the skin seems but little raised, and the fever appears quite 
 out of proportion to the severity of the general symptoms. Dur- 
 ing this fever thirst is extreme, the tongue is heavily coated, though 
 perhaps moist; there is usually nausea and vomitiiig with great pain 
 in the stomach on the second day and thereafter ; there is also ex- 
 treme pain in the head, especially over the eyes; pain in the small 
 of the back, radiating down the thighs, and w.indering pains in 
 various parts of the body. This pain in the small of the back is so 
 usual and so intense as to remind one of small-pox. The eyes arc 
 reddened and watery — a very constant mark of the disease. The 
 bowels are usually constipated; there is commonly delirium in severe 
 cases. 
 
 Ihis fever with the accompanying symptoms continues for sev- 
 eral hours, or even two or three days, at the end of which time there 
 is a decided abatement in the severity of the symptoms, like the 
 remission, of remittent fever. All the symptoms subside, though 
 there still remains considerable fever; this condition has been called 
 " the state of calm. " During this remission the yellowness of the 
 skin becomes quite marked. In mild cases the severity of the 
 symptoms may not recur; the patient improves slowly but surely, 
 and ultimately recovers. In the majority of cases, however, there 
 occurs the dreaded " state of collapse." During this period there 
 is extreme prostration of the nervous system, and the greatest 
 debility of the muscles; the pulse is rapid, irregular, almost imper- 
 ceptible; the skin intensely yellow or bronze; the tongue brown and 
 parched; delirium, convulsions or unconsciousness mark the impair- 
 
 I 
 
YKLI.OW FF.VEK. 
 
 83 
 
 jTicnt of the mental functions. But the most characteristic feature 
 .^ from which indeed the disease has obtained one of its numerous 
 names — occurs during this stage of collapse, the black vomit. In 
 the great majority of fatal cases, and in some of those which ulti- 
 mately recover, the black vomit occurs. This matter consists merely 
 of blood which has escaped into the stomach and has been changed 
 from rod to black by the action of the stomach juices. The matter 
 ejected from the stomach is a thin reddish brown or blackish liquid 
 with a sediment resembling coffee grounds; if the quantity of blood 
 which has escaped into the stomach be very great, the vomit is 
 usually red, because the blood has undergone but little change. 
 The influence of the stomach juices in turning the blood black may 
 be readily imitated outside of the body by adding a little acid, such 
 as strong vinegar, to fresh blood. 
 
 This black vomit rarely occurs until the first stage of the 
 disease is passed, and is most frequent during the period of collapse 
 which succeeds. The discharges from the bowels also frequently 
 present this same black appearance, resembling tar, due to the 
 presence of blood in the intestine ; sometimes red blood but little 
 altered is also evacuated from the bowels. It is during this stage 
 that the yellowness of the skin, from which the disease derives its 
 usual name, is especially marked; the mucous membrane of the 
 eye also exhibits this color, giving to the countenance a peculiar 
 appearance. This yellowness is due to certain constituents of the 
 bile, and occurs in the severer cases with especial frequency; in 
 fact, it is somewhat rare in the cases that recover ; in these latter it 
 persists until the patient is almost well. 
 
 Blood may escape from other portions of the body also than 
 the stomach and intestines ; it frequently appears in the urine, 
 causing the latter to assume a dark brown or smoky appearance. 
 Blood may also issue from the mouth, nostrils, female genitals, 
 sometimes even from the eyes, ears, and around the finger nails. 
 A remarkable feature of the disease is the apparent lightness of the 
 attack in cases which, nevertheless, prove suddenly fatal. Some- 
 times patients are not compelled to take to the bed, may even keep 
 about their usual employments, until a few hours before the fatal 
 result. Thus, one man shaved himself on the day of his death ; 
 another, a soldier, continued on duty until the black vomit occurred ; 
 still another wrote a letter a quarter of an hour before he died. 
 
84 
 
 CONSTITUTIONAL DISEASES. 
 
 '>! 
 
 
 S'l \ 
 
 11 H 
 
 Perhaps these cases should be considered as examples of the delirium 
 which not infrequently constitutes a feature of the disease. 
 
 The appearance of the face, too, is said by all observers to be 
 quite characteristic. There is a deep red flush on the countenance, 
 while the eyes are described as particularly brilliant, fiery, and 
 glass}'. The duration of this second stage is variable, according to 
 the severity of the case ; it may terminate in death in a few hours, 
 or lead to convalescence in one or two days. Then follows the 
 period of exhaustion, during which the majority of deaths occur. 
 The duration cf the disease is said to vary from three to nine days, 
 averaging less than a week. A certain degree of immunity against 
 subsequent attacks is said to be conferred by one attack of yellow 
 fever ; yet it is well known that the same individual frequently suf- 
 fers from it two or more times 
 
 It seems clearly established that yellow fever is not commu- 
 nicated by contagion from one individual to another, in which 
 particular it resembles the malarial fevers generally. It is a familiar 
 fact, for instance, that the ordinary intermittent fever, or " ague," 
 while attacking most individuals living within certain districts, is not 
 communicated by a sufferer from it to other persons. This fact has 
 been proven by numerous personal tests. Medical men have sub- 
 mitted themselves to direct inoculation from yellow fever patients ; 
 have slept in beds in yellow fever hospitals, in which patients had 
 just died with the disease. WhilCj however, the disease is not 
 spread by personal contagion, it is transferred by the atmosphere, 
 presumably, because the virus of the disease is composed of material 
 particles, which are swept abroad by currents of air. M kIi study 
 has been devoted to ascertaining the conditions under which the 
 disease becomes epidemic, as well as the agencies by which it is 
 spread from one center of infection to another. The extensive and 
 long-con*. inued observations made in the southern part jf our own 
 land during the last fortj' years have furnished the following facts 
 with regard to the origin and spread of the disease : 
 
 I . The yellow fever poison is usually diffused over very limited 
 districts ; it frequently happens that the area in which it appears is 
 but the fraction of a square mile. Beyond these limits no cases of 
 the disease appear spontaneously, and patients suffering from it when 
 removed out of this area do not comm'inicate the disease to others 
 with whom they may come in contact. 
 
YELLOW I'EVER. 
 
 85 
 
 2. The disease appears simultaneously at several points within 
 such an infected district; there is an apparently spontaneous 
 ori'^in ; that is, the first cases have not been exposed to contagion. 
 
 3. In the infected districts, scattered or sporadic cases occur 
 almost every year, though they do not result in general extension 
 of the disease ; yet, at intervals of years, epidemics arise in these 
 c-riie localities. This is true, for instance, of New Orleans, which 
 has experienced several severe epidemics in the last thirty years ; 
 yet scarcely a summer passes in which numerous cases do not occur 
 along the wharves and in the shipping in the river. 
 
 4. The germs of the disease, while apparently not communi- 
 cated by the clothing or the bedding of the patient, seem, :-ever- 
 thclcss, capable of maintaining thc'r infectious activity in a section 
 of the infected atmosphere — so to speak, be transported; thus 
 it is well established that the disease is transferred by ships, and 
 several local epidemics in seaports on the Gulf of Mexico have been 
 traced directly to the landing of vessels from the West Indies. Yet 
 even in these instances, if the port thus infected be not habitually 
 the home of yellow fever, the disease will spread but a short dis- 
 tance from the ship. It has been, also, abundantly established that 
 such infected ships can be thoroughly disinfected, by cleansing and 
 airing them. 
 
 5. It is evident that there is only a limited field for attempts 
 to prevent the spread of yellow fever. For a large section of the 
 country quarantine regulations are wholly unnecessary. The entire 
 population of Memphis, for instance, might have been transported 
 to Chicago without inducing a solitary case among the citizens of 
 that place, for the atmospheric conditions and the temperature in 
 Chicago are such as to render the development of the disease 
 impossible. On the other hand, quarantine regulations are utterly 
 impotent to prevent the appearance of the disease in New Orleans, 
 or similar localities where the disordor is generated. It is only in 
 one class of localities that quarantine can hope to accomplish much 
 — namely, in those places where the fever has been in previous 
 years spontaneously produced, but has not as yet made its appear 
 ance during the season in question. Such quarantine should be 
 rigorously enforced as to vessels, but can derive no advantage from 
 the detention of individuals. 
 
 6. It has been repeatedly demonstrated that the liability to 
 an epidemic of yellow fever can be much diminished by sanitary 
 
*v-i:. 
 
 W 
 
 i '■! 
 
 
 .1 
 
 -1 
 
 t. 
 
 ^ ^1* 
 
 fi 
 
 i 
 
 i;-' 
 
 86 
 
 CONSTITUTIONAL DISEASES. 
 
 regulations. Thus the rigid military rule of General Butler \\ New 
 Orleans, in 1862, prevented the usual extensive occurrence < -f the 
 fever that year. It seems probable, too, that the strict police regu- 
 lations in the same city, in 1873, prevented a disastrous epidemic 
 similar to that which was at the same time prevaihng at Shreveport 
 and in Memphis. 
 
 Treatment. — Up to the present time no treatment has: been 
 devised by which the duration of an attack of yellow fever can be 
 shortened or its course changed with certainty. There is, indeed, 
 no course of treatment the results of which have commended them- 
 selves to medical men as worthy of general adoption. There is, of 
 course, a vast number of remedies for which . special value in the 
 treatment of this disease is claimed ; but the very length of the 
 list is ample proof that no one of them is reliable. The only 
 rational course is, in every case, to meet, so far as possible, the 
 symptoms as they arise, and not to adopt any set of rules for treat- 
 ing the disease in general. 
 
 It is a fortunate fact that a considerable majority of cases tend 
 to recover spontaneously ; yellow fever, like the other infectious 
 diseases, is self- limited ; and if the patient survive for a certain 
 time, there is a strong probability that he will recover. Such is, 
 indeed, the history of many cases. Then, on the other hand, there 
 are instances which are inevitably fatal, the patient often dying in 
 a few hours after the attack begins. The suggestions for treatment 
 to be given here will, therefore, be indications for meeting the dif- 
 ferent s)i7iptoms according to tlie severity of the case. 
 
 In the milder cases no active measures are required for treat- 
 ment. The patient must be kept quiet. His diet must be light and 
 nutritious. And especial care should be directed to ventilation. 
 During the height of the fever the usual remedies employed during 
 febrile conditions may be used, such as cold applications to the 
 head, frequent sponging of the skin with lukewarm water, cold and 
 effervescing drinks, la.^atives in case of constipation. Dr. Stone, of 
 New Orleans, who has had much experience in the treatment of this 
 disease, recommends " foot baths under the bed clothes and spong- 
 ing the body with tepid water." Dr. Flint says that many cases of 
 mild yellow fever in New Orleans are managed by Creole nurses 
 without medical aid. This is doubtless true of the scattered cases, 
 but scarcely during epidemics. Furthermore, some of the cases 
 
YELLOW lEVER. 
 
 87 
 
 I 
 
 
 which at first appear mild may develop malignant features subse- 
 quently. It is therefore desirable to observe and meet carefully 
 every symptom of the disease. It is therefore of extreme import- 
 ance that the patient should in every case take to his bed at the first 
 indications of the disease. Both body and mind should be rested 
 as completely as possible, and the most careful attention be bestowed 
 even upon the slightest details. 
 
 In the more malignant cases the same general measures are 
 indicated; that is, extreme care as to all the hygienic surroundings of 
 the case. It is not advisable to follow the plan so much in vogue, 
 that the measures shall be the more heroic according as the severity 
 of the disease increases. It is doubtless possible to do much harm 
 by the use of powerful medicine; this is particularly true of purga- 
 tives, since the intestinal canal is in a very debilitated condition. 
 There is, perhaps, one indication for the use of sharp purgatives, 
 namely, unconsciousness or stupor on the part of the patient. By 
 causing the blood to flow to the alimentary canal we may succeed in 
 reviving the congestion of the brain, upon which the unconscious- 
 ness depends, ivuring the hot stage the remedies usually employed 
 in other fever:^ r ■■■■ be used to advantage; such arc sponging of the 
 skin, the use of ice in the mouth, etc. If the patient be extremely 
 restless and vigilant, opium will be found useful. Ten to fifteen 
 drops of laudanum may be given, and repeated in three hours, if 
 necessary. 
 
 The extreme danger comes usually during the stage of ex- 
 haustion. During this stage nothing may be left undone which can 
 sustain and invigorate the patient. These measures consist, of 
 course, first in the application of friction to the skin, which may be 
 vigorously rubbed with brandy or other alcoholic fluid. The use 
 of hot bottles or hot flat-irons to the feet and spine may im- 
 part strength, while the application of mustard plasters to the 
 stomach and abdomen may be efficient in relieving the black vomit 
 and discharge of blood from the bowels. In many of these 
 cases of collapse advantage is asserted from the application of 
 lecchc i to the back of the neck ; but the great reliance must 
 be, and is generally admitted to be, the internal use of alco- 
 holic stimulants. If there be one fact established in the treat- 
 ment of this disease, it is that lives have been saved by the 
 use of whisky and brandy in quantities that would, under other 
 circumstances, seem excessive. So far, therefore, as treatment 
 
 f 
 
 ■>% 
 
88 
 
 CONSTITUTIONAL DISEASES. 
 
 can be recommended in these cases of malignant yellow fever, 
 it may be summarized as follows: During the hot stage sponging 
 of the body, or hot baths ; the use of ice, cold drinks or effervescing 
 waters internally. During the collapse, stimulation by friction of 
 the surface, application of hot bottles around the patient, and the 
 use of whisky or brandy. 
 
 . 'I ii ^ ■' 
 
 Cholera. 
 
 
 I 
 
 :' : li 
 
 By this term is designated not the so-called cholera morbus 
 which may occur at any time in almost every community, but the 
 epidemic disease which we usually consider to be of Oriental origin, 
 and designate by the name of Asiatic cJiolcra. Volumes might be 
 written upon the history of this disease and upon its relations to the 
 political history of the world. It seems highly probable that this 
 disease was one of the plagues known to the ancients, yet we are 
 able to trace it definitely and exactly only about three hundred 
 years back. Since this date it has at irregular intervals swept the 
 entire civilized world, so that the very name inspires dread in the face 
 of all that science has as yet accomplished. In 1817, 36,000 people 
 were attacked by the disease in three months in Calcutta; "in No- 
 vember of the same year an English army marching through India 
 was decimated by it, 9,000 out of 90,000 men dying in twelve davs. 
 From India the cholera proceeded that year toward the west, and 
 in the succeeding fifteen years had traversed nearly all of the known 
 world. At the end of this time (in 1832) it arrived for the first time 
 in America. In 18 18 it raged again in India, spread thence into 
 different parts of Asia with frightful results. In the following year 
 150,000 persons died of it in one district of India alone. In 1823 
 it had reached China ; in 183.1 it had spread to the north of Europe. 
 During ihis year 100,000 Hungarians died of the disease. The 
 Austrians surrounded their capital, Vienna, with a double military 
 guard to protect themselves against their neighbors of Hungary, but 
 in vain. In 1831 it had reached England, whence it spread through 
 the British Isles. It first appeared 6n our continent, at Quebec, in 
 June, 1832; within three months it had spread over twelve States. 
 The following year the West Indies and Mexico were visited. In 
 1834 it returned to Southern Europe, where it remained with more 
 
 \ \ ' 
 
CHOLERA. 
 
 89 
 
 Qj. j(,ss intensity for three years. In 1837 it had entirely disap- 
 nearctl from Europe and America, and was not seen again for ten 
 veais. In 1847 the cholera started again from India, which seems 
 to harbor it constantly, toward the west, and reached the United 
 States in 1849, During this epidemic there was noticed a phenome- 
 non at that time new in the history of cholera, though the same 
 fact has been since repeatedly observed. The disease germs seemed 
 to traverse the ocean without human agency, for the cholera ap- 
 peared upon two emigrant ships a thousand miles apart, one of 
 which had been at sea sixteen days and the other twenty-seven 
 days, no cholera having occurred at the ports from which those 
 vessels had sailed. From this time onward the disease seemed to 
 linger in various parts of Europe and America for five years, when 
 another severe epidemic occurred. In 1865 the disease appeared 
 n<rain in Arabia and Egypt, crossed to Constantinople in July, and 
 
 **fc5 
 
 reached England by the autumn. In the following year the disease 
 broke out in America again. At the time of the writing of this 
 book it has once more appeared in Eastern Europe, and may be 
 expected again in our midst within a year or two. 
 
 Sffinploms, — The disease is usually developed without serious 
 premonitory symptoms. In the majority of cases there is no further 
 warning than simple diarrhea, the stools being numerous and pro- 
 fuse, but not attended with pain. Vomiting may also occur, 
 although this is not a constant symptom. Aside from these indis- 
 positions, which may of course be induced by other causes than 
 cholera, there is nothing to indicate the onset of this dread disease. 
 Unless the patient be already fearful of infection, it may be difficult 
 to persuade him that the diarrhea can have any particular import- 
 ance; but the discharges suddenly increase in quantity; or if there 
 have been no previous diarrhea, the onset of the disease is marked 
 by sudden and profuse discharges from the bowels. This is the 
 beginning of the disease, and in mauy rases occurs during the 
 night. From the first the stools possess the characteristic features 
 by which the cholera is especially distinguished — they resemble rice 
 water, and are ordinaril}'^ designated as " rice-water stools. " The 
 liquid will be found to contain numerous small white, solid particles, 
 resembling grains of rice; it possesses little or none of the usual 
 character of intestinal discharges, but emits a peculiar offensive 
 odor. Not less characteristic than the discharge itself is the action 
 
(!i: 
 
 n 
 
 a I 
 
 M^ 
 
 h, 
 
 90 
 
 CONSTITUTIONAL DISEASES. 
 
 of the patient. Ht suffers none of the pain usually incident to 
 diarrhea, but is simp'y impelled by a sense of distention to evacuate 
 the bowels, a proceeding which gives him no pain nor uneasiness. 
 If vomiting occur, as i*: usually does at some period of the disease, 
 the matter ejected from the stomach is a watery fluid, somewhat 
 similar to that constituting the stools. The vomiting is not usually 
 accompanied with much nausea or pain, the act occurring in con- 
 sequence of a sudden impulse, just as is the case in the evacuation 
 of the bowels. 
 
 These symptoms mark the beginning of the disease ; mean- 
 while there is a sense of profound exhaustion and debility. The 
 pulse is usually rapid and weak, the skin cool, or covered with 
 clammy perspiration, the face pinched, and the muscles may undergo 
 the most painful cramps. If the attack be not severe, these symp- 
 toms begin to improve within a few hours ; in fact the patient may 
 be convalescent in half a day. In the majority of instances, how- 
 ever, the outcome is not so rapid nor so favorable ; the patient 
 passes into what is called the stage of collapse. 
 
 In this condition the pulse is extremely rapid and feeble, beat- 
 ing even 140 times per minute; it may be extremely difficrlt to 
 distinguish the beat of the heart when the ear is applied to the 
 chest. The failure of the circulation is indicated also by the stag- 
 nation of blood in the veins, in consequence of which the face and 
 surface of the body generally become dark blue or livid ; this con- 
 dition is especially marked in the lips and at the roots of the nails. 
 If the patient be bled from the arm, as was formerly often done, 
 the blood oozes from the wound and does not flow in a continuous 
 stream; leech bites, too, are not followed by the usual amount of 
 bleeding; all these things indicate that the blood is materially 
 changed from its natural condition. 
 
 The breathing, too, presents certain characteristic features. 
 The patient complains of want of air, and sometimes even gasps 
 for breath; the respiration is irregular and sighing. The expired 
 breath feels cold to the hand held before the mouth. Tlie mind 
 seems usually overwhelmed; the patient does not realize the situ- 
 ation, has no fears for the result, even though previous to the attack 
 he may have harbored a profound dread of the disease. In some 
 instances he lies quiet and content, at other times is very restless, 
 though more from physical th^ii from mental d'stre=.s. The mus- 
 cular cramps usually appe-^ir at some stage of the disease; they 
 
 ii.i 
 
CllOLEKA. 
 
 91 
 
 affect especially the feet, calves and arms. To relieve himself the 
 patient sometimes walks about even a few minutes before death. 
 
 As the disease approaches a fatal termination, the patient's 
 body becomes intensely cold; he is usually unconscious, though if 
 so he usually complains of a sense of heat, and insists upon being 
 uncovered. The body temperature is sometimes decreased from 
 ninety-nine — the standard of health — to ninety, or even eighty; the 
 skin is wrinkled and shriveled ; the face pinched. The general 
 appearance is extremely characteristic ; one derives the impression 
 that the entire body has been diminished in size. The patient 
 appears to have grown old in a few hours, and the countenance 
 maybeso changed as to be unrecognizable even by friends. Such, 
 iiulecd, is the result of the excessive drainage of water from the 
 body; forthe constant discharges from intestines, stomach, andskin 
 result in a very material decrease in the weight of the body. This 
 loss of weight consists largely of the watery parts of the blood, 
 whence results the shrivelled appearance of the skin and body gen- 
 erally. Death often occurs in the state of collapse, though there 
 arc instances in which a fatal result ensues before this stage of the 
 disease is reached. 
 
 If the patient recovers from the stage of collapse, he does not 
 as a rule begin convalescence at once, but passes into what is called 
 {he stac'i' of reaction. In this period there is considerable fever; 
 the diarrhea continues, but the discharges lose the rice-water 
 appearance and become green. Vomiting is frequently a trouble- 
 some complication during this period, thevomited matter also being 
 green. Death may also occur during this stage of reaction, the 
 patient being exhausted by the long continued vomiting and diar- 
 rhea. Even if recovery ultimately ensue, the individual's powers 
 are apt to be impaired for a considerable time. 
 
 CuHSe, — There is, undoubtedly, a specific cause, a virus, v/hioh 
 is essential for the production of Asiatic cholera. This is evident 
 from the history of the epidemics which have from time to time 
 spread over the world. Tht fact that the disease is at honn , -o to 
 speak, in certain parts of Asia, that only under jieculiar concluons 
 it invades other countries; but especially the fact that its spread is 
 a continuous one from the original site of the disease — these all in- 
 dicate that there is a particular infectious material, without which 
 the disease does not exist. Ouite otherwise is it, however, with 
 
 
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 8 .fU\\ 
 
 Hi 
 
 92 
 
 CONSTITUTIONAL DISEASES. 
 
 the question whether cholera is communicated by personal contagion. 
 Such method of communication is certainly not necessary; many 
 instances such as that to which reference has been already made — 
 the occurrence of the disease on vessels which had been at sea for 
 several weeks — demonstrate that cholera can arise in a locality 
 without any importation of individuals already suffering from the 
 disease. Yet it might be also possible that cholera could be com- 
 municated by personal contact as well as by distribution through 
 the atmosphere. Yet many facts, positive as well as negative, in- 
 dicate that such transmission from person to person occurs either 
 not at all or extremely seldom; for it seems that among those who 
 are brought into contact with cholera patients, the disease is not 
 more frequent than among those who are not thus exposed. In 
 the report on cholera published by the French Government in 1831, 
 it is affirmed that among 55,000 persons attacked by the disease, 
 only 164 were individuals whose duties called them to associate 
 with the sick. These 164 persons had been employed as physicians 
 or nurses in the hospitals, where nearly 2,000 others, likewise em- 
 ployed, had escaped entirely. .A mong 58 persons employed in the 
 hospital at St. Petersburg, only one contracted the disease. 
 Similar observations have been made in great numbers, and show 
 that if cholera be contagious, its contagion is far less active than 
 that of other diseases, such as typhus fever. Then, again, cases of 
 the disease have been repeatedly imported into cities without 
 causing the multiplication of the disease in those localities; and, 
 finally, efforts have been made to induce the disease in healthy per- 
 sons by direct inoculation from cholera patients, but always without 
 success. 
 
 From these facts we may make the important practical deduc- 
 tion that there is but little, if any, personal danger in the presence 
 of a cholera patient; that nursing or attendance upon such a patient 
 does not increase the danger of contracting the disease. This is, 
 of course, quite contrary to the popular impression. We are 
 accustomed t-'- see and hear of people fleeing in dread from the 
 vicinity of such patients; and it is even affirmed that physicians 
 have been known to evade attendance upon such patients, out of 
 fear of personal contagion. It is, of course, true that the locality 
 in which cholera is epidemic is more dangerous than one out of the 
 usual path of the disease; yet this danger arises, not from the pres- 
 ence of cholera patients, but from the atmospheric conditions 
 (whatever they may be) which make cholera possible. 
 
 i 
 
 m^Y' 
 
CHOLERA. 
 
 93 
 
 While we are thus ignorant of the essential origin of cholera, 
 wc are quite familiar with the circumstances which promote its 
 spread and render personal liability to the disease greater. It is 
 tlie universal experience that cholera appears first, is most destruc- 
 tive and stays longest in those parts of a city in which sanitary regu- 
 I itions are poorest. The densest and filthiest cities, and parts of 
 cities, have always been the home and breeding-place of epidemic 
 cholera. Several apt illustrations of these facts were observed in 
 London during the epidemic of 1 849 ; in those districts of the city 
 supplied with drinking water from the Thames above the entrance 
 of the sewers the mortality was less than one-half of one per cent. ; in 
 those districts which were supplied from the river below the entrance 
 of the sewers the mortality was from four to eight times as great. Evi- 
 dently the best protection against cholera in a locality where the 
 disease is epidemic consists in the greatest attention to sanitary reg- 
 ilations, the avoidance especially of decomposing animal matter. 
 Defective sewerage, accumulations of filth, crowding of people in 
 unventilated tenement houses — these are active causes in promoting 
 the establishment of epidemic cholera. 
 
 Measures for individual protection rest upon the same general 
 principles. There can be and need be no set of rules to be observed 
 as personal protection against the disease, for every person living 
 in a district infected by epidemic cholera is liable to the disease, 
 liis chances of escape being proportioned simply to the excellence 
 of his general health and sanitary surroundings. The only salva- 
 tion from danger is flight to a locality unaffected and not likely to 
 be affected by the epidemic. Yet one measure of precaution may 
 become necessary, and should never be neglected during the preva- 
 lence of a cholera epidemic ; and that is prompt attention and 
 treatment of even the slightest diarrhea, for it is the universal tes- 
 timony that the attack of cholera is usually preceded by diarrhea, 
 and that the attack rarely occurs if this diarrhea be promptly 
 checked. 
 
 Every diarrhea, therefore, during the prevalence of cholera, 
 should be promptly treated by an astringent. A good mixture for 
 that purpose is the following : 
 
 Opium, - - - . One-half grain. 
 Camphor, - - - - Two grains. 
 
 A pill containing these ingredients may be taken every four 
 hours ; or half a teaspoonful of paregoric may be taken every two 
 
94 
 
 CONSTITUTIONAL DISEASES. 
 
 J "li 
 
 ij. !l 
 
 f J ' 
 
 ^Vi 
 
 hours during the day. No laxatives or cathartics should be admin- 
 istered. 
 
 Whether or not the access of country, or to a particular local- 
 ity of that country, can be prevented in the least by quarantine 
 regulations is still a debated question, though the evidence is over- 
 whelmingly in the negative. Yet it may be advisable to obtain the 
 benefit of the doubt and employ quarantine regulations, since even 
 a small degree of success in checking this formidable disease would 
 be a sufficient reward for the effort. It is scarcely necessary to 
 correct certain popular practices and impressions in regard to the 
 prevention of the disease. One of these is the idea that the adop- 
 tion of a light diet, such as rice, and the avoidance of fruits and 
 vegetables, diminishes the chances of infection, while others seem 
 to believe that the frequent indulgence in alcoholic stimulants will 
 accomplish the same result. Both these ideas are fallacies ; the one 
 object, as already indicated, consists merely in keeping the health 
 at the best possible standard. For feeble persons are not only less 
 able to resist an attack, but are also more susceptible to the disease, 
 although no age in life exempts from danger. Yet the largest 
 proportion of fatal cases is invariably among the aged, and the 
 next largest in early infancy. Thus the statistics of Duchesne, col- 
 lected from the Paris epidemic of 1849, show that the largest ratio 
 of deaths occurred between the ages of sixty and eighty-five years, 
 the next largest under five years. The actual mortality from 
 cholera is ordinarily not so great as the popular impression sup- 
 poses. During the epidemic of 1832 there occurred in London 
 one death among 1,228 inhabitants; in Edinburgh one death to 
 2,033 inhabitants. In the United States the ratio was much 
 larger. Thus, in New York there was one death to every one hun- 
 dred persons, in Albany one to seventy-seven, and in Quebec one 
 death to twelve. 
 
 Treatment, — In the treatment of cholera, nearly all the rem- 
 edies known to medicine have been at various times employed, and 
 a great number of these have received warm commendation from 
 various observers. Yet the fact is, that medicine knows to-day 
 no means which guarantee success, or even a probability of success, 
 in saving life under the formidable attack of epidemic cholera. In 
 this, as in most of the infectious diseases, the effort must be to sup- 
 port the patient until the disease has expended its fury; for cholera 
 
CHOLERA. 
 
 95 
 
 ,s A self-limited affection, which leaves the patient in comparatively 
 few days, if he but live so long. To outline a treatment, therefore, 
 is merely to give the experience of one or more men, an experience 
 which may be at variance with that of other physicians. All agree 
 that there is nothing by which the duration of the disease can be 
 shortened, nor its most dangerous symptoms controlled. Dr. 
 Austin Flint, of New York, states his own practice, based upon a 
 loii"^ and extensive ex^ . :ence, as follows : " The treatment is to 
 he considered as applicable to the different stages before collapse, 
 diiiiii;'^ the collapsed stage, and after the reaction. Prior to col- 
 lapse the paramount object is the arrest of the intestinal discharge. 
 This discharge into the intestine is the first appreciable link in the 
 chain of unnatural events, and if promptly arrested before it has 
 proceeded so far as to affect seriously the blood and circulation, 
 the patient is usually safe. The remedy on which most dependence 
 is to be placed in affecting this object is opium. Some form of 
 opiate is to be given promptly, in doses sufficient to effect the object. 
 The form of opiate is to be chosen with reference to promptness of 
 action and the probability of its being retained. Laudanum is to 
 be preferred. In the endeavor to effect the object of treatment in 
 this stage, moments are precious, for there is always danger that if 
 the object be not promptly effected, the patient will fall into the 
 collapsed state. The opiate should, therefore, be given in a full 
 dose. A grain of morphine (thirty or forty drops of laudanum) 
 is rarely, if ever, too large a dose for an adult. If the first dose 
 be quickly rejected by the stomach, a second should be instantly 
 given. The doses are to be repeated at intervals of from half to 
 three-quarters of an hour, until the discharges from the bowels 
 cease. If, owing to the occurrence of vomiting, the administration 
 of the drug by the mouth be ineffectual, it should be given by the 
 rectum, and in cases in which the symptoms are urgent, both modes 
 of administration should be resorted to. The system, even in this 
 stage of the disease, is not readily affected by opiates thus given. 
 If the administration be in the hands of the physician, and the 
 ctTccts of the doses watched with care, danger from this source 
 (the opiate) may generally be avoided. The practical point is to 
 employ the remedy freely and promptly, so as to effect the object, 
 bearing in mind the fact that the delay of half an hour or an hour 
 is often fatal. Relying upon the opiate, it is best not to add other 
 remedies, lest by increasing the bulk of the doses they will be more 
 
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 likely to be rejected. The patient in this stage should be restricted 
 to a very small quantity of water, or to small pieces of ice. Perfect 
 quiet is important. He should not be permitted to get up to go to 
 stools, and he should be urged to resist as much as possible the 
 desire to evacuate the bowels. 
 
 "I have repeatedly succeeded in arresting the disease by this plan 
 of treatment, and when arrested before proceeding to the stage of 
 collapse, the recovery is usually speedy. Regulated diet, rest, with 
 perhaps a tonic remedy, suffice for the cure. I believe no other plan 
 of treatment promises more than this, but it is not to be expected 
 thpt it will always prove successful. It will fail, or rather is not 
 available when, owing to the persistent vomiting and frequent purg- 
 ing, the remedy is not retained sufficiently long to exert its effect ; 
 and it is not available when the state of collapse occurs so quickly 
 that there is not time enough to obtain a remedial effect. These 
 difficulties are equally in the way of success from any remedies. 
 
 "In the stage of collapse the plan of treatment indicated prior to 
 this stage may prove not only ineffectual but hurtful. It is still an 
 object to arrest the discharge into the intestine if it continues ; but 
 to employ opiates very largely for this object may not be judicious 
 in this stage. The symptoms in this stage of collapse are due mainly 
 to the damage which the blood has stistained in the loss of its con- 
 stituents from the dischrirges which have already taken place. 
 Opiates should be given, but much care should be observed not to 
 induce narcotism. Astringent remedies, if the stomach will retain 
 them, may be added, such as tannic acid, etc. If, however, these 
 or other remedies provoke vomiting, they will be likely to do more 
 harm than good. 
 
 " In a large proportion of cases after collapse has taken place, 
 little can be done with much hope of success. Even if the vomiting 
 and purging cease, recovery may not follow. The blood may have 
 been damaged irremediably. Under these circumstances it is plain 
 that active treatment can effect nothing. Recovery, however, takes 
 place in a certain proportion of cases, and under a great variety of 
 treatment. It may take place when no treatment is pursued. My 
 first case of cholera, in 1849, illustrated the fact just stated. The 
 patient was brought into the hospital completely collapsed. 1 
 remained with him several hours, and resorted to various measures 
 of treatment. At length all remedies were discontinued ; he was 
 allowed to drink abundantly of cold water, under the impression 
 
CHOLERA. 
 
 97 
 
 that the case was utterly hopeless. Much to my surprise, after an 
 absence of several hours, I found the vomiting referred to had ceased 
 and reaction. was coming on; he recovered rapidly. I had been led 
 to doubt whether, in general, active treatment effects much for the 
 advantage of the patient in the collapsed stage of cholera, and I 
 cannot doubt that it is often prejudicial. The object of treatment 
 in this stage, aside from the arrest of vomiting and purging, is to 
 excite and aid the efforts of nature in restoring the circulation. The 
 measures to be employed for this object are external heat, stimulat- 
 ing applications to the surface, stimulants, and food. 
 
 " The application of heat may be made by means of warm blank- 
 ets or bottles of hot water placed near the body. Stimulants, in 
 the form of spirits and water, should be given as freely as the 
 stomach will bear, always recollecting the risk and the evils of 
 inducing vomiting. They will be most apt to be retained if given in 
 small quantities at a time, and often repeated, If vomiting be pro- 
 voked, either by drinks, remedies, or food, more or less injury is 
 done. Concentrated nourishment — essence of meat, chicken broth 
 and milk — is to be given in small quantities at a time, provided the 
 stomach will retain it. It is doubtless desirable to introduce liquid 
 into the system as far as possible. The only objection to drinking 
 water freely is the risk of promoting vomiting. Small lumps of ice 
 should be freely allowed. " 
 
 This description represents one of the chief lines of treatment 
 pursued in America. Another, which has also many advocates in 
 the medical profession, may be summarized as follows : During 
 the premonitory stage, including the diarrhea, reliance must be 
 placed upon rest, warmth, and mild but gently stimulating draughts, 
 paregoric, aromatic spirits of ammonia, tincture of ginger, with a 
 mustard plaster over the abdomen, and a hot mustard foot-bath if 
 coldness of the body increase and vomiting begin. 
 
 During the second, or rice-water stage, aromatics should be 
 given. A prescription much used and approved in India, is the 
 following : 
 
 Oil of anise, 
 
 Oil of cajeput. - 
 
 Oil of juniper, - 
 
 Ether, 
 
 Tincture of cinnamon, 
 
 Half a teaspoonful. 
 
 One teaspoonful. 
 Two ounces. 
 
98 
 
 CONSTITUTIONAL DISEASES. 
 
 / 
 
 Mix, and give ten drops in a tablespoonfui of water every fifteen 
 minutes. 
 
 Another formula, much used in this country, is as follows : 
 
 Chloroform, - - - A teaspoonful and a half. 
 
 Tincture of opium, - " " 
 
 Spirits of camphor, - " " . 
 
 Aromatic spirit of ammonia, " " 
 
 Creosote, . - - Three drops. 
 
 Oil of cinnamon, - - Eight drops. 
 
 Brandy, . - - Two drachms. 
 
 Mix. Dissolve a teaspoonful of this in a wineglassful of ice-water, 
 and give two teaspoonfuls out of this glass every five minutes, fol- 
 lowed each time by a lump of ice. — Hartshorn. 
 
 Bheumatism. 
 
 Several distinct affections are popularly included under this 
 term, rheumatism. First, an acute inflammatory affection of the 
 joints, called in medicine acute articular rheumatism. Second, the 
 disease, or perhaps series of diseases, called chronic rheumatism. 
 And third, muscular rheumatism. Indeed this term is popularly 
 applied with considerable license to almost any painful affection in 
 which there are no local signs of disease. 
 
 Acute Articular Rheumatism. 
 
 This disease affects the joints, as the name implies. It is 
 indeed an inflammation of a smooth membrane which lines the 
 joints, called the synovial membrane. At the same time it may 
 extend to other parts of the body containing this same membrane, 
 especially the heart. So long as the disease is conflned to the 
 joints it is not immediately dangerous; the peril to life consists in 
 the possibility that the inflammation may extend to the heart, in 
 which case there often results serious difficulty, which may cause 
 immediate death, or may result in permanent disease of the heart. 
 Perhaps the majority of cases of so-called organic heart-disease 
 originate in attacks of acute rheumatism. 
 
ACUTE ARTICULAR RHEUMATISM. 
 
 99 
 
 Symptoms, — Acute rheumatism usually begins with a sudden 
 attack, which may occur in the night. In some cases the manifesta- 
 tion of local difficulty — that is, pain in the joints — may be preceded 
 for a few hours or days by more or less fever. In most instances, 
 however, the fever and the local pain begin at about the same time; 
 it may indeed happen that soreness in the joints is felt for some 
 time before the fever begins. 
 
 The commencement of the disease consists in a painful swelling 
 in one or more joints, the skin around which is red and tender, the 
 intensity of the pain varies, but in most cases it is quite severe, and 
 becomes agonizing upon movements of the inflamed joints. Perfect 
 quiet is therefore requisite as one of the essentials for diminishing 
 pain. Pressure, too, over the joints'ls extremely painful, so that 
 even the weight of the bed clothes is at times unsupportable. Those 
 joints which are not covered by the muscles — the knee, wrist, elbow 
 and ankle for example — exhibit considerable swelling; while others, 
 such as the shoulder and hip, may be equally affected and equally 
 painful, but show only slight swelling. In some cases several joints 
 become inflamed at the same time, or in rapid succession, in others 
 the inflammation usually remains limited to one joint for some time 
 before spreading to others ; it rarely happens that the inflammation 
 is permanently limited to a single joint, since several joints are success- 
 ively atldcked, and various ones may be suffering from the inflam- 
 mation at the same time ; in severe cases it seems as if nearly all the 
 joints of the body were invaded by tlie disease during its course. It 
 is a singular feature in the disease that the corresponding joints 
 on the two sides of the body, both knees or both elbows for instance, 
 are simultaneously affected. The relative liability of the different 
 joints to the disease appears to be, first the knee, then the ankle, 
 wrist, shoulder, elbow, hip and fingers. 
 
 Acute rheumatism is always associated with more or less fever, 
 and is hence often called rheumatic fever. The appetite is impaired 
 or lost, there is great thirst, the tongue is thickly coated, the bowels 
 usually constipated. A special feature is' the profuse sweating 
 which occurs, especially at night ; the perspiration evolves a sour 
 odor. The mind is usually not impaired, unless the membranes of 
 the brain become involved in the inflammation. The patient's 
 strength is usually well preserved, his chief suffering consisting in 
 the pain in the joints. 
 
lOO 
 
 CONSTITUTIONAL DISEASES. 
 
 
 \ 
 
 Although the local inflammation in the joints may result in some 
 permanent stiflhess or deformity, yet the chief danger from the dis- 
 ease occurs, as has been stated, from the possible complication in 
 the heart, for the heart is lined by a membrane quite simiia*" to that 
 of the joints, and is covered over with another such membrane ; 
 either one or both of these may become the sent of the inflamma- 
 tory process, a complication which may occur at any time in the 
 course of the disease, though most frequently in its first half. 
 
 The various structures in the lungs and bronchial tubes seem 
 also liable to the rheumatic inflammation, though these complica- 
 tions are somewhat rare. The brain, too, is enclosed in membranes 
 similar to those of the joints, and these membranes may undergo the 
 same inflammatory process. In such cases active delirium, convul- 
 sions, and, finally, stupor may occur, though delirium doubtless 
 often occurs without there being any inflammation of the membranes 
 in the brain. 
 
 The natural duration of the disease varies, within wide limit, 
 from two weeks to two months, the average being perhaps about 
 four weeks. Its course can be considerably shortened by various 
 modes of treatment, and in the majority of cases cun be stopped 
 abruptly within two days by means to be presently described. If, 
 however, the heart complications occur, the illness may be indefi- 
 nitely prolonged. The joints, it is true, recover, but the patient 
 convalesces very slowly. 
 
 Another unpleasant feature in the disease is its liability to re- 
 commence when apparently about concluded ; that is to say, the 
 patient will sometimes, after weeks of illness, become quite free from 
 fever and pain, the joints are no longer swollen nor tender, and 
 complete recovery seems to be at hand, when suddenly the disease 
 begins again affecting perhaps the same joints as before, and mani- 
 festing the same intensity. 
 
 Cause,- -The popular idea attributes rheumatism to exposure to 
 cold. There may be, and doubtless is, some truth in the idea that 
 such exposure promotes the development of the disease. Yet it is 
 none the less certain that there is a certain predisposition to it ; that 
 the disease runs in certain families only as a rule. An individual 
 in whose family rheumatism has not occurred may, it is true, in ihe 
 course of time develop the disease ; but the majority of instances 
 occur in people who have a hereditary tendency to it* This is in- 
 
ACUTE ARTICULAR RHEUMATISM. 
 
 101 
 
 dicated by the occurrence of rheumatism in childhood, and by the 
 repetition of the disease in the same individual. Age, too, seems 
 to have a decided effect upon the susceptibility to the disease ; for 
 it rarely occurs, even among those who have a constitutional tend- 
 ency to it, under the age of fifteen years — the great majority of 
 cases occurring between the ages of fifteen and thirty years. It is 
 very rare to find an individual more than thirty years old who is 
 suffering from the first attack of the disease. Hence, it appears, 
 that the liability to acute rheumatism decreases after this age, and 
 becomes very slight after fifty years of age. 
 
 Trentniefit. — Until a few years ago, the treatment of acute 
 rheumatism was not entirely satisfactory, as was proven by the 
 fact that many methods were in use. The best results had been 
 obtained by the use of alkalies, with or without colchicum. A 
 formula frequently used was the following: 
 
 Carbonate of potassium, > c- i «. i i ir j i 
 
 ■KT. ^ e r • „ i bach two and a-half drachms 
 Nitrate of potassium. > 
 
 Water, eight ounces. 
 
 Dissolve and take a tablespoonfu) three times a day. 
 
 Much value seemed to be obtained also from the use of lemon- 
 juice in water, say a tablespoonful e very three hours. Yet, since 
 1876, there has been but little resort to these measures, because 
 means have been found by which the disease can be promptly and 
 effectually checked. Under the use of tlie alkalies and lemon-juice, 
 the patient was usually ill for two or three weeks at least, and ran 
 the risk of complications in the heart, which might prolong the dis- 
 ease indefinitely. At present, however, we are enabled to cut short 
 acute rheumatism usually within three days, sometimes within 
 twenty-four hours ; and not the least valuable feature of this 
 treatment is the avoidance of the heart complications, which often 
 prove the most serious feature of the entire illness. The measure 
 employed for this purpose is the use o{ salicylic acid, or some of its 
 compounds. The best form for general use will be the compound 
 of the acid known as the salicylate of sodium, which is less disa- 
 greeable and more easily administered than the acid itself. Perhaps 
 the best way to take it is in powder, ten grains of which may be 
 taken every two hours until six doses have been swallowed. It may 
 thon be desirable to discontinue the drug for six hours. If, 
 at the end of this time, the symptoms of the disease have not 
 
I02 
 
 CONSTITUTIONAL DISEASES. 
 
 materially subsided, the powder may be administered in the 
 same way and quantity for another twelve hours. In the ma- 
 jority of instances the remedy works like a charm, especially if 
 it be administered early in the disease, before complications have 
 arisen in other structures than the joints. The fever subsides, the 
 joints are less sore and not at all painful, the appetite returns, and 
 not infrequently the patient who a day previously was writhing in 
 agony upon the slightest movement, flushed and feverish, rises 
 from his bed and walks without pain. It must be said that this 
 result cannot always be depended upon. If the case has already 
 lasted one or two weeks, the drug does not always act so promptly 
 nor so efficiently, though even then it is usually the best treatment 
 that can be em'^loyed. Then again, there are cases in which the 
 disease is not very acute nor painful, in which the swelling of the 
 joints is moderate and the fever slight. These cases are apt to be 
 especially obstinate, and to resist the action of salicylic acid. It is 
 impossible to say in advance which of the cases will yield, and 
 which will resist this drug, although one may feel sure of the cases in 
 which the fever is high, and be somewhat doubtful in regard to those 
 in which the fever is very moderate. Yet in every case we should 
 begin the treatment — and the earlier the better — with the salicylic 
 acid. If this drug be efficient in controlling the case, the fact will 
 be evident within three days, at the outside, in the rapid diminu- 
 tion of the pain, swelling and fever. If, at the end of three days, 
 there be no evidence of improvement, it will be wise to resort to 
 the alkalies, as in the formula above given, and the lemon juice. 
 
 Local treatment may also be used for the swollen joints; these 
 may be enveloped in flannel or cotton wool, which may be sur- 
 rounded with oiled silk. Or the swollen joints may be wrapped up 
 in cloth saturated with chloroform liniment, as it is obtained in the 
 drug store. Much benefit is derived in some cases by gentle friction 
 of the joints with the dry hand or with chloroform liniment. The 
 choice of measures may be left largely to the selection of the 
 patient, since some individuals will prefer one and some another of 
 these local applications. In employing the friction, the pressure 
 must be at first, of course, extremely light, to avoid giving pain; 
 though many times the force employed can be gradually increased 
 with comfort to the patient until the attendant may use as much pres- 
 sure as he can conveniently employ. A method which has been 
 recently much employed consists in the application of fly blisters to 
 
CHRONIC RMUUMATISM. 
 
 103 
 
 the affected joints, permitting them to remain until some blistering 
 occurs. This plan doubtless relieves temporarily the pain in the 
 particular joint which is blistered, but seems to have no effect upon 
 the progress or course of the disease. On the whole, it is an unde- 
 sirable measure, since the blisters may subsequently give trouble. 
 
 Chronic Rheumatism. 
 
 This name should, according to all medical usage, represent 
 the continuation of an acute rheumatism in a less violent and pain- 
 ful form, and such cases are actually found under the name chronic 
 rheumatism. Yet this name, as ordinarily employed, designates 
 several affections, all of which are characterized by pains in the 
 joints or in the muscles, which have a tendency to persist indefinitely. 
 There is a form of chronic rheumatism which affects the patient like 
 the acute disease, except that the symptoms are less marked ; there 
 may be no fever, the pain and soreness are less intense, the tender- 
 ness on pressure is comparatively slight, and the swelling of the 
 joints may be scarcely noticeable. As in the acute variety, various 
 joints are affected successively; the disease may finally become con- 
 centrated and remain fixed in a single joint. In this disease there 
 is but little disturbance of the general health, insufficient, indeed, 
 to disturb the patient's avocation. Yet there are instances in which 
 movements of the affected part cause considerable pain, and 
 patients may be even confined to the bed. After long continuance 
 of the disease the affected joints may present irregular enlargements 
 and stiffenings, while the muscles of these limbs become small from 
 lack of use. 
 
 In many cases of acute rheumatism, the severity of the pain 
 varies extremely with the weather ; so that such individuals are 
 usually able to foretell, by a few hours, the occurrence of cold and 
 moist weather. There is a variety of rheumatism, so-called, in 
 which the pain is felt chiefly along the Itg bones, the " shins," and 
 occurs especially at night. This affection is often due to a syphilitic 
 taint, and will be discussed in speaking of syphilis. 
 
 Treatment, — One of the most important features of treatment 
 of chronic rheumatism, is care in wearing flannel next to the skin 
 throughout the year. The administration of drugs is by no means 
 
I04 
 
 CONSTITUTIONAL DISEASES. 
 
 certain to produce beneficial results. Some cases are materially 
 benefited by the regular employment of the hot air, or hot vapor 
 bath, the Turkish bath, etc. The fact is, that the treatment of 
 each case of chronic rheumatism is largely an experiment which 
 can be successfully accomplished after considerable time has been 
 spent in trials of drugs and remedial measures. Among the 
 medicines which are most frequently useful, are the iodide of potas- 
 sium, guiac, and cod liver oil. The following formula may be 
 given : 
 
 Iodide of potassium, - - - Five drachms. 
 
 Tincture of guiac, ... Two ounces. 
 
 Water, _ . . _ Two ounces. 
 
 Mix, and take a teaspoonful four times a day. 
 
 Other cases will be benefited by using colchicum with the 
 alkalies. An example of such mixture is the following : 
 
 One drachm. 
 Three drachms. 
 Three drachms. 
 Four ounces. 
 
 Wine of colchicum root, 
 
 Bicarbonate of potassium, 
 
 Rochelle salts. 
 
 Peppermint water 
 Take a tablespoonful three times a day. 
 
 Some of the various ..lineral waters are reputed to be efTica- 
 cious in the treatment of chronic rheumatism, though they 
 generally seem to be valuable, if at all, merely as a subordinate 
 element in the treatment. 
 
 Muscular B^domatism. 
 
 Although this affection is designated rheumatism, there is every 
 reason for believing that its cause is quite different from that of the 
 disease just described; It seems to be of the same nature as neu- 
 ralgia, and might properly be so described, though it is convenient 
 to follow the usual designation as already given. 
 
 Symptoms. — The disease is usually developed gradually. A 
 dull pain is felt in certain muscles, gradually increasing until it be- 
 comes quite severe. The pain is usually increased upon movement, 
 sometimes becoming convulsive and cramp-like, causing the patient 
 to groan, or even cry aloud. These movements, and the consequent 
 
MUSCULAR RHEUMATISM. 
 
 105 
 
 pain, may occur during sleep and awaken the patient. The muscles 
 thus afTected are somewhat tender upon pressure, but present no 
 other signs of disease, such as swelling or redness. The constitu- 
 tional condition is otherwise good, and no interference occurs in the 
 bodily functions except such as are consequent upon the painful 
 movements. 
 
 Th*^ duration of this disease may vary from a day to a week, 
 or may last, in less severe form, indefinitely. The muscles most 
 apt to be aflfected are those of the forehead and of the temples. 
 Another familiar example is in the neck, resulting in what is popu- 
 larly termed " wry-neck. " The pain may also be located in the 
 niiiscles of the back and loins, constituting the affection known as 
 lumbago. It occurs not infrequently in the muscles of the chest, 
 where it may for days render deep breathing impossible without 
 pain. 
 
 Wherever it may occur, the characteristic feature of muscular 
 rheumatism is the occurrence of cramp-like pain, aggr:'ated by the 
 movement of the part. In this particular it is distinguished from 
 neuralgia, which is a constant pain, affecting perhaps the same 
 localities. This form of rheumatism is undoubtedly promoted by 
 exposure to cold, and seems often to result from getting the feet 
 wet. The treatment should consist in improving the general con- 
 dition by such measures as will invigorate the health. In the acute 
 cases benefit can also be derived from the use of liniments and of 
 gentle friction. 
 
 Oout. 
 
 Gout is closely related to articular rheumatism; indeed, by some 
 the two diseases are regarded as essentially identical. However, 
 they are so distinct in their symptoms and course as to be generally 
 recognized and described as distinct diseases. They may be 
 regarded as allied, just as typhoid and typhus fever are allied. 
 Gout occurs both as an acute and a chronic disease. 
 
 SymptoniH. — In describing the symptoms, it becomes neces- 
 sary to distinguish between the transient acute cases, and those of 
 long duration, called chronic. The acute attack usually occurs 
 suddenly, often during the night. In many cases the patient has 
 
io6 
 
 CONSTITUTIONAL DISEASES. 
 
 retired in his usual health, though in others there may be certain pre- 
 monitory symptoms, such as pain in the region of the heart, belch- 
 ing of g.ns from the stomach, and mental depression or irritability. 
 These symptoms so frequently precede an attack of gout that many, 
 who have already experienced one attack, recognize in these symp- 
 toms the onset of another. The attack itself begins by extreme 
 pain in oneof the joints, usually that between the great toe and the 
 foot. This pain is variously described by patients as like that of 
 the gnawing of an animal, the dislocation of the bone, or like tear- 
 ing the flesh with pincers. A feeling of throbbing accompanies 
 the pain, and there is usually considerable fever, sometimes pre- 
 ceded by a chill. These features continue for several hours before 
 subsiding; at the end of this time the patient is reasonably com- 
 fortable, and usually falls asleep. 
 
 This attack is usually followed on succeeding nights by repeti- 
 tions of a similar nature; either during these repetitions, or perhaps 
 during the first attack, the painful joint becomes swollen, reddened 
 and exquisitely tender. The local affection may be limited to the 
 joint originally affected, but often attacks also the corresponding 
 joint of the other foot, or spreads to the instep and hollow of the 
 foot. Indeed, in individuals who have repeatedly suffered from this 
 disease, numerous joints in different parts of the body, even of the 
 hands, may become similarly affected. In many cases the pain 
 lasts but a few hours, and returns again on the following night. 
 There are instances, however, in which the pain merely decreases 
 in intensity during the day without entirely ceasing. Cramp may 
 affect the muscles of the legs, the thigh, and even other parts of 
 the body, though this is a somewhat unusual symptom. These 
 attacks may return nightly for a week or for several weeks. The 
 long continued attacks are usually less severe than the brief ones; 
 the result may be entire recovery or continuation as the chronic 
 form of the disease. Chronic gout may be the result of a series 
 of acute attacks of gout, or may begin in a very mild manner. In 
 either case the symptoms which characterize the acute affection are 
 present in but slight degree. The disorder is rather a constitu- 
 tional one, that is to say, the symptoms manifested in the foot are 
 so slight that attention is directed to the constitutional derange- 
 ment. There are usually disorders of indigestion — dyspepsia, 
 pain in the stomach, derangement of the bowels. In many cases 
 these derangements have caused serious impairment of the general 
 health. 
 
 \ 
 
 ;; .ill: 
 
OOUT. 
 
 107 
 
 Sooner or later there occurs in the chronic cases of gout a con- 
 dition quite characteristic of this atTcction : masses resembling chalk 
 arc formed in and around the small joints, and, indeed, some of the 
 lar^je ones ; the joint of the great toe is especially apt to exhibit 
 this appearance. As a result, the joints become deformed, stiffened 
 and even incapable of any movement. Sometimes collections of 
 this chalk-like matter can be felt just under the skin, and if opened 
 this matter can be pressed out. Sometimes matter forms around 
 these masses and makes its way through the skin, resulting in the 
 formation of openings, called fistnlie. The result of all these 
 changes is that both hands and feet become strangely deformed, 
 presenting apprearances which have been likened to a bunch of 
 parsnips. Similar formations of chalk-like matter have been known 
 to occur in various parts of the skin, on the eyelids and in the ear. 
 
 Tiiere has long been an impression among medical men, wbi^ h 
 has become a popular belief among the people, that gout may be 
 manifested, not merely in th-. joints, but also in the internal organs, 
 such as the stomach, heart and brain. Disorders which affect thest 
 organs during an i.ack of gout are supposed to be due to the 
 gouty influence; the gout has " struck in. " This expression is par- 
 ticularly applicable to those attacks of gout during which the affec- 
 tion of the joints suddenly ceases, and symptoms indicating some 
 derangement of some internal organ follow. There is, doubtless, 
 some connection between the local attack and the affection of the 
 internal organs. This is amply shown in the fact that remedies 
 addressed to the gout relieve these symptoms. 
 
 Those who have long been subject to gout usually present 
 certain disorders which constitute the dangers of the disease ; for 
 the local affection of the feet, or of the hands, however painful and 
 unsightly, contains no element of danger to the patient. One of 
 the most serious complications occurring in gouty patients is a dis- 
 ordered action of the heart. This disorder occasions not only pal- 
 pitation, shortness of breath, sense of suffocation and pain in the 
 region of the heart, but may even cause sudden death, in conse- 
 quence of the sudden stoppage of the heart's action. Various 
 affections of the lungs also are popularly, and doubtless properly, 
 attributed to the gout. Among these are persistent cough, bron- 
 chitis and asthma. The explanation of many an intractable case of 
 asthma has been found in the gouty condition of the patient, and 
 relief from the asthma has followed remedies addressed to the gout. 
 
 
io8 
 
 CONSTITUTIONAL DISEASES. 
 
 1 
 
 I) 
 
 So, too, various pains designated as neuralgia, — particularly neu 
 ralgia of the face and of the iiip (sciatica) — periodical headache 
 and even hysteria, seem to be promoted by the gouty condition of 
 the patient. 
 
 Another most serious complication of the gout is a disease of 
 the kidney, one form of the so-called " Bright's disease." This dis- 
 ease is so common among those affected with gout that the sm.ill, 
 hard kidneys characteristic of this affection are called " gouty kid- 
 neys. " This form of Bright's disease is not indicated by the symp- 
 toms characteristic of the ordinary acute Bright's disease ; there is 
 no dropsy, no fever, in fact none of the usual signs. The most 
 characteristic feature, at least the one most readily recognized by 
 the non-professional observer, is the fact that the patient passes an 
 unusually large quantity of urine. These patients are almost always 
 advanced in years. 
 
 Cause. — Gout, like rheumatism, is a disease occurring with 
 especial frequency in certain families. It is, indeed, largely the 
 result of a hereditary taint, which may be transmitted through sev- 
 eral generations ; yet it is not always so inherited, since i-: may be 
 as readily acquired by errors in diet and the mode of life. Nor docs 
 it follow that the children of gouty parents will themselves necessa- 
 rily suffer from gout. The tendency to the disease varies also with 
 the age ; it rarely occurs at an age under fifteen years, und then 
 only in the children of gouty parents. It affects most frequently 
 middle life, thirty to fifty years. Sex, too, exerts a marked influ- 
 ence over the disease, sinre women are very rarely affected with 
 gout. But the most direct and powerful influences leading to the 
 acquirement of gout seem to be the habitual use of over-stimulating 
 food, and of wine or malt liquor. The disease is proverbially fre- 
 quent among the wealthier classes of society, who are addicted to 
 luxurious habits of life, so that gout is regarded generally as one of 
 the penalties of wealth. It is impossible to ascribe accurately and 
 definitely the e.xact influence exerted by each one of the factors 
 which enter into a lu.xurious life ; it is, however, certain that over- 
 indulgence in the pleasures of the table, even without the use of 
 liquors, promotes the production of this disease. As a matter of 
 fact, gout is by no means a monopoly of the wealthy, since it is 
 quite common among the London laborers who dr-nk porter and 
 stout to excess. 
 
GOCJT. 
 
 109 
 
 Treatment, — One of the most important measures in the 
 treatment of gout consists in the regulation of the diet; the avoid- 
 ance of excesses at the table and in the use of liquors is an evident 
 necessity. Among the remedies used during the attack, reliance is 
 chiefly placed upon colcfncum and alkalies. Instead of the latter, 
 various mineral waters have been highly recommended by different 
 authors; perhaps the most noted and universally used of these is 
 the so-called " Lithia Water," which may be obtained at the drug- 
 gist's. This is. in reality, not a natural mineral water, but an artificial 
 solution made by dissolving the citrate of lithia. If this be not 
 procurable, a solution of magnesia and colchicum may be em- 
 ployed as follows: 
 
 Wine of colchicum root, - - - One drachm. 
 
 Magnesia, ------ One drachm. 
 
 Peppermint water, . . _ - Four ounces. 
 Mix; take a tablespoonful three times a day. 
 
 It may be necessary also to protect the inflamed joint; this may 
 be accomplished by the means prescribed in treating of rheuma- 
 tism — by enveloping the joint in cotton, or by wrapping it with 
 cloths which have been saturated with the tincture of belladonna or 
 with the tincture of aconite. The chloroform liniment will also be 
 found advantageous for local use in this affection. During the par- 
 oxysms it may be necessary to relieve pain by the use of opiates; 
 for this purpose twenty drops of laudanum, or ten grains of Dover's 
 powder may be employed. If the opiate cause unpleasant effects, 
 such as nausea and headache, we may substitute teh drops of the 
 tincture of belladonna, which may be repeated in two or three 
 hours. In the intervals between the attacks the diet must also be 
 restricted — should embrace no wines or malt liquors, and but 
 little, if any, meat; a simple, unstimulating diet of milk, eggs, fish 
 and vegetables will materially assist in preventing the return of the 
 attack. So, too, the remedies useful in treating the paroxysm — 
 especially the colchicum — may be continued during the intervals 
 between the attacks. If the indications, such as dyspeptic symp- 
 toms, render the patient suspicious of an approaching attack, it will 
 be well to employ the colchicum and the alkalies in advance. For 
 there is reason to believe that impending attacks can be in this way 
 warded off. 
 
 The local affections of the joints may sometimes require atten- 
 tion after the severity of the paroxysm has subsided, for, as already 
 
no 
 
 CONSTITUTIONAL DISEASES. 
 
 said, the joints are often rendered permanently stiff and deformed by 
 the deposit in and around them of chalk -like masses. This stiff- 
 ness can be sometimes partially relieved by systematic gentle 
 friction, and by the arrangement of the shoes so as to afford the 
 parts ample room. The swelling can be sometimes diminished 
 before the deposit of chalk is apparent, by the use of repeated 
 blisters, not allowed to remain long enough to produce' excessive 
 blistering. After this chalk -like matter has been deposited in 
 abundance no measures can be successfully applied for its removal. 
 
 With reference to the use of mineral waters. Dr. Garrod, the 
 most eminent authority oi this subject, says : " They should be 
 altogether prohibited when there is considerable structural disease in 
 any important organs, especially in the heart or kidneys ; and even 
 when the organic mischief is slight, the greatest caution is necessary 
 in their use. They should be avoided when an acute attack is 
 either present or threatening. 
 
 " The waters should be selected according to the nature of the 
 case. When the patient is robust and of a full habit, the alkaline- 
 saline springs; when torpidity of the bowels predominates, the 
 purgative waters; when there is a want of vascular action, the 
 saUne water ; when the skin is inactive, the sulphur springs ; lastly, 
 when debility prevails, ihen the more simple warm waters should 
 be chosen. In all cases the use of the waters should be cautiously 
 commenced, and care taken not to oppress the stomach by giving 
 too much liquid, nor to induce debility or any other injurious 
 effects by allowing a too long sojourn in the bath." 
 
 Rheumatic Gout. 
 
 This term is much used to denote a combination of the two 
 diseases, rheumatism and gout ; a use which is rarely proper, since 
 the two diseases seldom occur in the same individual. The proper 
 use of the term is to designate an affection which is neither rheuma- 
 tism nor gout, but presents some of the characteristics of one or 
 the other, or both, of these diseases. To prevent this misunder- 
 standing, it has been proposed to call the disease in question rheu- 
 mato diarthritis. This disease is either acute or chronic, usually 
 the latter. In the acute form, if the larger joints are affected, it 
 
RHEUMATIC GOUT. 
 
 Ill 
 
 resembles acute rheumatism, though the fever is less marked, and 
 the joints more swollen than in rheumatism ; moreover, there is not 
 the same tendency to spread from one joint to another, nor is there 
 danger of inflammation in and around the heart. The chronic form is 
 distinguished, also, from rheumatism by the amount of liquid in 
 the affected joints, and by the tendency to destroy the ends of the 
 bones constituting the joints. One of the most characteristic 
 features is a tendency to a peculiar distortion of the fingers, which 
 are directed toward the outer side of the hand, and cannot be 
 retained in their proper position. Rheumatic gout occurs at all 
 periods of life, most commonly in people suffering from feeble 
 health. It is said to be especially apt to affect the children of con- 
 sumptive parents, and the offspring of gouty or rheumatic persons. 
 " It fixes upon the girl just arriving at puberty, in whom the uterine 
 functions are not well performed ; it invades the stiffening joints of 
 the woman who has arrived at that time of life which is marked by 
 the cessation of the monthly periods ; it shows itself during the 
 state of debility which follows in a miscarriage or a difficult and 
 protracted labor, more especially when accompanied by flooding ; 
 it is a frequent attendant upon kidney disease, and upon the ill 
 health produced by syphilis, or gonorrhoea ; it is a common sequel 
 of prolonged suffering, of excessive venery, of severe and long- 
 continued mental exercise, and of mental distress and bodily 
 exhaustion. " — Fuller. 
 
 Treatment, — Since this disease rarely occurs, so long as the 
 health is kept at par, it may be laid down as a general principle, 
 that the first object of treatment is almost invariably the improve- 
 ment of the individual's general condition. For this purpose, 
 hygienic measures — food, air, exercise — should be carefully regula- 
 ted ; and, in addition, it may be advisable to take some of the 
 usual tonics containing iron. There may be, of course, in every case 
 special circumstances which require particular attention. 
 
 The swollen joints require especial attention, not simply to 
 relieve the painful symptoms, but also with the hope of checking 
 the inflammation, so as to prevent the destructive results which often 
 occur in the joints. It is absolutely necessary that the joints be kept 
 perfectly quiet; they should be enveloped in hot cloths enclosed in 
 oiled silk. Sometimes advantage may be derived from the appli- 
 cation of the tincture of iodine to the skin; this may be painted on 
 
112 
 
 CONSTITUTIONAL DISEASES. 
 
 with a camel's hair brush or with a piece of soft rag, or small fly 
 blisters may be applied to the swollen joints, first on one side and 
 then upon the other, so as to keep up a certain amount of irritation 
 for several days. These measures (the iodine and the blisters) are 
 beneficial after the acuteness of the pain has subsided. So long as 
 the symptoms are violent, it will be better to keep the joints wrapped 
 in flannels wrung out of hot water, A considerable degree of 
 stiffening often persists for a considerable time, and may be relieved 
 by passive motion of the limbs ; that is, having them gently bent 
 by the attendant, and by gentle friction with some liniment, such as 
 the chloroform liniment. 
 
 Scurvy. 
 
 This is a disease long known, which formerly proved exceed- 
 ingly destructive, both in cities and among armies, and it was the 
 bane of ocean voyages, particularly the long ones which were 
 inevitable before the application of steam to navigation. This disease 
 caused enormous loss of life in the English and French armies dur- 
 ing the war of the Crimea ; and the United States forces were 
 materially weakened by it during the war with Mexico. At present 
 the disease is quite controllable, and has lost the terrors which it 
 formerly inspired. It now occurs only as the result of ignorance or 
 neglect to comply with known rules of health. 
 
 Sf/mptomH. — The characteristic features which mark the onset 
 of the disease are usually preceded for several weeks by general 
 languor and weakness ; the patient is listless and indisposed to exer- 
 tion, mental or physical ; he loses flesh, becomes pallid, the appetite 
 fails, and digestion is impaired. The first symptoms are swelling of 
 the gums, which become quite spongy in texture and bleed upon 
 the slightest pressure, or even spontaneously ; the gums are espe- 
 cially swollen and spongy around the teeth, and these become loose 
 and fall out, or may remain sticking in the food. Meanwhile blood 
 may escape also from other mucous membranes, from the nostrils, 
 the chest and the bowels; sl'ght hemorrhages, too, occur in the skin 
 forming reddish spots of varying size, which subsequently undergo 
 the usual changes of color observed in "black and blue" spots ; these 
 
SCURVY. 
 
 113 
 
 spots are produced spontaneously, and are formed whenever even 
 tlic slightest bruise is inflicted upon the skin. 
 
 In a short time the body becomes somewhat swollen, especially 
 the feet, ankles and face. The patient complains of pain, chiefly in 
 the lower limbs, but also in the small of the back and loins. The 
 muscles of the legs become hard and swollen. The depressions in 
 the skin of the thigh, which indicate the hollows between the muscles, 
 an; often streaked with blood ; slight pressure over the lower limbs 
 usually causes considerable pain. The blood, which has escaped 
 into the spaces between the muscles, sometimes interferes seriously 
 with the movements of the patient, who is therefore compelled to 
 seek comfort in the recumbent posture. In fact, after a few days 
 the patient's strength is so much reduced that he can walk with diffi- 
 culty, if at all. He is short of breath and exhausted by the slightest 
 exertion. In extreme cases, indeed, the attempt to rise or to walk 
 induces fainting, or even serious collapse. The eyesight becomes 
 impaired, so that the patient may be practically blind. The mental 
 faculties usually remain natural, though delirium may finally occur. 
 The lips become almost as blanched as the skin, and the eyes some- 
 times present a curious and startling appearance, because the part 
 that is naturally white is thickly streaked with red, while the red 
 membrane of the lid has become quite white. 
 
 Scurvy is to-day a comparatively unimportant, because easily 
 controlled, disease, and the cases are rare in which the patient can- 
 not be restored to health by proper treatment, however exhausted 
 and pallid he may be. Under certain conditions, where it is im- 
 possible to obtain the necessary remedies, however, scurvy is still 
 a fatal disease. Even during the late civil war in America, very 
 many soldiers became victims to it. 
 
 Tiwatment, — The treatment of scurvy consists in the adop- 
 tion of those measures which, if earlier used, prevent the disease 
 entirely. It is now pretty generally known that the disease results 
 from lack of vegetable food, or perhaps it would better to say, of 
 fresh food. It is only in the absence of sucn supplies that the 
 disease occurs ; a fact which accounts for its especial prevalance on 
 military and naval expeditions, upon long sea voyages, etc. If the 
 patient be not yet extremely exhausted, no other treatment is 
 necessary than a reasonably abundant supply of fruits and vege- 
 tables. Flesh is, of course, not injurious, and may be taken in 
 
 8 
 
114 
 
 CONSTITUTIONAL DISEASES. 
 
 i 
 
 t t 
 
 proper quantities in order to promote the strength. During sea- 
 sons when it is impossible to obtain fresh vegetables, an excellent 
 substitute will be found in lemon juice, which may be taken in such 
 quantities as the stomach can endure, say at least three ounces daily 
 If lemon juice also be unobtainable, good can be derived from an 
 abundant supply of /rr^// meat, though the patient's improvement 
 under this treatment will be by no means so rapid. 
 
 If the patient be much exhausted when treatment is com- 
 menced, caution must be exercised in permitting him fruits and 
 vegetables, since the stomach will be unable to retain as much as 
 he will desire to eat. In such cases small quantities of fruits and 
 vegetables may be permitted at short intervals, the amount being 
 increased as rapidly as the patient's digestive powers will permit. 
 Such cases of extreme exhaustion will be benefited by alcoholic 
 stimulants, especially wines. The condition of the gums can be 
 improved by gently rinsing the mouth with a solution of tannic acid 
 in glycerine and water (one drachm of the acid to two ounces 
 each of glycerine and water); or alum may be dissolved in brandy 
 and water. 
 
 Since the origin of scurvy is thus known, it is desirable to 
 adopt such precautions as will prevent the disease, rather than to 
 wait for a chance of curing it. It is now generally understood 
 that any expedition which will be deprived of opportunities for 
 obtaining fresh food, should be amply supplied with the best pos- 
 sible substitutes for it. Experience has shown that the best pos- 
 sible substitute is potatoes eaten raw; onions, tomatoes, turnips, cab- 
 bage, corn, apples, sauerkraut, are all valuable. Yet for long voyages, 
 the most convenient of the reliable preparations is, of course, lemon 
 juice. A daily allowance of one to two ounces of fresh lemon 
 juice has been amply proven by the experience of naval expeditions 
 to prevent the outbreak of scurvy. 
 
 Purpura Hemorrhagica. 
 
 This term refers simply to the existence of purple spots in the 
 skin, resulting from the escape of blood. It is always easy to dis- 
 tinguish between a spot due simply to inflammation and one due 
 to the escape of blood into the meshes of the skin. In the former 
 
 
PURPUKA llEMl>kkUAGlCA. 
 
 ii5 
 
 case (as in the rash of scarlatina or measles) there is no rupture of 
 blood vessels ; hence, if we press the finger upon one of these spots 
 fur an instant, and then remove it, the spot has disappeared and 
 the skin is momentarily white. When, on the other hand, the red- 
 ness of the spot is due to the presence of blood in the meshes of 
 the skin as a result of the rupture of blood vessels, such pressure 
 of the finger does not cause the disappearance of the color ; these 
 latter spots are characteristic of the disease in question. 
 
 Such spots may, it is true, occur in the course of several dis- 
 eases, such as typhus and typhoid fevers, and cerebro-spinal menin- 
 gitis ; and, as just remarked, they are present usually in large 
 numbers in scurvy. Yet there is recognized in medicine a condi- 
 tion characterized by many of the appearances of scurvy, among 
 them these extensive ruptures of blood vessels in the skin, whence 
 the disease has received the name purpura hemorrhagica. The 
 disease is distinguished from scurvy by the fact that there is less 
 swelling of the gums, which may, indeed, remain entirely unaf- 
 fected. There is rarely so much swelling and stiffness of the 
 muscles, and the disease does not seem definitely traceable to the 
 lack of vegetable food. Furthermore, the treatment which is so 
 efifectual in relieving scurvy (the use of fresh food and vegetables), 
 is by no means so certain to effect relief in purpura as in scurvy. 
 Purpura seems to occur in consequence of reckless violation of the 
 laws of health, or of privation and suffering. The danger from it, 
 like that from scurvy, consists in the general exhaustion conse- 
 quent upon this condition, and also in the possibility that such 
 large amounts of blood may be lost during the hemorrhages from 
 mouth, nose, throat, and intestines, as to seriously endanger the 
 patient's recovery. 
 
 The object of the treatment is the restoration of the natural 
 condition of the blood, increase in the vital powers generally, and 
 the arrest of hemorrhage. To accomplish these ends medicines 
 arc of little avail without the use of food in proper quantity and 
 quality, and the avoidance of any unnecessary demands upon the 
 patient's health or strength. The treatment, therefore, should 
 consist of generous diet, re-enforced by wine ; while vegetables 
 should, of course, constitute a part of the diet, they are not so 
 essential to success as is the case in the treatment of scurvy. 
 

 'B: 
 
 Il6 
 
 CONSTITUTIONAL DISEASES. 
 
 It sometimes becomes necessary to administer remedies which 
 shall check the escape of blood. For this purpose half a teaspoon- 
 ful of the tincture of ergot may be given every four hours until si.\ 
 doses have been taken. Some have recommended the oil of 
 turpentine, a tablespoonful of which has been given in half a glassful 
 of milk. The skin may be sponged with whisky and water or with 
 a solution of alum (on- ounce), in brandy (six ounces). 
 
 Tonic remedies are useful ; two grains of quinine should be 
 taken three times a day, either in powder or in the following pre- 
 scription : 
 
 Quinine, ------- One drachm. 
 
 Dilute sulphuric acid, - - - - Four drachms. 
 
 Water, To make four ounces. 
 
 Take a teaspoonful in water before meals. 
 
DISEASES OF THE THROAT AND GHEST. 
 
 AFFECTIONS OF THE LARYNX. 
 
 Catarrh of the Larynx. 
 
 In treating of the diseases affecting the organs of breathing 
 one naturally begins with the organ situated at the beginning of 
 the windpipe, and making the projection at the front of the throat, 
 popularly termed "Adam's apple." This organ, the larynx, is 
 composed ot pieces of cartilage, and is one of the continuations 
 of the back part of the mouth, or pharynx. Stretched across its 
 cavity, and lying in the tube through which the air passes, are two 
 clastic bands — the vocal cords — which are so essential in articu- 
 late speech. The inside of the larynx, like that of the trachea and 
 lungs, is lined with moist membrane, which covers also these elastic 
 bands or vocal cords. This, like all other mucous membranes, is 
 liable to a condition called catarrh. For the popular impression 
 that catarrh means an affection of the nose or head, is not in 
 accordance with the technical use of that term ; for any mucous 
 membrane, whether of the nose or throat, or intestine or bladder, 
 may be, and often is, the subject of catarrh. 
 
 By catarrh, we understand an inflammation; the blood vessels 
 of the part increase in size, there is an increased flow of liquid, 
 and sooner or later a casting off of some part of the membrane 
 itself, causing a thick, ropy discharge. This is the history of a 
 catarrh, no matter where it appears — that is, no matter what 
 mucous membrane be affected. The liability to catarrh varies 
 extremely among different persons ; a slight exposure to cold, or 
 rapid transition from one temperature to another, is quite sufficient 
 to excite a catarrhal inflammation somewhere in many individuals, 
 while other persons exposed to the same influences suffer from no 
 
 "7 
 

 Il8 
 
 DISKASES OK THE THROAT AND CHEST. 
 
 such inconvenience. Then, too, among those who are liable Id 
 catarrh there is considerable diversity as to the part most easily 
 affected; in some, exposure to cold is followed by discharge from 
 the nose ; in others bronchitis and cough occur ; while still others 
 are apt to suffer from inflammation of the lungs or of the kidneys. 
 All these things may result from " taking cold," though the catarrh 
 inflammation more frequently affects the mucous membranes situ- 
 ated nearest the surface, among them that of the laryn.x. VVc 
 may say in general.that poorly-nourished people are more prone to 
 a catarrh as a result of exposure to cold, than healthy and robust 
 individuals; and those who are constantly exposed to the weather 
 in the performance of their usual avocations arc less easily affectcti 
 than those whose pursuits are sedentary. Another factor is im- 
 portant in determining the liability to catarrh; namely, that after 
 repeated attacks a mucous membrane becomes more readily affected ; 
 it is a weak spot, and yields most readily to any influences tendiii>; 
 to derange the individual's health. 
 
 Among the exciting causes of catarrh of the larynx are the 
 breathing of very cold air, or dust; excessive efforts at singing, 
 shouting, screaming, and violent coughing. But, in addition, 
 agents which do not affect the larynx directly, may also cause a 
 catarrh of this organ; thus, chilling of the skin, especially that of 
 the feet, is frequently the direct cause of the catarrh. Then, again, 
 a catarrhal inflammation may spread through the laryn.x from 
 adjacent organs; thus it not infrequently occurs that an inflamma- 
 tion of the throat, such as diphtheria, will, in the course of a few 
 days, spread through the larynx. Another familiar example is the 
 catarrh of the larynx, almost invariably found in habitual drinkers, 
 in whom the disease usually begins first in the pharynx, and sub- 
 sequently extends to the larynx. 
 
 Beside these various causes which may induce a catarrh of the 
 larynx in any individual, there are certain other factors which fre- 
 quently induce the disease. Some very obstinate cases of catarrh 
 of the larynx are due to constitutional taints, such as syphilis; and 
 finally there are numerous instances of the disease in which the 
 cause is to be found in the growth of a tumor in the larynx. 
 
 Sifmptonis — Acute catarrh of the larynx does not usually 
 cause serious constitutional symptoms ; though in some instances 
 slight shiverings mark the onset, and some fever accompanies the 
 
CATARRH (>!• Illl, LARYNX. 
 
 119 
 
 disease. The patient complains of a sensation in the throat, which 
 he describes usually as tickling, or, in more severe cases, as burn- 
 \\v' or soreness ; this sensation is aggravated by coughing or 
 speaking. At the same time, the voice is changed in character, 
 <Tr(i\vs deeper, hoarse, perhaps cracked, and, finally, may be lost 
 altogether. This change in the voice indicates that the mucous 
 iiuimbrane covering the vocal cords is in a state of inflammation 
 or catarrh. Another constant symptom is a violent cough, due to 
 tho irritation in the inflamed mucous membrane. There may be 
 also a spasm of the muscles of the larynx, whereby the passage for 
 the air is so much diminished in size as to cause a wheezing sound 
 during the breathing. 
 
 If the catarrh affect the larynx only, — a somewhat rare occur- 
 rence — there is but little matter expectorated. The cough is 
 hard, dry, ringing. It often happens that a child who has coughed 
 somewhat during the day, and has been rather hoarse though not 
 ill, wakes up suddenly in the night with great difficulty in breathing. 
 The little patient seems suffocated ; gasps for breath, and throws 
 himself about in the bed in terror, perhaps clutching anxiously at his 
 throat. The cough is loud and hoarse — " barking. " These are the 
 cases commonly called croup by mothers, and are really merely 
 attacks of slight catarrh of the larynx. So soon as the child has 
 cleared his throat of the mucus which has collected there during 
 his sleep, the breathing becomes again easier, the cough subsides, 
 and the patient falls asleep. 
 
 Acute catarrh of the larynx usually terminates, if uncompli- 
 cated, within a week ; though if neglected, or if the patient be in 
 poor health, it may last for several weeks. 
 
 Chronic catarrh of the larynx is marked by hoarseness, obsti- 
 nate cough, and finally permanent change in the character of the 
 voice. This difficulty may result from an acute attack, but more 
 commonly appears only after frequent catarrhs. 
 
 Treatment, — Since the acute attack usually subsides spon- 
 taneously within a week, treatment with medicines is usually 
 unnecessary. It will suffice to direct the patient to remain so far as 
 possible in a uniform temperature, and not expose himself to 
 sudden changes of atmosphere ; he should avoid the effort to talk, 
 so far as possible, and should especially resist the inclination to 
 cough. He will of course say that he can't help it, but he must 
 
I20 
 
 UISEASKS OK THE THROAT ANU ( HEST. 
 
 '♦1 
 
 I 
 
 I 
 
 help it. The irritation of the larynx, and hence the tendency to 
 cough, can be much diminished by one of the following prescrip- 
 tions : 
 
 Hydrocyanic acid (dilute) - - Half a drachm. 
 
 Sulphate of morphia - - - Half a grain. 
 
 Syrup of tolu . . - - One ounce. 
 
 Water One ounce. 
 
 Mix and take a teaspoonful every two hours. 
 
 Or relief may be obtained from the following : 
 
 Syrup of wild cherry - - - - One ounce. 
 Syrup of squills - - - - One ounce. 
 
 Camphor water ----- One ounce. 
 Mix and take a teaspoonful every two hours. 
 
 At the very first indication of " taking cold," wheth.r the 
 mucous membrane affected be that of the larynx, or elsewhere, it 
 is often possible to cut the matter short by promoting free perspi- 
 ration. This can be easily accomplished by soaking the feet in hot 
 water for fifteen minutes, the patient being meanwhile enveloped in 
 a quilt or blanket ; at the expiration of this time the feet should he 
 well dried, the patient tucked snugly in bed, and ten grains of 
 " Dover's powder " may be administered. The throat may be 
 wrapped in flannel, though it is not necessary to apply petroleum 
 or hog's fat, or any of the other popular domestic remedies. If 
 the individual be constipated, a saline laxative may be administered 
 with advantage. 
 
 The treatment of chronic catarrh of the larynx must consist of 
 local applications, which are best made by means of a brush. This 
 requires especial manual skill, and must, therefore, be entrusted 
 oiily to professional hands. It sometimes happens that a long-con- 
 tinued catarrh results in the formation of ulcers in the larynjt, even 
 in those who are not afflicted with any constitutional taint, such as 
 syphilis or tuberculosis. Such a complication — the formation of 
 an ulcer — is not always indicated by additional symptoms; per- 
 haps the most characteristic feature is pain upon swallowing ; in 
 such cases, too, the matter expectorated is often streaked with 
 blood. 
 
 The ulcers of the larynx consequent upon a syphilitic or 
 tubercular taint, will be described in connection with these diseases 
 respectively. 
 
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 p- 
 
 the 
 
 L", it 
 
 ■spi- 
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 d in 
 dbe 
 s of 
 ' be 
 cum 
 If 
 :red 
 
 St of 
 
 us 
 
 Isted 
 
 :on- 
 
 pvon 
 
 as 
 In of 
 
 ncr- 
 
 Ivi 
 
 in 
 th 
 
 or 
 ises 
 
ItJ 
 
 < 
 
 i 
 
 12.— Chronic Phtbisis ; intervesicular changes. 
 
 11.— Pleuro- Pneumonia. 
 
 14. — Croupos of Veslcului Hiicuiu* 
 nia. Stage of consolidatiui). 
 
 IB.— Surface of normal Cheat ; outlines of cardiac dulnasa to the left of the 
 Sternum. The spaces inclosed in dotted lines represent the interspaces. 
 
 f ':: 
 
PLEURISY. 
 
 121 
 
 Tumors of the Lar3mx. 
 
 The tumors most usually found ir. the larynx are of u fibrous 
 /'nature, and may be; as large as a bean. Bt:sides these, there occur, 
 also, thickenings of the mucous membrane, called po/yps and cancers. 
 
 Symptoms, — The presence of a growth in the larynx may be 
 accompanied by a variety of symptoms, none of which are per- 
 fectly characteristic of the disease ; among these are difficulty it 
 breathing, without apparent cause, and, in some cases, sudden and 
 violent choking fits. There is, also, usually a chronic catarrh of 
 the larynx, causing hoarseness, cough, and some pain. Yet, a posi- 
 tive opinion can be reached only by the use of an instrument called 
 the laryngoscope, or throat -mirror, whereby the physician can look 
 directly into the throat, and detect, with the eye, the presence of 
 any foreign body. 
 
 Treatm,ent. — If the tumor be of such a nature that its pres- 
 ence causes only mechanical difficulty, its removal is justifiable. 
 These operations are so successful as to have become a recognized 
 surgical procedure. 
 
 .!|pi 
 
 I 
 
 AFFECTIONS OF THE LUNGS. 
 
 Pleurisy. 
 
 By pleurisy we understand an inflammation of the membrane 
 which covers the lungs and liiics the chest. For it will be remem- 
 bered that the chest is a cavity, or rather a pair of cavities, in 
 each of which is contained a lung; that during the movements 
 of the chest in breathing, the lung is rubbed against the inner 
 surface of the ribs, and that to render this friction as light and 
 easy as possible, a very smooth membrane — the pleura — is so 
 arranged as to cover the lung and to line the inside of the chest 
 wall. In this way the delicate structures of the lung are protected 
 from actual contact with the chest wall ; the friction necessary dur- 
 ing the movements is borne by the smooth and tough membrane 
 called the pleura. 
 
122 
 
 DISEASES OK THE THROAT AND CHEST. 
 
 Whenever inflammation occurs anywhere except on a mucous 
 surface, there occurs what is called an exudation. This is familiar 
 to us in the examples of inflammation which take place at or near 
 the surface of the body ; a boil, for example, is a circumscribed 
 inflammation, and we are well aware of the fact that a considerable 
 amount of material is deposited in the inflamed spot, making a 
 swelling. So, too, in acute rheumatism, a large amount of liquid 
 or exudation takes place into the joint, resulting again in swelling. 
 When the membrane covering the lungs becomes inflamed, a simi- 
 lar exudation of liquid takes place into the space between the ribs 
 and the lung. The amount of this exudation varies considerably, 
 amounting sometimes to several pailfuls. The result of the pres- 
 ence of this liquid in the chest is, of course, to compress the lung 
 and interfere seriously with breathing. 
 
 Symptoms. — There is usually no premonitory stage preceding 
 an attack of pleurisy. An individual exposes himself to cold, gets 
 his feet wet, or is caught in a heavy shower ; after an interval which 
 may vary from a few hours to several days, the patient experiences 
 a shivering ensation, which may sometimes develop into a pro- 
 nounced chill. About the same time he begins to feel considerable 
 pain in one side of his chest. This pain is usually sharp and cut- 
 ting in character, increases during the act of breathing, to such an 
 extent that the individual unconsciously arrests the motion of his 
 chest on that side. Any violent motion, particularly coughing and 
 sneezing, is accompanied by exquisite pain ; and even the ordinary 
 movements of the body occasion considerable uneasiness. The 
 pain is usually referred to the middle and lower part of the chest, 
 especially in front and under the arm ; it may not be limited to any 
 particular spot, but may seem to spread over the entire side. 
 
 Meanwhile, the chill has been followed by fever, which is not, 
 however, extreme. The usual evidences of constitutional indispo- 
 sition — thirst, wandenng pains, headache, restlessness and debility 
 — are usually present ; yet it is not seldom to observe a case in 
 which most of these symptoms are wanting — the patient complain- 
 ing almost exclusively of the sharp sticking pain in his side upon 
 breathing. 
 
 Such are the symptoms during the stage of inflammation which 
 precedes the exudation — that is the escape of liquid into the 
 cavity of the chest. When this exudation has occurred, the 
 
PLEURISY. 
 
 •23 
 
 symptoms change materially ; the pain is much diminished, pre- 
 sumably because the inflamed surfaces which had been previously 
 rubbing against each other during every act of breathing, are now 
 separated and bathed by the liquid exudation. The acts of cough- 
 ing become less frequent and less painful ; the fever subsides 
 somewhat, and may even cease ; the patient feels more comfortable, 
 acquires a little appetite, and may even rise from his bed and 
 walk about. If the amount of exudation which has been thrown 
 out into the cavity of the chest be so considerable — say several pints 
 
 as to compress the lung on the same side of the chest, the 
 
 breathing will be hurried, since the individual now has the use of 
 but one lung ; if the amount be excessive, the respiration is 
 extremely rapid ; the skin may be blue, indicating that the patient 
 gets an insufficient quantity of air ; he is often compelled to sit 
 upright, in which position he is enabled to breathe easier. Yet 
 tl' '-e is considerable diversity in the symptoms, even when one 
 ; jf the chest is distended with fluid. Cases are sometimes seen 
 in which, even under these conditions, the patient is perfectly com- 
 fortable, and seems to suffer from no lack of air. 
 
 Another sign that the exudation has occurred, is more apparent, 
 perhaps, to the non-professional eye than those just discussed ; it 
 consists in the change of position of the patient, for during the first 
 stage, before the water has been poured out into the chest, that is, 
 while the inflamed surfaces are rubbing against each other, the 
 patient cannot bear to lie upon the affected side ; he reclines, always, 
 either upon the back or upon the healthy side. So soon as the 
 exudation has occurred, on the other hand, he finds most comfort 
 when lying upon the affected side, for now this gives him no pain, but 
 permits him to use the healthy side for breathing. 
 
 The further course of the disease consists, in the majority of 
 cases, in the removal of this liquid again from the chest cavity, 
 leaving the chest in almost the same condition as before the disease 
 began. This, however, is a gradual and often a long process. 
 Weeks may elapse, even aitt.- the patient is apparently convalescent, 
 before all the liquid has been taken from the chest. On the other 
 hand, it sometimes happens that the liquid is not promptly removed 
 from the chest, that a considerable quantity of it may remain for 
 months, retarding the patient's recovery, and perhaps requiring 
 ultimately artificial means for its removal. A still worse sequel to 
 the disease consists in the gradual formation of matter — suppura- 
 
 i 'tf 
 
 ! 
 
 If! 
 
 I 
 
 I 
 
124 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 tton — in the cavity, so that the liquid becomes gradually transformed 
 from water into pus. This constitutes the affection known as 
 empyema, which may entail the most serious consequences, and will 
 be later discussed. 
 
 In the majority of cases the liquid is sooner or later entirely 
 removed from the chest cavity. In the most favorable cases the 
 compressed lung regains its former size and use so soon as the com- 
 pressing liquid is removed, and the patient may recover the entire 
 use of the lungs and chest, so that even a careful medical examina- 
 tion can detect no trace of the disease. In a considerable number 
 of cases there remain, however, certain reminders of the affection, 
 in the shape of deformity of the chest. This results from the fact 
 that there have been formed during the inflammation certain 
 bands which unite the lung and the chest wall, preventing free 
 movement of the chest in breathing. In such cases the ribs may 
 be sunken, instead of bulging in the natural way; the entire side is 
 smaller, and the back bone may be curved toward the opposite 
 side, causing the shoulder of the diseased side to be lower than 
 the other one. Some cases of serious curvature of the spine 
 originate in the facts of |ileurisy during childhood or youth. 
 
 Acute pleurisy, whoii occurring spontaneously or as the result 
 of taking cold, usually af?. cts the entire side. It may, however, 
 occur as a sequel and result of some other inflammation, such as 
 pneumonia and consumption. As will be remarked later, pleurisy 
 is responsible for many of the pains which occur during the course 
 of consumption. It may also be produced in consequence of a 
 wound which penetrates the chest, or of the fracture of ribs, even 
 without any wound to the skin ; it may also be developed as a 
 sequel of scarlet fever, measles, and of the infectious diseases 
 generally. 
 
 The disease may occur at any time of lif ., although it is 
 extremely rare in infancy and in old age ; it affects males far 
 oftener than females. 
 
 Treafinetlt, — Pleurisy itself is not ordinarily a grave disease, 
 though some of its possible sequels may be serious. The disease 
 usually subsides even without treatment ; yet the patient's comfort 
 can be materially enhanced by certain measures; 
 
 During the first stage the object is to arrest, if possible, the 
 course of the inflammation, or at least diminish its intensity, with 
 
FLKURISY. 
 
 125 
 
 the hope of restricting the amount of exudation which is to follow. 
 VVe know of no means which can be relied upon for arresting the 
 (H.-f ase. In former years blood-letting, opium and mercurials were 
 Iar"'cly employed for this purpose, but have all been abandoned. 
 It will usually be found that some form of opium will be necessary 
 f(,r subduing the pain ; for this purpose we may employ an 
 cl<^lith of a grain of morphine. But a better measure will be ten 
 (jrains of Dover's powder, in which we obtain not only the sooth- 
 iii' effects of opium, but also secure free action of the skin. If the 
 tciTiperature be high, the patient should be either freely sponged or 
 may take a hot bath. Much relief will be afforded by applying to 
 tlie chest, over the painful part, either cotton wool covered with 
 oiled silk, or a light poultice of flaxseed. Regular evacuations of 
 the bowels should be secured by the use of saline laxatives, if any 
 medicines be necessary. 
 
 When the escape of the liquid into the chest cavity — the exuda- 
 tion — has occurred, measures are usually adopted for the hasten- 
 in"' of the removal of the liquid again. For this purpose the chest 
 is usually painted with the tincture of iodine, or several blisters are 
 applied in succession, and permitted to remain until the skin is 
 fairly raised. In oostinate cases there can be no doubt that these 
 measures, the iodine and the blisters, mav accomplish the desired 
 object. Yet, until there is some evidence that the case is proceed- 
 in"^ less rapidly than usual, it is doubtful whether any such meas- 
 ures should be used. Another plan, which may be combined with 
 the local application to the chest, consists in the administration of 
 saline cathartics to such an extent as to cause several evacuations 
 of the bowels every day ; or, the following prescription may be 
 
 given 
 
 Powder of squills 
 Powdered digitalis 
 
 - One drachm. 
 
 - sixteen grains. 
 
 Mix and divide into sixteen pills ; take one three times a day. 
 The object of this is, of course, to remove the liquid from the 
 chest, causing it to be taken into the blood and pass out with the 
 evacuation from the bowels. It must be said, however, that this 
 plan is not so successful in the removal of water from the chest, as 
 in the removal of water from the legs or from the abdomen, that is 
 " dropsy. " It often becomes necessary to employ mechanical 
 means for this purpose, to make an operation which is known as 
 aspiration of the chest. This consists in introducing a fine needle 
 
 
 
126 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 into the cavity of the chest, between two adjacent ribs, and in 
 attaching a syringe so that the fluid can be withdrawn without per- 
 mitting any air to enter. In this way the chest cavity can be easily 
 emptied, without causing the patient any more pain than the prick 
 of the needle. Yet it is a fact that the liquid usually returns in this 
 cavity, and has to be removed again. However, the result sought 
 can be finally secured in the great majority of cases. 
 
 During convalescence the patient's strength must be of course 
 invigorated by the usual strengthening diet, and by the use of 
 tonic remedies, especially iron. If the lung be bound to the chest 
 wall by bands, as above described, much maybe done by persistent 
 and systematic efforts to dilate the lung by deep inspirations. 
 This practice should be continued for months, perhaps even years; 
 it is certainly sometimes possible to restore the natural form and 
 functions to a chest which seems permanently damaged. 
 
 It sometimes happens that both sides of the chest will be 
 inflamed at the same time; that there is in fact a double pleurisy; 
 this of course increase the gravity of the case, since all of tlie'TlT 
 effects are doubled. It may also happen that while the patient is 
 convalescent from a pleurisy on one side, he is attacked by the 
 same inflammation on the other side of the chest. Yet these cases 
 not infrequently recover, however serious they may appear for a 
 time. 
 
 Empyema. 
 
 This affection consists in the formation of matter in the chest 
 cavity, and is one of the ways in which pleurisy may terminate. 
 It may be suspected, if during the apparent convalescence of 
 the patient, he suddenly become feverish, and again complain 
 of severe pain in the side. The quantity of liquid usually in- 
 creases, and before long the patient will have a series of chills at 
 irregular intervals. Sometimes the liquid in the chest cavity 
 see"is tc contain pus almost from the beginning, in this case the 
 .«?> \f: i constitutional disturbances are much greater than 
 
 . / ijv li\ the disease. The fever is more intense, the chills 
 i.rr ., ' 'r d, and the patient shows in every way th» ^flfccts of 
 severe ^ki>vahc. 
 
 u, 
 
EMPYEMA. 
 
 127 
 
 W? ther the pus be formed in the cavity of the chest as a com- 
 plication during the convalescence, or whether it be present from 
 the first, the condition of the patient is one to excite grave appre- 
 hension. It is easy to remove the pus from the chest cavity, but 
 this will rarely have any effect in arresting the disease, since more 
 pus will be promptly formed. Debility, emaciation and continuous 
 fever gradually break down the patient's strength, and death is the 
 result in the majority of cases. There is but one means which 
 aflfords any hope of success, and by means of this many cases of 
 empyema have been cured. This consists in making an opening 
 into the chest wall, permitting the escape of the pus and giving an 
 opportunity for washing out the cavity of the chest with carbolic 
 acid solution or other disinfectant. In the majority of instances it 
 will be found necessary to make two openings, several inches apart, 
 in order to permit the escape of the pus as rapidly as it is formed. 
 This must, of course, be left to the skill of the surgeon. 
 
 Pneumonia. 
 
 Under this term is understood an inflammation of the lung 
 itself, as distinguished from pleurisy, which is an inflammation of 
 the membrane covering the lung. As in other inflammations, there 
 occurs in this disease an exudation of material from the blood ves- 
 sels. In the case of pleurisy the exudation escapes into the cavity 
 of the chest, between the lung and the chest wall; in pneumonia it 
 escapes into the substance of the lung itself. Now, the lung, as is 
 well known, is merely a framework enclosing numerous openings, 
 which may be likened perhaps to a honey-comb. These spaces are 
 during the natural condition filled with air, just as the honey-comb 
 is filled Avith honey. In pneumonia, however, the exudation 
 escapes into these air cells, filling them up and preventing the 
 access of air. One of the results is then, evidently, that the indi- 
 vidual has less lung space for breathing purposes than when in his 
 natural condition. 
 
 Symptoms, — In the large majority of cases pneumonia begins 
 with a pronounced chill; this attack is usually abrupt, without any 
 premonitory symptoms, and often occurs during the night. At the 
 
 9 
 
 .1 r 
 
128 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 same time, there occurs a sharp pain, which is usually referred to 
 a point near the nipple of the affected side; this is one of the early 
 signs distinguishing pneumonia from pleurisy. This pain may be 
 very severe, causing the patient to " catch his breath" at every 
 attempt to inspire; on the other hand, cases occur in which the 
 pain is comparatively trifling. 
 
 Immediately following the chill, there occurs a fever, usually 
 of great intensity, all the usual symptoms — thirst, intense heat of 
 the skin, constipation, pain in the head and in the limbs — indi- 
 cating severe constitutional disturbance, are noted. The face is 
 flushed, though not usually uniformly so, for there is apt to be an 
 intense circumscribed redness of one or both cheeks, while the sur- 
 rounding skin may be of rather dusky appearance. 
 
 An early feature of the disease is a cough, which occasions 
 the patient much pain and annoyance, since every act of coughing 
 is accompanied by great pain. The matter expectorated is at first 
 scanty and transparent, but later becomes more profuse and acquires 
 a reddish brown tint, like tfiat of iron rust. This tint is due to the 
 admixture of a small amount of blood from the lungs. At times 
 this amount may be much increased, so as to give the expectorated 
 matter bright red color. Cases occur, however, in which there is 
 no expectoration until late in the disease. The breathing is usually 
 hurried and labored, and the patient frequently complains of 
 extreme pain in every breath. 
 
 Such are the symptoms when the inflammation is limited to a 
 portion of one lung, as is usually the case. If a greater amount of 
 the lung tissue be involved, the symptoms are correspondingly 
 more severe. At times the entire lung on one side becomes 
 inflamed, or what is more frequently the case, a portion of each 
 lung is subject to the disease. In this case, the embarrassment of 
 breathing becomes greater, the blueness of the skin is more marked, 
 the fever is higher, and the patient's prostration is much greater. 
 Then again, it may happen that but a part of the lung is involved 
 at first in the inflammation, and that during the patient's conva- 
 lescence the disease spreads to the rest of the same lung. This 
 complication is indicated by the occurrence of another chill, or by 
 a sudden and rapid increase in the intensity of the fever. 
 
 After the symptoms of the disease have remained at their height 
 for several days, signs of improvement appear; the fever diminishes, 
 the cough and expectoration are decreased ; the breathing becomes 
 
PNEUMONIA. 
 
 129 
 
 easier and less frequent; in short, the patient is evidently conva- 
 lescing. For several days the patient remains extremely weak and 
 prostrated ; there is a marked difference in this respect between the 
 profound exhaustion following pneumonia, and the comparatively 
 sliL'ht debility after pleurisy. If the disease progress without 
 complication, the patient's restoration to health is usually completed 
 in two or three weeks. There are, however, several unfortunate 
 terminations, which may either protract the disease indefinitely, or 
 may finally exhaust the patient's strength ; one of these termina- 
 tions is the so-called abscess of the lung. In this case the lung does 
 not gradually resume its natural condition, but a certain amount of 
 it becomes converted into pus, so that an abscess is produced. Then 
 again, it happens that the patient's convalescence stops at a certain 
 point, he does not recover his health entirely, remains weak, pale and 
 feeble ; begins to have a little fever in the afternoon, perhaps pro- 
 fuse perspiration at night ; suffers from an occasional shivering sen- 
 s.atiptt^t night, agd j,s found upon examination to be suffering from 
 "galloping consumption." 
 
 Pneumonia occurs frequently as a complication of other dis- 
 eases, such as typhoid fever and measles. Yet the majority of cases 
 occur spontaneously. Many times the disease seems to be induced 
 by exposure to cold, and there can be no doubt that such exposure 
 does at least promote the development of this affection. It seems 
 however probable that there is some especial cause behind, without 
 which the exposure to cold is not sufficient to induce this disease. 
 Pneumonia may occur at any period of life, and is more common 
 among males than among females. It occurs over the entire United 
 States, oftener in the Southern and Middle, than in the Northern 
 States ; it is more frequently met with during the winter and spring 
 months than at other times in the year. 
 
 The patient's chances for life depend largely upon the amount 
 of lung-tissue involved in the inflammation. If the patient be in 
 fair health, and but a portion of one lung become inflamed, recov- 
 ery is the rule, to which there are but very few exceptions. If, 
 however, the extent of diseased lung be much greater, or other 
 complications occur, the disease is followed by a considerable 
 percentage of mortaHty. The treatment must be regulated by 
 the condition of the patient, since it must ever be borne in mind 
 that the object is to support the patient through the disease. The 
 great danger in this disease occurs from the failure of the heart's 
 
130 
 
 DISEASES OF THE THROAT AND CHEST, 
 
 action, although we might suppose, from the blueness of the 
 patient's skin, that there is danger of gradual suffocation ; yet the 
 difficulty is to be remedied not by any efforts addressed to the 
 lungs, but by supporting the heart, so as to keep the blood circu- 
 lated through the lung. If the patient be in robust health, there 
 is but little danger that his heart will flag, unless, indeed, an exces- 
 sive amount of the lung be inflamed. If but a portion of one 
 lung be diseased, it will not be necessary to employ very active 
 measures of treatment, since recovery is practically assured. For 
 these favorable cases it suffices to diminish the pain and to reduce 
 the intensity of the fever. The pain will be best controlled by a 
 large, soft linseed poultice, made to cover the affected side, bound 
 tightly on and covered with oiled silk. This poultice should be 
 changed at least every three hours. Opium, in some form (best, 
 perhaps, as ten grains of Dover's powder), will also diminish the 
 pain and the tendency to a distressing cough. The temperature 
 of the body may be reduced by frequent sponging with lukewarm 
 water, or by the hot bath, or the wet pack. These mea^5ures are, 
 however, rarely necessary, except in the complicated cas<;s. Free 
 evacuations of the bowels should be secured, for which, perhaps, 
 the best means are twenty grains of the cream of tartar or the 
 citrate of magnesia. 
 
 If, however, the previous health of the patient have been 
 unsatisfactory; if he have been weak and debilitated, and from the 
 onset of the disease shows plainly its depressing effects, an entirely 
 different line of treatment is required. These are the cases in 
 which the power of the heart must be stimulated to prevent a fatal 
 result. For this purpose whisky or brandy must be freely used, 
 preferably in the shape of milk punch. Quinine, too, is required 
 in these cases — two grains every four hours in a tablespoonful of 
 brandy. It is rarely beneficial to give any medicines for the relief 
 of the cough, since with opium we diminish the tendency to cough 
 and accomplish the desired object. The greatest attention should 
 be paid to the diet, since food is of course an absolute necessity in 
 sustaining the patient's strength — milk, broths, eggs, all liberally 
 supplied with alcoholic stimulants. 
 
 The supporting measures are usually called for also in the cases 
 marked by delirium, since this syn otom is usually an indication of 
 debility. After convalescence from an attack of pneumonia, the 
 lung will be for some time unusually susceptible to changes of tern- 
 
BRONCHITIS. 
 
 •31 
 
 perature. It is, therefore, important to take especial pains not to 
 " take cold." Flannel should be worn next to the skin for a con- 
 siderable time after convalescence. 
 
 Bronchitis. 
 
 This is an inflammation affecting the lining membrane of the 
 bronchial tubes — that is the tubes which form the continuation of 
 the windpipe. These tubes are lined with mucous membrane, 
 which is the continuation of the membrane in the windpipe, larynx, 
 and the mouth above and of the lungs below. It is evident, then, 
 that this membrane may become inflamed as a continuation of an 
 inflammation from the larynx and windpipe above or from the 
 lungs below; bro'n,nitis, therefore, may occur by the spreading of 
 the laryngitis c r of a pneumonia. It also occurs as a primary 
 affection, that i; one in which the bronchial tubes become inflamed 
 without the existence of a previous inflammation elsewhere in the 
 air passages. Under these circumstances, bronchitis seems to be 
 the result of exposure to cold, and is popularly termed a " cold on 
 the chest." Then, again, the disease sometimes occurs as an epi- 
 demic, when it seems to be associated with some special influence 
 of soil or atmosphere. 
 
 Bronchitis also often occurs during the course of other diseases, 
 such as scarlet fever, measles and typhoid fever. It may also be 
 induced by the local effect of irritating gases taken into the lungs 
 with the breath. It is more apt to attack individuals who spend 
 their time in close and warm rooms, than in those constantly exposed 
 to the weather. 
 
 Stfinptotns. — Acute inflammation of the bronchial tube usually 
 begins with a cold in the head ; that is, a catarrh of the nose. 
 Thence it extends down the throat and larynx to the bronchial 
 tubes. Thus a variable period, from a few hours to two or three 
 days, may elapse from the beginning of the catarrh in the nasal 
 passages to the establishment of the bronchitis. The inflammation 
 in the bronchial tubes begins with a sense of tigl^tness across the 
 chest, accompanied with a feeling of rawness or soreness. These 
 sensations are aggravated by every act of coughing ; there is at 
 the same time a certain amount of fever, usually slight. The con- 
 
 i 
 
 I' ' 
 
J|i 
 
 ■>mmmm\h 
 
 t i. 
 
 132 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 stitutional disturbance may be so considerable as to prevent the 
 patient from attending to his usual vocation, or may be almost 
 imperceptible. The cough is at first dry, but very little mucus 
 being expectorated. During, and especially at the end of, each act 
 of coughing a painful sensation is felt under the breast bone ; this 
 is also the case upon breathing cold air, or upon drawing a long 
 breath. 
 
 After some days the cough becomes " looser ;" the expectora- 
 tion becomes easier, more profuse and less painful ; the matter 
 expectorated being frothy, viscid, and often streaked with blood. 
 After three or four days it becomes thick and yellow, or green. By 
 this time most of the disagreeable symptoms have subsided ; the 
 patient is troubled by no other symptoms than the necessity for 
 frequent, sometimes violent, coughing. The usual duration of the 
 attack is twelve to fourteen days, though this period is often pro- 
 longed by carelessness or neglect on the part of the patient. 
 
 The disease contains no element of danger except to the feeble, 
 whether old or young. In infants, it is always a serious affection, 
 since they are often physically unable to remove, by expectoration, 
 the secretion in the bronchial tubes ; hence, death not infrequently 
 occurs from suffocation. In aged people, too, the disease may also 
 be serious, and for the same reason. In feeble individuals a serious 
 degree of exhaustion, also, may follow long and protracted efforts 
 at clearing the bronchial tubes by the act of coughing. 
 
 Tretitment. — It is often possible to cut short a " cold on the 
 chest" within twenty -four hours, by taking, at bed -time, a hot 
 foot-bath, a glass of hot toddy or lemonade, and ten grains of 
 Dover's powder. This attempt will, however, be unsuccessful 
 unless made after the first indication that the individual has taken 
 cold — that is, before the sense of tightness »n the chest occurs. 
 If this measure be omitted, a brisk saline C3tha:tic, such as the 
 citrate of magnesia, should be given. The p;'.n and soreness in 
 the chest will be relieved by a light mustard -plaster over the 
 breast -bone ; the cough may be " loosened " by taking a half- tea- 
 spoonful of the compound syrup of squills every two hours. If 
 this remedy provoke nausea, it may be replaced by the following : 
 
 Tartar emetic, - - - Two grains. 
 
 Syrup of wild cherry, - 
 
 Water, _ . - - Each three ounces. 
 Mix ; take a teaspoonful every two hours. 
 
CHRONIC BRONCHITIS. 
 
 133 
 
 So soon as expectoration becomes easier, the removal of the 
 mucus from the bronchial tubes may be promoted by giving a 
 quarter of a teaspoonful of the syrup of ipecac every hour ; or, if 
 the cough be somewhat violent, the following prescription : 
 
 Nitrate of potash, - - Two drachms. 
 
 Syrup of squills, - - Two ounces. 
 
 Tincture of digitalis, - - Half a drachm. 
 
 Sugar, - - - . 
 
 Gum arable. - - - Each two drachms. 
 Water enough to make six ounces. A teaspoonful of this may 
 be put in a wineglassful of water and sipped every ten or fifteen 
 minutes. 
 
 Acitie Bronchitis in Young Children requires especial notice, 
 because of the peculiar danger of the disease at this time of life. 
 In consequence of th: infant's inability to expectorate the mucus 
 which collects in its bronchial tubes, this matter may accumulate so 
 as to prevent the access of air to the lungs. This accident may be 
 suspected if the child's breathing becomes especially frequent and 
 accompanied by decided movements of the nostrils, and especially 
 if the skin become livid. 
 
 The most efficient means of relieving this difficulty in children 
 is the use of mild emetics, such as the syrup of ipecac. The act of 
 vomiting often promotes the escape of mucus from the bronchial 
 tubes, which could not otherwise be effected. 
 
 Chronic Bronchitis. 
 
 This affection is usually a sequel of acute bronchitis; the latter 
 disease loses its characteristic acute features, but there remains a 
 persistent cough, with considerable expectoration. This disease 
 affects especially the aged. 
 
 Sjftnptofns, — There is rarely any pain, or, at most, an occa- 
 sional uneasy sensation under the breast bone. If the cough be 
 violent and frequent, there may be also some soreness at the lower 
 part of the chest, on both sides. The general health is not usually 
 affected, so long as the disease remains limited to the bronchial 
 mucous membrane. The expectoration varies considerably in dif- 
 ferent cases. It is often profuse, whitish, and viscid ; at other 
 
 If 
 
 t'i 
 
134 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 
 u\ i 
 
 times thick yellow, while in still other cases it may be almost solid 
 greenish, and streaked with blood. At times a considerable quan- 
 tity of matter escapes in the expectoration. In many instances 
 this disease of the bronchial tubes is associated also with catarrh of 
 the nasal passages ; it also results from organic disease of the heart. 
 In many cases it seems to be the direct efifect, like the catarrh in 
 the head, of sudden and rapid changes of a variable climate. It 
 does not contain any element of danger to life, unless, indeed, in the 
 aged; but it may result in the development of other lung troubles, 
 such as asthma, all of which together may materially shorten the 
 patient's i'lia by the constant annoyance to which he is subjected. 
 
 Treatment, — The treatment of chronic bronchitis must consist 
 of attention to general health, as much as in remedies addressed 
 directly to the lungs; indeed, there are cases in which the only 
 hope of cure, or, indeed relief, lies in a change of climate. The 
 locality to be sought, in the hope of relieving chronic bronchitis, 
 must be warm, dry, and free from sudden and violent changes of 
 temperature. AH other measures which contribute to the improve- 
 ment of the general health will also materially hasten relief from 
 this disease. If it be impossible to avoid extremes of temperature, 
 the greatest care should be observed that the body be warmly 
 clothed throughout the year. In a cold climate, woolen or silk 
 garments may be worn next to the skin ; and it is advised to wear 
 over these, during cold weather, a garment of chamois leather or 
 buckskin. At any rate, it will be found judicious at least to wear 
 flannel next to the skin throughout the year. 
 
 Measures addressed directly to the chest may consist, first, of 
 local applications, -'id second, of cough remedies. Benefit may 
 often be derived from the applicatiCii of various remedies directly 
 to the skin ; thus, three drops of croton oil, mixed with the same 
 quantity of olive oil, may be applied to the chest every night by 
 means of a camel's hair brush ; or tincture of iodine may be applied 
 in the same way, for the same purpose. The medicines that may 
 be administered have for their object the loosening of the mucus 
 and the restoration of the membrane to its natural condition. It 
 is impossible to give any one prepcription which shall be applicable 
 to all cases cf chi-onic bronchitis, because the condition of the 
 patient, as well as the condition of the bronchial tubes, varies ex- 
 tremely in different cases. It may be said, in general terms, that 
 
EMPHYSEMA. 
 
 135 
 
 Four drachms. 
 Two ounces. 
 Two ounces. 
 
 if there is but little expectoration, if the patient is troubled with a 
 dry, hacking cough, much benefit may be derived from some med- 
 icine which will allay the irritation. For this purpose the following 
 prescription may be used : 
 
 Dilute hydrocyanic acid, - - - Half a drachm. 
 
 Sulphate of morphia, ... Half a grain. 
 
 Syrup of tolu, - - - - -. Two ounces. 
 Of this, a teaspoonful may be taken every three hours. If the 
 mixture cause any feeling of nausea the amount of syrup can be 
 diminished to one ounce, the other ounce being filled up with 
 water. If there be much secretion, with considerable difficulty in 
 expectoration, the following may be given : 
 
 Chloride of ammonium. 
 
 Paregoric, 
 
 Syrup of squills, _ . - . 
 
 Mix ; take a teaspoonful every two hours. 
 
 Most patients suffering from chronic bronchitis experience 
 great relief during the warm weather, and suffer again during the 
 fall and winter. Such individuals are, of course, benefited by 
 residence in a warm climate during the winter. Chronic bronchitis 
 itself is not so injurious or dangerous as to compel the patien. to 
 employ extraordinary measures for 'ts relief; hence, such patients 
 are usually content to suffer the annoyance year after year, until 
 they become quite habituated to it. Yet, such persons should 
 remember that a chronic bronchitis often brings in its train a series 
 of other evils, which cannot be indifferently endured and neglected. 
 Not the least of these ills to which chronic bronchitis often serves 
 as an introduction, is consumption. In view of these facts, it 
 behooves the individual to take the matter early, even before it 
 seems absolutely necessary, for if he wait, it is often impossible to 
 repair the damage done. 
 
 Emphysema. 
 
 The human lung may be compared, as already slated, in 
 its general structure, to a honey-comb; it consists of elastic struc- 
 tures hollowed out so as to enclose numerous small cavities 
 separated from one another by thin partitions, just as are the open- 
 
 1 
 
 II 
 
 <!!lt' 
 
136 
 
 DISEASES OF THE THROAT AND CHEST, 
 
 I 
 I 
 
 ings in the honey-comb. These little compartments in the lungs 
 are called air cells. These openings are very minute and open 
 out from the small bronchical tubes ; hence the bronchical tube and 
 the air cells opening from it resemble a bunch of grapes, the 
 tube corresponding to the stem of the bunch. Now it happens 
 under various circumstances that these air cells, which are merely 
 little bags of elastic rubber-like tissues, become greatly stretched 
 and finally enlarged; if the cause which produced this stretching 
 continue to act, it often happens that the walls of these little 
 bags give way, so that two or more adjacent cells become converted 
 into one cavity. If this happens in many places throughout the 
 lung, the result is that the breathing becomes impaired. For since 
 the partition walls between these cells are gone, it follows that 
 that there is less surface exposed to the air entering the lungs than 
 was formerly the case ; the effect of breaking down these partitions 
 is the same as would result if a portion of the lung were removed. 
 
 This condition may result evidently from any cause which inter- 
 feres seriously with the exit of air from the air cells; for with every act 
 of breathing, these air cells are distended with air during inspiration, 
 and collapse or fall together during expiration. Hence any impedi- 
 ments in the exit of air interfere with this falling together of the 
 cells, and may, if sufficiently long continued, result in permanent 
 distension, or emphysema. A familiar example occurs in musicians 
 who habitually perform upon brass wind instruments. For these 
 individuals drive the air from the lungs with considerable force 
 against the obstacle, and frequently suffer from emphysema in 
 consequence. 
 
 Symptoms. — Emphysema may, doubtless, exist to a consider- 
 able extent without attracting the patient's attention to the fact 
 that something is wrong in the lung ; but after a time it is indicated 
 by labored breathing and shortness of breath, especially upon 
 active exercise. The difficulty in breathing is quite characteristic, 
 in that the expiration is long and labored. In fact, the natural 
 proportion between drawing the air in and breathing it out — 
 inspiration and expiration — is reversed. For in the natural condi- 
 tion of the lungs the act of inspiration is three or four times as 
 long in duration as the following act of expiration ; in cases of 
 emphysema, however, the act of expiration becomes much longer 
 than that of inspiration. 
 
EMPHYSEMA. 
 
 137 
 
 Emphysema occurs from a variety of causes, among them 
 chronic bronchitis and asthma. Indeed, it is somewhat rare to find 
 a case of spontaneous emphysema, or one which is not associated 
 with some other disease of the lungs. Many of the symptoms 
 which are usually considered to be caused by emphysema, are 
 really due to the bronchitis or asthma, or both, which are so often 
 associated with this disease. Thus, there is usually cough and 
 expectoration, the cough being violent, and being characterized by 
 prolonged convulsive efforts at expiration, so that it resembles 
 somewhat whooping cough. The matter expectorated varies con- 
 siderably, just as it does in bronchitis. 
 
 This disease is obstinate and long continued ; though it causes 
 directly no other ill effects than the annoyance due to the difficulty 
 of breathing, yet it is apt to occasion derangement in the circula- 
 tion of the blood. For all the blood in the body must pass through 
 the lungs in order to give off carbonic acid gas and take up 
 oxygen ; now, when the lungs are thus partially disabled, the 
 blood does not pass so readily, and hence the work of the heart is 
 much increased. The blood is not completely purified, and hence 
 emerges from the lungs not red, as it should, but still somewhat 
 blue. The result is, that the skin of the individual is apt to 
 exhibit a bluish tinge ; the veins of the face and neck are often dis- 
 tended, giving the countenance an expression of distress. All 
 these symptoms are increased by exercise, whether in walking, 
 working, or speaking. Most of these individuals suffer at times 
 from paroxysms of labored breathing, which are usually caused by 
 the accompanying asthma, and not by the emphysema itself. 
 
 This disease may be developed at anytime of life, and, indeed, 
 seems to commence in many cases during infancy or childhood, 
 though it rarely becomes troublesome, or, indeed, is noticed at all 
 until middle life is attained. The disease appears to be hereditary. 
 
 In well-marked cases of emphysema the form of the chest is 
 so characteristic that the experienced physician recognizes the dis- 
 ease at a glance ; the upper part of the chest is barrel-shaped, not 
 flattened from side to side, as is the natural condition ; during 
 inspiration, too, the chest sinks in at the lower part and above the 
 breast bone, while the ribs and breast bone together rise as if they 
 constituted one piece. 
 
 Treatment. — The treatment of emphysema must consist 
 usually in the effort to cure the bronchitis, with which it is com- 
 
138 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 monly associated ; for when the latter difficulty is relieved, the 
 patient exhibits but little annoyance from the emphysema, although 
 the latter be continued undiminished. The measures already indi- 
 cated as useful in bronchitis may, therefore, be employed in the 
 treatment of this afifection also. 
 
 Asthma. 
 
 This term has been applied to difficulty in breathing, from a 
 variety of causes. The condition i.^ which physicians apply this 
 name is a spasmodic contraction of <;he ' inalier bronchial tubes, as 
 a result of which less air than natural is admitted to the lungs, and 
 the individual consequently suffers from d^'.;«ency of breath. 
 
 Symptoma. — Asthma occurs in paroxysms, at irregular intei- 
 vals. The paroxysm seems to be brought on both by certain con- 
 ditions of the patient himself and by certain conditions of the atmos- 
 phere. The attack may begin without warning, though those 
 individuals who have long suffered from the disease can usually 
 predict some hours in advance the approach of the paroxysm. The 
 attack may come on slowly, requiring, that is, two or three hours 
 for its development ; or it may attain its full intensity in a few min- 
 utes. The paroxysm usually occurs at night, or early in the 
 morning. 
 
 The patient is awakened with a feeling of suffocation; he is 
 unable to lie down, but finds relief in sitting with his elbows on the 
 knees, the head thrown back, the mouth open. Even in this posi- 
 tion the patient usually gasps for breath, and often feels compelled 
 to open the window in the hope of securing more air. The breath 
 is drawn in with considerable effort, while the expulsion of the 
 air from the lungs is a long, laborious process accompanied with a 
 wheezing sound. The patient's utterance is difficult, the words 
 being spoken in a jerky, interrupted way. The face is pale and has 
 often a bluish tinge ; perspiration is profuse. The skin is cool ; 
 the countenance exhibits anxiety and distress; the nostrils are often 
 dilated at each attempt to breathe. 
 
 A patient suffering from a severe attack of asthma presents a 
 most distressing and even alarming appearance; the bystanders 
 Mnfamiliar with the disease, regard the patient as dying. The most 
 
ASTHMA. 
 
 139 
 
 distressing symptoms endure, however, as a rule, but a short time, 
 usually not more than fifteen minutes to an hour; they may, how- 
 ever, last for several hours or even days. At the conclusion of the 
 paroxysm the patient ordinarily enjoys profound and refreshing 
 sleep; there is considerable cough with the expectoration of mucus, 
 varying in quantity and quality according to the amount of the 
 accompanying bronchitis. This expectoration may continue for 
 several days after the paroxysm has subsided. 
 
 Attacks of asthma affect individuals at certain seasons of the 
 year, or during certain kinds of weather. In this particular, there 
 is no constant law, though, generally speaking, the disease is more 
 frequent during damp and chilly weather than at other times. 
 Many persons suffer repeatedly and severely from asthma during 
 the winter and spring, but remain quite free from the disease 
 during the summer months. Then, again, the presence of an 
 unusual quantity of dust in the atmosphere, provokes an attack in 
 those predisposed to asthma. Individuals exhibit also personal 
 peculiarities ; thus, one individual has asthma whenever he has an 
 attack of indigestion ; another, whenever he sleeps upon a feather 
 bed ; and women not infrequently suffer at the menstrual period. 
 Mental emotions, too, may contribute to the development of the 
 attack. It is also well known that in some localities the liability to 
 asthma is much greater than in others. The disease occurs more 
 frequently in males than in females, and is apt to occur at any 
 period of life, though more frequent in advanced years. A 
 paroxysm of asthma, however serious and dangerous it may appear, 
 does not imperil the patient's life ; since no instance is on record in 
 which an individual died from an attack of asthma. Indeed, it 
 seemp well ascertained that individuals subject to asthma are often 
 long lived. Yet this longevity is enjoyed not because of, but in 
 spite of, the disease. 
 
 Treatment, — The treatment of asthma consists of two parts : 
 the management of the patient during the paroxysms, and the 
 treatment during the intervals. During the paroxysms, numerous 
 measures have been tried and found to give more or l6ss relief. 
 But before resorting to the use of medicine, it must be remembered 
 that the attacks in many cases seem to be brought on by influ- 
 ences which can be removed. It has been found, for example, that 
 asthmatic attacks are favored in some individuals by constipation, 
 
140 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 I \ I 
 
 I 
 
 H 
 
 
 
 m 
 
 S^Bm 
 
 
 mmWMM 
 
 1 
 
 or by excesses at table. In such cases a cathartic, or an emetic, 
 may be not only beneficial, but quite essential for relief. After 
 the surroundings of the patient have Lcen properly regulated, after 
 he has been placed in a large airy room, some of the more usual 
 remedies may be employed. Among the quickest to afford relief 
 — in those cases in which it possesses any influence — is stramonium, 
 taken in the shape of cigarettes, or the leaves may be burned and 
 the smoke inhaled. If no stramonium leaves can be obtained, the 
 same effect may be produced by tobacco leaves or cigars, though 
 this means is far less reliable. Next to stramonium in efficacy is 
 the nitrate of potassium or niter. Pieces of paper which have been 
 soaked in a solution of niter may be burned, and the smoke inhaled; 
 or, if preferred, they may be made into cigarettes and smoked. If 
 all these measures prove unsuccessful, relief can be obtained at 
 once by the inhalation of chi'^ orm, or ether, a few drops of 
 which may be sprinkled upon a handkerchief and held to the face. 
 A still more efficient reme jy ii the nitrite of amyl, two or three 
 drops of which may be inhaled h% m a nandkerchief in a like man- 
 ner. It must be said in reference to these three agents, chloroform, 
 ether, and the nitrite of amyl, that they should not be administered 
 except in cases of emergency by any one except a phy.' inn, since, 
 unless judiciously employed, they are capable of inducing serious 
 effects. This is particularly true of the nitrite of amyl ; the writer 
 has known most alarming symptoms of fainting and collapse fol- 
 low the inhalation of a few drops from the handkerchief. Another 
 disadvantage in the use of these remedies lies in the fact that relief 
 is afforded only during the inhalation, for a few minutes after the 
 vapor has been dissipated, the paroxysm is apt to return undi- 
 minished. A remedy which may be easily procured and always 
 used without danger, is the following : 
 
 Tincture of lobelia, two ounces. 
 
 Wine of ipecac, two ounces. 
 
 Mix; take half a teaspoonful every half hour until expectora- 
 tion or nausea is induced. 
 
 If this does not answer, half a teaspoonful of " Hoffman's ano- 
 dyne" may be taken every hour. 
 
 Benefit may be derived from the application of mustard plasters 
 to the feet, or from the use of chloroform liniment upon the back. 
 
 The treatment during the intervals consists usually in measures 
 addressed to the relief of the accompanying bronchitis. It is 
 
CONSUMPTION. 
 
 141 
 
 always well to try the effect of iodide of potassium in these cases, 
 as well as in those where there is little or no accompanying bron- 
 chitis. This may be given by dissolving five drachms of the iodide 
 of potassium in four ounces of water, of which a teaspoonful may 
 be taken every four hours. A remedy which has recently been 
 extensively employed, though not with the success which was 
 anticipated, is the fluid extract oi grindelia robusta, which may be 
 given in half teaspoonful doses every four hours. It must be 
 stated in general terms, that up to the present time no remedy is 
 known which will certainly benefit all cases of asthma ; it is usually 
 necessary to try several of the remedies named, in order to ascer- 
 tain which of them, if any, can be relied upon to benefit the case 
 in hand. If all measures prove unsuccessful, the patient can often 
 obtain relief by change of climate. 
 
 Consumption. 
 
 Consumption o' the lungs, also called in medicine pulmonary 
 tuberculosis, and popularly known as the decline, is the most 
 formidable enemy of the human family in the United States, as 
 well as in other parts of the world. Small-pox, yellow fever and 
 cholera devastate whole cities, and carry off thousands ; their 
 approach carries dismay and terror into entire communities. But 
 neither yellow fever nor cholera, nor both of them combined, can 
 exhibit a death roll comparable to that of consumption ; for this 
 insidious disease, to whose presence we are so accustomed that its 
 ravages awaken no remark nor attention, carries off one-seventh of 
 the entire civilized world. From this disease there is no exemption 
 of sex nor age, of social condition nor personal hygiene ; the 
 infant in arms as well as the gray-haired grandfather fall alike victims 
 to the disease. Each year three million human beings succumb to 
 consumption. 
 
 Tuberculosis is not always nor necessarily a disease of the 
 lungs; since it may invade many other organs of the body and 
 cause fatal results. The intestines and the brain are especially 
 liable to be attacked by it; in fact, most of its victims under the 
 age of puberty die of " consumption of the bowels," or of the 
 brain. The term consumption, however, is usually limited to the 
 
142 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 
 disease as it occurs in the lungs, the word tuberculosis being 
 employed to designate it when it attacks other organs of the body. 
 The disease is, however, one and the same process, wherever it 
 may occur, though the details vary, of course, according as one 
 organ of the body or another is affected. Without entering into 
 particulars, we may say in general, that pulmonary consumption 
 consists in the deposit of scrofulous matter in the substance of the 
 lungs. This scrofulous matter — technically called tubercle — is 
 the result of a long continued inflammation ; it follows that con- 
 sumption is essentially a slow or chronic inflammation of the lungs. 
 This explains to us the familiar fact that consumptive patients 
 have usually suffered for a considerable time from a chronic bron- 
 chitis or from repeated attacks of pneumonia before the symptoms 
 of consumption became apparent.* In fact, even the physician often 
 finds difficulty in deciding whether a patient who has long suffered 
 from chronic bronchitis has already begun to have consumption. 
 So, too, individuals who have repeatedly suffered from pneumonia 
 are apt to become finally consumptive, because the inflammation of 
 the lungs becomes permanently established — the repeated pneu- 
 monias, in other words, develop into consumption. 
 
 The deposit of scrofulous matter, or tubercle, varies consid- 
 erably as to its rapidity and location in the lungs. There are, 
 accordingly, different types of consumption, some of which run a 
 rapid course to a fatal termination, while others drag along slowly, 
 and may even terminate in recovery, if the individual be given a 
 good opportunity to throw off this scrofulous deposit. Then, 
 again, the formation of the tuberculous deposit does not proceed 
 uniformly ; a considerable amount will be formed in a short time, 
 after which the patient, in consequence of a change of residence or 
 other cause, improves in health. For a considerable time the dis- 
 ease may make no progress, and may occasion the patient far less 
 annoyance than formerly ; in consequence of which the individual 
 and his friends may be sanguine of ultimate recovery. But, sooner 
 or later, there comes a relapse ; the patient takes cold, or sojourns 
 in a damp climate, as a result of which the tuberculous deposit is 
 increased and the old symptoms return with renewed vigor. This 
 matter is usually deposited at the upper part of the lungs, just 
 under or near the collar-bone; and the observation of a large 
 number of cases seems to indicate that the left lung is somewhat 
 more frequently affected than the right. After the amount of mat- 
 
CONSUMPTION. 
 
 143 
 
 ter deposited has attained a certain size, it undergoes a process of 
 softening, becomes liquid, and is expelled in part, at least, from the 
 lungs by the act of coughing. If the tuberculous deposit only 
 were thus affected, the disease would doubtless end in recovery, 
 since the lung would heal up after this matter had been expecto- 
 rated. Such is, indeed, the actual history of some cases of pulmo- 
 nary consumption. Individuals who have given all the evidence 
 of consumption, and in whose chests the deposit has been recog- 
 nized upon medical examination, ultimately recover entirely, and an 
 examination of the lungs shows that the deposit has been entirely 
 removed. These are the favorable cases, and, unfortunately, the rare 
 ones ; for, in the large majority of instances, the softening of the 
 deposit is accompanied by a destruction, a " breaking down," of 
 the lung tissue itself surrounding the deposit. This broken-down 
 lung tissue is cast out by expectoration with the softening tuber- 
 cular deposit, giving to the expectorated matter and to the breath of 
 the patient that peculiarly offensive putrid odor so often observed 
 in consumptive patients. In course of time, a considerable por- 
 tion of the lung substance may be thus expectorated, so that there 
 remain large cavities in the lung. It is, in part at least, from the 
 walls of such cavities, where the lung tissue is constantly breaking 
 down, that the hemorrhages occur which constitute one of tl -^ 
 formidable symptoms of this disease. 
 
 Syrnptotns. — Pulmonary consumption is usually very slow 
 and gradual in its development ; indeed, it is often impossible, as 
 already remarked, to fix definitely the exact date of its commence- 
 ment. In many cases, the symptoms indicating lung difficulty are 
 preceded for weeks or months by general ill health, loss of strength 
 and of weight ; yet, since these symptoms may be caused by other 
 affections, it is impossible to ascribe them definitely to incipient 
 consumption. In a larger number of cases, the symptoms of lung 
 trouble, particularly. the cough and expectoration, are present for 
 a considerable time before any evidences of general debility are 
 observed ; yet these early symptoms may be indistinguishable from 
 those of chronic bronchitis. 
 
 Usually, one of the earliest symptoms noticed is cough ; and, 
 after the patient's attention is called to it, he will often remember 
 that at first he used to cough chiefly in the morning, upon rising, 
 being comparatively free from this troublesome symptom during 
 
 
 i! 
 
 10 
 
144 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 ill-: 
 If ' 
 
 
 ft. 
 
 m 
 
 I 
 
 the day. The cough is usually slight, dry and hacking at first , 
 the matter expectorated is slight in quantity, white and glairy. 
 The patient's attention is rarely directed to this symptom, unless 
 one of two things should happen — either spitting of blood, or 
 marked loss of flesh and strength. The expectoration of blood, 
 while a more usual symptom at an advanced stage, may never- 
 theless occur at an early period of the affection ; the blood raised 
 is usually small in quantity, of a bright red color, and occurs as 
 streaks in the mucus. This is sure to attract notice, and to alarm 
 the patient. It is usually only after the appearance of this blood 
 that he seeks medical advice, having treated his previous cough as 
 insignificant. 
 
 Pain in the chest is not a necessary symptom of pulmonary 
 consumption, since it is not caused by the disease itself, for the 
 lung tissue — the part affected in consumption — seems to have but 
 Uttle susceptibility to pain. The individual suffers from pain in 
 his chest only when the membrane covering the lungs — the pleura — 
 is involved in the inflammation, for this pleura is exquisitely sensitive 
 to pain. Sometimes, however, the pleura becomes involved early in 
 the disease, in which case pain is an early and prominent .symptom 
 of the disease. This pain is sharp, and is described by the patient 
 as stitches in the chest, commonly referred to the upper part of the 
 lung, just under the collar bone, often shooting through to the 
 back. This pain is by no means constant, even in the same case 
 being sometimes so severe as to keep the patient within the house, 
 at other times so slight as to pass unnoticed. These pains have 
 considerable significance for the physician, though they are usually 
 considered by the patient to be rheumatic or neuralgic. 
 
 The breathing is usually somewhat increased in frequency, 
 though this increase rarely attracts the patient's attention, unless 
 he be engaged in some occupation requiring considerable physical 
 activity; in this case he is apt to observe that his breath is shorter 
 than formerly, and may be indeed compelled to give up the most 
 severe part of his labor because of this shortness of breath. 
 
 Another early symptom, often noticed by the patient himself, 
 or by his friends, is increased heat and dryness of the skin. As 
 the disease advances, this heat amounts to positive fever, which 
 usually increases toward evening, when there is apt to be a decided 
 flush on the cheeks. At this time, too, the patient often has ill- 
 defined, chilly sensations, or shiverings ; or well marked chills, fol- 
 
CONSUMPTION. 
 
 145 
 
 lowed by fever and perspiration, may occur with such regularity 
 that the difficulty is supposed to be ague. Another symptom 
 oiian present with these is the occurrence of " night sweats." 
 
 As the strength and weight of the patient decrease, there is 
 usually some impairment of the appetite and digestion, amounting 
 at times to a decided aversion for food ; the patient usually has a 
 special dislike for fatty articles. Emaciation is the rule in consump- 
 tion, but at times there is but little apparent loss of flesh, though 
 the patient becomes very pale. The strength is usually impaired, 
 even though the bulk of the body be not materially diminished. 
 
 During the early part of the disease diarrhea is an occasional 
 but by no means constant symptom ; in the more advanced stages 
 it is usually pronounced and troublesome, and then often indicates 
 that the disease is affecting the bowels as well as the lungs. In 
 some instances obstinate and frequent recurring diarrhea, and a 
 persistent cough are the first indications of pulmonary consumption. 
 In females there is always, usually at an early period of the disease, 
 an interference with the menstrual function; as a rule, the discharge 
 becomes gradually less in quantity, the periods irregular and finally 
 suppressed. A popular idea is inclined to ascribe the disease in 
 some way to a suppression of the menses, but the fact is that this 
 suppression is not the cause but the result of the disease, or rather 
 of the impairment of health and loss of flesh incident to the con- 
 sumption. 
 
 The mind usually remains perfectly clear and unaffected until 
 within a few days of the fatal termination ; and what is far more 
 remarkable, the patient is usually cheerful and confident of ultimate 
 recovery. This delusion amounts sometimes to actual infatuation, 
 causing the individual to disregard the grave symptoms of his case 
 and to conceal them from the physician; and if informed of the 
 actual state of the case, he is apt to take offense or to under- 
 value the professional ability of the medical adviser. 
 
 The disease advances to what is termed the second stage, by 
 which is meant the period during which the tuberculous deposit is 
 becoming softened and expectorated. During this stage the pre- 
 vious symptoms continue in somewhat exaggerated form ; the cough 
 becomes a prominent and troublesome symptom, for though less 
 irritating to the patient, it is more frequent, and usually followed 
 by expectoration. During the transition from the first to the 
 second stage, expectoration is apt to be diflicult, the patient being 
 
 H 
 
 I 
 
146 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 compelled to cough long and painfully before he succeeds in raising 
 any material from the lung. But as the breaking down of the lung 
 tissue proceeds, the cough becomes easier, since the matter is more 
 readily loosened and brought up. This expectorated matter now 
 consists, in addition to the white and frothy material of the first 
 stage, of thick yellow masses, sometimes streaked with blood. The 
 amount of material expectorated varies considerably, depending 
 largely upon the rapidity with which the softening process proceeds 
 in the lung; it may amount even to a half pint or a pint daily. 
 Sometimes the patient will suddenly expectorate a considerable 
 amount of matter during a few acts of coughing, owing to the 
 sudden loosening and discharge of larger masses of softened 
 tuberculous matter. As the patient becomes weaker, the act of 
 coughing becomes a severe task upon his strength, and in the later 
 stages expectoration is often but imperfectly performed. 
 
 Hemorrhage occurs less frequently perhaps after the forma- 
 tion of cavities than in the earlier stages of the disease; yet when 
 they do occur, such hemorrhages are far more alarming. For not 
 only is the amount of blood lost greater than formerly, but the 
 effect upon the patient is more decided, since the loss of a given 
 amount of blood now affects his diminished strength more than was 
 previously the case. It occasionally happens that a blood vessel 
 of considerable size gives way in the lung, and the patient dies in 
 a few minutes, either from loss of blood or from suffocation in con- 
 sequence of the presence of the blood in the air passages. During 
 this stage another symptom, which is often present in the first stage 
 of the disease, or may even be one of the earliest signs, becomes 
 prominent. This symptom is huskiness of the voice, which often 
 increases to hoarseness, or may proceed to complete loss of voice, 
 so that the patient is unable to speak above a whisper. This 
 results from the spread of the disease to the larynx, usually involv- 
 ing the vocal cords, and often causing ulceration upon them and in 
 their vicinity. The pains in the chest are apt to be continued from 
 time to time in the second stage, and occasionally become constant 
 symptoms. The appetite is now decidedly impaired, diarrhea is 
 frequent and persistent. At times, indeed, this looseness of the 
 bowels becomes a serious matter, exhausting the strength of the 
 patient in spite of all efforts to control it. 
 
 A symptom upon which considerable stress is laid by medical 
 men is the appearance of the finger ends, which become quite club 
 
CONSL'MPTKjN. 
 
 147 
 
 shaped, the nails being curved downward toward the end and 
 toward the root, while the middle makes the summit of the curve. 
 This appearance is by no means constant, though quite character- 
 istic when present. During this stage, too, the feet and ankles are 
 usually swollen, especially if the patient walk or sit erect. This 
 symptom merely indicates the general failure of the patient's 
 rength, and possesses no other significance. 
 
 The course of pulmonary consumption is apt to be hastened by 
 complications which arise in other organs ; among these the most 
 frequent, perhaps, is consumption of the bowels, indicated by pro- 
 fuse and obstinate diarrhea — the spread of the disease to the 
 abdominal cavity, and to the organs contained in it. In some 
 cases the disease occurs also »n the membranes covering the brain, 
 causing interference in the mental functions — a complication more 
 frequent in young persons than in adults. The disease may also 
 affect the urinary and the genilal organs, causing difficulty in urina- 
 tion ; not infrequently there occurs an entire loss of the power to 
 propagate in the male, as a result of this disease, and this ' )ss may 
 occur before the symptoms of lung difficulty arouse suspicion as to 
 ic nature of the disease. 
 
 Cause, — Consumption, or, speaking more generally, tui)ercu- 
 losis, whether it occurs in the lungs or brain, or other organ of the 
 body, is due to a specific and particular cause. The researches of 
 the last two years, conducted in all parts of the civilized world, 
 have demonstrated what is now universally admitted — that the 
 body of every consumptive individual, as well as of every tuber- 
 culous animal, harbors immense number^ of minute vegetable par- 
 asites. These organisms, belonging to the general class of plants 
 known di^ fungi, of which the mould on jelly is a familiar example, 
 invade the body of the individual, and seem to act as a source of 
 irritation which results in the tuberculous inflammation. These 
 parasites ordinarily gain access to the body in the air which is 
 inspired ; and hence the disease is usually first manifested in the 
 lungs. Yet they may secure access to the blood, and thence be 
 carried all over the body, affecting any or all of the organs. So 
 far as we know, consumption never occurs without the presence of 
 these parasites; yet it is equally evident that certain other circum- 
 stances must contribute in order that this disease may be estab- 
 lished, for these parasites do not gain a foothold so long as the indi- 
 
 I 
 
 ij 
 
 m 
 
 
 
I4« 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 vidual enjoys perfect health. It is only when the system has been 
 prepared in advance for the reception of these organisms — when, 
 in other words, there occurs some departure from the usual state of 
 health — that the individual becomes liable to consumption. This 
 departure from the natural standard of health — or predisposition 
 to consumption, as it is technically termed — may be either inher- 
 ited or acquired. Long observation has rendered the fact familiar 
 to all, that the children of consumptive parents are especially liable 
 to the disease in question. There appears to be a peculiarity of 
 constitution which renders the individual especially favorable, or 
 predisposed, to the development of consumption ; and this peculiar- 
 ity of constitution is transmitted from parent to child, just as pecu- 
 liarities of feature or of mind are likewise transmitted. While this 
 hereditary tendency is perhaps often overestimated, yet that there 
 is such a tendency cannot be, and is not, denied. It by no means 
 follows that the children of consumptive parents must necessarily 
 become tuberculous; nor that those of non-consumptive parents 
 are safe from the disetse. Indeed, the vast majority of cases occur 
 in individuals whose family history contains no record of consump- 
 tion. Most cases of consumption, in other words, are acquired — 
 that is, the individual, though not burdened with any known hered- 
 itary taint, lapses into such a condition of health as to make him 
 liable to the invasion of the disease. 
 
 Among the causes which predispose to the development of 
 consumption, is a cold, moist, variable climate; and it seems to be 
 the variability, rather than the coldness of the climate, which is to 
 be held responsible for the influences favoring the disease, for 
 certain parts of the world, even of our own country, are cold and 
 moist, and yet afford such protection against consumption as to 
 have become a refuge for consumptive patients ; whilt, on the other 
 hand, certai" localities located so near the tropics as to be quite 
 warm the year round, are also unfavorable to the development of 
 the disease. Consumption seems to prevail more upon the sea- 
 coast than in the interior at the same latitude, perhaps because of 
 the sudden and rapid changes to which the former localities are 
 especially susceptible. It has also been shown that in the State of 
 Massachusetts, cases of consumption occur more frequently along 
 the borders of streams and marshes than in other localities. The 
 most favorable climate seems to be warm and dry, and free from 
 the rapid changes which characterize a considerable part of our own 
 
CONSUMPTION. 
 
 149 
 
 land. Another influence which predisposes to the development 
 of tuberculosis is the frequent or repeated occurence of other in- 
 flammations in the air passages, such as bronchitis and pneumonia. 
 Possibly these repeated inflammations are to be regarded as an 
 evidence of the inherent weakness of this part of the individual ; 
 at any rate, it is an unquestioned fact of observation, that con- 
 sumption is often preceded by a long and obstinate bronchitis, or 
 by repeated attacks of pneumonia. 
 
 Still another influence, or rather set of influences, are the 
 conditions inseparable from sedentary pursuits. It is well estab- 
 lished that consumption is especially prevalent among those whose 
 occupations confine them to close, ill-ventilated rooms, where they 
 are not only deprived of exercise, but are compelled also to breathe 
 impure, vitiated air for many hours a day. These influences 
 explain, too, to a certain extent, the extreme prevalence of the 
 disease among the poorer classes of society living in crowded and 
 not over-clean quarters, and subsisting upon inadequate or 
 improper food. An interesting observation in this connection is 
 the universally recognized fact that wild animals in confinement are 
 apt to suffer and die from this disease; for consumption is not a 
 monopoly of the human family, but attacks a large number of the 
 lower animals, wild as well as domestic, and it is well ascertained 
 that domestic animals kept in close confinement are far more liable 
 to the disease than animals of the same species permitted to enjoy 
 abundant air and exercise. " The stabled cow, the penned sheep, 
 the tame rabbit, the monkey, the caged lion, tiger or elephant, 
 are almost invari.->bly cut off by tuberculous affections. " — Aitken. 
 There is reason for believing also that an improper diet, one which 
 does not furnish the different substances required for the system, 
 is often an important factor in inducing the disease. Such diet 
 may be improper, not because it is deficient in quantity, but 
 because it is not judiciously selected and regulated. The liability 
 to consumption varies also with age, the most susceptible period of 
 life being from twenty to thirty years, the next most susceptible 
 time between ten and twenty years of age ; yet no period of life 
 affords exemption from consumption, since the disease may affect 
 even the child in the womb. 
 
 Observation indicates that certain other diseases exert an 
 influence in favoring or opposing tuberculosis. The disease seems 
 to occur somewhat frequently after typhoid fever, measles, and 
 
ISO 
 
 DISEASES OF THE THROAT AND CHEST 
 
 scarlet fever. On the other hand, consumption is rarely found in 
 individuals suffering from organic heart disease, or from emphy- 
 sema of the lungs. It has been asserted, too, that during preg- 
 nancy a woman is but slightly susceptible to consumption, even 
 though she .nay become so after delivery ; yet, more careful obser- 
 vation indicates that this idea is not founded on fact. Indeed, 
 certain observations would indicate that pregnancy and lactation 
 rather favor the development of consumption ; for Pollock found 
 that of one hundred and fifty-five cases of consumption occurring in 
 women recently confined, the disease began in forty-eight of them 
 during pregnancy, and in fifty-one about the time of confinement. 
 
 Intimately associated with the subject of consumption are the 
 other manifestations of tuberculosis in the various organs of the 
 body; but the only one that will be mentioned here is the enlarge-. 
 ment of the glands in the neck. It is a common observation that 
 children exhibiting the so-cal!od " scrofulous habit," that is, those 
 with thin, white skins, watery eyes, and inclination to a sandy 
 complexion, are subject to enlargement of glands in the neck, even 
 from early childhood. These enlarged glands may remain for a 
 long time in the same condition, without giving rise to much pain 
 or annoyance ; but, sooner or later, they are apt to become larger 
 and somewhat tender, the skin over them is reddened, and finally 
 is perforated, giving exit to a quantity of matter. The openings 
 made in this way are apt to be very slow and obstinate in healing, 
 and may resist all ordinary efforts and treatment for months; and, 
 when finally healed, there remain ragged, irregular, and unsightly 
 scars. Such children seem especially prone to the development of 
 tuberculosis in various internal organs, though it has not been 
 observed that when they reach adult age they are especially liable 
 to consumption. It seems unquestionable that this enlargement of 
 the glands, accompanying the general debility and feebleness of 
 health, is one of the many manifestations of tuberculosis. 
 
 The duration of pulmonary consumption varies extremely, 
 according to the original condition and subsequent surroundings of 
 the patient ; yet, it cannot be too emphatically stated that con- 
 sumption is not always fatal. It is a prevalent belief that the indi- 
 vidual who has become tuberculous, has practically received his 
 death warrant. Now, while it must be admitted that a large major- 
 ity of cases terminate fatally, yet, it is equally true that a small 
 minority recover entirely from the disease. In many cases the 
 
 M. 
 
CONSUMPTION. 
 
 151 
 
 progress of pulmonary consumption is extremely slow, because it 
 seems to be for a long time a doubtful battle between the disease 
 and the individual ; and it is just these cases in which the scale can 
 be turned in favor of the patient by judicious treatment in the way 
 of sanitary surroundings as well as medicines. In all cases it is, 
 of course, of supreme importance that the actual facts in the case 
 should be ascertained as early as possible ; for, if anything is to be 
 done in the way of cure, it must be done early. Every individual, 
 then, who has any well-grounded suspicions that he is already 
 attacked, or is especially liable to be attacked by consumption, 
 should at once ascertain the truth by consulting a competent phy- 
 sician. If he be the child of consumptive parents, and have an 
 obstinate, even though slight, cough ; if he lose flesh rapidly, even 
 without sufficient cough to attract attention ; if he be troubled with 
 pains in the chest, with an obstinate and long -continued diarrhea, 
 or with other symptoms which do not yield readily to the treatment 
 employed, it is the wisest policy to submit himself to a thorough 
 examination, in order that the existence or non-existence of tuber- 
 cular disease should be ascertained. And, even if there be no 
 record of consumption in the family, it should be borne in mind 
 that this fact does not give positive assurance of safety from the 
 disease ; since, as has been stated, the majority of cases occur in 
 individuals who have no suspicion of the true nature of the disease, 
 feeling assured of their immunity from consumption by the fact 
 that it has not afflicted other members of their family. These are 
 the persons who neglect, year after year, a persistent, hacking 
 cough, which troubles them, at first, only in winter, and leaves 
 them comparatively free in the summer; and, even if their atten- 
 tion is directed to the possibility of consumption by their friends, 
 they are inclined to ignore the warning, or, at least, postpone it. 
 Many such are first seriously awakened to the danger by a hemor- 
 rhage more or less severe. 
 
 In those cases in which recovery occurs the tuberculous matter 
 is either softened and expelled from the lungs by expectoration, or 
 they become hardened by the deposit in them of lime and similar 
 salts, after which the tuberculous masses cease to cause breaking 
 down of the lung tissues, and the disease is arrested. Sometimes 
 these little balls of lime which have been formed in and around the 
 tuberculous masses are finally loosened and expectorated, when 
 they are called lung stones. These favorable terminations usually 
 
152 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 P 
 
 W'' 
 
 occur as the result of careful managing and treatment, yet instances 
 are recorded in which the patient recovered from undoubted pul- 
 monary consumption without any other treatment than simple 
 cough medicines, yet such cases of spontaneous recovery from 
 consumption are so rare as to be curiosities, and can not unfortu- 
 nately be expected in any but the rarest instances. 
 
 There are many cases in which it seeems for a time that such 
 spontaneous recovery is going to occur; the patient and his friends 
 observe that all the symptoms decrease as spring and summer 
 approach, and are deceived by this lull in the disease into a 
 belief that recovery will occur. Such belie* has doubtless prevented 
 many a patient from resorting to the measures necessary to save 
 his life. For it should be known that consumptive patients 
 are always better in warm weather, whether the disease affects the 
 lungs, the bowels, or the bladder; but they are just as certainly 
 worse again during the following winter, and although another 
 improvement may occur during the second summer, yet the patient 
 has lost ground very decidedly. There is one symptom, how- 
 ever, which is rarely neglected, the hemorrhage from the lungs; 
 this warning truly ala'-ms the patient, and if repeated will surely 
 lead him to do his uttermost to check the disease. It is very satis- 
 factory to know that these cases in which repeated hemorrhages 
 occur to terrify the patient and his friends, are usually the most 
 favorable. 
 
 Treatment, — The first item in considering the treatment of 
 consumption is naturally the possibility of preventing or escaping 
 it. Unquestionably the best protection against consumption, as 
 against so many other diseases, consists in maintaining the highest 
 possible standard of health; diet, air, exercise and clothing should 
 all be carefully attended to, not only in a general way, but also in 
 detail. The food of patients inclined to consumption should be 
 nutritious, easily digestible, and generous in quantity and quality. 
 It is a mistake to prescribe definite rules for the guidance of the 
 appetite in such cases. Many people make a hobby of insisting 
 upon just so many ounces of bread and meat per day. The only 
 valuable rule consists in permitting and encouraging the patient to 
 eat such food and in such quantity as he desires ; his own experi- 
 ence will teacli him to avoid such articles as he cannot readily 
 digest. In some cases, it is true, it will be especially desirable that 
 
CONSUMPTION. 
 
 153 
 
 the diet should include meats and milk ; in nearly all, care should 
 be taken that butter, cream and other fatty matters should be 
 included in the diet. The object is always to secure the best possi- 
 . ble nutrition ; it will rarely, if ever, happen that the patient incurs 
 harm by over-eating. 
 
 Another most important item is fresh air, especially if taken 
 out doors. It is perhaps impossible to overestimate the benefit to 
 be derived from out-door exercise. Dr. Flint, of New York, some 
 years ago, reported the history of sixty-two cases which had fallen 
 under his own observation, in which the disease was arrested. After 
 discussing these cases in detail, he remarks : " In twenty of these 
 cases the arrest took place under hygienic measures, without me- 
 dicinal treatment. In these cases the most important point related 
 to change of habit as regards exercise and out-door life. In many 
 cases the change consisted in relinquishing sedentary callings for 
 other pursuits, in order to carry out more eftectually the desired 
 reformation. I am well satisfied that here is the foundation for the 
 successful management of pulmonary tuberculosis. I would rank 
 exercise and out-door life far above any known remedies for the 
 cure of the disease. There are grounds for believing that the 
 advantage of a change of climate mainly consists in its being a 
 change of habits as regards exercise and out-door life. " It is 
 scarcely necessary to remark that exercise is rarely beneficial if 
 taken merely as exercise, and without the charm of amusement or 
 interest to engage the attention. The same remark applies to 
 the different plans recommended for inflating the chest. Thus we 
 are told that much benefit is to be derived from the habi^ of slowly 
 expanding the chest, and as slowly permitting the air to escape, 
 this exercise being repeated morning and evening. Doubtless 
 much might be done by such measures, were they persevered in; 
 yet, because performed merely as a hygienic measure, they will be 
 rarely followed out faithfully. In most instances the best plan is 
 to give up the usual employment entirely, and to devote the time 
 to the restoration of health by engaging solely in such out-door 
 occupations as secure amusement and entertainment as well as 
 physical exercise. 
 
 A most important point for such patients as seem predisposed 
 to the disease is the care to avoid taking cold; that is, to avoid 
 wetting the feet, draughts of air, and sudden changes of temperature. 
 This does not, of course, mean that the patient should be confined 
 
154 
 
 DISEASES OF THE THROAT AND CHEST. 
 
 to the house; for, when properly protected by warm clothing, he 
 is much better in the open air than in the house. Indeed, many 
 patients have gone to California and the Sierras, into localities 
 where the temperature was uniform, though not too warm, and 
 have here spent months in the open air, sleeping at night with no 
 other protection than that of a tent. In many parts of our country, 
 however, where the climate is subject to sudden changes, it is 
 advisable for the patient to be within the reach of shelter at all 
 times. In such places especially it is desirable that warm clothing 
 should be worn throughout the year ; either woolen or silk goods 
 may be worn next the skin, reinforced in colder weather by a 
 garment of buckskin or chamois leather. Such clothing should be 
 worn not simply around the chest, but over the entire body, from 
 neck to ankles. Another measure, which is often useful in harden- 
 ing the individual, is cold bathing, a sponge bath being taken night 
 and morning. This should not, however, be insisted upon if it be 
 manifestly a severe test of the patient's endurance. 
 
 So soon as it becomes apparent that the individual is acquir- 
 ing consumption, no means should be neglected which can possibly 
 contribute to the arrest of the disease. One of the most important 
 of these means is unquestionably residence in a climai"e which is 
 not subject to sudden changes of temperature. It is doubtless true 
 that a change of residence contributes in many ways to the im- 
 provement of the individual's health, since, under the circumstances, 
 he is very apt to devote himself to the care of his physical condi- 
 tion, and to employ his time in out-door amusements and exercise. 
 Yet, making due allowance for the value of these measures, there 
 remains considerable importance to be attached to the climate 
 itself Much attention has been devoted to this subject, and the 
 relative worth of numerous localities and of various climates has 
 been the subject of close observation and study. Several popular 
 errors in regard to this subject have been corrected; among these 
 was the idea, which is even to-day quite prevalent, that a warm 
 climate was absolutely essential for improving the consumptive's 
 condition. Upon this subject Aitken says: " It was long a preva- 
 lent belief that consumption was limited by latitude, and that it 
 never appeared in warm countries — for instance, south of the Medi- 
 terranean. But this is proved not to be the case, for the returns 
 of the army, prepared by the above writer, have shown that con- 
 sumption is more frequent in the West Indies than even in England 
 
CONSUMPTION. 
 
 55 
 
 a statement first made by Sir James Clark in his work on climate, 
 
 in illust ".'lon of the injurious effects of that climate on consumptive 
 patients sent there from this country. 
 
 " According, also, to the opinion of this author, great heat 
 appears to have a powerful effect in predisposing to tuberculous 
 diseases, probably by diminishing the exercise in the open air. 
 That it is not the climate of the place which alone produces this 
 result in the West Indies, is shown by tlie fact that officers were 
 attacked in infinitely smaller proportions than private soldiers ; and it 
 is more than probable that crowded barrack rooms, a restriction to 
 salt diet and drinking spirits may have produced the result. 
 
 " It would appear that England and Wales, the Cape of Good 
 Hope, Canada and Malta are more exempt from consumption than 
 many countries which, from their higher temperature, have hitherto 
 been supposed to enjoy a remarkable exemption from this com- 
 plaint." 
 
 The feature which has been supposed to exercise much in- 
 fluence upon the progress of consumption is the moisture of the 
 climate ; it has been found that not only particular localities, but 
 even particular districts, and even individual houses in the same 
 district, vary much as to the prevalence of consumption, according 
 to the moisture of the soil. It seems, indeed, well established that 
 those localities particularly favorable to the development of the dis- 
 ease are usually marked by an unusual degree of moisture. Yet it 
 is equally true that moisture alone does not constitute a necessary 
 barrier to the improvement of a consumptive's health, since some 
 of our noted resorts have a more or less moist climate. When it 
 becomes evident that the patient is suffering, or is about to suffer, 
 from consumption, the question arises, where shall he go ? The 
 answer must depend largely upon the condition and history of the 
 patient ; for let it be understood that there is no charm, no specific 
 curative influence in any climate ; the object is merely to place the 
 patient under the best possible conditions for preserving his strength 
 and for removing him from those influences which seem most injuri- 
 ous. There is, therefore, no one rule which applies to all cases, 
 and no one climate which is suitable for all consumptives. One 
 feature is absolutely necessary, namely, a reasonable uniformity of 
 temperature through the season ; that is, the absence of those sud- 
 den and excessive changes which are so characteristic of our Atlantic 
 seacoast, for example. Dryness is best adapted to a considerable 
 
156 
 
 DISEASES OF THE THROAT AND ClIKST. 
 
 number of cases, though not to all ; warmth is favorable for most 
 consumptives, though some cases improve more rapidly in colder 
 localities. This last fact has been well brought out by observation 
 on the effects of residence in the northern part of the United States. 
 Instances are known in which consumptive patients who had 
 scarcely been able to hold their own in Florida or other warmer 
 places, have rapidly improved in Minnesota, Dakota and other 
 localities in the same latitude ; and this improvement has continued 
 even during the winter, which is in these regions extremely 
 severe. Such cases are doubtless in the minority, since the 
 greater number seem benefited by the warmer climate of Southern 
 California, Colorado and even Florida ; but the fact indicates that 
 there is a diversity in the requirements of different cases. Probably 
 the best way for conjecturing the most suitable climate is to be 
 derived from the feelings of the patient at different seasons. If his 
 condition be better during the hot summer months at home than 
 during the cooler spring and fall, he will probably be better suited 
 by sojourn in a warm climate ; while if he feel oppressed and en- 
 feebled by the summer heat when at home, he might try to advan- 
 tage the more Northern resorts already named. 
 
 " With reference to the particular situation to be selected," 
 says Dr. Flint, " it should contain resources for occupation and 
 mental interest. There must be inducements for out-door life, i 
 have known patients who had been accustomed to active habits, 
 suffer intolerably from ennui, in going to places where the supposed 
 excellence of climate was the only attraction. It is frequently 
 better to move about from one place to another, than to remain 
 stationary. As soon as the place becomes tiresome, it is best to 
 leave it. Traveling in foreign countries, without any special regard 
 for climate, is often the best plan, the advantage consisting in the 
 interest and inducements to exercise derived from a succession of 
 new scenes. A sea voyage is generally useful, and if patients are 
 fond of the sea, a long voyage, if practicable, may be advised. 
 Places which are especially the resort of patients are to be avoided ; 
 the moral effect of seeing daily examples of the different stages of the 
 disease is unfavorable. A change is often useful when there is no 
 superiority on the score of climate, because it is in this way only 
 in certain cases thai relief from the cares and anxieties of business 
 can be secured. 
 
CONSUMPTION. 
 
 »57 
 
 " The habits and taste of the patient are to be considered. Per- 
 sons who are dependent on the associations and comforts of home 
 and friends for their happiness will not be likely to be benefited 
 by being sent away, especially if alone and among strangers. The 
 stage of the disease and the rapidity of its progress are points of 
 great importance. It is truly a cruel act to send to a distance pa- 
 tients who are in a condition admitting of but little prospect of 
 improvement, and who would probably not live to return. The 
 amount of damage which the lungs have sustained, as determined 
 by physical signs as well as the symptoms, are to be taken into 
 account, before entertaining the question relative to change of 
 climate. And finally, if a change be made and prove effectual, 
 it becomes an important question whether, if practical, the change 
 should not be permanent. An arrest of the disease does not extin- 
 guish the predisposition to it, and the safest course, undoubtedly, 
 is to take up a residence in the climate in which the disposition to 
 consumption is less liable to be reproduced than in the climate in 
 which it has been already once developed. " 
 
 The followir g extracts, from a table prepared by Dr. Mat- 
 tocks, indicate the relative frequency of consumption in different 
 parts of the Union. As is shown in this table, the disease is far 
 more frequent in the older, more thickly settled portions of the 
 countryj being most prevalent in New England, and least frequent 
 in the Western and Southern States. In 860, there was in Massa- 
 chusetts one death from consumption for every 250 inhabitants; 
 
 Maine ------ 
 
 New Hampshire - - - - • 
 
 Rhode Island - . - 
 
 Connecticut _ - - . 
 
 Vermont - - - - - 
 
 New York - - - - - 
 
 New Jersey . - . _ 
 
 Delaware - - - - - 
 
 Maryland -----. 
 
 Pennsylvania - - - _ 
 
 Michigan - - - . - 
 
 Kentucky - - - - - 
 
 Ohio 
 
 California - - - . - 
 
 Virginia - - - « . 
 
 I in 
 
 280 
 
 I in 
 
 280 
 
 I in 
 
 300 
 
 I in 
 
 360 
 
 I in 
 
 400 
 
 I in 
 
 470 
 
 I in 
 
 490 
 
 I in 
 
 S50 
 
 ! in 
 
 570 
 
 I in 
 
 580 
 
 I in 
 
 630 
 
 I in 
 
 660 
 
 I in 
 
 670 
 
 I in 
 
 720 
 
 I in 
 
 7 SO 
 
158 
 
 DISEASES OK THE THROAT AND CHEST. 
 
 Indiana 
 
 Tennessee 
 
 Louisiana 
 
 Wisconsin 
 
 Illinois 
 
 Missouri 
 
 Iowa - 
 
 Kansas 
 
 Minnesota - 
 
 North Carolina 
 
 Arkansas 
 
 Mississippi - 
 
 Texas - 
 
 Florida 
 
 Alabama 
 
 South Carolina 
 
 Georgia 
 
 I in 
 I in 
 I in 
 I in 
 I in 
 I in 
 I in 
 I in 
 
 760 
 770 
 840 
 850 
 880 
 900 
 902 
 910 
 I in 1,139 
 I in 1,300 
 I in 1,322 
 I in 1,420 
 I in 1,430 
 I in 1,440 
 I in 1,618 
 I in 1,720 
 I in 2,150 
 
 The treatment of consumption must consist chiefly in attention 
 to the general health, and in such measures as shall increase the 
 patient's strength and vigor; and these measures consist largely in 
 the regulation of diet, air and exercise, and a change of climate, as 
 already described. Yet something can be done by the use of 
 medicines, which indeed become absolutely essential in the later 
 stages of the disease, when the only hope and object of treatment 
 is to palliate the sufferings of the patient. Chief among these 
 remedies are alcohol and cod liver oil, neither of which has any 
 special curative effect in opposing the disease; each of them acts 
 apparently merely by furnishing rich and easily digestible nourish- 
 ment in concentrated form. While all admit the value of alcohol 
 late in the disease, when the patient's strength is exhausted and his 
 body emaciated, yet comparatively few, perhaps, realize how bene- 
 ficial it may be at an earlier stage. Indeed, when the first symp- 
 toms of the disease become pronounced, the amount that may be 
 prescribed with benefit is much in excess of the quantity ordinarily 
 given; patients have been known to improve materially, even 
 apparently to recover, by taking a pint or more of whisky daily. 
 In these cases there is rarely observed any evidence of the intoxi- 
 cating effects of the drug which are so common under ordinary 
 circumstances ; a weak, emaciated patient may swallow eight ounces 
 
ill 
 
 CONSUMPTION. 
 
 • 59 
 
 of whisky daily without showing any unusual impairment of the 
 mental faculty. Yet it must be admitted that some cases do not 
 bear whisky so well ; that even in larger quantities it does not seem 
 to cause marked improvement. Such cases may often be benefited 
 by the substitution of wine or malt liquors for the whisky. The 
 amount of liquor that may be prescribed with benefit is to be 
 regulated by the feelings of the patient; if it be not followed by a 
 sense of lassitude, headache and other signs of intoxication, the 
 quantity is not excessive. 
 
 Co/d liver oil, too, is to be regarded as a food, and not as a 
 specific cure for the disease. It is found beneficial not only in the 
 advanced, but also in the early stages of consumption. An adult may 
 take with advantage one or two tablespoonfuls three times a day, 
 preferably after meals. The nauseous taste of the oil is in many 
 cases a serious impediment to its use, some individuals being 
 utterly unable to take it. For such cases, some one of the many 
 compounds prepared expressly to disguise the taste of the oil — 
 emulsions, combinations with malt, etc. , can be used; if these also be 
 objectionable to any fastidious palate, the oil can be taken inclosed in 
 capsules. It sometimes happens that even when thus taken, so that 
 the taste is disguised, the oil materially impairs the appetite or 
 digestion, or both ; in such cases the unpleasant effects may often be 
 avoided by diminishing the quantity of the oil ; in any case it is 
 advisable to begin the use of this agent by giving small quantities, 
 say a teaspoonful or less, and gradually increasing to one or two 
 tablespoonfuls. 
 
 Certain symptoms of the disease may also require treatment, 
 among them the cough, diarrhea, and night sweats. The cough is 
 inevitable, so soon at least as the softening and breaking down of 
 the lung tissue begins; hence the only object in treating the cough 
 is to diminish the irritation and consequent exhaustion of the 
 patient. Hence such remedies as squills and ipecac are out of 
 place, and may even do harm ; but some sedative mixture may be 
 of service, such as the following : 
 
 Dilute hydrocyanic acid, - - Half a drachm. 
 
 Sulphate of morphia, - ... Half a grain. 
 
 Syrup of tolu, water, - - - Each one ounce. 
 Mix, and take half a teaspoonful every hour. 
 
 II 
 
i6o 
 
 DISEASliS OF THE THROAT AND CHKST 
 
 In 
 
 Or, instead of this, tlic following mixture may be given : 
 Paregoric, - - - - - 
 Syrup of wild cherry, - - - Each one ounce. 
 Mix, and take half a teaspoonful every hour or two. 
 
 The night sweats of consumption may be quite profuse and 
 exhausting, even before the later stages of the disease arc 
 reached. They are best and soonest relieved by improving the 
 patient's strength and vigor, since the night sweats are merely 
 indications of the general debility and exhaustion induced by the 
 disease. It may be possible, also, to materially reduce this per- 
 spiration and its ill effects, either by using some astringent wash 
 externally, or a preparation of belladonna as a medicine. For the 
 former purpose, alum may be dissolved in alcohol, and the patient 
 lightly sponged with this, before retiring ; at the same time minute 
 quantities of atropia — one one-hundredth of a grain — may be 
 given as a pill, at night. Or the following mixture may be given: 
 
 Aromatic sulphuric acid, - - . Three drachms. 
 
 Sulphate of quinine, - - - Fifteen grains. 
 
 Water to make two ounces. Mix, and give a teaspoonful in water 
 at night. 
 
 The pains in the chest are often so troublesome as to disturb 
 the patient's rest extremely. These can usually be relieved by che 
 use of belladonna plaster applied to the painful spot, or friction 
 with chloroform liniment or a light mustard plaster may also prove 
 beneficial. 
 
j 
 
•IB^&lj 
 
 489.— An anterior vie w o< the 
 Heart in a vertical position, 
 with itk vessels injected. 
 
 44U.— A posterior view ot tlie 
 Heart In a vertical position, and 
 with its vessels injected. 
 
 430.— A view of the Bronchia and Blood-vessels of the Lungs, 
 as shown by dissection, as well as the relative position of the 
 Lungs to the Heart 
 
 4-('i.— A vertical view of the Auriculo- 
 Ventricular and Arterial Valves of the 
 Heart 
 
 HEA.RT. 
 
 444.— A three-quarter view of the 
 Left Ventricle after the removal of its 
 Anterior Parietes. 
 
DISEASES OF THE ORGANS OF GIRCDUTIOR. 
 
 DISEASES OF THE HEART. 
 
 Pericarditis. 
 
 By this term is meant an inflammation of the membrane 
 which surrounds the heart, the pericardium. For the heart, like the 
 lung, is enveloped in a smooth membrane, so arranged that the heart 
 itself is not exposed to friction during the movement which accom- 
 panies its natural action. This membrane covers the heart, and is 
 then reflected so as to make a closed sac. In this sac there is dur- 
 ing life a small amount, perhaps half a teaspoonful of watery liquid, 
 which lubricates the two surfaces cf the membrane lying in contact. 
 If this membrane becomes inflan^ed, the same genera! process 
 occurs which has been described in ti>e discussion o{ pleurisy — that 
 is, the inflammation of the membrane ."(urrounding the lung. With- 
 out entering into a repetition of details, it will suffice to say, in 
 general, that there occurs an exudation into the pericardium., con- 
 sisting at first of liquid perhaps, and subsequently containing a 
 considerable amount of solid matter called lymph. If the case 
 terminate in recovery, this liquid is taken back again into the blood, 
 — th^X IS absorbed — leaving the solid material in the sac. This 
 material then forms bands, which unite the two surfaces of the 
 pericardium, so that there is sometimes interference with the free- 
 dom of the heatt's movements. In other Cases, the liquid is not 
 absorbed at the usual time, and may even become filled with mat- 
 ter that is purulent. Such cases involve the patient in considerable 
 danger, and often result fatally. 
 
 Symptomti, — The symptoms of pericarditis are apt to be asso- 
 ciated with those of other affections existing at the same time, 
 because pericarditis rarely occurs as a primary affection, but 
 
 i6i 
 
 
l62 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 usually as a complication of acute rheumatism or of kidney disease. 
 If a patient be suffering from one of these affections, it is the duty 
 of the physician to watch for the development of pain in the region 
 of the heart. This pain is usually sharp and cutting in character, 
 like that of pleurisy; moreover, it is increased during deep breath- 
 ing, so that this disease has been often mistaken for pleurisy. There 
 may be also a dry, hacking cough. In fact, the symptoms gener- 
 ally direct the attention to the breathing apparatus, rather than to 
 the heart itself. The action of the heart is however much dis- 
 turbed, as may be discovered by the pulse, or by placing the hand over 
 the point of the heart between the fifth and sixth ribs. So soon as the 
 exudation begins, the system changes somewhat; the pain and sore- 
 ness become less acute, and if the amount of liquid be considerable, 
 there may be some protrusion between the ribs in the region 
 of the heart. But other and more serious results follow the pres- 
 ence of the liquid in the pericardium, because the heart is com- 
 pressed by this liquid, and its movements are impeded. The re- 
 sult of any impediment to the heart's movement is, of course, an 
 interference in the circulation of the blood, and this interference 
 is manifested by blueness of the face and hands, by a feeling of 
 suffocation, perhaps even delirium and convulsions. Indeed, it 
 sometimes happens that the inflammation in the heart itself is over- 
 looked, because the other symptoms, such as derangement of the 
 mind, are so prominent. 
 
 The severity of the affection is measured by the amount of 
 exudation; if this be slight, the symptoms are not severe and the 
 danger is not great, but if a large amount of liquid escape into 
 the pericardium, the disease is extremely dangerous and often 
 fatal. 
 
 Cause, — Acute inflammation of the pericardium may be pro- 
 duced by an injury such as a stab, or by a blow upon the chest, 
 especially if a rib be fractured, in the neighborhood of the heart. 
 Several curious accidents are reported in which pericarditis pro- 
 ceeded from unusual causes ; thus, Walsh mentions an instance in 
 which, during the juggler's trick of swallowing a sword, the instru- 
 ment passed from the oesophagus into the pericardium, which lies 
 adjacent, and caused a fatal inflammation. Flint also mentions a 
 case in which a set of false teeth were swallowed while the owner 
 was profoundly intoxicated ; the teeth lodged in the lower part of 
 
PERICARDITIS. 
 
 163 
 
 oesophagus, and ultimately worked their way through into the 
 pericardium, inducing a fatal inflammation ; after death the teeth 
 were found in the pericardium. Pericarditis, when it does not result 
 from injuries, is almost always a complication of some other disease, 
 especially acute rheumatism. Until the use of salicylic acid 
 became general for the treatment of rheumatism, pericarditis was a 
 quite frequent occurrence, it being estimated that it occurred in 
 one out of every six cases of rheumatisip. It is also a frequent 
 complication of inflammation of the kidneys, of erysipelas, typhoid 
 and typhus fever, and of many of the infectious diseases. 
 
 The height of the disease is usually reached within a week or 
 ten days, though it does not follow that recovery will begin at the 
 expiration of that period. For in many cases the patient remains 
 in a dangerous condition for two or three weeks, and even when 
 the liquid has become absorbed the patient is by no means out of 
 danger ; for the heart remains weak for a considerable time, and 
 the patient should not be permitted to make any severe exertion. 
 Flint reports a case in which a patient sufierirg from pericarditis 
 died instantly upon getting out of bed. 
 
 Treatment. — In most cases pericarditis is, as has been 
 aheady remarked, a complication of other diseases ; hence the 
 treatment consists, in most cases, of measures adapted for the relief 
 of these other diseases. The treatment for the pericarditis itself 
 consists in the relief of pain by opium, and in local applications 
 over the region of the heart. Before the exudation has occurred, 
 a light mustard poultice may be applied over the heart ; and so 
 soon as there is evidence of the presence of liquid in the peri- 
 cardium, the skin may be painted with the tincture of iodine once 
 every day. It is desirable to avoid blisterin,'. i'>e skin in this region. 
 
 If the amount of liquid become so great as to threaten life by 
 impeding the movement of the heart, there is still a resort which 
 has in skillful hands repeatedly saved the lives of patients suffering 
 from pericarditis ; this measure consists in what is termed aspira- 
 tion. This means that a very fine needle is inserted through the 
 skin into the pericardium, and the liquid is drawn off" by means of 
 a syringe. In this way the pressure on the heart is removed, and 
 the immediate danger is averted. 
 
 During convalescence extreme care should be taken to protect 
 the patient against severe physical effort of any sort, since the 
 
l64 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 heart is so weak that a degree of exertion which is not noticed 
 during health, may be sufficient to make the heart stop beating 
 entirely. 
 
 Endocarditis— Heart Disease. 
 
 By this term is designated what is popularly known as " heart 
 disease. " It consists in an inflammation of the membrane which 
 lines the inside of the heart, the endocardium, for the heart is hol- 
 low, and its cavities are, during life, always full of blood ; the 
 surface over which the blood moves is covered with a smooth 
 membrane, quite similar to that which covers the heart, the/m- 
 cardium, and to that which covers the lung, the pleura. The 
 endocardium, like either of the other membranes named, is subject 
 to inflammation, during which a certain amount of material is 
 formed on its surface, called the exudation. This exudation may 
 occur anywhere within the cavity of the heart, but is found with 
 especial frequency at those parts of the lining membrane which 
 project so as to form the valves of the heart. These valves, it will 
 be remembered, are folds of the lining membrane of the heart, so 
 arranged as to prevent the blood from flowing backward. So long 
 as these valves retain their natural condition they are smooth and 
 fit tightly into one another, so as to prevent the blood stream from 
 passing through them. When, however, they become inflamed, 
 and the exudation already described takes place on their surface, 
 they become rough and uneven, and are no longer capable of fitting 
 so closely against each other as to prevent the return of blood ; the 
 valves are, in other words, no longer blood tight. In the most 
 favorable cases this exudation may be absorbed, and the valves 
 become smooth and even again ; yet, in the majority of instances, 
 this exudation is never entirely removed, but remains in and around 
 the valves, keeping them rough and preventing them from shutting 
 tightly. The result is that the blood does not circulate so well as 
 before, and this is the origin of the so-called heart disease ; that is, 
 of what physicians call organic disease of the heart. 
 
 It is, of course, impossible to detect by any ordinary means 
 the presence of this exudation on the surface of the valves and of 
 .the endocardium, but the properly trained physician can readily dis- 
 
ENDOCARDITIS. 
 
 "65 
 
 cover such a condition by applying the ear to the chest, for the 
 beating of the healthy heart is accompanied by certain sounds, 
 which may readily be distinguished by listening over the chest 
 « between the fourth and sixth ribs, a little to the left of the breast 
 bone ; and although there are certain variations in different indi- 
 viduals, yet the sound caused by the circulation of the blood 
 through the heart is essentially the same in all healthy persons. 
 But so soon as this circulation of the blood through the heart is 
 disturbed by disease of the valves, so soon as the blood fails to 
 flow always through the organ in the proper direction, and begins 
 to flow backward through these diseased valves, the sounds 
 heard by placing the ear over the heart are quite different from 
 those of the normal chest. In this way, therefore, it becomes 
 easy, after acquiring proper experience, to detect disease of the 
 heart valves. 
 
 By post mortem examination it is found that the exudation 
 which takes place on these valves is often arranged in the shape of 
 little masses or bunches looking like warts or pimples ; sometimes 
 these masses attain considerable size, becoming as large as a bean, 
 or even a hazel nut. As will be mentioned later, these little masses 
 constitute a constant source of peril to the patient's health, or even 
 life ; for they are constantly washed by the stream of blood passing 
 with great force through the heart ; and it not infrequently hap- 
 pens that small pieces will be torn off and carried along in the cur- 
 rent of blood, just as trees on the bank of a stream may be under- 
 mined and swept away by the current. So long as these little 
 masses circulate in the blood there is no particular danger ; but 
 they are apt to become lodged in the arteries in various parts of 
 the body, blocking up the blood vessel, and thus cutting off the 
 supply of blood from some of the organs. The result of this must 
 be a suspension, partial or complete, of the functions of that 
 organ thus deprived of blood. This is the explanation of many 
 cases of so-called apoplexy ; in these cases the individual drops 
 suddenly to the floor, paralyzed in some of his limbs, or perhaps 
 falls unconscious, and dies in a short time. The explanation is 
 simply that some fragments of this exudation have been washed off 
 from the heart valves, and have lodged in some of the blood vessels 
 going to the brain, cutting off the supply of blood to this organ, 
 and thus causing paralysis. 
 
 ii 
 
 mm 
 
i66 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 Symptoms. — Inflammation of the lining membrane of the 
 heart occurs, in the vast majority of cases, as an incident in the 
 course of other diseases, especially of acute rheumatism. As has 
 been already remarked in discussing rheumatism, the chief danger 
 from this disease lies in the possibility that inflammation of the 
 heart may occur. Before the use of salicylic acid, it was estimated 
 that endocarditis occurred in one-third to one-half of all the cases 
 of acute articular rheumatism 
 
 Whenever, then, the patient has a protracted attack of acute 
 rheumatism, the possibility, in fact probability, must be borne in 
 mind that an inflammation may occur ;n the heart. This will 
 usually be indicated by a dull, heavy pain in the region of the 
 heart. In other cases the sensation does not amount to pain, but 
 is rather a feeling of distress. There is usually, at the same time, 
 very rapid and irrejjular action of the heart, indicated by palpita- 
 tion. But the only positive means for rcognizing the affection 
 consists in applying the ear (either directly or indirectly, through 
 the stethoscope) to the chest, whereby the sQunds of the heart, 
 indicating disease, may be detected. In many cases, endocarditis 
 is associated with pericarditis, and the recognition of both diseases 
 requires considerable skill and experience on the part of the physi- 
 cian, since many of the symptoms are common to both diseases. 
 
 Trentinetit. — The treatment of endocarditis is merely that of 
 the disease with which it is associated, generally acute rheumatism ; 
 in lact, the inflammation in the heart may be regarded as a part of 
 the disease. 
 
 I) 
 
 I 
 
 Organic Disease of the Heart. 
 
 The inflammation of the lining membrane — endocarditis — 
 lasts but a few weeks ; but the results of this inflammation fre- 
 quently constitute a permanent afiection, which interferes more or 
 less seriously with the patient's health, and may ultimately cause 
 his death. The source of this difficulty lies, as has been already 
 stated, in the imperfect closure o*" the valves in the heart, resulting 
 from the exudation in and upon them. It has been already related 
 that sudden paralysis or even death may result from the loosening 
 of such particles, which may then be swept into various blood 
 
ORGANIC DISEASE OF THE HEART. 
 
 167 
 
 vessels in various parts of the body. But even if this do not 
 happen, there results almost certainly a gradual interference with 
 the circtilation of blood. We can readily understand that if the 
 valves of a pump or syringe do not close properly, water cannot be 
 projected by the instrument with the same force nor to the same 
 distance as before; and it is just so with regard to the heart, which 
 is merely a living pump for throwing the blood through the vessels 
 into different parts of the body. When the valves of this pump 
 become so damaged by disease as to close but imperfectly, the 
 blood will not be pumped throughout the body with the same force 
 as before; and the results of this imperfect circulation of the blood 
 will be manifested in different organs of the body according to the 
 degree of impairment in the heart's action. 
 
 Though the symptoms vary in detail according to the valves 
 affected, yet certain general symptoms are generally found in all 
 cases; among the first of these is shortness of breath. The patient 
 first observes that he cannot take exercise with the same freedom 
 of breathing as before ; and he usually observes that he cannot 
 even walk up stairs without a feeling of oppression in the chest or 
 even of suffocation. Such effort, too, is accompanied by a some- 
 what violent action of the heart, which the patient probably 
 describes as " palpitation." If persisted in, such exercise causes a 
 feeling of faintness. After a time this shortness of breath, which 
 was at first felt only upon exercise, becomes habitual; so that the 
 ordinary duties of life occasion extreme inconvenience. This diffi- 
 culty in breathing is usually accompanied by a cough and some 
 little expectoration; at times this expectoration is streaked with 
 blood. There is not usually any considerable pain, but simply a 
 feeling of distress in the chest, often accompanied by a state of 
 mental anxiety and depression quite out of proportion to the 
 apparent physical derangement. The sleep, too, is often disturbed 
 by unpleasant dreams, in which the patient fancies himself exposed 
 to danger and death. 
 
 There is apt to be a blueness of the skin, indicating impaired 
 cir«ulation of the blood. All these symptoms become exaggerated 
 with the lapse of time, until the heart meets the increased demand 
 upon its strength by an increase in size. For just as a man's arm 
 becomes thicker and stronger after long continued use of a sledge 
 hammer, so the heart increases in size, in order to accomplish the 
 severer task imposed upon it by the failure of the valves. Hence 
 
1 68 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 rt 
 
 it happens that the subjects of organic disease of the heart usually 
 exhibit, sooner or later, an enlargement of the heart. This en- 
 largement is not to be regarded as a disease in itself, but is merely 
 the result of the previous disease of the valves. The enlargement 
 is in fact a beneficial change, as is indicated by the improvement 
 which takes place in the patient's symptoms. It is not uncommon 
 to find individuals with organic heart disease who enjoy, neverthe- 
 less, excellent health, because the heart is sufficiently powerful to 
 circulate the blood properly, notwithstanding the impediment in 
 the valves. 
 
 But sooner or later the heart becomes unequal to the ever- 
 increasing resistance, and the original symptoms return with even 
 greater intensity. There now occurs, if it has not previously taken 
 place, swelling of the body, usually beginning in the feet and legs, 
 and spreading over the entire trunk. At the very beginning, this 
 dropsy is noticed in the feet only toward the close of the day, and 
 has disappeared when the patient rises in the morning. But it 
 finally becomes persistent, and occasions the patient a great deal 
 of annoyance. The face becomes swollen and livid, there is often 
 so much liquid in the chest cavities as to seriously impair the 
 breathing; the abdomen, too, becomes distended with fluid, and 
 the feet and legs acquire such a size that the skin seems to be on 
 the point of bursting. When the disease has progressed so far as 
 this, the patient is often unable to maintain the recumbent posture 
 with comfort ; he is compelled to sleep in a chair or bolstered up 
 in bed. The sluggishness of the circulation impairs also the func- 
 tions of most of the organs; the stomach and intestines fail to 
 perform their work in the usual way ; the appetite and digestion 
 become impaired, and there is often obstinate diarrhea. The pa- 
 tient is also often frequently troubled with piles. 
 
 Organic disease of the heart may remain for a long time harm- 
 less; indeed, examiners for life insurance companies not infrequently 
 find such diseases in individuals who had never been led to suspect 
 the existence of serious disease of the heart or elsewhere. Indeed 
 after the disease has been discovered, and the patient is even suffer- 
 ing from the lighter symptoms, many years may elapse without the 
 occurrence of serious interference with the health ; many indi- 
 viduals afflicted in this way live to a good old age, and ultimately 
 die of affections in no way attributable to the heart disease. So 
 soon, however, as enlargement begins, it is to be expected that 
 
ORGANIC DISEASE OF THE HEART. 
 
 169 
 
 sooner or later — in the course of many years perhaps — the severe 
 symptoms will follow ; and there is always a possibility that a fatal 
 result may occur suddenly, either from apoplexy in the way already 
 described, or from paralysis of the heart. 
 
 Treatment, — Until the symptoms indicate an impairment of 
 function of various organs, — shortness of breath, etc. — organic 
 disease of the heart frequently requires no treatment. Indeed, in 
 many cases, it is advisable that the fact of the disease should be 
 concealed from the patient if possible, as is often the case when the 
 discovery be made accidently by a physician ; for an individual 
 conscious that he is suffering from" heart disease," is apt to regard 
 himself as an invalid and to adopt a mode of life which will render 
 his general health delicate, and will thus favor the development of 
 the disease in the heart. Such an individual should place himself 
 under the best possible conditions for the maintenance of health, 
 including a fair amount of exercise in the open air ; and it is just 
 this latter point from which he will shrink if he be aware of the 
 existence of heart disease. Yet it is advisable that such patients 
 should avoid those influences which can exert a sudden strain upon 
 the heart and thus tend to increase the difficulty; he should, there- 
 fore, abstain from very violent physical exertion, from excessive 
 mental emotion, and from the use of alcoholic stimulants. Yet if 
 he bear this general principle in mind, it is far better that he do not 
 attempt to regulate his life by any set of rules, but merely observe 
 the general facts of hygiene, by keeping himself well fed, well 
 clothed and in good exercise. 
 
 After the symptoms begin to indicate that the heart is no 
 longer equal to the demand made upon it, that the circulation is 
 becoming feeble, much can be done to retard the progress of the 
 disease and to restore the patient to a fair degree of health by 
 the use of digitalis. The effect of this drug is to stimulate and 
 strengthen the heart's action ; under its use the breathing becomes 
 easier, the skin loses its bluish tinge, and the patient fec^s much 
 improved. Ten drops of the tincture of digitalis may be admin- 
 istered every four hours, in water. 
 
 When the disease has advanced to such a stage that general 
 dropsy and the accompanying symptoms are present, but little can 
 be done to materially prolong the patient's life. The dropsy can 
 be, perhaps, diminished by the use of saline laxatives, though the 
 
170 
 
 IJISKASES OF THE ORGANS OF l.IKCULATION. 
 
 exhaustion consequent upon their use is apt to weaken the patient 
 materially. All the symptoms must be treated as they arise. 
 
 Death ordinarily occurs after a long period of suffering, though 
 it may happen from sudden distension of the heart, caused by un- 
 usual physical effort or mental excitement ; in these cases there is 
 either a paralysis of the heart or a rupture of its walls. 
 
 Enlargcvicnt of the heart, technically called hypertrophy, may 
 result from several other causes than the one just mentioned. In 
 the majority of cases it is doubtless due to a previous inflammation 
 of the endocardium, as described above; but there are instances 
 in which there have been no endocarditis, and no impairment of 
 the valves. These causes may be located in various parts of the 
 body quite removed from the heart, for since the function of the 
 heart is to propel the blood through the body, any obstacle to the 
 passage of the blood through the vessels will increase the work of 
 the heart, and hence cause it to enlarge. Several of these causes 
 will be discussed under the appropriate headings, such as aneur- 
 ism and disease of the kidneys. But one disease will be described in 
 which enlargement of the heart is a prominent symptom ; this is 
 
 :| 
 
 fl' 
 
 Exophthalmic Goitre. 
 
 This affection, which is also known as Graves^ disease, is, per- 
 haps, not primarily a disorder of the heart. The most prominent 
 characteristics are protrusion of the eyes, enlargement of the neck 
 and violent action of the heart. This disease is somewhat rare, 
 though since attention has been especially directed to it, a compara- 
 tively large number of q^ses have been observed. 
 
 The most prominent feature of the disease is protrusion of the 
 eyes. This change of position begins gradually, but may attain an 
 extreme degree. The eyeballs are more prominent than before, 
 and hence escape to a certain extent from between the lids, so that 
 the eyes can oftentimes not be closed completely. Ta these cases 
 the whites of the eyes are visible above and belo\7 as well as at the 
 sides of the pupil, so that the patient has a peculiar staring and 
 even fierce expression. The sight is not usually impaired. Indeed, 
 the only unnatural feature about the eyes is their prominence. At 
 times their may be a dull aching pain in the orbits, though this is 
 not a necessary feature. 
 
PALPITATION OK THE liKART. 
 
 71 
 
 The neck is usually enlarged, more especially upon the right 
 side. This swelling is not necessarily painful, but often leads to 
 embarrassment in breathing and in speaking, from pressure upon 
 the windpipe and upon the nerves of the larynx. The swelling 
 often pulsates quite markedly. The action of the heart is un- 
 usually violent, giving the patient the sensation of constant palpi- 
 tation. At times the heart's beat becomes much increased in force 
 and frequency, constituting paroxysms which are quite distress- 
 ing to the patient. The individual is usually in poor health, and 
 is apt to be quite pale. In the course of the disease various symp- 
 toms of mental and physical disturbance occur, such as despon- 
 dency and irritability, hysteria, inability to sleep; in women, 
 derangements of menstruation, loss of appetite and impairment of 
 digestion. The disease is chronic, lasting for months or years. 
 It does not seem to destroy life directly, yet most of the patients 
 die of other affections, which seem to be hurried on by this disease. 
 
 The disease is especially apt to occur in young women, and it 
 has been supposed that it could be traced to excessive sexual ex- 
 citement — a supposition as yet not proven. Some cases have been 
 known to recover ultimately. 
 
 The best results from treatment have been thus far obtained 
 from the continuous electric current, and from the administration 
 of digitalis and the iodide of potassium. Much can be accom- 
 plished by surrounding the patient with such influences as shall 
 secure amusement, exercise and the avoidance of mental anxiety. 
 
 Palpitation of the Heart. 
 
 Palpitation of the heart is the popular term for designating 
 certain irritable conditions of the heart, which manifest themselves 
 to the patient by disordered and violent action. The individual 
 has a painful sensation of depression in the region of the heart ; 
 the organ seems frequently to move about within the chest, and 
 even to rise in the throat. At the same time there is great mental 
 disturbance and nervous anxiety ; at such times the pulse is apt to 
 be irregular. These paroxysms of irregular action occur only at 
 intervals, and vary much in severity, sometimes quite prostrating 
 the patient. Although the palpitation usually lasts but a few 
 hours or less, it may persist for days or weeks. 
 
172 
 
 DISEASES OF THE ORGANS UF CIRCULATION. 
 
 One of the most common symptoms during such an attack 
 is the patient's dread of impending death, due partly to the un- 
 pleasant sensations which he experiences, and in part, doubtless, 
 to his conviction that he has heart disease. It may be said, once 
 for all, that palpitation of the heart, however distressing and un- 
 pleasant it may seem, is usually quite independent of organic dis- 
 ease of the heart, and, in such cases, contains no element of 
 danger. 
 
 The causes of this palpitation are several. Slight attacks 
 often occur in those especially addicted to the pleasures of the 
 table, particularly if they take but little exercise. It is often doubt- 
 less the result of excessive indulgence in liquor, venery and 
 tobacco; and it is highly probable that addiction to strong tea and 
 coffee may be followed by the same disorder of the heart. So, too, 
 in some individuals it occurs from exhaustion, whether from 
 physical effort or from mental strain or anxiety. In girls it is a 
 not infrequent accompaniment of the green sickness, chlorosis, and 
 of hysteria. 
 
 The first point in the consideration of palpitation of the heart, 
 is to determine whether it be due to one of these causes, which we 
 may distinguish as nervous, or whether it be actually associated 
 with organic disease of the heart. It may be said in general terms, 
 that the latter condition is a comparatively rare one as a cause of 
 palpitation; that the great majority of cases of so-called palpitation 
 are purely nervous, and not dependent upon any actual disease of 
 the heart. The truth can be ascertained at once by a careful exami- 
 nation of the heart with the stethoscope; and it is very desirable for 
 the sake of the patient, to learn whether any such disease of the heart 
 actually exist. Yet, even without such an examination by a physi- 
 cian, it will be usually found that a distinction can be made in this 
 way : Nervous palpitation is apt to occur especially at night soon 
 after the patient retires, while palpitation from organic disease 
 occurs most frequently after physical exertion. Nervous palpita- 
 tion is usually accompanied by other symptoms of nervousness, 
 increasing whenever the patient's mind is disturbed, and rather 
 diminishing when his attention is engrossed by actual physical 
 exercise ; organic palpitation is not associated with mental so much 
 as with physical causes. 
 
 " It is extremely desirable, in view of the comfort and welfare 
 of the patient, to determine with positiveness, in cases of func- 
 
PALPITATION OF THE HEART. 
 
 173 
 
 tional disorder, that structural disease does not exist. If, on a 
 careful examination of the chest, the heart be not found to be en- 
 larged, if there be no murmur present, and the heart sounds be 
 normal, the affection may be confidently pronounced functional 
 (nervous); without the nejjativc proof afforded by examination of 
 the chest, the mind of the practitir)ner must be in doubt as to the 
 diagnosis. If he give a decided opinion, it is a guess which may 
 prove to be cither right or wrong. If he avoid giving a decided 
 opinion, the inference which the patient usually draws is that 
 organic disease exists, and that the physician is reluctant to tell 
 him the truth. I could cite from the cases which have come under 
 my observation, not a few in which patients were for many years 
 rendered unhappy and deterred from engaging in the active duties 
 of life, by either an erroneous medical opinion that they had 
 organic disease of the heart, or by a fixed belief that such was the 
 fact, based on the indecision of their physicians. " 
 
 After it has been decided that the disease is really not located 
 in the heart, but that the palpitation is merely an evidence of a 
 nervous disorder, the treatment will of course consist in discovering 
 and removing the cause of the nervousness. In most cases it will 
 be found necessary to regulate the amount of food, and to carefully 
 avoid L'xcesses of all kinds, including tea, coffee and tobacco; pro- 
 vision should also be made for a proper amount of out-door exer- 
 cise and for mental recreation. Not the least important item in the 
 treatment consists in the positive assurance to the patient that he 
 is free from " heart disease," properly so-called. He should also be 
 assured that there is no danger of a genuine heart disease arising 
 from repeated attacks of nervous palpitation. 
 
 Many cases will doubtless resist treatment for a long time, 
 especially if they have existed for many years. Perhaps the most 
 promising cases are those in which the disease is evidently a result of 
 impoverishment of the blood, — anaemia — as is so often the case in 
 girls and women ; for in these instances the anaemia can usually be 
 relieved and the palpitation stopped. 
 
 During the paroxysm of palpitation relief can often be obtained 
 by the use of stimulating liniments, such as the chloroform liniment 
 over the chest, and by the inhalation of hartshorn and similar 
 agents. 
 
 i> 
 
11 
 
 a 
 
 1 
 
 I 
 
 174 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 ti } 
 
 Angina Pectoris. 
 
 This is a symptom rather than a disease, since it means merely 
 a severe pain in the chest; but it is a symptom, usually, of some 
 disease of the organs of circulation, especially of the heart and the 
 aorta, and may be therefore properly discussed in this connection. 
 The pain comes on in paroxysms, the first ones of which are usually 
 slight and attract but little attention ; but in course of time these 
 paroxysms recur with greater force as well as frequency. When 
 well developc'd the paroxysm is marked by sharp pain beginning in 
 the region of the heart or under the breast bone, and radiating from 
 this point in different directions — around the chest on both sides 
 into the back, but especially up to the left shoulder, often extend- 
 ing down the left arm and fore-arm ; less often invading the face and 
 head. The pain is often of a burning or tearing character, some- 
 times so intense as to .ender the patient almost delirious; there 
 may also be a feeling of tightness in the chest. 
 
 The paroxysm usually begins suddenly, compelling the patient 
 to remain perfectly quiet, and inspiring him with a feeling of inde- 
 scribable dread, so that he seems often afraid to move or even to 
 breathe deeply. The surface is usually cold and frequently bathed 
 with clammy perspiration. The heart's action is usually tumultu- 
 ous and disordered, adding to the patient's distress. 
 
 Angina pectoris is, as has been said, usually an incident in 
 organic disease of the heart or of the aorta; and in the majority of 
 cases the evidence of such disease is apparent upon close examina- 
 tion; the angina is in fact merely a severe neuralgia accompanying 
 the heart disease. Angina is a dangerous affection, r to speak 
 more correctly, the cases of heart disease in which this severe form 
 of neuralgia occurs usually terminate fatally. Death often occurs 
 suddenly, frequently during a paroxysm of pain. On the other 
 hand (.here are some cases of this rare disease in which there is no 
 evidence of serious affection of the heart, and which may recur for 
 years without imperiling the life of the individual. Generally 
 speaking, we may say that the danger is proportional to the disease 
 of the heart and not to the intensity of the pain. 
 
 Beside the genuine angina pectoris there may occur neuralgic 
 pains in the chest and near the heart, which do not depend at all 
 upon nor originate in the heart, and which should therefore be dis- 
 tinguished from the latter variety. These slight neuralgic attacks 
 
 may be co 
 
 of the stor 
 
 petent phys 
 
 The real an 
 
 the age of ^ 
 
 The trc 
 
 oxysm; anc 
 
 some form. 
 
 morphia, or 
 
 intensity of 
 
 better to adi 
 
 or if that is i 
 
 at once, and 
 
 light mustarc 
 
 the chest. I 
 
 voke a parox 
 
 ical effort. 
 
 By aneur 
 increase in siz 
 not necessary 
 are subject to 
 by various su 
 aorta, howevei 
 artery leading 
 of the body 
 tation, or aneu 
 and must run ii 
 termination, wl 
 times cured spc 
 remove this coi 
 an aneurism in 
 many symptom- 
 bles us to at lea 
 a time the fatal 
 
 Symptom 
 
 vary considerab 
 
ANEURISM OF THE AORTA. 
 
 175 
 
 may be confined to the chest wall, or may originate in distention 
 of the stomach with gas ; ar^ examination of the heart by a com- 
 petent physician will usually d.:tect the true nature of the complaint. 
 The real angina affects women but rarely, and is not frequent before 
 the age of 30 years. 
 
 The treatment consists of measures for the relief of the par- 
 oxysm ; and this relief can be best afforded by the use of opium in 
 some form. The most effectual way is the hypodermic injection of 
 morphia, one-eighth to one-fourth of a grain, according to the 
 intensity of the pain. If no physician can be secured, it will be 
 better to administer the same quantity of the drug by the stomach ; 
 or if that is not procurable, twenty drops of laudanum may be given 
 at once, and repeated in half an hour if the pain still be severe. A 
 light mustard plaster or chloroform liniment may be applied over 
 the chest. It is also desirable to avoid such influences as can pro- 
 voke a paroxysm — excess in food or drink, mental strain and phys- 
 ical effort. 
 
 Aneurism of the Aorta. 
 
 By aneurism is meant a dilated condition of an artery — an 
 increase in size which may be induced by various causes that it is 
 not necessary to discuss here. Many different arteries in the body 
 are subject to such dilatation, and some can be cured or removed 
 by various surgical procedures. When the dilatation affects the 
 aorta, however, the case is different ; since the aorta — the large 
 artery leading directly from the heart, through which all the blood 
 of the body ;; asses — cannot be meddled with nor treated. A dila- 
 tation, or aneurism of the aorta, therefore, is not susceptible to cure 
 and must run its course ; in most cases this course leads to a fatal 
 termination, while in the favorable exceptions the affection is some- 
 times cured spontaneously. Yet, notwithstanding our inability to 
 remove this condition, it is important to recognize the existence of 
 an aneurism in the chest, since this knowledge gives us the clue to 
 many symptoms which cannot be otherwise understood, and ena- 
 bles us to at least retard the progress of the disease and to avei I for 
 a time the fatal results. 
 
 Symptoms, — The symptoms caused by aneurism of the aorta 
 vary considerably, according to the part of the vessel which is 
 
 ri:i 
 
 ik 
 
 
176 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 H I 
 
 affected. The aorta extends upward from the base of the heart, 
 behind the upper part of the br *ast bone, and then curves back- 
 ward and to the left, so as to reach the spinal column, along which 
 it proceeds into the abdomen. The artery may be dilated at any 
 point in its course, but is especially apt to undergo this change in 
 the immediate vicinity of the heart. If the dilatation occur at th«rt 
 part of the vessel which lies behind the breast bone, there is often a 
 swelling or tumor in the upper part of the chest, sometimes press- 
 ing one or two ribs a little forward, at other times merely filling out 
 the spaces between the ribs. This tumor is apt to be tender upon 
 pressure and painful. It usually gives a feeling of throbbing, corre- 
 sponding in time to the beats of the heart. When situated in this loca- 
 tion the tumor sometimes causes some numb is and loss of power 
 in one or both arms. The circulation of the arms may be very 
 feeble, causing one limb to be cooler than the other. This feeble- 
 ness of the circulation may be also indicated by the absence of 
 pulse at the wrist of the same arm. Sometimes, too, there is 
 decided interference with the return of blood from the head, causing 
 the face to be somewhat puffed, and to exhibit a dusky or livid 
 color. 
 
 If the dilatation take place a little further toward the left, the 
 dilated vessel may press upon the windpipe or one of its branches, 
 causing an obst; action to breathing ; if this be considerable, the 
 effect is indicated by a loud, hoarse noise, which may be heard at 
 some distance dUring the ac^of breathing. If the obstruction be 
 considerable, the patient may show signs of a lack of breath by 
 blueness of the skin. There may also occur a spasm of the larynx 
 in consequence of this pressure upon one of its nerves ; in this 
 case the patient suffers extremely in his efforts to breathe, and may 
 seem to be suffocating. These symptoms may be so prominent as 
 to mislead the physician into the belief that there is an obstruction 
 in the iarynx itself, and instances are known in which an operation 
 has been performed for opening the windpipe, under the impression 
 that the breathing would be thereby relieved. 
 
 The tumor may press also upon the oesophagus, whereby the 
 passage of food into the stomach is impeded. Sometimes the 
 most prominent symptoms are associated with the digestive organs, 
 the patient being afflicted with obstinate vomiting. At other 
 times pressure on certain nerves may cause partial or complete 
 paralysis of a considerable part of the body. As has been already 
 
 rem ark ( 
 
 pain in 
 
 nated <?; 
 
 Iti- 
 
 tion of <i 
 indeed, 1 
 this diffic 
 self as to 
 able in 
 trusted tc 
 Anei 
 chief ques 
 the patien 
 ery has oc 
 cases thed 
 blood. B 
 bursting o 
 minutes, o 
 upon diiibr 
 from aneur 
 'I'lother, sii 
 pressure ha 
 are known i 
 individuals, 
 disease, in ' 
 death to be 
 No trea 
 be cured, or 
 ment must, 
 and the prok 
 of the circula 
 must be avoi 
 vessel such i 
 acti.c physic 
 avoided. Th 
 as possible, tl 
 sivcly stout. 
 cities, the qt 
 pain. 
 
 I mil 
 
 si'' ! 
 
ANEURISM OF THE AORTA. 
 
 177 
 
 remarked, the pressure of the tumor frequently causes extreme 
 pain in the chest and arm, these neuralgic attacks being desig- 
 nated angina pectoris. 
 
 It is evident, from what has been already said, that the detec- 
 tion of an aneurism of the aorta is a by no means easy matter ; 
 indeed, the physician himself, though suspecting the existence of 
 this difficulty, may long remain in doubt before he can satisfy him- 
 self as to the nature of the difficulty. The symptoms are so vari- 
 able in diffit;rent cases that a non-professional person cannot be 
 trusted to ascertain the presence or absence of aneurism. 
 
 Aneurism of the aorta almost invariably results in death. The 
 chief question after the diagnosis has been settled, is, how long can 
 the patient survive? There are, it is true, instances in which recov- 
 ery has occurred, either spontaneously or under treatment; in these 
 cases the dilated part of the vessel becomes filled up with coagulated 
 blood. But in the great majority of cases death results either from 
 bursting of the aorta, so that the patient bleeds to death in a few 
 minutes, . if- m the long continued pressure of the dilated vessel 
 upon dii;- T' i, organs, causing fatal disease. A patient suffering 
 from aneurism of the aorta is not sure of life from one hour to 
 another, since death may result even before the symptoms from 
 pressure have occasioned serious inconvenience. Indeed, instances 
 arc known in which sudden death has occurred in previously healthy 
 individuals, who had never exhibited marked symptoms of any 
 disease, in which post-mortem examination has shown the cause of 
 death to be the bursting of an unsuspected aneurism. 
 
 No treatment is known whereby an aneurism of the aorta can 
 be cured, or the dilatation of the vessel even arrested. The treat- 
 ment must, therefore, be directed simply to the relief of suffering 
 and the prolongation of life. Everything which increases the force 
 of the circulation, or stimulates the heart to unusually strong action, 
 must be avoided; since, by increasing the strain upon the dilated 
 vessel such influences increase the danger of rupture. Hence, all 
 acti.e physical exertion and all extreme excitement should be 
 avoided. The general condition of the patient should be as good 
 as possible, though it is not desirable that he should become exces- 
 sively stout. The pain must be relieved by opiates or other nar- 
 cotics, the quantity of which depends upon the intensity of the 
 pain. 
 
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178 
 
 DISEASES OF THE ORGANS OF CIRCULATION. 
 
 Aneurisms sometimes occur in other parts of the body. That 
 is, it is in other arteries than the aorta. Among the most frequent 
 locations is the back of the knee ; the large artery which passes 
 from the thigh to the leg runs across the back of the knee-joint, 
 and in this situation is sometimes enlarged. This affection can be 
 readily recognized by the size and shape of the tumor, as well as by 
 its pulsations. 
 
 The treatment of an aneurism at the back of the knee is a 
 surgical procedure which should not be attempted by inexperienced 
 hands. 
 
 Aneurisms are also liable to occur in the arteries of internal 
 organs, especially of the brain. In these cases it becomes im- 
 possible to recognize the nature of the condition, since the symp- 
 toms are merely those of interference with the functions of the 
 various organs. The bursting of an anuerism of the brain is a 
 frequent cause of apoplexy. 
 
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DISEASES OF THE DIGESTIVE ORGANS. 
 
 Sore Throat— Pharyngitis. 
 
 This is the technical name for what is popularly termed " sore 
 throat. " There are, it is true, several varieties of sore throat, some 
 of which are features of the various infectious diseases, scarlet 
 fever, diphtheria, etc. But by pharyngitis we understand a simple 
 inflammation of the mucous membrane in the throat, such as occurs 
 after taking cold. The surface of the throat and back part of the 
 mouth are red and swollen ; at first the throat feels dry and parched, 
 and the act of swallowing is accompanied by considerable pain. 
 After a time the throat becomes moistened by the secretion of 
 thick mucus, which occasions constant efforts at expectoration. 
 If the inflammation extends low down into the throat, there usually 
 occurs a short, dry cough; yet so long as the disease does not reach 
 the larynx, the voice is not affeictcd, though in the majority of 
 cases the larynx is involved in the inflammation resulting in hoarse- 
 ness. The tonsils, also, are usually involved in the inflammation, 
 and their surface presents white spots of thickened mucus. These 
 white specks are not ulcers, as is usually believed, but merely the 
 thickened secretion from the mucous membrane. There is usually 
 a slight degree of fever attendant upon such an attack, though the 
 constitutional disturbance is not sufficient to prevent thv. pafirat 
 from attending to his usual avocation. 
 
 The disease subsides spontaneously in a few day-^, though it is 
 apt to recur again upon slighter provocation than Aefore.' and, 
 indeed, frequently assumes a chronic state The treatment consists 
 of mild gargles, such as a solution of chlorate of potash, or a hzde 
 glycerine may be taken into the mouth at short mtervals. 
 
 Chronic Pharyngitis is a frequent result of the acute form of 
 the disease. After the first attack of acute pharyngitis, the throat 
 will entirely recover its usual condition, but after repeated attacks 
 
 179 
 
 v^ \ 
 
1 80 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 3 ■'< 
 
 there remains a permanent condition of inflammation. In this con- 
 dition the mucous membrane is reddened and thickened, and often 
 presents on its surface a number of Httle projections, which arc 
 called gramdatious. In other cases the mucous membrane of the 
 throat is smooth, dry and glazed, looking almost as if it had been 
 varnished. In the latter case the patient complains of dryness of 
 the throat, and frequently experiences unpleasant sensations upon 
 swallowing. In other instances the throat is constantly covered 
 with thick, stringy mucus, which is especially recognizable by the 
 patient upon awakening in the morning. In most cases of chronic 
 pharyngitis there occurs, sooner or later, an extension of the inflam- 
 mation to the larynx, causing a hoarseness of the voice upon slight 
 exertion in speaking or reading. 
 
 This form of pharyngitis occurs, therefore, with especial fre- 
 quency among public speakers, particularly among clergymen, 
 from which fact it has been called clergyman's sore throat. Yet it 
 does not seem to be proven that this affection results from over use 
 of the voice, for chronic pharyngitis is really not more common 
 among clergymen than among others of sedentary habits. It is 
 especially common among business men. bookkeepers, salesmen, 
 etc., who are habitually confined many hours a day in close rooms. 
 Such patients also not infrequently suffer from other ailments — 
 dyspepsia, general debility and palpitation of the heart. Yet one 
 point should bo mentioned to correct a popular misapprehension : 
 there is no tendency to consumption — as is generally supposed — 
 in a chronic pharyngitis ; indeed, it would seem that the subjects 
 of this chronic sore throat rarely become tuberculous. 
 
 One of the most serious effects of chronic pharyngitis is the 
 impairment of hearing which so frequently occurs. This results 
 from the fact that the bony channels leading from the throat to 
 the ears (the eustachian tubes) are very small, and the orifices 
 leading from them into the throat become closed by the thickening 
 of the mucous membrane ; if the air cannot pass readily through 
 these channels the hearing is apt to become impaired. Furthermore, 
 the inflammation itself may extend along these eustachian tubes into 
 the ear, and thus aggravate the impairment of hearing. Hence it 
 has come to pass that patients who complain of deafness are regu- 
 larly examined to see what the condition of the mucous membrane 
 in the throat is. 
 
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PHARYNGITIS — SORE THROAT. 
 
 i8i 
 
 The treatment of chronic pharyngitis must usually consist in 
 improving the patient's sanitary surroundings ; thus a clergyman 
 will rarely be relieved of the disease until he seek recreation 
 away from his usual round of duties. Yet while reliance must 
 be chiefly placed upon the improvement of the general health, 
 certain benefits can be derived from the application of medicines ■ 
 directly to the inflamed mucous membrane of the throat. These 
 applications can be made either with camel's hair brush or with a 
 fine atomizer; in either case, care should be taken to apply the 
 remedy not only to the sides and back of the throat and to the 
 tonsils, but also to the top or roof of the pharynx ; this is situated 
 behind and above the soft palate, which hides it from view upon 
 ordinary inspection through the mouth. 
 
 The medicines used for this purpose may be alum, tannin, or 
 iodine, Any one of the following prescriptions may be employed : 
 
 Iodine,, --.-_. Ten grains. 
 
 Glycerine, . . - . . 
 
 Water, -.--_. Each one ounce. 
 To be applied as a spray or with a brush. 
 
 Tincture of the chloride of iron, 
 Glycerine, - - . - 
 
 Or, 
 
 Alum, - - . - - 
 Tincture of myrrh, 
 Glycerine, _ _ - . 
 Water, . _ - . 
 
 This may be used either for application with a brush or as a 
 gargle. 
 
 If the patient adopt no other measures for relief than these 
 local applications for the throat, it is scarcely probable that imme- 
 diate success will be achieved ; in such cases it may be well to 
 apply the following : 
 
 Nitrate of silver (lunar caustic), - - Ten grains. 
 Water, ._-.._ One ounce. 
 
 Apply carefully with a camel's hair brush. It will be 
 well not to resort to lunar caustic until other measures have had 
 a fair trial. 
 
 Each one ounce. 
 
 Two drachms. 
 One ounce. 
 
 Each four ounces. 
 
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1 83 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Quinsy. 
 
 By quinsy we designate a form of pharyngitis in which the 
 tonsils especially suffer from the inflammatory process. In all 
 cases it is true the tonsils are usually more or less involved in the 
 inflammation; but in many instances they do not occasion any 
 particular symptoms. In the inflammation of the throat known as 
 quinsy, the tonsils become extremely swollen, so that they may 
 indeed meet in the middle of the throat and seriously obstruct the 
 passage of food or of air down the throat. There is usually a cer- 
 tain amount of general disturbance — headache and soreness in the 
 throat — for a day or two before the disease becomes manifest. 
 The symptoms already described as accompanying pharyngitis — 
 pain, soreness upon swallowing, dryness of the throat — are pre- 
 sent. In addition there are certain symptoms due to the excessive 
 enlargement of the tonsils. The voice acquires a nasal twang; the 
 patii.nt is often compelled to keep the mouth open in order to get 
 sufficient air for breathing; he is usually unable to swallow solid 
 food, and may even find difficulty in swallowing liquids, which are 
 frequently returned through the nostrils upon an attempt at swal- 
 lowing. If the patient can open his mouth sufficiently, we observe 
 at the commencement of the disease that the tonsils are red, 
 swollen and dry; a few days later the tonsils and the back part of 
 the mouth are bathed in profuse secretion, which may contain also 
 a little blood. But the important point to be remembered with 
 regard to quinsy is that the surface of the tonsils is frequently 
 covered with a grayish layer, quite suggestive to an inexperienced 
 person of the false membrane of diphtheria. Doubtless many cases 
 of quinsy are for this very reason miscalled diphtheria. It is always 
 easy to distinguish one from the other in this way: if we take a 
 camel's hair brush and gently raise the whitish matter lying upon 
 the tonsil, we find that in quinsy it is easily detached, leaving a 
 smooth red surface beneath ; whilst in diphtheria the grayish 
 material can be raised from the tonsil with considerable difficulty, 
 and when it is thus removed there remains a raw, uneven surface, 
 on which a few drops of blood become visible. It is important 
 that we make this distinction for the benefit both of the patient and 
 of his neighbors. For if the disease be quinsy, we may anticipate 
 a speedy recovery and no spread of the disease; while if it be 
 

 QUINSY. 
 
 183 
 
 diphtheria, we must take the best care of the patient and prevent 
 the communication of the disease to others in the vicinity. 
 
 The constitutional symptoms accompanying quinsy are often 
 more severe than we would expect from the insignificance of the 
 local disease in the throat. The fever is often very high, there is 
 great headache, and pain in various parts of the body; there 
 may occur also a decided chill and vomiting. The patient is greatly 
 prostrated, a fact which becomes evident during convalescence, for 
 even after the throat difficulty has subsided he remains for several 
 days unable to resume his usual employment. 
 
 The disease appears to result from simple exposure to cold ; it 
 is most frequent in young persons and during the changeable 
 weather of spring and fall. If the inflammation be severe, and the 
 swelling of the tonsils extreme, matter may be formed in the tonsils ; 
 in many instances it becomes necessary to give exit to the matter 
 thus formed by an incision into the tonsil. This operation, slight 
 as it is, should not be performed by any but a professional hand, 
 since it is easily possible, by a little awkwardness, to occasion 
 serious damage. 
 
 Treatment, — ^The patient who has the disease for the first 
 time will not, of course, recognize its nature until the tonsils have 
 become swollen and sore, and may even then remain in ignorance 
 of the true nature of the complaint. Many individuals, however, 
 suffer repeatedly from quinsy, and usually know what they are to ex- 
 pect a day or two before the throat affection has become prominent. 
 During the premonitory stage — that is, before the fever has become 
 high — much good rnay be done by simply provoking profuse per- 
 spiration. To accomplish this the patient should take a hot foot 
 bath in the evening before retiring, covering himself meanwhile 
 with a blanket or comforter ; after fifteen or twenty minutes, free 
 perspiration will be excited, upon which the patient's skin may be 
 carefully dried, and he should be warmly covered in bed ; at the 
 same time ten grains of Dover's powder may be administered. So 
 soon as the inflammation has been developed in the throat, a gargle 
 should be employed, either the chlorate of potash, or alum and 
 myrrh, as stated above. If it can be accomplished, the most 
 satisfactory results will be obtained from the inhalation of steam. 
 If there be no steam atomizer at hand, it will be a simple matter to 
 arrange a tube so that the steam issuing from a kettle of boiling 
 water can be conducted into the patient's throat. If the patient be 
 
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 DISEASES OF THE DIGESTIVE ORGANS. 
 
 a child, and therefore unmanageable, the steam may be conducted 
 into a tent surrounding the bed. The throat may be enveloped in 
 cloths wrung out in hot water,- or in light linseed poultices. 
 
 An important item in treatment is to sustain the patient's 
 strength by nourishing food, which must, of course, be liquid. Milk 
 is the staple article of diet, reinforced, if necessary, by whisky or 
 brandy. It may be necessary also to administer the following pre- 
 scription: 
 
 Sulphate of quinine, - - • 30 grains. 
 
 Tincture of the chloride of iron, - Half an ounce. 
 
 Water to make two ounces. 
 Mix ; take a teaspoonful in water every four hours. 
 
 Humps. 
 
 This is an inflammation of one of the glands which secrete 
 saliva — the parotid gland, situated at the angle of the jaw, just 
 below and in front of the ear. 
 
 Symptoms, — The disease frequently begins with a slight chill 
 and a feeling of general indisposition ; within a day or two a per- 
 ceptible degree of fever occurs, though this seldom attains a high 
 degree of intensity. At this time the patient feels a certain tender- 
 ness at the angle of the jaw, which becomes quite painful during 
 the act of chewing. This part of the face is swollen, tender and 
 may be red ; if the swelling be extreme, thepatientis unable to take 
 any solid food, and may find difficulty even in swallowing liquids. 
 The swelling usually subsides in four or five days, by which time 
 the other symptoms have disappeared ; yet it is not unusual for 
 the little patient, while still congratulating himself on his recovery, 
 to find that the other side of the jaw is becoming similarly affected. 
 In some instances, indeed, both sides may be attacked simultane- 
 ously, or one may be followed a day or two after the other. The 
 disease always results in recovery, and is rarely complicated by the 
 formation of matter within the gland ; yet it is stated that mumps 
 not infrequently induce an inflammation in the genital organs of 
 male or female. Undoubtedly instances are known in which such 
 inflammation has ensued upon an attack of mumps ; yet it seems 
 scarcely established that the latter causes the former. 
 
ULCERATED SORE THROAT. 
 
 185 
 
 The disease seems to attack, most frequently, individuals 
 between 20 and 30 years of age, though it may occur at any time 
 previous to this period, and is not infrequently observed before 
 puberty. Males are more frequently affected than females, and one 
 attack of the disease seems to secure protection against subsequent 
 seizures. 
 
 Although mumps affect primarily and chiefly the parotid gland, 
 it appears to be not merely a local, but also a constitutional disease. 
 There seems but little doubt, moreover, that it is a communicable 
 disease, which may indeed at times become epidemic. It is 
 especially during these epidemics of the disease, that the cases are 
 observed in which the disease is followed by a swelling of the 
 testicle in the male, and of the breast in the female. 
 
 Treatment* — The only treatment required is the palliation 
 of the pain, which is often very severe. The application of cloths 
 wrung out in hot water, or of linseed poultices, frequently changed, 
 will usually relieve the severity of the pain. If the painful feeling 
 be felt especially in the ear, it may be well to syringe the ear gently 
 with warm water three or four times a day, yet there is no danger 
 that the ear itself is involved in the inflammation. The use of mild 
 liquid diet — milk and soups — completes the care necessary during 
 this disease. 
 
 Ulcerated Sore Throat 
 
 This term is rarely used by physicians, but is popularly em- 
 ployed to designate several different affections. 
 
 The first of these is merely a severe form of " sore throat," or 
 pharyngitis, already described. If the inflammation be very severe, 
 ulcers are formed on the tonsils and at the back of the mouth. 
 These raw spots usually heal, under the treatment recommended 
 for sore throat; if they remain ulcerated, they must be touched 
 either with a pointed stick of lunar caustic, or with the following 
 solution : 
 
 Lunar caustic, - - - - Forty grains. 
 Water, ----- One ounce. 
 
 A camel's hair brush should be dipped in this liquid, and 
 applied to the raw spots once a day. 
 
I86 
 
 ULCERATED SORE THROAT. 
 
 Ulcerated sore ♦^hroat is often caused by syphilis. Ulcers 
 appear in the throat, on the tonsils, on the gums and on the inner 
 surfaces of the lips. A description of this aflfection, and directions 
 for treatment will be found in the chapter devoted to the subject of 
 syphilis. 
 
 A third form of ulcerated sore throat results from tuberculosis 
 or consumption. In some cases the affection of the throat occurs a 
 considerable time before the lungs are visibly affected. The nature 
 of these ulcers can be recognized only by an experienced physician. 
 
DISEASES OF THE STOMACH. 
 
 Inflammation. 
 
 Acute inflammation of the stomach occurs almost exclusively 
 as the result of irritation caused by matters taken into the stomach ; 
 thus it often occurs as the result of attempts at suicide, in which 
 individuals swallow corrosive substances, such as large doses of 
 arsenic. A more frequent cause, however, is the swallowing of 
 alcoholic stimulants ; the derangement of the stomach which follows 
 a debauch is usually an attack, more or less mild, of acute inflam- 
 matio;i ; it may also follow excessive indulgence in the pleasures of 
 the table, though in this case it amounts to but little more than a 
 mild catarrh. 
 
 While the acute inflammation of the stomach alone is thus a 
 comparatively rare affection, an acute catarrh involving the stomach 
 and the upper part of the small intestine is a frequent incident, 
 attributable to indulgence in food of improper quality or quantity; 
 this catarrh is the condition commonly termed " biliousness, " and 
 will be discussed hereafter. 
 
 An acute inflammation of the stomach occasions intense burn- 
 ing pain in the region commonly termed the " pit " of the stomach ; 
 this pain is increased during breathing, so that the patient often 
 carefully avoids any movement which would require more active 
 breathing. But the most prominent symptoms are violent and 
 obstinate nausea and vomiting, the stomach rejecting everything, 
 even water in small quantities ; the matter vomited is thick and 
 ropy, of a yellowish green color and bitter taste; there is often, 
 also, blood to be seen. There is usually intense thirst, and the 
 patient constantly gratifles it by drinking water or other liquors, 
 although he knows that this act will be followed by painful 
 vomiting. 
 
 18; 
 
 ii-ii 
 
1 88 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 The constitutional symptoms, also, are severe. While the fever 
 may not be very intense, yet the patient's countenance exhibits great 
 depression and anxiety. The skin is usually at first warmer than 
 natural, though it may be later cool and clammy. The disease is 
 usually fatal within a few days. The acts of vomiting become more 
 frequent and exhausting, the matter ejected resembling coffee- 
 grounds, an appearance due to the large admixtuse of blood. In 
 the latter days of the disease, violent hiccough becomes a promi- 
 nent symptom. If the patient ultimately recover, the convalescence 
 is slow and protracted, and the stomach usually remains extremely 
 susceptible for a long time afterward. 
 
 Treatment, Acute inflammation of the stomach will proba- 
 bly never be met by the reader, except as the result of attempts to 
 destroy life by swallowing poison, or by the accidental introduction 
 of poisonous substances into the stomach; the treatment of such cases 
 will be discussed at length under the head o{ poisons. It may suffice 
 to say here, that the first object is always to remove the offending 
 substance from the stomach, and that this can be done best and 
 quickest by the use of the so-called " stomach pump. " This con- 
 sists merely of a rubber tube, one-half or three-quarters of an inch 
 in diameter, which is introduced through the mouth and oesophagus 
 into the stomach, and thus constitutes a channel whereby the stomach 
 can be thoroughly washed out. In this way, by the tise of large 
 quantities of warm water, the poisonous matters may be rinsed out 
 of the stomach, and any medicines which may be deemed necessary 
 can be applied. Although the introduction of this tube into the 
 stomach is a comparatively easy and simple procedure to one who 
 has been properly instructed, yet it is a somewhat formidable and 
 dangerous operation in the hands of an inexperienced person. 
 
 Aside from the use of the stomach pump, comparatively little 
 can be done in the treatment of acute inflammation of the stomach. 
 To quench the intense thirst small pieces of ice may be held in the 
 mouth, or minute quantities of ice water maybe swallowed at short 
 intervals. An opiate should be administered preferably as one- 
 eighth of a grain of morphine injected under the skin. If this be 
 impracticable, the same quantity may be placed dry upon the 
 tongue, where a certain amount of it will be absorbed. A mustard 
 plaster or a light Spanish fly blister may be placed over the stomach, 
 with the hope of relieving the vomiting ; but nothing should be 
 administered by the mouth except the small pieces of ice or quanti- 
 
ULCER OF THE STOMACH. 
 
 189 
 
 ties of ice water, as already mentioned ; for during the acute 
 inflammation, nothing will be retained by the stomach, and any 
 attempt to introduce substances, no matter how bland and unirri- 
 tating, will merely aggravate the already obstinate vomiting. 
 
 The patient's nourishment must be provided for by injections 
 into the rectum. For this purpose several preparations are recom- 
 mended, the best perhaps being a mixture of milk and beef tea or 
 broth in equal parts. If the patient's strength be failing, a table- 
 spoonful of whisky may be added to this mixture and administered 
 every two hours. 
 
 Chronic inflammation of the stomach may follow the acute 
 affection, but is more frequently the result of lonp-continued errors" 
 of diet. It is especially apt to occur in habitual drinkers, but may 
 also be found in those addicted to excesses in diet. In the earlier 
 stages it is indicated by tenderness over the region of the stomach, 
 and by a tendency to vomit after meals. There is usually consid- 
 erable pain, too, during the first half hour or hour after the con- 
 sumption of food. In the later stages it becomes merged into the 
 condition popularly known as " dyspepsia, " which is really in 
 many cases merely a symptom of a chronic inflammation of the 
 stomach. 
 
 The treatment consists chiefly in the regulation of the diet, 
 especially in the avoidance of excessive consumption of food. The 
 diet should consist only of bland articles of food ; in obstinate cases 
 the habitual use of kumyss is found extremely beneficial. In gen- 
 eral, the diet may consist of milk, eggs, rice, oatmeal, and similar 
 articles of food. Heat, alcoholic stimulants, and all highly-seasoned 
 food should be avoided. It will be, also, found advantageous to 
 take food in small quantities attd at shorter intervals than usual, so 
 that the patient partakes of food five or six times per day. But 
 few medicines can be used with profit in this affection ; subnitrate 
 of bismuth may be taken in twenty-grain powders half an hour be- 
 fore eating. 
 
 Ulcer of the Stomach. 
 
 This is one of the most obstinate and troublesome of the many 
 diseases affecting the stomach, as well as one which is often difficult 
 to recognize. In the most troublesome cases, which often end 
 
I90 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 fatally, there is found to be a hole in the wall of the stomach, round 
 and clean cut as if made with a punch. This ulcer may vary in 
 size from that of a pea to that of a silver dollar. So long as only 
 the inner coats of the stomach are eaten through, the disease in- 
 volves no danger to life, except from long-continued impairment of 
 digestion ; the chief danger lies in the possibility that the ulcer may 
 eat through the outer coat of the stomach; opening, therefore, into 
 the cavity of the abdomen, and permitting the food and other con- 
 tents of the stomach to escape into the abdomen. The result of 
 this accident is a fatal inflammation in the abdominal cavity, 
 peritonitis. 
 
 Symptoms. — l.ie most prominent symptoms are pain, 
 tenderness on pressure over the stomach, vomiting after eating, 
 and the escape of blood with the vomited matters. The 
 pain is usually of a gnawing or burning character, beginning very 
 soon after food has been taken into the stomach, and continuing 
 until the food has escaped from this organ, either into the intestine, 
 or has been ejected by vomiting. The pain then usually ceases, to 
 begin again so soon as more food is taken into the stomach. 
 Sometimes pain is felt not only in the region of the stomach, but 
 also in the back, between the shoulders. 
 
 Vomiting is a quite constant symptom, occurring a short time 
 after food has been taken. The act of vomiting is not usually pre- 
 ceded by much nausea, but is followed by marked relief from the 
 pain. The vomited .natter usually contains some blood, and at 
 times a quanty of bright red blood may be ejected with the food ; 
 indeed, alarming, and even fatal, hemorrhage has been known to 
 occur immediately after food has been taken into the stomach. 
 This symptom — the vomiting of blood very soon after food has 
 been swallowed — is especially characteristic of this affection. It 
 will be noticed, too, that the vomiting and the quantity of blood 
 ejected vary considerably with the kind and quantity of food taken. 
 Indigestible and highly-seasoned articles are more likely to provoke 
 the stomach to vomiting and to cause the appearance of blood than 
 bland substances, which are easy of digestion. Hot food, too, is 
 not so well borne as cold articles. 
 
 Sometimes it happen that, although but little blood is present 
 in the vomited matters, a considerable quantity may be passed 
 with the stools. In this case the blood is black and tar-like, so that 
 the nature of the substance may not be suspected. 
 
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ULCER OF THE STOMACH. 
 
 19! 
 
 Cause, — There are two or three varieties of ulcer of the 
 stomach, which may be traced to different causes. It is not neces- 
 sary to explain the somewhat complicated processes by which 
 ulcers are formed in the stomach. It may suffice to say, that the 
 disease occurs most frequently in women, especially in those of 
 feeble constitutions ; an especially large number of cases have been 
 noted among young female servants. 
 
 Ulcer of the stomach may ultimately recover ; in fact this 
 termination is believed to occur in a large majority of cases. On 
 the other hand the disease may prove fatal in any one of several 
 ways : death may occur from profuse hemorrhage ; or from per- 
 foration of the coats of the stomach, causing peritonitis ; or the 
 patient's strength may be ultimately exhausted, because he is unable 
 to retain sufficient food upon the stomach to nourish his body ; in 
 this case he dies therefore of starvation. 
 
 The duration of the disease is very uncertain. Death may 
 take place from hemorrhage, or from perforation, within a few weeks 
 after the commencement of the ulcer ; on the other hand, if these 
 accidents do not occur, the disease may last for many months or even 
 years. Flint reports a case in which an ulcer existed for thirty-five 
 years, and instances of shorter duration than this are not uncommon. 
 In some cases recovery occurs either spontaneously or under treat- 
 ment ; in others the symptoms disappear for a time, but subse- 
 quently return. 
 
 Treatment, — The most important object of treatment is to 
 give the stomach as much repose as possible. This object can be 
 secured, if at all, by the regulation of the diet. It is important, of 
 course, that the patient be properly nourished, while at the same 
 time all unnecessary irritation of the stomach is to be avoided. For 
 this purpose the bland and sole articles of food, liquid when possi- 
 ble, are to be employed — milk, eggs, arrow root, jellies, etc.; and 
 if necessary, the patient can live for a considerable time on milk or 
 kumyss. Solid and indigestible food, meat, sugar, spices, alcoholic 
 stimulants, should be avoided. In this disease it will be found 
 advantageous to administer food in small quantities at short inter- 
 Tals ; for in this way there will be less probability of provoking 
 Tomiting. 
 
 Yet cases are found which obstinately resist all attempts to 
 secure repose for the stomach ; the blandest articles of food, even 
 cold water itself, provoke vomiting and pain ; in such cases there is 
 
igt 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Still a resort which has been successfully employed in many instances 
 otherwise unmanageable : The patient can be nourished entirely 
 for weeks or months by the injection of food into the rectum, noth- 
 ing whatever being taken into the stomach, and only small pieces 
 of ice being held in the mouth. In such cases there is apt to come 
 a time when the rectum becomes so irritable as to eject all food. 
 In these cases the patient must of course be nourished again 
 through the stomach, and it will be found that after a rest of a 
 month or two the stomach has become far less irritable than before, 
 so that the patient can now be sustained by a careful diet without 
 provoking pain or vomiting. An instance of this sort is quoted 
 by Prof. Flint, as follows: The patient was a female, age 26. She 
 appeared to vomit everything taken, a few moments after eating ; 
 circumscribed tenderness existed over the stomach ; she was ema- 
 ciated, feeble, and had been confined to the bed for three months ; 
 purulent matter (pus) was ejected from the stomach with the food, 
 and sometimes by itself. Severe pains were referred to the region of 
 the stomach. Remedies, as well as food, being quickly vomited, 
 Dr. Pierce proposed to her to submit for a month to entire absti- 
 nence as regards food by the stom7';h, and to try the plan of taking 
 nourishment by injections into the rectum, to which she assented. 
 A half pint of good lamb or mutton broth was injected every three 
 hours. For the first week she took by the mouth, several times a 
 day, a tenspoonful of gum arable or pure water, but after the first 
 week this was discontinued. The skin over the stomach was blis- 
 tered and the suwace sprinkled with morphine. During the first 
 week vomiting of pus occurred several times daily, but during the 
 three following weeks it was diminished, and she was in all respects 
 oaore comfortable. It was resolved to continue the plan for an- 
 other month. The vomiting of pus occurred during this month 
 only occasionally, and the improvement continued. It was agreed 
 to continue the plan for still another month. The improvement 
 still progressed rapidly, and by the middle of the month all evi- 
 dence of stomach disease had disappeared. She began, before the 
 month ended, to take a little water and mucilage. She had gained 
 in flesh and strength during this plan of treatment. On returning 
 to the introduction of food by the stomach, the symptoms did not 
 retura, and two years afterward the patient was in the enjoyment of 
 excellent health. 
 
 In order to arrest hemorrhage, small pieces of ice may be 
 swallowed, and lumps of ice wrapped in cloth may be applied over 
 
 the si 
 tannin 
 yet lit 
 ing us 
 
 T 
 form t 
 one-ei{ 
 
 ir 
 
 Th 
 
 ailments 
 
 of sym] 
 
 designat 
 
 as folloi 
 
 dyspepsi 
 
 sympton 
 
 also callt 
 
 describe, 
 
 acu/e an< 
 
 Acu 
 taking 
 mental ei 
 a feeling 
 tinue unt 
 at first 
 while th 
 stituting \ 
 days aftei 
 suflfers fro 
 impaired 
 
 In otl 
 in diet, bu 
 cases then 
 •ng of nan 
 The mattet 
 a bitter tas 
 
DYSPEPSIA. 
 
 •93 
 
 the stomach. If the bleeding still continues, twenty grains of 
 tannin, or half a teaspoonful of the tincture of ergot, may be given ; 
 yet little reliance can be placed upon these measures, since vomit- 
 ing usually occurs when the blood escapes into the stomach. 
 
 To relieve pain, opium in some form should be used, the best 
 form being the hypodermic injection of morphine, beginning with 
 one-eighth of a grain in ten drops of water. 
 
 Dyspepsia. 
 
 This term is popularly used to designate almost all the chronic 
 ailments of digestion, and there is accordingly the greatest diversity 
 of symptoms presented by different cases, all of which may be 
 designated dyspepsia. Thus an attack of acute indigestion, such 
 as follows excessive indulgence in food or stimulants, is called 
 dyspepsia ; while on the other hand, the group of unpleasant 
 symptoms which are apt to occur after eating in brain-workers is 
 also called by the same name. For our purpose it will be well to 
 describe, under the head of dyspepsia, two distinct conditions — 
 acute and chronic indigestion. 
 
 Acute indigestion may be occasioned by gormandizing, by 
 taking indigestible articles of food into the stomach, by excessive 
 mental emotion, bodily fatigue, etc. The disorder is indicated by 
 a feeling of fulness, weight, and pain over the stomach, which con- 
 tinue until nausea and usually vomiting occur. The bowels are 
 at first constipated, but subsequently become relaxed. Mean- 
 while there is some fever, and dull, aching pain in the head, con- 
 stituting what is ordinarily known as " sick headache. " For several 
 days after these prominent symptoms have subsided the patient 
 suffers from general indisposition, bitter taste in the mouth, and 
 impaired appetite. 
 
 In other cases the difficulty is not traceable directly to errora 
 in diet, but seems to occur as the result of taking cold. In these 
 cases there is less pain and uneasiness in the stomach, but the feel- 
 ing of nausea is usually greater, and the headache is very severe. 
 The matter vomited is greenish or yellowish in appearance, and has 
 a bitter taste — it contains, in fact, the bile. The tongue is heavily 
 
194 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 coated, and the patient has a bitter taste in the mouth; the face is 
 often sallow, the bowels are usually constipated. 
 
 This is the condition popularly known as " biliousness," and is 
 really a catarrh of the stomach and the upper part of the small 
 intestine ; when the headache is so severe as to be the most promi- 
 nent symptom, this affection, like the other form of acute indiges- 
 tion, is called " sick headache. " 
 
 Treatment, — If the symptoms be caused by errors of diet, 
 but little is necessary beside abstinence from food for twenty-four 
 hours ; the prevalent practice of dosing such patients with cathar- 
 tics and emetics certainly does not hasten recovery. All that is 
 necessary is to give the stomach a rest and a chance to recover from 
 the effects of the abuse to which it has been subjected. If the 
 patient must take medicine, he may have some alkaline water, mag- 
 nesia, or the bicarbonate of sodium. 
 
 The treatment of a so-called " bilious attack " is somewhat 
 different. In these cases it is well to administer a cathartic so soon 
 as the vomiting has subsided a little. For this purpose three grains 
 of blue-mass combined with ten grains of the bicarbonate of sodium 
 may be given at night, and followed the next morning by some cit- 
 rate of magnesia ; or, instead of the blue-mass, one fourth of a 
 grain of podophyllin (May-apple) may be given at night. A bil- 
 ious attack can often be warded off at the appearance of the first 
 symptoms. To accomplish this the patient should restrict his diet 
 to a small quantity of food of a bland character, and should take 
 the blue-mass and soda at night, as recommended above. If this 
 be done when the headache and feeling of nausea are just begin- 
 ning, it is often possible to escape the subsequent symptoms of an 
 ordinary attack. 
 
 Chronic Indigestdon. 
 
 The various conditions grouped under the general term dyspep- 
 sia are but different forms of chronic indigestion. 
 
 Sym/ptoms, — A description of the symptoms of dyspepsia 
 may seem superfluous to many, since the disease is so prevalent 
 throughout the country; yet the fact is, that this term is so loosely 
 employed that it is made to cover almost any difficulty of the 
 
 stomaci 
 
 and wii 
 
 scribed 
 
 stomach 
 
 nutritioi 
 
 In , 
 
 bined; i 
 
 and his ^ 
 
 t'igestion 
 
 stances o 
 
 's, the p; 
 
 health rcr 
 
 Of al 
 
 The heal t J 
 
 location of 
 
 existence a 
 
 « true, aJw 
 
 <^"", heavy 
 
 patient is aj 
 
 «*"''. heavy 
 
 Often ther 
 
 throat upon 
 
 an indispos 
 
 gradually b< 
 
 somewhat en 
 
 distended wi 
 
 nient ofdigc- 
 
 the action of 
 
 though this V. 
 
 After the con 
 
 symptoms wh 
 
 ach ; thus, the 
 
 perhaps even 
 
 patient into th 
 
 There are 
 
 during most c 
 
 enabhng us to 
 
 stomach. Am, 
 
 "quids from the 
 
 termed regurgi 
 
IIS 
 
 CHRONIC INDIGESTION. 
 Stomach. The svm«» '^^ 
 
 •••nd with the ac^crlrhZ7^''^'^y ^'^^ the cause of th. ^• 
 
 ^n most cases nf ^ f '^u 
 
 aX^ •'•e patient, /ffetTeritrr °^ '''"•P'-'-e co„. 
 ""d l>.s general health suffers evfdH r"'"^ P""'* "f dicestion 
 
 The healthy ZiZl,'L7Z "' ""'" """ "-'^ /"' M, ./.«. ' 
 '-cation of the stomach tr ' ""^"^ '"" '' '« ">e exist? ' 
 «;-ence and oUH:rt)l%ZZTJ' """^^ conscToT X^ 
 
 otnTere-r 1" ^ ^-^ - "^^ti: t" atV/= ? ^ 
 
 --ponris'iV Th:::ratrtr/^- --' - 
 
 an 'nd'sposition fr^.- . 6*^"eral Jack of vipni- a«^ 
 
 «"c.ua,,/hecl"es'°;a,:rd'T,/'n^' " "•-» = he""!^: 
 
 somewhat craaciated- yet , he Im""' "" '''^^ ^""''^n the b^^ 
 *stendcd with gas in ,ul , ^'"''"nc" '^ "s-ally quite mil h^ 
 ment of digestion I "'%"<'""«^l> and intestines Tl',' ''"« 
 'he action ofteVo' et" , "j""-"' -'"""y. "; deltgetr" 
 "•oughthis is often intr upte^'hT '""^"^ '' '" "-Xr 
 
 -- h^ a1 rrsf,;-p;p^.a rrof^;:,;:^':^^ 
 
 ..V..«««,-„ay „„„r a. any ..-j; hulltS 
 
 :»,i:rf. 
 
196 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 frequent immediately after eating, acd after long fasting. The 
 materials thus brought up into the mouth vary somewhat, but are 
 usually quite sour, and even scalding to the throat. At other times 
 large quantities of gas will be belched up — an almost characteristic 
 symptom of dyspepsia. This gas may be merely sour to the taste, 
 or if it be expelled during digestion, may have various unpleasant 
 odors, even that of bad eggs. These gases indicate that the food 
 is undergoing putrefaction and not digestion. Sometimes these 
 expulsions of gas are accompanied by the ejection of a sour or salty 
 liquid into the mouth. This occurs especially when the stomach is 
 empty, and therefore in the morning, and is known as water 
 brash. 
 
 Another symptom of dyspepsia is what is popularly termed 
 heart-burn. This consists of pain over the stomach, of a gnawing 
 or burning character, gradually spitading into the breast, and 
 seeming to the patient to involve the heart. This symptom seems 
 to depend upon the presence of an acid liquid in the stomach, 
 for it can be at once relieve.) by taking an alkali, such as baking 
 soda. Another symptom, which is often quite distressing, is a dis- 
 tention of the stomach with gas. This gas is produced by the 
 decay of food in the stomach. The result is a decided fullness of 
 the abdomen, which may become so great as to interfere with 
 breathing, and to embarrass somewhat the action of the heart, 
 causing palpitation. This is especially apt to occur in females, and 
 in them may be accompanied by painful contractions of the intes- 
 tines. The habitual distention o<" the stomach with gas occasions 
 in some individuals a peculiar splashing sound whenever liquids are 
 taken upon an empty stomach, a sound which is often heard in 
 horses. This feature of the case, while occasioning no physical 
 distress, is the source c! much mortification, especially to women. 
 It may usually be avoided by swallowing only small quantities of 
 liquid at a time. 
 
 Dyspepsia is not usually accompanied by vomiting — a point 
 whereby it may be distinguished from certain other disorders of the 
 stomach, such as chronic inflammation and ulcer. There are times, 
 it is true, when the condition of the stomach becomes aggravated 
 by some error in diet or neglect of personal care ; at such times 
 the individual may '-uffer from repeated nausea and vomiting. As 
 a rule, however, wlile there may be large quantities of gas and 
 Hquid expelled from the stomach by the act of belching, yet there 
 
CHRONIC INDIGESTION. 
 
 I9f 
 
 rarely occurs any genuine vomiting, or even nausea. Exception 
 must be made to this, however, in a certain form of dyspepsia 
 confined almost exclusively to young females. In these cases the 
 vomiting is obstinate and constant, so that the patient seems to be 
 in danger of death from starvation. In consequence of the violence 
 of the vomiting, there may be at times a few streaks of blood in 
 the ejected matter. Indeed, the symptoms may simulate very 
 closely those of ulcer of the stomach, for which the disease has 
 been mistaken. This variety of dyspepsia must be distinguished 
 from the usual forms ; it seems to be largely dependent upon a 
 hysterical element in the patient — a point of importance with 
 regard to treatment. 
 
 Among the second class of symptoms — those associated with 
 other organs than the stomach — the most prominent are perhaps 
 the mental disturbances, for dyspeptic patients seem unusually lan- 
 guid and dull, not only during the somewhat painful process of 
 digestion, but also at other times. " There is great languor and 
 incapacity for exertion, coming on generally about an hour after 
 food, and accomp>anied in some cases by an almost irresistible 
 drowsiness, which lasts for several hours. This symptom is par- 
 ticularly marked in the afternoon, if the patients dine in the middle 
 of the day, and endeavor to continue their employment afterward. 
 Yielding to the drowsiness and taking a siesta seem to make mat- 
 ters worse, for there is usually felt after such an indulgence an 
 intense headache or giddiness, which continues longer than the 
 symptoms would have dono had the inclination to sleep been 
 resisted. The depression of spirits is not so remarkable as the 
 feeling of utter helplessness, both of mind and body, accompanied, 
 in persons naturally active, with a sense of shame at their unwonted 
 apathy. ' — Chambers. This dullness and languor are apt to be fol- 
 lowed by some general impairment of the mental faculties, which 
 is often indicated by the patient's nervous anxiety about his health, 
 and his disposition to magnify the importance of every unfavorable 
 feature, however slight. As the disease progresses, other symp- 
 toms are added to these of mental disorder. The action of the 
 bowels becomes very irregular ; the skin becomes rough and dry ; 
 the sleep is unsatisfactory and disturbed by dreams ; the patient 
 often rises in the morning quite wretched and miserable ; and not 
 infrequently a dry cough is added to the other annoyances of the 
 patient. 
 
 ! 
 
 !^ 
 
■98 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 \i 
 
 Cause, — The popular idea that dyspepsia is always and neces- 
 sarily the result of errors in diet, is not warranted by the facts. 
 Doubtless in many cases the disease can be traced directly and 
 positively to excesses in eating and drinking ; but to induce the dis- 
 ease the food need not be excessive in quantity, if the quality be 
 improper. Not the least frequent cause of dyspepsia is the abuse of 
 spirits, resulting first in inflammation of the stomach and then in 
 dyspepsia. This variety of dyspepsia has been described as the 
 " remorse of a guilty stomach. " 
 
 There are various departures from health which indirectly 
 induce dyspepsia. Among these are mental causes — long con- 
 tinued anxiety and depression ; the excessive and continuous 
 mental effort of professional or commercial pursuits. So, too, a 
 combination of mental worry and physical fatigue, of bad air and 
 insufficient food, sedentary habits — these are merely instances of 
 the cases which may ultimately develop dyspepsia. Other causes, 
 which may be easily overlooked, may be found in the absence of 
 teeth — more than one obstinate cause of dyspepsia which has 
 resisted all manner of treatment, has promptly recovered upon the 
 substitution of artificial teeth for decayed stumps ; doubtless the 
 peculiarly American habit of bolting the food half masticated ia 
 also responsible for much of the dyspepsia so prevalent in ou? 
 country. That simple excessive quantity of proper food can in- 
 duce dyspepsia is not denied ; but it is equally true that very many 
 high-livers and professional epicures escape the disease entirely. 
 
 Treatment, — In the treatment of dyspepsia the first consid- 
 eration is to determine, as accurately as possible, the cause of the 
 difficulty. It is quite irrational and impossible to prescribe any 
 treatment " for dyspepsia " which will be valuable in all cases. 
 For in some instances we have to do with the results of improper 
 modes of eating and the use of improper food ; in other cases we 
 have, in a case of dyspepsia, merely the case of mental worry and 
 exhaustion. In some instances, therefore, the dyspepsia is merely 
 an incident to the depressed condition of the body generally, and 
 in such cases the treatment should be directed to the restoration of 
 the health without especial attention to the stomach itself. In 
 other instances the disease is evidently the result of inflammation 
 of the stomach, and the treatment must consist of measures in- 
 tended to improve the condition of this organ. Generally speak- 
 
CHRONIC INDIGESTION. 
 
 199 
 
 ing, we may say that measures of treatment in all cases may be 
 divided into three classes : First, those relating to the regulation 
 of food ; second, those addressed to the general condition of the 
 patient; and third, medicines. 
 
 If the dyspepsia be apparently the result of errors or excesses 
 in diet, the stomach should be rested by restricting the food to 
 reasonably small quantities of easily digested food. Yet it is 
 important that the patient should not go to the other extreme, as he 
 is so often inclined to do. Many individuals doubtless derive a 
 certain moral benefit by thus doing penance for their previous 
 excesses; but the effect upon the body is rather disastrous, if the 
 quantity of food be suddenly reduced from excess to a starvation 
 or slop diet. Indeed many cases of dyspepsia occur in persons 
 who have acquired the idea that they should live upon coarse food 
 in small quantities. Not a few of those who follow out some 
 hobby of this sort become victims to dyspepsia, which they fondly 
 believe attacks only epicures. 
 
 " As regards the diet for dyspeptics, there are no rules suited to 
 all cases. Individual experience in each case is to be a guide. But 
 there is a liability to error in regard to this experience. Unusual 
 difficulty or disturbance of digestion after a meal is often imputed 
 by the patient to certain articles of food, when it was due to some 
 other incidental circumstance. Peculiarities in relation to particu- 
 lar articles of food are far less common than the statements of 
 patients would lead one to suppose. In general, articles which are 
 wholesome to most persons, are not unwholesome to any. It is 
 rarely true that what is one man's meat is another's poison. As a 
 a rule, when a patient says that he cannot take such and such articles, 
 which general experience shows to be digestible and nutritious, it 
 is fair to presume that he is deceived, and of this the patient may 
 generally be convinced, if he be persuaded to persist in their use. 
 At first the expectation that an article will prove hurtful, contrib- 
 utes to render it so; but after a time the idea is overcome; it is 
 often an object in the treatment of dyspepsia, to do aw3y with 
 these fallacious ideas respecting various kinds of food. Some 
 persons seem to be fond of encouraging the notion that their 
 digestive organs are endowed with peculiar susceptibilities which 
 prevent them from conforming to general rules of diet. In most cases 
 of dyspepsia animal food is best digested, especially old and tender 
 meats plainly but well cooked; but in some cases a milk and 
 
200 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Starchy diet is found to agree best. An obvious reason why 
 so many persons imagine they do not digest milk well, is that 
 it is generally taken as a beverage after or with solid food, the fact 
 that it is in effect a solid article of food not being appreciated. 
 Bread to be readily digestible should not be new, nor is it desirable 
 when stale. Well boiled rice and corn meal mush are easy of 
 digestion. Crude vegetables are apt to be digested with difficulty 
 in cases of dyspepsia, but not invariably ; some dyspeptics find 
 the much abused cucumber grateful to the stomach as well as to 
 the palate. Pastries, rich puddings and sweetmeats, are generally 
 to be eaten sparingly or discarded. Ripe fruits in moderation are 
 useful. It is generally not advisable for the patient to limit himself 
 to a restricted range, or to adopt any particular system of diet; on 
 the contrary, he should persevere in attempting to digest all the 
 varied forms of wholesome food, not confining himself to meat or 
 a vegetable diet, but aiming to eat like persons in health, without 
 the need of particular care in the selection of food. " — Flint. 
 
 It is also advisable that the meals should be taken at regular 
 intervals, and in most cases it will be found more agreeable for the 
 patient to take food at least four or five times a day, including a 
 light supper shortly before retiring. It follows, of course, that if 
 food be so frequently taken, the quantity should be proportionately 
 less at each meal. It is a general principle, that in dyspepsia the 
 appetite is not a reliable guide as to the quantity of food required ; 
 for, in many instances, there is a craving for more food than can be 
 digested. 
 
 The most readily digested articles are, among meats, beef, 
 mutton, chicken, turkey ; roast, stewed or steamed oysters — not 
 raw nor fried. Young vegetables generally are desirable. As to 
 the use of spirits, certain care must be exercised, though it will 
 generally be found beneficial to take an ounce or two of claret, or 
 other light wine, with the meals. Tea and coffee, especially the 
 latter, are best avoided, unless the patient has become inseparably 
 attached to their use ; even in this case the quantity may usually be 
 diminished. Yet it may never be forgotten that the object in diet- 
 ing a dyspeptic patient is not to have him live upon just as little 
 food as will support life, but simply to give him such food and at 
 such times that he can readily digest it. Hence under-feeding is to 
 be avoided as carefully as over-feeding. 
 
 Another important object in the treatment of dyspepsia is to 
 provide for proper exercise in the open air. On this point, too, the 
 
CHRONIC INDIGESTION. 
 
 20I 
 
 general impression and the usual practice of dyspeptics is incorrect 
 and injurious. An individual who finds himself dyspeptic usually 
 ascribes the affection to over-eating, and endeavors to counteract 
 the effect by indulging in unusual and violent exercise. He 
 begins to take long walks, to exercise with the health-lift, or per- 
 haps indulge in still more laborious exercise. This is carrying 
 matters to an extreme, which is doubtless more injurious than even 
 a complete abstinence from exercise. This is especially so if, as so 
 often happens, the patient, while performing this increased amount 
 of work, diminishes at the same time the amount of food taken. 
 Certainly, exercise in the open air is desirable for a dyspeptic patient 
 as well as for other individuals. It tends to recruit the system and 
 to improve the general health ; but such exercise should never be 
 carried to exhaustion. 
 
 One of the most valuable restorative means in dyspepsia, as 
 in other chronic complaints, is a change of scenery and of employ- 
 ment. It may not be necessary to take a formal vacation and a 
 long journey, since the same benefits may accrue from relaxation 
 and amusement. 
 
 Much good may accrue, also, from the moral treatment of 
 patients by securing the sympathy and confidence of the sufferer. 
 It is doubtless true that many dyspeptics, especially those who 
 have suffered long, indulge in many imaginary complaints and 
 conjure up many symptoms and fears which have no foundation in 
 fact or experience. The tendency among the friends, and even on 
 the part of the physician, is, therefore, to ignore or even to ridicule 
 the complaints of the patient, and to make light even of those 
 symptoms which are genuine evidences of the disease. The patient 
 need not be humored in all his vagaries, but can be instructed that 
 his mental state is largely due to the disordered condition of his 
 body. By securing his confidence, we may not only divert his 
 attention from many needless fears, but may also secure a hearty 
 co-operation in the measures recommended for his relief. It has 
 been observed that when dyspeptic individuals dine alone, they are 
 very prone to employ themselves in watching minutely all the sen- 
 sations connected with the process of digestion, and to interpret as 
 unfavorable as possible the slightest indication of unhealthy action. 
 By keeping the mind pleasantly occupied during digestion, as well 
 as other times, the patient is rendered less morose, and positive 
 good is accomplished in the treatment of the disease. 
 
 ' 
 
202 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 The use of drugs, although perhaps the least important part in 
 the treatment of dyspepsia, is nevertheless a matter of some con- 
 sequence. For much may be done to relieve some of the most 
 distressing symptoms of this affection. The distension of the 
 stomach with gas can often be at once relieved by the administra- 
 tion of charcoal, either in powder or in the shape of wafers pre- 
 pared for that purpose. This effect may also be induced or assisted 
 by the oil of cajeput, two or three drops of which may be dropped 
 upon a small lump of sugar and swallowed. This is especially 
 useful if the distension of the stomach be accompanied with pain, 
 as is so often the case. Instead of the cajeput, the following 
 mixture may be given : 
 
 Bicarbonate of sodium, . . _ One drachm. 
 
 Compound spirits of lavender, - - One ounce. 
 
 Spirits of camphor, - , - - Two drachms. 
 
 Aromatic syrup of rhubarb - - Half ounce. 
 
 Peppermint water, - Enough to make four ounces. 
 
 Take a teaspoonful every half hour until relieved. A domestic 
 remedy much used for the same purpose is the familiar Jamaica 
 ginger. 
 
 Heartburn. 
 
 Heartburn seems to depend chiefly upon an unnatural acidity 
 of the stomach, and can be relieved by alkaline remedies with or 
 without aromatic substances ; thus a pinch — five to ten grains — of 
 baking powder will often accomplish the result if taken immediately 
 after eating ; or half a tablespoonful of lime water may be given 
 for the same purpose. If these be unsuccessful, five to ten drops 
 of chloroform may be given in a teaspoonful of weak brandy or 
 whisky. 
 
 The water-brash can often be relieved by fifteen or twenty 
 grains of the subnitrate of bismuth ; yet, in most cases, this 
 troublesome symptom will disappear only after the patient's gen- 
 eral condition has been much improved. The hiccough, an occa- 
 sional symptom, often disappears under the use of hydrate of 
 chloral, in doses of ten to fifteen grains three times daily. 
 
 One of the most important objects to be obtained by medicine 
 is the improvement of the patient's general condition by the use of 
 tonics. This is especially valuable if the dyspepsia be the result 
 
HEARTBURN. 
 
 203 
 
 One of the best 
 
 One drachm. 
 One drachm. 
 One ounce. 
 Three ounces. 
 
 not of errors in diet, aut of nervous exhaustion, 
 formulae for this purpose, is as follows : 
 
 Fowler's solution of arsenic, 
 
 Sulphate of quinine, - . - - 
 
 Tincture of nux vomica, - - - 
 
 Wine of pepsin, 
 
 Take half a teaspoonful after meals. In these cases it is well 
 for the patient to take five or six drops of the dilute muriatic acid 
 just before eating. If the patient be quite pallid or ancemic, ben- 
 efit may be derived from the following prescription : 
 
 Sulphate of quinine, . - - - Forty grains. 
 
 Arsenious acid, - One-third of a grain. 
 
 Extract of nux vomica, - - - - Eight grains. 
 
 Reduced iron, - Twenty grains. 
 
 Mix, and make into twenty-four pills. Take one before meals. 
 
 In order to afford some assistance in the selection of diet for 
 dyspeptic patients, the following table, adapted from Hartshorne, is 
 added : 
 
 Moderately Digestible. 
 
 Easy of Digestion. 
 Mutton, 
 Venison, 
 Chicken, 
 Turkey, 
 Hare, 
 Beef tea, 
 Mutton broth, 
 Milk, 
 
 Most fresh fish, 
 Turbot, 
 Sole, 
 Haddock, 
 Roasted oysters, 
 Rice, 
 Tapioca, 
 Sago, 
 
 Arrowroot, 
 Asparagus, 
 Cauliflower, 
 Baked apples, 
 Oranges, 
 Grapes, 
 Strawberries, 
 Peaches, 
 Ale. 
 
 Beef, 
 
 Lamb, 
 
 Rabbit, 
 
 Duck, 
 
 Pigeon, 
 
 Snipe, 
 
 Soups, 
 
 Eggs, 
 
 Raw oysters, 
 
 Stewed oysters, 
 
 Potatoes, 
 
 Beets, 
 
 Turnips, 
 
 Cabbage, 
 
 Lettuce, 
 
 Celery, 
 
 Apples, 
 
 Raspberries, 
 
 Bread, 
 
 Puddings, 
 
 Rhubarb, 
 
 Chocolate, 
 
 Coffee, 
 
 Porter. 
 
 Hard to Digest. 
 Pork, 
 Veal, 
 Goose, 
 Salt meats. 
 Sausages, 
 Salt fish, 
 Lobster, 
 Herring, 
 Salmon, 
 Shrimps, 
 Oils, 
 Cheese, 
 Fresh bread, 
 Toast, 
 Pastry, 
 Cakes, 
 Nuts, 
 Pears, 
 Plums, 
 Cherries, 
 Cucumbers, 
 Onions, 
 Carrots, 
 Parsnips, 
 Pickles. 
 
204 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 Dilatation of the Stomach. 
 
 This is one of the conditions which often result in long con- 
 tinued dyspepsia. The gas which is constantly formed in the 
 stomach when the food is not properly digested, distends this organ, 
 occasioning a sense of fullness and the belchings of wind so charac- 
 teristic of dyspepsia ; in course of time the stomach yields to this 
 continued pressure and becomes permanently dilated — that is, 
 stretched so as to occupy a much larger space in the abdominal 
 cavity than is natural ; in fact the organ is sometimes so much dis- 
 tended as to extend over the entire cavity of the abdomen ; its 
 capacity being increased from less than a quart, which is the natural 
 size, to several gallons. 
 
 This condition of dilatation may result from any one of several 
 causes, but is usually associated with dyspepsia or chronic inflam- 
 mation of the stomach. The condition may exist in a dyspeptic 
 patient without exciting his suspicions, or those even of the attend- 
 ing physician; for unless the dilatation become excessive the symp- 
 toms are essentially those of dyspepsia. 
 
 Symptoms. — The symptoms which have been mentioned as 
 characteristic of dyspepsia are usually present in dilatation of the 
 stomach. In addition there may be a decided and persistent promi- 
 nence over the region of the stomach, and extending downward 
 in the abdomen. By tapping gently upon this prominence, a 
 resonant, drum-like sound will be heard, indicating distension 
 of the organ with gas. If the patient take a glass of water, and 
 the body be gently shaken, a splashing sound may be heard. The 
 food collects in large quantities in this dilated cavity, occasioning a 
 constant sense of uneasiness, which is relieved every few days by 
 vomiting. The ejected natter often gives signs of putrefaction, 
 and consists of the imperfectly digested food as well as of much 
 thick mucus from the stomach. In consequence of the imperfect 
 digestion the patient is poorly nourished and often becomes quite 
 emaciated; he suffers extreme inconvenience from the constant dis- 
 tension of the abdomen and frequent escape of gas from the stom- 
 ach. At times the patient gets into the habit, or rather the stomach 
 acquires the independent habit of expelling food and liquids with- 
 out any premonitory signs, causing the individual much inconven- 
 ience and annoyance. 
 
PAIN IN THE STOMACH — GASTRODYNIA. 
 
 205 
 
 Treatment, — The regulation of the patient's diet and habits, 
 already described in connection with dyspepsia, is an important 
 measure in the treatment of this affection also. But something 
 more is necessary here, since even if it be possible to cure the 
 dyspepsia, the stomach remains dilated, and the result will be accu- 
 mulation of food and a return of the symptoms as before. The 
 only satisfactory method of treatment for this condition consists in 
 regular and thorough washing out of the stomach. This can be 
 accomplished very readily by the use of the elastic stomach tube, 
 already described, whereby the contents of the stomach can be 
 removed, the accumulation of undigested food prevented, and the 
 stretching of the stomach by the formation of gas avoided. An 
 individual suflfering from this complaint can readily learn to intro- 
 duce the tube himself, and to wash out the stomach without any 
 assistance. For this purpose it is desirable to use first lukewarm 
 water; the quantity to be poured into the stomach at once varies 
 according to the amount of dilatation present, from a quart to a 
 gallon ; in general terms it may be said that the amount of water 
 poured into the stomach through the tube should be just sufficient 
 to cause a feeling of distension in that organ. After the stomach 
 has been rinsed out with warm water, it may be washed with a 
 solution of the sulphite of sodium, half an ounce of which may be 
 dissolved in a pint of water for that purpose. 
 
 At the beginning of the treatment it may be necessary to wash 
 the stomach every day; but if care be taken to regulate the diet, 
 if the patient will be content to live upon milk, eggs, and liquid 
 food taken in small quantities at short intervals, it may soon be 
 possible to discontinue the use of the stomach tube, or at least 
 employ it but once in three or four days. It may be necessary to 
 continue the treatment for months, especially in those cases in 
 which the disease has lasted for a long time; improvement can 
 always be obtained, though an actual cure cannot be predicted 
 unless the dilatation of the stomach has occurred very recently. 
 
 Pain in the Stomach— Oa43trod3rnia. 
 
 This is a symptom of various affections of the stomach, such as 
 inflammation, ulcer, dyspepsia, and cancer; if it occurred only as 
 an incident in these affections there would be no occasion for 
 separate discussion. 
 '4 
 
206 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 
 There are, however, cases in which a severe pain in the stomach 
 is a most prominent and distressing symptom, but in which no 
 structural disease of the organ, such as ulcer or cancer, can be dis- 
 covered. In these cases the pains appear to be neuralgic, and the 
 affection is indeed often called neuralgia of the stomach. 
 
 Symptoms. — The pain begins suddenly, oftentimes awaken- 
 ing the patient at night ; it becomes at times agonizing, causing the 
 patient to twist and groan from the severity of his suffering. There 
 is sometimes decided tenderness over the stomach though in most 
 cases this feature is absent, and the pain is indeed often somewhat 
 relieved by pressure of the hand. There is sometimes a feeling of 
 tightness or constriction around the body. In many cases violent 
 vomiting occurs, though this is not a necessary symptom. In some 
 instances, particularly in women, the pain recurs at intervals with 
 especial severity, so that it is to be described as "bearing down" 
 pain. The attack varies in duration from a few minutes to several 
 hours, and leaves the patient sore and exhausted. 
 
 These attacks of neuralgia in the stomach rarely occur in indi- 
 viduals who enjoy robust health. The sufferers from this affection 
 are usually in a state of general debility from over-work, either phys- 
 ical or metltal, from excessive mental emotion and strain, or from 
 neglect of sanitary regulations. In such individuals these attacks 
 occur spontaneously, or may be induced by eating certain articles 
 of food ; such individuals usually learn by experience to avoid par- 
 ticular articles of diet, which may be eaten by other people with 
 impunity. Thus, in one instance, strawberries will be found to 
 provoke such an attack if a patient be at all exhausted; while in 
 another, even stewed oysters may have the same effect. 
 
 TreatmmiU — The treatment of such an attack comprises 
 two measures: first, the relief of th^-i pain; and second, the effort to 
 avoid future attacks. The pain can of course be removed by the 
 various agents at our command ; if severe, so that the patient 
 writhes in anguish, chloroform should be administered at once, a 
 teaspoonful being poured upon a handkerchief and held near, not 
 to, the patient's nostrils. Meanwhile morphine should be given, a 
 sixth of a grain, if the patient has not vomited ; but if his stomach 
 has been irritable, and rejects all medicines, an eighth of a grain of 
 morphine may be administered hypodermically. A light mustard 
 plaster applied over the stomach and a tablespoonful of whisky 
 containing Jamaica ginger will often shorten the paroxysm of pain. 
 
CANCER OF THE STOMACH. 
 
 S(^ 
 
 To avoid repetition of such paroxysms the effort must be made 
 to improve the patient's general health. In the majority of instances 
 it will be found that the patient is already suffering from mental or 
 physical exhaustion ; until this exhaustion is relieved by recreation, 
 diet, and medicine, the attacks of neuralgia will be apt to recur. 
 This disease appears to be confined to middle life, rarely occurring 
 in childhood or in old age. 
 
 Cancer of the Stomach. 
 
 In nearly one-third of all the cases of cancer, the stomach is 
 the seat of the disease, and the cancer occurs with special frequency 
 at that end of the stomach which joins the small intestine, and 
 which lies nearly under the end of the breast bone. 
 
 Symptoms, — When the disease has existed for some months, 
 the symptoms are so plain as to admit of but little doubt concerning 
 the nature of the affection. But in the early stages of cancer 
 of the ftomach the symptoms do not enable us to distinguish this 
 disease with certainty from several other affections of the stomach, 
 such as ulcer, chronic inflammation, and dyspepsia. 
 
 For some months previous to the development of marked 
 symptoms the patient usually suffers from an impairment of the 
 appetite, and some of the symptoms of indigestion. There is 
 usually some pain, even at an early stage — a pain which is de- 
 scribed as gnawing or cutting. There may be, also, tenderness 
 over the stomach. Even before it becomes possible to detect a 
 tumor in the abdomen, there is usually decided evidence of impair- 
 ment of the general health ; there is some loss of strength and of 
 flesh, an unusual pallor of the skin, sometimes fever and derange- 
 ment of the bowels. 
 
 As the disease progresses, vomiting becomes a prominent 
 symptom. The matters ejected are at first merely the partially 
 digested fragments of food which have been swallowed, but later 
 contain also considerable blood and mucus. This blood is at first 
 dark, giving the vomited matter an appearance resembling that of 
 coffee grounds; but later in the disease the blood appears in larger 
 quantities and with a bright red color. After the vomiting becomes 
 frequent the patient's strength fails rapidly, and emaciation becomes 
 
208 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 a marked feature of the disease. The sufferer's condition now be- 
 comes deplorable. All food, even the blandest articles, is rejected 
 by the stomach. The act of vomiting is now accompanied by 
 extreme pain. In the intervals between attempts at eating there is 
 more or less pain, often sharp and shooting. The escape of blood 
 may take place not only during vomiting, but also at other times 
 without apparent provocation. At times the hemorrhage becomes 
 quite severe, the patient expectorating great quantities of bright 
 red blood. In other instances death occurs suddenly from hemor- 
 rhage into the stomach. 
 
 Sooner or later there is usually developed in the abdomen a 
 tumor, situated a little below the breast bone, and ordinarily some- 
 what to the right of the middle of the body. This tumor may not 
 be appreciable to the eye, but can be felt by gently pressing upon 
 this locality. This swelling is usually detected by the patient him- 
 self, though it may at times escape his observation and be discov- 
 erable only upon careful examination. 
 
 While this is the usual history of cancer of the stomach, yet 
 cases occur in which most of the symptoms detailed above are ab- 
 sent. In these cases the patient appears to have merely some dys- 
 pepsia. The appetite remains fair. There is no vomiting of blood, 
 perhaps no vomiting at all. The pain is merely of the dull, aching 
 character so often met in simple dyspepsia. In these cases death 
 may occur after a very short illness, the real nature of the difficulty 
 being unsuspected perhaps until a post-mortem examination is made. 
 It will be seen from the above description that the symptoms 
 presented by cancer of the stomach are very similar to those of 
 several other diseases ; even the vomiting of blood occurs as regu- 
 larly an ' uniformly in cases of ulcer of the stomach. It is 
 important that this similarity should be remembered, in order that 
 no groundless suspicions may annoy and terrify the patient. It 
 must be stated, that in the early stages of the disease the physi- 
 cian himself is often puzzled to decide whether or not the affection 
 is a cancer, though with the lapse of time the diagnosis usually 
 becomes easy. 
 
 In this connection, a word may be properly said regarding the 
 popular ideas concerning cancer. The prevalent impression at- 
 taches entirely too much importance to the hereditary influence of 
 cancer. It is by no means proven that there is any hereditary 
 predisposition for cancer ; although physicians generally attach 
 
CANCER OF THE STOMACH. 
 
 ao9 
 
 some importance to the fact that a patient's parent has suffered 
 from cancer, yet such a fact carries no weight in deciding a doubt- 
 ful case. Many people, some of whose relatives have had cancer, 
 live in constant dread of becoming victims to the disease ; the 
 slightest ailment whose cause is not at once apparent, servos to 
 arouse their slumbering fears that the long-dreaded disease has 
 finally appeared. To all such it cannot be too emphatically 
 asserted, that the previous occurrence of cancer in the family does 
 not warrant the least anxiety as to the safety of the individual. It 
 is, doubtless true, that the children of cancerous parents are some- 
 times attacked by the disease; but, while this fact is generally 
 known and appreciated, it is forgotten that the great majority of 
 the children of cancerous parents do not suffer from the disease, 
 while the great majority > ' cases of cancer are found to occur in 
 individuals whose family history contains no record of the dis- 
 ease. 
 
 Cancer of the stomach rarely occurs before forty years of 
 age, usually after fifty. Males are more frequently attacked than 
 females, the ratio being about two to one. 
 
 Treatment, — The only hope of relieving a patient from can- 
 cer lies in the removal of the tumor. If situated on the skin, or 
 elsewhere within reach of the eye and finger, the nature of the dis- 
 ease can be recognized early, and its removal at an early period 
 often relieves the patient permanently of the disease. Within 
 recent years the internal organs of the body have been rendered 
 more accessible to the surgeon's knife ; cancers of the womb, of 
 the rectum, and of the larynx, have been successfully removed with 
 the result not only of relieving the patient from the tumor in ques- 
 tion, but also of protecting him from a return of the disease. 
 Within the last three years the same plan has been pursued as to 
 cancers of the stomach. In i88i Billroth, the celebrated surgeon 
 of Vienna, removed about a third of the stomach of a woman 
 afflicted with cance . He had, in connection with his assistants, 
 experimented for several years upon dogs, and had found that these 
 animals recovered perfect health after the removal of considerable 
 parts of the stomach. The history of this case showed that the 
 human animal, even when suffering from disease, possesses the 
 same power ; for the woman operated upon recovered entirely, and 
 was able to consume ordinary diet without any discomfort. Since 
 that time Billroth has performed the same operation on two other 
 
2IO 
 
 DISEASES OF THE DIGESTIVE ORGANS. 
 
 patients with the same happy result. One of them is now living, 
 two and a half years after the operation, and enjoys robust health. 
 It is, as yet, too ^ rly to affirm, or even hope, that this operation 
 will become a jjeneral means for relieving these painful cases of 
 cancer of the stomach ; indeed, there are many difficulties to be 
 overcome besides the performance of the operation itself. Time 
 and experience alone can decide how useful this operation may 
 prove. 
 
 Aside from this operative procedure, we have absolutely no 
 means for relieving cancer of the stomach. There are, it is Irue, 
 cases which are falsely called cancer of the stomach, that ultimately 
 recover ; these are generally cases of tilcer of the stomach, in 
 which the symptoms closely resemble those of cancer, as has been 
 already stated. True cancer always results fatally. The duration 
 of the disease appea's to be, on the average, about a year ; the 
 patient dies, in most cases, from exhaustion and starvation. 
 
 The treatment consists merely in an attempt to palliate suffer- 
 inrf. Foremost in this direction comes opium in some form, prefer- 
 ably morphine. In most cases of disease the physician is very 
 reluctant to prescribe morphine habitually, fearing that his patient 
 will acquire the opium habit; in these cases of cancer of the stom- 
 ach such an objection has, of course, no weight ; the patient should 
 be supplied with morphine in sufficient quantities to keep him free 
 from pain. 
 
 The diet should, of course, be unirritating and nutritious, and 
 should be taken in such quantities and at such intervals as the 
 patient finds to be best. Sometimes much comfort can be derived 
 from washing out the stomach through the rubber tube, as already 
 described in discussing dilatation of the stomach. 
 
 
DISEASES OF THE INTESTINES. 
 
 Diarrhea. 
 
 Diarrhea is a symptom rather than a disease — a symptom of 
 numerous disorders ; among them typhoid fever and cholera. Yet, 
 aside from these cases, thete occur numerous instances of diarrhea 
 which appear to be largely local diseases of the intestines, and not 
 dependent upon any constitutional disease. 
 
 Symptoma, — ^The disorder is so familiar that no detailed 
 account of symptoms is necessary. It is, however, important to 
 distinguish diarrhea from another disease characterized by frequent 
 liquid stools — dysentery. In the latter affection there is an inflam- 
 mation of the mucous membrane lining the intestinal canal ; and 
 the discharges are usually mixed with blood and slime, and are 
 attended with great pain. 
 
 For convenience we may distinguish cases of diarrhea as 
 acute and chronic. The acute diarrhea is familiar to us all as the 
 result of errors and indiscretions in diet, being produced by exces- 
 sive indulgence in food as well as by eating certain indigestible 
 articles. This diarrhea is 'ir,ually transient and subsides spontane- 
 ously in a few days. In such cases there should be no meddling 
 interference with the discharge, which is really nature's effort to 
 rid the stomach and intestines of irritating material. If at the end 
 of a day or two the discharge continue to be profuse and frequent, 
 the following prescription may be given : 
 
 Aromatic syrup of rhubarb, - 
 Magnesia, ------- 
 
 Compound spirits of lavender, 
 Camphor, water, - - - - - 
 
 Two ounces. 
 One drachm. 
 One drachm. 
 Each one ounce. 
 
 Mix, and take half a teaspoonful every half hour. 
 
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 313 
 
 DISEASES OF THE INTESTINES. 
 
 Diarrhea sometimes results not from indigestion, but mental 
 emotion, or from exposure to cold. In these cases, also, the affec- 
 tion is usually cured spontaneously within a few days. 
 
 The chronic forms of diarrhea are by no means so simple nor 
 so easily managed as the acute form. A chronic diarrhea is in 
 most cases a symptom of some serious disease of the intestinal 
 canal ; and the physician's tact and knowledge are tested to the 
 uttermost to detect the origin of the difficulty. Sometimes the 
 cause is to be found in a tttberctiloxts condition of the intestines ; 
 sometimes the difficulty lies in obstinate indigestion or dyspepsia; 
 at other times the fault is to be found in disease of the liver, and 
 still again cases occur in which inflammation of the kidney is re- 
 sponsible for the diarrhea. In fact a chronic diarrhea, notwith- 
 standing its apparent simplicity as a disease, is one of the most 
 troublesome and often intricate affections which the physician is 
 called upon to treat. It will be, therefore, out of place to attempt 
 a detailed account of the means for recognizing the various causes 
 of diarrhea in the individual cases. 
 
 Yet certain ^eneral measures will be found advantageous in 
 all cases of chronic diarrhea, and may be mentioned here. In 
 every case the regulation of the diet is a matter of importance, for 
 persons often acquire improper habits of eating, the avoidance of 
 which suffices in itself to cure the diarrhea. It will be well to keep 
 the patient upon animal food largely, avoiding fresh fruits and 
 vegetables. Milk, eggs, and broth, reinforced by rare meat and 
 old bread, will be found most suitable, especially if taken in small 
 quantities and at shorter intervals than usual. Starchy food may 
 be allowed when properly cooked, as well as a moderate indul- 
 gence in ripe fruits. In this disease, too, attention should be di- 
 rected to the teeth, since the difficulty may arise from imperfect 
 mastication of the food. 
 
 The medicines to be used vary extremely, according to the 
 nature of the case ; some chronic cases of diarrhea, those espe- 
 cially which have originated during military life and are especially 
 frequent among soldiers, have been cured by large doses of ipecac — 
 twenty grains every four hours. This measure is not however to 
 be adopted until milder ones have failed, since it causes profound 
 nausea and vomiting. Various admixtures are found to be bene- 
 ficial in different cases, among them the following : 
 
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 amount of r 
 accompanie( 
 
DYSENTERY. 
 
 213 
 
 - 20 grains. 
 
 - Each six grains. 
 Take one every four hours; or 
 
 - One drachm. 
 
 - Three ounces. 
 
 - One ounce. 
 
 Camphor, 
 
 Ipecac, 
 
 Opium, - 
 Mix and make twelve pills. 
 
 Prepared chalk, 
 
 Tincture of kino, 
 
 Laudanum, 
 
 White sugar, - - - - 
 
 Gum arabic, - - - - Each one drachm. 
 Mix. Take a teaspoonful every three or four hours. 
 
 In many cases the following combination will be effectual : 
 
 Subnitrate of bismuth, - - Four drachms. 
 
 Tannin, ----- Haifa drachm. 
 
 Ipecac, - - - . - - Fifteen grains. 
 Mix and make eight powders. Take one every two hours, 
 
 A prescription commonly known as Hope's mixture is often 
 beneficial; it is made as follows: 
 
 Nitric acid, - - _ . Four drops. 
 
 Laudanum, - - . - One drachm. 
 
 Camphor water, . - - Four ounces. 
 Take a tablespoonful every two or three hours. 
 
 In all cases of chronic diarrhea the patient should be extremely 
 careful to protect himself against sudden changes of temperature, 
 against wetting the feet, etc. He will find it advisable to be 
 warmly clothed, even during the summer, and so long as the 
 diarrhea is severe, to avoid unnecessary physical effort. 
 
 Dysentery. 
 
 This is an inflammation of the mucous membrane of the large 
 intestine, especially of the rectum. 
 
 Symptoms, — As it occurs in scattered or " sporadic " cases, 
 dysentery is ordinarily preceded for one or more dj.ys by an ordi- 
 nary diarrhea ; there may also be some nausea and vomiting, 
 though these do not differ necessarily from the symptoms of 
 diarrhea. After a time the stools begin to contain an unusual 
 amount of ropy mucus ; the desire to go to stool is frequent, and 
 accompanied by severe griping pains ; the act itself causes a burn- 
 
 
■Hi 
 
 214 
 
 DISEASES OF THE INTESTINES. 
 
 ing sensation and even sharp pain in the bowels. Meanwhile, there 
 is apt to be considerable constitutional disturbance, general pros- 
 tration, some fever, perhaps repeated chilly sensations. After a 
 few hours or days, blood appears in the stools, at first in small 
 quantity, but afterwards increasing so that the entire stool seems to 
 consist of almost pure blood. One of the most dist.*essing symp- 
 toms — one quite characteristic of this disease — is the irresistible 
 desire to strain, even after the bowel has been completely evacu- 
 ated. In mild cases, these symptoms persist from five to ten days, 
 after which the bowel gradually returns to its natural condition, or 
 at least the more acute symptoms mbside, leaving the bowel in an 
 irritated condition, which constitute.: chx. nic dysentery. 
 
 Sporadic cases of dysentery usual 'y terminate in recovery 
 under proper treatment ; but occasional cases are observed in 
 which the symptoms occur with much greater intensity ; there is 
 constant and severe pain in the abdomen, the stools are very fre- 
 quent and painful, and the patient's general condition indicates 
 extreme prostration. These fatal cases are, however, more apt to 
 occur during an epidemic of dysentery than at other times. 
 
 Cause, — Acute dysentery usually occurs during the late 
 summer and early fall, especially during particularly hot seasons. 
 In this regard the disease resembles several of those which are 
 known to be induced by the entrance into the body of agents from 
 without. However, we have no knowledge as to the existence of 
 any specific agent in Ihe production of this disease ; whatever may 
 be its cause, it is certainly favored by exposure to cold, by sudden 
 changes in temperature, by excesses in eating and drinking, by 
 indulgence in unripe fruits, etc. 
 
 Treatment, — The first requisite in the treatment of dysentery 
 is rest; the patient should be kept perfectly quiet on his back, then 
 a single dose of some laxative should be administered ; for this 
 purpose a teaspoonful of castor oil with twenty drops of laudanum 
 used to be generally employed. This will answer if administered 
 early in the course of the disease, otherwise some citrate of mag- 
 nesia may be given. After this, the plan usually adopted in India, 
 may be followed : thirty drops of laudanum are given, and half an 
 hour later twenty grains of ipecac — the latter administered in a 
 little syrup of orange peel, to conceal the taste. Fo/ three hours 
 afterward the patient should abstain from all liquids and remain per- 
 
EPIDEMIC DYSENTERY. 
 
 215 
 
 fectly quiet ; in this way nausea and vomiting can be usually 
 avoided. Eight hours after the first dose of ipecac a second of 
 fifteen grains may be given, followed, as before, by perfect rest on 
 the part of the patient. The English physicians in India report 
 exceedingly good results from this plan of treatment. 
 
 In this country such treatment is always supplemented by injec- 
 tions into the rectum. The tendency to strain and the pain at 
 stool can be much diminished by injecting into the rectum two 
 ounces of starch, with forty or fifty drops of laudanum — to be 
 repeated in three hours if necessary. If the difficulty is not im- 
 proved, the rectum may be filled with a pint of hot water, which 
 can usually be retained, and is found to be very soothing to the 
 patient. 
 
 If the ipecac in the above description be not well borne, that 
 is, if vomiting occur after it is taken, there should be administered 
 one of the following prescriptions : 
 
 Camphor, - . - . Twenty-four grains. 
 
 Ipecac, ----- Twenty grains. 
 
 Opium, ----- Ten grains. 
 Mix, and make twenty-four powders. Take one every hour. 
 / Blue mass, - . - - Ten grains. 
 
 Camphor, . - - . Fifteen grains. 
 
 Opium, - - - - Ten grains. 
 
 Make twenty pills, and take one every hour. This will be found 
 more useful than the foregoing if there be much tendency to vomit- 
 ing. If the patient be much exhausted, his strength should be 
 supported by the administration of a tablespoonful of whisky or 
 brandy, mixed with a little milk, every houror two, and if necessary, 
 two giains of quinine may be given with the brandy every two hours 
 until six doses have been taken. During the attack of dysentery, 
 and the convalescence which follows it, the diet should be restricted 
 to liquid food, though no attempt should be made to starve the 
 patient, since the object is merely to relieve the intestine so far as 
 possible, and not to reduce the patient's strength. 
 
 -i"v .'1 
 
 Epidemic Dysentery. 
 
 This is essentially the same disease as the sporadic variety, 
 though it is usually far more dangerous, and often fatal. The 
 symptoms are those just described, though usually much aggra- 
 
 
mrm m ,m 
 
 216 
 
 DISEASES OF THE INTESTINES. 
 
 ! 
 
 vated. The discharge from the bowels contains so much blood that 
 the disease is popularly known as bloo'^yflux. It is especially apt 
 to occur when large numbers of persons are closely quartered, as 
 in military camps, on shipboard, and in densely populated portions 
 of large cities. The disease is usually accompanied by far greater 
 prostration and debility of the patient than is observed in the spo- 
 radic cases. In the treatment there is, therefore, greater demand 
 for those measure which support the patient's strength, such as 
 alcoholic stimulants, and opium is ordinarily required and endured 
 in larger quantities than in the sporadic form of the disease. 
 
 Cliroric T- antery. 
 
 In this affection, which is sometimes the sequel to an acute 
 attack, the symptoms are much nild.i, occasioning the patient 
 considerable annoyance but not much distress. The stools do not 
 exhibit the blood and mucus to the extent which characterizes the 
 acute attack; indeed, the discharges are sometimes of a clay color. 
 The patient's general condition is, however, unsatisfactory, the 
 constant annoyance and loss of strength resulting in marked im- 
 pairment of the general health. 
 
 This disease is usually found in those who have suffered an 
 acute attack in warm climates, and is especially frequent, in our 
 latitude, among the soldiers of the late war; cases were still more 
 numerous among the United States troops who were engaged in 
 the war with Mexico forty years ago. It is an extremely obstinate 
 affection. Dr. Flint, in discussing the subject, says : 
 
 " Chronic dysentery is one of the most intractable and hopeless 
 of diseases. For a time, if the evacuations be held in check by 
 palliative measures, the appetite and digestion not being greatly 
 impaired, the general aspect and strength may not show much 
 deterioration, but at length the appetite and digestion fail, and a 
 continued irritation and loss of fluids induce progressive emaciation 
 and debility. The duration of the disease embraces usually several 
 months, and sometimes years. If not destroyed by some inter- 
 current affection, the patient becomes extremely emaciated, reduced 
 almost to a skeleton ; the surface is usually dry, cool or cold ; the 
 pulse becomes more and more feeble ; the mental faculties are 
 
CHRONIC DYSENTERY. 
 
 317 
 
 weakened, delirium rarely occurring, but the mind, in certain cases, 
 falls into an apathetic state, the patient being indifferent to and 
 taking but little notice of persons and things around him. The 
 appetite is lost, and vomiting, in some cases, is a prominent 
 symptom. 
 
 " The diet for this class of patients should be restricted theoret- 
 ically, at least, to those articles of food which are as completely 
 digested as possible. This is done upon the principle of keeping 
 an inflamed part at rest. Our object is to prevent as far as pos- 
 sible the exercise of any function by the large intestine — that is, 
 we administer nourishment which leaves but little matter to pass 
 into this portion of the alimentary canal. Cold water and ice ap- 
 plied to the rectum sometimes relieve the straining. Warm sooth- 
 ing applications over the abdomen usually afford a certain measure 
 of relief. We are to be guided to a certain extent by the instincts 
 and desires of the patient, and I am willing to say that in almost 
 every disease, if the patient has a well-defined desire for any article 
 of food, it is wise to allow it to be taken. We are much safer in 
 following the in-:incts of the patient in this respect than in follow- 
 ing out any set of dietetic rules with theoretical form. I cannot 
 but think that adopting the same general dieting rules and endeav- 
 oring to apply them to every case is harmful. 
 
 " Next, with regard to the treatment of the severer cases of 
 dysentery, which are usually epidemic. In severe cases of epidemic 
 dysentery we have to deal with a very formidable disease. So far 
 as medical treatment is concerned our chief reliance must be placed 
 upon opium. It is a noteworthy fact that the quantity of opium 
 which can be administered in these cases without exposing the 
 patient to danger from over use of the drug, is sometimes very 
 large. For example, I have given a patient sttffering from epidemic 
 dysentery, a grain of the sulphate of morphia every hour — twenty- 
 four grains in the day — and continued such doses for several days 
 without producing the least manifestation of narcotism ; and the 
 patient was a person not accustomed to taking opium. That was 
 an extraordinary case, it is true, but I have been repeatedly led to 
 observe a greatly increased tolerance of opium in this class of 
 cases. 
 
 In our climate we rarely see a case of chronic dysentery. It 
 is essentially a disease of the tropical climates. With regard to 
 sporadic and epidemic dysentery, as it occurs in this climate, there 
 
 
ai8 
 
 DISEASES OF THE INTESTINES. 
 
 
 h 
 
 is scarcely any tendency to the supervention of the chronic form of 
 the disease, whereas in tropical climates there is considerable tend- 
 ency to this result. 
 
 These patients are to be sustained by tonic remedies and a 
 nutritious diet. More advantage may perhaps be derived from 
 hygienic treatment than from any other. A change of climate is a 
 most important element in the treatment of chronic dysentery. I 
 am speaking particularly of cases occurring in a tropical climate. A 
 change from a warm to a temperate or cold climate is beneficial. A 
 uniformly cold and dry atmosphere is best suited to these cases. 
 During the late civil war and also during the Mexican war, we had 
 occasion in New York to treat numerous cases of chronic dysen- 
 tary contracted in the Southern States and in Mexico, and the 
 most effectual measure for their relief was a change of climate. " 
 
 m 
 
 Ui 
 
 \m 
 
 f 
 i 
 
 Constipation. 
 
 This is essentially an affection of the rectum, which becomes 
 unable to perform properly its usual function. In its natural con- 
 dition the rectum is usually empty, and is endowed with a sensibil- 
 ity which at once gives notice of the necessity for an evacuation. 
 The act is performed partly by the contraction of the muscular 
 coat of the rectum. When, however, this organ is habitually dis- 
 tended, its muscular coat becomes more or less paralyzed, and is 
 thus unable to expel its contents. This habitual distention is usu- 
 ally the result of neglect to respond to the calls of nature. In 
 consequence of the artificial relations of our social life, it is often 
 extremely inconvenient to perform the act when required ; and 
 many individuals seem to exhibit an unaccountable reluctance in 
 the discharge of this duty, deferring it so long as possible; ifc is 
 considered an annoyance to be avoided. The result is in some 
 cases an incredible degree of constipation ; some persons, especially 
 women, not infrequently permit one, two, or even three weeks to 
 elapse between two consecutive evacuations of the bowels. Many 
 other influences contribute also to constipation, such as those which 
 interfere in general with the health of the body — excessive brain 
 work and mental emotion, neglect of physical exercise, and im- 
 proper diet. 
 
 f- f -i ( -mm _ 
 
CONSTIPATION. 
 
 219 
 
 Treatment, — ^The treatment of habitual constipation is a 
 tedious, and by no means always successful, effort ; for the difficulty 
 seems so trifling, its effects are apparently so insignificant, that 
 many persons cannot be induced to adopt the simple measures 
 necessary, which seem to them needlessly irksome. The favorite 
 plan is a resort to cathartics — a plan which, while securing imme- 
 diate relief, aggravates the difficulty in several ways. Laxatives 
 certainly have a proper place in the treatment of many cases of 
 constipation, but they are abused far more than they are properly 
 used. 
 
 The individual who is subject to habitual constipation should 
 awaken to the fact that he is suffering from a serious complaint, 
 which can be relieved only by energy and perseverance on his own 
 part ; a cure will depend far more upon himself than upon his 
 physician. His first effort should be to remove the cause of the 
 constipation. If he be the subject of dyspepsia, his bowels will 
 scarcely resume their natural action until the stomach does its work 
 properly ; if he is cultivating and exercising the mind, to the 
 neglect of the body, he can scarcely hope that the latter will per- 
 form all of its functions properly. To remedy the constipation, it 
 will be necessary, perhaps, to effect a radical change in his personal 
 habits, quite independently of medicines. 
 
 Then comes attention to the diet; and here we come upon a 
 subject which has given rise to numerous hobbies that are enthusi- 
 cally ridden by non-professional persons as well as by physicians. 
 First among these is the graham bread and fresh fruit idea. There 
 can be no doubt that brown bread and fruit are beneficial in those 
 cases of constipation which depend upon torpor of the bowels ; but 
 it is a mistake to suppose that an exclusive diet of these substances 
 will cure all cases of constipation, or indeed any case unless other 
 measures be added. It is well to have a variety in the diet — 
 fruits, vegetables, bread and meat ; but it is not desirable to exclude 
 digestible articles which are eaten with avidity, for it must be 
 remembered that the food must be digested in the stomach before 
 reaching the intestine ; and to derange the stomach by a diet im- 
 proper for it is to promote constipation, by favoring dyspepsia. 
 One kind of food should probably be avoided in all cases of consti- 
 pation — pastry ; aside from this, the individual may consult his 
 own tastes and inclinations. 
 
 Another item of importance is bodily exercise; not a dismal 
 
 "^1 
 
 
 'it V 
 
220 
 
 DISEASES OF THE INTESTINES. 
 
 and formal performance of certain bodily motions, which passes for 
 the name of exercise, but a hearty indulgence in some sort of 
 movement which interests and amuses the mind, while keeping the 
 body active. The particular exercise best adapted for any individual 
 case can, of course, be better determined by the person himself than 
 by any set of rules. 
 
 " The most important part of the management in cases of habit- 
 ual constipation is the adoption of a rule to solicit an evacuation 
 of the bowels at the same hour daily. The importance of this rule 
 is to be enforced ; but, of course, its success will depend upon the 
 perseverance of the patient. The time of the day most convenient 
 for the act of defecation is to be selected, and in general the most 
 favorable time is in the morning, after breakfast. At the time fixed 
 upon the patient should devote a reasonable period to the evacua- 
 tion of the bowels, but without persisting in violent, fruitless efforts. 
 This should be considered in the light of a duty, not to be omitted 
 a single day, except from necessity. It may be long before the 
 desired object is accomplished, but sooner or later, with the aid of 
 some of the other means which have been indicated, the desire will 
 be felt at the appointed hour, and the ability to empty the bowel 
 at that time will be acquired in the great majority of cases. It is 
 impossible to secure regularity and sufficiency of the evacuations 
 without perseverance in this part of the management. 
 
 " If this plan were early inculcated and carried out /;/ health, 
 habitual constipation would be as rare as it is now frequent. The 
 prevention is not less sure than simple. The function may be 
 brought fully under the control of habit. This fact should be 
 generally understood, more especially in the training of girls, most 
 of whom become affected with habitual constipation, and suffer 
 from it all their lives. Unfortunately, the existence of the func- 
 tion of defecation is often ignored from notions of false delicacy, 
 and the affection becomes established, because parents and teachers 
 are either themselves ignorant of this simple method of prevention, 
 or consider the subject as belonging exclusively to the physician. " 
 
 If it become necessary to use medicines, care must be taken 
 to avoid harsh and violent cathartics ; a mild laxative is often suffi- 
 cient as an assistance to the efforts of nature in relieving the 
 
'^1.— A view of the muBclcD oi Uie 1 uiigue 
 whui'ii in itH lower Burface. 
 
 m.—A front view of tlie upper sur- 
 tace of the Tongue, a>i well as the 
 Palatine Arch. 
 
 278.— A view of llie lA)wer Jaw. flnth the 
 Toiigue drawn upwards, so as to Uuow It*" 
 niider surface in situ. 
 
 2«0.— A view of tlie undel 
 surface of tlie Tongue, with 
 tlie muscles uonnectud with it. 
 
 271).— A view of the iJnrsum oi 
 the Tongue, from which, by mac- 
 eration, the Periglottis lias been 
 removed and turned Imcli ou the 
 right side. 
 
 282,— A view of a section of the anterior portioa 
 of the Tongue, as seen from behind. 
 
 T^ 
 
 J* 1 'i 
 
 I'M 
 U ' • it 
 
 f If I > , 
 
 is t 
 
 ^Jpll 
 
 )>. "., 
 
 '5 
 
 TONGUE. 
 
bowels. 
 
 followinj 
 S 
 I. 
 S 
 F 
 
 l'ulvcriz( 
 tablespo 
 Thij 
 siiicrablc 
 demand 
 
 A no 
 palion re 
 
 P( 
 P( 
 E: 
 
 Mix and 
 Ano 
 
 ' safety f 
 Ej 
 E> 
 E> 
 Pc 
 
 Mix and i 
 
 If th 
 the habiti 
 a time exi 
 a quart of 
 for a cons 
 time, abs<; 
 an evacuE 
 not tend 
 in avoidin 
 The I 
 has now h 
 tion. Of 
 create a d^ 
 ent upon t 
 
CONSTIPATION. 
 
 221 
 
 bowels. One of the best remedies for habitual constipation is the 
 following : 
 
 - Three ounces. 
 
 II 11 
 
 - Two 
 
 - One ounce and a half. 
 Six ounces. 
 
 Take from a teaspoonful to a 
 
 Senna leaves, 
 Licorice root, 
 Sulphur, - - - 
 Fennel seed, 
 White sugar, 
 Pulverize thoroughly and mix, 
 tablcspoonful, cither dry or in water. 
 
 This powder has the advantage that it can be used for a con • 
 siiicrable time without weakening the bowels, and thus creating a 
 demand for more powerful laxatives. 
 
 Another proscription which will be found beneficial in consti- 
 pation resulting from indigestion, is the following : 
 
 Powdered rhubarb, - - - - 12 grains. 
 Podophylline, ----- 4 " 
 Extract of nux vomica, - - - 8 " 
 
 Mix and make 24 pills. Take one at night. 
 
 Another formula which has been much used is the so-called 
 ' safety pill : " 
 
 Extract of hyoscyamus, 
 Extract of nux vomica, 
 Extract of aloes, 
 Powdered ipecac. 
 Mix and make 20 pills. Take one at night. 
 
 If the patient have been in the habit of abusing the bowels by 
 the habitual use of cathartics, it may be well for him to resort for 
 a time exclusively to rectal injections. The injection of a pint to 
 a quart of water, in the morning, is a measure which may be used 
 for a considerable time without damage ; yet these become, after a 
 time, absolutely essential, so that the patient is unable to secure 
 an evacuation without such assistance. Injections, therefore, do 
 not tend to cure the constipation, but are merely temporary aids 
 in avoiding the ill effects. 
 
 The use of various popular and well-advertised mineral waters 
 has now become a very common means of treatment in constipa- 
 tion. Of these, it must be said that, like other laxatives, they 
 create a demand for their use, so that the patient becomes depend- 
 ent upon them, instead,of acquiring health by attention to hygiene. 
 
 10 
 
 g 
 
 rams 
 
 6 
 
 
 (( 
 
 30 
 
 
 u 
 
 2 
 
 
 11 
 
 
 Ni 
 
 
223 
 
 DISEASES OF THE INTESTINES. 
 
 In this way, and this only, can the various ills consequent upoi 
 habitual constipation — piles, diseases of the genital organs, etc.-" 
 be avoided. 
 
 Colic. 
 
 This term is applied to sharp, spasmodic pain in the abdomen, 
 which may be caused by any one of several conditions. We recog- 
 nize, for convenience, several varieties of colic : i . Flatulent, or 
 wind colic'; 2. Bilious colic; 3. Lead colic; 4. Uterine colic; 5. 
 Gouty, or Rheumatic colic. 
 
 Flatulent colic is familiar to all from personal experience. It 
 is due to the collection of gas in the intestine, which is, in its turn, 
 the result of indigestion. Tnis form of colic often follows consti- 
 pation in one unaccustomed to it, and continues until the bowels 
 are evacuated. This form of colic may follow exposure to cold, or 
 the consumption of indigestible articles of food. It would seem 
 also, to follow simple exposure to cold, or physical exhaustion, 
 though these causes probably induce colic indirectly by occasioning 
 indigestion. 
 
 The symptoms are so familiar that no description is necessary. 
 Yet it may be well to remark, that the abdomen is sometimes the 
 seat of spasmotic pain from other causes than the collection of gas 
 in the intestine ; thus, the passage of gall stones from the gall blad- 
 der into the intestine may occasion spasms of pain similar to those 
 of colic, and which are, indeed, called "Hepatic (liver) colic." 
 Then, again, attacks resembling those of ordinary wind colic occur 
 as an early symptom in one of the severest diseases of the nerv- 
 ous system — locomotor ataxia. Again, attacks of colic occur as 
 one of the results and symptoms of a most dangerous accident — 
 acute rupture or strangulated hernia. The possibility of these 
 causes for colic must be borne in mind, though, of course, the in- 
 stances in which they occur are few in comparison with the numer- 
 ous cases of ordinary wind colic resulting from errors of diet. 
 
 Treatment, — In mild attacks, it will suffice to place hot cloths 
 or a light mustard plaster upon the abdomen, and to give a little 
 Jamaica ginger in a tablespoonful of brandy or whisky, by the 
 mouth. If this be not efficient in relieving pain, chloroform may 
 be administered, either by inhalation or twenty drops of it may be 
 
 in the t- 
 
 relieve 
 
 chloiofo; 
 
BILIOUS COLIC. 
 
 223 
 
 given in a little brandy. In most cases it will be desirable that the 
 patient take some opium, not only to secure immediate relief from 
 the spasm, but also to promote the evacuation of the bowels, which 
 must happen before the patient will be entirely safe from a recur- 
 rence of the pain. Twenty drops of laudanum may be given, or 
 if the patient be constantly vomiting, a teaspoonful of laudanum 
 mixed with a little starch may be injected into the rectum. If the 
 pain be not subdued within an hour, this dose may be repeated. 
 
 In most cases vomiting constitutes one of the features of the 
 attack; if this be not the case, and there be reason for supposing 
 that the colic is the result of indigestion, an emetic should be 
 administered in order to empty the stomach. The quickest, though 
 not the most certain, way of securing vomiting, is to tickle the 
 throat with the finger or with a feather; if this measure be not 
 successful, half a tablespoonful of common salt or mustard may be 
 dissolved in a glass of warm water and swallowed. This may be 
 repeated in ten minutes if the vomiting be not induced within that 
 time. 
 
 The patient will not be entirely free from pain and soreness 
 until the bowels are evacuated. To secure this object it is much 
 better to rely upon injections into the rectum, than upon cathartics; 
 an injection of warm water containing a tablespoonful of castor oil 
 or soap suds, will usually secure a speedy evacuation. 
 
 ii! 
 
 Bilious Colic. 
 
 This usually begins somewhat less abruptly than the ordinary 
 wind colic, some hours elapsing before the pain begins. The 
 matter vomited is often green or yellow in color, from the presence 
 of bile; sometimes the patient's skin becomes slightly yellow dur- 
 ing the attack. There is also more general depression and debility; 
 that is, the parent's health is more deranged in this variety of colic 
 than in the ordinary form, although the pain may be more intense 
 in the latter case. 
 
 Treatment, — During the attack, bilious colic is to be treated 
 in the t,ime way as the form just described; the first object is to 
 relieve the pain by hot applications externally, and the use of 
 chloroform and opium internally ; the stomach should also be 
 
 I s iW 
 
 
224 
 
 DISEASES OF THE INTESTINES. 
 
 « 
 
 evacuated. After the attack has subsided, treatment should be 
 adopted to avoid a repetition of the same ; to acomplish this, the 
 general health must be regulated, as will be described in discussing 
 diseases, of the liver ; for bilious colic seems to depend upon some 
 deran; ement in the secretion and discharge of the bile. 
 
 Lead Colic. 
 
 ! 
 
 ■Mil 
 
 This is a symptom of a disease which may run a long and pain- 
 ful course, and may terminate in disaster or even death to the 
 patient. The disease is most frequent among those whose avoca- 
 tions compel them to work in contact with lead or combinations of 
 lead ; such as painters, plumbers, glaziers, etc. ; yet the disease is by 
 no means limited to workmen of this class; it may occur from 
 drinking wine, spirits or Cider which have been kept in leaden 
 vessels, or which have been submitted to the action of lead in 
 course of distillation ; it has also been known to occur from the use 
 of drinking water which had become saturated with lead compounds 
 by passing through improperly-made service pipes. 
 
 Another source of lead poisoning is in the use of powders and 
 cosmetics for toilet purposes. It has been induced by the use of 
 flour which had been ground on stones containing lead. Some 
 years ago a local epidemic of lead colic was observed in New Or- 
 leans and traced to the presence of lead contained in soda water. 
 
 Symptoms, — The patient is usually ill for a considerable time 
 before the colic is manifested. He becomes pallid, loses appetite, 
 strength and flesh. He has a metallic taste in the mouth, and the 
 breath emits a peculiar fetid odor. He becomes afflicted with obsti- 
 nate constipation, and suffers pain in the abdomen, which is at first 
 slight, but gradually increases in intensity, so as to become the most 
 prominent symptom. The pain is generally felt around the navel, but 
 may shoot to the back, the sides, and the hips. The intensity of 
 the pain varies at dirfcrent times, being sometimes dull and aching 
 and at other times sharp and spasmodic in character. During the 
 latter occasions the abdomen is usually hard and tense, perhaps 
 tender. There is nausea and vomiting. The patient often expe- 
 riences relief during these attacks of colic by gentle pressure upon 
 the abdomen, and is therefore apt to lie upon the breast, with a 
 pillow or other article placed undor the abdomen. 
 
 topics, 
 
 i 
 
LEAD COLIC. 
 
 225 
 
 Under proper treatment the first attack of lead colic usually 
 subsides without leaving any permanent injury ; but if the patient 
 resume the employment or the habit which occasions exposure to 
 the lead, the symptoms are apt to recur in an aggravated form. The 
 strength fails rapidly. There is a blue line along the gums at the 
 roots of the teeth. Paralysis is manifested in certain of the muscles, 
 especially those of the fore-arm, as a result of which the patient.is un- 
 able to ext<-nd the hand. The hand, therefore, hangs loosely from the 
 wris;, a condition which is known dA drop-wrist . This occurs more 
 frequently upon the right side than upon the left. Subsequently 
 various other muscles, the legs as well as the arms, may become 
 paralyzed. In severe cases there occur symptoms indicating dis- 
 ease of the brain — delirium, convulsions, stupor. 
 
 Treatn^snt, — To relieve the pain occurring during the parox- 
 ysms, the same general measures are useful which have been de- 
 scribed in the treatment of ordinary colic. Yet in lead colic opium 
 has a much more important part than in the other, since the drug 
 not only diminishes the pain, but also relaxes the spasmodic con- 
 traction of the intestine. In fact, opium is absolutely necessary in 
 the treatment of this disease. Next most important is the iodide 
 of potassiitm, which may be given in doses of five to ten grains 
 every four hours. If the ledd poisoning have come on in a short 
 time, the sulphate of magnesia will exert a good effect ; otherwise 
 it will be unnecessary. 
 
 Under the use of opium and the iodide of potassium the more 
 acute symptoms, including the colic and the intestinal derange- 
 ment, will subside ; in treating the paralysis, however, it will be 
 often necessary to resort to electricity. 
 
 Uterine colic is apt to occur during various chronic diseases of 
 the womb ; and is also a feature of certain affections of the ovaries. 
 This will be dincussed at length in connection with these several 
 topics, and it may suffice to say here, that the treatment requires 
 hot applications to the abdomen, and in most cases a hot hip bath 
 or hot water injections into the vagina. 
 
 Infants are especially susceptible to colicky attacks, particularly 
 during the first year of life. These attacks occur sometimes frcru 
 the condition of the mother's milk, which may be deranged by im- 
 proper diet on her part, or by excessive mental emotion. In many 
 other cases the colic of infants is due to the almost universal habit of 
 
 ( :• 
 
 ki. 
 
 ' ^'^i 
 
 ' i '^w 
 
 it 
 
 
 
226 
 
 JDISEASES OK THE INTESTINES. 
 
 giving thorn artificial food too early ; it may also result from im- 
 proper clothing, whereby the child is not sufficiently protected. 
 
 An infant afflicted with colic is very restless, screams constantly 
 and draws the lower extremities violently upward toward the abdo- 
 men ; there is often vomiting, and the abdomen is usually hard and 
 distended. 
 
 Treatment, — Infants can be usually protected from colic i{ 
 they can be properly fed and clothed, and escape from the innum- 
 erable household remedies which nurses are so fond of administer- 
 ing upon the slightest provocation. Du' ng an attack hot cloths 
 may be applied, and an injection of a .^ine-glassful of water and 
 a teasponful of castor oil should be given at once by the rectum ; 
 if this do not provoke an evacuation of the bowels the following 
 mixture may be injected : 
 
 Gin, - - . _ _ - One teaspoonful. 
 
 Tincture of asafoetida, - - Ten drops. 
 
 Castor oil, . _ . _ One teaspoonful. 
 
 Warm water, - . - . Four ounces. 
 
 Passage of Oall-Stones. 
 
 i! 
 
 I* 
 
 I*. I 
 
 ^ 
 
 i 
 
 A most painful form of colic is that which accompanies the 
 passage of gall-stones from the gall-bladder into the intestine. 
 These stones are collections of substances which have been depos- 
 ited from the bile while retained in the gall-bladder. They may vary 
 in size, from that of a pin-head to that of a hickory nut. So long 
 as they remain in the gall bladder they may occasion no difficulty ; 
 but if they are carried into the little tube which leads from the 
 gall-bladder into the intestine — the biliary duct —they occasion 
 intense pain by stretching this duct, as well as by preventing the 
 bile from passing through. Such spasms rarely occur, although it 
 is a frequent occurrence to find gall-stones in the bodies of indi- 
 viduals who have never been known to suffer from such attacks. 
 
 The paroxysms attending the passage of gall-stones often 
 occur in individuals in perfect health, without apparent cause. 
 The attack is sudden, beginning with extreme pain in the right 
 side, just under the ribs spreading over to the left side. The pain 
 is sporadic, occurring with the greatest severity at intervals. 
 
INFLAMMATION OF THE BOWliLS — PERITONITIS. 
 
 !27 
 
 There is usually nausea and vomiting ; the bowels are constipated ; 
 if the attack be a long one, the skin may acquire a yellow hue. 
 The duration of the pain varies from a few minutes to several 
 hours, according to the time required for the escape of the stone 
 into the intestine. Finally the symptoms suddenly cease, leaving 
 merely the exhaustion and soreness. This sudden cessation of the 
 pain indicates the escape of the stone into the intestine, which, 
 because of its large size, affords ample room for the accommo- 
 dation of the gall-stone. 
 
 These attacks are apt to recur in the same individual after 
 .ntervals varying from years to days. In some cases a series of 
 paroxysms is experienced in rapid succession, prostrating the 
 patient and seriously deranging his digestive organs. 
 
 The paroxysm usually terminates by the passage of the gall- 
 stones into the intestine ; yet, in some cases, the stone is too large 
 to escape in this way, and remains permanently in the gall-blad- 
 der. The result of this may be an ulceration through the wall of 
 the gall-bladder and a general inflammation of the abdominal cav- 
 ity. If this accident occur, the symptoms of peritonitis super- 
 vene. 
 
 Treritnient, — During the passage of gall-stones nothing can 
 be done except to palliate the severity of the sufiering. For this 
 purpose opium is employed, as described under the treatment of 
 ordinary wind colic ; if the pain be excessive, relief can be obtained 
 from Ihe inhalation of chloroform. Hot applications over the 
 abdomen, or immersion in a hot bath, may also be employed. To 
 obviate subsequent attacks, nothing better can be done than care- 
 ful attention to the digestion and the general health. 
 
 « 
 
 Inflammation of the Bowels"— Peritonitis. 
 
 We have already described a membrane called the pleura, 
 which surrounds the lung and lines the inner surface of the ribs ; 
 and another membrane of similar nature, the pericardium, which 
 surrounds the heart. Still another smooth membrane, much larger 
 in extent than either of those named, though possessing essentially 
 the same structure, surrounds the intestines, liver, and other organs 
 in the abdomen, so that they may move freely upon one another 
 
 
228 
 
 DISEASES OF THE INTESTINES. 
 
 with as little friction as possible. This membrane is called the 
 peritoneum ; and an inflammation involving this membrane is called 
 peritonitis. If the entire membrane be inflamed, the disease is one 
 of the most dangerous affecting the body, and usually results 
 fatally ; but if only a portion of this extensive surface become 
 inflamed, the patient may escape without serious illness, 
 
 SyfnptotnH, — The disease usually begins abruptly, though in 
 exceptional cases some pain and soreness may be felt for two or 
 three days before the patient becomes seriously ill. The pain 
 begins at some particular point, and extends over the entire abdo- 
 men ; it is usually of a sharp, cutting nature, aggravated by move- 
 ments of the bcdy, or even by a deep breath. The patient, 
 therefore, is extremely careful to avoid any change of position, or 
 any violent use of the lungs, such as sneezing or coughing. The 
 patient usually finds that the pain is less acute if the knees be 
 drawn up toward the abdomen ; he therefore assumes this posture 
 in the majority of instances. The abdomen is extremely tender, 
 even the pressure of the bed-clothes occasioning pain ; and there is 
 jsually swelling and distension of the abdomen from the presence 
 of gas in the intestines. The attack is usually ushered in with vom- 
 iting, an act which occasions great pain. 
 
 The prostration of the patient is a marked symptom of the 
 disease ; the countenance denotes anxiety and distress, and the 
 face sometimes exhibits a peculiar pinched expression, the upper 
 lip being drawn tightly over the teeth. This, the so-called " hip- 
 pocratic countenance," is quite characteristic of the disease when 
 present. There is usually difficulty in emptying the bladder and 
 bowels — a difficulty largely due, doubtless, to the pain occasioned 
 by the effort. 
 
 Cause, — Acute peritonitis is usually secondary to an inflam- 
 mation in some one of the abdominal organs ; most frequently to 
 the inflammation of the womb which occurs in child-bed. Some- 
 times disease of the intestines will cause peritonitis; and the disease 
 may also result from an inflammation in the female genital organs, 
 which so often occurs from iniprudence during menstruation ; from 
 attempts at abortion ; and from the various affections of the female 
 genital organs. Acute peritonitis may also result from direct 
 injury to the abdomen, such as a blow, or the kick of a horse. In 
 a few cases there appears to be no cause for the disease, which is 
 apparently spontaneous. 
 
CHRONIC PERITONITIS. 
 
 229 
 
 It is necessary for the non-professional observer to remember 
 tV . several other affections present symptoms more or less resem- 
 bling those of peritonitis. The most frequent of these is colic, in 
 which, however, the prostration of the patient is far less severe. 
 
 In some cases the inflammation remains confined to a portion 
 of the peritoneum, in which case the disease is, of course, less 
 severe. The pain and tenderness are confined to a limited part of 
 the abdomen. The prostration of ^he patient is less marked. 
 
 Treatment. — The most important agent in the treatment of 
 this disease is opium. As the patient usually vomits, the drug 
 must be given either by injection into the rectum or by insertion 
 under the skin. The patient can usually endure, without danger, 
 an amount of opium which could not safely be administered to a 
 healthy person ; thus half a grain to a grain of opium can be given 
 every three or four hours, according to the severity of the pain; 
 the general plan is to administer the drug until the pain is subdued. 
 Hot applications should also be made to the abdomen ; these may 
 consist of light mustard poultices, or of cloths wrung out in hot 
 water ; the latter may be sprinkled with turpentine. It should be 
 remembered that the bowels must not be disturbed during peri- 
 tonitis ; even though the patient have no evacuation for several 
 days or a week, it is advisable to avoid the use of cathartics. 
 Whenever it becomes necessary to secure a passage of the bowels, 
 this may be done by a rectal injection of hot water. 
 
 These constitute the measures which are applicable to all cases 
 of peritonitis. In many individual instances it is desirable to 
 employ other remedies also, which must be determined for each 
 particular case. 
 
 Chronic Peritonitis. 
 
 This disease may occur as a sequel to an acute attack of peri- 
 tonitis, but is more commonly due to some constitutional cause. 
 Thus it is especially frequent in tuberculous individuals, and may 
 also occur in those suffering from cancer. In these cases the 
 disease is very insidious, and may exist for a considerable time 
 before its true nature is suspected. 
 
 '\m 
 
230 
 
 DISEASES OF THE INTESTINES. 
 
 Symptoms. — These consist of pain and tenderness of the 
 abdomen, not so marked as in an acute attack, but often sufficient 
 to confine the individual to the bed. General debility and emacia- 
 tion, in some cases also fever, are observed; and there may occur 
 some effusion of liquid into the peritoneal cavity, so that a certain 
 amount of swelling or dropsy is apparent. 
 
 The disease always terminates fatally; that is, the general con- 
 dition — of tuberculosis or of cancer — is one from which recovery 
 cannot occur. 
 
 Inflammation of the Bowels. 
 
 This name is often applied to the affection just described, peri- 
 tonitis ; but the latter is really and primarily an inflammation of 
 the membrane covering the bowels. Inflammation of the intestines 
 begins in the mucous membrane lining the bowels, and need not 
 extend to the peritoneum at all. 
 
 Sym,ptoms, — The symptoms resemble in many respects those 
 of peritonitis; there is pain, tenderness on pressure over the abdo- 
 men, nausea, vomiting and diarrhea. The latter symptom is an 
 almost invariable occurrence in inflammation of the bowels, but 
 exceptional in peritonitis, where constipation is the rule. The pain 
 is not so intense as in peritonitis, and the general prostration of the 
 patient is less marked. 
 
 The disease must be distinguished from several affections pre- 
 senting similar symptoms, prominent among which is typhoid 
 fever. The latter disease is, however, usually acompanied by far 
 more constitutional disturbance than is found in simple inflamma- 
 tion of the bowels. 
 
 This inflammation is in adults rarely a serious disease, the 
 patient recovering in most cases within two weeks. In children it 
 constitutes many of the cases of the dreaded "summer complaint," 
 and will be discussed under that head. 
 
 Treatm,ent. — The object of treatment is to secure rest of the 
 bowels, which can be best accomplished by opium. One of the 
 best forms for this purpose is Dover's powder, ten grains of which 
 may be administered every four hours, until six or eight powders 
 have been taken. 
 
INTESTINAL WORMS. 
 
 331 
 
 Intestinal Worms. 
 
 Like other animals, man harbors numerous smaller creatures 
 in various parts of his body. It seems to be a general law of 
 nature, that the larger and stronger organisms shall furnish suste- 
 nance to other beings less capable than themselves of maintaining 
 the struggle for existence with the inorganic world. These crea- 
 tures, which thus live at the expense and in the bodies of other 
 organisms, are termed, in general, /«r«j?V^j. The human animal 
 harbors a considerable variety of parasites, animal as well as vege- 
 table; and this is true of the healthy as well as of diseased 
 human beings. Every one of us, however healthy and however 
 cleanly, nourishes a considerable colony of vegetable parasites in 
 the mouth and alimentary canal; and many perfectly healthy in- 
 dividuals harbor, also, numerous animal parasites. Most of these 
 organisms are so minute as to be visible only with the aid of a 
 powerful microscope, and unless present in great numbers occasion 
 no symptoms of ill health. Even that object of popular dread, 
 the trichina, is found after death in the bodies of many individuals 
 who had never been suspected of harboring a dangerous parasite. 
 
 Many of the organisms which live in the human body, how- 
 ever, are of large size, so as to be plainly visible to the naked eye. 
 Among these are several varieties of worms which find the most 
 favorable conditions for their existence in the human intestine. 
 Those of most frequent occurrence are the round worm (Ascaris 
 Luinbricoides), the thread worm {Ascaris Vcrmicularis), the various 
 species of tape worm ( Tcenid) and the trichina spiralis. 
 
 The round worm is familiar to every mother of a large family. 
 It resembles in appearance the common earth-worm, though it is 
 usually of larger size. The body is round, tapers toward either ex- 
 tremity, and is of a yellowish white color. It varies in length from 
 six to twelve or fourteen inches. 
 
 This worm is quite rare during infancy, being most frequently 
 found between the ages of four and twelve years ; yet it may also 
 inhabit the intestines of adults. Numbers of these worms are 
 usually found in the same individual, sometimes coiled together 
 in balls of considerable size. They are frequently passed from the 
 bowels with the evacuations, and sometimes though less frequently 
 pass upward into the stomach and even into the mouth. They are 
 
 i It 
 
 m 
 
232 
 
 DISEASES OF THE INTESTINES. 
 
 occasionally found in matter which has been ejected from the 
 stomach by vomiting. 
 
 These worms are generally supposed to be found in the intes- 
 tines of poorly nourished individuals, though this is by no means 
 the invariable rule. They are sometimes observed in the stools of 
 perfectly healthy individuals, who present no symptoms of any 
 difiiculty of the bowels or other organs. It seems, therefore, 
 probable that these worms are not generally detrimental to health, 
 or at least that their presence is the result rather than the cause of 
 the ill health of those who happen to harbor them. It may be said 
 of most of the intestinal worms that they are not known to oc- 
 casion serious illness. 
 
 The round worm grows from eggs which are laid by the parent 
 worm in the intestine, and escape with the stools ; these probably 
 enter the body of another individual with the drinking water. 
 Having once found access to the intestine the eggs develop into 
 mature worms. 
 
 Various symptoms are supposed to indicate the presence of 
 these worms in the intestine ; among these are swelling of the 
 abdomen and colicky pains over the bowels ; impairment of the 
 appetite, unusual flow of saliva, an offensive odor of the breath, 
 itching about the nose, and especially grinding of the teeth during 
 sleep. All of these symptoms may, however, be present in cases 
 in which no worms can be found ; but in such cases it is advisable 
 to administer a cathartic, and to observe the stool as to the presence 
 of these worms. 
 
 Treatment, — The expulsion of round worms from the intes- 
 tine is usually an easy matter. A full dose of some cathartic, such 
 as the citrate of magnesia, may be administered, and after it has 
 acted, the following prescription may be given : 
 
 Santonin, _ . - _ Twenty grains. 
 
 Divide into ten pills, and take one morning and night. This dose 
 will suffice for a young adult ; for a child it should be reduced ; or, 
 instead of this there may be given a teaspoonful of the fluid extract 
 of senna and spigelia, which may be taken before breakfast on an 
 empty stomach. For children the latter prescription will usually 
 be the better, because safer, since santonin has been known to pro- 
 duce serious prostration and nervous exhaustion in young indi- 
 viduals. 
 
THREAD WORMS. 
 
 233 
 
 Since these worms are probably taken into the stomach with 
 the drinking water, it becomes desirable to exercise some care in 
 avoiding a recurrence of the trouble. To do this the child should 
 not be permitted to drink water from shallow wells or from muddy 
 streams, especially from such as are found in the immediate neigh- 
 borhood of dwellings. 
 
 Thread Worms. 
 
 These worms, also called pin worms, or seat worms, are found 
 chiefly in the lower part of the bowel, especially in the rectum. 
 They are much smaller than the round worm, varying from y^\.o y^ 
 an inch in length. They, like the round worms, are often found in 
 masses of considerable size. They occur chiefly in young children, 
 though occasionally found in adults. 
 
 These worms usually indicate their presence by itching around 
 the fundament, sometimes accompanied by pain. The patient often 
 feels a great inclination to strain at stool, and may experience the 
 same sensation upon passing water. In females the worms some- 
 times escape from the rectum into the vagina, and occasion 
 itching and unpleasant sensations in this organ also. At times the 
 worms leave the body, especially at night, and may be found on 
 the bed-clothes or on the skin of the buttocks. It is believed, and, 
 doubtless correctly, that the irritation caused by these worms may 
 occasion unnatural excitement of the sexual organs, and perhaps 
 lead to unnatural habits of gratification ; at any rate, leucorrhoea 
 may be caused by the presence of these parasites in the vagina. 
 
 If there be any doubt as to the presence of these worms in the 
 intestine, the question can be decided by inspection of the stools, 
 as well as of the skin of the fundament. They can usually be dis- 
 covered without difficulty. 
 
 Treatment, — The worms can usually be destroyed and ex- 
 pelled from the bowels by simple injections of salt water, while the 
 irritation of the parts may be soothed by applying vaseline, or by 
 the injection or an ounce or two of sweet oil. If the injection 
 into the rectum fail to accomplish the purpose, one of the prescrip- 
 tions already mentioned for round worm may be employed, or a 
 teaspoonful or two of turpentine may be given in a cup of milk an 
 
 , i i 
 
■T^ 
 
 ri 
 
 
 
 
 II 
 
 : S 
 
 
 ! 
 
 riii 
 
 1 
 
 
 ,I:J 
 
 234 
 
 DISEASES OF THK INTESTINES. 
 
 hour after breakfast. In any case an occasional laxative, such as 
 castor oil or the citrate of magnesia, may be given every second or 
 third day. In most cases it will be found necessary to persevere in 
 the use of injections or medicines, or both, for one or two weeks, 
 in order to expel all the worms, otherwise even though several days 
 elapse without any of the worms appearing, there may nevertheless 
 still be some remaining in the bowel, in which case they will subse- 
 quently reappear in numbers as great as before. 
 
 Tape Worms. 
 
 Several species of tape worm arc known to inhabit the human 
 body, as well as those of other warm blooded animals. The life 
 history of these parasites is a peculiar one, and quite dififerent from 
 the ordinary course of events in the development of the animals 
 familiar to us. These animals usually attain their mature form 
 only after passing through and residing in another animal from 
 the one in which they attain their full development. To illus- 
 trate: There is a tapeworm which inhabits the bodies of dogs ; the 
 eggs of this worm are expelled from the dog's intestine, and become 
 scattered around upon the surface of the ground. Those eggs find 
 their way into the stomachs of sheep, for instance, being swallowed 
 with the grass ; arrived in the body of the sheep the eggs develop 
 into an immature worm, surrounded by a little sac CDntaining 
 liquid, at which stage the tape worm is called a cysticercus, and is 
 located in various organs of the sheep's body, — brain, liver, etc. 
 In the sheep the worm undergoes no further development, but 
 when the flesh of the animal is devoured by the dog the imperfectly 
 developed worm — the cysticercus — develops in the stomach and 
 intestines of the latter animal into its mature form, and becomes a 
 tape worm. So, too, the commonest tape worm found in the human 
 subject — the tcenia solium — has a similar life history. Its eggs 
 are discharged from the human intestine, and enter the stomach of 
 certain animals, especially sheep and hogs, where the egg undergoes 
 partial development, and becomes a cysticercus. These immature 
 worms are found scatter-^id through the body of the animal ; when 
 present in large numbers they give the flesh that peculiar speckled 
 appearance which is familiar to us under the name of " measly 
 
TAPE WORMS. 
 
 235 
 
 pork." If this flesh be eaten raw or partially cooked, these imma- 
 ture worms undergo development in the human stomach or intes- 
 tines, and become full-fledged tape worms. Thorough cooking 
 (listroys the cysticcrci, so that no development into worms occurs. 
 It is a familiar fact that butchers and cooks are especially prone to 
 t.ipe worms, a fact which is explained by their habit of eating raw 
 or partly cooked meat. In the same way tape worms are doubtless 
 often acquired by children who are fed upon raw meat or slightly 
 cooked broths — a practice which has become quite ct)mmon in the 
 treatment of the summer diarrhea of infants. It is said that in 
 Abyssinia, where the practice of eating uncooked meat is general, 
 almost every individual harbors at least one tape worm. 
 
 The solitary tape worm — tienia solium — so called because in 
 most cases but one worm is found in the same individual, is a 
 ribbon-like animal, composed of numerous joints, each of which is 
 provided with male and female organs of generation. The worm 
 varies in length from two or three to forty feet, consisting of from 
 500 to 1 ,000 joints. The end of the worm near the head is quite 
 slender, the body becoming gradually larger toward the other ex- 
 tremity, the largest joints being half an inch or more in breadth. 
 The head is small and provided with four suckers, and often with a 
 row of hooks, ten or fifteen in number, surrounding the suckers. 
 The joints composing the tail of the animal are often thrown ofi" 
 and escape from the bowel in the stools. In these joints are found 
 enornums numbers of eggs, the number contained in the entire 
 t.ipe worm being estimated at from five to ten millions. 
 
 Sfiniptonii*. — There are no signs by which the existence of a 
 tape worm can be positively asserted. Numerous symptoms are 
 supposed to indicate the presence of the animal — dizziness, ringing 
 in the ears, impairment of vision, flow of saliva, itching about the 
 nose, impairment of appetite and digestion, colicky pains in the 
 ' metj and general emaciation. These, however, may all exist 
 liom other causes in cases where no tape worm is present ; while 
 on tf e other hand the worm may be discovered in individuals who 
 con, der themselves perfectly well. The bad effects caused by 
 these worms have doubtless been much exaggerated by the popular 
 liorror at the idea of the existence of such animals in the human 
 body. When patient is once aware of the existence of such a 
 worm in his body, he is apt to refer all unusual symptoms of what- 
 ever nature to the presence of the animal. 
 16 
 
 

 i 
 
 236 
 
 DISEASES OF THE INTESTINES. 
 
 The only positive proof of the existence of a tape worm is the 
 passage of some of its joints from the intestine. If the worm have 
 attained considerable size, such fragments are passed daily, or at 
 least at short intervals. If careful examination for several days 
 fails to reveal any of these joints, a cathartic may be given, which 
 generally results in the detachment of several pieces. A negative 
 result may satisfy the physician that there is no worm present ; but 
 the patient is apt to remain fully convinced that there is a tape 
 worm in his bowel. Not infrequently such an individual retains 
 this conviction in spite of all argument and proof to the contrary ; 
 he may, indeed, acquire an insane delusion in regard to the matter. 
 These are, indeed, the most troublesome to treat — not those who 
 have, but those who have not a tape worm, though fully convinced 
 to the contrary. 
 
 Treatment, — One of the commonest, and certainly a very 
 efficient, means for expelling the worm is turpentine. This is given 
 in quantities varying from one to two tabi^^poonfuls for adults, 
 usually mixed with the same quantity of castor oil, and taken float- 
 ing on milk. This dose may be repeated every second or third 
 day, until the fragments of the worm cease to appear. The objec- 
 tion to the use of turpentine is that it s.- metimes causes difficulty 
 in passing water, and it may induce a state of intoxication in some 
 cases. 
 
 Another popular remedy is the oil of male fern. This may 
 be given in doses of one or two teaspoonfuls, either in mucilage or 
 in gelatine capsules. Two hours after this dose the patient may 
 take a teaspoonful of turpentine in a tablespoonful of castor oil. A 
 still more familiar remedy is made of pumpkin seeds. Two ounces 
 of the seeds are pounded in a mortar with six ounces of water, 
 the mixture then being strained. Half of this may be taken in the 
 morning and half in the evening. It will probably be necessary to 
 repeat this treatment for several successive days. 
 
 Several other remedies have been proposed and successfully 
 used for the expulsion of tape worms. Among these is kousso and 
 the bark of pomegranate root ; and common salt has been some- 
 times found efficient in cases where other remedies had failed. Half 
 an ounce to an ounce of salt taken in gruel before breakfast every 
 morning for several days may b^: tried, if other mea^-, are found 
 inefficient. 
 
■I 
 
 TRICHINA SPIRALIS. 
 
 237 
 
 Whatever remedy may be selected, it is important thi.t certain 
 preparatory treatment should be adopted before the worm remedy 
 itself is given. This treatment consists in abstinence from food for 
 several hours, or a day ; or the patient may employ light diet, such 
 as broth and milk, for two or three days previous to the use of the 
 remedy. It is supposed that by thus withholding food the worm is 
 weakened, since its nourishment is derived from the matters which 
 pass along the mtestine, and not from the wall of the intestine 
 itself. After one or two days of this treatment the worm remedy 
 maybe given, and followed in three or four hours by a purgative 
 dose of castor oil. If the first dose be unsuccessful, the plan may 
 be repeated, after an interval of two or three days. Complete suc- 
 cess is Indicated by the appearance of the worm's head in the stools. 
 Yet it should be remembered that ii" the greater part of the body 
 be expelled — as may be inferred from the passage of successively 
 smaller joints — the animal will probably die, even though the head 
 may not have been expelled. Unless fragments are again observed 
 in the stools, it may be assumed that the treatment has been suc- 
 cessful. 
 
 The preventive treatment of tape worm is not less important 
 than the measures for the cure. These worms are taken into the 
 body with imperfectly cooked beef, mutton and pork. Preven- 
 tion, therefore, consists simply in eating only thoroughly-cooked 
 meat. It is also possible that the worms gain access to the 
 stomach with the drinking water. H^nce a certain amount of cau- 
 Uon in this regard is also to be recomni^ended. 
 
 Trichina Spiralis. 
 
 In 1832 it WIS discovered that the ilesh of human beings some- 
 times contains large numbers of microscopic worms, which are 
 found coiled np in the muscles of the body. This worm v/as 
 named, from its hair-like appearance, trichina, and from the spiral 
 coil in which it is usually found in the muscles, spiralis. In i860, 
 Zenker, of Dresden, observed a case in which it was shown for 1:he 
 ilrst time that these niinute worms were capable of causing a fatal 
 illness. A girl died after an illness lasting several weeks, during 
 which she had suffered from fever, prostration, sleeplessness, great 
 pain and tenderness in the abdomen and limbs. It was found that 
 
238 
 
 DISEASES OF THE INTESTINES. 
 
 i 
 
 vT 
 
 ■H 
 
 her flesh was swarming with trichinae, and that numerous worms 
 were present in the intestines. Zenker was able to trace the source 
 of the disease to certain ham and sausages, after eating which the 
 girl had been taken ill. It was found, on microscopic examination, 
 that the ham and sausages contained numerous living trichinae. 
 
 Since that time numerous cases have been observed in which 
 a similar disease has been traced directly to the consumption of 
 pork — commonly as uncooked ham or sausage — in which trichinae 
 have been detected. In one instance a large party, partaking of 
 a festival dinner during a celebration, consumed among other 
 things some raw sausage. Among one hundred and three persons 
 at the table, nearly all were attacked by the disease, and a consid- 
 erable number died. On microscopic examination it was found 
 that these sausages, and the pork from which they had been made, 
 contained numerous trichinae, and the same worms were discovered 
 also in the muscles of those who had died of the disease. In our 
 own country cases of this malady — trichinosis — have been fre- 
 quently reported, many of them ending fatally. The trichina 
 obtains entrance to the human body through the consumption of 
 pork. The original source of the worm is not as yet definitely 
 known, but it seems that the rat is the natural host of the parasite, 
 and that the worm enters the body of those hogs which devour 
 infected rats. However that may be, the fact remains that a con- 
 siderable percentage of American hogs are infested with the 
 trichina ; the exact percentage has varied somewhat in different 
 examinations, according to the source of the pork and the care of 
 the examiner. Examinations of many hundred hogs shipped to 
 the Chicago market have shown that from two to eight hogs in 
 every hundred contain trichinae. The presence of the worm in the 
 hog does not necessarily occasion any symptoms which attract 
 attention to the animal's condition ; in fact, it has been found that 
 many hogs whose bodies contain a large number of the worms, 
 are in perfect health up to the time of being slaughtered. The 
 condition which gives to pork the appearance known as " measly" 
 is not due to trichinae, as is commonly supposed, but to tlie eggs 
 of a tape worm. One who is familiar with the appearance of 
 trichinous meat can often detect the presence of the parasites when 
 they occur in large numbers, for in this case, especially after they 
 have been contained in the animal a considerable time, numerous 
 white specks, like grains of fine sand, can be observed scattered 
 
 |i 
 
TRICHINA SPIRALIS. 
 
 239 
 
 
 through the meat. Yet the absence of these specks does not 
 prove that there are no trichinae present, since the white specks are 
 really due, not to the worm itself, but to .little masses of matter 
 which collect around the worm as it is coiled up in the muscles. 
 When flesh containing the worm is taken into the stomach of a 
 human being, the little sac containing the worm is dissolved, and 
 the animal is set free in 'the juices of the stomach and intestines. 
 Here they undergo a rapid development ; so long as they remain 
 coiled up in the muscles they are immature and sexless creatures, 
 of comparatively simple structure ; but when they arrive in the 
 human stomach and intestine they grow rapidly, acquire sexual 
 organs, and within eight or ten days the now fully developed female 
 worms contain hundreds of living young. These microscopic 
 worms escape from the body of the parent into the alimentary 
 canal, and pass soon afterwards out from the intestine into the 
 muscles of the human body. Having thus migrated all over the 
 body, they coil themselves up in the muscle, and remain an indefi- 
 nite period — even twenty years — without undergoing any further 
 change : in fact, they are capable of no development until taken 
 into the stomach of another animal. It is the irritation caused by 
 the passage of these worms from the intestines to different parts 
 of the body, it is the irritation and fever attendant upon it, which 
 constitutes the disease known as trichinosis. So soon as the adult 
 worms in the intestine have ceased to propagate, and so soon as 
 the young produced have escaped from the intestine, the fever 
 ceases, and the individual begins to convalesce. 
 
 The number of worms contained in the human body is some- 
 times enormous ; this can be readily understood when we consider 
 the rapidity of propagation. For the trichinae may exist in the 
 infected pork in large numbers ; as rr yy as 200,000 having been 
 estimated to occur in a cubic inch of tne meat ; now, when it is 
 remembered that many cubic inches of infected meat may be 
 devoured at a meal, and that each female worm may produce from 
 600 to 1 ,000 young within ten days, it may readily be believed that the 
 entire number of young produced and coiled up in different parts of 
 the human body may amount to 30,000,000 or 50,000,000, Such 
 at least seems to be the case in many instances, yet it is important 
 for us to remember that the number of worms taken into the stom- 
 ach varies according to the amount of flesh eaten, as well as to the 
 number contained in every cubic inch of the infected meat ; that 
 
 ,v, ,■ 
 
240 
 
 DISEASES OF THE INTESTINES. 
 
 "■mi 
 
 m 
 
 iJili! 
 
 the amount of meat eaten at a meal varies considerably in different 
 persons and at different times is familiar. Hence it sometimes hap- 
 pens, that of two individuals who consume trichinous flesh at the 
 same time, one will be taken seriously ill, while the other will escape 
 with slight symptoms, or even entirely. In the same way the effects 
 vary according to the number of worms contained in the infected 
 pork. In some instances as many as 200,000 trichinae have been 
 found in a cubic inch, while at other times only ten or twenty worms 
 were contained in the same quantity. It is evident that the con- 
 sumption of pork containing only a few worms would be followed 
 by less serious effects than by that of meat which was crowded with 
 the worms. Hence the severity of trichinosis varies extremely, all 
 degrees of illness being caused, from a slight indisposition to death 
 itself. 
 
 Yet it must not be supposed that the consumption of trichin- 
 ous meat necessarily causes the symptoms of trichinosis ; there is 
 nothing poisonous about the worm itself, the damage which it 
 inflicts being due simply to the irritation caused by its burrowing 
 through the flesh. Hence if only a few worms — say one or two 
 thousand — are produced in the intestine, there may be no symp- 
 toms whatsoever to indicate disease, and the individual may there- 
 fore never suspect that his flesh contains trichinae. Doubtless 
 many of us carry a considerable assortment of these worms in our 
 flesh ; at any rate, it has been found that over two percent, of indi- 
 viduals dying in certain large European hospitals, contained some 
 trichinae ; and that, too, without regard to the cause of death, there 
 being no suspicion in any case that the individual had ever had the 
 disease. 
 
 After the young worms which have thus migrated from the 
 intestine become coiled up in the muscles they cease to cause any 
 symptoms of illness, and remain for an indefinite time, even many 
 years, without undergoing any development. For it will be remem- 
 bered that these worms can develop only when taken into the stom- 
 ach of another animal. So long, therefore, as they remain in the 
 muscles of the first animal, they retain their immature sexless con- 
 dition, and do not propagate. Having, therefore, recovered from 
 the early effects of eating the infected pork the individual is safe 
 from any further sickness from this cause, unless, indeed, he de- 
 vours infected pork a second time. 
 
 Symptoms, — For the first few days after the infected pork is 
 eaten the individual manifests no symptoms of disease. It is only 
 
TRICHINA SPIRALIS. 
 
 241 
 
 when the young worms are born and begin to pierce the walls of 
 the intestine on their way to the muscles that the evidences of dis- 
 ease become manifest; this begins from six to ten days after the 
 meat has been taken into the stomach. The first symptoms consist 
 of pain in the abdomen, diarrhea and vomiting, accompanied by 
 threat constitutional disturbance. The general condition is one of 
 nervous exhaustion, very much resembling typhoid fever, for which 
 disease trichinosis is doubtless often mistaken. So soon as the 
 young worms begin to find their way into and through the muscles, 
 symptoms occur which indicate a disturbance in the muscles ; these 
 symptoms consist of acute pains in the limbs and in the back, usu- 
 ally aggravated by motion — a condition which the patient regards 
 as rheumatism. In some cases several of the muscles will remain 
 in a state of contraction, that is, the leg will be bent at the knee, or 
 the arm at the elbow, for instance, any attempt to straighten these 
 limbs causing severe pain. There usually occurs during the second 
 or third week considerable swelling of the face, and perhaps of the 
 skin generally. This is a symptom which should arouse suspicion 
 of trichinosis in a patient who otherwise has the symptoms of ty- 
 phoid fever. 
 
 Treatment, ~^ln most cases of trichinosis the cause of the dis- 
 ease is not suspected until ten days or two weeks after the pork has 
 been eaten. Exceptions to this rule occur only in cases where a 
 considerable number of healthy people are suddenly taken ill with 
 the same symptoms after eating at a common table — an instance of 
 which occurred in Prussia, where three hundred people became ill 
 within a few days from eating a certain lot of sausages. In those 
 cases where there is no suspicion of the true source of the disease 
 until the pain in the muscles and swelling of the skin occur — usually 
 twelve or fourteen days after the flesh has been eaten — nothing can 
 be done except to support the strength of the patient; for the young 
 worms are now swarming through his body, and cannot be destroyed 
 by any agency without injuring the patient himself. In these cases 
 it remains simply to support the patient's strength by nutritious 
 food combined with alcoholic stimulants — the quantity of the latter 
 varying with the amount of nervous prostration. The pain may 
 also be so severe as to require the use of an opiate. 
 
 If the nature of the difficulty be suspected within a very few 
 days after the consumption of the pork — that is, before the young 
 worms have begun to leave the intestines — it is advisable to admin- 
 
242 
 
 DISEASES OF THE INTESTINES. 
 
 VUl 
 
 ister brisk cathartics, with the hope of carrying the worms out of 
 the alimentary canal. Some have advised the administration of 
 carbolic acid, or the hyposulphite of sodium, with the hope of 
 destroying the worms in the intestines. As to this mode of treat- 
 ment, it can only be said that while these agents are certainly 
 capable, in sufficient strength, of destroying the worms, yet it is 
 very doubtful whether they ever have that effect in the alimentary 
 canal, since we are compelled to administer them in weak solutions 
 in order not to damage the intestine itself. In short, it must be 
 said that we know absolutely no treatment which can be relied upon 
 either to destroy the worms or to prevent them from burrowing into 
 the muscles ; all we can hope to do is to assist the patient in tiding 
 over the attack. 
 
 Yet, while the treatment is thus unsatisfactory, the prevention 
 of the disease is extremely simple. It consists merely in avoiding 
 all pork, in whatever form, which has not been thoroughly cooked. 
 Smoking, salting and pickling do not destroy the trichinae contained 
 in hog's flesh, so that hams and sausages are quite capable of com- 
 municating the disease ; in fact, most of the cases observed have 
 resulted from eating raw sausages and uncooked ham. 
 
 Guinea Worm. 
 
 1:1! 
 
 11 
 
 ■ 'i 
 
 This parasite is found only in tropical regions, especially on the 
 western coast of Africa. It finds its way into the skin of the feet 
 and legs of individuals who walk barefoot over swampy ground and 
 in shallow streams. A small vesicle forms on the foot or leg, and 
 finally bursts, giving exit to a number of small worms ; these are 
 the young brood, the mother remaining in the tissue just under the 
 skin. This adult worm is from six inches to five or six feet long, 
 and a twelfth of an inch broad ; it is said that the natives remove 
 the worm by seizing the end of it and winding it round a stick, 
 windlass fashion; or a little weight is attached to the worm, which 
 is thus gradually drawn out of the skin. The disease is a long, 
 tedious and painful one, tho^jh fortunately rare outside of the 
 tropics. 
 
FILARIA SANGUINIS HOMINIS. 
 
 243 
 
 Filaria Sanguinis Hominis. 
 
 This name, which means the thread-like worm of the human 
 blood, is found, as the name indicates, in the blood of man. It is 
 a microscopic animal about i^^ of an inch long, and therefore 
 invisible to the naked eye. This parasite, like the guinea worm 
 and so many other animal and vegetable parasites, is found in 
 tropical countries chiefly ; it has been observed in India, China 
 and Australia. These minute worms float in the blood, sometimes 
 in enormous numbers; in a case which the writer saw, there were 
 on the average 1 00 of these worms in every drop of blood, which 
 would therefore indicate about 50,000,000 in the entire body. 
 
 Another peculiarity of this worm — one which remains as yet 
 entirely unexplained — is the fact that they are visible in the blood 
 only at night, disappearing entirely during the day. In the case 
 above referred to, this fact was abundantly established by observa- 
 tions made night and day during a period of three months. The 
 blood was examined with a microscope every three hours day and 
 night, and it was found that while no worms could be discovered 
 from 8 or 9 o'clock in the morning until 5 or 6 in the afternoon, yet 
 at this hour they began to appear, and by midnight were very 
 abundant. Toward morning they decreased again in number, and 
 by. 8 or 9 o'clock had entirely disappeared. These worms in the 
 blood are in an immature, embryonic condition, like the trichiiiie 
 in the muscles. The fully developed worms are between two and 
 three inches in length, as large around as fine thread; these appear 
 to live in the water of shallow pools and streams. 
 
 The individual whose blood contains these worms may for a 
 considerable time present no symptoms of disease ; sooner or later, 
 however, the urine becomes milky in appearance, and the patient 
 often has considerable difficulty in passing water. In many cases 
 there ultimately occur numerous abscesses in various parts of the 
 body, and the condition known as pyaemia, or blood poisoning, 
 which usually results fatally, is induced. 
 
 The existence of this parasite was discovered but a few years 
 ago, and as yet but few opportunities have been offered for study- 
 ing it and its effects upon the human body ; as yet no means have 
 been found for destroying the parasite within the body. 
 
 The only cases of this disease which have been observed 
 
 I' A. 
 
244 
 
 DISEASES OF THE INTESTINES. 
 
 in Europe or America occurred in individuals who had recently 
 arrived from tropical climates and who had contracted the disease 
 in these climates. 
 
 Dropsy. 
 
 !i 
 
 hi! 15) 
 
 Dropsy is not a disease but a symptom; but as it is a symptom 
 of very many diseases it may be as well to discuss it as a separate 
 topic. 
 
 By dropsy is understood the presence of the watery elements 
 of the blood in portions of the body where they are not usually 
 found. There are various parts of the body where this fluid may 
 collect in considerable quantity; these are, i. The loose connective 
 tissue situated under the skin; when the meshes of this tissue become 
 filled with watery liquid the skin presents a white, puffed appear- 
 ance, the foot and leg, perhaps also the body and arms, being 
 swollen. This general dropsy of the tissue under the skin is called 
 anasarca. 2. Another locality where the watery part of the blood 
 often collects is the cavity of the abdomen. In this case the fluid 
 collects between the abdominal wall and the intestine, and the 
 dropsy is called ascites. 3. The water may also collect in the chest, 
 between the lung and the ribs; in this case the dropsy is called 
 hydrothorax. 4. The fluid may also collect between the brain and 
 the skull, the dropsy then being called hydrocephalus, water on 
 the brain. 5. The water may collect in a tumor of the ovary, and 
 is then called ovarian dropsy. There are also various smaller 
 cavities in the body where the watery elements of the blood may 
 accumulate so as to constitute a local dropsy ; such is hydrocele, 
 dropsy of the testicle. 
 
 Causes, — Dropsy, whether general or local, is the result of 
 either, i. interference in the circulation of the blood ; or 2, of im- 
 poverishment oi the blcod ; or 3, of certain inflammations of the 
 kidneys. Dropsy often occurs in the advanced stages of many 
 wasting diseases, such as consumption; in this case it is probable 
 that the dropsy is due to the first of the above named causes — /«> 
 terference in the circulation of the blood, from the weakness of tht 
 heart which accompanies the general failure of the patient's strength. 
 The swelling which often occurs around a local inflammation, such 
 as a felon or an erysipelas, is not properly called dropsy. 
 
DROPSY. 
 
 245 
 
 General dropsy — anasarca — may be due to any one of several 
 causes. One of the most common of these is heart disease, as a 
 result of which there is an impediment in the circulation of the 
 blood. It follows, therefore, that the blood will collect in some 
 parts of the body, most naturally at the lower parts, — the feet and 
 legs — because the heart is not strong enough to force the blood up 
 again from the feet into the trunk. The result of this accumulation 
 i)f blood in the feet and legs is the escape of some of its watery 
 elements into the loose tissue under the skin — that is dropsy. This 
 dropsy begins at the feet and legs, and may for a considerable time 
 remain limited to these parts of the body ; but as the heart grows 
 gradually weaker, the circulation becomes more and more feeble, 
 and the dropsy correspondingly greater. Hence after a time the 
 swelling usually extends up the legs to the trunk and even to the 
 face and head. 
 
 Another form of dropsy results from disease of the kidney — 
 " Bright's disease. " In this case the dropsy usually begins in the 
 feet, gradually extending up the body as the disease progresses in 
 the kidney. Finally the face also becomes swollen and distorted. 
 
 An acute inflammation of the kidney may cause general dropsy 
 within a few days ; in this case the swelling often appears in the 
 face first, especially under the eyes ; but in a few hours or days 
 there may be a general puffiness of the skin throughout the body. 
 Such a dropsy will be readily recognized by the accompanying 
 symptoms, since there is almost invariably fever, pain in the back 
 and other evidences of constitutional disturbance. It is from this 
 cause that the dropsy originates which often occurs during the con- 
 valescence from scarlet fever. 
 
 These are the most frequent causes of general dropsy ; and an 
 individual who becomes the subject of such a dropsy, should at 
 once submit himself to medical examination, in order that the cause 
 may be discovered, and, if possible, be removed. There are in 
 addition numerous causes which occasionally induce general dropsy. 
 It has been already noticed that an impoverishment of the blood 
 results in anasarca (dropsy), examples of which are sometimes seen 
 in those who have long suffered from malarial fev .-, and in the 
 subjects of advanced consumption. So, too, any obstruction to the 
 circulation of blood may be followed by general dropsy. This 
 obstruction ma)- be not merely organic disease of the heart, already 
 mentioned, but also various tumors within the chest and abdomen 
 
 V 
 
 k'-.!, 
 
 
246 
 
 DISEASES OF THE INTESTINES. 
 
 may result in the same way by impeding the circulation. Several 
 diseases of the lungs also, whereby the flow of blood through these 
 organs is prevented, may result in more or less general dropsy. 
 
 Dropsy of the abdomen [ascites) is a frequent form of dropsy. 
 It occurs not only in connection with general dropsy, from the 
 causes which have been already enumerated, but may also exist 
 without any swelling in other parts of the body. In this case the 
 abdomen is swollen sometimes enormously, so that the skin of this 
 part of the body is tightly stretched, and the veins are often sharply 
 outlined as blue lines running near the surface. The most common 
 cause of ascites is disease of the liver, especially that form of liver 
 disease which is brought on by long indulgence in the use of alco- 
 holic beverages. It may, however, also result from disease oi 
 other organs in the abdomen, as well as from pressure of a tumor 
 on the large vein which leads from the liver, or from disease of the 
 vein — the portal vein — which collects the blood from the intes- 
 tines and carries it to the liver. Abdominal dropsy may also occur 
 from an ovarian tumor or even from a natural pregnancy, because 
 the tumor or the enlarged womb presses upon the veins ; yet in 
 pregnancy the dropsy is more apt to begin in the feet and to affect 
 the feet and legs rather than the abdomen. 
 
 Dropsy, whether it be general or confined to the abdomen, is 
 apt to result, sooner or later, in symptoms which seriously impair 
 the patient's comfort. Not only do the different members of the 
 body become unwieldy from the amount of water contained in 
 them, but the breathing also is apt to become impaired in conse- 
 quence of interference with the movements of the diaphragm. In 
 many cases of general dropsy, too, water accumulates in the chest, 
 still further interfering with the expansion of the lung. 
 
 The distension of the skin often causes serious difficulty when 
 the dropsy has existed for a long time. The skin becomes bluish, 
 and may finally break — an accident most frequent between the 
 knee and ankle. If the difficulty do not result in actual breaking 
 of the skin there may be, nevertheless, a diseased condition known 
 as eczema, or salt rheum ; in this state the skin becomes red and 
 rough, and there is transuded a watery fluid, which keeps the limb 
 constantly moist, and results in the formation of sores or ulcers. 
 Even before this stage arrives the patient is troubled by the most 
 intense itching of the skin, chiefly on the legs. Sometimes, too, 
 when the swelling has involved the body, the patient is annoyed 
 by a similar intense itching around the genital organs. 
 
 •I! 
 
DROPSY. 
 
 ■247 
 
 Treatment, — Since dropsy is merely a symptom and a 
 result of certain diseased conditions of the body, it is evident that 
 the treatment must be directed, not to the dropsy itself, but to the 
 cause. If the swelling result from the disease of the heart, it is 
 often possible, by the use of proper remedies, to strengthen the 
 heart's action and thus improve the circulation of the blood, so 
 that the dropsy may be much diminished or even entirely removed. 
 So, too, in certain cases of dropsy from disease of the kidneys, it 
 may be possible, at least, to improve the condition of the patient, 
 though these cases are less promising than some others. 
 
 To strengthen the action of the heart we commonly employ 
 digitalis, ten or fifteen drops of which may be given in water, 
 three or four times a day, as already directed in discussing the dis- 
 eases of the heart. To relieve the dropsy from disease of the 
 kidneys, it is usually necessary to give the patient tonics, whereby 
 the condition of the blood can be improved. In all cases, unless 
 the patient is quite weak, the dropsy may be diminished by the 
 use of certain purgatives which cause the watery part of the blood 
 to be passed into the intestines and evacuated in the shape of 
 watery stools. For this purpose the following prescription may be 
 given : 
 
 Jalap, ------ Forty grains. 
 
 Cream of tartar, - _ _ - Four ounces. 
 Give one-fourth of this every second day. 
 
 If the patient be much debilitated, these purgatives which 
 provoke large and watery stools cannot be well borae, and should 
 not be employed in quantities so large as indicated in the above 
 prescription. In these cases, however, it may be possible to reduce 
 the dropsy somewhat by giving the sweet spirits of nitre, one or 
 two teaspoonfuls twice a day. Another remedy which is usually 
 very successful in promoting the removal of water from the skin is 
 jahoratidi, or its active ingredient, pilocarpine. The objection to 
 its use consists in the exhaustion which is entailed by it. If, how- 
 ever, the patient's condition is such as to warrant its use, ten grains 
 of jaborandi may be given once a day ; in all these cases where 
 powerful drugs are used to diminish the dropsy, the patient's con- 
 dition should be carefully watched, since it is possible to do more 
 harm — even though the dropsy be diminished — by weakening the 
 patient, than good. 
 
 • J 
 
 i S«f 
 
 'M' Iff 
 
248 
 
 DISEASES OF THE INTESTINES. 
 
 
 Although these measures may succeed for a time in diminish- 
 ing the dropsy, or at least preventing its increase, yet unless it be 
 possible to remove the diseased condition upon which the dropsy 
 depends, the amount of water in the skin and consequent swelling 
 will gradually increase, in spite of all efforts to control it. Even 
 then it is often possible to secure temporary relief by the operation 
 of tapping, a measure which is especially useful in dropsy of the 
 abdomen or of the chest. Tapping consists in the introduction of 
 a tube through the wall of the abdomen or of the chest, whereby 
 the accumulated water is permitted to escape. It is a matter re- 
 quiring much care and skill, and should, of course, be performed 
 only by a competent physician. The relief afforded is often very 
 great ; the patient is no longer compelled to struggle for breath, 
 but becomes temporarily quite comfortable. In most cases the 
 dropsy returns again far more rapidly than was the case originally ; 
 in a few weeks or months the patient requires tapping again. 
 There is, of course, in this operation of tapping nothing which can 
 tend to cure the disease, nor even to arrest its progress. Yet the 
 relief obtained is so great that the operation is a boon to the 
 patient, as well as to his friends. In some cases, tapping is re- 
 peated a dozen or a score of times, each time with the effect of 
 improving the patient's condition, although he may ultimately suc- 
 cumb to the disease which causes the dropsy. 
 
 ¥ 
 
 1,1 
 
 Dropsy of the Chest 
 
 This may occur as the result of inflammation of the membrane 
 covering the lungs, as has been described under the subject ol pleurisy . 
 It may also occur as a part of general dropsy, especially when this 
 dropsy results from disease of the heart. Although the fluid itself 
 contained in the chest is not poisonous nor otherwise injurious, 
 yet its presence causes mechanically effects which may seriously 
 incommode the patient, The effect results from the mechanical 
 compression of the lung, whereby the breathing becomes labored. 
 Evidences of this are to be found in the hurried acts of breathing, 
 and in the sense of suffocation which occurs whenever the patient 
 lies down , he is often compelled to sleep in the sitting posture, or 
 with the head propped up by pillows. The face becomes swollen. 
 
 ;iji> 
 
i! 
 
 540.— A view of the course of the anterior 
 columns of the Spinal Marrow to their ter- 
 mination In the Hemisphericol Ganglia of 
 the Cerebium. 
 
 538.— A vertical section of the Corpus Calloaum thn.iigli 
 its midiilc. Tlie left internal side of the Cerebrum is also 
 shown. 
 
 a aaasb 
 
 633.-.\ view of the base of the Cerebrum and Cerebellum, together witi. -heir nerves 
 
 JiJ» 3 
 
 !i37.— A section of the Hoad to show the Falx 5h.._A view of the appearance of the convoliilitni»- 
 
 liif/. — A SeullUIl t'l lilt; in'im 1*7 BiMHY iin: i-niwv nii. . — A Vlt'W tM MIC ll|t|icniaim; v/i i,»i%^ *^"" • "■ 
 
 Miijor. Tentorium, and other parts found under the one side of the Cerebrum, a.s .Keen from above, 
 median line of the Head. 
 
 JBRi^IN. 
 
DROPSY OK THE BRAIN. 
 
 249 
 
 the lips and even the cheeks are livid. By the time that these 
 symptoms have supervened there is usually swelling of the feet and 
 legs. 
 
 The treatment is essentially that already recommended for the 
 management of general dropsy, though if the dropsy be confined 
 to the chest alone, it is much better to remove the liquid by tap- 
 ping than to torment the patient with cathartics. 
 
 Dropsy of the Brain. 
 
 This condition, also called " water on the brain," is a symptom 
 of an inflammation of the membrane covering the brain and lining 
 the skull. Fluid may collect therefore between the brain and 
 skull, in just the same way it collects in the chest from an 
 inflammation of the membranes in the chest, and as it collects 
 in the abdominal cavity as a result of the inflammation in this part 
 of the body. This inflammation maj' be induced by any one of 
 several causes, prominent among which are the various infectious 
 diseases. But perhaps the most frequent of those causes which 
 excite this inflammation is the condition known as scrofula. The 
 effect of this constitutional taint is the induction of tubercular 
 meningiti' jat is of an inflammation in the membrane of the brain 
 accompanied by the formation of tubercles, just as consumption 
 causes the formation of tubercles in the lungs. In fact this form of 
 dropsy occurs with especial frequency in the children of consump- 
 tive parents. 
 
 Syinptonis. — The symptoms which indicate dropsy of the 
 brain are usually preceded for months by a mild inflammation of 
 the membranes covering this organ. This inflammation is indicated 
 by impairment of health in the child; for the subject of the disease 
 is usually a child; he becomes dull and moody, constantly urcwsy, 
 but usually sleeping less soundly than before; he suffers from head- 
 ache and pains in the limbs; is apt to lay his head in his mother's 
 lap without uttering any special complaint to account for his unusual 
 depression of spirits; in many cases there will be sudden spells of 
 vomiting without any especial feeling of nausea, and not to be 
 accounted for by errors in diet. 
 
 17 
 
 
 i t'? Wn 
 
 U' 'I 
 
 ?**! 
 
i'i 
 
 'I ■; 
 
 
 250 
 
 DISEASES OF THE INTESTINES. 
 
 When the inflammation has lasted a considerable time the water 
 begins to collect around the brain, and additional symptoms 
 become manifest. These consist in impairment in various 
 muscles ; the child's gait becomes uncertain and peculiar ; he may 
 drag one foot after him, stumbles over slight obstacles, and perhaps 
 staggers while walking. Later, there may occur some impairment 
 in the movements of the face, the child displaying an inclination 
 to squint ; finally there occurs a paralysis of certain parts of the 
 body, stupor, delirium, convulsions, orother symptoms, which excite 
 attention and alarm the friends. A fatal result is apt to follow soon 
 after the manifestation of these symptoms. 
 
 In some cases the symptoms are confined to the brain and 
 muscles, as indicated in the foregoing paragraph ; at other limes 
 there is evident, also, some unnatural con .ion in the abdomen ; 
 the child 's belly becomes swollen and tender to the touch ; it may 
 also be bloated, though in the majority of instances the abdomen 
 is sunken : the bowels are usually constipated, though there may 
 be some diarrhea at intervals. 
 
 Dropsy of the brain from this cause usually ends fatally, espe- 
 cially if it be undetected until the more serious symptoms such as 
 paralysis and stupor occur. It not infrequently happens chat 
 several children of the same family die in succession during the 
 early years of life from this cause. 
 
 Treatment, — The only hope of escape from the usually 
 fatal result of this disease lies in the improvement of the general 
 health. This can be best accomplished by a change of residence 
 and of occupation, by the use of tonic remedies and nutritious 
 food. The medicines which will prove most useful are iron, quinine, 
 strychnine and cod liver oil, directions for administering which 
 have been already given in discussing plumonary consumption. 
 In addition, it may be well to give the iodide of potassium in doses 
 adapted to the age of the patient. Thus, a child of three years 
 may take two or three grains of this remedy three or four times a 
 day. The following prescription may be administered: 
 
 Mix 
 
 Iodide of potassium. 
 Tincture of nux vomica. 
 Syrup of tolu, 
 
 Water, . . . . 
 
 take a teaspoonful after meals. 
 
 One drachm and a half. 
 Two drachms. 
 An ounce and a half. 
 To make four ounces. 
 
 ! • '* 
 
 it' 
 
CHKONIC DKOI'SV OK THK BRAIN. 
 
 251 
 
 141 
 
 Chronic Dropsy of the Brain. 
 
 This consists in tlie gradual accumulation of watery fluid in the 
 cavities of the brain, and between the brain and the skull. This ac- 
 cumulation sometimes takes place to an enormous extent, so that 
 the child's head becomes excessively large, weighir>g more, appar- 
 ently, than the rest of his body. This process may begin before 
 the birth of the child. In this case, the enlargement of the head 
 may be so great as to render natural delivery impossible ; the 
 physician is compelled to puncture the head, and permit the water 
 to escape before the child can be delivered. In other cases the 
 enlargement is not so great as to prevent the birth of a living 
 child, though the head will usually be found increased in size, its 
 bones separated by broad channels, between which a soft fluctuat- 
 ing mass c:m be felt. Children whose heads have undergone this 
 change before birth rarely survive many months. 
 
 In the majority of cases which come under the physician's 
 notice, the dropsy of the brain, and the corresponding cnlarge- 
 m lit. vl the skull, begin during infancy or early childhood. In 
 faci, ^w. : process may continue for some time before attracting 
 the attention of the parent. It will be noticed that the child's 
 temper is changed for the worse ; that it becomes unusually 
 peevish, dull, and drowsy ; the child begins to walk unusually 
 late, or it may fail to walk at all. The mental faculties, too, 
 are not developed as in other children. The child is not so 
 bright, nor so apt to acquire the power of speech ; the utter- 
 ance is indistinct ; in the worst cases the child is idiotic. The 
 senses of sight and hearing are usually impaired; in some cases, 
 the eyes roll around aimlessly, or may e.xhibit a squint. As the 
 child becomes older, the symptions become more marked. What- 
 ever acquisitions the child may have made in the way of walking 
 or speaking are lost, though cases occur in which the mental remain 
 almost unimpared to the close of life. The digestive system becomes 
 deranged, vomiting being a frequent occurrence, while the bowels 
 are irregular. The head attains an enormous size, the bones being 
 pressed far apart ; the weight of the head is so great that the child 
 is unable to stand, or even sit erect, and must therefore retain the 
 recumbent posture. It is these cases of advanced dropsy of the 
 tirain which are exhibited now and then at cheap museums and 
 
 t 'si 
 
 / ' 9'- ' 
 
 ,f« 
 
 
 m 
 
 m 
 
 I m 
 
 i -iik 
 
252 
 
 DISEASES OF THE INTESTINES. 
 
 !M! 
 
 similar entertainments, where the child may pass a few weeks near 
 the close of its life, helpless and unconscious of its surroundings. 
 
 Treatment. — There is no known means by which this affec- 
 tion can be. cured, or even arrested. A few instances are, indeed, 
 on record in which children have recovered from the early stages of 
 the disease under treatment, but since the same treatment has been 
 found ineffectual in numerous other cases, it is evident that the good 
 result could be attributed not so much to the treatment as to the 
 inherent vitality of the child. 
 
 DISEASES OF THE LIVER. 
 
 The liver is in the popular mind the scapegoat upon which is 
 laid the responsibility for many of the ailments to which the body 
 is liable. " Liver complaints " and " biliousness" are the banners 
 with which any number of patent medicine vendors, " liver pad " 
 makers, electric belt manufacturers, etc., assail the pockets of the 
 credulous. The fact is, that in our climate affections of the liver 
 which occasion appreciable symptoms are comparatively rare, 
 except as complications of other complaints ; primary disease 
 of the liver itself, limited to the liver, is a by no means frequent 
 occurrence. 
 
 Among the most common affections involving the liver is the 
 catarrh of the stomach, small intestine and gall ducts, resulting in 
 the group of symptoms known as " biliousness. " The symptoms 
 of this affection vary according as the stomach is involved to a 
 greater or less degree ; there is usually vomiting of a greenish or 
 yellowish matter, constipation, pain in the head and over the 
 stomach, a bitter taste in the mouth, possibly a little yellowness of 
 the eyes or of the skin. Similar symptoms varying somewhat in 
 details maybe induced by 
 
 Acute Inflammation of the Liver. 
 
 This disease usually begins with shivering, perhaps with a 
 pronounced chill, followed by fever, nausea and vomiting; the 
 tongue is heavily coated, yellow or white ; the bowels are consti- 
 
 the livel 
 interval^ 
 the rigj] 
 throbbii 
 'ng couj 
 numbtr 
 In the.se i 
 and thus 
 
 Tr< 
 
 vented 
 can oftej 
 ^vithstanc 
 
ABSCESS OF THE LIVER. 
 
 253 
 
 pated ; the urine is scanty, but often of a deep brown color ; the 
 patient complains of a bitter taste in the mouth ; the matter vom- 
 ited is usually yellow or greenish yellow. There is usually consid- 
 erable pain over the liver, sometimes very sharp and increased by 
 coughing, by deep breathing, or by pressure upon the affected part. 
 There may be also jaundice and pain in the right shoulder, though 
 these symptoms are not always present. 
 
 Treatment. — The disease, if devoid of complications, usually 
 terminates in one or two weeks ; the only treatment necessary is 
 the employment of a light diet, and the use of some remedy which 
 may promote the escape of the bile. For this latter purpose the 
 most useful agent is blue mass, two grains of which may be given 
 as a pill at bed-time, to be followed in the morning by the usual 
 dose of citrate of magnesia ; or one-fourth of a grain of podophyl- 
 line may be taken morning and night for three days. If the fever 
 be high, warm baths will be both beneficial and agreeable. 
 
 In warm climates, inflammation of the liver is more common 
 than ar.iong us, and often results in the formation of an 
 
 
 m 
 
 
 Abscess of the Liver. 
 
 This may also be the termination of an acute inflammation 
 of the liver in this climate, though such cases are far less frequent 
 than in tropical countries. 
 
 Symptorna. — The formation of an abscess, suppuration^ in 
 the liver is indicated by a series of shiverings or chills at irregular 
 intervals, followed by fever and profuse perspiration. The pain in 
 the right side becomes sharper, and may be accompanied with a 
 throbbing sensation. There may also occur a short, dry but annoy- 
 ing cough. While these symptoms are usually present, a certain 
 numbtr of cases occur without manifesting themselves in this way. 
 In these cases the abscess may exist unsuspected until it breaks, 
 and thus gives evidence of its existence. 
 
 Trenttnent. — The formation of the .ibscess cannot be pre- 
 vented by any means at present known ; but after once formed, it 
 can oftentimes be emptied with safety to the patient. For, not- 
 withstanding the delicate nature of the structures which surround 
 
 I 'Amm 
 
254 
 
 DISEASES OF THE INTESTINES. 
 
 \m 
 
 it, it has been found possible to pass fine needles into the liver and 
 withdraw the matter. The same object has been attained by a 
 surgical operation. 
 
 If no surgical measures be employed, the abscess is often apt 
 to terminate in the death of the patient. This fatal result may 
 occur in one of two ways : the abscess may break into the abdom- 
 inal cavity, causing a general inflammation ; or, the patient may be 
 worn out by long-continued fever, vomiting and inability to digest 
 his food. 
 
 Chronic Inflammation of the Liver. 
 
 This affection sometimes results from an acute inflammation, 
 but is more commonly the result of other causes. 
 
 Sifrnptoms, — One of the chief symptoms is pain over the re- 
 gion of the liver, that is, over the lower ribs on the right side and 
 between the two sets of ribs in front. This pain is apt to be in- 
 creased by active exercise of any sort, even by running up stairs. 
 It is also aggravated by excesses in eating and drinking. Another 
 prominent symptom is a short dry cough, which is so characteristic 
 that it has received the name of " the liver cough. " In many cases 
 there is a distinct yellowish tinge of the skin and of the whites of 
 the eyes. The stools are usually of an unnatural light color, like 
 clay. The urine, on the other hand, is very dark, and usually de- 
 posits a heavy sediment. 
 
 Treatfnent. — The remedies which are used to act directly 
 upon the liver when in a state of chronic inflammation have not 
 been highly successful. The best results in the treatment of this 
 affection have been obtained by strict attention to all those details 
 which can improve the general health, including a judiciously se- 
 lected diet, and the selection of an employment which will busy 
 the individual largely in the open air. These measures are espe- 
 cially valuable for those who have been engaged in sedentary pur- 
 suits, and it is among such that the disease is especially frequent. 
 Among the remedies used are the following: 
 
 Nitro muriatic acid, - . A drachm and a half. 
 
 Water, . - . - Four ounces. 
 
 Mi.x. Take a teaspoonful in water before meals. 
 
 
GIN LIVER — CIRRHOSIS OK THE LIVER. 
 
 255 
 
 Bicarbonate of sodium, - Four drachms. 
 
 Calomel, - - - Twenty-four grains. 
 
 Make twelve powders. Take one morning and night. Or podo- 
 phylline may be given in doses of one-fourth of a grain morning 
 and night. 
 
 One form of chronic inflammation of the liver is especially 
 frequent and especially important. In this form the liver becomes 
 much harder than is natural, and gradually shrinks to but a fraction 
 of its former size. This affection is known as 
 
 m 
 
 ^ 
 
 ill 
 
 m 
 
 Gin LivG'r— (Cirrljosis of the Liver.) 
 
 From the fact that this condition often results from the abuse 
 of alcoholic liquors, this condition is known d^s gin liver. 
 
 SfftnptOins. — /\lthough this is a serious affection, which in 
 fact usually results fatally, yet no definite symptoms occur until the 
 abdomen begins to swell. This swelling is due simply to dropsy 
 in the abdominal cavity, and this dropsy results from the inflamma- 
 tion in the liver, whereby the blood which enters that organ from 
 the intestines is impeded and collects in the abdominal organs. In 
 a certain proportion of cases the swelling of the abdomen is fol- 
 lowed by a similar dropsical swelling in the feet and legs; yet this 
 is not an invariable symptom of the disease, and, indeed, does not 
 result directly from the affection of the liver, but usually from some 
 coincident disease of the heart or kidneys. 
 
 The symptoms which precede this dropsy of the abdomen are 
 not sufficiently definite to locate the source of the difficulty. There 
 may be an impairment of the appetite, a sense of fullness after 
 eating, perhaps vomiting, and sometimes an escape of blood from 
 the stomach or bowels ; yet even these symptoms may not appear 
 until after the abdominal dropsy has become manifest, iir some 
 cases a yellowness of the skin is noticed, though this is rattter the 
 exception than the rule. 
 
 Cause. — Although the disease may possibh be induced hv 
 other causes, yet, in the vast majority of instances, it is trace'tbie 
 to the abuse of liquors. By this abuse is understood m* nt ces- 
 sarily the habit of habitual intoxication, but also the constant 
 
 
!56 
 
 DISEASES OF THE INTESTINES. 
 
 indulgence, several times a day, in alcoholic beverages, as is so 
 frequently done at table in certain classes of society. There can 
 be no doubt that the habitual use of wines and liquors, as a part 
 of the daily bill of fare, is responsible for a considerable number 
 of fatal cases of this disease. 
 
 Treat fitent. — No means are known for arresting the progress 
 of this disease ; it is possible that its course sometimes stops 
 spontaneously. All that can be done is to put the system in the 
 best possible condition by diet, exercise, etc. If the impairment 
 of indigestion be a troublesome symptom, some improvement may 
 be obtained by the use of bitter tonics, such as a teaspoonful of 
 the infusion of the gentian, or a half teaspoonful of the compound 
 tincture of cinchona, half an hour before meals. If constipation be 
 troublesome, some of the ordinary saline laxatives may be employed 
 to advantage. 
 
 One of the results of the disease — the abdominal dropsy — 
 usually requires treatment ; this topic has been already discussed 
 under the head of dropsy. 
 
 [3 
 
 ■I'll 
 
 
 ml ^ . 
 
 Hydatid Tumors of the Liver. 
 
 These consists of sacs, which may vary in size from that of a 
 pea to the dimensions of a hen's egg, enclosing a clear watery fluid. 
 These cysts may occur either individually or collected in groups. 
 Microscopic examination of the contents of these sacs shows that 
 they contain tape worms in an embryo state. So long as the 
 animal remains thus imbedded in the different organs it undergoes 
 no development ; yet the fluid which surrounds it may become in- 
 creased in quantity to an enormous extent. 
 
 These worms remain in this embryonic condition an indefinite 
 time ; sometimes they retain their vitality, at other times they die. 
 In the latter case the sac usually collapses to some extent. 
 
 These sacs — the so-called hydatid cysts or tumors — may 
 occur in various organs of the body, but are found with especial 
 frequency in the liver. They may exist in different parts of this 
 organ, either near the surface or deeply placed in its tissues ; che 
 location is a matter of considerable influence in enabling us to 
 detect their existence. 
 
HYDATID TUMORS OK THE LIVER. 
 
 257 
 
 Symptomtt, — These cysts may exist for a considerable time 
 without causing any appreciable symptoms ; in fact, so long as the 
 tumors remain small and do not encroach upon neighboring organs, 
 tliere is no interference with the bodily functions which can attract 
 attention to these cysts. In fact a positive diagnosis is possible 
 only when the cyst has attained such size as to become perceptible 
 through the abdominal wall. Previous to this time there may be 
 certain indefinite symptoms which do not enable one to locate or 
 recognize the source of the difficulty ; thus pressure upon various 
 organs in the abdomen may cause pain, vomiting, constipation and 
 various other symptoms. If one or more of these cysts be located 
 near the surface, they usually attract atteution sooner or later by 
 causing a prominence at or below the margin of the ribs on the 
 right side. There are, it is true, several other tumors which may 
 appear in this location; and it would be out of our province to dis- 
 cuss the various means for distinguishing this variety from the 
 others. In some cases it becomes possible to detect a distinct sense 
 of fluctuation upon tapping the abdominal wall over the liver. If 
 it be impossible to determine otherwise the exact nature of the 
 tumor, decision can be attained by inserting a fine needle into the 
 cyst and withdrawing some of the contents. If it be a hydatid 
 tumor, there will be found in the fluid some of the booklets char- 
 acteristic of the worm. 
 
 A hydatid cyst of the liver is serious only because of its size 
 and of the danger which may result if it burst. For it sometimes 
 happens that the contents of the cyst will in consequence of some 
 excessive bodily exertion, or from other cause, be discharged from 
 the sac into some neighboring organ. The danger consequent upon 
 this rupture of the sac depends upon the course of its contents. If 
 these escape into the stomach or intestine, they may be expelled 
 by vomiting or at stool, and recovery may occur. If, however, the 
 contents of the sac escape into the abdominal cavity, or into the 
 chest, or into some large blood vessel, death may usually be ex- 
 pected in a short time. Such an accident may happen suddenly in 
 consequence of a blow or a fall ; and instances are known in which 
 death has resulted from this cause in cases where there had been no 
 suspicion during life of the existence of a hydatid cyst. 
 
 Treatment. — Comparatively few hydatid cysts of the liver 
 are recognized for treatment until they acquire very large size ; at 
 this period they usually require surgical treatment, either by ^a/>- 
 
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 258 
 
 DISEASES OF THE INTESTINES. 
 
 /««^, or by the injection of iodine or similar substances into them. 
 No remedies are known which have any decided influence, either 
 in arresting the growth of the cyst, or in destroying the contained 
 parasite. Instances are recorded in which the entire cyst and its 
 contents have been removed by a surgical operation. 
 
 In this country the disease is fortunately rare, and is probably 
 never found except in advanced years. At any rate, the growth 
 of these cysts is so slow, requiring many years for their develop- 
 ment to a size which can be appreciated, that they are not discov- 
 ered until the individual haS passed middle life. 
 
 Jaundice. 
 
 Jaundice, like dropsy, is a symptom, and not a disease. It 
 designates a yellow condition of the skin, which is also more or less 
 evident in various of the mucous membranes, particularly in the eye. 
 
 Cause, — This yellowness is due to the presence of the bile 
 or some of its constituents in the blood. The bile is formed in the 
 liver and should pass out through the gall duct into the intestine. 
 A failure on the part of the liver to form the bile, or the presence 
 of some obstruction in the gall duct, which prevents the escape of 
 bile into the intestine, is followed by the appearance of this yellow 
 coloring matter in the blood and the consequent yellowness of the 
 skin through which the blood circulates in large quantity. 
 
 The first of these causes, the failure of the liver to perform 
 its functions properly and secrete the bile, usually occurs during 
 some of the infectious diseases, or in consequence of a disease in 
 the liver itself. Thus some of the diseases which follow surgical 
 operations — septicaemia and pysemia, for example — are not infre- 
 quently accompanied by a decided yellowness of the skin. Inflam- 
 mation of the liver itself may be associated with the same symptom. 
 It would seem also that the action of various agents directly upon 
 the blood may cause jaundice, without affecting the liver itself. Thus 
 this yellow color has been observed after the long continued inhala- 
 tion of chloroform, from the bite of venomous serpents, from violent 
 mental emotion, grief, fear or anger ; and it sometimes occurs, 
 without apparent cause, in those who have long resided in malarial 
 districts. 
 
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 iii 
 
JAUNDICE. 
 
 259 
 
 But the most frequent and usual causes of jaundice arc obstruc- 
 tions somewhere in the channels through which the bile flows in its 
 passage to the intestines. The most frequent condition is probably a 
 catarrh of the stomach and intestine, the condition described as 
 " biliousness," whereby the gall duct becomes swollen and closed. 
 Another frequent obstruction is the presence of gall stones, de- 
 scribed on a previous page. 
 
 Sffniptonitt. — The most prominent symptom is the yellow tinge 
 which becomes visible first in the whites of the' eyes, and then ex- 
 tends over the face, neck and chest. It is apt to be accompanied 
 by an annoying itching or tingling sensation. The perspiration is 
 usually tinged with it, and may therefore stain the body linen. The 
 urine acquires a dark brown color, which may deepen almost to black 
 if the jaundice be intense. In this case it usually deposits a heavy 
 sediment. At times the stools are a slate color or almost white. 
 The symptoms manifested by the alimentary canal vary in different 
 cases according to the condition which causes the jaundice. In most 
 cases there is a bitter taste in the mouth ; the tongue is heavily 
 coated, and there is apt to be a feeling of nasuea, perhaps even vom- 
 iting. There may be also decided depression of spirits and indis- 
 position for exertion. 
 
 Jaundice may exist for a considerable time without giving rise to 
 other than the symptoms already noted. In many cases the patient 
 remains sufflciently strong and active to attend to his usual avocation. 
 The duration and ultimate outcome depend, of course, upon the 
 condition which induces the jaundice. If this be a catarrh of the 
 stomach and intestine, as is often the case, the color usually disap- 
 pears from the skin in from two to four weeks, the other symptoms 
 subsiding even earlier. If the jaundice be due to the presence of a 
 gall stone obstructing the gall duct, the duration of the discoloration 
 may be much greater. Cases are known in which such obstruction 
 of the gall duct and consequent jaundice have persisted for years 
 without materially impairing the nutrition of the body. Yet in 
 most instances the general health fails, the patient becomes emaci- 
 ated, and death finally results. 
 
 Treatment. — In every case the object is, of course, to remove 
 the cause of the jaundice. Hence the treatment must necessarily 
 vary according to the supposed cause. In most cases a few doses 
 of podophylline may be administered to advantage — a quarter of a 
 
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 DISEASES OF THE INTESTINES. 
 
 grain morning and night ; or two grains of calomel in powder may 
 be given at night, followed by ten or fifteen grains of the bicarbon- 
 ate of soda in the morning. Yet no time should be lost in endeav- 
 oring to discover the source of the difficulty, and direct treatment to 
 the removal of this source. 
 
 DISEASES OF THE KIDNEYS. 
 
 The kidneys are situated on either side of the spinal column, 
 just at the region where the last ribs join the backbone ; they lie, 
 therefore, in the small of the back, though somewhat higher in the 
 body than is popularly supposed. The kidneys cannot be felt, 
 except by the employment of special measures, either from the 
 back or from the abdominal surface of the body. Affections of 
 the kidneys sometimes cause pain in the back, though in most in- 
 stances kidney diseases are either accompanied by no pain at all in 
 the neighborhood of the kidneys, or are associated with sharp pain 
 running down the front of the body into the groins. It should be 
 remembered, therefore, that pain in the small of the back is rarely 
 a symptom of kidney disease ; although the popular conception is 
 inclined to attribute most painful sensations in this region to 
 the kidneys. In the majority of instances it will be found that 
 the pain is due to rheumatism of the loins, and has nothing what- 
 ever to do with disease of the kidneys. 
 
 The function of the kidneys is to drain off from the blood cer- 
 tain elements of that fluid which are no longer required in the 
 animal economy. Many of these substances are products which 
 are formed in the different organs of the body during the natural 
 processes of life ; these substances are produced during those chem- 
 ical changes which are necessary for the performance of the vital 
 functions ; they may, therefore, be likened to the smoke and the 
 ashes resulting from the combustion of fuel under the boiler of a 
 locomotive ; unless this smoke and these ashes be removed further 
 combustion is of course impossible, the fire dies out and the ma- 
 chine ceases to run. So it is in regard to the human body ; the 
 fuel which is taken into the body through the stomach and the 
 
 lungs ( 
 
 to com 
 
 we hav 
 
 be ren 
 
 the ani 
 
 Se 
 
 the esci 
 
 circulat 
 
 intestin 
 
 have ais 
 
 plish n( 
 
 the bloi 
 
 thus sej 
 
 kidneys 
 
 the func 
 
 sympton 
 
 blood. 
 
 upon an 
 
 urine fro 
 
 escape, t 
 
 even hoi 
 
 due to t 
 
 same effe 
 
 animal. 
 
 exhales j 
 
 urine ; sc 
 
 matter al< 
 
 the const 
 
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 finally coi 
 
 The 
 showing t 
 of materia 
 b}' the ki( 
 similar sy 
 subject als 
 the ureter; 
 times just 
 — kidney 
 Instances j 
 
DISEASES OF THE KIDNEYS. 
 
 261 
 
 lungs undergoes certain chemical processes which may be likened 
 to combustion, and is transformed into certain waste products which 
 we have likened to smoke and ashes. Unless these waste products 
 be removed, further combustion and therefore further activity of 
 the animal machine is impossible. 
 
 Several organs in the body are especially designed to secure 
 the escape of these waste products out of the blood in which they 
 circulate ; these organs are the kidneys, the lungs, the skin, the 
 intestines and the liver. All of these, however, except the kidneys, 
 have also other duties to perform ; the kidneys alone seem to accom- 
 plish no other work than the separation of waste materials from 
 the blood. A large part of these waste products are, therefore, 
 thus separated — or excreted, as it is technically termed — by the 
 kidneys alone ; and any serious interference in the performance of 
 the functions of the kidneys is manifested within a short time by 
 symptoms due to the retention of these waste products in the 
 blood. These facts have been often demonstrated by experiments 
 upon animals. If, for example, the channels which conduct the 
 urine from the kidneys — the ureters — be tied, so that no urine can 
 escape, the result is the death of the animal within a few days or 
 even hours. This fatal result is preceded by symptoms which are 
 due to the accumulation of certain substances in the blood ; the 
 same eflFects are observed if the kidneys be removed from the living 
 animal. In either case the animal soon becomes restless ; the skin 
 exhales profuse perspiration, which has often an odor like that of 
 urine ; some hours later vomiting and diarrhea occur, the vomited 
 matter also emitting an odor similar to that of urine. Meanwhile, 
 the constitutional disturbance of the animal increases, symptoms 
 of derangement of the mental functions become manifest, and 
 finally convulsions, stupor and death occur. 
 
 The history of an animal after such an operation is valuable as 
 showing the effects produced upon the animal body by the retention 
 of materials which should be and usually are expelled from the body 
 by the kidneys ; and it is especially interesting because precisely 
 similar symptoms, including the fatal result, occur in the human 
 subject also when the excretion of the urine is arrested. Although 
 the ureters are never tied intentionally in man, yet they are some- 
 times just as effectually obstructed by the presence of minute stones 
 — kidney stones — which are occasionally formed in the kidneys. 
 Instances are on record in which symptoms quite similar to those 
 
 i 
 
 ■.i' 
 
 I'M 
 
 'Hii 
 
 ii 
 
 !;Pi 
 
DISEASES OF THE INTESTINES. 
 
 produced by tying the ureters in an animal have been observe'' in 
 human patients, whose ureters have been found upon examination 
 after death to be obstructed by kidney stones. So, too, the 
 removal of both kidneys from the human subject has never been 
 performed ; but very similar symptoms have been repeatedly ob 
 served in cases in which the kidneys were so disorganized by dis- 
 ease as to be incapable of doing their work, so that the individual 
 was practically left without kidneys. In many cases one kidney 
 has been removed from the human subject, the remaining kidney 
 being usually competent to perform the work of both ; but in a few 
 remarkable instances the removal of one kidney has been followed 
 by all the symptoms which occur in animals after the removal of 
 both kidneys, and in these remarkable cases it has been found after 
 death that, by a singular accident of formation, the individuals in 
 question possessed originally only one kidney, the removal of 
 which left the patient literally without any kidneys, and conse- 
 quently resulted in death. 
 
 Another point of interest in the experiment upon animals, to 
 which allusion has already been made, is the fact that wh'.^n the 
 kidneys fail to perform their functions their work is assumed, so far 
 as may be, by the skin and the intestines. For it is observed in 
 human patients as well as in animals, that when the kidneys are in- 
 active, the perspiration is increased in quantity, en'its a urinous odor, 
 and actually contains some of the ingredients of the urine, while the 
 secretions of the stomach, which are ejected by the act of vomiting, 
 are found similarly supplied with certain constituents of the urine, 
 as evinced by the characteristic odor. 
 
 The danger to be apprehended in disease of the kidneys is, 
 therefore, such an interference with the separation of waste mate- 
 rials from the blood as will cause an accumulation of these materials 
 in the system, notwithstanding the efforts of the skin and of the 
 intestines to eliminate them ; and the treatment of diseases of the 
 kidney comprises, therefore, in general, _/?r.y/, the effort to restore- 
 the kidneys to the natural condition of activity ; and, second, the 
 attempt to excite the skin and alimentary canal to such temporary 
 activity as will suffice to keep the system clear of these poisonous 
 materials until the kidneys shall have had time to resume their usual 
 work. 
 
ACUTE BRIGHT S UISKASE. 
 
 263 
 
 Inflammation of the Sidney— Bright's Disease. 
 
 This affection is termed Bright's disease, after an English physi- 
 cian, Dr. Bright, who sixty years ago discovered that the symptoms 
 which characterized it were caused by inflammation of the kidney. 
 It will be convenient to consider this inflammation under two heads 
 — Acute and Chronic Bright's disease. 
 
 Acute Bright's Disease. 
 
 This usually occurs either as a sequel to some of the infectious 
 diseases, or after exposure to cold, especially if the feet and legs 
 be kept wet for a considerable time. 
 
 Symptoms, — The patient usually experiences a chilly sensa- 
 tion, which may be merely a slight shivering or may amount to a 
 pronounced chill; this is followed by decided fever, nausea, vomit- 
 ing, headache and pain in the small of the back. While these symp- 
 toms are well marked in many cases, they may be less pronounced 
 in others ; and, indeed, most of them are sometimes entirely absent. 
 But close upon these follows a symptom which rarely fails to appear, 
 namely, dropsy. This usually begin'= by puffiness under the eyes ; 
 in a few- hours the entire face as well as the feet are perceptibly 
 swollen ; by this time there is often considerable difficulty in breath- 
 ing, the respirations being short and hurried. In children, the dis- 
 ease not infrequently causes delirium and convulsions, though these 
 are seldom present in adults, except in rapidly fatal cases ; the 
 skin is very dry, the face pale. 
 
 But the most characteristic symptoms, those indeed upon 
 which the physician relies for a positive opinion, are found in the 
 urine. This is usually much diminished in quantity ; in severe 
 cases, indeed, it is almost or quite suppressed. The urine which 
 may be passed is of a very deep color, has usually a strong odor, 
 and deposits, upon standing, a heavy sediment. If the case be 
 severe, this sediment contains a large proportion of blood, which 
 may be visible to the naked eye as a brick red or brown layer, and 
 which gives to the urine a peculiar smoky appearance. Perhaps 
 the best estimate of the gravity and danger of the case can be 
 
 ■i 
 
 11 
 111 
 
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 r- 
 
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 Hi i' i- 
 
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 264 
 
 DISEASES l)F THE INTESTINES. 
 
 obtained by the uninitiated from the quantity and appearance of 
 the urine. In health, the avemge adult should pass in twenty-four 
 hours about fifty ounces — three pints — of urine. In acute Brit^ht's 
 disease, the quantity may be diminished to thirty, twenty, ten or 
 even less ounces. 
 
 In the majority of cases which occur " spontaneously," that 
 is, without any connection with the infectious diseases, recovery 
 may be expected. After one, two or three weeks the symptoms 
 gradually subside, the urine increases in amount and resumes a 
 more natural appearance, the swelling of the body disappears and 
 the patient recovers his usual health. Yet this is by no means inva- 
 riably the issue of the disease. In some cases death occurs ; in 
 others the patient recovers a certain degree of health, but does not 
 regain his former strength ; in still others there is an apparently 
 perfect recovery, and the individual has no suspicion of any fur- 
 ther difficulty until, perhaps years subsequently, it is discovered 
 that the disease has assumed the chronic form, and is firmly fixed 
 in his system. 
 
 If death occur, it is, in the majority of cases, the result of 
 uramia. By uraemia we mean the retention of urea in the blood. 
 Urea is one of those substances which is produced in the various 
 tissues of the body during the ordinary processes of 'ife, and one of 
 those substances which it is the especial duty of the kidney to sep- 
 arate from the blood and eliminate from the body with the urine. 
 If the disorganization of the kidneys be extreme, that is, if the 
 attack of Bright's disease be very severe, the kidneys fail to secrete 
 much or any urine, and the urea, which is always produced so long 
 as the individual lives, cannot, of course, escape from the body. 
 Some of it, it is true, is ejected by the stomach during the acts of 
 vomiting, which always accompany severe cases of the disease. 
 Some of it also is expelled by the alimentary canal in a watery 
 diarrhea, which is also apt to be one symptom of severe cases. But 
 notwithstanding these efforts of nature to eliminate the urea, and 
 thus to save the system from poisoning, the result is usually fatal 
 if the action of the kidneys be nearly or quite suppressed ; for the 
 urea is a poisonous element if it accumulate in the blood, and the 
 patient dies from urea poisoning, or urcemia. 
 
 Another mode of death which sometimes happens is from 
 dropsy of the chest and of the lungs. In this case the danger is 
 indicated by the short and hurried acts of breathing, as well as by 
 
ACUTE UKIOIIT'S DISEASE. 
 
 26$ 
 
 the blueness and lividity of the skin for some days before the fatal 
 result. 
 
 The occurrence of urjemia is preceded by symptoms of mental 
 derangement, at first amounting merely to depression of spirits, 
 then proceeding to delirium, unconsciousness and convulsions. 
 These are the evidences of the effects of urea on the brain. At 
 times, too, impairments of vision and partial blindness are 
 observed. 
 
 Treatnient, — As already indicated, the objects of treatment 
 are-chiefly the restoration of the functions of the kidney, and 
 the elimination of the urea and other constituents of the blood by 
 the skin and intestines. To accomplish the latter the skin must be 
 stimulated to activity by heat and moisture, in the shape of warm 
 baths, or, better by hot air baths. These may be taken once or 
 twice a day until the patient perspires freely ; they must not be too 
 often repeated, since they are somewhat exhausting, especially the 
 hot water bath. The bowels may be excited to activity by cathar- 
 tics, especially by the saline purgatives. For this purpose there 
 maybe given, morning and night, the following powder: 
 
 Jalap, Five grains 
 
 Creani of tartar, - - - - A teaspoonful. 
 
 A pleasant and almost as efficient purgative is the citrate of 
 magnesia. 
 
 In order to promote the excretion of the urea and other 
 poisonous materials, the patient should be permitted the free use 
 of water, lemonade and other bland liquids for which he may 
 express a desire. 
 
 In order to restore the function of the kidneys, but one object 
 can be carried out — namely, to give these organs a rest. In order to 
 accomplish this, the skin and the intestinal canal — which are really 
 accessory kidneys, as it were — are stimulated to unusual activity by 
 the baths and purgatives already mentioned. The same object can 
 be promoted by the use of measures which will diminish the 
 quantity of blood in the kidneys. The most cflfcctive means for 
 this purpose is dry cupping over the loins. This can be imitated 
 quite effectually in the household, cither by the application of hot 
 cloths over the loins, or by the use of a light poultice which has 
 been sprinkled with a little mustard. These should be changed 
 every hour or two so as to keep them hot. Dry cupping itself may 
 
 i 
 
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 -! 
 
 A 
 
 .Ji(| 
 
 m 
 
^ 
 
 266 
 
 DISEASES OF THE INTESTINES. 
 
 ri 
 
 
 n 
 
 m 
 If 
 
 In 
 
 \' I 
 
 be successfully done by putting into a tumbler a piece of blotting 
 paper two or three inches long and an inch wide, saturating this 
 with alcohol, setting fire to the alcohol, and applying the mouth of 
 the glass quickly to the skin at the small of the back. During the 
 burning of the alcohol the air in the glass is heated, and upon cool- 
 ing, the air contracts again and the skin is pressed slightly inti' 
 the glass. In performing this little operation, care should be- 
 taken that the burning paper does not come in contact with the 
 skin ; this can be avoided if the patient assume a sitting posture, 
 or lie upon the side. 
 
 It is quite important that the diet be judiciously selected 
 during the disease, especially since the stomach is apt to be irri- 
 table. By employing chiefly milk and eggs we can, to a certain 
 extent at least, diminish the work required by the kidneys. 
 
 Chronio Bright's Bisease. 
 
 Under this name we understand a chronic inflammation of the 
 kidney. Although the disease may begin quite differently in dif- 
 ferent cases, yet the later course follows one of two types ; in other 
 words there are two forms of chronic Bright's disease, which we 
 shall describe separately. 
 
 The first one results oftentimes as a sequel of the acute form 
 of Bright's disease; the second seems to occur from habitual excesses 
 in eating and drinking. So frequently is this form of the disease 
 found in those who are partial to the pleasures of the table, that 
 this variety is often called the " gouty " form of Bright's disease, 
 from its frequent occurrence in those who are subject to gout. 
 
 Sh/niptoms, — That form of Bright's disease which we fre- 
 quently see as the result of an acute attack, is developed somewhat 
 insidiously. In a large number of cases the attention is first 
 attracted to the possibility of organic disease by the occurrence of 
 dropsy. This dropsy begins as slight swelling of the feet, noticed 
 usually at first only at the close of the day, after the patient has 
 been actively engaged upon his feet for several hours. In other 
 cases the individual becomes aware of a slight though unmistakable 
 failure of the health, which manifests itself by an impairment of 
 strength and by an unusual degree of pallor. In still other cases 
 
I IIKOMC HKKiins DISKASE. 
 
 267 
 
 the first intimation of the disease comes in the shape of shortness 
 of breath, noticed especially when the patient ascends stairs rapidly. 
 In still other instances the vision becomes somewhat impair'xl ; and 
 in many cases the patient has no suspicion of disease clsewher*. 
 than in the eye, until he consults an oculist, who, upon examininj; 
 the eye with a mirror, disccjvers certain changes which direct his 
 attention to the condition of the kidneys. 
 
 In whatever way the disease begins, a certain group of symp- 
 toms manifest themselves after the lapse of a few months. First 
 among these is dropsy. This begins, as has been stated, in the 
 feet, and gradually proceeds up the limbs, until finally the entire 
 body becomes swollen, sometimes to an enormous extent. The legs 
 become so large that it seems impossible for the skin to hold them 
 without bursting. After a time the body and limbs become so un- 
 manageable from the dropsical swelling that the patient is unable 
 to walk. By this time there are usually some sores on the legs, 
 and the skin is the seat of intolerable itching. The patient looks 
 almost bloodless, except in the face, which is sometimes of a dark 
 color, because the breathing has become so impaired that the blood 
 is imperfectly aerated. 
 
 In the course of time the digestive system also shows signs of 
 derangement. The appetite becomes impaired, there is some indi- 
 gestion and even dyspepsia ; in many cases there is a constant ten- 
 dency to diarrhea and the formation of gas in the intestine. Later 
 in the disease vomiting often occurs in a peculiar violent and sud- 
 den way, which has led to the employment of the term " explosive 
 vomiting." There are cases, indeed, in which these symptoms of 
 impaired digestion occur before any other signs of kidney disease 
 are apparent ; in such cases the patient is sometimes treated for 
 weeks or months for dyspepsia before the true source of the com- 
 plaint is discovered. 
 
 The breathing, too, is impaired sooner or later in this disease ; 
 sometimes by the accumulation of watery fluid — that is dropsy — in 
 the cavity of the chest. This is especially apt to be the case if, as 
 often occurs, there is also disease of the heart. This dropsy of the 
 lungs is at times'suddenly developed, and may then prove to be the 
 cause of death. Dropsy of the larynx is also an occasional symp- 
 tom, and always a dangerous accident. 
 
 Among the symptoms, too, are some which must be referred to 
 the nervous system. Among these is obstinate and frequently 
 
 % 
 
 11 
 
 i '1 
 
 
 
 
 I, 
 1^ 
 
268 
 
 DISEASES OK THE INIESTINES. 
 
 h 
 
 IS' 
 
 recurring headache, attacks of dizziness, impairment of sight, and 
 neuralgia in different parts of the body. These affections of the 
 eyes frequently occur in the hiter stages of the disease. As the 
 affection approaches a fatal termination, occasional transient delirium 
 is not infrequently observed ; and for some days, before death the 
 patient frequently lies in a state of stupor, interrupted perhaps bj' 
 occasional convulsions. These appearances show that ur.i;niia is 
 occurring — that the kidneys have become so disorganized as to be 
 incapable of performing their duty ; hence the urea accumulates in 
 the blood and exerts its poisonous effects upon the brain. Some- 
 times unTimia, stupor, convulsions and death occur suddenly before 
 the other symptoms have become pronounced, and while the dropsy 
 is still slight in quantity. In fact, there are instances, though not 
 very numerous, in which the patient dies suddenly in convulsions, 
 although no suspicion of kidney disease had been entertained. 
 These cases occur more frequently in the other form of chronic 
 Bright's disease, the " gouty" form, to be presently described. 
 
 The urine also exhibits characteristic changes during this form 
 of Bright's disease ; it becomes diminished in quantity and deposits 
 a heavy sediment, as a rule. This urine contains albumen, and 
 the sediment exhibits certain delicate structures derived from the 
 kidney and termed tuie casts. These are to be discovered only b)' 
 the use of the microscope ; indeed, it is impossible to make a posi- 
 tive diagnosis in the early stages of this disease without a careful 
 chemical and microscopical examination of the urine. It should, 
 however, be said, for the comfort and benefit of numerous individ- 
 uals, that the presence of albumen alone in the urine does no/, 
 necessarily, prove the existence of Bright's disease. This remark- 
 is emphasized, because the writer has been so often consulted by 
 individuals in whose urine albumen has been discovered, and upon 
 whom the dreadful sentence, "Bright's disease," had been pro- 
 nounced. There are numerous other causes which may induce the 
 presence of albumen in the urine ; and until the .symptoms have 
 become pronounced, until the dropsy, emaciation and loss of 
 strength are unmistakable, no one, not even a physician, can be sure 
 of the existence of Bright's disease without a most careful micro- 
 scopical examination of the urine. 
 
 It is the popular impression, that to be afflicted with Bright's 
 disease is equivalent to receiving a sentence of death. It must be 
 confessed that in most, perhaps all, of those cases in which the 
 
 
CHRONIC HRIGHT'S DISEASE. 
 
 »69 
 
 symptoms above described are pronounced and of lonjj standing; 
 in which the dropsy has become extensive, and in which the 
 symptoms of digestive disturbances and of nervous disorders arc 
 apparent — in such cases it is doubtless true that recovery rarely, if 
 ever, occurs. But it must be remembered that Bright's disease is 
 usually far advanced when it has resulted in the production of these 
 ^symptoms. There is an earlier stage of the disease, lasting months 
 at least, in which the affection is not fully recognized, nor perhaps 
 even suspected ; and it is equally certain that recovery does some- 
 times occur from this early stage. This is proven by the records 
 of cases in which the disease has been detected at an early period 
 by especially skillful physicians, and has been cured by them ; and 
 has been equally well demonstrated by post-mortem examinations 
 of pcrsotis who, at the time of death, had no Bright's disease, and 
 yet whose kidneys showed undisputable evidence that such disease 
 had previously existed. 
 
 Tiwatment, — In the vast majority of cases the disease is not 
 recognized until it is too late to expect recovery under any plan of 
 treatment ; yet the sufferings of the patient can be decidedly 
 mitigated, and indeed his life prolonged, by attention to certain 
 measures. 
 
 Among the most important of these is the observance of 
 proper sanitary regulations. The patient should carefully avoid 
 exposure to wet and cold ; should not undergo physical or mental 
 fatigue ; should avoid excesses at the table or otherwise. The 
 diet should contain but little meat, and may consist largely of milk, 
 eggs, fruits and vegetables. The clothing may be warm, flannel 
 being worn next to the skin. 
 
 Among medicines most good will be derived from iron, which 
 may be given in that form that the patient findc most agreeable. 
 Sometimes some little care and experimenting are necessary in order 
 to discover the particular form of iron which can be best borne. 
 In some cases the tincture of the chloride of iron in doses of from 
 ten to fifteen drops, taken before meals, will agree with the 
 patient's stomach. Others again will be best satisfied with the 
 'itratc of iron, five grains of which may be given three times a 
 day ; still other cases will be most benefited by the syrup of the 
 iodide of iron, though the syrup in this preparation is apt to disa- 
 gree with the stomach. Cod liver oil will also be found of use in 
 strengthening the patient ; few persons suffering from this disease 
 
 
 '■'■Sllfc 
 
 I VI 
 
 ,!l.)' 
 
»70 
 
 DISEASFS OK TIIK IN TKSTINF.S. 
 
 ■i i 
 
 will be able to take the article in its crude form ; it will generally 
 be found necessary to give it in the shape of an emulsion, many «)f 
 which can be found at the drug stores. 
 
 The dropsy usually requires treatment quite early in the dis- 
 ease. To reduce it, the bowels may be kept active by means of 
 saline laxatives, with or without jalap powder, as described in dis- 
 cussing the subject of dropsy. Hut it must be repeated, that it is 
 possible to exhaust the patient materially by the over-zealous use 
 of cathartics for the purpose of reducing the dropsy. Another 
 measure is the hot air bath, or the hot vapor bath, which may be 
 used with less detriment to the patient. And finally cases occur in 
 which the abdomen must be tapped to remove the water, and, 
 perhaps, slight incisions made in the legs in order to permit the 
 fluid to drain away. 
 
 The other form of chronic Bright's disease, that tcj which ref- 
 erence has already been made, under the name of the " goutj- " 
 variety, differs from that form just described in many essential 
 particulars. It is one of the most insidious and gradual diseases 
 with which we are acquainted. It has been known to exist in an 
 individual for ten, fifteen or even twenty years before reaching a 
 fatal termination. 
 
 SffinptoniH. — As to the symptoms whicn accompany the 
 oeginning of the disease, it is almost impossible to give any descrip- 
 tion, because the onset is so slow and insidious that it is rarely 
 discovered until it has evidently existed for a considerable time. 
 
 In this form of the disease there is rarely any dropsy until 
 v/ithin a very short period before death, and even then it occurs 
 only in exceptional cases. The patient is usually led to seek med- 
 ical advice for some symptom which has but little if any relation 
 with the kidney. In one case the difficulty complained of will be 
 impairment of vision ; in another, obstinate and violent headache ; 
 in the third the patient will seem to suffer from dyspepsia ; in 
 others again there will be palpitation of the heart. In many cases 
 attention is first drawn to the difficulty by the excessive secretion 
 of urine, several quarts of which may be passed in twenty-four 
 hours, compelling the patient to arise at night in order to evacuate 
 his bladder. 
 
 The patient's general health may remain unimpaired for years, 
 and he may in fact have no suspicion that serious organic disease 
 exists. These are the cases which are so often discovered unex- 
 
CHRONIC imUiill S DISKASK. 
 
 9ft 
 
 pcctedly during; examinations for life insurance, or upon other 
 critical medical inspection, since such individuals often suppose 
 themselves to be and really seem to be in perfect health. 
 
 As the disease advances, several troublesome symptoms are 
 apt to occur. l''oremost amon^ these is the frequency of urination, 
 for in this disease there is an excessive amount of urine passed. 
 The patient is compelled to evacuate the bladder frequently, often- 
 times by ni^ht as well as by day ; yet the act is not accompanied 
 by pain, but is natural in every respect. The urine passed is clear, 
 often somewhat lighter colored than natural, but contains no sedi- 
 ment. 
 
 After the affection of the kidneys h:\^- endured for some time, 
 there occurs in the majority of cases an « riargement of the heart. 
 In fact, there are numerous instances in which this change in the 
 heart seems to occur almost or quitr ;> early as th' Jisease in the 
 kidney. This enlargement of the heart causes a feeling of weight 
 Pit J fullness in the chest, often accompanieii by fits of palpi^ltion ; 
 the pulse it the wrist becomes very luird, almost resembling an 
 iron wire ; there is apt to be painful throbbing of the vessels of 
 the neck and head. This feature is a most importai!^ part of this 
 form of chronic Bright's disease, because many of the symptoms 
 characteristic of the disease, and many of the sudden deaths from 
 so-called " apoplexy," are really due to the enlargement of the 
 heart which accompanies this inflammation of th<; kidneys. 
 
 In the majority of cases this form of Bright's disear.e occurs in 
 advanced life, and is especially frequent, though by no means con- 
 fined to those who are especially prone to over-indulgence in 
 eating and drinking. Many of the sudden deaths which occur in 
 men of full habit, with thick necks and rotund forms, are due to 
 apoplexy, that is to a bursting of blood vessels within the brain. 
 Now this rupture of the vessels is in many cases due to the excessive 
 force of the blood current, which is propelled by a heart cf unusual 
 size and power. In fact the immediate danger in these cases of 
 Bright's disease is from a rupture of blood vessels, since the disease 
 of the kidney itself rarely causes a fatal result excent after several 
 years of existence. 
 
 Another feature sometimes observed in this form of Bright's 
 disease is a slow poisoning by the accumulation of urea in the 
 blood — chronic urcBtnia, as it is technically called. The symp- 
 toms which indicate uraemia in acute Bright's disease have been 
 
 '1 n 
 
 
 ' ft ,r 'Ik 
 
272 
 
 DISEASES OF THE INTESTINES. 
 
 Ill^ 
 
 m ■ 
 
 %'^: 
 
 already descrih;^d ; these consist of violent and severe vomiting and 
 purging, excessive perspiration, delirium, stupor and convulsions. 
 In chronic uraemia similar symptoms may be present though in a 
 less intense degree, so that in some instances no suspicion of the 
 real cause of the difficulty exists. In these cases the patient is apt 
 to have chilly sensations or even pronounced chills, followed by 
 fever and perspirations ; there may be some inclination to vomit 
 and an obstinate diarrhea. Cases are recorded in which the 
 patient had been treated for some time for malarial fever when he was 
 reallv suffering from chronic ursemia and Bripfht's disease : the 
 mistake arose from the occurrence of chills and fever every day or 
 two, strongly suggestive of ague. In other instances again a 
 chronic diarrhea of long standing has been found to be due to 
 Bright's disease of the kidneys. In still other instances the attempt 
 to eliminate the urea seems to fall largely upon the lungs, resulting 
 in a persistent bronchitis, often associated with asthma. 
 
 In fact, after the attention of the physician has once been 
 called to the diversity of symptoms by which this form of chronic 
 Bright's disease may manifest itself, he is always watchful for its 
 existence in middle-aged or elderly people, especially in those who 
 are troubled with chronic affections of the alimentary canal, of the 
 lungs, or of the heart. Yet while the majority of cases are detected 
 in people who have attained or have passed middle age, the disease 
 may occur in youth or even in childhood. 
 
 TreatrneMt, — There is no plan or treatment known whereby 
 this form of Bright's disease can be cured or even arrested. That 
 recovery does sometimes occur admits of no question ; yet it is by 
 no means established that such recoveries are due to the treatment 
 purs.ied and not to other influences of which we have no con- 
 ception. 
 
 It seems quite certain that by avoiding those articles of food 
 the consumption of which throws extra work upon the kidneys, wc 
 may, to a certain extent, give these organs a rest, and thus put 
 them in the best possible condition for recovery. Such articles 
 include, generally speaking, meats and animal food, and alcoholic 
 stimulants. It is, therefore, advisable to restrict the diet of the 
 patient with regard to these articles of food ; he should be encour- 
 aged to liv^e largely upon milk and eggs, indulging his appetite for 
 fruits and vegetables, as he may please. Beyond this we cannot 
 go in our efforts to improve the condition of the kidneys. 
 
CHRONIC BRIGHT S DISEASE. 
 
 273 
 
 Yet there is often a considerable field for medicines in the 
 treatment of this complaint. The safety and welfare of the patient 
 depend upon the maintenance of an excessive secretion of urine ; 
 so long as the heart is sufficiently powerful to force the blood 
 through the kidneys, the secretion continues. But there often 
 occur times when the heart seems unable to accomplish this work 
 without assistance ; this assistance can be rendered by the use of 
 digitalis. 
 
 Another important item is the avoidance of sudden and ex- 
 cessive physical effort or mental emotion. For it is frequently by 
 some such effort or emotion that an attack of apoplexy is provoked. 
 Care should be taken that there be no unnecessary exposure to 
 cold or wet, since aggravations of the disease are thereby induced. 
 
 It is the fashion nowadays for patients with kidney disease to 
 resort to mineral springs, many of which are well advertised as 
 cures for Bright's disease, and in fact almost all complaints of the 
 urinary organs. There can be no question of the benefit derived 
 by many sufferers from Bright's disease from visits at these springs. 
 It is equally certain that the benefit thus derived is not to be 
 ascribed in the minutest degree to any virtues possessed by the 
 waters, but is due wholly and entirely to the invigorating effect 
 which follows the change of life and scenery and occupation incident 
 to a residence at these watering places. There is absolutely no 
 remedy, whether in the shape of drug or mineral water, which has 
 ever been known to exert the slightest influence in arresting those 
 changes in the kidney constituting Bright's disease. Yet this 
 remark is not intended to decry in any way the value of a sojourn 
 at one of these popular resorts ; for everything which can con 
 tribute to the comfort and enjoyment of the patient has a beneficial 
 effect, not by arresting the disease, but by invigorating the patient, 
 so that he can resist its ravages with better effect and for a longer 
 time. 
 
 In some forms of Bright's disease residence at one of these 
 springs has an additional advantage, namely, that the patient is 
 thereby induced to drink more water than he otherwise would. It 
 is not to be laid down as a general principle that to drink an excess 
 of water has a beneficial effect. It is the popular idea that impuri- 
 ties can be washed out of the human body by an abundance of water, 
 just as filth can be "flushed" out of sewers by flooding these channels. 
 Such a conception can of course exist only where the most child- 
 
 '\ i!r^^- 
 
 %' 
 
 f ; 
 
 
 %k^- A 
 
274 
 
 DISEASES OF THE INTESTINES. 
 
 like innocence oi human physiology prevails. Were tnc body merely 
 a system of sewers, benefit might always be expected from rinsing 
 the sewers with an abundance of water ; but under the present con- 
 struction of the human body the maintenance of health is a matter 
 by no means so simple. 
 
 Gravel. 
 
 In a previous chapter we have described the formation and pass- 
 age of gi.ll-stones through the gall ducts, whereby paroxysms of 
 agonizing pain are induced, causing the symptoms known as 
 " liver colic. " Similar paroxysms of pain are induced by the 
 passage through the ureters of small stones formed in the kidney 
 by the deposit of sediment from the urine. It will be remem- 
 bered that the urine escapes from the kidney into a funnel-shaped 
 sac called the pelvis, the lower end of which — the tube of the fun- 
 nel — is prolonged as a membranous channel about as large as a 
 goose-quill, which terminates below in the bladder. The urine escapes 
 from the kidney into this funnel-shaped pelvis and runs through 
 the quill-like channel until it reaches the bladder. The small size 
 of the ureter renders it liable to be obstructed by small impedi- 
 ments ; and some of these obstructions are often formed in the 
 kidney in the shape of small stones. The urine consists of water 
 which holds in solution a certain number of crystalline substances. 
 So long as these substances remain dissolved they are of course 
 readily passed through the ureter ; but in various unhealthy con- 
 ditions of the body these crystalline substances do not remain dis- 
 solved, but are deposited as a sediment in the pelvis of the kidney. 
 Here they form little masses called kidney-stones. Many of these 
 masses are small enough to pass through the ureter and are washed 
 down into the bladder with the urine, forming here a nucleus for a 
 bladder-stone in the bladder. But many of them are too large to 
 pass readily through the ureter, and either remain in the funnel- 
 shaped pelvis or become lodged in the ureter. If in the latter case 
 they are finally forced onward, their passage through the ureter 
 into the bladder occasions the most intense pain — paroxysms which 
 are known as " renal colic," or a " fit of the gravel. " 
 
 A paroxysm of kidney colic, or " a fit of the gravel," is usually 
 developed somewhat suddenly, though in some cases it may be 
 
GRAVEL. 
 
 275 
 
 preceded for hours or days by a dull pain in the back and groin. 
 The paroxysm soon reaches the height of its intensity, the pain 
 often being agonizing. The pain is usually felt in the region of the 
 lowest rib on the side, radiating downward and forward into the 
 groin, perhaps even to the thigh ; in the male it is usually felt in 
 the testicle, which may be drawn violently up toward the body. ' 
 The patient may endeavor to secure relief by changing his position, 
 walking about the room, and by compressing the abdomen with the 
 hands. In fact, the symptoms resemble largely those of wind colic 
 except in the location of the pain. The suffering continues with- 
 out intermission, though not of uniform severity. There is a con- 
 stant, or frequent, desire to pass water, though but little 'urine is 
 secreted, and that which is passed is often bloody 
 
 Accompanying these symptoms of local difficulty are variou.s 
 evidences of constitutional disturbance — nausea and vomiting, 
 profuse perspiration, pallor of the surface. After an interval which 
 may last from fifteen minutes to one or more days, the symptoms 
 suddenly cease, leaving the patient in an exhausted but comforta- 
 ble condition. The sudden cessation of pain is usually followed by 
 an abundant discharge of urine ; the kidney-stone has evidently 
 reached the bladder, and the urine which had been dammed up 
 behind it during its passage through the ureter is now permitted to 
 escape. 
 
 It sometimes happens that other renal stones follow the first 
 down the ureter at short intervals, so that the patient has several 
 fits of the gravel within a few consecutive days ; in this case the 
 succeeding ones are not usually so violent or painful as the first. 
 Although these paroxysms are extremely painful, they are not 
 immediately dangerous, and if the stone finally escape into the 
 bladder the health is entirely restored ; yet one attack is apt to be 
 followed sooner or later by others. 
 
 Sometimes these fits of the gravel terminate in the discharge 
 of a fine red sand, containing perhaps several larger masses, which 
 collect in the bottom of the vessel contaming the urine. In other 
 cases the urine will be perfectly clear and free from gravel at the 
 time of its passage, but will deposit a heavy sediment after stand- 
 ing a few hours. Sometimes a similar occurrence is witnessed for 
 a few days before the attack begins. 
 
 Treatment. — During the paroxysm the object of treatment is 
 of course relief of pain. This can be accomplished by a free use 
 
 !i \im: 1 
 
 
 !; • } 
 
 h 
 
176 
 
 DISEASES OF THE INTESTINES. 
 
 ii:.!. 
 
 of opium ; a quarter of a grain of morphine may be given to an 
 adult and repeated in three or four hours if the pain be severe. If 
 the stomach be very irritable, it will be better to admini.ster the 
 morphine by injection under the skin. In some cases, however, the 
 pain is so severe and begins so suddenly that we cannot wait for 
 the action of morphine; in these instances chloroform should be 
 inhaled until the morphine, which should be given as early as pos- 
 sible, has had time to manifest its effects. Nothing can be done to 
 promote the passage of the stone along the ureter beyond the 
 inhalation of chloroform, which seems to relax the channel. 
 
 Much can, however, be done to prevent the recurrence of 
 these attacks. For the formation of renal stones is, in the majority 
 of cases, due to an excessive acidity of the urine; this is especially 
 true in those cases in which a red sand is deposited. In these cases 
 it may be possible to ward off future attacks by preventing the 
 urine from becoming so acid. This may be accomplished by giving 
 twenty to thirty grains of the bicarbonate of potash in water 
 three times a day ; or by administering five grains of the carbonate 
 of lithia, or by giving ten grains of benzoic acid. In other cases 
 the kidney-stones are formed of materials which are deposited from 
 alkaline urine ; an examination of the urine and of the sediment 
 will at once determine which variety of kidney-stones is present in 
 any given case. The acid condition of the urine is especially apt to 
 occur in persons of full bodily habit, who are accustomed to partake 
 largely of meat ; the alkaline condition is most frequent in nervous 
 individuals, especially those of sedentary habits. Various mineral 
 waters may be employed to render the urine arid or alkaline as 
 required, though care must be taken in selecting the proper 
 variety. 
 
 If the stones formed in the kidneys do not escape through the 
 ureter, but remain permanently in the pelvis of the kidney, they 
 cause an irritation and inflammation which is known as pyelitis. 
 In this affection there is apt to be a dull pain in the loins, aggra- 
 vated by violent motion. The urine usiially contains a considerable 
 sediment of pus This disease is important, because it is so often 
 mistaken for Bright's disease of the kidney ; in fact it is impossi- 
 ble to recognize it without the use of the microscope ; it will be, 
 therefore, unnecessary to describe it here in detail. 
 
 In all cases where there is a disposition to the formation of 
 gravel, it is a matter of importance to regulate the diet of the 
 
STONE IN THE BLADDER. 
 
 277 
 
 patient. By this it is not meant that the patient should be starved, 
 Init that he should avoid those articles of diet which predispose to 
 excessive acidity of the urine. It is, therefore, necessary that he 
 abstain from excessive indulgence in meats, or at least employ at 
 the same time a proper proportion of vegetable substances. Yet 
 there are certain vegetables, rhubarb for example, which are 
 especially likely to induce acidity of the urine. 
 
 Stone in the Bladder. 
 
 When these minute stones have escaped through the ureter 
 into the bladder, the patient is relieved from the severe pain which 
 attended its passage down the ureter, and is apt to regard the diffi- 
 culty as finished. In some cases it is so; the stones escai)e from 
 the bladder through the urethra, oftentimes without causing any 
 pain, or even without attracting the patient's attention ; this is par- 
 ticularly true in women, while in men, owing to the difference in 
 the size and course of the urethra, the passage of the stone from 
 the bladder to the external world is sometimes almost as painful as 
 its passage from the kidney to the bladder. Sometimes, indeed, 
 such a stone becomes lodged in the mal urethra, requiring an 
 operation for its removal before the patient is able to pass water. 
 
 In some instances however, these stones, which reach the blad- 
 der from the kidneys, do not pass out through the urethra, but 
 remain in the bladder. So long as they are small they occasion no 
 symptoms of sufficient moment to r^ttract the patient's attention, but 
 in course of time these stones become larger by the addi'^^ion of new 
 matter upon their exterior. This matter consists of crystalline sub- 
 stances which arc deposited from the urine around the little kidney- 
 stone. After a few months the stone may have attained many times 
 its former bulk, and may now be as large as a hickory-nut or a wal- 
 nut. Upon cutting it open, this stone is found to consist of numer- 
 ous layers arranged aiound a common center, and presenting, there- 
 fore, something the appearance of an onion. The center is found 
 to be the original kidney-stone. 
 
 Although this is the way in which most stones are formed in 
 the bladder, yet any foreign body may serve as a nucleus around 
 which layers of crystalline matter will be deposited, so as to form a 
 
 11 
 
 '!f. 
 
 "ff (j''l 
 
 t' \ 
 
 f: 
 
 ;i 
 
 
 i^'fi 
 
 i M 
 
2-8 
 
 DISEASES OF THK INTESTINES. 
 
 li 
 
 i'l 
 
 bladdcr-stonc. Thus straws, hairpins, pipestems and similar objects 
 whicli have been used by the patient in the unnatural gratification 
 of the sexual appetite, sometimes slip into the bladder and remain 
 there, constituting the nucleus around which a stone is subsequently 
 formed. So, too, fragments of bone and bullets have been found 
 in the interior of stones of the bladder in individuals who had suf- 
 fered wounds in this portion of the body. At other times a simple 
 clot of blood or mass of pus which has escaped into the bladder, 
 may constitute the beginning of the stone. It has also happened 
 that catheters have been broken off when inserted into the bladder, 
 the broken ends constituting the nucleus for the future stone. 
 
 Symptotna, — The symptoms caused by the presence of a 
 stone in the bladder are quite different in the male than those 
 exhibited by the female. For evident reasons, stones are far more 
 common in the male sex than among females, and the symptoms 
 to be narrated are those observed in men. For a considerable 
 time, while the stone remains small, no definite symptoms are 
 observed ; the patient may at times have an uneasy sensation in the 
 vicinity of the bladder, especially at the time of making water. 
 When the stone increases in size — a change which may occur 
 rapidly in the course of a few months, or gradually, requiring years 
 for its accomplishment — the symptoms become pronounced and 
 characteristic. The patient has constantly a dull pain around the 
 neck of the bladder ; he is compelled to evacuate the urine at short 
 intervals by day, though he may experience comparative comfort 
 at night; he is apt to have a sharp pain at the close of the act of 
 urination. The urine contains a sediment, at first slight and cloudy; 
 subsequently thick and slimy ; there is apt to be a little blood mixed 
 with the urine, especially after exercise. At times there occurs a 
 characteristic symptom, which is not, however, invariably present; 
 this consists in the sudden stoppage of the stream during urination, 
 the patient being unable to complete the act until he has changed 
 his position. Considerable irritation, amounting oftentimes to acute 
 pain, is felt along the course of the male organ, especially at the 
 extremity. This constitutes one of the chief and most reliable 
 symptoms in children who are too young to give accurate informa- 
 tion as to the state of their feeling. Such boys are constantly 
 fingering the parts, and frequently pull the foreskin, especially after 
 making water. 
 
 % •■ 
 
STONE IN THK Bl,Ani)Kk. 
 
 279 
 
 Motion of the body, such as riding, driving or walking, rail- 
 road travel and the like, aggravates the sufferings of the patient, 
 compels him to empty the bladder more frequently, and increases 
 the amount of blood and slime which escapes with the urine. If 
 permitted to go without treatment, the disease ultimately results in 
 death, the patient being harassed and exhausted by the frequent 
 and painful acts of urination. In the course of time, too, a serious 
 inflammation of the bladder is induced, which may spread to the 
 kidneys and cause a fatal result. 
 
 Treatment, — When it has been definitely ascertained that an 
 individual is suffering from stone in the bladder, but one thing is to 
 be done — to remove the stone. It is important that this fact be 
 early recognized, since a failure to submit to an operation insures a 
 fatal result, and, furthermore, the longer the matter is postponed, 
 the greater is the danger attendant upon the operation. 
 
 Until recently stones were removed from the bladder by a cut- 
 ting operation, called lithotomy, whereby the bladder was opened 
 and the stone removed by a strong forceps — pincers. This was a 
 serious operation, sometimes causing the death of the patient, and 
 always confining him to the bed for several weeks. One of the 
 greatest advances in modern surgery consists in the introduction of 
 an operation whereby stones can be, in most cases, removed from 
 the bladder without the use of the knife, and without injuring the 
 parts concerned. This operation is called litliotrity — stone crushing 
 — and is accomplished by the introduction of a pair of strong 
 forceps into the bladder through the urethra. The stone is crushed 
 as it lies in the bladder, and the fragments are washed out through 
 a large catheter. A few years ago this operation was modified and 
 improved by Dr. Bigelow, of Boston, Massachusetts, so that it 
 has now become possible to crush and remove the entire stone at 
 one operation. By this operation, the danger of a fatal result is 
 much diminished, and the patient is confined to his bed for only a 
 few days, if at all. This operation is especially valuable in case of 
 elderly men, who suffer a far greater mortality from operation for 
 the removal of stones than younger people. Owing to the small size 
 of the parts in boys under puberty, it is rarely possible to employ 
 litliotrity in these patients ; this is, however, a matter of small con- 
 sequence, since the cutting operation is rarely followed by a fatal 
 result in boys. The danger increases, other things being equal, 
 
 If 
 
 ^1 ^' 
 
 lo 
 
 f'Jff. 
 
 /'r^ 
 
^ 
 
 280 
 
 DISKASKS OF THE INTESTINES. 
 
 with the age of the patient; yet if the kidneys and urinary organs 
 generally are in good condition, stones may be removed even from 
 aged men with perfect safety. 
 
 In women, stone in the bladder is a far less serious and danger- 
 ous complaint. Although the symptoms induced are quite similar 
 to those exhibited by men, yet the removal of the stone is a far 
 simpler matter, for the female urethra is not only very short, but is 
 easily stretched to a large size, so that a stone can often be removed 
 even without crushing. 
 
 Sugar in the Urine— (Diabetes). 
 
 m 
 
 M'«-i 
 
 m\ 
 
 This term is applied to two distinct afifections, each of which is 
 marked by an increased flow of urine; one of them — diabetes 
 insipidus — is a comparatively unimportant affection which occurs 
 as a complication of other diseases. The disease ordinarily meant 
 when we speak of diabetes, is the so-called saccharine diabetes — 
 diabetes viellitjis — so called because the urine contains sugar. This 
 is a serious, usually a fatal, affection. 
 
 SffiiiptoniH. — The subject of this disease is usually a sufferer 
 from impaired health for some time before the true nature of the diffi- 
 culty is ascertained or even suspected. The first symptoms are 
 indigestion, constipation, loss of flesh and strength, thirst and capri- 
 cious appetite, sometimes amounting to voracity. After a time the 
 first suspicious symptom makes its appearance ; the patient observes 
 that the acts of urination are more frequent, and that the quantity 
 of urine passed at a time is considerably greater than before. The 
 urine is usually clear and pale, and it emits a sweetish odor. As 
 time elapses the calls to urinate becomes so frequent as to consti- 
 tute an annoying symptom ; the patient's rest is seriously disturbed 
 in consequence. In some cases the urine causes a stinging, hot 
 sensation as it passes along the urethra, and soreness of the skin — 
 eczema — is frequently induced around the genitals, especially in 
 women. This complaint is aggravated, perhaps in part caused by 
 the intense itching of the skin — a desire which is in itself a most 
 annoying feature of the disease, especially to females. 
 
 The quantity of urine is sometimes increased to an enormous 
 extent ; instead of three pints, the average amount of a healthy 
 
SUGAR IN THK liRINK — UIAUETES. 
 
 281 
 
 • \ 
 
 adult, ten, twenty, thirty, and even forty pints may be passed in 
 tlic twenty-four liours. The urine contains sui^ar, as can be 
 demonstrated by the jMcipcr chemical tests ; not the orcHnary table or 
 cane sutjar, but a sub^l,lnce which is identical with the suj^ar of 
 j^rapes, and is hence termed t;ra[H- su;j,ar. 'Jlie cjuantity of sugar 
 passed in twenty-four hours ma\- \ary fi\/m half a pound to six or 
 ei^ht pounds. 
 
 Meanwhile other sytun'.oiiv. quite characteristic of the disease 
 are deveU^ped. 'I'iie sl.in li' iimim . iir_\- and liai h ; the patient loses 
 
 flesh and strength ; tl 
 
 u' ail 
 
 .(-'.Iti- is usua.lly voracious — a feature 
 
 which, coupled with tin- proi.rcF ive loss of flcsii, should alone 
 arouse suspicions as to the nature of tin; disease. Thirst, too, is a 
 prominent symptom, as c;in be readily untlerstood when we consider 
 the enormous cpianlities of w.iler excreted in the twenty-four hours. 
 Digestion usually remains ;;<( d until the disease is far advanced ; in 
 exceptional cases ob.-li:iatc viuiii'.iiig oicurs. The teeth are often 
 loosened, and may fall out spontaneously ; the gums are often soft 
 •ind bleed readily upon presnire. This condition of tlie mouth is 
 apt to make the breath unpleasant and fetid. In other cases there 
 is a sweetish odor about the breath which is quite characteristic. 
 
 Sometimes, too, di.d)i tic pa'iints are troubled with a series of 
 boils, which torment the individual for nidiiths at a time. In fact, 
 one who is troubled by numerous and frecpiently recurring boils 
 should submit his urine for examination, since this is occasionally 
 one of the earliest manifestations of the disease. Various dis- 
 eases of the skin, and sometimes ulcers of the lower limbs, are 
 accompaniments of the disease. 
 
 The eyes, too, are the subject of serious difficulties in this dis- 
 ease. At times feebleness of vision and even complete blindness 
 may occur without any apparent disease in the eye ; in other cases 
 a whitish opacity of the crystalline lens occurs, so that the pupil 
 looks gray or white instead of black. This condition is known as 
 ciitaract, and causes partial or complete loss of vision. The ner- 
 vous system is also affected, as is shown by dull pains in various 
 parts of the body, especially across the loins, by dizziness and 
 headache, and by an irritable and morose condition of the mind 
 which sometimes culminates in imbecility. In the female the men- 
 strual flow gradually diminishes, and finally ceases entirely ; in both 
 sexes the sexual appetite is impaired or lost. 
 
 The progress of the disease is usually slow and gradual ; it 
 
 19 
 
 
 I 
 111 
 
^7^ 
 
 282 
 
 DISEASES OK THE INTESTINES. 
 
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 m y. 
 
 11'.' 
 
 has been known to exist for many years before terminating fatally, 
 yet other cises occur in which death results after a few months; 
 this fatal result at an early date is commonly due to some other 
 affection which has been implanted upon the diabetic patient. It 
 has been observed that such patients are not only especially prone 
 to certain diseases, especially of the lungs, but also that they mani- 
 fest but little power of resistance to disease. A diabetic patient 
 who acquires pneumonia or consumption rapidly succumbs to the 
 disease. 
 
 Cause. — Up to the present time, we are in ignorance as to 
 what part of the body is at fault in this disease. We arc accus- 
 tomed to think of it among the diseases of the kidneys, though of 
 course the kidneys are not at fault, since they are merely elimi- 
 nating from the blood materials which cannot be used in the system. 
 It seems extremely probable that the root of the disease lies in a 
 fault of the brain, for it is well known that by injuring a certain 
 part of the brain in an animal it is possible to induce a flow of 
 sugary urine. Moreover, it has been repeatedly observed in post- 
 mortem examinations of diabetic patients that this particular part 
 of the brain was the subject of disease or injury. 
 
 As to what should cause this affection, we can as yet only 
 speculate. It has been ascribed to exposure of the body to cold 
 and wet, to the abuse of alcoholic liquors, to sexual excesses, to 
 overwork, and to violent mental emotion. Doubtless these pre- 
 dispose to the development of diabetes, as well as to other diseases 
 of the nervous system, yet that they are alone sufficient to cause 
 the disease is not as yet established. 
 
 Diabetes usually results fatally, yet recoveries do undoubtedly 
 occur. While we are not acquainted with any plan of treatment 
 which can arrest the disease after it has endured for a considerable 
 time, yet much can be done if treatment be begun in the early 
 stage of the disease. Diabetes usually occurs between the ages 
 of 30 and 50 years, and about twice as often in males as in females. 
 With reference to the prospects for life, Dr. Roberts says, in this 
 connection : " The younger the patient, the less hope of ultimate 
 recovery. All the cases under 20 which I have seen have eventu- 
 ally succumbed. In persons advanced in years, the appearance 
 and persistence of sugar in the urine is a far less serious affair ; it 
 may continue for many years, in oscillating quantity, with fair 
 preservation of health. It is a curious circumstance that diabetes 
 
SU(iAK IN THE URINE — DIABETES. 
 
 a«3 
 
 in corpulent persons is very markedly less formidable than in those 
 of spare habit. Saccharine urine, without excess in the quantity 
 of urine, is far less serious than when the urine is abundant. Cases 
 wliTch can be traced to mental anxiety and to injuries, appear to be 
 somewhat more hopeful than those for which no tangible cause can 
 be assigned. " 
 
 Tfentment. — The treatment of diabetes must consist chiefly 
 in such regulations of the diet as shall avoid the introduction into 
 the system of articles containing sugar or starch. It hus been 
 shown by long experience that this is the only method which affords 
 even partially satisfactory results. Among medicines nothing has as 
 yet been found which can be relied upon to cure or even to arrest 
 the disease. There are, it is true, several remedies which diminish 
 quite markedly the amount of sugar passed with the urine ; and on 
 this account these remedies have been extolled as efficient agents 
 in controlling the disease. Yet observation shows that although 
 the amount of sugar may be diminished under the" use of certain 
 drugs, yet the disease, the steady decline of the patient's health, is 
 not thereby materially retarded. The best standard for estimating 
 the progress of the disease is found to be, not the quantity of sugar 
 present in the urine, but the ivcight of the patient. So long as the 
 patient's weight steadily decreases the disease is progressing, no 
 matter what be the quantity of sugar passed in the urine. 
 
 Among the remedies which have found most favor the follow- 
 ing prescriptions may be given : 
 
 Bicarbonate of soda, - - - - 20 grains. 
 Bromide of potassium, - - - 15 " 
 
 Water, ..._._ i ounce. 
 
 To be taken three times a day. If preferred, the powder may 
 be taken dry without the water. 
 
 Salicylic acid, in doses of five to ten grains, and carbolic acid, 
 in one drop doses taken in water, have also been employed. 
 
 Among the most frequently used remedies are opium, ergot, 
 ;ind tannin. These may be combined as follows : 
 
 Opium, ...--- 10 grains. 
 
 Tannic acid, - . - - - - 3 drachms. 
 
 Tincture of ergot, - - - - 6 ounces. 
 
 Mix, take a teaspoonful four times a day. 
 
 If this mixture be rejected by the stomach, the opium itself may 
 
 
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 ill 
 
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 w. 
 
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 V 
 
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 284 
 
 nrsKASKs oi- riiK intkstinks. 
 
 be administered alnne in (lo-u,s of oiic-lialf a grain three rimes a 
 day, ,t;railiially increased to one oi- luo L;raiiis at a dose. If no 
 preparation o*" ()|)iiini c;in hi* well taken, belladonna may be sub- 
 stituted, 'riiii m.iy he [^ivrn in the >lia|)e of the tiiictnrc, fifteen 
 or twenty di ops of w liie'i m,i\- Ik; t.iKcn three times a day ; or a. pill 
 may be ;,;ive!l afli i' t'l.- Inllow in;; ('.Hiiiula : 
 
 l''xtrae'i of bvllailoniui, - - - - 8 {grains. 
 ICxtracl of mi\ Viiiiiea, - - - 6 " 
 
 Kxtrai-l of I r,4 .t, - - - - 4 " 
 
 Mix, and make tvveiit) -T'lir pii!^; let one be taken before 
 meals. 
 
 One of the troublesome ; xnip'.onH which may require treat- 
 ment is the /////j/. 'lliis can sduietinies be relieved by the use of 
 lemonade, without ^U'^^ar, or of c Uric aei ' ; or fifteen drops of diluted 
 phosphoric acid may be given in water as often as required. 
 
 The chief reliance in treatment i-;, however, upon the regulati:)n 
 of the diet. This regulation inJiules the exclusion of sugar and 
 articles containing it, as well as I he avoidance of starch ; for during 
 digestion starch is converted into sugar and enters the blood as such. 
 The diet may, therefore, include meats of all kinds, excepting 
 liver. Butter, cream, cheese and eggs may be given, but milk should 
 be avoided. Among the vegetables, lettuce, cabbage, celery, onions 
 and spinach may be taken, as they contain but a small amount of 
 starch. Tea and coffee may be taken, though they should be sweet- 
 ened not with sugar but with glycerine. If it be necessary to give 
 wines or liquors, those should be preferred which contain the least 
 sugar ; these are claret, sherry and whisky. An important point 
 in the diet of those patients is variety, both in the articles selected 
 and in the mode of their preparation. 
 
 The stumbling block in prescribing a diet for diabetic patients 
 consists in the want of bread ; for no matter how great the variety 
 of other food, the patient has a longing for bread which finally be- 
 comes irresistible. To supply this deficiency much ingenuity has 
 been employed, and bread, or rather mixtures which are by courtesy 
 called bread, have been made out of a variety of substances, even 
 out of almonds. That which has secured the most favor among 
 medical men is the bran bread, devised by Dr. Camplin, of London. 
 This gentleman was himself a sufferer from diabetes, and ascribes 
 his recovery for a period of ten or twelve years to the use of certain 
 dietary measures, among them the use of this bread. His recipe is as 
 
1 I 
 
 su<;au in tiik ukink — diahetes. 
 
 2«5 
 
 follows : " Take a qiiaiil. of wheat bran, boil it in two successive 
 watcrsfor aqiiailcrof an hour, each lime straining itthrou";]! a sieve ; 
 wash it well with cold water on liu; siive until the watf;r runs off per- 
 fectly clear. Squeeze the um- h vl b'.iii in a cloth as dry .'is possil)le, 
 then spread it thinly on a di U .ind pl.u c it in a slow oven. When 
 it is perfectly dry anil cri-p it is fii fi>i f.'iinding into fine jiowder. 
 
 " The bran thus prep. ued i'. jjround in the mill for the purpose, 
 and must be sifted throu;.',h a wire sieve of such ("incii" -; as to 
 require the use of a brush to p.iss it throuj^h, and wh.it icmains on 
 the sieve must be reyrouiul 'lill it is sulficienlly soft ar.d fiiu-. 
 
 " To prepare a cake fioiii it, lake u\' this bran pf)v, d", \h':cc or 
 four ounces, three new-l.iid e;.',;;s, one and a half or t'Ao o.'.iicc^s of 
 butter and about half a pint of milk. Mix the eijLjs \\\'A\ a little of 
 , ( milk and warm the butt^'r with the remainder ot llii; ir.i'.k ; stir 
 i.,e whole well tojjether, addiiv^ a little nutmeg and [\\u[, , ov any 
 other spice that may bo a;;reeable. Hake in sni.;Il p. ; (i>.illy 
 pans, which must be well buttered) in a r.ither quick o\en for ai)out 
 half an hour. The cakes, when baked, should be a little thicker 
 than a captain's biscuit. 
 
 " These cakes may be eaten with meat or cheese for breakfast, 
 dinner or supper, and require a free allowance of butter ; and the 
 cakes are more pleasant if placed in the oven a few minutes before 
 bein^ placed on the table. 
 
 " When economy is an object, when a change is required, or if 
 the stomach cannot bear butter, the cakes may be prepared as fol- 
 lows : 
 
 " Take of the prepared bran four ounces, three eggs, about 
 twelve ounces of milk, with a little s[)ice and salt ; to be mixed and 
 put into a basin which h.is \).^cn previously well buttereil. Hake it 
 for about an hour ; the loaf may be then cut into convenient slices 
 and toasted when wan'. ■■! ; ur, after t-licing, it may b.: rebakcd and 
 kept in the form of ru 1. ;. 
 
 " Nothing has yet li -.mi i!i 'covered of eqiM! ulilii_\- to thr- -c bran 
 cakes, combining as lli >■ i!o iii' 'il'r.iie eo-t will ri\>..'.o;n from 
 starch and siiiVicicnt pliM -.m: iii'. s ,i .m .irtii:Ie of t'n.iJ." 
 
 Vaiious oilier pkiii-; 111" dii't li.i'.v" l).-i.-n i'lopi)-,. .1, but none of 
 them seem entirely sati-M'.i. ■■uy. 'riiii-:, an (.'Me'u; i\ '.)• .-iniiii.il diet 
 lias been observed in iiiuiieirius ches with the eilccl; of certainly 
 diminishing rapidly the amount of sugar in the urine, but such a diet 
 cannot be long endured ; and, indeed, it is not reasonable to deprive 
 
 li 
 
 n 
 
 l.*fr'tl 
 
286 
 
 DISEASES OK THE INTESTINES. 
 
 man of vegetable food. The same remarks apply to another exclu- 
 sive diet which has been used apparently with success in several 
 cases by a well-known British physician. This consists exclusively 
 of skim milk, six, eight or ten pints of which may be given in 
 twenty-four hours. If the patient is to be improved by this diet, 
 the improvement will be manifest within a week. Others have sub- 
 stituted Xv/wj'.sw for the skim milk in this plan of treating diabetes. 
 
 One of the most important items in the treatment of this, as in 
 most other diseases of the nervous system, is a complete change in 
 the habits of life, whereby the body may be placed under the best 
 possible conditions for health. Change of scene, including abundant 
 amusement and recreation, have often improved these cases won- 
 derfully, even without very rigid attention to the dietary laws above 
 prescribed. An eminent French physician, Trousseau, has found 
 the best results from residence in the country combined with a lib- 
 eral diet of fruits and of those vegetables which do not contain 
 much starch. He has even allowed such patients small quantities 
 of bread, and believes that they derive benefit from its use not- 
 withstanding the increase in the amount of sugar in the urine. 
 
 Diabetes Insipidus. 
 
 This affection presents some of the symptoms of diabetes mel- 
 litus, just described; but it is a far less serious affection. 
 
 Hijtnitioms. — The premonitory symptoms may be essentially 
 those of genuine diabetes; and the patient soon begins to pass 
 excessive quantities of water, amounting even to ten or twenty 
 pints daily. The thirst is intense, the skin becomes hot and dry ; 
 the patient gradually loses flesh and strength, the appetite becomes 
 impaired, and in a certain number of cases a fatal result ensues. 
 It occurs more frequently among males than among females, and 
 usually begins in childhood or youth. It may last for many years, 
 or even for a lifetime, sometimes ending spontaneously, and often 
 cured by the occurrence of some acute disease. 
 
 Cause, — It has been supposed that disease of the brain, 
 habitual drunkenness and injuries to the head are active agents in 
 inducing this disease ; though in some cases of it none of these 
 causes can be reasonably supposed to exist. 
 
 1 
 
 ;? 
 ■•'t 
 
1 
 
 ADDISONS DISEASE. 
 
 287 
 
 Treatnient. — It is sometimes possible to arrest the disease 
 by the administration of ergot, a teaspoonful of the tincture being 
 given three times a day, and gradually increased to two tea- 
 spoonfuUi. 
 
 It is important to distinguish this disease from diabetes mel- 
 litus ; not only for the sake of the patient's feelings, but also be- 
 cause the treatment need not be so rigorous as in the case of the 
 latter disease, for in diabotes insipidus it is not necessary to with- 
 hold sugar and starch from the patient. 
 
 Addison's Disease. 
 
 if 
 
 This disease — so named after Dr. Addison, of London, who 
 first described it in 1855 — is characterized by progressive emacia- 
 tion and loss of strength, and by a peculiar bronze color of the 
 skin. It occurs in both sexes, usually after middle life. It begins 
 slowly and insidiously ; the face becomes pale, the flesh soft and 
 flabby ; there is shortness of breath, and indisposition to exertion. 
 Palpitation of the heart is not infrequent ; the lips, gums and 
 tongue become blanched ; the muscular weakness is extreme. The 
 most remarkable feature in the disease is a peculiar brownish dis- 
 coloration of the skin, which commonly pervades the entire surface, 
 though most marked on the face, neck and upper extremities. This 
 color is sometimes so intense as to give the individual the appear- 
 ance of a mulatto. 
 
 The disease invariably terminates fatally within four or five 
 years, the average duration being eighteen months to two years. 
 Thij patient may retain a considerable degree of flesh to the last, 
 though the strength be almost entirely gone. 
 
 As to the treatment of Addison's disease, nothing is as yet 
 decided to be beneficial. The objects of treatment are merely to 
 support the flagging strength of the patient, though with the 
 assurance that nothing more than slight prolongation of a wretched 
 life can be hoped for. 
 
 ;!'., I >l 
 
 i ■ ■ 
 
 
 
288 
 
 DISKASES OK THE INTKrfTfNKS. 
 
 .1! 
 
 Forty grains. 
 
 Six clracluns. 
 
 One oiiiicr. 
 
 To make four ounces. 
 
 The usual tonic remedies, quinine, iron and nux vomica, may 
 be given in the following prescription : 
 Ouininc, - _ . _ 
 
 Tincture of the chloride of iron, 
 Tincture of nux vomica, 
 Orange flower water. 
 Mix and take a teaspoonful in water bcfoie me.iis. 
 
 Advantage has been asserted from the use of the following 
 prescription : 
 
 Tincture of iron, - . . . One ounce. 
 
 Spirits of chloroform, ... One ounce. 
 
 Glycerine, ----- Six ounces. 
 Mix and take a teaspoonful four times daily. 
 
 i"l 
 
 .'in. 
 
 H. 
 
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 H 
 
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 *\$ 
 
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 hm 
 
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 <fl 
 
I 
 
 111 
 
 624.— The Oreat Sympathetic Nerve. 
 
 7.— View of the Nervous System of Man, showing the uerve 
 centres (brain and spinal cord) giving off nerves (o suppty the 
 whole of the body. 
 
 627.— A view of the nerves on the back of the forearm and hand. 
 
 NERVES. 
 
DISEASES OF THE NERVOnS SYSTEM. 
 
 By the nervous system we understand ordinarily those nerv- 
 ous structures contained in the skull and spinal colum. These 
 consist of the brain and the spinal cord. These constitute, how- 
 ever, but a portion of the entire nervous system. Man, like the 
 other higher animals, is provided with two nervous systems 
 intimately connected, and yet having many duties to perform inde- 
 pendently of each other. The first of these, the so-called sympa- 
 thetic ox ganglionic system, comprises numerous masses ox ganglia 
 of nervous tissue which are scattered throughout the body, accom- 
 panying the blood vessels everywhere, and regulating the functions 
 of the variors organs — stomach, intestines, heart, lungs, etc. — 
 which are concerned in the maintenance of the individual. The 
 duties of this nervous system are therefore the regulation of the 
 animal economy, the maintenance of equilibrium among the diflferent 
 parts of the organism. In some of the lower animals this is the only 
 nervous system present. As we ascend the scale of animal life, 
 the other system — the cerebrospinal — appears at first in a very 
 simple and rudimentary form, increasing in complexity as the struc- 
 ture and functions of the animal become more elaborate. This 
 cercbro-spinal system presides over those portions of the animal 
 which bring him in contact with the external world. The simplest 
 animals, which are merely masses of jelly without any organs of 
 sense or of locomotion, have no such nervous apparatus, while in 
 the warm-blooded animals, which are provided with complicated 
 organs of sense, the cerebro-spinal system is more elaborate than 
 the sympathetic. As a natural result, the diseases of the brain and 
 spinal cord, those parts of the nervous system which are concerned 
 in the intercourse of the individual with the external world, are 
 more easily recognizable, and have been far more thoroughly 
 studied. 
 
 389 
 
 
 'fit' MffclBif^' 
 
 ) Ml- 4 
 
 
290 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Inflammation of the Brain. 
 
 W h 
 
 ifc'ifei;.": ' 
 
 The popular conception of this disease applies rather to another 
 disease, inflammation of the membranes covering the brain, or 
 meningitis. For it should be remembered that the brain itself, 
 composed of nervous tissues, is surrounded by membranes which 
 are not nervous tissues, but are simply coverings for the protection 
 of the delicate structures of the brain. These coverings or mem- 
 branes may become inflamed without involving seriously the brain 
 underneath. 
 
 For practical purposes, however, it is impossible to distinguish 
 accurately between an inflammation of the brain and an inflamma- 
 tion of the membranous covering; in fact, in many instances the 
 two are involved together. 
 
 The disease usually begins abruptly, perhaps with a chilj ; 
 there is intense pain in the head, redness of the face and eyes, vom- 
 iting, roaring in the ears, an excited, distressed look, and extreme 
 sensitiveness to light, sound and movement. The pain may be felt 
 over the entire head, or chiefly in certain limited portions of it. 
 The eyebrows are usually contracted, in order to shield the eyes 
 from the light, and sometimes the patient keeps his face buried in 
 the pillow for the same purpose. Movement of the body or of the 
 bed is apt to occasion unpleasant sensations. There may be 
 delirium and convulsions, the latter especially in young children. 
 Sometimes the delirium becomes a prominent symptom so early in 
 the disease that the patient is considered insane. There is intense 
 fever. After a day or two there may be an exaggeration of the 
 head symptoms, the patient becoming so furiousthatit is necessary to 
 confine his limbs in order to prevent him from injuring himself or oth- 
 ers. After some hours, perhaps two or three days, there ensues what 
 has been called the " stage of oppression. " This case occurs when 
 an exudation has taken place from the membranes of the brain, 
 whereby this organ is compressed. The result is impairment, or 
 even abolition, of many of the functions of the brain ; the pain in 
 the head is decreased, or at least is not complained of; the extreme 
 sensitiveness to light, sound and movement ceases ; the delirium dis- 
 appears, and instead of it the patient is often stupid, or even un- 
 conscious ; paralysis of various parts of the body occurs ; this may 
 result in the production of squint ; sometimes both pupils are con- 
 
 t ' 
 
 i 
 
 is 
 
INFLAMMATION OK THE BRAIN. 
 
 291 
 
 tracted, or both dilated, or they may be unevenly contracted, the 
 one large and the other small ; the respirations are slow and labored ; 
 one arm or leg, or perhaps half the body, may become limp and 
 powerless. If the disease terminate in recovery, these symptoms 
 gradually disappear ; yet some of them are apt to persist for months, 
 or even permanently. Thus there may be permanent impairment 
 of vision or of hearing, or paralysis of various muscles. At other 
 times the general bodily health may be recovered, but permanent 
 impairment of the mind, even imbecility, may remain. 
 
 In the majority of cases, death occurs usually in eight or ten 
 days, sometimes within thirty-six hours. In these cases which ter- 
 minate fatally so early, the onset of the disease is not marked by 
 the symptoms which have been described, for the patient seems to 
 be overwhelmed as if by a large dose of opium. Almost from 
 the first he lies stupid, almost unconscious, complaining little 
 or not at all, and soon manifesting the signs of approaching dissolu- 
 tion. 
 
 Treatment, — One of the first objects of treatment is to keep 
 the bowels active. If the condition of the patient permit, free purg- 
 ing with some saline, such as the citrate of magnesia, may be em- 
 ployed ; but if, in consequence of delirium or obstinate vomiting 
 it be not advisable to administer salts, a drop of croton oil may be 
 placed upon the tongue. On the succeeding days smaller doses of 
 the citrate of magnesia or half-drop doses of croton oil may be 
 employed, so that the bowels may be kept free during the entire 
 course of the disease. 
 
 The head should be closely shaved and pounded ice applied to 
 the scalp, enclosed in a bladder or an india-rubber bag. Care 
 should be taken that the influence of the cold be distributed evenly 
 over the entire head, and not limited to a single spot. If ice can- 
 not be procured, cloths should be wet in cold water and applied to 
 the head. In this case care should be taken to change these cloths 
 every five or ten minutes, since otherwise they become warm and 
 useless. 
 
 There should also be used some means for causing the blood 
 to circulate in the feet and limbs rather than in the head. For this 
 purpose light mustard plasters may be applied to the soles of the 
 feet and to the calves. Good results have indeed been obtained 
 from immersion of the patient in a warm bath during the first two 
 or three days of the disease. 
 
 
 h vkm 
 
li 
 
 292 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Care should also be taken to keep the room dark, and to avoid 
 all unnecessary annoyance in the way of noise or bustle. The diet 
 should be bland, and consist entirely of liquids. 
 
 After the appearance of those signs which indicate that exuda- 
 tion has occurred in the brain — that is, after the patient becomes 
 quiet and ceases to complain, the iodide of potassium may be given in 
 doses of five grains three or four times a day in water. The scalp may 
 also be painted with the tincture of iodine. During this stage it 
 becomes necessary for the attendants to supply all the wants of the 
 patient without waiting for him to express them. Thus he must 
 be fed, and in most cases alcoholic stimulants are required to sup- 
 port the patient's exhausted powers. It is often also necessary to 
 employ the catheter, since the patient will be unconscious of the 
 necessity of evacuating the bladder. 
 
 Chronic Meningitis. 
 
 This affection is somewhat rare, and will seldom be recognized 
 except by an experienced physician, since the symptoms are not 
 characteristic of this affection, but may be caused also by other 
 diseases. There is pain in the head, persistent vomiting, perhaps a 
 little fever. A degree of mental dullness, sometimes amounting to 
 stupidity, is also observed. In some cases paralysis occurs in 
 various parts of the face and body. 
 
 < ■■( 
 
 
 { 
 
 i'i'll 
 
 
 
 
 Tuberculous Meningitis. 
 
 This is a form of inflammation of the brain which occurs 
 especially in scrofulous individuals. It seems to be one of the 
 manifestations of the hereditary taint acquired from tuberculous 
 parents — a taint which sometimes appears as consumption, some- 
 times as disease of the joints, and sometimes as this inflammation 
 of the brain. 
 
 This variety of meningitis occurs chiefly in children, though it 
 has been known to affect adults also. Its development is not sud- 
 den, as is the case with accute inflammation of the brain, but comes 
 on slowly and gradually. There is usually pain in the head, espe- 
 
SPINAL MENINGITIS. 
 
 293 
 
 cially in the forehead. During this time the child becomes some- 
 what pale and emaciated, the appetite is impaired, the temper be- 
 comes irritable, and there is a loss of the usual disposition for 
 amusement and exercise. An early symptom, sometimes a promi- 
 nent one, is vomiting ; there is usually some fever, though not 
 sufficient to attract attention. The pain in the head is perhaps the 
 most prominent symptom in children old enough to talk, who fre- 
 quently complain of this symptom and carry the hands to the head. 
 The child is unusually sensitive to light and sound, prefers the dark 
 and quiet room. In consequence of the pain to the eyes from 
 light, the child acquires a habit of frowning to avoid the light ; the 
 face is often flushed, and sometimes it may be noticed that the 
 countenance becomes pale and flushed in rapid succession. In 
 younger children convulsions are often observed. 
 
 Later in the disease the child becomes drowsy and stupid, 
 there is less suffering from headache, the eyes and ears are less sen- 
 sitive. The patient becomes quite stupid, answering questions 
 reluctantly or not at all ; any attempt at conversation is apt to be 
 incoherent and imperfect. The pupils become larger and do not 
 contract when exposed to a bright light as they do in health. 
 Sometimes irregular movements of the eyes are observed and a 
 squint is frequently developed ; during sleep the child closes the 
 eyes but partially. Sight may impaired or even lost ; sometimes 
 there is paralysis of one side of the face or of the entire body. The 
 abdomen is sunken, the bowels usually constipated. Finally the 
 patient becomes unconscious. Convulsions may occur at short in- 
 tervals and a fatal result ensues. 
 
 The duration of the disease varies from one to four weeks, and 
 it appears to be invariably fatal. Cases, it is true, have been re- 
 ported in which recovery occurred ; but it is probable that these 
 were not instances of tuberculous meningitis but of some other 
 similar affection. If there be no mistake in the diagnosici, treat- 
 ment is futile ; the most that can be done is to relieve the patient's 
 suffering. 
 
 Spinal Meningitis. 
 
 This is an inflammation of the membranes which susround the 
 spinal cord as it lies enclosed in the back bone. It is a rare dis- 
 ease, because an inflammation affecting the membranes in either 
 
294 
 
 DISKASKS OK THE NERVOUS SYSTEM. 
 
 the skull or the back boriL" is not usually confined to the original lo- 
 cation, but extends to the brain or to the spinal cord, as the case 
 may be. 
 
 Symptoms. — There is pain along the entire length of the 
 spinal column, radiating to the extremities, and aggravated b\' 
 movements of the body ; there is extreme sensitiveness of the en- 
 tire surface of the body, so that the least touch or even the wave 
 of air from a fan causes the patient to complain. It is impossible 
 for him to endure the weight of the bedclothes. In a few days 
 the muscles in different parts of the body become stiffened and 
 rigid, and there may be spasmodic contractions of the limbs. 
 
 The disease runs a rapid course, rarely lasting more than a 
 week, and usually terminating fatally. In the few cases that 
 recover there are apt to remain distortions of the limbs. 
 
 Cerebro-Spinal Meningitis. 
 
 i|i 
 
 This affection, which is also known as ccrebro-spinal fever 
 and as spotted fever, occurs somewhat rarely as a sporadic affection, 
 but almost always as an epidemic. As such it has caused 
 great destruction in Europe as well as in America for three hundred 
 years. It first appeared in the United States in 1806, in New 
 England ; thence it spread through the Middle States and finally 
 reached the Southern and Western States. It consists of an inflam- 
 mation of the membranes covering the brain and spinal cord, an 
 inflammation from which the most characteristic features of the 
 disease are derived. 
 
 Sfiimptoins. — ^The onset of the disease is usually sudden, and 
 includes a chill, nausea and vomiting, with intense pain in the head. 
 This pain, which soon extends to the back of the neck and along 
 the spine, seems simply agonizing, and soon renders the patient 
 delirious. The pain is aggravated by light, sound, and movements 
 of the body ; so sensitive is the individual to the slightest disturb- 
 ance, that it is almost impossible to stay in his vicinity without 
 causing him annoyance. Notwithstanding the pain along the spine, 
 there is frequently no tenderness in this region, pressure being borne 
 without flinching ; yet the pressure of the hand upon the stomach 
 and abdomen, or upon the skin in different parts of the body, is 
 
 13^ !'»S ' '.-'^ 
 
e, 
 
 CEKEBRO-SPINAL MENINC;ITIS. 
 
 39S 
 
 apt to be painful. As in the cast- of spinal nocningitis, the skin is 
 everywhere intensely sensitive, so that a slight touch or the pressure 
 of the bed-clothes is sufficient to cause pain. 
 
 In most cases, delirium occurs in a few hours; this delirium 
 varies considerably in intensity and in its character. At times 
 several hours elapse before the friends become aware that the 
 patient is not in his usual mental condition ; at first he merely dis- 
 plays a difficulty in collecting his ideas and in answering questions; 
 but after a time he becomes sullen and morose, making no response 
 upon being addressed. In other cases, the delirium is from the 
 first an active one, the patient shouting, singing, and attempting 
 violence to others as well as to himself. In this variety of delirium 
 the patient usually has calm intervals during the day, being violent 
 at night. If there be no delirium the patient is extremely despon- 
 dent and fearful, or becomes stupid and unconscious. Sight and 
 hearing may be impaired ; the face is hot and flushed. 
 
 The condition of the muscles aftbrds valuable information as to 
 the nature and progress of the disease. Violent contractions of 
 tlit'ferent muscles are apt to occur in the limbs, but especially of the 
 neck and back. The result of this rigidity of the muscles of the 
 back and neck is a peculiar position of the head, which is drawn 
 back forcibly, so that the neck and back are somewhat bow-shaped, 
 the back of the head being buried in the pillow. Various other 
 muscles may assume a similar state of contraction, so that the. arms 
 and legs, the hands and feet arc twisted into unusual positions ; and 
 an)' effort to straighten them out occasions intense pain. The 
 various charges in the position of the eyes, also, which have been 
 described in connection with inflammation of the brain, may occur 
 in tlii^: disease. Paralysis is a somewhat infrequent symptom. 
 
 Nausea and vomiting are usually among the first symptoms of 
 the disease, and persist, sometimes, throughout the attack. The 
 tongue is often large and flabby, and when protruded shows the 
 indentations in the sides left by the teeth. The lips and teeth are 
 frequently covered with dark material called sordcs. 
 
 The fever is not so intense as might be expected from the 
 severity of the disease ; indeed, at the beginning of the illness the 
 boily heat is often lower than that of health, as ascertained by the 
 thermometer. At no time in the disease is there marked fever, 
 unless it be for a few hours just before death. 
 
 Another feature, from which the disease gets its name spotted 
 fever, consists of spots due to the escape of blood into the skin. 
 
 /n. 
 
 U ! 
 
 20 
 
296 
 
 DISEASES OK INK NKKVOUS SYSTEM. 
 
 These may vary in size from that of a pin's head to a quarter or 
 half an inch in diameter, and may appear on different parts of the 
 body, particularly on the chest and abdomen. These spots are not 
 always present, even in fatal cases of the disease. 
 
 The disease occurs with especially frequency among children, 
 and is attended with the {greatest mortality. Males more frequently 
 die of it than females. Kpidcmics occur most frequently in cold 
 weather, especially in winter, being next most frequent in the 
 spring. 
 
 There is no evidence that this disease is contagious. 
 
 Treatment, — We are in ignorance as to the cause of this dis- 
 eas,, ..:id naturally ignorant as to the proper means for treating it. 
 A large majority of the patients die, no matter what remedies ot 
 what kind of treatment be employed. In every case, therefore, the 
 patient must be treated and not the disease, and it is impossible to 
 lay down rules which shall apply to all cases. The application of 
 ice to the head and to the spine, the administration of opium, and 
 friction of the body with whisky may perhaps afford relief. 
 
 Apoplexy. 
 
 I ■• 
 
 This term signifies a shock or stroke, and the condition desig- 
 nated by it is really a symptom rather than a disease. For a 
 so-called "apoplectic stroke" may be the result of any one of sev- 
 eral changes occurring in the brain or elsewhere. 
 
 In the majority of cases an apoplectic stroke occurs as the 
 result of a hemorrhage withir the skull. The escape of blood from 
 the vessels causes, of course, a compression of the brain and an 
 arrest of the function:? ot 'iiis organ. Now, since different parts of 
 the brain have different functions to perform, the effect produced 
 by a hemorrhage varies according to the part of the brain in which 
 the escape of blood occurs. If the hemorrhage take place in those 
 parts of the brain which are concerned in the state of consciousness, 
 the effect will be to produce unconsciousness, as well as to inter- 
 fere with other bodily functions, producing paralysis for example. 
 In this case, although the individual be uncon.scious for a time, his 
 breathing and the beating of his heart may not be interfered with ; 
 he may survive an indefinite time, may recover consciousness, and 
 
AI'OI'I.FXY. 
 
 297 
 
 indeed may finally recover the use of the paralyzed members. In 
 other cases the hemorrhage may occur in s ich a part of the brain 
 as to comj^ress the portion which is necessa ,' to continue the breath- 
 '\n\i and the beating of the heart. In this .:as«> death occurs imme- 
 diately. If is such causes as these vvhicl result in the sudden death 
 of individuals while quietly lyin^j in bed, even during sleep. 
 
 In other cases there is no perceptible hemorrhajje, in fact, 
 post-mortem examination fails to shov anythinj; more than a con- 
 gestion of the brain. In still other cases, an injury received months 
 previously may suddenly cause death unexpectedly. Such was 
 the case of Daniel Webster, who dic;l six months after receiving an 
 injury to the head. Short!/ after this injury he addressed a public 
 meeting in Boston withoit giving evidence of any unnatural con- 
 dition of the brain. At the time of death a thick layer of fibrine 
 was found covering a jonsiderablc part of his brain. 
 
 Si/mptorns,- In a great majority of cases the attack occurs 
 witlxnit warning. In some it is preceded by a sense of weight and 
 fullness in the h^ad, dizziness, roaring in the ears and flushing of the 
 face; the apprarance of sparks or motes before the eyes, and per- 
 haps an unusual sense of sleepiness. It seems that in many in- 
 stances, however, the attack occurs at a moment when the individual 
 feels unusually well. 
 
 The patient, if walking or standing, falls to the ground as if 
 leveled by a blow ; in other cases the loss of consciousness is not 
 so sudden, the patient having time to seat himself, or at least recog- 
 nize the necessity and make the attempt to do so. In such cases 
 the patient is aware that something unusual has happened to him, 
 as several seconds, or even minutes, may elapse before he has lost 
 consciousness. If this loss of consciousness be complete, the 
 patient cannot be aroused by iny efforts, but lies with puffed and 
 livid face, breathing slowly and loudly, and often frothing at the 
 mouth. In these cases there are no voluntary movements; except for 
 the movements of breathing, the patient lies as if dead. In other 
 cases the patient may be unconscious and still endeavor to make 
 aimless movements of the limbs ; in the course of these movements 
 it becomes apparent that some of the members are paralyzed ; for 
 it is generally observed that while the arm and leg of one side are 
 readily moved, the corresponding members of ':he other side are 
 motionless, except as they are stirred by movements of the trunk. 
 
 ■i * 
 
 'i ■? 
 
 •Ill 
 
298 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 ■1. 1 
 
 Another feature of apoplexy, which is important as enabling 
 us to distinguish from certain conditions in which the patient is also 
 unconscious, is exhibited by the pulse. The pulse is slow and very 
 full, striking against the finger laid upon it with a great deal of 
 force. The face is usually flushed and somewhat livid ; the skin is 
 often warm and moist. If the eyelids be raised it will be observed 
 that the pupils are often contracted to very small sizes ; and they 
 are also of unequal diameter. The limbs which are paralyzed arc- 
 oftentimes rigid so that they cannot be bent by the patient nor by 
 others. Early in the attack the patient usually vomits. 
 
 The loss of consciousness varies extremely in its duration ; it 
 may pass away in a few minutes, or it may persist for hours and 
 even days. Generally speaking, the severity of the attack, so far at 
 least as danger to life is concerned, may be estimated by the time 
 during which the patient remains unconscious. If consciousness 
 be recovered in a few minutes, there is not usually immediate dan- 
 ger to life ; but if unconsciousness persist for ten or twelve hours, 
 without manifesting signs of improvement, the outlook for the 
 patient's ultimate recovery is very doubtful. 
 
 It is important to be able to distinguish apoplexy from several 
 other affections in which loss of consciousness is present. One of 
 these, which, however, could rarely be mistaken for apoplexy, is 
 the ordinary fainting fit. This, however, is marked by pallor of 
 the face, and by unusual weakness of the heart's action, as shown 
 by the pulse, and sometimes by almost complete suspension of the 
 breathing. 
 
 A condition which presents a much greater resemblance to the 
 symptoms of apoplexy is epilepsy, or the " falling sickness. " After 
 the epileptic patient has fallen to the ground, he lies in an uncon- 
 scious state, breathing slowly and laboriously, his face swollen and 
 livid, foam and blood issuing from his lips. In these symptoms 
 there is an extreme resemblance to apoplexy, and from these alone 
 it would be almost impossible to distinguish between them. Yet 
 the attendant circumstances make the diagnosis easy, for the 
 epileptic fit is usually preceded by convulsive movements, and fre- 
 quently by a scrernr, as the patient falls ; apoplexy, on the other 
 hand, occurs suddenly without the convulsive movements or a 
 .scream. Then again, in a very few moments afler the patient has 
 fallen in an epileptic paroxysm his limbs, which at first were rigid, 
 become strongly convulsed ; he executes jerking movements with 
 
 
APOPLEXY. 
 
 299 
 
 the arms and legs, and usually with the face ; his eyes roil, and the 
 lividity of the countenance gradually decreases. These symptoms 
 are not present in apoplexy. It is quite important to make the 
 distinction, because the patient recovers from an epileptic paroxysm 
 without treatment, and no alarm need be felt, while the apoplectic 
 stroke is always a matter of peril and apprehension. 
 
 Another condition which may sometimes be mistaken for 
 apoplexy is a hysterical convulsion. In these cases it is true the 
 previous history of the individual, and her previous accomplish- 
 ments in the same direction, render the diagnosis easy, even to the 
 unprofessional friends. For a few moments the symptoms ma}- 
 simulate those of apoplexy with wonderful accuracy. There is 
 however a point of difference which enables one to distinguish 
 immediately between the two, and it is this : The apoplectic stroke 
 is almost invariably accompanied by a loss of consciousness, and 
 by the immobility of the face and eyes ; during the hysterical fit, 
 on the other hand, the consciousness is not lost, notwithstanding 
 the apparent stupor of the patient, for if the cold douche be 
 brought into requisition, or any other decidedly unpleasant appli- 
 cation be employed, the patient ndicates at once by serious 
 remonstrances that she is quite aware of the attention bestowed 
 upon her. 
 
 Another condition in which apoplexy is simulated, is profound 
 alcoholic intoxication. This state must be carefully distinguished 
 frr^n apoplexy, since an error in either direction would be at least 
 annoying, and might be the cause of serious results. The dis- 
 tinction is in most cases easy, if the possibility of error be remem- 
 bciL-d ; for intoxication is revealed at once by the odor of the 
 breath, and by the matter ejected from the stomach ; moreover, the 
 pulse is not slow and full, as in apoplexy, but rather rapid and 
 weak. Then, again, the patient can be, by 3='''.d''ous efforts, aroused 
 to some manifestations of consciousness, it ne be only drunk; but 
 if he have received an apoplectic stroke, S!ich efforts remain unsuc- 
 cessful. 
 
 The duration of an attack of apoplexy varies considerably ; in 
 some cases it results fatally in a few minutes ; in others, the patient 
 sinks gradually, and dies in a few days ; in still others, conscious- 
 ness returns, but the paralysis remains — sometimes permanently, 
 at other times disappearing in the course of some months, partially 
 or ct)nipletely. It is impossible to predict what the result wiM 
 
 1^1 
 
 
300 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 for instances have been known in which perfect recovery has oc- 
 curred. Cases are known in which the bodily functions have been 
 entirely recovered, while various impairments of the mind have 
 persisted. Sometimes the patient is merely morose and irritable ; 
 at other times he is easily affected to displays of emotion, laujjhini; 
 and weeping at trifles. In some cases the patient loses the power 
 of speech, not from inability to utter sounds, but from a loss of 
 memory as to the meaning of words. This condition is called 
 aphasia. Many of these cases are most interesting objects of 
 study. They evidently think without being able to employ 
 language. Sometimes the patient does not remember a sinjjle 
 word ; at other times they are able to employ a few words, though 
 evidently quite ignorant of the meaning. Thus, some will say yes 
 or no, in reply to every question, without regard to the significance 
 of the words. It is still more interesting that many of these 
 patients understand everything perfectly, and may even be able to 
 write with some degree of accuracy. In a few cases, such patients 
 have been successful in learning to talk over again, but in most 
 instances all attempts to make this acquisition have failed. 
 
 This loss of speech in connection with apoplexy happens with 
 especial frequency, if the right side of the body be paralyzed during 
 the stroke. 
 
 Cause, — Apoplexy is generally a hemorrhage into the 
 brain, and in most instances there is a disease of the arteries, 
 whereby the escape of blood occurs more readily than in the 
 healthy condition of the vessels. At otl r-r times the fault seems to 
 lie largely in the heart, which has become unusually large and 
 powerful, and hence forces the blood through the vessels with 
 extreme power. 
 
 The disease of the vessels which renders the escape of blood 
 so easy, is often the deposit of lime salts in the walls of the arteries 
 — a condition known as rt^//rr<?;«dr. This condi ion occurs almost 
 invariably after middle life, and attacks of apoplexy are known to 
 happen also with especial frequency in elderly persons. 
 
 The enlargement of tlie heart is usually associated either with 
 chronic Bright's disease, or with some organic disease of the heart. 
 These patients, the subjects of heart disease and Bright's disease, 
 are especially apt to have apoplexy. 
 
 But there are numerous cases of apoplectic stroke in which the 
 kidney and the heart seem to be perfectly healthy, and indeed an 
 
APOPLEXY. 
 
 301 
 
 V. 
 
 examination of the vessels of the brain after death shows that they 
 too are healthy. It seems probable that in these cases the apoplexy 
 is produced by over work of the body or mind, the latter especially. 
 The popular idea that high living is a frequent cause of apoplexy 
 <loes not seem to be in accord with the fact. It is the general 
 impression that there is a so-called apoplectic constitution, consist- 
 ing in a good deal of fat and a short thick neck, constituting what 
 is known as a " full habit. " But the examination of a considerable 
 number of cases of apoplexy with regard to this very point, shows 
 thac the disease occurs more frequently in people of ordinary or 
 even of rather spare habits, than in those addicted to corpulence. 
 
 The occurrence of one attack of apoplexy seems to predispose 
 to subsequent ones ; or to put it more correctly, the individual has 
 acquired such a condition of the vessels as permits a hemor- 
 rhage upon even slight causes. There is a popular impression 
 that the third stroke of apoplexy is invariably fatal. It can 
 merely be said that the dangers increase with every attack, the 
 patient's chances for recovery diminishing as the attacks recur. 
 
 Treatment, — The most important part of the treatment of 
 apoplexy consists in sanitary regulations and precautions. After 
 tlie blood has once escaped into the brain, but little can be done to 
 remedy the disastrous effects. Immediately after the stroke the 
 head may be kept raised and cold cloths should be applied to it. 
 Mustard plasters may be applied to the feet and to the calves for 
 the purpose of drawing the blood from the head. 
 
 A drop of croton oil may be placed upon the tongue in order 
 to promote early and active discharges from the bowels. The 
 paralysis which remains after apoplexy often persists in spite of all 
 treatment. The best results are obtained of electricity and of 
 massai^'-/'; that is, rubbing and kneading with the hands. 
 
 Yet in many cases changes occur in the brain which cannot be 
 altered by any means at our command ; and in most cases there 
 remains permanent impairment of either body or mind, or both. 
 After suffering one attack of apoplexy the patient should take 
 extreme care to avoid, so far as possible, a repetition of the disaster. 
 On this point Dr. Flint says : 
 
 " The liability to a recurrence of apoplexy, after the recovery 
 from the attack, renders it important to observe all possible pre- 
 caution in the way of prevention. Placing the system in the best 
 possible condition by means of a well regulated diet and regimen, 
 
 ■4.1 
 
302 
 
 DISEASES OK THE NERVOUS SYSTEM. 
 
 and avoiding exciting causes, will afford all the security which can 
 be obtained. It is not probable that any protection is afforded by 
 reducing the powers of the system, and other evils may thereby be 
 induced. It is injudicious to adopt a diet which is insufficient for 
 the wants of the system, or to resort to repeated blood-letting, 
 cathartics or other lowering measures. In striving to avoid ex- 
 cesses and imprudences of all kinds, a care must be taken not to 
 err in the opposite extreme. Mental occupation within certain 
 limits is advisable. 
 
 " The liability to apoplexy, if an attack has never occurred, 
 cannot be .'s.Smated with any degree of certainty. This is one of 
 the affection': »"h- :h persons are apt to apprehend, and if certain 
 cerebral sympioms be experienced, especially dizziness, the fear of 
 apoplexy is often : 'ource of much unhappiaess. The suggestion 
 by the physician that there is danger of this affection is an indis- 
 cretion which I have known to prove most calamitous. When 
 apprehension is felt the physician is warranted in giving assurances 
 that dizziness and other cerebral symptoms are sufficiently common 
 without being followed by apoplexy, and that an apoplectic attack 
 is rarely preceded by obvious premonitions. Needless uneasiness 
 may oftentimes be removed by these assurances. " 
 
 Falling Sickness— (Epilepsy). 
 
 This disease, also known as the " falling sickness," is one of 
 the oldest known to medicine. It is further interesting from its 
 association with several names noted in various departments of the 
 world's history ; Julius Caesar, Mohammed and Napoleon Bona- 
 parte are all known to have been sufferers from this disease. 
 
 Symptoms, — In the majority of cases a paroxysm occurs 
 without any warning symptom ; in others there is a certain amount 
 of premonition. This warning usually consists in sensations which 
 the patient describes somewhat vaguely, the descriptions varying 
 considerably in different cases. In many there is headache, dizzi- 
 ness, ringing in the ears, irritability of temper and specks floating 
 before the eyes before the attack. These sensations may be felt 
 even a day or two before the convulsion occurs. In many there is 
 no warning symptom until a few minutes before the fit begins. In 
 
 
FALLING SICKNESS — EPILEPSY. 
 
 303 
 
 these cases there is a fcclirifj of tingling or pain in one of the 
 fingers or toes ; sometimes this feeling is first experienced at the 
 pit of the stomach. This feeling or tingling seems to rise through 
 the body and up into the throat, when the patient falls unconscious. 
 In other cases the patient describes the feeling as if a ball were 
 rising from the stomach into the throat. 
 
 Yet, in majority of cases, there is no sensation of this sort ; 
 when the patient least expects it, perhaps when sitting quietly, 
 or walking along the street, he suddenly utters a loud piercing 
 cry, and falls unconscious. This shriek is loud, short, and from 
 its unnatural character and suddenness, seems terrific. At the 
 <;\me time the face becomes extremely pale. So soon as the 
 patient falls the convulsive movements begin. In some cases these 
 movements seem to begin before the body falls to the ground ; in 
 this case violent and aimless jerking movements of the arms are 
 observed, or the head is drawn around towards one of the shoul- 
 ders. In the majority of cases the first intimation is the pallor of 
 the face, followed almost instantly by the scream, the fall, and the 
 convulsive movements. The person usually falls forward on the face, 
 often injuring the head and face severely. Indeed, one of the 
 greatest dangers of epilepsy is the possibility of serious, or even 
 fatal injury from the falls, since individuals have been known to 
 drop onto heated stoves, into an open fireplace, or to scald them- 
 selves fatally with boiling water. The onset of the attack is so 
 sudden and unexpected in most instances, that the patient is utterly 
 powerless to avoid injury, if circumstances permit it. 
 
 At first the entire body assumes a condition of extreme rigidity, 
 the muscles of the head, trunk, arms and legs seem all strained to 
 the uttermost, the body being bent sometimes in one direction, 
 sometimes in another, but always as stiff as iron. Meanwhile the 
 breathing is arrested, th« face becomes swollen and purple ; saliva 
 issues from the mouth, often tinged with blood from injuries 
 received by the tongue. It occasionally happens that the tongue 
 is caught between the teeth and deeply lacerated as the jaws close 
 upon it. 
 
 This state of rigidity lasts only from a few seconds to half a 
 minute, and is followed by violent movements, which may involve 
 the whole body, or may be limited to the extremities or to the 
 head. The face is terribly distorted, the jaw opens and closes con- 
 vulsively, deep violent efforts at respiration are made, the patient's 
 
 
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 ii li 
 
 304 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 body is often thrown violently from side to side, sometimes sus- 
 taining sevf"? bruises ; sometimes, indeed, bones are dislocated, or 
 even broken from the violence of the movements. 
 
 These convulsive movements last not more than two to four 
 minutes ; their violence then decreases, the respiration becomes 
 more nearly natural, the face becomes less livid, and finally the 
 patient draws a deep sigh, and the paroxysm is ended. The con- 
 sciousness may be now regained at once ; the patient, however, is 
 not aware of what has happened. He experiences a sense of fatigue, 
 and usually falls into a heavy sleep. In most cases, however, the 
 individual remains unconscious for some time, even half an hour 
 after the convulsions have ceased ; during this time his breathing 
 is heavy and labored, and his lips are puffed out during expira- 
 tir n. . times the patient passes from this state into one of 
 deliriuni, talking incoherently, and even becoming maniacal. This, 
 however, is but transient, the patient finally recovering conscious- 
 ness CO.. plet(.;_> . He appears confused and bewildered by his own 
 condition, and is at a loss to understand how it came to pass. 
 After the individual has long been subject to these attacks he 
 becomes accustomed to the situation and manifests less surprise. 
 
 In most cases but one fit occurs at a time, the patient recover- 
 ing consciousness completely. In other instances a second par- 
 oxysm occurs before the patient has recovered from the first ; in 
 fact, several fits may follow one another in rapid succession. 
 
 The paroxysms of epilepsy are sure to return after the patient 
 has had one. The intervals that elapse after the first vary extreme- 
 ly. Sometimes months may elapse between the first and sec- 
 ond ; in these cases the intervals become shorter as time passes. 
 In other cases the paroxysms occur at short intervals even from the 
 first, and, after a few months, they may recur every day, or even 
 several times a day. In some instances the fits come on at regular 
 intervals. In females, the paroxysms at times occur regularly with 
 the menstrual periods. 
 
 The general course of the disease is that the fits recur at con- 
 stantly decreasing intervals ; in other cases, however, the intervals 
 become longer after a time, so that the disease seems to be wearing 
 itself out. Yet spontaneous recovery does not occur, since sooner 
 or later the paroxysms recur, usually with the same frequency as 
 before. 
 
 The greatest diversity prevails as to the intervals which may 
 
FALLING SICKNESS — EPILEPSY. 
 
 305 
 
 elapse in different cases. In some instances a year or more tran 
 spires ; while in others, fifty or one hundred paroxysms occur in 
 twenty-four hours. Dr. Flint mentions a case in which the fits 
 occurred at intervals of a few moments during fourteen consecutive 
 da\s, yet the patient recovered and remained free from the dis- 
 ease for several months. Sometimes paralysis, partial or complete, 
 appears as a sequel to these series of attacks at short intervals ; yet 
 the paralysis is usually but temporary. Another feature which 
 often occurs after the patient has had numerous fits in rapid suc- 
 cession, is a marked impairment of the mental faculties ; the indi- 
 vidual remains childish, or even imbecile, for some hours or days, 
 but soon recovers his usual mental condition. Epileptic fits may 
 occur any hour of the day or night, though in many instances, 
 there seems to be an especial disposition to their occurrence at 
 ni"^ht. In some cases, indeed, they happen only at night for a con- 
 siderable time ; and inasmuch as the patient is unconscious of their 
 occurrence, the disease may exist for a long period before it is dis- 
 covered. It is further interesting that the attacks usually cease if 
 the patient become afflicted with an acute disease. Thus during 
 the course of typhoid fever, small -pox, pneumonia and the like, 
 the individual usually remains free from epilepsy, which however, 
 returns so soon as he recovers from the other disease. 
 
 Cause, — The disease seems to result, in many cases at least, 
 from abuses of alcoholic stimulants as well as from sexual excesses. 
 Yet it is highly probable that venereal excesses and habits of mas- 
 turbation are not so frequently and so directly responsible for the 
 manifestation of epilepsy as the popular impression supposes. 
 Indeed, it is still an open question whether the disposition to sexual 
 excesses and the epilepsy are not to be regarded as the resuits of 
 the same cause. 
 
 Epilepsy has also been known to occur as the result of slow 
 poisoning by lead, as well as by other metals ; and instances have 
 been known to occur in persons afflicted with tape-worms, and to 
 cease when the worms were expelled. 
 
 As to what provokes a paroxysm in a person subject to epilepsy 
 there is no definite information. In some cases it seems that unusual 
 eniotion or excitement acts as a cause in provoking a fit. Thus 
 instances have been known in which a woman has experienced her 
 first epileptic attack on the night of her marriage, and in which the 
 fits have recurred with every subsequent sexual act. Yet in the 
 
 
3o6 
 
 DISEASES or THE NERVOUS SYSTEM. 
 
 majority of cases no such exciting cause is discovered. In many 
 cases tile patient feels indisposed for some time before a fit occurs, 
 and seems to be better after the paroxysm. 
 
 Hysteria seems also to exert a predisposing influence, or it 
 may be more nearly correct to say that individuals subject to hys- 
 teria are prone to the manifestation of epilepsy. In such cases, 
 epileptic fits are sometimes developed apparently as an act of 
 mimicry. Thus it has been repeatedly observed that women sub- 
 ject to hysteria have, after association with people subject to 
 epilepsy, become epileptic themselves. This same development of 
 epilepsy by imitation has been witnessed also in a dog, after asso- 
 ciation with another dog already subject to the disease; for epilepsy 
 is quite common among cats and dogs. 
 
 This disease is sometimes simulated with great success by indi- 
 viduals who seek thereby to obtain sympathy, to arouse attention, 
 and sometimes for purposes of gain. Not long ago it was dis- 
 covered that a certain noted pickpocket of New York was in tht- 
 habit of picking pockctS while apparently suffering a severe fit of 
 epilepsy. His plan was to be attacked with a severe paroxysm of 
 epilepsy while in the midst of a crowd, and then in the excitement 
 and commotion aroused by his " fit," he managed to insert his 
 fingers into the pockets of those bystanders who sympathizingly 
 assisted and protected him. In this case the deception was easily 
 detected when subjected to medical scrutiny ; but another instance 
 is known in which a most accomplished simulator of epilepsy dc-' 
 ceived the medical inspector of a certain state prison, by whom he 
 was, on account of his epilepsy, transferred from the prison to the 
 hospital, from which he readily made his escape. 
 
 Epilepsy seems to be most frequently developed in childhood 
 and youth, and to occur more frequently among females than amonj^f 
 males. The disease, though presenting some of the most terrifying,' 
 pictures, involves no immediate danger to life. It is extremely 
 rare that a patient dies during a paroxysm, no matter how violeiu 
 this may be. 
 
 Yet epilepsy conveys a certain amount of danger to the patient; 
 danger that his mental powers will become impaired. For it is un- 
 questioned that those who have been long subject to frequent at- 
 tacks of epilepsy become, in many instances, weak of intellect, and 
 even idiotic. This result may be, it is true, due somewhat to other 
 causes than the epilepsy itself ; thus those who in early life are sub- 
 
FALLING SICKNESS — EPILEPSY. 
 
 307 
 
 ject to the disease, are not usually permitted to enjoy the same ad- 
 vantages of education and training as others. 
 
 The above description applies to the ordinary form of epilepsy; 
 but there is another form less violent and not marked by such char- 
 acteristic symptoms, which is, nevertheless, the same disease. The 
 attack consists in a sudden loss of consciousness, lasting usually 
 but a few seconds. The individual does not scream nor fall, nor 
 do the convulsive movements occur such as have been described in 
 connection with epilepsy. The individual's movements are sud- 
 denly arrested ; if walking he stops, if conversing he suddenly be- 
 comes quiet, and remains apparently in deep abstraction. Almost 
 before the attention of the bystanders is attracted, the patient re- 
 sumes his former occupation, walking or conversing, taking up the 
 subject where he had dropped it and proceeding as if nothing had 
 happened. To him indeed nothing has happened. He has no 
 knowledge of the occurrence, and it may be long before it dawns 
 upon the friends that the individual is at the time unconscious and 
 not simply lost in thought. 
 
 This mild form of epilepsy may last for an indefinite time with- 
 out undergoing any essential modification ; while in other cases it 
 serves merely as an introduction to the severer form, in which the 
 patient falls and his body becomes contorted by convulsive move 
 ments. In other cases the mild form of epilepsy occurs in the in 
 tervals between the severer attacks, the patient being subject to 
 both varieties at the same time. Almost all degrees of severity be- 
 tween the two extremes narrated have been known to occur; in some 
 cases there is loss of consciousness attended by convulsive move- 
 ments of the jaws or of the face only; in other cases the patient 
 falls to the ground but rises in a few seconds, no convulsive move- 
 ments having occurred. 
 
 " In other epileptic attacks sudden delirium occurs, continues 
 for a few seconds and passes off, leaving the mind in the condition 
 in which it w;is :it the instaal of the seizure. The delirium is 
 manifested in different ways. Trosseau cites a case in which the 
 patient uttered a burst of laughter, and when asked why he 
 laughed, he looked surprised, having no knowledge of what he 
 had done. " The same author relates instances in which indi- 
 viduals, who were engaged in conversation, have abruptly rushed 
 into the street, bare-headed, as if struck by a happy thought, have 
 walked about and then returned, and have finished the conversa- 
 tion, as if nothing had happened, " A female patient, quietly 
 
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 Wmn 
 
 ^<..v.|. 
 
 
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 m' ■ : 
 
30« 
 
 !)!SI:ASES ok the NKRVOUS SYSTEM. 
 
 'ii 
 
 SI ! 
 
 ;. i 
 
 li I 
 
 standing in one of the wards of Bcllcvuc hospital, suddenly uttered 
 a cry and ran from one end of the ward to the other. The urine 
 was at the same time expelled, leaving on the floor traces of hrr 
 course. Having reached the end of the ward, she stopped, looked 
 somewhat confused, and quietly returned. The following is 
 another example : Some years ago a young man who had been 
 subject to ordinary epilepsy for twelve years, came to see me, 
 accompanied by his attending physician. On the previous evening, 
 from time to time, he had paroxysms of jumping up and down 
 witli violence for a few seconds. In walking to my residence, lu- 
 stopped now and then and performed these jumping movements in 
 the street. After sitting down and replying quietly to my ques- 
 tions, he began to jump violently in the chair for a few seconds, 
 and continued to do so at short intervals. " — Flint. 
 
 Tt'entnient. — During the paroxysm the treatment is quite 
 simple ; the patient should have plenty of air, and the bystanders, 
 who are in the habit of crowding around out of curiosity or sym- 
 pathy, should be kept back. The clothing around the neck may 
 be loosened, and, if it can be done early, a pen-holder or a piece 
 of cork may be inserted between the jaws, to prevent the patient 
 from biting his tongue. It is quite unnecessary and undesirable 
 to throw water upon the patient, or in any other way attempt to 
 '?ring him to his senses ; this result will follow spontaneously, and 
 i,aunot be hastened by any such measures. It need scarcely be 
 said that the patient should be placed so that he cannot, during his 
 convulsive movements, do himself any damage ; he should, therefore, 
 be placed in an open space, in the middle of the floor, for 
 example, or on a large bed. 
 
 To break up the paroxysm is, of course, the prime object of 
 treatment. To accomplish this, an immense number of remedies 
 have been employed, and success has been claimed for many of 
 them. The largest number of cases have been benefited by the 
 use of the bromide of potassium, with or without one of the other 
 bromides. The following prescription has been used extensively : 
 
 Bromide of potassium, - - One drachm. 
 
 Bromide of ammonia, - - One-half drachm. 
 
 Iodide of potassium, - - One drachm. 
 
 Bicarbonate of potassium, - Forty grains. 
 
 Infusion of colurr.bo, - - Six ounces. 
 
 Take a tablespoonful before meals, and two tablespoonfuls at bed- 
 time. 
 
 
 
FALI-ING SICKNESS — EPILEPSY. 
 
 309 
 
 In most Ctises better results will be obtained by the following 
 prescription : 
 
 Iodide of potassium, 
 Bromide of potassium, 
 Bromide of ammonium. 
 Bicarbonate of potassium, 
 Tincture of gentian, 
 
 One drachm. 
 One ounce. 
 Four drachms. 
 Forty [jrains. 
 Six ounces. 
 
 A teaspoonful in water before meals, and three tcaspoonfuls at bed- 
 time. 
 
 The bromides should not be taken for a lon^i; time without the 
 direction of a physician, because certain ill results may follow which 
 can be avoided by varying the remedies used. After a certain 
 time the bromide causes mental languor and a certain degree of 
 stupidity. If the use of the bromide causes an eruption on the 
 face and body, as it often will, it may be combined with three or 
 four drops of Fozvler's solution at each dose. 
 
 In every case the bromide should be tried first ; if this fail, 
 after a faithful trial for six or eight months, the following prescrip- 
 tion may be employed : 
 
 Oxide of zinc, - - - -• - 30 grains. 
 Bromide of zinc, - - - - 20 " 
 
 Extract of nux vomica, - - - 8 " 
 
 Make 30 pills ; take one morning and night before meals. 
 
 An important part of the management of epilepsy is the 
 observance of sanitary conditions. All excesses and unnecessary 
 excitement must be avoided. Regul.irity in the evacuation of the 
 bowels, the use of a nutritious diet and abundant exercise in the 
 open air are extremely important. 
 
 Within the last few years the nitrite of amyl has been some- 
 what employed in order to cut short the paroxysms. It has been 
 found that in those cases in which the patient has warning of the 
 attack, by the sensations in the throat aht.u y described, the 
 paroxysm can be often averted by the inhalation of a few drops of 
 the nitrite of amyl. Two or three drops of this substance are 
 placed upon the handkerchief and held to the nose. The imme- 
 diate effect is a sense of dizziness, accompanied by flushing of the 
 face. Yet this remedy is capable of causing serious effects and 
 should not be used except under the direction of the physician. 
 
 While it is in almost every case possible to improve the 
 patient's condition materially, so that the paroxysms shall recur 
 
 ■-«——< — 
 
 Hi 
 
 
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 t 
 
 m 
 
 
3>o 
 
 niSEASKS OF IIIK NKKVOUS SYSi'IiM. 
 
 I 
 
 at much longer intervals and shall be less violent, yet it must be 
 admitted that a permanent cure can be anticipated only in recent 
 cases. Yet in every instance a faithful trial of the more important 
 remedies, extending over two or three years if necessary, should bi- 
 made. For it is to be remembered that the most disastrous feature 
 in the disease is not the convidsions, but the deterioration of tiu- 
 intellect; which is almost sure to follow if the disease 1 'wed to 
 
 progress without treatment ; and that although it may not be pos- 
 sible to arrest wholly the occurrence of the paroxysms, that if they 
 can be checked the prospect for preventing the impairment of the 
 mental faculties is much improved. 
 
 Attention should be called to one other feature of the disease 
 also, namely, that in some cases delirium lasting several hours oi 
 even days, succeeds a paroxysm of epilepsy ; during this time the 
 patient is not in his right mind, and therefore not responsible for his 
 actions. Instances have been known in which patients in this 
 condition have been guilty of acts of violence which would, under 
 other circumstances, have rendered them liable to severe punishment 
 at the hands of the law. 
 
 Catalepsy. 
 
 This appears to be one of the forms or manifestations of 
 hysteria, or at least closely allied to this latter affection. 
 
 In this condition the patient appears to be entirely uncon- 
 scious, his senses and will being for the time quite inactive. The in- 
 dividual remains motionless, preserving the position in which the 
 body happens to be placed at the time when the attack began. 
 Sometimes these positions are such as it would be impossible to 
 maintain for any length of time in health, even by the strongest 
 exertion of the will. Thus the arm may be held out from the body 
 for an incredibly long time, or the individual may balance himself 
 on the floor, in a sitting posture, with the fee, raised, so that the 
 entire weight of the body rests upon the buttocks. Sometimes 
 these positions are maintained for a few seconds only, sometimes 
 for minutes or hours. The other functions of the body do not 
 seem to be disturbed. The breathing and the action of the heart 
 are uniform and natural, and if food be introduced into the patient's 
 
ST. VITUS' DANCE — CHOREA. 
 
 311 
 
 stomach digestion is well performed. In some cases a single 
 paroxysm occurs at a time, the patient being then free from the 
 affection for months. In other instances paroxysms recur in rapid 
 succession, just as they are known to do in epilepsy. 
 
 Co use, — This disease appears to be an affection of the nervous 
 system, and is induced certainly in many cases by excessive emo- 
 tit)n and violent excitement. It seems possible that the starting 
 point of the disease in catalepsy, as well as in hysteria, may be some 
 bodily affection, whereby irritation of the nervous system is pro- 
 duced. In the great majority of cases the disease occurs in hystor 
 ical individuals, and of course chiefly in females. 
 
 This affection is closely allied with the conditions known ;i& 
 trance, somnambulism and mesmerism. 
 
 
 1 ;Jii. it 
 
 St. Vitus' Dance— (Chorea). 
 
 This disease, also known as St. Vitus' dance, is characterized by 
 irregular and aimless contractions of different muscles, without the 
 agency of the will, in fact often in opposition to the desire of the 
 individual. The muscles first affected are commonly located either 
 in the arm and hand or in the face. The irregularity of movement 
 may remain limited to a single extremity for a long time, or may 
 rapidly progress so as to involve all of the extremities and even the 
 trunk itself. The appearances presented by the subject of this 
 affection are most ludicrous ; the first impression derived by the 
 si)cctator is that it is a voluntary performance designed for the 
 amusement of the bystanders. More than a century ago Sydenham 
 described chorea as " a species of convulsions, which for the most 
 part attacks boys or girls from the tenth year to puberty. First it 
 shows itself by a lameness, or rather instability of one of the legs, 
 which the patient drags after him like a fool. Afterwards it ap- 
 ix'ars in the hand of the same side, which he that is affected with 
 the disease can by no means keep in the same posture for one 
 moment. If it be brought to the breast or any other part, it will 
 be distorted to another position or place by a convulsion, let the 
 jiaticnt do what he can. If a cup of drink be put into his hand, he 
 makes a thousand gestures, like jugglers, before he brings it to his 
 mouth; for whereas he cannot carry it to his mouth in a right line, 
 
 21 
 
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 i'}'' 
 
 ^^:! 
 
 
 ■»» 
 
312 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 his hand being drawn hither and thither by the convulsion, he turns 
 it often about for some time, till at length, happily reaching his 
 lips, he flings it suddenly into his mouth, and drinks it gref ^ily, as 
 if designing only to make sport. " 
 
 The constant activity of the muscles causes exhaustion, so 
 that the patient may be unable to perform the acts necessary to 
 supply his bodily wants. He may even be unable to wrlk, not be- 
 cause his legs are too weak, but simply because they do not obey 
 his will. In most cases the contortions become more violent as the 
 patient's efforts to control his muscles become more vigorous. 
 
 The affection is not accompanied by fever, but the general 
 health is usually somewhat impaired. In many instances there is 
 decided pallor and often some emaciation. The mind becomes 
 impaired. At times the power of speech is practically lost on 
 account of the lack of control of the muscles whereby articulation 
 is affected. In these cases the individual seems even more stupid 
 and imbecile than is actually the case. The strength of the mus- 
 cles which are affected by the disease is diminished, and in conse- 
 quence there is apt to be general impairment of muscular strength. 
 At times, also, the sense of touch is impaired, especially in that 
 part of the bod)^ which is subject to the disease. 
 
 St. Vitus' dance may occur at any period of life, but is most 
 frequent during the years preceding puberty ; that is, from ten to 
 fifteen. Girls are more frequently affected than boys, in the pro- 
 portion of three to one. 
 
 The affection lasts ordinarily from two to four months ; it 
 may terminate earlier than this period, or may, on the other hand, 
 last for many years. Cases are known, indeed, in which the 
 individual has suffered from it during his entire life. It terminates 
 usually in recovery ; yet the disease may recur several times in tlic 
 same individual, althugh finally disappearing permanently. These 
 relapses occur after intervals of several months, or even one or two 
 years. 
 
 As to the cause of chorea nothing definite is known. There 
 are certain reasons for believing that in many cases at least the 
 affection is a disease of the brain, consequent upon organic heart 
 disease. Yet in the majority of cases there is apparently no diseas-^ 
 of the heart, and it is impossible to ascribe the affection to this 
 source. In other cases St. Vitus' dance commences immediately 
 after a fit of excessive emotion, such as anger or terror. There is 
 
 %■■»: 
 
ACUTE CHOKEA. 
 
 313 
 
 a popular idea that this affection, lilvc so many others, is to be 
 ascribed to worms in the intestine ; as to this, it can only be said 
 that there is no evidence to this effect. It is quite possible that 
 the irritation caused by the presence of worms may aggravate the 
 condition, though it does not seem possible, in the light of our 
 present experience, that the disease should ever be due entirely 
 to them. 
 
 Acute Chorea. 
 
 In certain rare cases St. Vitus' dance appears in an entirely 
 different guise. In these cases there is not merely a twitching of 
 certain muscles, without constitutional disturbance, as in ordinarj' 
 cases. In these instances the patient's entire body becomes sud- 
 denly affected with the most violent convulsive movements. He- 
 is unable to take food or drink, cannot speak coherently, and is 
 tossed about violently in spite of all his efforts to remain quiet. 
 It is usually necessary to restrain the movements of his body by 
 tying the limbs to the bed, since otherwise the patient would suffer 
 serious physical injury through his own involuntary movements. 
 The patient is apt to be at first amused by the absurdity of his own 
 situation, and laughs heartily at the violence of his own grotesque 
 and aimless movements. Within twenty-four hours it becomes 
 evident, however, that the affection is no laughing matter ; the 
 patient becomes exhausted by the violence of his own uncontrolla- 
 ble movements ; high fever occurs ; the patient must be nourished 
 artificially. But in spite of all that can be done, in spite of mor- 
 phine, chloral and chloroform, the patient continues the move- 
 ments, and in from four to eight days dies exhausted. These cases 
 are fortunately rare ; but up to the present time all modes of treat- 
 ment are alike hopeless. 
 
 Ti'eatment, — In the majority of cases chorea terminates in 
 recovery spontaneously. Hence it has happened that a vast num- 
 ber of remedies have acquired a reputation as specific cures for the 
 disease, for the patient recovers no matter what remedy, provided 
 it be harmless, be administered to him; hence every remedy which 
 is thus used seems to cure the disease. It would be quite useless 
 to name all the medicines which have beesi given for the treatment 
 
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 t! iJSi 
 
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 \u 
 
 II 
 
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 lilftiri 
 
 314 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 of St. Vitus' dance with apparent succ? -.s. Those most frequently 
 used are the bromide of potassium and the valerianate of zinc. 
 In most cases it becomes necessary to administer tonic medicines, 
 for the children are evidently in need of some blood-making reme 
 dies. They are pallid and become more so as the disease progresses. 
 It is therefore desirable to administer iron and cod liver oil. For 
 this purpose one of the following prescriptions maybe given : 
 
 Syrup of the iodide of iron, - Two ounces. 
 Take ten to fifteen drops in water after meals. 
 
 Citrate of iron and quinine, - On* " achm. 
 
 Cod liver oil, . . - 
 
 Glycerine, . - - - Each two ounces. 
 Mix and take a teaspoonful after meals. This dose may be grad- 
 Ue.".ly increased if the stomach bear the oil well. 
 
 Arsenic, - . - - One-quarter of a grain. 
 
 Reduced iron, - - - Ten grains. 
 
 Extractofnux vomica, - Two grains and a half. 
 
 Sulphate of quinine, - Ten grains. 
 Mix and make twenty pills. Take one before meals. 
 
 In other cases Fowler's solution has been used with advantage, 
 two or three drops being given before meals three times a day, and 
 the dose gradually increased. 
 
 Whether these or other remedies be tried, there will be found 
 cases which obstinately resist all treatment, at least by medicines 
 alone; on the other hand, cases have recovered under strict atten- 
 tion to sanitary regulations after they had baffled almost all modes 
 of treatment by drugs. This treatment consists of light and 
 nourishing food and exercise. In some cases systematic gymnastics 
 have been employed; but it may be laid down as a fact, that exer- 
 cise is beneficial only when the mind is employed as well as the 
 body; hence a residence in the country or at the seashore, or some 
 other way of combining bodily exercise and mental recreation, is 
 far preferable. 
 
 If the child is compelled to remain at home, the cold bath 
 should be employed every morning ; if possible a course of sea 
 bathing will be found very beneficial. 
 
 Another point is that the child should receive the sympathy 
 and attention of parents and friends, and should be protected from 
 the thoughtless ridicule which is naturally excited among children 
 by the grotesque movements that cannot be controlled. 
 
 P 
 
 
LOCK-JAW — TETAN US. 
 
 315 
 
 In every case which proves at all obstinate, the patient should 
 be submitted to the best medical advice. 
 
 Lock-jaw— (Tetanus). 
 
 This affection consists of a series of painful and violent con- 
 tractions of the voluntary muscles, either of the jaw alone or of a 
 considerable part of the body, while the intelligence and mental 
 faculties remain unimpaired. In th : majority of cases the disease 
 occurs after a wound or injury, while in others there appears to be 
 no exciting cause. 
 
 Symptoms, — The earliest symptom is usually a stiffness of 
 the muscles about the neck and at the back of the head, which is 
 commonly noticed first upon awakening in the morning. This stiff- 
 ness extends or perhaps begins in the muscles of the lower jaw, 
 while the throat becomes dry and somewhat painful. At first the 
 pain and stiffness may not attract attention, since precisely similar 
 symptoms may follow exposure to currents of air. But it soon be- 
 comes evident that this is something more than the stiffness following 
 a cold, for the jaws are found to be firmly closed by the spasmodic 
 contraction of the muscles; at first the patient opens his mouth with 
 great difficulty and can swallow but imperfectly. It is from this 
 feature of the affection that the disease derives its name of locked 
 jaiv. In some cases these contractions remain limited to the mus 
 cles about the neck and face. The mouth in many instances cannot 
 be opened either by the patient himself or by the use of any force 
 which it would be prudent to employ; nourishment can only be 
 given through the spaces which naturally exist between the teeth. 
 Sometimes the muscles of the face also are involved in these con- 
 tractions, occasioning the most frightful contortions of the counte- 
 nance. Sometimes the muscles of the throat are so much involved 
 that swallowing becomes quite impossible. 
 
 If the muscles of the trunk also become involved, the move- 
 ments of the chest necessary to breathing ar-i embarrassed, so that 
 the patient appears at times in danger of suffocation. The abdomen 
 is drawn inward and becomes very hard and stiff. Sometimes the 
 limbs too are similarly affected, so that they are held as firmly as 
 
IW) i ' 
 
 m 
 
 I 1 • 
 
 H 
 
 
 iHl * ii 
 
 
 Hiiy;-,: 
 
 316 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 bars of iron. In such cases the entire body may be raised from a 
 single limb or even by the head, as if it were a statue of marble. 
 
 In many cases when the limbs and trunk are involved in this 
 rigidity the body rests not flat on the back but in the shape of a 
 bow, the weight being supported by the head and heels. Some- 
 times the body is bowed in the opposite direction, so that the 
 patient can be placed with his head and toes on the floor while the 
 body is raised some inches. It may also happen that the body is 
 bent toward one side or the other. 
 
 The suffe: .• from tetanus is a most pitiable object ; the re- 
 markable positions which the body assumes during the spasms. 
 the fantastic and distorted countenance produced by spasm of the 
 muscles of the face, the peculiar sardonic grin caused by the con- 
 traction of the muscles about the mouth, and withal the evident 
 pain and distress of the individual, combine to render the sight an 
 extremely painful one. 
 
 The muscles remain rigid continuously, but there occurs at 
 intervals a spasm, whereby the force of their contraction is increased. 
 It is during these spasms especially that the peculiar postures are 
 assumed by the body. These paroxysms occur at intervals 
 and vary extremely in their duration ; they are attended also with 
 extreme pain. These spasms seem to be excited by movements of 
 the body and by mental emotion, and may even be induced by con- 
 tact of e.xternal objects with the skin. 
 
 The mind remains unaffected ; there is no delirium nor stupor 
 in uncomplicated cases. The spasms are more apt to occur during 
 the day than by night, presumably because the influences which 
 can excite the patient are more abundant by day. There is, 
 usually, some fever, and the skin is often moist with clammy per- 
 spiration. 
 
 The disease usually terminates fatally in from two days to two 
 weeks. Sometimes death is caused by suffocation, the patient's 
 chest being so convulsed that he is unable to draw his breath. At 
 other times the patient's strength cannot be sustained in conse- 
 quence of the difliculty of introducing nourishment into his mouth ; 
 and in many cases the fatal termination of the disease seems to be 
 the result of exhaustion consequent upon the extreme muscular 
 exertion performed by the patient. This exhaustion is increased 
 by the fact that the patient is usually unable to sleep, being kept 
 in constant wakefulness day and night by the muscular activity. 
 
LOCK-JAW — TETANUS. 
 
 317 
 
 Tetanus, or locked jaw, occurs also in infants. In these cases 
 there is usually no cause apparent for the difficulty ; though it occurs 
 almost entirely among the poorer classes, who live without any ob- 
 servance of the principles of hygiene. It usually appears within 
 two weeks after birth, and commonly terminates fatally two or three 
 days later. The paroxysms are provoked by the slightest causes, 
 such as a flash of light, a breath of air, or a sudden noise. 
 
 Ti'eattnent, — It seems to be well established that tetanus can 
 often be controlled and cured by the use of calabar bean, given in 
 frequently repeated doses, if treatment be begun sufficiently early. 
 Good results have also been obtained by the use of curare. But 
 these remedies are too powerful and too dangerous to be used by any 
 one except a physician. Other measures to be employed are opium, 
 a grain of which may be given every two hours ; chloral, twenty 
 grains of which have been employed in the same way; bromide of 
 potassium, and stimulants, especially brandy and whisky. 
 
 If the services of a physican cannot be at once procured, the 
 following mode of treatment should be adopted until a medical man 
 can arrive : 
 
 Ice should be applied to the spine, wrapped up in soft, thin 
 cloths. 
 
 A grain of opium may be given in a tablespoonful of brandy 
 or whisky, mixed with the same quantity of milk, every two 
 hours. 
 
 The violence of the spasms may be controlled by permitting 
 the patient to inhale chloroform. 
 
 The great difficulty attending success in the treatment of tetanus 
 arises from the fact that the disease is not recognized until some 
 time after its appearance, because the early symptoms of lock-jaw 
 are not dirtingushed from the stiffness and soreness of the nc":k, 
 such as occurs after simple exposure to cold. It should be remem- 
 bered that if the patient has been wounded or injured in any way, 
 if even his skin has been bruised, the possibility of tetanus must 
 not be forgotten ; and the appearance of stiffness in the jaws and 
 of difficulty in swallowing must be regarded as the possible evi 
 dences of the onset of this disease. 
 
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 DISEASES OF THE NERVOUS SYSTEM. 
 
 Hydrophobia. 
 
 '^y:r\ ^ 
 
 This affection, also called rabies, seems to be due to the action 
 of a special poison, which is derived from the saliva of certain ani- 
 mals, particularly the cat, dog, wolf and fox. This poison appears 
 to be present exclusively in the fluids of the mouth ; the rest of the 
 body seems incapable of communicating the disease. It seems 
 also certain that the virus enters the body of a healthy animal only 
 through a wound or abrasion in the skin. So long as the skin 
 remains unhurt the poison cannot penetrate and does not cause any 
 ill effects. It may even be taken into the stomach, like snake poison, 
 without affecting the health of the animal. 
 
 The period which may elapse after an animal has been bitten, 
 before the disease manifests itself, varies considerably. It is gen- 
 erally stated to be from thirty to forty days. There seem, however, 
 to be instances in which several months have elapsed between the 
 reception of the wound and the first manifestation of the disease ; 
 but it is not probable that the current stories, according to which 
 several years may elapse, are well founded. 
 
 The fact is, that genuine cases of hydrophobia are very rare. It is 
 a subject about which there is much popular misapprehension and 
 misinformation. A large number of cases of so-called hydrophobia, 
 in men as well as in animals, are really very different affections. It 
 is a very common thing, for instance, to hear this name applied to 
 an animal which acts strangely, and many a dog suffering from epi- 
 lepsy has been destroyed as a " mad dog. " Doubtless the disease 
 does sometimes exist among dogs, and many people are apparently 
 bitten by such animals; but the fact is, that unless the animal's 
 teeth come into contact with an unprotected part of the skin, such as 
 the hand or face, the saliva (and hence the virus) is not apt to reach 
 the body of the individual, since in passing through the clothing 
 the animal's teeth are wiped and cleansed from the adherent 
 sali\'a. 
 
 I'he wound made by the teeth of a rabid animal heals in a few 
 days in the usual way. In some cases the wound is said to reopen 
 when the disease is manifested, or the scar becomes painful, swollen 
 and red. Yet this is not necessarily the case, since hydrophobia 
 may be manifested without any changes in the scar of the original 
 wound. 
 
 (I 
 
HYDROPHOBIA. 
 
 319 
 
 The onset of the disease is usually gradual. For some days 
 the patient is restless, agitated, wakeful, and perhaps tormented by 
 frightful dreams ; he may also suffer from nausea and vomiting. 
 After a few days he may experience a slight chill, or at least a 
 shivering, which is usually followed by fever. 
 
 The patient then suddenly discovers that it is extremely diffi- 
 cult for him to swallow ; that there is some soreness and stiffness of 
 the neck, perhaps associated with a sense of compression. The 
 throat sometiir<es is the seat of violent spasms which seem to 
 threaten to suffocate the individual. This difficulty in swallowing 
 applies, of course, to all substances taken into the mouth ; but it is 
 almost always discovered in the effort to swallow water, because 
 the patient is constantly calling for water in consequence of his 
 feverish symptoms. After a few unsuccessful attempts to swallow, 
 which may result in strangling and a sense of suffocation, the 
 patient naturally acquires a dread of the effort to swallow. There 
 is really no fear of water, as the word hydro-phobia (fear of water) 
 implies ; the patient fears merely the effort to swallozv, because such 
 efforts occasion violent spasms of the throat, resulting in partial 
 suffocation. After several unsuccessful efforts to swallow water, 
 the patient acquires a dread even of the sight of water ; in some 
 cases spasms of the throat are provoked even by looking at water. 
 This is, however, not always the case, since some individuals suffer 
 no annoyance from seeing or hearing the sound of water, so long 
 as they are not called upon to swallow it. In some cases, too, 
 although the patient is unable to swallow water from a goblet, he 
 can take it without much inconvenience from a teaspoon. Some- 
 times, too, the individual finds no difficulty in swallowing other 
 liquids, such as brandy and whisky, although he may be unable to 
 accomplish the same feat with water. In some cases spv^sms of the 
 throat occur even when the patient is not attempting to swallow 
 anything ; and a current of air may be sufficient to occasion the 
 same result. Sometimes, indeed, any mental emotion, a loud 
 sovmd or a bright light, induces violent spasms of the throat. In 
 such patients the countenance constantly expresses anxiety, distress 
 and terror, since they are tormented upon the slightest provocation 
 by spasms which threaten to terminate their lives. 
 
 After some time these convulsive movements spread to other 
 parts of the body, so that the entire person may be tossed about 
 at every spasm. 
 
 •/life 
 
330 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 
 ¥ '. 
 
 An abundant secretion or thick mucus collects in the throat, 
 and this, together with an increase in the quantity of saliva, causes 
 frequent efforts at expectoration, a characteristic feature of the 
 disease. The effort to raise this mucus from the throat and to 
 expectorate it, often causes the production of certain harsh sounds 
 which are likened by the terrified friends to the growling or bark- 
 ing of a dog. There is, however, no ground for the popular belief 
 that the unfortunate patient assumes the character of the animal by 
 which he was bitten, and attempts to bite the bystanders. It is 
 true that he becomes delirious, talks wildly, and may even require 
 forcible restraint. He may be possessed by certain delusions, but 
 does not manifest the peculiarities of any particular animal. 
 
 Even at the height of the disease the patient can not resist the 
 temptation to quench his fiery thirst with water, though conscious 
 of the failure which has attended his previous efforts. He sum- 
 mons resolution, and by a violent effort raises the glass to his lips, 
 but before he can swallow he suffers a violent spasm of the throat, 
 the water spurts from his mouth and nose, and with a look of terror 
 he relinquishes the vessel and the attempt. 
 
 There is no instance on record in which an undoubted case of 
 hydrophobia has recovered. Death occurs usually on the second 
 or third day, and always within six or seven days after the disease 
 has become developed. Numerous cases have been recorded in 
 which the affection continued for several weeks, but it is evident 
 from their history that they were not cases of genuine hydro- 
 phobia. 
 
 And this leads us to the remark, that many cases of so-called 
 hydrophobia seem to be merely the result of fear and anxiety. An 
 individual who has at some time been bitten by an animal, even 
 though there was at the time no suspicion that this animal was 
 rabid, suddenly conceives a dread that he is about to become a vic- 
 tim of hydrophobia. This belief and fear lead to the production 
 of certain symptoms of the disease, especially the dread of water, 
 delirium, and an apparent disposition to bite others. If these symp- 
 toms be developed immediately after the reception of the bite, or, 
 on the other hand, several years subsequently, it may be taken for 
 granted that the affection is merely the result of mental excitement, 
 perhaps of reading newspaper accounts of such cases. It will 
 certainly not be the genuine disease, unless there be marked spasms- 
 of the larvnx. 
 
HYDROPHOBIA. 
 
 321 
 
 Trentment, — As has been said, no well-authenticated case 
 of hydrophobia has ever been known to recover, although the 
 greatest variety of medicines have been employed in the treatment 
 of this disease. At present we know of no means of controlling it. 
 The most that can be done is to palliate the dreadful sufferings 
 which otherwise afflict the patient. For this purpose he should be 
 kept under the influence of opium, and in some cases inhalations 
 of chloroform seem to have diminished the violence of the spasms. 
 
 Although we are thus impotent to arrest the course of the dis- 
 ease when once established, it is quite possible to prevent its develop- 
 ment by removing at once the poison from the wound. For this 
 purpose the most efficient and only reliable means is to cut out the 
 tissue around the wound made by the animal's teeth. This must be 
 done thoroughly, a liberal piece of the surrounding tissue being 
 removed with the edge of the wound. This somewhat severe 
 measure can rarely be accomplished sufficiently early, since no one 
 but a professional man will undertake it, and the physician can sel- 
 dom reach the patient early enough to accomplish the object. But 
 there is one measure which any one can do without delay, and this 
 is to sttcA the animaVs saliva from the wound. This may seem a 
 repulsive task, but it is surely not too great a price to pay for a 
 human life. If the wound be situated on a part of the body, such 
 as the hand, where the patient himself can apply his lips to it, he 
 may, of course, attempt to clease it with his own mouth; otherwise 
 there should be no hesitation among the bystanders to perform this 
 office for him. If there be no wound on the lips or in the mouth 
 of the individual who performs this duty, he runs no risk of infection 
 himself. He should, of course, immediately eject from his mouth 
 the fluid which may be thus obtained. It may be well, also, for 
 him to rinse his mouth thoroughly after accomplishing this benevo- 
 lent work. 
 
 After the wound has been thus cleansed so far as possible, it 
 may be cauterized with lunar caustic, or with a white hot iron, such 
 as an iron wire, which can always be obtained and readily heated. 
 If it be possible to thus remove from the body the poisonous fluids 
 — and it is only possible within a few minutes after the infliction of 
 the bite — the patient may rest without any anxiety as to his 
 future. 
 
 It would be desirable in every case, for the comfort and wel- 
 fare of the patient, to know whether or not the animal which has 
 
 
 \ ? sf 
 
3: 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 ':! i li 
 
 :i i 
 
 inflicted the bite be really" mad." As has been already stated, 
 dogs and cats are subject to epilepsy, and these paroxysms have 
 been frequently regarded as evidences of hydrophobia. After the 
 infliction of a bite, the animal suspected of hydrophobia should be, 
 if possible, confined and kept for observation, and not killed. If 
 he be really rabid, the animal becomes shy, sullen and irritable ; he 
 avoids the light, his former friends and canine associates, and may 
 even snap at his master. He refuses food, but is apt to eat other 
 articles, such as pieces of paper and straws. For some time he 
 usually recognizes those whom he knew intimately, and may even 
 fawn upon them ; in fact, it is such individuals who are most likely 
 to be bitten, since an animal in the first stages of the disease will, 
 without manifesting any marked symptoms, suddenly change his 
 demeanor and bite the hand which he licked but a moment before. 
 After a day or two the animal's appearance is much changed ; he 
 looks haggard, his head and tail droop, the tongue hangs from the 
 mouth, and there is an excessive flow of saliva ; the eyes are red 
 and watery. If he be permitted his liberty, he runs along panting, 
 with the tongue hanging from his mouth. He is inclined to snap 
 at every animal, human or otherwise, that he meets, and even bites 
 pieces of wood, posts and stones on his way. But he rarely becomes 
 aggressive, does not go out of his way to attack anybody — indeed, 
 rather avoids a meeting. He does not bark, but utters a peculiar 
 growl, which seems to be due, in part, to the effort to expel the 
 mucus from his throat. At times he appears to be subject to 
 delusions, and to give way to fits of fury, snapping at imaginary 
 objects. Exhaustion and death occur within five days after the 
 development of the disease. 
 
 Hydrophobia does not occur with especial frequency during 
 the hot weather, but may be exhibited at any time during the year. 
 
 i] V 
 
 Alcoholism. 
 
 The habitual use of alcohol in excess is known to have delete- 
 rious effects upon nearly all the organs and tissues of the body. 
 These effects are in part manifested in the symptoms of various 
 affections, such as chronic inflammation of the liver, fatty degenera- 
 tion of the liver, dyspepsia, abdominal dropsy, and Bright's disease 
 
 i i. 
 
ALCOHOLISM. 
 
 3^3 
 
 of the kidneys. The use of alcohol not only induces directly these 
 and other diseases, but impairs the vital powers of the system so 
 that the individual is less capable of resisting an attack of the acute 
 diseases generally, and succumbs more readily than when he is in 
 liis natural state, to diseases and injuries in general. 
 
 The habitual use of alcohol in excess causes an impairment of 
 the bodily functions generally; the digestion is weakened, the blood 
 is impoverished, the general nutrition is impaired, the power of the 
 muscles is diminished, and emaciation frequently occurs. The 
 effects on the mental faculties are no less injurious and marked than 
 on the physical powers; the mental and moral faculties are blunted 
 and impaired, so that the individual finally drifts into a condition 
 which has been called dipsomania, a form of derangement which is 
 manifested by the patient's uncontrollable desire for drink. 
 
 Before this stage is reached, there are various symptoms indi- 
 cating the decay of the nervous system ; such are sleeplessness, 
 headache, dizziness, tremblings of the muscles, occasional delusions, 
 and a state of mental depression. Indeed, the impairment of the 
 nervous system may be so pronounced that paralysis of movements 
 or of the sense of feeling, or of both, occur, and finally there results 
 unmistakable insanity. Other affections, such as epilepsy and 
 imbecility, are occasional manifestations of the effects of alcohol. 
 
 This subject, the use and abuse of alcohol, has become one of the 
 most important of the topics which medical men are called upon to 
 treat and to consider, in most of the countries of the civilized world, 
 and certainly in America. Although various forms of alcohol arc 
 used by preference in different countries of the world, yet the same 
 general effects are manifested, since the injurious principle in all — 
 alcohol — is the same. Yet it becomes a question whether the 
 acquisition of the habit of drinking is not in some cases the result 
 of previous disease of the brain ; it seems quite possible that we 
 are attributing too much evil to alcohol when we ascribe all mental 
 and moral wrecks which occur in inebriates to the use of this sub- 
 stance alone. It seems unquestionable that in many cases there is 
 a previous condition of the individual which predisposes him to the 
 use of stimulants. And while the excessive use of alcohol can and 
 ■ undoubtedly does aggravate and hasten the mental disease, yet it 
 must be regarded merely as an agent whereby the individual grati- 
 fies an unnatural craving. For in modern society there is a wide- 
 spread yearning for unnatural stimulants, which fiinds gratification 
 
 
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 t' ' 
 
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324 
 
 IJISKASES OK TIIK NKKVOUS SYSTEM. 
 
 U ' !'i I 
 
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 I 
 
 ' I'- 
 
 not only in the abuse of alcohol, but also In the excessive use of 
 opium, chlciral and other narcotics. 
 
 Dr. Heard, who has devoted especial attention and study tt> 
 this subject, remarks: 
 
 " I would specially insist on the si^jnificance of civilization as 
 the great predisposing cause of chronic alcoholism. Alcohol alone, 
 in quantities however great, seems to be powerless to produce this 
 disoriler unless it acts on the nervous system previously made sus- 
 ceptible by indoor life and nerve-exhausted influences, such as the 
 printing press, the telegraph and the railways, that are peculiar to 
 our modern civilization. It is not necessary that we should become 
 excessively nervous, but that we should become considerably so, 
 before alcohol can produce chronic alcoholism. In this view I am 
 justified by the fact that we have no clear evidence from history that 
 chronic alcoholism exists as a disease among the savage or semi- 
 savage people who are the grossest abusers of alcoholic liquors; and 
 it is far more frequent now than it was among our ancestors of but 
 a few generations back, who indulged in intoxicating drinks to a 
 degree that seems to us past belief There never was a time in the 
 recorded history of modern civilization when, in proportion to tin 
 numbers, there was so little use of alcoholic liquors among tlu- 
 respectable classes as now ; and there never was a time probabl\' 
 when there was so much of chronic alcoholism among these very 
 classes ; indeed, it is but recently that attention has been called to 
 this disease, and we may justly believe that it.i increase in fre- 
 quency has compellt;d our scientists to give it attention. The 
 Anglo-Saxons are by nature a race of gluttons and drunkards 
 (although by grace and culture the better portion have become 
 temperate and gentlemanly), and the climate in which the English, 
 Americans and Scandinavians live is one specially calculated to 
 foster the habit of inebriety ; and yet the alphabet <ir ('-itiking is 
 something that we have yet to learn. Ther ar .ribes in /\fri» a 
 and in the islands of the Pacific, who are <' anost from birth 
 
 to death ; their normal condition is to be < .v, as with us is to 
 be sober. 
 
 " We are all aware that a century or so ago it vas the custom 
 among our ancestors, especially in Scotland, to celebrate every di> 
 tinctive or trifling event — births, funerals, weddings, barn-raisings, 
 house-warmings, etc., to infinity — with profuse imbibing of strong 
 liquors. Now, among certain savage tribes this custom still prevails 
 
I iriiiii 
 
 ALCOHOLISM. 
 
 i»$ 
 
 ill nmst disgusting enormity. The Kast African drinks till he can 
 no longer stand, lies down to sleep, and awakens to drink again. 
 Reprove an Anglo-Negro for being drunk, and he will reply : 
 'Why, my mother is dead!' as if that were excuse enough. In 
 our land the sight of a man who has been wounded and scarred in a 
 drunken brawl is by no means common, save among the very 
 lowest orders ; but in certain regions of Africa there are whole 
 tribes, nearly all of whose members are thus disfigured. The truth 
 is, that this whole habit of intemperate drinking is a survival of 
 savagery ; it is a projection of barbarism into civilization, and, 
 like other savage survivals, it is gradually disappearing among all 
 those classes where civilization really prospers. 
 
 " It is true that all savages in cold or hot climates ai" no. intem- 
 perate, but that is because they can get nothing to drink. The 
 North American Indians are generally sober, but for the same 
 reason that the inmates of Sing Sing are sober ; they live under 
 ,1 rigid prohibitory law ; but open a cask of rum before a hundred 
 Indians, and in an hour you will have a hundred drunkards. And 
 yet, notwithstanding this enormous excess of savages, there is no 
 evidence that I can find that chronic alcoholism prevails among 
 them ; injured they must be by their prodigious potations, but 
 probably not through any form of nervous disease. Among all 
 barbarous people insanity, hysteria, neuralgia, insomnia and nerv- 
 ous, dyspepsia, and all other functional diseases are either rare or 
 utterly unknown. Chronic alcoholism is one of a large number of 
 diseases for which we have to thank the 19th century. It seems to 
 increase as the habit of drinking diminishes. Formerly any amount 
 of drinking would not cause it ; now it may follow excesses com- 
 paratively slight. 
 
 " Granting that in the long lapse of ages, in the slow evolution 
 of humanity, through we know not how many millions of centuries, 
 race is a result of climate ; yet in appreciable historic time, that is 
 within the past three or four thousand years, race rises everywhere 
 more or less superior to climate, and within certain limits prevails 
 over it ; and this habit of drinking is one of the features in which the 
 dominance of race seems prominent. Most strikingly is this illus- 
 trated by the history of the Hebrews. This peculiar people have 
 gone out through all the world, and their descendants to the very 
 ends of it, under all climes and in the presence of all forms of 
 
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 in 
 
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 ^^^H^BP ii 
 
 ^''■^p 
 
 ^'^^E 
 
 ^^^H^HDj-i: 
 
 H 
 
 Bii 
 
 326 
 
 DISEASES OK THE NERVOUS SYSTEM. 
 
 alcohol, and yet chronic a)col olism is very ra^e among them, if 
 indeed it can be said to have with them any existence. 
 
 " They are not abstainers ; they drank the wines o" ':heir native 
 Palestine. They drink the beers and wines of Germany and 
 America ; there is no other race that so universally drink, there is 
 no other race that is so universally sober — they drink, but are not 
 drunkards ; but there seems cO be in their nervous system some subtle 
 and never-failing transmissible force or quality, as much a part of 
 their constitution as their physiognomy or avarice, which, mightier 
 than climate and stronger than all temptation, enables them to 
 take coals in their hands without being burned; which can always 
 say to alcohol, under all its disguises, ' hitherto shalt thou come, but 
 no further; and here shall your fiery power be staid.' 
 
 " There are no other people who have gone into all climates to 
 the extent that the Jews have, and yet retain so successfully the 
 habits of temperar.-'-. The Italians and Spaniards are much less 
 disposed to chronic alcoholism than the more Northern nations. 
 In recent times the disease seems to have been incrci'sing in 
 France, where formerly it was uncommon. But the race above all 
 others predisposed to this disorder, is the Anglo-Saxon. It is 
 indeed in England and America and among the Scandinavians that 
 attention was first and most earn'^stly called to this disease. 
 
 " In regard to the influence of climate, independently of^race, 
 my researches seem to show that the disease is most frequent in 
 temperate and cold climates. The habit of excessive drinking is 
 not confined to any climate ; it most abounds in the tropics and in 
 the coldest regions of the North ; but between the temperate and 
 tropic regions there is what I have termed the temperate belt, 
 which embraces the southern of the north temperate and the 
 northern part of the torrid zone, and in which, all around the globe, 
 there is less intemperance than in any other inhabited region, either 
 north or south of it. This belt includes Spain, Italy, Southern 
 France, Turkey, Syria, Persia, North Africa, Southern China, and 
 Mexico. The excessive drinking of hot, or even of warm climates, 
 induces diseases of the liver, but not chronic alcoho'ism, at least 
 among the natives The chosen home of this disease, so far i; ^ we 
 know, is the belt including Sweden, Great Britain, and the United 
 States. It is a noteworthy fact, that not only alcoholic liquors, 
 but coiTee, also, can be used more freely in warm than in cold 
 climates. In a most interesting way this' is illustrated in our own 
 
 ci 
 
ALCOHOLISM. 
 
 327 
 
 pt 
 
 county, where the Southerners of the respectable class drink far 
 more freely than their Northern friends of the same class, and show 
 it less. Moisture and dryness, and probably also atmospheric 
 electricity and ozone, and especially the alternations of heat and 
 cold in the northern part of the United States, are factors that give 
 us a partial explanation of the unparalleled nervousness of the 
 Americans, and also of the great prevalence of chronic alcoholism, 
 in spite of the fact that in our better classes there is more of total 
 abstinence than in any other civilized nation. The air of California 
 is exceptionally dry, and nervous diseases are alarmingly frequent 
 there, and the effects of inebriety are of the most serious character, 
 even in the wine-producing district?. " 
 
 Chronic alcoholism is regarded by many, as by the author just 
 quoted, as essentially a disease of the nervous system, not produced 
 by intoxication, but manifesting itself in such intoxication, and 
 hastened by the abuse of alcoholic beverages. 
 
 Treatment, — The object of treatment is to restore the nerv- 
 ous system to a condition wherein the individual shall lose the de- 
 sire for excessive stimulation, and at the same time lose the 
 necessity foi- the use of intoxicating liquors. The treatment should 
 therefore be °ssentiaily tcnic. All those measures should be em- 
 ployed which ':an assist in toning up the deteriorated nervous 
 system. 
 
 For this purpose the most important agents are quinine, 
 strychnine, phosphorus and cod liver oil. 
 
 The following prescription may be given : 
 
 Pyrophosphate of iron, - - _ Forty grains. 
 Quinine, _ . . . . Twenty grains. 
 
 Extract of nux vomica, - - - Five grains. 
 Mix and make twenty pills. Take one before meals. 
 
 In many castj the o\ide of zinc has been found useful. Of 
 this preparation one to two grains may be given three times a day, 
 either dry in the form of powder or made up into pills. 
 
 The cod liver oil is a valuable tonic, and may be given first as 
 tciir.poonful doses after meals. As the patient becomes accustomed 
 to it the quantity may be increased to one or two tablespoonfuls. 
 
 In some cases benefit has been derived from the use of elec- 
 tricity applied along the spine. This is a measure which can be 
 
 5 'i M 
 
 
 at 
 
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 !!;.: 
 
 I hf' 
 
 ill 
 
 328 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 administered only by one thoroughly familiar with the method and 
 well provided with electrical apparatus. 
 An incident in chronic alcoholism is 
 
 Delirium Tremens. 
 
 This affection occurs in habitual drinkers — sometimes after 
 excesses, at other times from unusual abstinence. Thus it may 
 happen in individuals who undertake to reform and to give up in- 
 temperate habits ; and may also occur in those who are compelled 
 by accident or disease to abstain for an unusual time from in- 
 dulgence in their usual stimulants. It is therefore especially com- 
 mon among drunkards who are committed to prison, and is a 
 frequent occurrence among patients admitted for severe injuries to 
 hospitals. It may also follow a debauch, even in those who are 
 accustomed to the free use of liquor. 
 
 Symptoms, — In some cases there occur certain warning signs 
 of impending delirium. The patient is peevish and irritable ; his 
 sleep is disturbed, and he appears depressed. After a few days of 
 this state, evidences of mental derangement become apparent. In 
 other cases the symptoms are connected particularly with the 
 stomach, there being nausea, perhaps vomiting ; loss of appetite ; 
 the tongue is thickly coated. 
 
 The stage which precedes the appearance of delirium, lasting 
 two or three days, is one of great mental depression ; the patient is 
 sometimes so despondent that he makes attempts to commit suicide. 
 This condition is called by drunkards " the horrors. " 
 
 The attack begins with the manifestation of active delirium. 
 The countenance becomes wild ; the eyes are widely opened and 
 staring; the patient is in a state of constant activity, making quick 
 nervous movements and talking constantly. His attention is 
 diverted rapidly from one topic to another ; he is apt to have delu- 
 sions ; he imagines himself engaged on important business, and is 
 constantly desirous of going out. He must be, therefore, carefully 
 watched. In addition to these delusions, he has various illusions 
 of the senses ; he sees around him disgusting and unpleasant 
 objects, such as mice, lizards, snakes, etc. ; he hears sounds made 
 by imaginary men and animals, and is often possessed with the 
 
 11' .'' ' i; 
 
DELIRIUM TREMENS. 
 
 329 
 
 idea that he is surrounded by enemies who threaten him with per- 
 sonal violence. At first these delusions occur merely occasionally, 
 the patient meanwhile being in his sound mind and able to recog- 
 nize the fact that these delusions are imaginary ; but after a time 
 they become real to him, and his sane intervals cease. 
 
 Meanwhile the hands, and perhaps the entire body, is in a state 
 of tremor ; this tremulousness is especially manifest in the tongue, 
 whenever the patient attempts to put the tongue out of the mouth. 
 He is generally weak, but is able when excited to manifest unusual 
 muscular power. 
 
 After the delirium has become well established the patient is an 
 object of terror to others and of danger to himself. For his delu- 
 sions often inspire him to acts of violence against others, and to 
 deeds which may result in serious injury or even death to himself. 
 The patient has no conception of danger ; is constantly trying to 
 rise from his bed, and if he succeeds, endeavors to leave the room 
 and the house ; he often neglects to pass out of the room by the 
 door, but springs from the window as the most convenient and 
 quickest way of escape. If he be spoken to quietly there is rarely 
 any difficulty in leading him back to bed ; but if accosted roughly, 
 or if attempts are made to force his movements, he is inclined to 
 suspect mischief and to resist violently. When once aroused to 
 forcible resistance, it is by no means easy to quiet and soothe him ; 
 he employs, in self-defense, any weapons that may be at hand, and 
 must often be overpowered and secured by main force. In most 
 instances the patient's safety can be secured only by confining him 
 in a straight jacket, or by securing him in a room, the walls and 
 floor of which are padded to prevent him from using violence 
 upon himself. ». i ler the influence of these delusions the patient 
 is sometimes led to perform the most singular and ludicrous acts, 
 while at other times he exhibits remarkable power of endurance 
 and recklessness of danger. Thus a case has been known in which 
 a patient laboring under delirium tremens, leaped from a window 
 and ran, bare-footed and in his night clothes, fifteen miles over 
 frozen ground, before he was overtaken by his pursuers, who were 
 mounted on horseback. 
 
 One of the most serious features of such an attack is the 
 wakefulness of the patient ; he lies awake for days and nights con- 
 secutively, frequently falling into a doze, as frequently awakened 
 in a short time by some frightful dream. The delirium is usually 
 
 \ m 
 
 •:i 
 
:•[■)} 
 
 330 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 worse at night, when the patient becomes loudest in his outcries 
 and most violent in his movements. If he sleeps at all it is usually 
 during the day. 
 
 The patient rarely complains of any pain, nor even of head- 
 ache, although the head may be hot and the skin dry. 
 
 After two, three or four days of this state, the patient usually 
 falls asleep. If he once begins to sleep soundly, the danger is 
 usually over ; for after profound slumber for several hours, the 
 patient awakes in his right mind, although, of course, much 
 exhausted. Sometimes he is still delirious after his first sleep, but 
 soon falls asleep a second time and awakens in the possession of his 
 faculties. For the first day or two the patient manifests a constant 
 desire to sleep, and if the case be favorable, spends much of his 
 time asleep. 
 
 If, however, the patient be unable to obtain refreshing sleep, 
 by the termination of the fourth or fifth day of the attack, the dis- 
 ease is very apt to terminate fatally. In this case the sleeplessness 
 persists, and the patient becomes profoundly exhausted. Yet even 
 when thus prostrated, the delirium continues, and the individual 
 continues his frequent efforts to get out of bed and to resist the 
 imaginary attacks of the enemies or animals which he supposes to 
 surround him. The last hours of life are commonly passed in a 
 state of profound stupor. 
 
 The disease usually terminates in recovery. It is important to 
 recognize its true nature, and not to mistake it for inflammation of 
 the brain, or one of the forms of meningitis. It can be usually dis- 
 tinguished at once by the absence of pain, by the tremulousncss of 
 the patient, as well as by the previous habits of the individual. 
 Yet in this connection it must be remembered that many people 
 are in the habit of drinking secretly to an extent not suspected by 
 their friends. Inflammation of the brain, it will be remembered, is 
 accompanied by intense pain in the head, by extreme susceptibility 
 to light and sound, and by high fever. 
 
 The use of alcohol sometimes causes a form of delirium which 
 is not to be confounded with delirium tremens. In this case there 
 is active delirium, accompanied sometimes by fits of violence. 
 This is caused, however, not by habitual indulgence in liquor, but 
 by excessive use of alcoholic beverages on a single occasion. It 
 is, therefore, usually the effect of a debauch, and passes away 
 within a few hours after the individual stops drinking. It is char- 
 
DELIRIUM TREMENS. 
 
 331 
 
 acterized by headache and fever. This may occur in habitual 
 drinkers, and be followed by an attack of delirium tremens. 
 
 Treatnient. — The chief object in the treatment of delirium 
 tremens is to induce sleep. For this purpose he must be carefully 
 protected from the inquisitive gaze and questioning of friends and 
 acquaintances. It is also necessary that he be confined in such a 
 way as to prevent him from harming himself. In some cases it will 
 be necessary only for a friend to stay in the room with him, and to 
 judiciously soothe and quiet him during the more violent parts of his 
 delirium ; in other cases it will be necessary to put him in a straight 
 jacket, or in a padded room. In general, no more violence should 
 be used than is absolutely necessary to control him. 
 
 The following prescription may be ordered : 
 
 bromide of potassium, - - - 2 ounces. 
 
 Hydrate of chloral, - - - - i " 
 
 Syrup of orange peel, - - - - 2 " 
 
 Water, 2 " 
 
 Give a teaspoonful in water every two hours, until four doses 
 have been taken, unless the patient becomes quiet. In using this 
 mixture certain caution must be observed, especially after three or 
 four doses have been given. 
 
 It will be advisable not to give opium or any of its prepara- 
 tions, which are apt to aggravate the patient's mental condition. 
 So soon as the violence of the attack is over, measures should be 
 taken to tone up the patient's nervous system. For this purpose 
 the following mixture may be used : 
 
 Tincture of nux vomica, - - - 6 drachms. 
 
 Tincture of digitalis, - - - 6 
 
 Tincture of gentian, - - - - 6 
 Wine of pepsin to make four ounces. 
 ]\Iix, and take a teaspoonful before meals. 
 
 Much good has been observed from the application of a small 
 mustard plaster over the pit of the stomach, especially those cases 
 in which obstinate vomiting occurs. 
 
 One of the most important items in the treatment of delirium 
 tremens is the employment of nutritious food in an easily digesti- 
 ble form. For this purpose, milk and eggs are the staple articles ; 
 they may be supplemented by soups and beef tea. These should 
 be given in small quantities, at intervals of two or three hours. 
 
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 Td 
 
 .t.\ 
 
 
I' 
 
 1 1 1 
 
 I 
 
 f ■■ i! 
 
 'J 
 
 332 
 
 DISEASLS OF THE NERVOUS SYSTEM. 
 
 It must be remembered that delirium tremens is a disease of 
 exhaustion ; notwithstanding the patient's frenzy and frequent ex- 
 hibition of strength, his nervous system is profouncWy prostrated ; 
 hence all measures employed in the treatment of the disease should 
 tend to build up the patient's exhausted powers. 
 
 Neuralgia. 
 
 Under this term is included a group ot symptoms character- 
 ized by pain, but exhibiting no evidences of inflammation. 
 
 Neuralgia is of very frequent concurrence, and especially in this 
 country afflicts almost every family. It would seem that neural- 
 gias are becoming more frequent, but many of the affections now 
 so-called, were formerly described as rheumatic or spasmodic. 
 
 Any part of the body which has sensitive nerves may become 
 afflicted with neuralgia ; the disease is most frequent in those parts 
 of the body which are most abundantly supplied with these nerves. 
 
 Neuralgia may occur abruptly, but in the greater number 01 
 cases is preceded by certain premonitory symptoms. These con- 
 sist chiefly in a feeling of weight, and a sense of heat or prickling 
 in the part. After a time this sensation gives place to positive pain, 
 which may occur continuously without much intermission, but is 
 usually felt in paroxysms. During the intermission between these 
 paroxysms, the patient is not entirely free from pain, since he suf- 
 fers a dull, heavy pain all the time; but during the paroxysms the 
 pain becomes sharp and intense. These paroxysms may last for a 
 few seconds only, or for several hours; and the intermissions be- 
 tween them vary in the same degree. The pain usually shoots along 
 the course of some nerve, so that the patient can map out accurately 
 the path of these nerves by the sensations of pain which he expe- 
 riences. In other cases, pain is felt chiefly at certain limited spots 
 separated some distance from each other, and quite tender upon 
 pressure. 
 
 Til's latter point is quite important in determining the nature ot 
 neuralgia.. When the points of the fingers are first pressed upon 
 these painful spots, the patient often flinches and cries out with 
 pain; but if the pressure be continued for some little time, the 
 
NEURALGIA. 
 
 333 
 
 pain may cease entirely. This tenderness on pressure is most 
 marked during the paroxysms of pain and may quite disappear in 
 the intervals between. 
 
 Paroxysms of neuralgic pain maybe provoked or increased by 
 sudden or violent movements of those parts of the body in which 
 the pain occurs; the same result follows a cough or a sneeze. 
 
 There is no fever nor general constitutional disturbance dur- 
 ing neuralgia, though sometimes an increased secretion may take 
 place in the mouth or in the eyes, if these parts be afflicted. 
 
 Neuralgia may last an indefinite time. Sometimes after per- 
 sisting for months or years, it terminates spontaneously or under 
 treatment, while in other cases the pain continues throughout life, 
 in spite of all means that can be brought to bear upon it. 
 
 Sometimes the pain can be traced to a definite cause. Thus, 
 the pressure of a tumor on a nerve is found to be the origin of the 
 difficulty. That severe and agonizing form of neuralgia known as 
 angiina pectoris, is often due to the pressure of an enlarged blood 
 vessel — an aneurism. In other cases it is due to malarial influence. 
 In this case the paroxysms may recur with the same regularity as 
 the fever and chills of ague. Neuralgia may also be the result of 
 lead poisoning. 
 
 An impoverished condition of the blood, often manifested by 
 pallor and emaciation, is a frequent cause of neuralgia. This form 
 of the disease occurs especially among women, particularly those 
 who are afflicted with diseases of the womb. There is still another 
 class of neuralgias which are dependent upon diseases of the brain 
 or spinal cord. In these cases the difficulty is not to be sought in 
 that part of the body which experiences the pain, but in the nerve 
 centers themselves; for it is to be remembered, that a disease 
 of a nerve center — that is a part of the brain or spinal cord — will 
 cause pain in that part of the body to which the nerves running 
 from this center proceed. Thus, a disease of the spinal cord, to be 
 presently described, known as locomotor ataxia, is characterized by 
 spasms of intense pain in the stomach and in the thighs — cases 
 which are doubtless often considered to be neuralgia of the stomach; 
 but in this disease the seat of the difficulty is not in the stomach, 
 nor the thighs, but in the spinal cord. 
 
 There still remains a considerable number of cases the cause 
 of which is unascertained. These are the obstinate cases which 
 resist all method of treatment. 
 
 :, 'It 
 ■i 
 
 l-^"." ^ h Wi 
 
334 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 
 >' ? 
 
 Neuralgia is most frequent between the ages of 20 and 45, and 
 is very rare before the tenth year. Neuralgia affects certain parts 
 of the body, the hip for example, in males more frequently than 
 females, while the latter are more often subject than males to neu- 
 ralgia in the face and in the chest. 
 
 Treatment, — Neuralgia is essentially pain, and as such is 
 merely the symptom of a disease. In every case, therefore, treat- 
 ment is to be preceded by an attempt to ascertain the seat of the 
 difficulty. The promiscuous application of liniments and plasters 
 to all parts of the body for pain is not a rational way of treating 
 the disease. 
 
 In many cases neuralgia is easily curable. If the patient be 
 living in a malarial district, it is quite probable that the pain is 
 of malarial origin, and that three grains of quinine, administered 
 four times a day, will cure the neuralgia. If the patient be pale 
 and bloodless, and evidently in poor health, tonic medicines are 
 required ; for this purpose the following prescription may be 
 given : 
 
 Tincture of the chloride of iron, 
 
 Sulphate of quinine. 
 
 Syrup of orange peel, - 
 
 Water to make four ounces. 
 Mix and take a teaspoonful in water before meals. Such individuals 
 should of course have good food and plenty of air, sunshine and 
 exercise. 
 
 Neuralgia may be the result of some constitutional taint which 
 has been inherited or acquired. Thus syphilis frequently causes 
 intense pain, particularly in the legs and in the body; the various 
 minerals, especially lead, may also cause severe neuralgia, as one 
 of the symptoms of poisoning. In all these cases the treatment 
 consists, in part, in the effort to remove the cause. 
 
 In every case the treatment must also aim at relieving the 
 pain. For this purpose various measures have been employed, all 
 of them with advantage in certain cases. The tincture of aconite 
 may be rubbed upon the skin every hour (and this simple measure 
 sometimes suffices to relieve the pain), or the following ointment 
 may be used : 
 
 Veratria, Fifteen grains. 
 
 Pure lard, One ounce. 
 
 Mix and apply to the skin. If the pain be severe, relief can be 
 
 One ounce. 
 One drachm. 
 Half an ounce. 
 
NEURALGIA. 
 
 335 
 
 obtained immediately by the inhalation of chloroform ; meanwhile 
 a quarter of a grain of morphine may be given, either dropped dry 
 upon the tongue or dissolved in a little water, or the following 
 combination may be employed : 
 
 Tincture of gelsemium, 
 
 Tincture of belladonna, - - Each two ounces. 
 Take fifteen drops every two hours, increasing the dose gradually 
 to thirty drops, if required ; or the following may be found useful : 
 
 Chloroform, 
 
 Muriate of morphia, 
 
 Ether, 
 
 Oil of peppermint, 
 
 Dilute hydrocyanic acid. 
 
 Tincture of capsicum, - 
 
 Gum arabic. 
 
 Water and molasses. 
 
 Four drachms. 
 
 Five grains. 
 
 Two drachms. 
 
 Eight drops. 
 
 Two drachms. 
 
 Six drachms. 
 
 Two drachms. 
 
 To make five ounces. 
 
 ,Mix and take a teaspoonful every two hours. 
 
 In some cases of neuralgia, relief has been obtained by the 
 application of blisters along the course of the nerve, and in severe 
 cases a grain of morphine may be applied to the raw surface after 
 the blister is removed. 
 
 After other remedies have failed, relief can often be obtained 
 by the simple application of cloths wrung out in hot water, or by a 
 hot bath. Electricity, when properly applied, is a valuable agent 
 in many cases of neuralgia, and seems, indeed, sometimes to exer- 
 cise a curative influence. 
 
 Nearly all cases of obstinate neuralgia are benefited by the 
 use of iron. In females particularly the following prescription can 
 be employed with advantage : 
 
 Carbonate of iron, _ . . Forty grains. 
 
 Sulphate of quinine, - - - Thirty grains. 
 Extract of belladonna, - - Five grains. 
 
 Mix and make twenty pills. Take one before eating. 
 
 Many cases of obstinate neuralgia iti the face are relieved by 
 croton chloral hydrate ; five grains of the drug may be given in a 
 teaspoonful of syrup, and repeated until five doses have been taken 
 or relief afforded. 
 
 After this discussion of neuralgia in general, we may dismiss 
 
 i . Ill 
 
3; it; 
 
 
 fil 
 
 336 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 with a lew words the special neuralgia affecting particular parts of 
 the body. These may be named as follows • 
 
 Neuralgia of the face {trifacial). 
 
 Neuralgia of the neck and head (ccrvico-occipital). 
 
 Neuralgia of the neck and arm {cervico-brachial). 
 
 Neuralgia of the side {intercostal). 
 
 Neuralgia of the loins {liimbo-abdominal ). 
 
 Neuralgia of the groin {crural). 
 
 Neuralgia of the thigh {sciatica). 
 
 In facial neuralgia the pain seems to be located in the large 
 sensitive nerve of the face, which physicians call the fifth or tri- 
 facial nerve. The pain may follow particular branches of this 
 nerve, and hence be felt only in certain small parts on one side of 
 the face, or the entire nerve may be involved, and the pain be felt 
 over half of the face from brow to chin. There are certain points 
 which are almost always very tender when pressed upon ; one at 
 the inner side of the eyebrow, and another just below the angle of 
 the eye, near the nose. These are the points where the nerve 
 comes through the bone. 
 
 There is usually pain in and around the eye, which may be 
 extremely sensitive to light, unusually red, and produce an in- 
 creased discharge of tears. Hence this affection may be mistaken 
 for an inflammation of the eye. There may be also increased heat 
 of the nostril on the same side, and an unusual discharge of mucus 
 from the nose. In some cases there occur also spasmodic con- 
 tractions of the muscles on that side of the face which is affected 
 with pain ; from this feature the disease used to be called tic- 
 doulotireux. In most cases the neuralgia is felt on one side of the 
 face only. 
 
 In every case of facial neuralgia attention should be directed 
 to the teeth. For cases do occur, though not perhaps very fre- 
 quently, in which the trouble originates in decayed teeth. It is, 
 however, far more frequently the case that a number of teeth are 
 sacrificed and extracted with the hope of relieving the pain. It 
 must not be supposed that simple tenderness of the teeth when 
 pressed upon is sufficient proof that the pain originates in the teeth ; 
 for the fact is, that in every case of facial neuralgia involving the 
 jaw, the teeth are more or less tender upon pressure. If the cause 
 of the pain be actually disease of the tooth, pressure upon this tooth 
 will provoke a paroxysm of pain which will extend over a consid- 
 erable part of the face. 
 
SCIATICA. 
 
 337 
 
 Facial neuralgia is generally curable ; not necessarily by lini- 
 ments, but by proper attention to the health of the individual and 
 by the use of tonics, as has been already directed in discussing 
 neuralgia in general. In recent years much success has been attained 
 by the use of croton chloral hydrate, as already mentioned. 
 
 As .1 last resort the nerve has been divided, and pieces of it 
 cut out by a surgical operation. These are obstinate cases, in which 
 the scat of the disease appears to be in the brain and not in the face. 
 This operation has been followed by relief from pain for months or 
 even years, although the trouble usually returns ultimately. 
 
 Intercostal Neuralgia. 
 
 Is pain in the chest wall, which is som-ctimes mistaken for pleu- 
 risy or pneumonia. In this affection there is acute pain between 
 the ribs, sometimes seeming to spread over the entire side of the 
 chest. This pain is especially severe upon deep breathing, in which 
 respect it resembles pleurisy. There may also be a dry cough. 
 
 It is almost always possible to find three painful points, one 
 just beside the spinal column, another about half way around the 
 chest, and the third near the breast bone. These three points will 
 all be found between the same pair of ribs, between the seventh and 
 eighth for example, or between the fifth and sixth ribs. This form 
 of neuralgia occurs more frequently on the left than on the right 
 side, and oftener in females than in males. It seems to be more 
 frequent, too, among the poorer classes than among those who are 
 comfortably situated. 
 
 Treatment. — In nearly all cases of intercostal neuralgia the 
 patient requires tonics, especially iron and qumine, which may be 
 ordered in one of the prescriptions given in the discussion of neu- 
 ralgia in general. Chloroform liniment, or the tincture of aconite, 
 may be applied to the skin where pain is felt. In obstinate cases 
 it may be necessary to use blisters, which may be applied over the 
 most painful points. 
 
 Sciatica. 
 
 Sciatica is the name usually applied to neuralgia in the large 
 nerve called the sciatic. This nerve runs along the back of the hip. 
 
 
J38 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 V ■ i: 
 
 iHi'li 
 
 !!l:i 
 
 and passes down the posterior side of the thigh, and it is in the long- 
 est course that the pain is especially felt. 
 
 In some instances, sciatica is caused by pregnancy and by 
 tumors in the pelvis, which press upon the nerve ; but in the ma- 
 jority of cases it appears to be a functional disease. 
 
 The pain may be so intense that the patient refuses to move 
 the affected limb, and feels compelled to keep the bed. Indeed, 
 any movement of the leg is apt to be painful. In other cases the 
 patient can walk, though with difficulty, and he experiences pain, 
 especially when the weight of the body comes upon the affected leg. 
 Sometimes the pain diminishes, or even ceases, after the patient 
 has walked a little, being severe only at the beginning of the ex- 
 ertion. 
 
 It is important to distinguish sciatica from certain other diseases 
 which occasion pain in and around the hip joint. 
 
 Sciatica occurs more frequently in males than in females, and 
 is oftener observed in advanced life than among the young; prac- 
 tically, it never occurs before the age of twenty. 
 
 Headache. 
 
 Headache is the symptom of numerous affections ; in most 
 instances the cause of the difficulty is to be found not in the head, 
 but in various organs of the body. If, for any reason, the difi'ercnt 
 functions of the body are not properly performed, so that the waste 
 materials are not carried off as they should be, there is apt to occur, 
 among other symptoms, a headache. Thus in Bright's disease of 
 the kidneys, headache is often a prominent symptom ; in habitual 
 constipation of the bowels the same symptom is apt to occur ; 
 irregular menstruation may be also accompanied by it ; most of the 
 acute diseases are ushered in by headache among other symptoms. 
 In fact, almost any derangement of the body or its functions maj- be 
 accompanied by a pain in the head. 
 
 There is undoubtedly a certain predisposition among many 
 individuals to the occurrence of headache ; since the same exposure 
 to cold which will induce severe headache in one individual has no 
 such effect upon another. This predisposition to headache prob- 
 ably arises from certain peculiarities in the performance of the 
 
 it ,• I: 
 
HEADACHE. 
 
 339 
 
 bodily functions. In some cases the pain in the head seems to be 
 of neuralgic character. 
 
 There arc, therefore, almost as many causes for headache as 
 there are diseased conditions of the body ; it is impossible to refer 
 to them all in detail, and we shall be content with describing two 
 conditions accompanied with headache, which are especially com- 
 mon, and therefore especially important. These are sick headache 
 and nervous headache. 
 
 By sick headache is understood that frequent form of pain in 
 the head accompanied with nausea. In many cases this sick head- 
 ache can be traced directly to a derangement of the digestive 
 organs, and is then usually one of the symptoms of biliousness. 
 
 There is usually impairment of the appetite, an uneasy feel- 
 ing in the region of the stomach, a bitter taste in the mouth; the 
 tongue becomes coated and the breath may be offensive. There is 
 pain in front of the head especially, and a general indisposition for 
 exertion. 
 
 In other cases sick headache appears to be a form of neural- 
 gia ; it occurs without perceptible cause, and seems to run in 
 families ; it is frequently the case that some member of the family 
 will be afflicted with some nervous disorder, such as epilepsy or 
 hysteria, while other members suffer particularly from sick head- 
 ache. Various mental derangements, such as melancholy and 
 insanity, seem also to occur with especial frequency in individuals 
 who have been subject to sick headache. In many persons, espe- 
 cially females, this form of headache recurs at regular intervals, 
 sometimes associated with the menstrual periods, though at times 
 quite independent of them. 
 
 The constitutional disturbance which accompanies the head- 
 ache indicates that the nervous system generally is at fault, for the 
 depression and languor which are present during the attack are far 
 more pronounced than those which accompany an attack of neural- 
 g\A in other parts of the body, no matter how severe. 
 
 After a variable duration, the attack passes off usually with 
 free vomiting or purging. After recovery the patient often feels 
 much brighter and in better spirits than before, as if the system 
 had been relieved of a burden. 
 
 In some cases the attack occurs, as has been said, without any 
 perceptible cause. At other times it is the direct result of excessive 
 
 
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 ¥''%^'h 
 
340 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 emotion, bodily fatigue, exhaustion, the consumption of indigesti- 
 ble food, exposure to cold and over-heating. 
 
 Treatment. — Until the cause and seat of the difficulty can be 
 accurately located, attempts at treatment must be necessarily 
 somewhat experimental in character. There are numerous reme- 
 dies which have been used to relieve this afifecti' i, and it is 
 quite certain that many individuals can be completely cured of the 
 difficulty. Yet it is impossible to say in advance just what plan of 
 treatment will be adapted to a particular case. We shall, therefore, 
 mention several plans, which may be tried in succession. 
 
 In many instance?, particularly those associated with bilious- 
 ness, a mercurial laxative will secure relief. For this purpose, 
 
 lake — 
 
 Calomel, - - - . . 5 grains. 
 
 Bicarbonate of sodium, - - ID grains. 
 
 Where there is no evident disturbance of digestion to account 
 for the difficulty, and where the individual is " nervous, "the follow- 
 ing prescription may be given : 
 
 Extract of guarana, - - - - 40 grains. 
 
 Extract of cannabis indica, - - 30 grains. 
 
 Citrate of caffeine, - - - - 60 grains. 
 
 Mix, and make forty pills ; take one pill, and repeat the dose after 
 
 two hours, if not relieved. 
 
 In many cases, thirty or forty grains of the bromide of potas- 
 sium, taken in half a glass oi water, will secure relief. 
 
 In other cases, three g lins of the monobromated camphor, in 
 the shape of a pill, will be efficient. 
 
 One to two teaspoonfuls of the fluid extract of guarana 
 have occasionally relieved sick headache after other measures had 
 failed. 
 
 One or two grains of the citrate of caffeine may be placed upon 
 the tongue dry and swallowed. This has proven efficient in many 
 cases where the ordinary remedies had been used without success. 
 
 In obstinate cases relief can often be secured by the hypodermic 
 injection of the following : 
 
 Sulphate of morphia, - One-twelfth of a grain. 
 
 Sulphate oi atropia, - One one-hundredth of a grain. 
 
 Distilled water, - - - Ten drops. 
 This can be administered only by an experienced hand ; indeed 
 these remedies are too powerful lo be entrusted to any other. 
 
 
DIZZINESS — VERTIGO. 
 
 341 
 
 Nervous headache is the term used to designate essentially the 
 same condition as sick headache, except that the nausea and vomit- 
 ing are lacking. It does not seem to be associated with bilious- 
 ness, but is almost always the result of exhaustion, physical or 
 mental. It is especially apt to occur in females who are subject to 
 diseases of the womb. 
 
 Whenever it is possible to trace this headache to a definite 
 cause, measures should, of course, be taken to remove this cause. 
 Aside from such measures the treatment will be the use of one or 
 more of the remedies already mentioned in connection with sick 
 headache. 
 
 Dizziness— (Vertigo). 
 
 Dizziness is usually merely a symptom of disorder in various 
 parts of the body, especially of the digestive organs. Yet attacks 
 of it often occur under circumstances which do not point to derange- 
 ment of the stomach as the cause of the difficulty. 
 
 It sometimes happens that an individual in good health sud- 
 denly becomes dizzy and reels like a drunken man. This sensa- 
 tion is often accompanied by considerable prostration of the nervous 
 system, and perhaps by nausea and vomiting. Yet the nausea 
 appears to be under these circumstances a result rather than a cause 
 of the difficulty. 
 
 These attacks may last but a few moments, but are apt to be 
 repeated at intervals of a few days or weeks. They are of but little 
 importance, except that the individual almost always is very appre- 
 hensive of serious disease. There is a popular impression that 
 attacks of dizziness precede for some time serious diseases of the 
 brain, such as apoplexy, paralysis and epilepsy. As a matter of 
 fact these diseases are not to be suspected when the patient is 
 subject to dizziness, for those who become victims to grave diseases 
 of the brain are rarely troubled in advance by these dizzy fits. 
 The fits of apoplexy, it is true, often begin with dizziness, but are 
 not preceded for any considerable period by this feeling. 
 
 Dizziness is sometimes a symptom of heart disease ; in these 
 cases it is very apt to be associated with palpitation of the heart. 
 An examination of the heart itself will decide at once whether or 
 not this condition exists. 
 
342 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 t 
 
 ^i.5 
 
 
 lii other cases dizziness appears to be caused by dyspepsia. In 
 the majority of instances individuals are over-worked ; it is es- 
 pecially common among those persons whose pursuits are sedentary. 
 Among such, fits of dizziness may be brought on by study ; in some, 
 even a slight mental effort, such as reading a book, is followed by 
 an attack of vertigo. 
 
 In every case the treatment is to be regulated by the cause. 
 It will usually be necessary for the patient to work less and devote 
 more time to recreation ; most obstinate cases have been cured by 
 complete relaxation from business, even without medicine. 
 
 It is believed by some physicians that excessive smoking and 
 venery are resp'- i.sible for many cases of the disease. At any rate 
 a patient who is addicted to either of these practices and suffers 
 from habitual dizziness, should discontinue the practice. In every 
 case benefit is derived from the assurance that the dizziness is not 
 the forerunner of any serious affection of the brain. 
 
 Locomotor ACaxia. 
 
 This disease, which was for a long time confounded with par- 
 alysis, is characterized by inability of the patient to control the 
 voluntary muscles, especially those of the lower extremities, so as 
 to execute the requirements of his will. 
 
 Sytnptotns, — For a long time prior to the manifestations of 
 these symptoms, the patient is afflicted with various indefinite ail- 
 ments, which are usually referred to other causes than the disease 
 in question. 
 
 Among these is neuralgia of the stomach. This occurs in 
 paroxysms, at intervals of a few weeks or months, for years. It 
 may be, before the impairment of motion becomes manifest, these 
 attacks consist of excruciating pain, felt chiefly in the region of the 
 stomach and often extending into the abdomen. They may be 
 accompanied by nausea and vomiting. Unless there be other 
 symptoms which point to locomotor ataxia as the cause of the 
 difficulty, these attacks are usually supposed to be due to the 
 passage of gall-stones, or to some other local difficulty ; their true 
 nature is not suspected. It may be several years before other 
 symptoms are manifested which direct the physician's suspicions to 
 the nervous system as the source of the pain. 
 
 
LOCOMOTOR ATAXIA. 
 
 343 
 
 Another symptom which may exist for some time before the 
 true nature of the disease is recognized, is impairment of vision. 
 The sight may fail to a marked degree, or even be lost entirely, 
 before the other manifestations of the disease render the diagnosis 
 possible. In addition to these symptoms, wandering pains in dif- 
 ferent parts of the body, which are supposed to be neuralgic or 
 rheumatic in character. In men, too, an early symptom is some- 
 times loss of the sexual appetite, accompanied by an impairment 
 of sexual power. 
 
 After these symptoms have existed for a certain time, perhaps 
 years, symptoms occur which direct attention to the true nature of 
 the disease. The patient notices that he is not so steady upon his 
 feet as formerly. He does not walk with the same confidence in 
 the dark, and if he closes his eyes he staggers and would fall, if 
 not prevented by others. He is especially apt to have his attention 
 called to this by observing that he does not stand firmly in per- 
 forming his morning ablutions, during which the eyes are closed. 
 Soon after this it will be noticed by his friends that the patient's 
 gait is peculiar ; he raises his feet from the ground more than 
 is natural, and brings them down so that the heel strikes the floor 
 with unusual force. The movements of the legs are apt to be 
 jerky and uncertain ; they are thrown forward, apparently without 
 any definite idea as to their destination. The body sways from 
 side to side, and the arms are thrown out to maintain the equi- 
 librium, like those of a person who is walking a tight rope. In 
 many cases the patient is unable to rise from the chair without fall- 
 ing to the floor ; but if placed upon his feet by others, he is able to 
 walk. In advanced cases the patient loses altogether the ability 
 to walk. 
 
 Notwithstanding the difficulty experienced in maintaining the 
 body, there is no loss of power in the limbs; the patient who can 
 not walk without aid of a cane to steady himself, can nevertheless 
 exert the usual force with the legs. This may readily be shown by 
 attempting to bend the patient's leg, requesting him at the same 
 time to resist the effort. It will be found that the strength of the 
 limb is by no means impaired. 
 
 The patient's explanation of his difficulty in walking is usually 
 that he " cannot feel the floor " with his feet ; he is compelled to 
 keep his eyes fixed upon the ground, in order to walk at all, since 
 he is otherwise incapable of placing the feet as they should be. So 
 
 23 
 
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 Witt'^' 
 
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 344 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 soon as he looks away from the ground, his gait becomes un- 
 steady. 
 
 Sooner or later the arms also become similarly affected. There 
 is no loss of muscular power ; the patient's grip may remain as firm 
 as ever, but he is unable to unbutton his vest, for example, unless 
 he keeps his eyes fixed upon the spot. Another* characteristic 
 feature is the fact, that when his eyes are closed the patient cannot 
 place his finger accurately on the end of his nose ; in the effort to 
 do so the hand wanders about the face, or is placed at some other 
 part than on the object sought. In the later stages of the disease 
 the patient may be unable to feed himself, because he cannot con- 
 trol his hands sufficiently. 
 
 After a time the speech becomes impaired, since the muscles 
 eng M/cd in articulation, like those of the limbs, are no longer under 
 control of the will. 
 
 In a considerable number of cases the sensibility of the skin 
 is impaired; pins may be stuck into the patient's flesh without caus- 
 ing him any particular annoyance. Sometimes the patients suffer 
 serious injury merely from their inability to recognize painful 
 sensations. After a time the patient loses to a certain exte:it 
 control over the bladder and rectum, so that the contents of these 
 organs are evacuated without the exercise of his will. 
 
 Cause. — The disease appears to be the result of over-exertion ; 
 it occurs especially often in those who are compelled to stand many 
 hours a day at their work. It is supposed to be brought on also 
 by sexual excesses, though we have no foundation for such a belief 
 in actual observations. In the last few years many facts have been 
 brought forward which seem to indicate that this disease is especially 
 frequent in those individuals who have previously suffered from 
 syphilis. 
 
 Certain it is, that locomotor ataxia occurs far more frequently 
 among males than among females, and that it is pre-eminently a 
 disease of adult life. 
 
 Treatment, — There are as yet no well authenticated instances 
 in which recovery has occurred from this disease ; the cases th.it 
 are reported to have recovered seem somewhat doubtful examples 
 of locomotor ataxia. The best results — that is, the postponement 
 of the advanced stage of the disease — appear to have been secured 
 first by rest; and, second, by the iodide of potassium. The patient 
 
f f li, 
 
 WASTING PALSY. 
 
 345 
 
 Five drachms. 
 One ounce. 
 Three ounces. 
 
 should keep the recumbent posture as much as possible, and avoid 
 all violent or long-continued bodily exercise. He should take also 
 the following prescription : 
 
 Iodide of potassium, 
 
 Tincture of ergot, 
 
 Syrup of sarsaparilla. 
 Mix ; take a tcaspoonful four times a day. 
 
 In addition to these measures, it may be necessary to employ 
 agents which shall relieve the neuralgic pains in different parts of 
 the body. For this purpose, it is almost always necessary to 
 use opium ; for since the difficulty is situated in the spinal cord, 
 and not in the skin or muscles, liniments and plasters are of no 
 avail. 
 
 The disease is always of long duration, and rarely terminates 
 fatally in less than three or four years ; yet a fatal result must 
 always be expected. 
 
 Wasting Palsy. 
 
 This disease, also known as progressive mnscular atrophy, 
 consists in a gradual loss of flesh, especially in certain musclesj 
 and accompanied by a corresponding loss of strength. This 
 wasting of the muscles is termed atrophy. 
 
 The atrophy usually begins in one of the upper extremities, 
 more frequently in the right than in the left ; in numerous cases 
 some of the muscles of the hand are the first to be affected, 
 especially those constituting the ball of the thumb. In other 
 instances the wasting begins in the shoulder or in the arm. The 
 aiTection gradually extends to other muscles, being first manifested 
 in the corresponding muscles of the opposite arm. Sonit^times 
 those muscles by which breathing is affected become involved, and 
 death results simply from inability to breathe. 
 
 The appearance of the affected parts is very characteristic ; 
 thus, one entire arm may seem shriveled, while the rest of the 
 body is well developed ; or the arm below the elbow is shrnnken 
 and emaciated, while above the elbow it is of the usual size. 
 
 The wasting of the muscles is accompanied with corresponding 
 weakness ; and there may be some pain, though this is usually not 
 
 
.!. ,i 
 
 ^tl 
 
 346 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 severe. In some instances, twitchings or quiverings of the muscles 
 are observed ; these movements take place quite independently of 
 the will. 
 
 The progress of the disease is slow, though in most cases 
 sure. After lasting for years the patient dies, perhaps from some 
 other disease, or sometimes from the wasting of certain muscles 
 which are necessary to life. In the most favorable cases the wast- 
 ing stops after a certain number of muscles have become affected. 
 Thus, it may cease after the ball of the thumb in one hand has 
 completely disappeared. Yet such a favorable termination cannot 
 be expected ; the disease usually continues until death results. It 
 has been known to last for twenty-three years. 
 
 This is essentially a disease of the spinal cord ; as to its 
 cause we are as yet quite ignorant. Males are more frequently 
 afflicted with it than females, and it has been known to occur in 
 several members of the same family. 
 
 Treatment. — The best results have been obtained from the 
 use of electricity, which must be applied regularly and persistently 
 for months. In addition, strychnine may be given in the following 
 prescription : 
 
 Sulphate of quinine, - - Thirty grains. 
 
 Extract of nux vomica, 
 
 Extract of belladonna, - - Each five grains. 
 
 Mix, and make twenty pills. Take one before meals. 
 
 V I 
 
 
 I') 
 
 Paralysis. 
 
 By paralysis we ordinarily understand a loss of the power of 
 movement. The term, however, is used in medicine also to 
 embrace a loss of the sensibility of a part. In this discussion we 
 shall employ the word in the popular sense, namely, as designat- 
 ing an impairment in the power of motion. 
 
 In order to understand the conditions which cause paralysis, 
 we must remember the conditions which must exist in order that a 
 part of the bod)' can be moved at will. Movement is, of course, 
 performed by the contraction of muscle ; but this muscle does not 
 contract of itself. Under natural conditions a contraction of the 
 voluntary muscles occurs only under the influence of nervous force. 
 
 
PARALYSIS. 
 
 347 
 
 This originates in the nerve centers — especially in the brain and 
 spinal cord — and is conducted along the nerve, just as electricity 
 passes along the wire. When this nervous force reaches the muscle, 
 contraction occurs and the part is moved. In order, therefore, that 
 a voluntary movement shall occur, it is necessary that the nervous 
 force shall be manufactured ; that is, that the brain or spinal cord 
 must be in a healthy condition. Secondly, it is essential that the 
 nerve leading from the brain to the muscle shall be sound ; if this 
 be injured in any way, the force which is produced in the brain is 
 interrupted in its passage along the nerve, just as the electric cur- 
 rent is interrupted if the conducting wire be cut ; and finally, the 
 muscle itself must be in a condition to respond to the influence of 
 this nervous force. 
 
 It is evident, therefore, that paralysis — that is, loss of motion 
 — may result from any one of three causes : first, disease or injury 
 of the brain or spinal cord ; second, disease or injury of the nerve ; 
 third, disease or injury of the muscle. 
 
 In various diseases we have illustrations of these different 
 causes of paralysis ; thus, in apoplexy a portion of the brain is 
 destroyed and a portion of the patient's body is paralyzed, though 
 the muscles and the nerves of the paralyzed part remain uninjured. 
 In certain cases a nerve of the arm for instance is cut or injured 
 by a wound, paralysis of the muscles to which this nerve runs is a 
 consequence, although the brain and the muscle itself are uninjured. 
 Then, again, the muscle itself sometimes becomes incapable of con- 
 tracting, as in the disease knov/n as wasting palsy, which has just 
 been described. In this case there is paralysis, although the brain 
 and the nerve remain intact. 
 
 Whenever therefore a patient is paralyz'-d, it becomes neces- 
 sary to ascertain what part of the apparatus is at fau't ; whether the 
 paralysis results from disease of the brain, so r^at no nervous force 
 is generated ; or whether tin nerve going t.^ ne part is injured, so 
 that the nervous force cannot b». conveyfii to the muscle ; or 
 whether finally the muscle itbclf is diseascu, so that it fails to re 
 spond to the nervous influence. Paralys;!? therefore is a symptom 
 of a disease rather than <. disease itself 
 
 As to the paralysis of sensaii^t . it will not be necessary- to 
 enter into any detailed discus>»*^<« SenaitMi^ like motion, may be 
 lost in anyone of three ways: injury to the brain, injury to the 
 nerve, injury to the skin of the part affected. In many cases -on- 
 
 
 M 
 
348 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 sation and motion are transmitted by different nerves ; that is to 
 say, there may be paralysis of motion in consequence of injury to a 
 given nerve, while the sensibility of the part remains unimpaired ; 
 in the same way the sensibility may be lost while the part can be 
 moved without difficulty. 
 
 Paralysis receives different names according to the part of the 
 body which is paralyzed, and according to the nerve which is 
 injured. It sometimes happens that an entire half of the body — 
 one side of the face, one arm, one side of the body, and one leg — 
 will be paralyzed, while the other side remains intact. This 
 condition is technically termed — 
 
 Hemiplegia. 
 
 13 1 'm ' 
 
 Uf'f!; ! 
 
 h^tfJ' 
 
 The causes of this condition are various, but almost invariably 
 there is some disease inside of the skull. In many cases the diffi- 
 culty is apoplexy; that is, an escape of blood into one side of the 
 brain arrests the action of this organ, so that the part of the body 
 which is moved by nervous influence from this side of the brain is 
 paralyzed. It is an interesting fact that the paralysis occurs on the 
 side of the body opposite to that on which the brain is injured ; 
 thus, an injury to the right side of the brain causes paralysis on the 
 left side of the body. The reason for this lies in the fact that the 
 nerves running from the right side of the brain proceed to the left 
 side of the body, and vice versa; so, too, injuries to one side of the 
 head may cause paralysis on the opposite side of the body, and 
 tumors growing in the skull may also cause paralysis. 
 
 Siiniptoms. — Hemiplegia is easily recognized ; one arm an 
 one leg lie limp and powerless, in spite of the patient's efforts to 
 move them. 
 
 The expression of the face is quite striking and peculiar. The 
 eyelids on the afifected side are usually partially closed, but the 
 patient is unable to open the eye, and sometimes to close it. The 
 result is that the patient winks only on the sound side. More- 
 over, the features are drawn over toward the sound side, so that 
 the symmetry of the face is lost. This results from the fact that 
 each side of the face is provided with a set of muscles which ordi- 
 narily balance each other, and thus keep the movable parts of the 
 
 n.A 
 
HEMIPLEGIA. 
 
 349 
 
 If 
 
 'mm 
 
 :9ir 
 
 face in equilibrium. In hemiplegia, however, the muscles of one 
 <i(le of the face are paralyzed, so that those on the other side have 
 nothing to oppose them, and consequently draw the lips and chin 
 toward the ear of the same side. The wrinkles, too, which are 
 caused largely by the action of muscles, disappear on the affected 
 side ; hence it sometimes happens that one side of the face of an 
 aged person presents the usual wrinkles incident to age, while the 
 other side is as smooth and plump as that of youth. Sometimes, 
 too, the corner of the mouth on the paralyzed side cannot be closed, 
 and the saliva consequently dribbles away. 
 
 When the patient protrudes the tongue, the tip of this organ 
 is usually pointed toward the paralyzed side. When food or drink 
 is taken into the mouth, it escapes from the corner, or collects 
 between the teeth and the cheek on the same side. It will be seen, 
 upon opening the mouth and depressing the tongue, that the pro- 
 jection from the soft palate, technically termed the uvula, is also 
 directed toward one side. 
 
 The subsequent history of a patient afflicted with hemiplegia 
 varies much in different patients. It is impossible to predict what 
 will happen ; we cannot say how long the paralysis will endure nor 
 how much improvement will be manifested. In some cases death 
 occurs within a few hours; in others improvement may take place 
 within a week and entire recovery in a few weeks. These are the 
 extremes; in many instances a slow improvement begins a con- 
 siderable time after the occurrence of the hemiplegia and progresses 
 gradually up to a certain point. The improvement is usually first 
 manifested in the face, and next in the lower extremity. It some- 
 times happens that the patient can walk again without much diffi- 
 culty, while the arm still remains paralyzed. In the great majority 
 of cases the recovery is never perfect ; there always remains a 
 weakness of the paralyzed limbs, which may be so great as to seri- 
 ously impair the functions of these limbs. In the course of time 
 it usually becomes evident that the limbs which have been para- 
 lyzed are softer and less bulky than the sound ones. It sometimes 
 happens, too, that the muscles are not restored to a uniform 
 degree ; those on the back of the arm, for instance, will not 
 acquire so much strength as those on the front. The result of this 
 is permanent deformity, since the hand is bent somewhat into the 
 shape of a bird's claw. 
 
 In some cases of hemiplegia the mind is not at all afifected ; in 
 
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 350 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 the majority of instances, however, there is evidently some impair- 
 ment of the mental faculties. The individuals are more easil\- 
 moved to a display of emotion, and are usually fretful and irri- 
 table. 
 
 An occasional incident is the loss of speech. This has been 
 already discussed in describing apoplexy; and some cases of hemi- 
 plegia are merely instances of apoplexy. Yet this loss of speech 
 may also occur in other instances. 
 
 The subsequent history and ultimate outcome of these cases 
 depend upon the cause of the difficulty ; and it is sometimes 
 impossible even for the physician to ascertain what that condi- 
 tion is. 
 
 Paraplegia. 
 
 This term is used to indicate paralysis of the lower part of the 
 body, including both lower extremities and the muscles of the 
 trunk below the waist. It occurs often as the result of an injury 
 to the back, and frequently in consequence of disease of the spinal 
 cord. 
 
 Symptoms, — The most typical examples of this afifectioii 
 occur in cases in which the spinal cord has been ini .red. It will 
 be found that the legs are completely paralyzed, and that the 
 patient has lost control of the bladder and of the rectum. In some 
 instances there is unusual sensitiveness of the skin in the paralyzed 
 parts. 
 
 The outcome of the disease depends upon the extent and 
 nature of the injury. In some cases the patient is permanently 
 paralyzed, and may never recover complete control of the bladder 
 and of the rectum. In these cases the bowels are evacuated with- 
 out the influence of the will, in fact often without the patient's 
 knowledge, and the catheter must be constantly used to draw the 
 urine. In most cases a severe inflammation of the bladder occurs, 
 and may shorten the patient's wretched existence. 
 
 Most of the cases of paraplegia which result from disease are 
 due to an inflammation of the spinal cord. In these cases the 
 patient usually notices for some time before the paralysis becomes 
 evident, that he is not so steady upon his feet as formerly ; and he 
 is especially apt to trip and stumble while walking. After a time 
 
FACIAL PARALYSIS. 
 
 351 
 
 he experiences a sense of constriction around the waist, as if a band 
 were bound tightly around his body. Subsequently he notices 
 that the power of the legs is impaired, and often perceives that the 
 sensibility of the skin is also less acute. 
 
 A most troublesome and severe symptom of this complaint is 
 the occurrence of bed sores. These may be formed on any pro- 
 jecting part of the paralyzed limb, and occur with especial frequency 
 on the buttocks and over the hip bones. They are apt to begin 
 with a simple reddening of the skin, which soon gives place to a 
 deep ulcer. This ulcer increases rapidly in size as the flesh morti- 
 fies, and may become as large as the palm of the hand. The 
 bottom and sides of these ulcers are covered with gray, decaying 
 flesh, and the odor emitted by the patient is overpowering. 
 
 Recovery from this affection rarely, if ever, occurs; in the 
 majority of cases a fatal result ensues within a few months. 
 
 Sometimes the paralysis is limited to a single nerve, and the 
 symptoms depend, of course, upon the nerve thus affected. Among 
 the most commonly affected nerves are those which supply the eye- 
 lids and those which run to the face. 
 
 Paralysis of the nerve supplying the eyelids causes a drooping 
 of the upper lid, and usually a squint. If the paralysis be caused 
 by cold or by nervous exhaustion, it may disappear spontaneously 
 after a time, and usually yields readily to treatment. 
 
 Facial Paralysis 
 
 Is a frequent occurrence. It often results from exposure to 
 cold, after a person has slept by an open window. 
 
 Symptoma. — This condition is at once indicated by the ap- 
 pearance of the face, some of the symptoms of which have been 
 already described in speaking of hemiplegia. The mouth is drawn 
 toward the sound side of the face ; the patient is usually unable to 
 close the eye or to wink ; the tears escape over the lids and roll 
 down the cheek; the wrinkles are smoothed out of the forehead. 
 The cheek is usually puffed out during efforts to speak, and may be 
 caught between the teeth in chewing. 
 
 In most cases recovery occurs in the course of a few weeks ; 
 but if the disease originate in some difficulty within the skull, it may 
 be permanent. 
 
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352 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Infantile Paralysis. 
 
 This affection as the name implies occurs with especial fre- 
 quency in infancy, though it may also happen during later child- 
 hood. It is essentially a disease of the spinal cord. 
 
 Almost the first symptoms noticed when the patient is an in- 
 fant, is a loss of movement in the affected limb, usually a leg. Thi^ 
 may be accompanied by evidences of severe pain, and by fever. 
 The acute symptoms subside within a (c\,v weeks, but as the child 
 grows, it is noticed that the affected limb does not keep pace with 
 its fellow; it remains smaller, shorter, and weaker. When the indi- 
 vidual attains maturity, the leg is usually considerably shorter than 
 the other, so that that the patient is compelled to wear a shoe espe- 
 cially made for it, having a high heel and a thick sole. 
 
 General Paralysis of the Insane, 
 
 Is a form of paralysis affecting the encire body, and accom- 
 panied by symptoms of insanity. It will be described under this 
 topic. 
 
 Shaking Palsy 
 
 Technically known as paralysis agitans, is a name applied to 
 that form of muscular debility which is found especially in the 
 aged. It affects the hands, which cannot be held quiet unless the 
 patient's attention is especially directed to the accomplishment of 
 some object. It often happens that if the patient extends the hand 
 to grasp an object, the tremor ceases. Sometimes the lower limbs, 
 also, are so tremulous that the patient can scarcely walk. 
 
 While this affection is most common in elderly people, it may 
 occur in the young and middle-aged as the result of excesses in 
 drink or in sexual indulgence ; in fact, any long-continued excessive- 
 demand upon the nervous system, of whatever nature — worry 
 anxiety, excitement, fatigue — may be followed by this form of 
 paralysis. 
 
WRITERS CRAMP. 
 
 Writers' Cramp 
 
 353 
 
 Is a form of paralysis usually limited to certain muscles of the 
 hand. As the name indicates, the affection is especially common 
 amon<'^ those whose occupation compels them to hold the pen many 
 hours a day. It may be indicated by actual paralysis, so that the 
 fiii'^cr and thumb cannot be brought together with the usual power ; 
 in other cases, the muscles controlling the fingers are firmly con- 
 tracted, so that the thumb and fingers cannot be moved or are 
 moved irregularly. Unlike most of the forms of paralysis, this 
 affection can usually be cured by rest and treatment. 
 
 Persons engaged in other occupations than writing, who are 
 compelled to use the same muscles constantly for many hours daily, 
 are often similarly affected. Tailors and sewing -girls, for example, 
 may lose the power of holding and guiding the needle ; and women 
 who arc compelled to work a sewing machine may have a similar 
 affection of the feet and legs. 
 
 Ti'catwent of Paralysifs. — In every case the first object is 
 to ascertain the cause. In many cases careful investigation will 
 show that the cause can be removed and the paralysis relieved. 
 Thus paralysis affecting various parts of the body, even an entire 
 half, as in hemiplegia, may be due to sypliilis, for an individual 
 who has had this disease is liable to inflammations in the brain 
 which may paralyze his muscles. These are the most favorable 
 cases for treatment, since, if taken early, they may be readily cured 
 by the following prescription : 
 
 Iodine, 
 
 Iodide of potassium, 
 
 Syrup of sarsaparilla. 
 
 Eight grains. 
 Ten drachms. 
 Eight ounces. 
 
 Mix, and take a teaspoonful after meals ; the dose may be grad- 
 ually increased to two or even three teaspoonfuls. 
 
 In other cases paralysis results from slow poisoning of some of 
 the metals, such as lead and mercury. These forms of paralysis 
 are, of course, found with especial frequency in those who are com- 
 pelled to handle and work with these metals. Lead poisoning may 
 occur, too, among women who employ cosmetics containing the arti- 
 cle, and from the use of drinking-waters which pass through imper- 
 fectly constructed pipes. In these cases relief may be obtained by 
 
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 354 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 the use of the following in connection with the measures to be pres- 
 ently mentioned : 
 
 Iodide of potassium, - - Five drachms. 
 
 Water, - - - - Four ounces. 
 
 Take a teaspoonful four times a day. 
 
 In addition to this the sulphate of magnesia may be given in 
 doses sufficient to keep the bowels active ; for this purpose it may 
 be necessary to give from a teaspoonful to a tablespoonful of this 
 laxative every day. 
 
 It would be impossible to follow out in detail all the different 
 measures which may be at times useful in the treatment of paralysis ; 
 for every case must be studied and treated seoarately ; it has been 
 already stated that paralysis is a sym.ptom and not a disease. 
 
 Yet there are certain measures which will be found useful in 
 almost all cases, and which may be therefore mentioned here. 
 Prominent among these is electricity. Physicians have come to 
 rely upon this agent as furnishing excellent results though it 
 must not be expected that a cure can always be effected. When, 
 for example, paralysis results from an inflammation or hemorrhage in 
 the brain, the application of electricity to the arm or to the leg can 
 be of no service. 
 
 Another most valuable agent is massage. This process, which 
 is now extensively employed by physicians, is performed as follows : 
 the patient is stripped, or at least as much of the body is laid bare 
 as is required for treatment ; an attendant then kneads, pinches, 
 pulls and rubs the flesh until a gentle glow and feeling of warmth 
 are excited. This process may seem at first somewhat rough, and 
 may leave a slight soreness, but in a short time these symptoms no 
 longer occur and evident benefit results. Considerable practice is 
 required for the skillful performance of massage, but much benefit 
 can be conferred even by an inexperienced person who will perse- 
 vere in the effort. 
 
 It is highly important that those afflicted with paralysis should 
 have the benefit of fresh air and of such exercise as they arc capa- 
 ble of taking ; for this purpose it may be necessary to furnish tlicm 
 with the assistance of perambulators, easy chairs, and other iia- 
 chanical contrivances. 
 
 Among the remedies which may be employed with advantage 
 
NERVOUS EXHAUSTION. 
 
 355 
 
 in certain cases of paralysis, are strychnine and phosphorus. The 
 former may be given in the following prescription : 
 
 Sulphate of strychnia, - - Half a grain. 
 
 Reduced iron, - - - Thirty grains. 
 
 Extract of belladonna, - - Eight grains. 
 
 Mix and make thirty pills. Take one morning and night. 
 
 Phosphorus can be best given dissolved in almond oil ; one- 
 fourth of a grain of phosphorus may be dissolved in two ounces of 
 the oil, and a teaspoonful of this may be taken morning and night. 
 
 Nervous Exhaustion. 
 
 This term designates a condition which is known by physicians 
 as neurasthenia. It may be defined in short as a lack of nervous 
 force. It often exists in pallid, bloodless people, and disappears 
 when the patient's general condition is so improved that the blood- 
 producing organs again perform their functions properly, and the 
 individual acquires again the ruddy glow of health. Yet it often 
 happens that nervous exhaustion exists in individuals whose general 
 appearance would not lead any one to suspect any serious disease ; 
 the person may be stout and of full habit, may have a good appe- 
 tite and digest the food well, and yet may be and feel quite incap- 
 able of performing those duties which he had previously fulfilled 
 without difficulty. 
 
 The afifection seems usually to proceed from an improper de- 
 tjrce of activity of some part of the nervous system, more especially 
 in the exercise of the mental faculties. It seems also to be subject 
 to certain hereditary influences ; the children of parents who have 
 sufifered from chronic diseases of the nervous system, such as epi- 
 lepsy, hysteria and insanity, are especially prone, lo the manifesta- 
 tion of nervous exhaustion. 
 
 Physicians, especially those who practice in large cities, are 
 often consulted by individuals who, although manifesting no well- 
 defined disease, are evidently not in good health. It is possible that 
 these cases do not receive as much attention from friends of the 
 person, or even from the physician himself, as they deserve ; for 
 the tendency to complain, to exaggerate slight indisposition, is so 
 common, that unless there issomedefmiteand tangible derangement 
 
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 356 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 of the body, the tendency is to ignore and make light of thr 
 symptoms presetitcd. In nervous exhaustion, moreover, the indi- 
 cations of the difficulty are of a subjective rather than of an objec- 
 tive character ; that is, they are symptoms which the patient can 
 himself feci, but which no one else can perceive. 
 
 The subjects of nervous exhaustion complain of lassitude, a 
 want of buoyant feeling, an indisposition for exertion, mental de- 
 pression, and :-.ometimes wandering pains and aches are felt in various 
 parts of the body. Such individuals are wakeful at night, ami 
 arise with a sense of fatigue and a feeling that their sleep has not 
 refreshed them. When stimulated by some unusual excitement 
 they are capable of the usual exertion, but when the excitement 
 has subsided they feel exhausted. Such patients usually fancy 
 that they have some serious disease, and often become melancholy 
 at the thought that their powers are being undermined and that 
 they are " in a decline. " 
 
 A careful examination of the different organs usually fails to 
 disclose any evidence of disease. The heart, lungs, kidneys, etc., 
 are healthy. The physician is apt to regard such patients as the 
 victims of their own imagination. 
 
 Yet this condition is in many cases real, not imaginary. By :i 
 little inquiry it becomes manifest that such patients have been usu- 
 ally long harassed by the cares and responsibilities of business, by 
 excessive devotion to study, or by some similar strain on the nervous 
 system. In many cases this over-work is combined with carelessness 
 and neglect in diet and habits of life. 
 
 This disease is essentially and pre-eminently an affection of 
 modern society, and is found in its most aggravated type in tlic 
 United States. For the causes that stimulate the mind to exces- 
 sive exertion are especially active in this country. The inducements 
 to active effort are so great, that the business of life is assumed here 
 at an unusually early age and with extreme zeal. 
 
 This condition of nervous exhaustion is by itself a serious affec- 
 tion, and may indirectly induce or aggravate numerous oUierills; 
 for it favors the development of diseases to which the patient may 
 be predisposed, and aggravates the effects of such ailments as he 
 may acquire. 
 
 It would be impossible to detail all the symptoms which may 
 be caused by this condition of nervous exhaustion. Some of the 
 more important ones will be, however, briefly discussed. 
 
( 
 
 NERVOUS EXHAUSTION. 
 
 357 
 
 Spinal irritation is a manifestation of nervous exhaustion which 
 affl'Cts many of those enj,M^cd in active mental effort, and is cspe- 
 ciiiily common among women wlio are subject to diseases of the 
 womb. In this condition there is extreme tenderness all along the 
 spine ; there are usually flying pains, esj)ecially in the chest and 
 abdomen ; and the occurrence of hysteria as well as of convulsive 
 spasms of the limbs is a frequent symptom. 
 
 This condition of spinal irritation is usually periodical, and is 
 especially apt to occur after over-e.\ertion or excessive emotion. In 
 lu rvous women it occurs particularly during the period of menstrua- 
 tion. 
 
 There are also conditions which seem essentially the same as 
 spinal irritation, though there is no tenderness on pressure along 
 the back bone. The condition is manifested by unpleasant and 
 annoying sensations in different parts of the body. Some individ- 
 uals suffer from neuralgic pains in the limbs; others have throbbing 
 sensations in the chest and in the head. Another symptom is itch- 
 ing, which may occur in any part of the body without apparent 
 cause, and may be quite intense and persistent. 
 
 One of the most distressing symptoms is the wakefulness of 
 such patients. They lie awake and toss about for hours and per- 
 haps fall into a heavy sleep toward morning, from which they awake 
 without feeling much refreshed. This condition is obstinate and 
 nia\- not yield even to the bromide of potassium or to chloral, unless 
 taken in excessive doses. 
 
 Another manifestation of nervous exhaustion i.% dyspepsia, 
 which is rarely so distressing as those forms of dyspcpsi;- which 
 result from organic disease of the stomach, but is nevertheless a 
 source of much annoyance and uneasiness to the patient. 
 
 The special senses are also liable to derangements. Among 
 the most common of these are specks before the eyes, which appear 
 especially when the individual feels exhausted. Another occur- 
 rence is noise in the ears, which sometimes takes the ff)rm (jf a 
 coiuinual humming, and sometimes appears as sudden and loud 
 noise. 
 
 (^ne of the symptoms of nervous exhaustion, which is brought 
 to the notice of the physician with especial frequency, is derange- 
 ment of the sexual functions. This may take the form of impotence, 
 partial or complete. This is often manifested by a loss of sexual 
 power before the appetite disappears. Under these circumstances 
 
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 358 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 the patient is extremely depressed and despondent, as a result of 
 which the symptoms ar'. aggravated. Sometimes this sexual weak- 
 ness takes the form of seminal emissions. These are of course 
 natural and in perf ,ct accord with health and those who are con- 
 tinent ; but in conditions of nervous exhaustion these emissions are 
 apt to occur w'tn far more frequency than in health. These emis- 
 sions when PKcessive are of themselves somewhat exhausting, but 
 they are especially important as indications of nervous prostration. 
 The popular idea ascribes to seminal losses the symptoms which 
 occur in the individual at the time ; in other words the emissions 
 are assumed to be the cause of the patient's prostration. As a matter 
 of fact they are the result rather than the cause of the condition, and 
 the patients despondency should be relieved by the assurance that 
 when his general health shall be improved, thissympton will disap- 
 pear, provided there be no organic disease of the sexual organs. 
 
 In females nervous exhaustion is manifested by pain and 
 unusual prostration at the time of the menstrual epochs. Here 
 also the menstrual disorders are the result rather than the cause of 
 the nervous prostration accompanying them. 
 
 There may be in various parts of the body derangements of 
 motion and of sensation which are to be explained simply by the 
 general condition of the patient, and not by any local disease. 
 Thus it may happen that certain portions of the skin become quite 
 numb, and remain so for hours or days at a time ; in other cases 
 certain parts, such as a finger or toe, an arm or a leg, become ex- 
 tremely sensitive both to pain and to changes of temperature. At 
 times too there may occur what seems to be a genuine par.xlysis ; 
 the patient loses control of fingers, of thumbs, or even of the 
 entire hand or fore-arm. In other instances twitchings of the 
 muscles are constantly observed ; this is especially frequent in the 
 muscles of the eyelids. Such patients are annoyed by the con- 
 sciousness that they are constantly winking, and yet they arc 
 unable to control the eyelid. 
 
 Occasionally such patients are troubled also with unusual diffi- 
 dence, and even timidity, which sometimes manifests itself by an 
 aversion to society ; this is particularly apt to occur in those whose 
 nervous exhaustion takes the form of sexual incapacity. 
 
 This entire subject has been admirably summarized by a recent 
 writer on the subject, Dr. Beard, as follows : 
 
 " In regard to the above symptoms, it may be remarked that 
 
 ii:if 
 
 m 
 
NERVOUS KXHAUSTION. 
 
 359 
 
 thov are not imaginary, but real ; not trifling, but serious, although 
 not usually dangerous. The interchangeablcncss of these symp- 
 toms is also noteworthy. In nervous exhaustion, nothing is con- 
 stant exci.'pt inconstancy. The symptoms chase each other like the 
 shadow of summer clouds across the landscape. The moment one 
 leaves, another and several stand ready to take its place. In a 
 sin'dt- day one may go through the whole gamut of all these notes 
 of disease. 
 
 " The periodical and rhythmical character of some of these 
 symptoms is of much interest. I once had under treatment a 
 young man who had attacks of nervous depression every day about 
 noon; they lasted but for a short time, but were as periodic as 
 chills and fever, and, like chills, passed through definite stages. 
 
 " Nervous exhaustion is compatible with the appearance of per- 
 fect health. For this reason, as well as on account of the slippery, 
 fleeting and vague return of their symptoms, patients of this class 
 get but trifling sympathy. Sometimes they are fat and hearty, 
 and have a ruddy, vigorous strength, suggestive bearing; some- 
 times, also, they grow fatter as they grow worse. Noticeably the 
 disappearance of symptoms in the stomach, and the appearance in 
 their stead of symptoms in the brain and spinal cord, is followed 
 by increase in weight that deceives the friend, the physician, and 
 even the patient himself. Thus it happens that patients get the 
 least sympathy when they most need it. 
 
 " Nervous exhaustion is a modern disease, and pre-eminently an 
 American disease, and in this country is chiefly found in the North 
 and East. This disease must therefore be studied here ; we cannot, 
 as in so many other diseases, look to Germany for light and infor- 
 mation, for in Germany this condition is comparatively unknown, 
 and in France and England is far more rare than with us. 
 
 " Tlic diagnosis of nervous exhaustion is sometimes entirely 
 .icar, and again is quite difiicult. If a patient complains of general 
 malaise (indisposition), debility of all the functions, poor appetite, 
 abiding weakness in the back and spine, fugitive neuralgic pains, 
 hysteria, sleeplessness, disinclination for consecutive mental labor, 
 severe and weakening attacks of sick headache and other analogous 
 symptoms, and at the same time gives no evidenc of anaemia or 
 of any organic disease, we have reason to suspect that the general 
 nervous system is mainly at fault, and that we are dealing with a 
 typical case of nervous exhaustion. 
 
 
 ' * ii ' ] 
 
 ■■•■ :.m^ 
 
 H 
 
II I \'l 
 
 
 360 
 
 DISEASES 01> THK NERVOUS SYSTEM. 
 
 "Chronic nervous exhaustion — of which form I am chiefly 
 speaking — may result in paraplegia, in general paralysis, in ncu 
 ralgia, in uterine disturbances, in dyspepsia, in chorea, in hysturia 
 and in actual insanity ; or under proper treatment it may go on to 
 perfect recovery. 
 
 " Chronic neurasthenia sometimes proves directly fatal without 
 causing organic disease ; but such a termination is not usual. It is 
 a chronic condition, and patients afflicted with it may last for lialfa 
 century." 
 
 Tfenttnent. — Nervous exhaustion usually requires, first of .ill, 
 complete relief from care, anxiety and exertion. It is not desir- 
 able that the patient should entirely relinquish his occupation ; l)iit 
 a respite for a certain period seems absolutely necessary. 
 
 Not less important is the avoidance of errors in the habits of 
 life. The inordinate use of stimulants, excesses of any kind, etc., 
 are of course to be avoided. The best sanitary regulations also 
 should be observed, and one of the most efficient remedies that 
 can be employed is a course of sea bathing. If this cannot be pro- 
 cured, the cold bath in the morning at least, or morning and night 
 if the patient can bear it, is a good substitute. 
 
 The diet should be generous and varied, even though the 
 patient may already seem to have an abundance of flesh. Among 
 the remedies to be employed, two are especially valuable — elec- 
 tricity and massage. Kxcrcise should be provided for, but not 
 taken in excess, since exercise of the body requires exertion on the 
 part of the nervous system. In some cases severe measures have 
 been employed to reliei'c spinal irritation ; small blisters and even 
 the white-hot iron have been applied along the spine. Such 
 measures must, of course, be used only under the advice of the 
 physician, since in every case it is the patient and not the diu-ase 
 that is under treatment. The drugs that are to be used vai\ in 
 different cases. In most cases strychnine, arsenic and quinine, with 
 or without iron, will be useful. These may be given in the follow- 
 ing prescription : 
 
 Sulphate of quinine, - 
 Arsenious acid, 
 Reducec' iron, 
 Extract of nux vomica, 
 Kxtract of cannabis indica, 
 
 Forty grains. 
 One-third of a grain. 
 Twenty grains. 
 P'our grains. 
 Five grains. 
 
 Mix, and make twenty pills. Take one before meals. 
 
 in ; 
 
 I 
 
 (Ic 
 
 lowing. 
 
 Mix- 
 
 . .1 
 
 
 If 
 
 may 
 
 b{ 
 
§.*. :Hj 
 
 SUNSTKOKi:. 
 
 361 
 
 Tf there be symptoms of dyspepsia it '.vill be advisable to use 
 in addition to tiie above pepsin and extract of malt, as in the fol- 
 lowing prescription : 
 
 Extract of malt, - - . - Three ounces. 
 
 Wine of pepsin, . - . . Three ounces. 
 
 Mix, .md take a teaspoonful after meals. 
 
 if tile patient be troubled with sleeplessness, the foUowiu}^ 
 may 1)<.' administered at ni^ht : 
 
 Hromide of potassium, ... Two ounces. 
 
 Hydrate of choral, - - - - One ounce. 
 
 Syrup of orange peel, - - - Two ounces. 
 
 Water, ------ Four ounces. 
 
 Mix, and take a teaspoonful before retiring. The dose may be 
 rcpcaicd in an hour if needed. 
 
 Sunstroke. 
 
 The term sunstroke is applied to a condition of nervous pros- 
 tration induced by excessive heat. Althouj:;h this condition may 
 result from the heat of the sun, it may just as well follow exposure 
 to heat wiUiout sunlight ; indeed, cases of sunstroke occur in 
 individuals who are working in the shade, or even at night — the 
 condition might be better termed heat-stroke than sunstroke. 
 
 In a certain proportion of cases the condition seems to be one 
 closely resembling apoplexy. In many other cases the bodily state 
 may be likened to that which e.xists in a severe fainting spell. 
 
 There may be no premonitory symptoms to warn the patient 
 of an approaching attack ; he is suddenly seized with a severe pain 
 in the head, a sense of fullness of the stomach, followed by nausea 
 incl vomiting, dizziness, dimness of vision and sometimes ringing 
 in tlic cars ; immediately he becomes very weak, especially in the 
 lower limbs, and unless speedily supported falls to the ground. In 
 a very few moments after the beginning of the attack the patient is 
 unconscious ; the general symptoms are, in severe cases, those of 
 apoplexy, except that the patient is not paralyzed. The breathing 
 is slow and snoring, and may be occasionally accompanied by a 
 moaning sound. Convulsions frequently occur. 
 
 urllX 
 
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ii 
 
 7 i 
 
 
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 Uki 
 
 362 
 
 DISEASES t)K THE NERVOUS SYSTEM. 
 
 This condition may last but a few minutes and be terminated 
 by death. It sometimes happens that the patient expires evin 
 before assistance can reach him. In other cases, after this st;iu 
 has lasted for from twenty minutes to four iiours, the patici'i 
 gradually recovers consciousness, and in a few days is convalescent. 
 
 The most notabh; feature in these cases, and one which demaiids 
 particular attention in the treatment, is the excessive temperature 
 of the body. While the body heat, durinj; health, ran^a-s from yS 
 to 99 degrees, it may rise during an attack of sunstroke to loM 
 degrees, no, or even 112 degrees. The surface of the body i> 
 usually, though not always, quite warm. 
 
 The most important agent in the induction of sunstroke is 
 undoubtedly e.xcessiv'e heat. Yet there are certain influences wiiicli 
 predispose the individual to the effect of the heat. Kxcessivc 
 exertion, especially muscular effort, seems to favor the develop- 
 ment of sunstroke ; many cases occur in those who are engaged in 
 manual labor, yet this is not invariably the case. It has been 
 noticed that a considerable number of cases occur in individuals 
 who have just completed a hearty meal. 
 
 Cases of sunstroke arc more common in tropical than in otiicr 
 climates, notwithstanding the assumed power of the natives tu 
 withstand excessive heat. 
 
 About one-half of all individuals attacked with sunstroke die 
 of the affection. The occurrence of convulsions, of deep and loud 
 breathing, and of persistent unconsciousness, indicate that ila 
 attack will prove fatal. Perhaps the best index to the patient's 
 condition and prospects is to be found in the pulse ; if this be very 
 rapid and feeble, so that it can scarcely be felt or counted, the 
 condition is most grave. 
 
 In other cases the patient does not lose consciousness com- 
 pletely, or if he does, his condition resembles profound sleep rat.'ier 
 than the stupor of apoplexy. In these cases the pulse is usually 
 quite perceptible, though it may be quite rapid and feeble. 
 
 Trenttnent. — In the treatment of sunstroke, it is important 
 to remember that there are two different types of the affection, and 
 two different modes of treatment adapted to each. 
 
 For those cases in which t/ie skin is cool, the pulse so feeble as 
 to be almost imperceptible, the breathing easy and natural, the 
 patient must be stimulated, and that as soon as possible. The 
 
SUNSTROKE. 
 
 363 
 
 clotliint; should be loosened, especially from the neck ; the patient's 
 luail sliduld be kept low, the air allowed to circulate around the 
 body ; half a tablespoonful of whisky or brandy may be administered 
 every fifteen minutes until six doses have been taken ; hartshorn 
 should be applied to the nostrils. If there be any vomiting', the 
 whisky or brandy may be administered as an injection into the 
 rectum. In this case, an ounce (two tablespoonfuls) may be {jiven 
 for each dose. 
 
 It is highly important that such a patient be not moveu nor 
 agitated ; he should not, therefore, be taken home nor to a htispital, 
 iinicss the distance be short, but should be treated at oi'c/ at the 
 nearest convenient place. 
 
 The skin may be rubbed thoroughly with whisky and water. 
 But in this form of the affection no cathartics should b ; ;iven. 
 
 In those cases of sunstroke that resemble apople.xy, ai other 
 line of treatment is -equired. In these cases the patient is usually 
 unconscious, the pulse is slow and full, the breathing is .slow and 
 suoiinj^. '". these cases the patient should be packed in ice; 
 these are the cases in which the body heat runs very hiyii, and 
 constit itcs the chief element of danger. The object of treatment 
 is, therefore, to cool the body as rapidly and as early as possible, 
 For this purpose, lumps of ice wrapped in coarse cloths, may be 
 laid entirely around the body of the patient, especially around 
 the licad ; if an ice cap can be procured — a rubber bag made to 
 cover the entire head — it should be used. 
 
 If it be impossible to procure ice immediately, the patient may 
 be laid in a bath of cold water, and a stream of water poured upon 
 his head and neck. In short, without going further into details, it 
 will suffice to repeat that the chief object is to lower the tetnpera- 
 lurc of the body ; the means to be employed may vary with the 
 circumstances of the case. 
 
 In every case, one or two drops of croton oil should be placed 
 upon the tongue ; and if it can be arranged, light mustard plasters 
 should be applied to the soles of the feet and to the calves. 
 
 % 
 
 
i I 
 
 f : J 
 
 364 
 
 DISEASES OK THK NERVOUS SYSTEM. 
 
 Under such treatment, patients usually recover from sunstroke 
 if they can be promptly subjected to the measures described. 
 
 Whooping-cough. 
 
 This affection is by many classed among nervous diseases, 
 notwithstanding the apparently infectious nature of the complaint, 
 The symptoms of whooping-cough arc so familiar that no descrip- 
 tion is necessary. 
 
 Treatment, — The paroxysms can usually be shortened by 
 the use of emetics, which not only provoke vomiting but also loosen 
 the phlegm. For this purpose, we may give a full dose of ipecac 
 or squills. 
 
 Aside from this measure, but little treatment seems beneficial. 
 In fact the mild cases do best without medicine, if care be taken to 
 avoid exposure to the cold and to wrap the bodj- well in flannel 
 under-clothing. 
 
 To cut short the disease, a great many remedies have been 
 administered ; the fact that these remedies are so numerous, indi 
 cates that no one of them can be relied upon for all cases. Good 
 results have been reported from the use of belladonna. The fol 
 lowing mixture will be found of service : 
 
 Extract of belladonna, ... One grain. 
 
 Mucilage of gum arable, - - - Two ounces. 
 
 Give twenty or thirty drops of this every three hours. We 
 may also use to advantage the following prescription : 
 
 Fluid extract of hyoscyamus, - - Half a drachm. 
 Orange flower water, - - - - Four ounces. 
 
 Mix and give a tablespoonful every three hours. This dose is 
 suited to a child of 12 years, and must be correspondingly reduced 
 for a younger child. 
 
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 ■IBM. 
 
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 lltii 
 
 SKTN^. 
 
DISEASES OF THE SKIN. 
 
 
 The skin is not only a covering for the body, but also an im- 
 portant organ for the elimination of certain materials from the blood. 
 In this respect the skin ranks with the kidneys, the lungs and the 
 intestines; it is an organ of excretion — that is, its function is to 
 separate and throw off certain materials which are no longer required 
 in the animal econoni)'. 
 
 The skin, therefore, is liable to derangements of function as a 
 result of constitutional disturbance, just as are the kidneys, the 
 lungs and the bowels ; and in addition, its exposure to the weather 
 and to external influences of various kinds makes it especially often 
 the seat of disease. 
 
 The diseases to which the skin is liable are accordingly divided 
 into two general classes: 
 
 First. Those that proceed from within the body, — afilections of 
 the blood, and of the different organs — which may, therefore, be 
 called internal causes. 
 
 Second. Those which act from without, and may hence be 
 called external causes. 
 
 The influences which act from within the system upon the skin 
 arc various ; among them may be mentioned: 
 
 I. Blood poisoning. This might also be called impurities of 
 the blood • yet there is an objection to the use of this term because 
 of the popular errors in regard to its significance. For in the pop- 
 ular mind an impurity of the blood means usually that something 
 external to the body has been taken into the blood, and that this 
 impure substance is the cause of a rash upon the skin. By impuri- 
 ties of the blood, however, the physician understands not neces- 
 sarily that there has been any entrance of poisonous matter into 
 the body, but merely that the different organs — the kidneys, lungs, 
 liver, etc. — do not remove from the blood those materials which 
 
 365 
 
 If; 
 
 A% 
 
 '?h 
 
p 
 
 %\ 
 
 
 
 366 
 
 DISEASES OF THE SKIN. 
 
 have been consumed during the vital processes, and which must 
 therefore be thrown out from the body. Properly speaking, there- 
 fore, the blood of every individual is impure whenever he suffers 
 from Bright's disease, or liver complaint, or dyspepsia ; though in 
 these cases there is not usually any rash upon the skin. There arc, 
 it is true, certain impurities in the blood — such as the contagious 
 principle o( syphilis — which, at certain periods of the disease, 
 usually cause a rash upon the skin ; yet, it is equally true, that the 
 individual's blood may be loaded with the impurity of syphilis for 
 years at a time without showing any rash upon the skin. 
 
 It is evident, therefore, that the prevalent idea as to the con- 
 nection between a skin disease and " bad blood," is wholly errone- 
 ous ; since, in the first place, skin disease often exists in individuals 
 who are otherwise perfectly healthy, and whose blood is in conse- 
 quence, perfectly pure ; while in the second place, the skin is often 
 free from disease in individuals who are sinks of the foulest corrup- 
 tion. 
 
 If this fact be appreciated, it becomes apparent that the popu- 
 lar notions about " purifying the blood " are erroneous. 
 
 Thousands of gallons of " blood purifiers " are sold annually, 
 and used by individuals who imagine that a rash on the skin means 
 that some impurity of the blood is " breaking out " of the body. 
 Such persons are thoroughly well pleased when, after taking a few- 
 pint bottles of some patent medicine for purifying the blood, they 
 see pimples appear on the face, chest and back. They regard these 
 pimples as proof that the blood contained some impurity and that 
 the patent medicine has caused this impurity to work out through 
 the " pores of the skin." After using the medicine for a few weeks, 
 until they are satisfied that the impurities are driven out of the sys- 
 tem, they stop taking the mixture and the rash disappears. The 
 physiology of this whole matter is so simple and plain, that the in- 
 dividual probably never doubts for a moment that he has really 
 caused some impurities to escape from the system through the skin. 
 The fact is, that these blood purifiers so-called are constructed essen- 
 tially on the simple principle that certain drugs, when taken into the 
 system, cause a rash of pimples to appear on the skin. It is well 
 known to the general public as well as to the profession, that mer- 
 cury, when used to exciss, causes an excessive flow of saliva and 
 other symptoms constituting the condition known as " saliva- 
 tion. " It is equally well known to medical men, that the iodide 
 
GENERAL REMARKS. 
 
 367 
 
 of potassium, or the bromide of potassium, when taken for a lonjj 
 time or in large quantities, causes an eruption of pimples on the 
 face; indeed, if the drug be taken in sufficient quantity, the pim- 
 ples can be made to appear over the entire skin. The so-called 
 blood purifiers, which are so popular with the public, contain large 
 quantities of one of these or similar drugs ; ♦■^'cir efi"ect is, there- 
 fore, to cause a rash to appear upon the skin, which they will do 
 when taken by any person no matter how pure the blood may be. 
 The rash does indeed indicate that there is an impurity in the blood, 
 but this impurity was taken into the blood in the shape of the 
 blood purifier. 
 
 It should be said once for all, that no rash on the skin is ever a 
 means whereby the body is relieved of impurities ; nor is there any 
 remedy known by which impurities of the blood can be made to 
 escape from the body in the shape of a rash. 
 
 Closely allied with this superstition, is the idea so prevalent, 
 among women especially, that it is dangerous to " drive in " a rash 
 on the skin. The idea prevails that some poisonous material is 
 seeking to find its way out of the body through the pimples or 
 other eruptions which may be present ; and that to do anything 
 which could remove the rash would drive this supposed poisonous 
 matter back into the body and perhaps cause a fatal result ; the 
 rash, in other words, " strikes in," and does harm, indeed friends 
 often object strongly to any treatment which could have in view 
 the cure of a skin disease, especially if this disease has lasted for 
 some time ; and if the disease be nevertheless cured, any ailment 
 which may befall the patient in the succeeding months is sure to be 
 ascribed to the " striking in " of the skin disease. 
 
 This notion, too, is one of the exploded fancies which have 
 been left to us from medieval medicine ; and it may be emphat- 
 ically stated that no instance is known in which any disease of the 
 skin has " struck in " and done injury. 
 
 Yet that the presence in the blood of various infectious mate- 
 rials which may perhaps be called " impurities," is abundantly 
 shown by the different eruptive diseases. It is well established 
 that there is a specific virus or poison whereby scarlet fever, for 
 example, is induced ; and it is also evident that the effect of this 
 poison is among other things to produce a rash on the skin. Yet 
 there is no reason for believing that the poison is located in the 
 skin ; in fact many cases of scarlet fever occur in which no rash can 
 
 ■:1'-^ 
 
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 H:'i 
 
 
 K":i;- ^''- 
 
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 1. 
 
 
 368 
 
 DISEASES OF THE SKIN. 
 
 be distinguished. The diflferent eruptions — scarlet fever, measles, 
 small-pox and the like — arc merely due to the derangement in the 
 action of the skin, just as the vomiting of small-pox and scarlet 
 fever is due to the deranged action of the stomach, and as the 
 delirium and convulsions are due to the deranged action of the 
 brain. 
 
 2. Hereditary influence is another of the internal causes 
 which are active in the production of skin diseases. Certain 
 eruptions on the skin, such as psoriasis and eczema, appear more 
 frequently in the children of parents who have suffered from these 
 diseases than in others. 
 
 3. Nerxwiis disturbance is another of the internal influences 
 which predispose to the formation of rashes on the skin, and at 
 times indeed seem quite responsible for the entire eruption ; thus, 
 excessive emotion has been known to cause the appearance of nettle- 
 rash. 
 
 Among the external causes which induce, or tend to induce 
 diseases of the skin, are those which act directly, such as irritating 
 substances. Familiar examples of these causes are the occurrences 
 of eruptions on the hands of bakers, washerwomen and brick- 
 layers, who are often afflicted with diseases of the skin caused by 
 the contact of the irritating substances which they are compelled to 
 handle. In this class too belongs the itch, which is caused by the 
 mechanical irritation of a microscopic animal ; and it is a familiar 
 observation that certain other small animals, not microscopic, fre- 
 quently cause eruptions. 
 
 Various other external influences act indirectly in causing skin 
 eruptions. Among these may be mentioned want of cleanliness 
 and the contact of irritating materials used for clothing. 
 
 In this connection it should be remarked that the popular idea 
 as to the relation between cleanliness and skin diseases is largely 
 incorrect. Many people believe that the appearance of a rash on 
 the skin indicates a neglect of cleanliness on the part of the indi- 
 vidual. There are, it is true, certain rashes which affect limited parts 
 of the skin if cleanliness be neglected ; but these are parts of the skin 
 which are not usually exposed to the public gaze. It may be safely 
 stated that no disease of the face or hands is ever caused by neglect 
 of cleanliness ; furthermore, a want of attention to personal cleanli- 
 ness is by no means sufficient of itself to cause a rash on the skin. 
 There must be a predisposition of the skin to the formation of the 
 
GENERAL KKMARKS. 
 
 369 
 
 rash, in order that the eruption shall appear, even if the person be 
 filthy. 
 
 The antiquated belief as to the relations between skin erup- 
 tions and " impurities of the blood," accounts also for the fact that 
 a disease of the skin is regarded as far more objectionable and 
 mortifying than a disease of the internal organs. The gout is 
 somewhat aristocratic ; dyspepsia is usually fashionable ; consump- 
 tion lends a certain air of melancholy interest; Bright's disease 
 enrolls the sufiferer among the martyrs ; but salt rheum, or any 
 other rash on the skin, is devoid of all such charms, and is the 
 source of mortification to the patient and of disgust to others. 
 
 Some of the diseases which afflict the skin could be avoided by 
 careful attention to the requirements of the body. This attention 
 includes not only the care of the skin, but also the regulation of the 
 general health. 
 
 One of the first requisites in the care of the skin itself is of 
 course cleanliness. The scales which compose the outer part of 
 the skin are constantly being thrown ofif, or at least becoming 
 loosened so that they can be readily removed ; and thousands of 
 glands — the sweat glands, so-called — pour out upon the surface 
 of the skin a considerable amount of watery liquid ; this perspira- 
 tion takes place all the time, by night and by day, in winter as well 
 as in summer, though varying of course in quantity. In addition 
 to these glands there are also numerous little pockets in the skin, 
 called sebaceous glands, which secrete and throw out upon the skin 
 an oily material. The result is that there is constantly accumulating 
 on the surface of the skin a quantity of material made up of the 
 dried scales composing the outer part of the skin, and of the liquids 
 which are discharged upon its surface ; these materials must be 
 removed in order to permit the free action of the various glands ; 
 since otherwise the openings of these glands — the " pores " of the 
 skin — become stopped up, and the result of this stoppage may be 
 an inflammation. 
 
 For the removal of this material there is required as a general 
 rule only soap and water. As to the selection of soap there are 
 certain popular impressions which are not altogether correct. There 
 are several requisites for a good soap : first the fat from which it is 
 made must be sweet, that is not rancid, for no matter what the 
 other excellencies of the article may be, the presence of rancid fat 
 in it is very apt to cause roughness and itching of the skin, which 
 
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 BhII' 
 
 i 
 
 370 
 
 I)Iseasf:s of the skin. 
 
 may even proceed to eczema or " salt rheum. " The second requisite 
 is that the soap shall not contain too much potash or other alkali. 
 The alkali or " lye" in the soap is intended first to combine with 
 the fat used in making the soap, and second to combine with the 
 fatty matters on the skin so as to facilitate their removal by the 
 water. An excess of potash makes the soap extremely irritating, 
 and may readily provoke diseased action in the skin ; we are all 
 familiar with the irritating effects of even short contact with ' soft 
 soft," which differs from the hard soap chiefly in the large amount 
 of lye which it contains. The third requisite is that the soap shall 
 contain no substances capable of inducing disease of the skin. 
 This may seem an entirely unnecessary remark, but experience 
 shows that the commoner varieties of soap frequently contain refuse 
 matters from the animals from which the fat used in making the 
 the soap was procured. 
 
 A fourth essential for a good soap is that it should contain no 
 other ingredients than the fat and the alkali. Many soaps are 
 intentionally adulterated with various foreign matters, especially 
 varieties of clay ; and numerous others are colored green, red, etc., 
 and are scented with questionable perfumes. We are familiar with 
 the fact that the dyes used in coloring candies, wall paper, stock- 
 ings, etc., are often productive of disease in those using them ; and 
 we may readily appreciate the fact, which has been established by 
 experience, that the coloring matters used in tinting soaps are fre- 
 quently as injurious as the dyes used in coloring stockings. The 
 perfumes, also, are usually of the cheaper sort, many of them 
 manufactured from petroleum ; these may retain the irritating prop- 
 erties of the substance from which they are made. 
 
 It has become quite popular in recent years to use so-called 
 " medicated " .•'.oaps, which are supposed not only to keep the skin 
 in excellent condition, but also to guard and protect it against the 
 numerous diseases to which it is liable. Thus we are flooded with 
 innumerable varieties of sulphur soaps, tar soaps, glycerine soaps, 
 carbolic acid soaps, etc. , without mentioning the numerous arti- 
 cles supposed to contain honey, lettuce, celery, etc. Of all these, 
 it may be said their use is advantageous only to the manufacturer 
 and the dealer. It is evident, upon the slightest consideration, 
 that even if these soaps were impregnated with materials which 
 could benefit the skin, no particular advantage would be derived 
 from such brief contact as is ordinarily given to a soap. But the 
 
GENERAL REMAKKS. 
 
 371 
 
 fact is, first, that these soaps do not contain enough of a remedial 
 afjcnt to accomplish any good; and, second, that most of the sub- 
 stances employed for this purpose possess no curative value for skin 
 diseases ; indeed, some of them are decidedly injurious to the skin, 
 and serve by constant irritation to provoke an inflammation. 
 I<\irthermore, the healthy skin requires no other care than simple 
 cleanliness. If this be secured, and if it be protected from contact 
 with irritating substances, the skin remains healthy, unless there be 
 some impairment of the general health. It may be, therefore, in 
 general stated, that the so-called medicated soaps are in no case 
 better than a good unmedicated soap, and are often times worse, 
 because positively injurious. 
 
 It may be said that physicians often prescribe medicated 
 soaps in private practice in the treatment of skin diseases. This is 
 undoubtedly true. There are several so-called soaps which are made 
 for the purpose and are not intended to cleanse the skin, but merely 
 to serve as a convenient means for applying remedies to the skin. 
 It is also true that physicians often prescribe some variety of tar 
 soap, but this is done in some cases merely to be certain that the 
 patient employs no injurious article, and in other cases largely for 
 its moral effect. People in general are far too much addicted to 
 taking medicine. A patient is apt to feel that he does not get his 
 money's worth upon consulting a physician, unless some medicine 
 is prescribed. Hence it sometimes becomes necessary to order 
 bread pills and colored water just for the patient's satisfaction, and 
 in the same way it is often the part of discretion to order tar soap 
 in the treatment of skin diseases. 
 
 But it must be remembered that diseases of the skin vary 
 much in their nature, and therefore in the treatment adapted to 
 them. Hence a remedy which may be useful in one is quite out of 
 place, and even injurious, in another. This fact alone demonstrates 
 that the use of any soap as a panacea for all diseases of the skin is 
 of necessity an absurdity. Physicians themselves derive much 
 benefit from this promiscuous use of medicated soaps, since these 
 articles are responsible for many cases of eczema, and of some 
 other skin diseases. 
 
 It would be out of place in this work to specify by name any 
 particular brands of soap which can be recommended; it will suffice 
 to say that white castile soap, when properly niade, is one of the 
 most satisfactory. This is made of soda and olive oil, and is free 
 from all injurious constituents. 
 
 i-f / 
 
 ,■) ■ 
 
 «> Vi' 
 
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 \ ) 
 
 ' : ,l' 
 
 M trj 
 
 ik 
 
372 
 
 DISEASES OF THE SKIN. 
 
 Among certain classes, the idea prevails that while soap should 
 be used on other parts of the body, it should be carefully kept from 
 the face. This, of course, is a mistaken impression ; the skin «)f 
 the face does not differ in any essential particular from that of the 
 rest of the body, and there is no reason why it should not be 
 cleansed as thoroughly as the remainder of the skin. In fact, it 
 seems probable that certain rashes which arc limited to the face arc 
 sometimes caused by the neglect to use soap upon the face, and the 
 consequent accumulation of materials which should be removed. 
 
 As to the water best adapted for cleansing purposes, it is gen- 
 erally understood that the purest water is the best; in other words, 
 that the so-called "soft water," — that is, that which does not 
 contain salts in solution is most advantageous. As to the tempera- 
 ture it may be said in general that the patient should be guided 
 by his own sensations, both during and after the application of the 
 water to the skin. 
 
 « 
 
 U 1 
 
 ^1 
 
 jSiH 
 
 * 
 
 Pimples " — CAone). 
 
 This is one of the commonest affections of the skin, and occurs 
 most frequently during youth. There are several affections which 
 are regarded as varieties of the same disease ; only two of these 
 need especial mention here — acne simplex and acne rosacea. 
 
 Acne simplex, or simple acne, is the affection commonly known 
 as pimples, black heads or flesh worms. It is, perhaps, the most 
 frequent of all the affections of the skin ; indeed, few people attain 
 the age of 30 years without having suffered — in mind if not in 
 body — from the occurrence of this annoying affection. It is espe- 
 cially aggravating, from the fact that it usually flourishes most 
 during the very years when the individual is most sensitive as to 
 his personal appearance and condition, and from the further fact 
 that if these pimples occur anywhere on the body, they are almost 
 sure to appear on the face, where they cannot be concealed. 
 
 It is a curious and familiar fact that the disease never makes its 
 appearance before puberty ; that it is most luxuriant during the ten 
 years following this period, and that it subsides spontaneously in 
 early manhood, usually by the thirtieth year. This occurrence 
 during these particular years of life has led to the popular 
 impression that there is some intimate connection between the 
 
 \ ' I 
 
PIMI'I.KS — ACNK. 
 
 37? 
 
 I m 
 
 presence of this disease and the sexual function. Various ideas 
 prevail as to the reasons for the occurrence of pimples upon the 
 face. Some people ascribe them to a repression of the sexu-il 
 instinct, and are firmly convinced that marriage would be a sov- 
 ereign remedy, while others regard the occurrence of acne as 
 evidence of improper excitation of the genital organs. Long 
 (il)scrvation by medical men has failed to reveal the slightest 
 foundation for either of these beliefs, and both are certainly 
 txtrcmely unjust to a great many young men and young women. 
 
 Acne is essentially a iliseasc of the sebaceous glands. The 
 mouths of these glands become stopped up, so that the material 
 which is secreted in the little sac cannot escape. It will be remem- 
 bered that these sebaceous glands secrete a certain oily material, 
 which is in the natural condition poured out upon the skin, and 
 serves to keep the surface smooth and flexible. This oily matter 
 should be constantly poured out upon the skin, since it is constantly 
 being secreted in the interior of the sac or gland. When from any 
 cause it fails to escape, either because there is some mechanical 
 obstruction, or because the secretion itself becomes so thick that it 
 cannot pass out of the little orifice or " pore," there results an accu- 
 mulation of this oily material in the sac. This sac is therefore grad- 
 ually distended, and becomes large enough to make a little elevation 
 (in the skin. Meanwhile the oily matter located in the pore of the 
 skin has usually absorbed enough dust and dirt to become black, 
 whence the name "blackheads." In some individuals these dis- 
 tended sacs remain for a considerable time without undergoing 
 further change ; in others the matter accumulates constantly, until 
 finallj' a considerable lump appears, which is known as a uicn. This 
 luippcns with especial frequency when the sebaceous glands of the 
 scalp become stopped up. But in the majority of Ciises the pressure 
 of the distended sac on the tissues around it causes an inflamma- 
 tion. This manifests itself by redness and by swelling; in this 
 way the familiar " pimple " is developed. Sometimes there occurs 
 nothing more than a red swelling, but in the majority of cases the 
 inflanmiation proceeds until matter is formed around the distended 
 sebaceous sac, making the pustule which so often disfigures the 
 face of the unfortunate patient. 
 
 If the contents of the sac be pressed out before the inflamma- 
 tion has proceeded to this extent, there appears a white, spiral- 
 shaped body, resembling a worm somewhat in shape. From this 
 
 'Kbia 
 
 ^ 
 
 li ' 
 
 ?5 
 
! 
 
 374 
 
 DISEASES OK TIIK SKIN. 
 
 : 
 
 n 
 if 
 
 ■'■ I 
 
 appearance there is derived the popular notion that the disease is 
 due to the presence of worms in the skin, Tiicse white bodies are 
 however, not worms, but merely the accumulated secretion of the 
 gland ; their form is simply that of the distended sac. There is 
 sometimes found in the contents of these glands a microscopic jjara- 
 sitc, which is not. however, a worm. There is no reason for believ- 
 ing that these parasites have anything to do in causing the disease, 
 since they are not found in all the pimples, but simply in compara- 
 tively few. 
 
 Cause. — Acne is essentially a disease of the sebaceous glands; 
 yet there must evidently be some cause affecting the system where- 
 by this diseased action of the glands is induced. For it seems 
 certain that the starting point of the whole difficulty is the change 
 in the nature of the secretion, so that the oily m?tter no longer 
 flows out of the gland but remains in a hardened condition. 
 
 It is also established by experience that this affection of the 
 skin can be and is often induced by derangements affecting other 
 parts of the body. There is a well-established relation between tiie 
 diet and the occurrence of this disease. Thus in many persons a 
 crop of acne pustules is sure toappearaftcr eating buckwheat cakes 
 or mince pic ; in other individuals cheese, nuts, raisins and pastry 
 induce the same effect. In some cases acne can be traced directly 
 to the abuse of alcoholic beverages ; indeed, this is frequently the 
 case in those instances of acne which occur in elderly people. 
 
 The condition of the bowels also seems to have a direct con- 
 nection with the appearance of these pimples upon the face ; many 
 individuals who suffer from acne arc troubled with habitual constipa- 
 tion, and procure relief from the skin eruption only after the bowels 
 are regulated. In other cases there is evidently imperfect activity 
 of th'j liver. Sometimes the appearance of these pimples is a reg- 
 ular sequel to over-indulgence in the pleasures of the table. 
 
 Another form of acne occurs particularly in poorly nourished 
 individuals, especially in those who are commonly termed " scrofu- 
 lous. " This form, however, is apt to appear more particularly on 
 the breast and on the limbs; it is not so troublesome as a deformity 
 in the face. 
 
 It should be mentioned in this connection that a rash quite 
 similar to acne is produced by the use of certain drugs. Thus, if 
 tar be painted upon the skin for several days in succession, a rash 
 quite similar to acne appears ; and this rash is often noticed on the 
 
riMI'LKS — ACNK. 
 
 375 
 
 jjcrsons of those wlu> have to use tar C()i..,.antly in their work. The 
 same effect is produced by tlie loiijf continued use of the iotlide of 
 potassium or by the liromide of potassium ; and may also follow 
 the application of petroleum to the skin. It has sometmies been 
 (pl)served in those who have to oil niachiucry, presumably from the 
 irritating' effects of the rancid oil. 
 
 'Vi'CdtnU'Ut, — The treatment of acne is one of the most 
 troublesome undertakinfjs which the physician is ever called upon 
 to ])erform. This difficulty arises doubtless from the fact that it is 
 often impossible to locate the source of the disease. For, as has 
 been said, the startinjj point of the affection may be found in 
 (Uran^ements of the various dij;estive organs ; while on the other 
 hand the indi\'''liial gives absolutely no other signs of disease than 
 iirc manifest o his face. In general it is necessary to secure regu- 
 lar evacuations of the bowels. This may be accomplished in the 
 way indicated while speaking of constipation : the use of a glass 
 or two of mineral water, or of a wincglassful of the liquid citrate 
 of potassium, will be one of the preparatory steps in the treatment 
 of the disease. 
 
 The diet, too, must be regulated so as to avoid those particular 
 articles which are found, by the experience of the patient himself 
 ,is well as others, to provoke the formation of pimples. In general 
 it may be observed that whatever causes marked flushing of the face 
 will be apt to favor the production of ac.j pustules. The use of 
 alcoholic beverages, of hot drinks, pastry, buckwheat cakes, etc., 
 should be carefully avoided in case it is found that pimples appear 
 in unusual number after indulgence in these articles. 
 
 The local treatment of acne must vary somewhat with the gen- 
 eral condition of the patient, as well as with the assumed cause of 
 the disease. The patient's inclinations lead him to remove the 
 unsij^htly black spots on the face. This may be done, but should 
 be (lone with care ; if the skin be merely compressed between the 
 lingers, there is apt to result much redness and swelling, which is 
 far more unsightly than the object whose removal is sought. It is 
 i;cncially recommended that a watch key be employed for the pur- 
 pose, being pressed firmly against the skin around the black spot. 
 .\ still better article is a small silver tube which is made for the 
 purpose. Even this procedure is apt to be followed by considerable 
 redness and swelling, hence it is advisable to employ this measure 
 
 I 
 
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 J'(' 
 
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 \ !1 
 
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 ,1: 1 ■ 
 
 ^ I 
 
 376 
 
 DISEASES OF THE SKIN. 
 
 only at night. The irritation may be somewhat lessened by bath- 
 ing th face with hot water or with bay rum. 
 
 Numerous lotions and ointments are recommended and sold 
 for the cure of acne; yet none of these can be relied upon, unless 
 proper measures are taken to remove the condition of the stomach, 
 bowels, liver, etc., upon which the difficulty depends. Among the 
 best of these are the following : 
 
 Flowers of sulphur, 
 Tincture of camphor, - 
 Glycerine, - - - - 
 Rose water, 
 
 This may be applied ove;- the affected spots, and may be ruobed 
 gently on those parts of the skin affected with the disease two or 
 three tines daily. 
 
 Two drachms. 
 Three drachms. 
 One ounce. 
 Four ounces. 
 
 Borax, 
 
 Carbonate of soda. 
 
 Glycerine, 
 
 Tincture of camphor, 
 
 Distilled water, 
 
 One drachm. 
 One drachm. 
 Four drachms. 
 One ounce. 
 To make six ounces. 
 
 Half an ounce. 
 Four drachms. 
 Two ounces. 
 One ounce. 
 One ounce. 
 
 This may be applied in the same way. 
 
 Precipitated sulphur. 
 
 Carbonate of po<-ash. 
 
 Glycerine, - - - - - 
 
 Sulphuric ether, - - - - 
 
 Alcohol, - ... 
 
 This mixture should be carefully applied to the pimples and to 
 those parts of the skin that seem liable to exhibit an eruption. In 
 all chese cases no more friction should be employed than is neces- 
 sary to apply the lotion. 
 
 In all cases success can be hoped for only after persevering usi 
 of the remedies, both those for application to thf skin and thosr 
 which are designed to improve the condition of the digestive organs. 
 Cases are found which seem to resist almost all measures of treat- 
 ment ; such individuals have at least the consolation that the affec- 
 tion will yield to tiiriv-, even if all medicines prove unavailing. 
 
DANDRUFF. 
 
 377 
 
 Dandruff. 
 
 This affection may bt,' naturally introduced here, since it also 
 depends upon a disorder of thf,- sebaceous glands. In this affection 
 the secretion of these glands is not so hard as in the case of acne, 
 but shows itself in the form of yellowish or whitish scales. The 
 affection is exhibited in the most marked degree on the scalp, since 
 here the secretion is not removed so often nor so completely as on 
 the rest of the skin. In some cases these scales become scatter ,d 
 through the mass of the hair, and are so plentiful as to keep falling 
 upt)n the shoulders. In other cases these scales remain matted 
 to'^ether in consequence of the large amount of oily secretion 
 which accompanies them. 
 
 Dandruff is not only annoying, but is also important, because 
 if allowed to continue without treatment, it almost always results 
 in a thinning, if not complete loss of the hair. This baldness is 
 not, properly speaking, a result of the dandruff; but both result 
 from the affection of the sebaceous glands. For the secretion of 
 the oil is a natural and necessary provision for the hair, without 
 which it is ultimately destroyed. 
 
 Tt'catlHcnt. — For the removal of dandruff it is necessary not 
 onl\- to keep the scales brushed out of the hair, but also to correct 
 if jiossible, the unhealthy action of the sebaceous glands. The 
 hair may be gently, brushed with a soft brush and then washed 
 with a little soap and water. After this, the yolks of two eggs 
 may be applied to and thoroughly rubbed into the scalp. The rep- 
 etition of this process daily is often of itself sufficient to remove 
 the dilTi>.ulty. If the scales still form, there may be substituted for 
 the eggH *.hc following prescription: 
 
 Tannic acid. 
 Simple ointment, - 
 
 Mix and rub thoroughly into the scalp. 
 
 Another valuable remedy is the following: 
 
 Hydrate of chloral, . . . Two drachms. 
 
 Water, . . _ _ . Four ounces. 
 
 One drachm. 
 One ounce. 
 
 ^ 
 
 m 
 
' i 
 
 
 378 DISEASES OF THE SKIN. 
 
 7 
 
 If there be much oily matter in the hair, the following pre- 
 scription may be used: 
 
 Aromatic spirits of ammonia, - - Four drachms. 
 Glycerine, ----- Half an ounce. 
 Rosemary water, - - - - Four ounces. 
 
 Itch -(Scabies). 
 
 The itch is a disease caused by the burrowing of a microscopic 
 parasite in the skin. The disease seems to have been known for 
 many centuries, and notwithstanding the minute size of the insect 
 which causes it, the animal was discovered at least as early as the 
 fourteenth century. The itch seems to be a cosmopolitan disease, 
 scattered all over the world, and not subject to any laws of climate 
 or soil. 
 
 Until the nature of the disease was discovered, ihc itcli was 
 one of the most troublesome and dreaded of all the aftections to 
 which flesh is heir. In former times the patient was an object of 
 loathing to others, and of torment to himself, for months and even 
 years at a time ; and although the disease does not affect the vital 
 organs directly, yet the dreadful scratching caused indirectly serious 
 impairment of the health. After the parasitic nature of the disease 
 was discovered, and a certain means for its cure came into use, the 
 spread of the disease was much restricted. At the present day the 
 itch is comparatively rare in the United States, though still very 
 common in many of the European countries. In the skin depart- 
 ments of the large hospitals in London, Paris and Vienna, for 
 instance, about one patient in five is afflicted with this disease. 
 
 The itch parasite, or itch mite, is a microscopic insect called 
 the acariis or sarcoptes scabici. It is a round, somewhat turtle- 
 shaped animal, provided with eight legs and with horny jaw s ; 
 with these they burrow into the uppei layers of the skin ami 
 crawl gradually along just under the surface. The female la\s 
 her eggs closely together in the burrow as she proceeds ; the track 
 of the insect and the row of eggs can usually be perceived as a 
 black line, from a sixteenth to an eighth of an inch long, near the 
 surface of the skin. The black color is due not to the insects 
 themselves, but to the dust and dirt with which the little groove in 
 
ITCH — SCABIES. 
 
 379 
 
 the skin becomes filled. After a time the adult insect dies, but not 
 until she has made ample provision for the propagation of her 
 spucies in the shape of numerous young; these attain maturity and 
 repeat the process of burrowing and of laying eggs. The life of tlie 
 insect seems to vary from three to eight weeks ; each female pro- 
 duces from ten to fifteen young. 
 
 The parasites are readily conveyed from one individual to 
 another, and even from man to several of the lower animals, espe 
 daily dogs and horses ; and it seems quite certain that the disease 
 can be communicated again from these animals to man. 
 
 It is probable that the disease is rarely communicated from 
 hand to hand. In most cases some more intimate contact of the 
 person is necessary. In the majority of instances the disease is 
 acquired by sleeping in the same bed with a person already suffer- 
 ing from it 
 
 Certain parts of the skin are more frequently visited by the 
 itch mite than others. This results partly from the fact that they 
 find the best nourishment in the thinner and more juicy parts of the 
 skhi, and partly because they are transferred by the fingers to cer- 
 tain parts of the body with especial frequency. Among the first 
 localities usually visited are the spaces between the fingers ; they 
 arc then found upon the sides of the firigcrs, on the front of the 
 wrist, on the inside of the elbow and around the armpit. In fact 
 all tliDsc parts of the skin which an individual is especially apt 
 to touch or rub soon become affected. Any part of the body 
 which is chafed or irritated by the clothing is sure to be plentifully 
 inhabited by the itch parasites. Thus in women they arc found on 
 the breast and around the waist. In men they can often be ob- 
 served to mark out the course of the suspenders over the shoulders. 
 Tht)se individuals who support their nether garments by means of a 
 stra[) or belt around the waist are sure to present a girdle of irrita- 
 ted and inflamed skin under this belt. 
 
 Sl/lHih'tti.us. — The first intimation that the patient has is an 
 intolerable itching, which is usually felt only over a limited part of 
 the body, especially in the hands and wrists. This itching is, of 
 course, followed by violent scratching, as a result of which the skin 
 becomes roughened and sore. Indeed it is rare that one sees the 
 changes caused in the skin by the itch mite without the complica- 
 tions due to the use of the finger nails. The rash caused by the 
 insect itself consists of pimples which resemble somewhat those of 
 
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 : ^\m 
 
 lU^ 
 
 m. 
 
 II J 
 
 'l^if 
 
 ill 
 
38o 
 
 DISEASES OK THE SKIN. 
 
 l^ > I ,3 
 
 r I 
 
 acne ; but as we see the patient, we rarely find any of these pim- 
 ples in a good state of preservation, for the top is usually scratched 
 off and replaced by a black crust of blood. Thus the entire surface 
 of the skin may be speckled over with these little black patches, tiic 
 intervening space diversified by welts raised by the finger nails. 
 Unless soon relieved, the patient presents patches oi ccacttta, or salt 
 rheum, in different parts of the body, a condition due entirely to 
 the irritation caused by the scratches. In advanced cases, indeed, 
 the physician himself may overlook the true cause of the disease, 
 since the appearance will be that of eczema simply. 
 
 Various other irritations may cause the appearance of a rash 
 similar to that of the itch, and may induce persistent and violent 
 scratching ; among these are body lice, which may sometimes afflict 
 individuals who have no suspicion of their existence. There arc 
 two points, however, which enable one to recognize the itch and to 
 distinguish it from all other affections ; first, the location of the 
 rash. For the itch parasites are distributed around the individual's 
 body by his own hand and are hence most numerous in those parts 
 of the body which are most accessible to the fingers. The rash is, 
 therefore, di.stributcd chiefly between the collar bones and the knees 
 on the front of the body, and it may often be observed that while 
 the skin in this locality is covered with blotches and scratches, the 
 skin between the shoulders of the same individuals is quite free 
 from them. This results from the fact that the itch insects do not 
 leave the skin for the clothing, and hence do not travel around the 
 body independently. Lice, on the other hand, live altogether in the 
 clothing, and hence are apt to affect all parts of the body indif- 
 ferently. 
 
 But the most characteristic feature in the recognition of the 
 itch, is the occurrence of minute black grooves in the skin. Tliese 
 look as if short pieces of fine black silk ' ave been drawn under tlit 
 surface of the skin ; it is often possible to detect by close scrutiii) 
 a minute whitish point, lookingsomewhat like a small blister locatecl 
 at the end of the black line ; this is the itch insect itself, and by 
 dextrous use of the needle the animal can be lifted out of the 
 groove. 
 
 The extent of the rash and the consequent irritation of the skin 
 vary much in different individuals, chiefly according to the clean- 
 liness which the person observes. In individuals of filthy habits 
 
 ^:ini 
 
ITCH — SCABIES. 
 
 381 
 
 the body is often a mass of eruption, and presents a most disgust- 
 ing and loathsome appearance. If, however, a person who is accus- 
 tomed to strict personal cleanliness be infected with the itch, the 
 nianifestations of the disease are not so numerous nor so aggra- 
 vated ; indeed it is quite possible for such a person to suffer for 
 some time from scabies without suspecting the true nature of the 
 disease. Even upon examination of the skin there will be 
 detected only a few black furrows here and there upon the hands 
 and wrist or in the vicinity of the genitals. Sometimes there will 
 be also a few pale red pimples scattered here and there over the 
 body. Such patients are often treated for weeks for some other 
 disease of the skin. 
 
 In every case in which a person of cleanly habits complains of 
 intense itching, especially at night, suspicion as to the existence of 
 tlie itch should be entertained, and a close search made to detect 
 tlie black furrows characteristic of the disease. In some cases the 
 rasli appears only in the vicinity of the genital organs, the rest of 
 the body being free from it ; and instances have been known in 
 which inflammation of the glands in the groins, resulting even in the 
 formation of matter, has resulted merely from the irritation of the 
 parasites in this locality. This point should be borne in mind by 
 the physician as well as by the non-professional, since the occur- 
 rence of suppurating glands in this region is usually a sign of 
 venereal disease. 
 
 Ti'i'atnicnt, — The object of treatment is simply to destroy 
 the itch mites, after which the rash subsides of itself. While this 
 is true of the itch in an early stage, or in an individual of cleanly 
 habits, it sometimes becomes necessary to adopt additional treat- 
 ment in those who have long suffered from the disease, or whose 
 habits are such that the rash has rapidly become extensive and 
 aijs^ravated. The disease is confined entirely to the skin ; there is 
 nil " impurity of the blood," and, therefore, no necessity for sulphur 
 and molasses, or other medicines internally. 
 
 In ordinary cases the plan to be pursued should be as fol- 
 lows: The individual should take a hot bath, lying in the water 
 sufficiently long to soak the skin thoroughly, and using plenty of 
 soap ; after leaving the bath the skin may be energetically rubbed 
 with a coarse towel. Then all parts of the body which show any 
 
 ■ 
 
 ' 
 
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1 *;■ I 
 
 Hi! 
 
 i 
 
 1 
 
 
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 ■1- 
 
 
 ii 
 
 
 3«2 
 
 DISEASES OF THE SKIN. 
 
 Three ounces. 
 Three ounces. 
 Flight ounces. 
 Eight ounces. 
 Two ounces. 
 
 One drachm. 
 I-'ifteen grains. 
 Ilalf an ounce. 
 Two ounces and a half. 
 
 indications of the rash should be annointed with one of the follow- 
 ing ointments: 
 
 Sulphur, - . - - 
 
 Tar, ----- 
 
 Soft soap, - - - - 
 
 Lard, _ . _ _ 
 
 Chalk, . - . . 
 
 Mix and make into an ointment. 
 
 Flowers of sulphur, 
 
 Ammoniated mercury, 
 
 Olive oil, - - - - 
 
 Lard, . _ . . 
 
 This will be found blander and less irritating than the former, 
 though it does not always act with the same rapidity. The simple 
 sulphur ointment as obtained at the drug store is usually efficient 
 in destroying the parasites. 
 
 If the skin be very delicate, as is often the case in young chil- 
 dren, ointments containing sulphur are apt to irritate extremely ; in 
 such cases the bahatn of Peru will be found serviceable. 
 
 The ointment selected should be applied morning and night for 
 three days ; at the end of this time the patient should again take a 
 warm bath, and he will usually find on the fourth day that there is 
 no further itching. It is highly important in applying these oint- 
 ments that they be thoroughly rubbed into all parts of the skin, 
 especially into the folds and creases between the joints, since it is 
 just here that the itch insects are abundant. There are various 
 affections of the skin, called bakers' itch, grocers' itch, and the like, 
 which are not due to parasites but are really forms of salt rheum or 
 eczema, caused by contact of the hands with irritating substances 
 which these persons are compelled to handle. 
 
 Salt Bheum — (Eczema). 
 
 This is one of the commonest, most troublesome and hence 
 I'liost important of all the diseases of the skin. It attacks different 
 parts of the skin, and occurs at all periods of life ; it is not limited 
 to any particular class of society, but may appear in those who 
 give the strictest attention to personal cleanliness. It is caused by 
 
SALT RHEUM — ECZEMA. 
 
 3«3 
 
 external irritation, and by disorders of the internal organs. Com- 
 paratively few individuals, perhaps pass throu<;h life without 
 having suffered, at some time, from some manifestation of this 
 disease. 
 
 Oiu- of the most common forms of eczema is that one familiar 
 to those who have much to do with infants and children ; it is the 
 eruption which appears upon the face and head of a chilil, usually 
 within the first two years of life, and often at the period of teeth- 
 iiit^. It usually begins in the shape of scattered red points or 
 pimples, which soon run together, and in a short time begin to 
 c.xude a watery fluid; this is called " weeping." The eruption is 
 always exceedingly itchy, and causes an irresistible desire on the 
 part of the patient to rub and scratch the diseased skin ; even 
 the infant in arms finds means to attempt the relief of this irrita- 
 tion. 
 
 In a short time after the rash has begun to " weep," crusts ar.- 
 formed ; these are at first thin and scattered, but arc soon united 
 into thick yellowish or brownish yellow layers, which may cover 
 i!ie entire scalp and form a mat, through which the straggling hairs 
 project. The disease is especially apt to occur behind the ears 
 and in the crease -of the skin under the jaw, though in infants it 
 commonly spreads from these localities, so as to involve the entire 
 scalp and the face as well. If there be a decided tendency to the 
 manifestation of the disease, eczema will soon be found in almost all 
 those localities where two surfaces of skin rub against each other ; 
 in addition to the spots mentioned, it is observed at the bend of 
 the elbow, at the back of the knee, between the thighs, and, in 
 very fleshy children, upon the wrists. In bad cases it may spread 
 so as to cover almost the entire body. 
 
 Kczcma upon the scalp and face of children is often called 
 " milk crust," because it is supposed that it is in some way asso- 
 ciated with the milk. This supposition does no harm, though 
 usually unfounded, but the child often suffers greatly from the belief 
 which is also entertained that the " milk crust " must not be treated 
 nor removed. It is popularly believed that if this rash be " driven 
 in," serious injury will result to the child ; hence the infant is per- 
 mitted to suffer untold torment fr<jm the itching and soreness of 
 the ^kin for months and years. 
 
 In previous pages we have endeavored to emphasize the 
 remark that no harm can result from " driving in " a rash on the 
 
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 1.5 f 
 
 1 m 
 
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 i 
 
-? f 
 
 !' 
 
 n 
 It 
 
 ,1' ' 
 
 384 
 
 DISEASES OK THE SKIN. 
 
 ■ 1 ! ij 
 
 skin ; in fact that is quite impossible by any means at present 
 known to us to " drive in " any rash. These remarkf^ are true of 
 ec/ema, as it occurs in infants ; in every case, the child should be 
 relieved as quickly as possible of the eruption, since ic is a constant 
 source of pain and annoyance to the infant, and reacts upon its 
 },'cneral health in a marked degree. Furthermore, it is true of 
 eczema, as of so many other diseases of the skin, that the longer 
 they last the more obstinate and difficult to cure they become. It 
 is by no means certain that the rash will disappear when the chikl 
 is weaned; and if it does not, it may be quite impossible, or next 
 to impossible, for the physician to control it after it has lasted so 
 long. 
 
 Sometimes eczema appears during the process of teething, 
 and the child becomes in this case also the victim of the mistaken 
 notion that the rash is a necessary part of the teething process, and 
 must not be interfered with. 
 
 When the children become somewhat older, they are less 
 liable to these extensive patches of eczema ; the disease occurs in 
 them as smaller patches, moist and red, which are especially often 
 located behind the ears. 
 
 Another form of eczema, which oiten occurs in children, 
 though sometimes observed in adults also, does not proceed as fai 
 as the " weeping " form ; this consists merely in redness and per- 
 haps rawness of the surface in the folds of the skin, and between 
 two opposing surfaces. This redness and rawness, caused by 
 chafing, is often found in fleshy infants, and in warm weather is 
 very apt to affect those parts of the body which are covered by the 
 napkins. This variety of eczema is usually dependent upon the 
 mechanical irritation or chafing in the one case, and upon the con- 
 tact of wet and soiled napkins in the other. It is, therefore, a 
 much less serious and obstinate affection than eczema of the scalp 
 and face, and yields far more readily to treatment. 
 
 In adults, eczema occurs in almost all parts of the body; the 
 forehead, the cheeks, the eyelids, the nose, the lips are very often 
 affected. When the disease occurs in the face, especially around 
 the mouth, it is apt to prove obstinate, in consequence of the 
 constant movement of these parts. In men, too, the presence 
 of the beard is an additional obstacle to the cure of the affection, 
 since, if the beard be allowed to grow, it is impossible to reach the 
 disease satisfactorily, while if the face he closely shaven, the eczema 
 is often thereby aggravated. 
 
SA I. r KIIKLM — K( /KMA. 
 
 3«i 
 
 In women eczemii is very common around tlic nipples and on 
 the [,fenitals. Man)- of the affections of tlie nipples durinj; nursing 
 are simply cases of eczema. Very many women who are afflicted 
 u itli diseases of the womb, or of the vagina, suffer constantly from 
 Lc/.ema on the neighboring skin, as the result of irritating dis- 
 charges. In some cases, too, eczema frequently appears periodi- 
 cally during the menstrual flow. 
 
 Eczema is also frequently found in adults on the leg, espe- 
 cially just above the .inkle. This is especially often the case with 
 those who are troubled with enlarged or "varicose " veins. In this 
 location the eczema is very obstinate and is apt to proceed in the 
 course of time to the formation of ulcers. 
 
 ('(Hise. — Pxzema is caused both by external irritation and by 
 derangements of various functions of the body. Among the former 
 is especially the irritation caused by the use of soaps, ointments, 
 powders and liniments. Foremost among these is the favorite tinc- 
 ture of (Viiica. Every physician of experience has seen cases in 
 which attacks of eczema, sometimes severe and obstinate, have fol- 
 lowed the application of arnica to the skin for some trifling bruise 
 or sprain. And there arc cases in which all treatment seems to be 
 ineffectual until the patient abandons the use of some particular 
 kind of soap. 
 
 In some individuals the habitual use of hot baths occasions 
 more or less extensive ecz'ema. The long continued application of 
 water, or of other substances which seem quite bland, occasions 
 eczema in some individuals. Washerwomen, cooks, waiters and 
 people of similar occupations, are often subject to the disease on 
 the hands and wrists. In these cases treatment is unavailing until 
 the patient abandons the employment which compels him to expose 
 the hands to the constant irritation. 
 
 Bakers are often subject to eczema on the hands and face. In 
 this case the affection seems to result from frequent exposure to a 
 high temperature. This affection is called from the frequency of its 
 occurrence in bakers, by the name "bakers' itch." People em- 
 ployed in grocery stores are often similarly affected, presumably 
 from contact of the hands with sugars and various irritating articles. 
 Bricklayers are especially prone to suffer from this disease. 
 
 One of the most frequent among the irritating causes of eczema 
 is the scratching which every one employs to relieve an obstinate 
 itching; hence any disease of ^he skin which is accompanied by 
 
 '$;••' 
 
 ;.'i ? 
 
 4 
 
 ■'\'\- 
 
'Hi 
 
 Ml 
 
 P 
 
 ; 
 
 1 
 
 i»t 
 
 • |: 
 
 if ji i^. 
 
 |; 
 
 3sr> 
 
 DISEASES OF THE SKIN. 
 
 itcliin<^, is very apt to be followed by eczema. It has btcr^ ali-cady 
 mentioned that the itch often becomes obscured and mistaken for 
 eczema, because the irritation, which is a prominent feature of the 
 itch, causes violent scratching, and this in turn excites an eczema. 
 Even the pressure of tight clothing, of bands, suspenders, belts, 
 garters, etc. may excite eczema in individuals predisposed to it. 
 Exposure to the rays of the sun, and even sudden changes of tem- 
 perature, may also provoke the disease. Pregnancy is very apt to 
 be accompanied by eczema in the legs and on che genitals, espe- 
 cially if there be swelling of the feet. Contact with a poison ivy, the 
 use of sulphur ointment, or articles of clothing containing irritating 
 substances, also frequently cause the disease. Among the most 
 frequent of such articles are colored stockings. 
 
 There is a great difference in the susceptibility of different 
 individuals to this disease, since some are readily affected by causes 
 which do not influence others at all. It may be said in general, that 
 blond individuals are more suseeptible to the disease than those of 
 darker complexion. 
 
 The internal causes — those conditions of the system which give 
 rise to an attack of eczema without external irritation — are by no 
 means well ascertained. It may be said in general, that those who 
 are afilicted with chronic diseases of the digestive organs and of 
 the kidneys, are far more liab!e to eczema than others. Scrofulous 
 individuals seem very susceptible ; and so do girls suffering from 
 ' green sickness " or chlorosis. A coincidence has been observed 
 between certain diseases of the womb and eczema ; and it has been 
 remarked that women are especially often afflicted with the disease 
 during the change of life. 
 
 Treatment. — In every case of eczema it is highly important 
 to ascertain the cause ; otherwise salves, ointments and powders 
 may be applied for months without improving the condition of the 
 skin. It is impossible to mention in detail all of the constitutional 
 conditions which seem to predispose to eczema, and which should 
 be, therefore, looked for in obstinate cases of the disease. Yet it 
 should always be borne in mind that if the patient be suffering 
 from the green sickness, diabetes, dyspepsia, constipation or other 
 affection, it will rarely be possible to relieve him entirely from the 
 eczema without first improving his general condition. 
 
 In all such cases it will be necessary to regulate the diet, and 
 
SALT KllKLM — lilZliMA. 
 
 387 
 
 t(i avoid such excesses in eating or drinking as evidently disturb 
 tlie patient's digestion. 
 
 The eczema of infants is often due to improper quality or 
 quantity of food. It is especially common among those infants that 
 arc nourished partly or completely with artificial food. In every 
 case of obstinate " milk crust," or of eczema in infants generally, 
 it is a matter of prime importance to secure the best possible diet, 
 whether this shall be mother's milk, that of a nurse, or some of the 
 artificial foods which are recommended at the appropriate place in 
 this book. In some cases the change of diet alone, without other 
 treatment, is sufficient to cure the disease. In fact, in almost every 
 case, whether the patient be adult or infant, careful attention to the 
 diet constitutes an important part of the treatment. 
 
 In those cases in which the disease is traceable to external irri- 
 t;U'.->ii, the source of this irritation should be of course removed. 
 n some instances this is, under the circumstances, impossible, since 
 the patient is unable to abandon his employment ; thus the most 
 obstinate cases occur in women who are compelled to have their 
 hands constantly in water. In such instances much good can be 
 derived from the use of rubber gloves. So, too, if the eczema 
 depends upon an irritating discharge from the vagina, it will be 
 necessary to adopt such treatment as will stop this discharge before 
 the eczema can be cured. In general in the treatment of eczema in 
 which there is considerable watery discharge and the formation of 
 crusts, the surface should be softened by oiling the skin thoroughly, 
 or by the use of a light flax-seed poultice. After this is accom- 
 plishcil and the crusts removed, one of the following ointments may 
 be applied : 
 
 Oxide of zinc, - - - 
 Lead water. 
 
 Glycerine, - - - - 
 
 Lime water, . _ . 
 
 This may be applied to the surface by means of a soft cloth, 
 such as an old handkerchief, which should be saturated with the 
 lotion and laid upon the raw surface. If there should be much 
 burning and itching, one of the following remedies may be 
 usL'd : 
 
 Two drachms. 
 Two drachms. 
 Four drachms. 
 To make eitrht ounces. 
 
 Carbolic acid, 
 Water, 
 
 Half an ounce. 
 One pint. 
 
 .'li'H 
 
 
 hi 
 
 i U 
 
38S 
 
 I)l^^;As^:s oi- riii-; skin. 
 
 Twenty grains. 
 
 rwcnt>- grains. 
 Ten grains. 
 Twenty grains. 
 Half an ounce. 
 Half an oiinci'. 
 
 This may be applied frequently upon soft cloths. Or 
 Camphor, ----- Que drachm 
 
 Horax, - - - . . Two drachms. 
 
 Alcohol, ----- Two ounces. 
 
 Rose water, . . . . Six ounces. 
 
 For tiu! eczema of the head in children, the following is reconi 
 mended by Fox : 
 
 Ammoniated mercurx'. 
 
 Nitrate of mercury ointment, 
 
 Acetate of lead, - 
 
 Oxide of zinc, 
 
 I'urified palm oil. 
 
 Fresh lard, . - . . 
 
 In many cases of eczema, especially in children, good results 
 can be obtained from the use of diachyliui oiutiucitt , which may be 
 applied on pieces of soft linen or flannel. If the child's skin !)(• 
 especially sensitive, the ointment may be mixed with one-third of 
 glycerine, after the following formula : 
 
 Diachylon ointment, - - - Three ounces. 
 
 Glycerine, ----- One ounce. 
 
 These ointments will generally be found more serviceable than 
 the one previously given for all cases in which the skin is sensi- 
 tive. 
 
 Whenever the skin begins to chafe in a fold, or where two 
 surfaces come in contact, much good can be done by dustini; tlio 
 parts with the following mixture : 
 
 Camphor, ----- ^Half a drachm. 
 
 Oxide of zinc, - - - - One ounce. 
 
 Powdered starch, - - - One ounce. 
 
 If these cases are not severe, they can often be relieved by the 
 use of a little vaseline, to whicli r'.iere may be added the oxide of 
 zinc in the proportion of ten grains to the ounce of vaseiinu. 
 Another soothing lotion, which may be used to advantage when 
 there is much itching and burning of the parts, is as follows : 
 
 Borax, 
 
 Carbonate of soda, 
 Glycerine, - 
 Strong carbolic acid, 
 Distilled water, - 
 
 One drachm. 
 Two drachms. 
 Two ounces. 
 Twenty drops. 
 Six ounces. 
 
 Mix and apply by means of soft linen or flannel. 
 
 mi 
 
SALl kllliUM — ECZEMA. 
 
 3«9 
 
 111 some obstinatf cases success has been attained by the 
 aijplication of tlie glyccrole of the acetate of lead, even after other 
 riiiKclics have been tried in vain. 
 
 In those cases in which eczema of the legs occurs as a result 
 of enlarj^ed veins, the (lire will be very much hastened by the use 
 of an elastic rubber bandage. In recent years this article has come 
 into general use for ulcers and eczema of the legs. The rubber is 
 made after a special formula, and is sold under the name of " Mar- 
 tin's bandage." 
 
 In the hospital wards of the renowned Hebra, in Vienna, suc- 
 ci'>s has been obtained, in obstinate cases, by the use of rubber 
 t'.iinients. If the hands alone arc affected, rubber gloves are worn 
 ni'dit and day ; if, as sometimes happens, there be extensive 
 eczema of the legs or the trunk, closely-fitting garments of light 
 rubber are made and worn constantly. If such garments or gloves 
 are used, the skin soon becomes softened and macerated from the 
 accumulation of perspiration and of the discharges. Hence it will 
 be necessary to remove these garments every two to four hours, 
 dry them, and wash the skin carefully. It is, therefore, necessary 
 to have at least two sets of garments, in order that one may be 
 worn while the other is drying. 
 
 Generally speaking, the skin which is affected with eczema 
 must be carefully protected from water and soap. There are cases, 
 it is true, in which it become necessary to wash the skin regularly, 
 but in the majority of instances water should be applied only when 
 absolutely necessary to remove the accumulated discharges. The 
 troud effects of such care are seen in those cases of eczema of the 
 iiands, in which the individual has been in the habit of washing the 
 hands frequently. Such cases often resist all sorts of treatment 
 until the hands are protected from water ; after this, recovery fol- 
 lows rapidly. 
 
 The following quotation shows how this disease is managed in 
 Vienna, the headquarters of the world for the treatment of skin 
 iliscases: 
 
 " In eczema of the scalp or of the ears, the crusts arc to be 
 removed by inunctions with oil, which are to be made twice a day, 
 about three ounces of oil being used each time. The crusts 
 arc thus removed, and the raw places are covered with flannel. If 
 the skin be not much thickened, the salves which have been men- 
 tioned above can be applied at once. If the skin be found red and 
 26 
 
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 I, 
 
 ' Jli 
 
 
 
 mv'Am 
 
 ..fmvl 
 
 ^1 M'4 
 
 ^vm 
 
 '4 iih' |j||, 
 
 mm 
 
 MM 
 
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 390 
 
 DISKASKS OK Till': SKIN. 
 
 'wccpiii}^,' il will bf necessary to apply iTctifuHl sjjirits ir|)rat((lly 
 VVluMi the swelling subsides, if the skir ':ontiiiues to secrete free!) , 
 tar ni;;y be applied in the case of adults; this a^-iil slnuild not 
 however, be used for childriii, because tluir skin is much iuok 
 sensitive, and swellinj;, perhaps even suppuration, of llie ^;lan(ls i- 
 the neck can be induced very easily. If the i-c/.enia e.vtend into 
 the ear, one may use injections or aslrinj^ents ; but in ordtr to 
 brinj.l[ the salve into contact with the entin- surface of the cui, ,1 
 piece of spoiv^e, properly shaped and covered with lint, should i>c 
 smeared over with the salve and inserted into the ear. If tlir 
 eczema extends hi^h into the nostril, we nia\' use suppositories, 
 ICach of these n>ay contain : 
 
 Cocoa butter, .... ICi^ht {.jrains. 
 
 Oxide of zinc, .... Five grains. 
 
 This should be inserted into the nostril. 
 
 " A child suflering from eczema of the face should have a piece 
 of linen smeared with diachyolon ointment laid upcMi the raw place; 
 this ma\- be fastened with a (lannel bandage and renewed constantly 
 until the crusts have been removed." — Neumann. 
 
 In some cases eczema appears suildenly in consequence eitlici 
 of some exposure to irritatinj^ substances or of some error in diii. 
 This is what is calleil acute eczema. There is considerable swelling; 
 and heat of the skin and the sore place dischar}.[es freely. 
 
 In the early days of this afiection excellent results are ob 
 tained by sponi;inj; the diseased surface with alcohol four or five 
 times a day; .ifter which, in the intervals, there may be a])plie(l ii|)(in 
 linen, iMie of the salves mentioned above, i^speciall)- the combina- 
 tion of bmax and glycerine, as follows: 
 
 liorax. ... - ()nc drachm. 
 
 Carbonate of soda, - - - Two drachms, 
 
 (ilyceiine, ... . . Two ounci-s. 
 
 Distilleil water, . . . . l"'our ounces. 
 
 %y '\ 
 
 H 
 
 Dry Tetter— (Psoriasis.) 
 
 This disease is one of the most frequent with which the physiriuii 
 has to deal ; and although it can with our present means be c.isily 
 
 V ^, 
 
DUV I i;iTI.K — I'suKlASIS. 
 
 39 « 
 
 ,111(1 r.ipiilly cured, yet tlic .ifTcciion displays the greatest p<'rvcrsity 
 .111(1 (lis|)()sili(iii to rcliirn a};aiii suhsccpiciitly. 
 
 This distMsc is ni.irki'd l)y llu- a|)pi'ai;mci' of scaly white 
 |);itclics, usually circular or oval in shajjc, and often swioundiii^ .' 
 pitch of healthy skin. Tlu-sc patclus appeal most frecpicntly upon 
 the otitii" surfaces of the elbows and ii])oM the front surfac(;s of 
 llic knees ; in fact, they are to lie found lure if anywhere on the 
 jialient's body. Yet they are by no means limited to these locali 
 tits, since they may spread over the trunk and limbs and even 
 cover the entire person from head to foot with a thick layer of sil 
 very-white scales. When these patches «)ccur on the head thc\ 
 cause annoyinj4 dandruff. 
 
 These patches may var)- in si/.e extremely, but can usually be 
 rcco^Mii/.ed by the fact that when j^ently scraf)ed with the (inkier 
 nails so as to remove the white scales, a few bleediu}^ jjoints appear 
 iinderneatii. Psoriasis rarely causis any itcliin}.; or scratching ; its 
 surface is not nioist unless greatly irritated, and it occurs on the 
 outer sides of the limbs. Hy these three characteristics it can 
 readily be distini^uished from the disease just described — ec/.eina. 
 
 Psoriasis is rarely developed in very youn^f cliih ren, nor does 
 it usually ajipear for the first time after the individual has attained 
 tiic ai;e of 35 or 40 years. It is usually developeil between 10 and 
 2$ years of a^e. 
 
 I'lic disease appears to be, to some extent, hereditary. Sev- 
 eral members of the same family will often suffer from it at the 
 same lime ; yet it is not in the least contagious, nor does it seem 
 to !)(• dependent upon any depravetl condition of tin; system, since 
 those who suffer from it are frecpief'ly pi'rfectly well in every other 
 respect. It often ap])ears in an individual only at certain seasons 
 of the year, especially in winter; after lastiuj^ for some months, it 
 (lisap|)( ars spontaneously, but returns a^^lin at the same season in 
 the iollowin^ )H'ar. 
 
 Tn'atmi'Ht. — In many cases it becomes necessary to use con- 
 stitution, il remedies in the treatment of psoriasis. This is especiall)' 
 '.rue in the treatment of children, whenever the scales are very j)lenti- 
 tiil and silvery. In all cases, attention should be directed to the 
 bowels, rei.;ular daily evacuations bcinjj insured. 
 
 Internally we may administer arsenic in some form, preferably 
 
:' ii f 
 
 m 
 
 m 
 
 i-f ;' 
 
 
 Jv I 
 
 f: r I 
 
 ■ « 
 
 392 
 
 DISEASES OK THE SKIN. 
 
 Fifty drt)ps. 
 Two drrtchms. 
 One ounce. 
 Five ounces. 
 
 One-third grain. 
 Half a drachm. 
 Haifa drachm. 
 Six grains. 
 
 as " Fowler's Solution. " This may be given in the following pre 
 scription : 
 
 Fowler's solution, 
 Wine of iron, . - - 
 Syrup of orange peel, 
 Water, - - - - 
 
 Mix, and take a tablespoonful after meals. 
 
 If the patient prefer to take pills, the following form of arsenic 
 may be administered : 
 
 Arsenious acid, - - - 
 Carbonate of iron, 
 Sulphate of quinine, - 
 Extract of nux vomica. 
 
 Mix, and make twenty-four pills. Take one half an hour 
 before meals. 
 
 In cases of scrofulous, pallid children, it will be advisable to 
 administer cod liver oil also. A teaspoonful of this may be given 
 morning and night, and the dose gradually increased to a table- 
 spoonful, if the stomach can bear it. 
 
 Yet, in most cases, it is quite possible cure to psoriasis by the 
 use of remedies to be applied directly to the skin. For this purpo.sc 
 various substances have been used, but within the last few years it 
 has become evident that reliance can always be placed upon some 
 of the derivatives of far. It is, therefore, a waste of time to eni])!oy 
 other and less trustworthy remedies. 
 
 The preparations of tar, which rarely fail to cure the disease 
 and cause a disappearance of the rash within two or three weeks at 
 most, are chrysopli'^Hic acid and pyrogallic acid. If the former is 
 to be used, the patient should take a warm bath and rub the skin 
 vigorously with soap and with a flesh brush, though not so roughly 
 as to cause bleeding ; the object is simply to remove the scalev 
 The following ointment may then be applied : 
 
 Chrysophanic acid, - Two drachms and a half. 
 
 Simple ointment; - Ten ilrachms. 
 
 These should be rubbed together very carefully by the apothecary; 
 there may then be added ten drops of the oil of bergamol. Ihis 
 salve is to be applied immediately after the patient leaves the bath 
 and has dried his skin. It should be rubbed only upon the diseased 
 patches, and not promiscuously upon the diseased and the healthy 
 
DRY TETTER — PSORIASIS. 
 
 393 
 
 skin alike ; for this agent irritates the skin considerably, and if 
 used carelessly it may cause considerable swelling and heat of the 
 skin. Indeed, the only objection to the use of this remedy is the 
 fact that it sometimes causes considerable irritation of the skin and 
 (if the kidneys as well. 
 
 In most cases it will be sufficient to apply this salve once a 
 (lay for three consecutive days. At the end of this time the 
 ])aticnt may take a warm bath and thoroughly cleanse the skin, h'or 
 several (five or six) days thereafter, the skin will probably exhibit 
 a certain amount o^ scaliness ; but this passes off entirely in eight 
 (ir ten days, and the eruption will be found to have disappeared. 
 In many cases the spots, where the salve has been rubbed in, ex- 
 hibit a dark red color, due to the chrysophanicacid ; this disappears 
 spontaneously in a week, and it can be removed in a few minutes 
 by washing the spots with benzine if necessary. The hair, also, is 
 apt to exhibit this color, especially the gray hairs. In this case 
 tlic color cannot be so readily removed, yet it is only in excep- 
 lional instances that this coloring of the hair can be objection- 
 able. 
 
 riu' chrysophanic acid stains the linen as well as the skin ; 
 the clothing is not thereby injured, yet it will be desirable that the 
 patient wear some old undergarments next to the skin so long as 
 the salve is used. 
 
 If we have to treat a particularly obstinate case, it will be 
 advisable to take especial pains in removing the scales before we 
 apply the salve. For this purpose we may not only use a hand- 
 brush while the patient is taking the preparatory warm bath, but we 
 may gently rub the diseased patches with benzole or with green soap 
 (sapo viridis), or we may prepare a sglution as follows : 
 
 Hicarbonate of soda, - - Two drachms. 
 
 Water, ----- Four ounces. 
 
 A piece of flannel may then be dipped in this solution and the 
 'icaly patches of skin gently rubbed with it until all the scales are 
 removed. 
 
 In obstinate cases — that is, those which have often recurred in 
 the same individual and have resisted other modes of treatment — 
 the salve may be applied for hve or six consecutive days, instead of 
 throe or four, as above directed, in fact, unless the diseased sur- 
 face br very extensive, the salve may be used for six to ten days 
 
 1 f 
 
 
 Mil 
 
 ^ '■ 
 
 
 
 1 
 
 
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 IT 
 
 
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 T 
 
 
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 »1 
 
 
 li 
 
 \\ mi^Hi>"^A 
 
 if 
 
 
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 ■k.'-A' 
 
 m 
 
394 
 
 DISEASFS OK THE SKIN. 
 
 without danger. If, however, there be a great many patches, 
 extreme caution must be employed ; and at the first appearance of 
 swelling in the face or in the healthy skin around the diseased 
 patches, or at the first complaint of indisposition on the part of the 
 patient, the salve should be discontinued and the patient should 
 cleanse the skin by means of a warm bath. 
 
 if the psoriasis affect the face also, this salve may be applied 
 to the skin of the face by means of soft cloths, upon which the oint- 
 ment may be smeared. 
 
 The pyrogallic acid can be used for the same purpose. It has 
 the advantage over chrysophanic acid that it docs not stain the skin 
 to the same extent, au ' does not cause the same amount of irrita- 
 tion. It may be use'J -,E-jcntially as has been directea for t:ic 
 chrysophanic acid. It ma; be employed in the following prescrip- 
 tion : 
 
 Pyrogallic acid, - . _ luo drachms. 
 
 Vaseline, .... Two ounces. 
 
 Mix well together and apply to the diseased patches after tiic 
 patient has taken a warm bath. 
 
 While these two remedies are extremely valuable, in fact the 
 best and quickest in their action that we possess, yet they have the 
 disadvantage that they sometimes cause unpleasant and even serious 
 irritation of the skin and of the kidneys. It is therefore advisee! 
 that if the treatment of psoriasis by means of either of these acids 
 be undertaken without the professional supervision of a physician, 
 extreme care be employed. Under these circumstances it will be 
 advisable to treat the patient by sections, as it were; that is, both 
 arms may be treated, and subsequently both legs, and ultimately 
 the trunk, if this also be affected. In every case of extensive 
 psoriasis involving trunk and extremities, it will be better to place 
 the patient in the hands of a physician for the reasons named ; but 
 if there be only a few scattered patches, especially at the elbows 
 and the knees, the treatment above detailed may be employed witli- 
 out professional assistance. 
 
 K' ii 
 
 
 i V 
 
 Ringworm. 
 
 Under the general term " Ringworm " are included several dis- 
 eases of the skin, each caused by a parasite. These parasites arc 
 all of vegetable nature, and belong to the same general class of 
 
KINGWOKM. 
 
 395 
 
 plants — the fungus family — as the yeast plant and the various 
 molds which so often appear upon jelly, moist bread, etc. For con- 
 venience, ringworm may be considered under the following heads : 
 The ordinary ringworm of the body, technically known as tinea 
 tonsurans ; ringworm of the scalp ; favns, another variety of ring- 
 worm of the scalp. Ringworm, that is the ordinary ringworm of 
 the body, is not caused by a worm, as the name would imply ; in 
 fact, it has nothing whatever to do with worms, directly or indi- 
 rectly. The name seems to be derived from the form of the 
 diseased patch, which is almost always circular, resembling, possi- 
 bly, a worm when coiled up. 
 
 The disease consists essentially in the growth upon and in the 
 skin of a microscopic plant, technically known as the trichophyton 
 tonsurans. The growth of this plant in the skin causes irritation 
 and inflammation, so that a certain amount of redness and even a 
 slight swelling may occur. A symptom which is rarely absent is an 
 intense itchiness. 
 
 If the course of the affection be closely observed, it will be 
 seen that the beginning of the disease is a small grayish speck. 
 wliich rapidly spreads in all directions from the common center. It 
 is peculiar that, as the disease spreads on the outside it heals on 
 the inside of the ring, so that in a few days there will be a ring of 
 perhaps an inch in diameter, composed of this minute plant, arrd 
 surrounding a circle of perfectly healthy looking skin, although this 
 circle was two or three days before quite covered with the plant. 
 A number of these rings may be formed near ciich other on the 
 skin. These are apt to run together and make a large spot, which 
 is bounded by an irregular, scalloped line. 
 
 The disease is highly contagious. Its occurrence in one mem- 
 ber of a family is usually followed in a few days by its appearance 
 on the skin of other members. Yet it is limited almost exclusively 
 to children. The aftection does not attack adults, even though the 
 plants be intentionally rubbed upon the skin. 
 
 It is a curious fact that this disease attacks several of the 
 lower animals, especially horses and dogs, and that it maybe trans- 
 mitted from them to man. It is probable that many cases originate 
 in this way, although opportunities enough are afforded for the 
 cdinnninication of the disease in the intimate contact of children at 
 play. 
 
 There is also a form of ringworm in which there can be seen 
 upon close inspection numerous little vesicles or blisters at the edge 
 
 
 \ 1 
 
 L \\ 
 
 
3 T 
 
 |) 4 
 
 mil !^ i *?■ ^i?^-if ii 
 
 ■• 
 
 .SQ""' 
 
 DISEASES OF THE SKIN. 
 
 of the diseased patch. This does not differ in any essentials fronj 
 the common form of ringworm, and yields to the same treat- 
 ment. 
 
 The development of ringworm is favored by warmth and mois- 
 ture and by the accumulation of scales upon the skin. Hence tin- 
 occurrence of the disease is favored by lack of cleanliness and bj- 
 the long-continued use of the same garments without washing. It 
 is t:pecially often found in those who inhabit damp dwellings, and 
 in those who habitually use flannel underclothing. 
 
 Ringtvornt of the scalp is essentially the same disease as ring- 
 worm on other parts of the skin ; it consists in the growth of a 
 microscopic vegetable, which causes a light inflammation and irri- 
 tation of the surrounding skin. In consequence of the presence of 
 the hairs, howevc ingvvorm of the scalp is a far more obstinate 
 affection than ringworm on parts of the body not covered with a 
 thick growth of hair, for these miscroscopic plants grow down into 
 the little sac.:) or . 'Hie'. . hich surround the roots of the hairs ; 
 hence it is far more difficult to destroy and eradicate the parasites 
 when they acquire a foothold on the scalp than it is when they grow 
 upon the surface of the skin elsewhere. 
 
 The fact that these plants grow into and fill up the hair follicles 
 explains another and characteristic feature of the disease, namely: 
 that the hairs become brittle and lose their natural luster ; in a short 
 time most of these hairs become broken off close to the scalp. In 
 course of time it may even happen that a considerable patch of the 
 scalp becomes quite bald. The hairs are not, however, perma- 
 nently destroyed, that is, so soon as the parasite is removed tlie 
 hairs grow again as before. 
 
 Ringworm of the scalp often exists for some time before it is 
 discovered ; because the little elevation caused by the growth of 
 the plant is concealed by the rest of the hair. It may thus hap- 
 pen that the diseased patch has attained a diameter of an inch or 
 more befoi^ '^ "" detected ; and in this case there are usually other 
 patches in different parts of the scalp, of greater or less size. Ring- 
 worm of the scalp usually causes considerable itching and scratch- 
 ing, as a result of which salt rheum or eczema is apt to follow. 
 The eczema causes the discharge of watery fluid, and this dries so 
 as to mat the hairs together, hence there may result from a simple 
 ringworm of the scalp an extensive sore on the head, which dis- 
 
KIN(;VV()kM. 
 
 397 
 
 charges profusely and causes the patient great annoyance. This 
 condition is popularly known as " scald head. " 
 
 When ringworm affects the beard, it runs essentially the same 
 course as on the scalp ; in this situation it is known as " barbers' 
 itch. " There are several affections of the hairs of the beard, which 
 arc also designated by this term ; the others are not contagious, but 
 ringworm of the beard is. 
 
 This form of barbers' itch causes the appearance of pimples in 
 and around the roots of the beard ; these often result in the forma- 
 tion of pustules in and around the hair follicles. Sometimes these 
 pustules occur close together, and coalesce, so as to form blisters of 
 considerable size ; when these break, and the matter in them dries, 
 a crust is made by which the hairs are matted together. 
 
 In some cases of disease it will be impossible to recognize ex- 
 actly the nature of the disease without a microscopic examination of 
 the scales and crusts. In case of ringworm, whether of the scalp or 
 of other parts of the skin, there will be found upon microscopic ex- 
 amination, numerous round or oval bodies, which are often arranged 
 in chains; and it is sometimes possible to distinguish in the short, 
 brokci. hairs, long chains composed of the parasite which causes 
 the disease. 
 
 Tfenttuent. — Ringworm on parts of the skin which are not 
 covered with hair is usually cured very easily. The principle of 
 treatment consists simply in the application of some material which 
 destroys the vegetable parasite ; so soon as the plant is killed the 
 irritation subsides, the crust is thrown off, the skin resumes its nat- 
 ural condition. 
 
 A considerable number of agents have been used for this pur- 
 pose ; among household remedies may be mentioned kerosene oil 
 and a solution of borax, as follows : 
 
 Borax, . . _ - . Half an ounce. 
 
 Water, - - - * - Half a pint. 
 
 Some of the borax remains undissolved at the bottom of the 
 vessel, but this is useful in order to keep the solution at full strength. 
 
 While these remedies are usually effectual, yet many people 
 object to the application of kerosene, which is moreover irritating 
 as well as unpleasant, and is apt to cause some swelling and pain of 
 the skin around the diseased spot. For these reasons various other 
 
 
 A\ 
 
 
 
39« 
 
 DISEASES OF THE SKIN. 
 
 I 
 
 
 ?' 
 
 a % 
 
 f 
 
 remedies arc to be preferred in the treatment of ringworm. Amon^j 
 those most employed by physicians are the following : 
 
 Hyposulphite of soda, - - - One ounce. 
 Dilute sulphurous acid, - - - Two drachms. 
 Glycerine, . . . . . One ounce. 
 
 Water, ------ Four ounces. 
 
 This should be applied to the diseased patches by means of a 
 stifif brush or a coarse cloth, which is to be dipped in the lotion. 
 Saturated solution of sulphurous acid, - One ounce. 
 Water, ------ Three ounces. 
 
 The removal of the parasites is hastened by the use of a remedy 
 in solid form, which can, therefore, be kept in contact with the skin 
 constantly, and not simply applied at intervals, as is necessary when 
 liquids are used. If the disease be located on the face, an ointment 
 can be applied at night and allowed to remain till morning ; for this 
 purpose any one of several ointments may be used, as follows : 
 
 Ammoniated mercury, - - Twenty grains. 
 
 Red oxide of mercury, powdered, - Twenty grains. 
 Simple ointment, - - - One ounce. 
 
 Mix thoroughly and apply directly to the skin, rubbing the salve 
 vigorously into the pores of the skin. 
 
 The simple oiutment of mercury will also be found efficient. 
 In most cases, too, the ordinary sulphur ointment can be success- 
 fully used for destroying the parasite. 
 
 This affection is entirely a local disease of the skin, and requires 
 no internal treatment. 
 
 Ringworm of the scalp is a far more toublesome and obstinate 
 affection to cure, not because the parasite is any more difficult to 
 destioy, but because it is extremely difficult to introduce the 
 remedy into the follicles of the hair, which are a continual breeding 
 place for these organisms. It will often happen that by a few 
 applications of one of the remedies above given the disea.se will 
 entirely disappear from the scalp, and the patient will consider 
 himself cured ; but in a few days or weeks it becomes evident that 
 the ringworm has started again in the same place. 
 
 It is, therefore, necessary to take especial pains to introduce 
 the various agents used for killing the parasites into the hair fdl- 
 licles. For this purpose the first requisite is to shave the head 
 closely, so as to remove all the hairs from the diseased patch and 
 
RINGWORM. 
 
 399 
 
 from its immediate vicinity. After this has been done there may 
 be rubbed into the scalp daily one of the followinj^j ointments : 
 
 Hyposulphite of sodium, 
 Vaseline, 
 
 One drachm. 
 One ounce. 
 
 Twenty grains. 
 One ounce. 
 
 Or. 
 
 Salicylic acid, . - _ 
 
 Vaseline, . . - . 
 
 In some cases good results may be obtained by brushing tlic 
 surface thoroughly with strong tincture of iodine. 
 
 Yet in many instances the most careful treatment in this way 
 will prove ineffectual ; the disease will seem to have disappeared, 
 treatment will be discontinued, but in a few days the parasitic 
 growth reappears. In such cases it becomes necessary to pull out 
 the hairs over the diseased patch. This is a most tedious and 
 laborious procedure, and quite painful to the patient. Much 
 trouble will often be experienced with children in persuading 
 them to submit to it. But there is no other means which can be 
 relied on to secure recovery, since the hair follicles are full of the 
 parasites, which can be reached only after the hair has been 
 removed. This process does not, of course, destroy the hairs, 
 which grow again in due time ; in fact, it often saves the hairs, 
 since the disease would otherwise result in the destruction of the 
 roots of the hair and permanent baldness in consequence. 
 
 There are cases in which even the pulling out of the hair does 
 not suffice ; in these instances it becomes necessary to apply a light 
 blister — plaster of cantharides — until the skin is quite red, after 
 which the usual lotions may be used. 
 
 As to the remedies themselves nothing further need be said ; 
 an\ of the prescriptions above given are quite efficient in destroying 
 the parasites. The difference in treatment required by ringworm 
 of the scalp consists merely in the care necessary to bring the 
 lotion into the hair follicles. 
 
 In that form of" barber's itch" which is really ringworm of the 
 beard, the same general treatment is necessary The face must be 
 kept closely shaven, and the lotions applied as already directed in 
 the treatment of ringworm affecting the scalp. In some cases 
 it will be found necessary to pull out the hairs of the beard also, 
 and to apply one of the salves or lotions mentioned after the hair' 
 follicles have been thus exposed. 
 
 f , 
 
 m 
 
 
400 
 
 DISKASKS OK THK SKIN. 
 
 |i -> 
 
 In all cases of ringworm affecting a hairy part of the skin, 
 patient and physician alike must be prepared for a long and tedious 
 course of treatment ; yet the patient should, for his own sake, never 
 despair nor give up treatment, for he may b*; sure that the disease 
 can be completely and finally eradicated, even though it require 
 months to accomplish. On the other hand he may be sure that if 
 allowed to proceed the disease will ultimately cause baldness of the 
 affected spots. 
 
 1 I 
 
 Favus. 
 
 f!f 
 
 \t^ 
 
 rt'" 
 
 This affection, technically called tinea favosa, is by no means 
 so common in the United States as in certain parts of Europi . 
 Yet it occurs here with sufficient frequency to require a description 
 and directions for treatment as a part of every household manual 
 of medicine. 
 
 Favus is caused by another vegetable parasite, a member of 
 the fungus family of plants, the achorion schoenleinii. This para- 
 site grows only on the hairy parts of the body as a rule, though it 
 occasionally appears on other parts of the skin. 
 
 In this disease crusts are formed in and around the hairs ; they 
 are often matted together so as tu constitute an enormous scab over 
 a large part or the whole of the scalp These crusts are of a 
 yellowish color, often somewhat saucer-shaped, and are pierced in 
 the middle by a hair. These crusts are formed almost entirely of 
 the vegetable growth itself. 
 
 When the crusts are removed there is observed underneath a 
 reddish surface from which the skin has been separated ; in bad 
 cases deep ulcers are found underneath the crusts. When these 
 masses are removed by treatment the skin heals again, but in many 
 cases the sites of the disease remain permanently bald ; this results 
 from the fact that the hair follicles are entirely destroyed by the 
 growth of the parasite. In aggravated cases, where the disease 
 has been neglected for months or years, the entire scalp may be 
 absolutely devoid of hair ; such cases are occasionally seen, espe- 
 cially among the low-caste Hebrews of Poland. 
 
 This disease affects the lower animals as well as man, and is 
 particularly common among dogs, cats and mice. This is cne of 
 
 iii 
 
FAVUS. 
 
 401 
 
 the affections which, when it occurs in dogs, is called the " mange." 
 It seems probable that the disease is often communicated to children 
 by these animals. 
 
 Trentinent, — The first object of treatment is to remove the 
 masses of the parasites which constitute the crusts on the head. 
 This must be done with care, since the scalp beneath will usually 
 be found raw and ulcerated. In order to remove these crusts the 
 head may be first thoroughly oiled, and may then be enveloped in 
 a flaxseed poultice, which may be changed every two or three 
 hours during the day. After ten or twelve hours' application of 
 the poultice, the crusts are usually softened and can be removed by 
 the hands without causing much pain. If they are still hard and 
 adhere closely to the .scalp the removal can be facilitated by soaking 
 the head in hot water; After the crusts are removed the hair should 
 be carefully cut or shaven around the diseased spots. There may 
 then be applied one of the following ointments: 
 
 Perchloride of mercury, - Fifteen grains. 
 
 Simple ointment, 
 
 Vaseline, ... Each half an ounc(;. 
 
 Mix and apply thoroughly to the scalp. If the scalp be ulcerated 
 extensively the ointment should be made somewhat weaker, say 
 live grains of the perchloride of mercury to the ounce ; and care 
 should be taken not to rub the ointment over the ulcerated spots. 
 
 One drachm. 
 Two drachms. 
 Half an ounce. 
 An ounce and a half. 
 
 Carbolic acid, 
 
 Flowers of sulphur. 
 
 Tincture of iodine. 
 
 Vaseline, 
 Mix and make an ointment. 
 
 The tincture of iodine alone may be applied by means of a 
 brush ; or the following may be employed instead : 
 
 Hyposulphite of soda, - Ten grains. 
 
 Vaseline, .... One ounce. 
 
 Most individuals who suffer from favus are in a poor btaie of 
 licalth, and require general treatment. In most cases the following 
 can be administered with advantage : 
 
 Tincture of the chloride of iron, Six drachms. 
 
 Tincture of nux vomica, - One ounce. 
 
 Compound tincture of gentian, To make four ounces. 
 
 Mix and take a teaspoonful in a half wineglassful of water half an 
 hour before meals. 
 
! I 
 
 I' r: 
 
 !l 
 
 ■ '■ 
 
 ll'-l 
 
 H\-^ 
 
 40^ 
 
 DISEASKS (»!■ IHL SKIN. 
 
 Liver Spots. 
 
 Uiulcr this term there are inchuled several distinct affections. 
 I'lie first of these is known in nietlicine as /i/itti iwrsicolor. This 
 consists of patches slightly elevated above the skin, anil exhibilip<' 
 an exquisite reddish brown, or fawn color. These patches v;' 
 much in size, and have no rej^ular outline ; they occur with especial 
 frequency at the upper part of the chest and at the root of tlu 
 neck, whence they may spread in various directions. Tlusc 
 patches are raised somewhat above the surface of the skin, and are 
 usually quite itchy; they cause no pain, and tlo not affect tlu' 
 jjcncral health. When scraped with the finger nail, the fawn-colored 
 material comes off from the skin in the shape of minute white 
 scales, leaving the skin underneath a little red, but otherwise 
 healthy. 
 
 These patches consist of a network of very fine vegetable 
 fibres ; they are in fact merely patches of mold, quite similar to 
 the scum which appears upon jelly. 
 
 Treatment. — The disease is readily cured by the applicati 
 of any remedy which destroys this vegetable parasite. It is, oi 
 course, desirable to make use of some agent which will not irritate 
 the skin. I'^or this purpose there may be used the following pre- 
 scription : 
 
 Hyposulphite of soda, _ - - Six drachms. 
 
 Glycerine, ----- Two ounces. 
 
 Water, - - - - " - Four ounces. 
 
 Mix, and rub thoroughly over the patches, by means of a flannel 
 or a stiff brush. This treatment should be continued for a week or 
 ten days after the skin is apparently again in its natural condition ; 
 since, otherwise, there may remain some seeds of the plant, wliich 
 will soon start again into vigorous growth. 
 
 This parasite grows with especial frequency when the skin is 
 kept moist and warm ; and its development is favored by weariiii; 
 flannels next to the skin, by residence in moist, damp dwellinj^s, 
 and by the use of imperfectly dried towels and bed 'inen. 
 
 Another form of liver spots is the variety popularly known as 
 " moth spots. " These consist of yellowish or brownish spots, 
 which occur especially around the angles of the eye and upon the 
 
KKVKk IJLISTKK — IIKUI'KS. 
 
 403 
 
 ft.rtluad ; they arc especially frequent in this latter situation (hirinj^ 
 nrij^nancy, and in tlie years inimi'<Iiati'ly suhsi;(iu(nt Id it. They 
 seem to occur also with especial Iretjuency in leniaK ^ who are 
 .ifflictetl with diseases of the woinli. 
 
 These spots are due to the deposit of an unusual amount of 
 coloring mailer in the lower l.iyirs of the skin. They have no 
 siL^Miificancc as an evidence «)f disease, and occasion the patient no 
 distress, beyond the annoyance to his vanity. They can sometimes 
 he removed by the use of the followinjj lotion : 
 
 Corrosive sublimate, - - - - One grain. 
 
 Water, ...... One ounce. 
 
 This may be rubbed thorouj^hly upon the spots, by means of a 
 uu'cc of flannel or other coarse cloth. Sometimes a saturated 
 solution of the hyposulphite of soda can be made to answer the pur- 
 pose. The corrosive sublimate solution must be used with caution, 
 since this substance is a deadly poison ; and when the spots are 
 located in the vicinity of the eyes especial care must be taken that 
 none of the mixture gets into the eye. 
 
 Fever Blister (Herpes). 
 
 This affection is known by various names, according to its 
 location ; when it occurs upon the lips it is popularly called " fever 
 blister " or " water blister ;" when upon the side of the body, it is 
 ^^cncrally designated " shingles. " 
 
 lleri)es consists in the formation of watery blisters, several of 
 uliich lie in close proximity, each surrounded by a reddened and 
 iiiilanied base. The vesicles do not burst, but their contents 
 hcconie somewhat milky, and finally dry up. The devel()i)ment 
 of the blisters is attended with itching, burning, and finally with a 
 smarting which amounts to acute pain. Inmanycases one blister, 
 or crni) of blisters, will be followed by a second before the first has 
 (Iricd ii[). 
 
 In many cases a certain amount of fever and general indispo- 
 sition precedes the development of the blisters ; in other instances 
 herpes appears, especially on the lips, in the course of acute dis- 
 eases. It is especially common during the convalescence from pneu- 
 iiionia. 
 
 
 .£ 
 
 'H 
 
 
 -ii iw 
 
 '■fki 
 
404 
 
 IHSKASK.S ()|- IHK SKIN. 
 
 Herpes may occur on the lip alone, though in many instances 
 blisters appear at the edge of the nostrils, and perhaps inside of tin- 
 mouth and on thc'palate. The blisters may occur on other parts 
 of the face as well as on the lip, especially on the cheeks and foir 
 head. Sometimes, too, the eruption occurs on the eye, when it is 
 quite painful and is apt to alarm the patient. 
 
 Among the other parts of the body which are especially lial)lc 
 to the occurrence of the eruption, are the genital organs of Ijotli 
 sexes and the sides of the chest. When it occurs in the former sit 
 nation it is apt, especially if combined with a guilty conscience, to 
 excite suspicion of venereal disease. Only a practiced eye can dis 
 tinguish between the latter affections and an innocent eruption of 
 herpes. When the rash appears in this locality in females, it excites 
 considerable burning pain and much annoyance. Some wonien 
 suffer from herpes on the genitals at every menstrual period. 
 
 Herpes occurring on the side of the chest is found to follow 
 the edge of a rib, perhaps all of the way from the backbone td 
 the frcMit of the chest. 
 
 The appearance of the eruption is often preceded by neuralgi.i 
 in the side, and perhaps even by attacks of colic, and by difficulty 
 in breathing. After two oi three days of this feeling the jxiticnt 
 perceives a burning sensation in the side, the skin being often sonu- 
 what tender upon pressure. With the appearance of the rash, the 
 burning pain subsides, but the skin becomes extremely itcli\ , 
 Herpes of the side follows pretty accurately the track of some one 
 of the nerves, from which fact it has been assumed to be essentially 
 a nervous disease. 
 
 Herpes of the side — shingles — may appear at any time of 
 life, even in infants, but is most frequently observed between ten 
 and twenty-five years of age ; men are more susceptible tliaii 
 women ; and spring and fall seem to furnish more cases than tiie 
 other seasons of the year. 
 
 The eruption of shingles begins with a reddening of the skin, 
 upon which a few vesicles or blisters as large as the head of a pin 
 appear. In the course of a few days these blisters have increased 
 in size, and may run together so as to form vesicles as large as ;i 
 bean. The contents of the blisters is at first a clear watery lluici 
 which gradually becomes cloudy and yellow ; in ten to fifteen days 
 the blisters begin to dry up and are replaced by blackish scabs. 
 
KEVKK HLISIKR — HERPES. 
 
 405 
 
 Ihf disease lasts from two to three weeks, and the eruption Ic.ives 
 no permanent scar. 
 
 A curious fact about shingles, .is well as about herpes gen- 
 t rally, is that it occurs only on one side of the body or face. It is 
 often remarkable to see how abruptly the rash ends exactly at the 
 middle line of the body. Yet cases do occur in which both sides 
 of the body are affected at the same time. 
 
 Tt'entHM'-Ht. — Herpes is a perfectly harmless and innocent 
 <liscase ; the popular impression that the patient would die if the 
 lasii should extend entirely around the body is, of course, an error, 
 it seems to have arisen from the fact that the rash rarely appears on 
 both sides of the body at the same time. Yet instances have been 
 known in which herpes zoster or " shingles " did appear on both 
 sides at the same time, and did encircle the body so far as it is 
 possible, yet the patients recovered. 
 
 The object of treatment is simply to diminish the irritation 
 caused by the rash and to prevent any aggravation of the difficulty 
 by tearing open the vesicles. Herpes of the lips rarely requires 
 any attention ; if it be recognized early it may be to a certain 
 extent cut short by a free and repeated application of the tincture 
 of camphor (spirits of camphor). Herpes occurring elsewhere 
 iiiiiy be treated by the application of some soothing ointment, such as 
 vaseline, and may be dusted with powdered starch. When it occurs 
 on the sides, as shingles, it becomes necessary to protect the blis- 
 ters and the surrounding inflamed skin from the friction of the 
 clolliiiiL'. I'or this purpose a piece of soft rag may be smeared 
 with vaseline, laid over the blistered surface, covered with flannel, 
 and kept in place by narrow strips of adhesive plaster. 
 
 When herpes occurs upon the genitals, it may be advisable to 
 l)rotect the inflamed surface in the same way by the use of soft 
 ra;.;s covered with vaseline or soaked with sweet oil. There is no 
 use in applying ointments or powders to hasten the disappearance 
 (jf the eruption, since this nni.st run its course. 
 
 If herpes occurs often in the same patient, attention should be 
 tlirectcd to the general health. Sometimes it becomes necessary 
 to relieve habitual constipation ; at other times there is ilecidcd 
 pallor; if the appearance of the rash be preceded and followed by 
 
 27 
 
 
 I* "V ' K 
 If ,!.■ \ 
 
 
 y-mm 
 
 
:) ■■•:. 
 
 ! ? 
 
 ^1 
 
 b !; 
 
 V*'l 
 
 406 
 
 DISEASES OF THE SKIN. 
 
 neuralgic pains in the side, benefit will be derived f-om the use of 
 the following prescription : 
 
 Sulphate of quinine, - . - Forty grains. 
 
 Reduced iron, . . . . Twenty grains. 
 
 Extract of nux vomica, - - Four grains. 
 
 Mix and make twenty pills ; take one morning and night. 
 
 In elderly people, especially, and sometimes in others, an 
 attack of shingles is followed by obstinate neuralgia in the side, 
 which persists for days or weeks after the rash is entirely healed. 
 In this case it will be necessary to employ, in addition to tb -bovc 
 prescription, some form of opium. The best form is a hyp 'ermic 
 injection of one-eighth of a grain of morphine, inserted under the 
 skin of the painful part. 
 
 Barbers' Itch — (Sycosis). 
 
 This is the technical term for what is popularly known as 
 " barbers' itch. " There are, as has been said, three varieties of 
 barbers' itch — that is, there are three distinct affections, which 
 attack the bearded part of the face and cause a pustular eruption. 
 First among these is " ringworm," which has been already described; 
 the second form is merely eczema, affecting this part of the skin. 
 In addition to these affections there is, however, a pustular inflam- 
 mation, which affects the hair follicles of the beard. This form of 
 barbers' itch is not contagious, but is often very obstinate. It is 
 especially apt to occur in those whose health is broken down by 
 debauchery, intemperance or dyspepsia. 
 
 There appear, oftentimes first on the upper lip, just below the 
 nostrils, a number of pimples ; at the same time the skin in the 
 vicinity becomes swollen, red, hot and painful. In a short time 
 these pimples show the formation of matter at their tops, thus 
 becoming pustules. Upon close inspection it will be seen that 
 each of these pustules is pierced by a hair. In a short time the 
 disease spreads and appears, perhaps simultaneously, on different 
 parts of the face, more especially around the chin and in front of 
 the ears. The hairs arc apt to fall out to a considerable extent, so 
 that bare patches appear. If left without treatment this form of 
 sycosis may last for years. 
 
BALDNESS. 
 
 407 
 
 TreMtment, — In every case attention should be directed to 
 the general condition of the patient, and any derangement of func- 
 tion of the internal organs, such as dyspepsia or constipation, 
 should be remedied so far as this is possible. 
 
 Then the face should be carefully shaven, and the beard kept 
 short by daily shaving. This is apt to be a painful process at first, 
 but it must be done. If there be much thickening of the skin, as 
 is often the case, the treatment should be begun by the application 
 of the ointment of mercury. The different pustules should be care- 
 fully opened, their contents gently pressed out ?nd the ointment 
 thoroughly rubbed into the surface. In some cases it may be 
 necessary to apply light poultices or flannel cloths wrung out in 
 jiot water, until the excessive pain and heat of the skin have sub- 
 sided. In case the eruption is quite extensive, it will be advisable 
 not to use the mercury ointment in full strength, but to employ the 
 following mixture : 
 
 Ointment of mercury, - - - Half an ounce. 
 Diachylon ointment, . _ - Half an ounce. 
 To this there may be added sufficient olive oil to make a soft and 
 agreeable salve. 
 
 In case there is not much thickening of the skin, and but little 
 redness and swelling, the rash can often be subdued by the diachy- 
 lon ointment alone ; if this be not sufficient, one -half or one -third 
 its weight of mercury ointment may be added to it. In every case 
 in which mercurial ointment is employed for weeks at a time, atten- 
 tion should be given to the condition of the teeth ; so soon as the 
 least tenderness is felt when the teeth are pressed firmly together, 
 the mercury ointment should be discontinued. , 
 
 This form of sycosis is, at best, an obstinate affection, and will 
 require weeks or months of careful treatment. 
 
 Baldness. 
 
 Baldness may be partial or complete, acquired or hereditary. 
 It is sometimes an affection by itself, at other times merely the 
 symptom of other diseases. It may result either from disease of 
 the scal|), such as favus, syphilis or eczema ; or it may be the con- 
 sequence of a general failure of nutrition, which manifests itself by 
 
 ;.' ■ 
 
 U?'\ 
 
] 
 
 i 
 
 !i!^ 
 
 Hi 
 
 %: 
 
 J 
 
 
 I 
 
 ni j 
 ill! -. 
 
 
 ""''te-^ 
 
 11^ 
 
 408 
 
 DISEASES OF THE SKIN. 
 
 changes in the body elsewhere. This latter form of the affection 
 is manifested especially in elderly people. 
 
 In some individuals there is congenital absence of the hair; 
 that is certain parts of the scalp are bald from birth on. In 
 some other cases these bald patches first appear in the early years 
 of life. Such congenital baldness is usually only partial, there 
 being in most cases one or more spots of limited extent on whicli 
 no hair grows. 
 
 Baldness is, however, in most cases acquired usually in 
 advanced life. The hair ^ ^ins to fall out first on those parts of 
 the head bordering upon the temples and around the, crown of the 
 head. In many cases there is a hereditary tendency to early bald- 
 ness, which is distinctly marked in several generations. 
 
 Several of the infectious diseases are usually accompanied by 
 a falling out of the hair ; among these are typhus fever, scarlet 
 fever, measles and syphilis. In most of these cases the hair grows 
 again so soon as the individual has recovered from the acute attack. 
 The hair may also fall out when the vital powers are diminished 
 from any cause ; it is a not infrequent occurrence in musing 
 women. 
 
 In all these cases the treatment should be addressed to the 
 general health ; the hair requires no special attention, provided it 
 be free from the various diseases which have been enumerated on 
 previous pages as causes of baldness. 
 
 It is interesting to know that baldness is far more common in 
 men than in women. Many explanations of this familiar fact have 
 been advanced ; a popular one, especiall)- with the male sex, is the 
 idea that excessive use of the brain is accompanied by interference 
 with the growth of the hair. This idea has, however, but little sup- 
 port in fact, though it is true that baldness is more common aniont; 
 those engaged in intellectual pursuits than among hand laborers. 
 Yet this fact can be explained more plausibly by the fact that brain 
 workers rarely have the same degree of physical health as those 
 whose occupations keep the body in a state of robust vigor. 
 
 It has been supposed, also, that men have less fatty tissiR 
 underneath the scalp than women ; and that in advanced years tlie 
 scalp becomes tightly stretched over the skull, so that the supply of 
 blood is to a certain extent cut off from the hair in men, while in 
 women the excess of fat still secures ample circulation of the blood 
 
bALDNESS. 
 
 409 
 
 to the hair. This seems a more plausible explanation, though still 
 lacking several facts for its support. 
 
 Another form of baldness is one which often occurs in child- 
 hood and youth, and is called alopecia areata. In this disease the 
 hair begins to fall out at one or more spots, and the scalp under- 
 neath is found to be very white and dry. It will be found that 
 although there is apparently no disease of the skin on these bald 
 spots, yet the hair follicles are very small, or have perhaps entirely 
 disappeared. When first discovered, these spots are usually half 
 an inch or more in diameter ; they usually increase in size, slowly 
 but surely. After a time, the spread of the baldness may stop 
 spontaneously, or it may progress until the greater part of the head 
 is quite bare, only a few tufts of hair scattered over the scalp re- 
 main ; the rest of the head may be as smooth and soft as the skin 
 of an infant. 
 
 This affection is most frequently met with in children who are 
 somewhat naturally delicate, or whose vital strength has been 
 broken down by prolonged disease. Such children arc especially 
 apt to suffer from the " green sickness " (chlorosis) or scrofula. 
 
 Ti'eatment, — The treatment of baldness will in every case be 
 determined by the supposed cause. In the form last described 
 — alopecia areata — the baldness is supposed to be due to a dis- 
 ease of the nerves. Treatment will therefore include attention to 
 the general health. If the patient be evidently debilitated, pro- 
 vision must be made for nourishing food, air and exercise. If 
 there be evidence of chlorosis, the following prescription may be 
 given : 
 
 Fowler's solution, • 
 
 Tincture of nux vomica. 
 
 Syrup of the iodide of iron, 
 
 Syrup of orange peel. 
 
 Water, ----- 
 
 Mix and take a tcaspoonful four times daily; if the child be 
 under 12 years of age the dose must be diminished correspond- 
 ingly. 
 
 Locally the treatment consists in the application of blistering 
 fluid to the bald spots. The hair around the spots may be shaven, 
 and the spot should be painted every day or two with the tincture 
 of cantharides (Spanish flies). After a time, which may vary from 
 
 Two drachms. 
 Four drachms. 
 Ten drachms. 
 One ounce. 
 To make four ounces. 
 
 Ill 
 
 rn 
 
 :-' i 
 
 15 *i|h 
 
i* ', 
 
 I-. 
 
 
 , 
 
 
 It < » 
 
 
 m ll^ 
 
 II ' 
 
 ■,* 
 
 im 
 
 J- 
 
 ml .,| 
 
 It 
 
 
 
 iU 
 
 iii'l 
 
 410 
 
 DISEASKS OV THE SKIN. 
 
 a few days to weeks, there will be observed a sli[;ht frrowth of short 
 soft, downy hairs, which arc apt to be of a lighter color than the 
 surrounding hair. The treatment should be persevered in, how- 
 ever, until the hair on the bald spots becomes so long that the 
 application of the fluid to the skin is no longer possible. 
 
 It is surprising to observe what can be and has been done in 
 this way in the restoration of the hair ; the writer saw in a London 
 hospital a woman, 27 years old, who possessed a beautiful head of 
 thick, long hair ; this individual had at the age of 12 years become 
 almost completely bald, only a few tufts of hair remaining on the 
 head; and this condition had lasted for six years. For some weeks 
 after treatment with the blistering fluid was begun, there was no 
 appearance of hair to encourage further efibrt. At the end of two 
 months there appeared a few thin, downy hairs, but it was not 
 until six months of treatment had elapsed that the growth of the 
 hair was at all satisfactory. 
 
 There are, however, cases in which the hair follicles are quite- 
 destroyed, and in such cases no mode of treatment can hope to 
 produce hair. In these instances it will be observed that the scalp 
 does not present the usual appearance ; that is, it is not studded all 
 over with minute openings or "pores;" the skin is smooth and 
 glistening. When this condition exists it is rarely possible to pro- 
 cure the growth of the hair ; and if after a few weeks' trial with the 
 blistering fluid there be no appearance of hair on the bald spots, 
 the attempt should be abandoned. 
 
 Hair Dyes. 
 
 The color of the hair varies in the age of the individual, and 
 is dependent upon the presence in the shaft of the hair of certain 
 coloring matters which are deposited as fine granules, set close!}- 
 together. When the hair becomes gray there is a gradual decrease 
 in the quantiiy of this coloring matter. In some individuals no 
 coloring matter is ever deposited in the hairs, and they are from 
 birth to old age provided only with white hair ; such indivi'' als 
 are called albinos. There is usually less coloring matter in other 
 parts of the body than is usually found ; thus, the colored rint^ 
 around the pupil of the eye — the iris — is sometimes quite 
 devoid of coloring matter, so that it looks pink from the reflection 
 of light which comes from the interior of the eye ; the skin, too, 
 
HAIR DYES. 
 
 411 
 
 is in such individuals extremely white, from the small quantity of 
 coloring matter contained in it. 
 
 The change in color, whereby the hair becomes gray, is usually 
 a gradual process ; yet instances occur in which the hair becomes 
 suddenly gray in the course of a few months. This is apt to hap- 
 pen after some severe acute illness, such as scarlet fever. There is 
 a popular belief that in consequence of violent emotion, such as 
 fright, the hair can becom.^ suddenly gray. Tt is said that Marie 
 Antoinette experienced such a sudden change in the color of the 
 hair in consequence of the terror inspired by the horrors of the 
 French Revolution. But little reliance can be placed upon such 
 legends ; yet there are well authenticated instances in which the 
 hair has, in the course of a few days, exhibited a decided change 
 in color. 
 
 In one case the hair became suddenly gray during an attack 
 of acute mania ; in another the hair of a soldier, which had been 
 black before a battle, was found to be gray after the conflict. 
 
 The prevalence of grayness of the hair has occasioned an 
 immense demand for hair dyes ; and enormous quantities of mix- 
 tures are sold under various names for this purpose. All of these 
 arc compounds either of lead or of nitrate of silver or of sulphur. 
 Of these three substances the least injurious is undoubtedly sul- 
 pluir ; yet sulphur alone is not always reliable for the purpose 
 desired. Even sulphur, when used in excess, can be decidedly 
 injurious to the system ; the nitrate of silver affects the general 
 system sooner than sulphur, and has the disadvantage that it colors 
 the skin as well as the hair. The most injurious of all is the lead, 
 which is not infrequently the cause of lead poisoning, indicated by 
 severe attacks of colic and by paralysis, as has been described in 
 previous pages. 
 
 In order to indicate to the reader the composition of the ordi- 
 nary hair dyes, the following analyses, made by an eminent British 
 chemist, are presented : 
 
 Sample No. i, Hair Restorer. — The sample examined consisted 
 of a colorless fluid and a grayish yellow deposit. The deposit 
 consisted almost entirely of sulphur, with a minute quantityi of 
 carbonate of lead. The solution contained acetate oi lead and 
 glycerine. 
 
 In a bottle containing ten fluid ounces, forty-four and eight- 
 tenths grains of sulphur, and lead corresponding to twenty-one and 
 ei;;ht-tenths grains of the acetate of lead, were found. 
 
 
412 
 
 DISEASES * F THE SKIN. 
 
 .*. I 
 
 
 Sample No. 2, Hair Restorer. — The bottle examined contained 
 eight and one-half fluid ounces of mixture, composed, like the last, 
 of a colorless fluid and a yellowish ^ray powder, this latter consist- 
 ing of sulphur, with a trace of carbonate of lead, the solution 
 containing acetate of lead and glycerine. 
 
 The results of an analysis of the contents of the eight and 
 one-half ounce bottle indicated seventy-five and six-tenths grains 
 of sulphur, and an amount of lead corresponding to eighty-seven 
 grains of acetate of lead. 
 
 Sample No. j, Hair Restorer. — Like the preparations previ- 
 ously noticed, this consisted of a colorless fluid and a yellowish 
 gray deposit, and also contained the same ingredients — sulphur, 
 acetate of lead and glycerine, the deposit in this case being pure 
 sulphur. 
 
 A bottle containing eight fluid ounces furnished eighty-one 
 and eight-tenths grains of sulphur, and lead corresponding to forty- 
 five and one-tenth grains of acetate of lead. 
 
 Another preparation was found to be similar to the others, the 
 deposit containing sulphur, sulphate of calcium, and a trace of 
 sulphate of lead, the solution containing acetate of lead, glycerine 
 and a trace of acetate of calcium. In distinguishing this prepara- 
 tion by the epithet vegetable, the maker has allowed his inventive 
 faculty to overstep the bounds of truth, and has given moralists 
 another instance of the common commercial practice of calling 
 things by their wrong names. 
 
 A bottle containing six fluid ounces furnished seventy and 
 two-tenths grains of sulphur, mixed with sulphate of calcium ; also, 
 lead corresponding to fifty and eight-tenths grains of lead. 
 
 As a matter of fact no hair dye has been invented which is 
 absolutely free from injurious effects. The numerous compounds 
 advertised as " purely vegetable " dyes, are found upon analysis to 
 contain one of the three substances named, as reported in the above 
 analyses. Yet various vegetable substances are capable of affordiii<; 
 materials which can be used as hair dyes. Among these is an 
 extract made from walnuts. A few formulae are appended as 
 examples of hair dyes : 
 
 Pyrogallic acid, - - - Fifteen grains. 
 Pyroligneous acid, - - An ounce and a half. 
 Rectified spirits, - - - An ounce and a half. 
 This mixture is to be marked number one. 
 
 'Si.-? 
 
HAIR DYES. 
 
 413 
 
 Nitrate of silver, - - - - Fifty grains. 
 
 Distilled water, . . . - Three ounces. 
 
 Dissolve, then add a solution of strong ammonia until the cloudiness 
 which appears at first disappears again. This is to be marked 
 number two. 
 
 Ihe hair should be thoroughly washed with soap and water, 
 iuul then number one should be api)lied by means of a piece of 
 flannel. Immediately thereafter number two should also be used 
 to wash the hair. Another formula is the following : 
 
 Nitrate of silver, - - . . One drachm. 
 
 Acetate of lead, _ - . _ Twelve grains. 
 
 Distilled water, . . _ Four ounces. 
 
 Still another may be made with lead alone : 
 
 Sugar of lead, . . _ . Forty grains. 
 
 Glycerine, . . . . _ One ounce. 
 
 Distilled water, . . . . Five ounces. 
 
 In certain Oriental countries the use of hair dyes seems to be 
 almost universal. The following account of the custom in Persia is 
 taken from Neumann's Treatise on Diseases of the Skin : 
 
 " In Persia the hair remains black from childhood to old age, 
 as the result of the use of dyes. These are always employed in the 
 so-called Turkish bath. The process is as follows : First, after re- 
 maining for a short time in the bath, the hair is well soaked and 
 washed with water, whereby it is cleansed from fat. Second, they 
 take some henna powder, mix it with warm water till it attains the 
 consistency of cream ; this is then smeared upon the hair. This 
 paste is allowed to remain upon the hair for more than an hour, 
 and is then washed off with warm water. It will now be observed 
 that the hair which was previously of a light color has acquired a 
 dark orange or saffron color. After this the powdered leaves of 
 the indigo plant are rubbed into a paste with water, and the hair is 
 at,niin smeared. This paste remains for an hour and a quarter and 
 is then washed off. The dyeing process is now complete, though 
 the dark hue appears in the hair only several hours later through 
 oxidation of the indigo. 
 
 " If it is desired to color the hair not black, but chestnut 
 brown, they take one part of the henna and three parts of the pul- 
 verized indigo leaves. These are smeared upon the hair after the 
 fat has been removed with soap and water, as in the former case. 
 
 f ^ 
 
 I t 
 
 if I 
 
 '4 
 
 i}„»i 
 
If :.L 
 
 ;i 
 
 414 
 
 DISEASES OF THE SKIN. 
 
 The longer this paste lies the darker is the shade. One hour is 
 usually enough to produce a light brown color, and an hour and a 
 half for the dark brown. If the first dyeing be found too light, the 
 paste must be renewed. 
 
 " Since both powders, henna and indigo, are quite harmless, 
 even upon accidental contact with the eyes, their employment 
 causes no injury to the body or to the hair. The Persians, indeed, 
 maintain that this dyeing process strengthens the scalp, a statement 
 which they seek to prove by the fact that baldness is a rare occiii- 
 rence among them. 
 
 " The henna retains its power a long while, but the indigo 
 powder takes up moisture and then becomes weak in color. The 
 result is that the powder when exported from Persia is usually quite 
 useless upon its arrival. According to Pollak, a substitute can be 
 prepared as follows: Take eight grains each of pulverized commer- 
 cial indigo, grape sugar, and a meal made from peas or beans; mix 
 these with two ounces of water and add a little yeast. Put the 
 vessel in a warm place, and employ the liquid for dyeing purposes 
 only when fermentation is going on. After the hair has been 
 smeared once or twice with henna, this fermenting liquid can be 
 applied, with the production of more or less dark color. As the 
 process is a tedious one, it is better adapted for ladies, since their 
 hair will need a repetition of the process only after several months. 
 It is self-evident that the fermenting indigo liquid must be prepared 
 fresh for every dyeing, since the dye disappears so soon as the 
 liquid ceases to ferment, " 
 
 Erysipela4Ei. 
 
 This disease, sometimes called Saint Anthony's Fire, is more 
 properly described among the diseases afifecting the general system 
 than among the skin diseases; yet, in many cases, it appears to be 
 not a general but a local disease, being limited to a circumscribed 
 part of the skin. Many other affections than true erysipelas are 
 often designated by this name. Many people are accustomed to 
 regard any redness of the skin accompanied with heat as erysipelas. 
 
 True erysipelas is an acute inflammation of the skin, whicli 
 may affect any part of the body, but is especially often met with 
 
 ; ii 
 
 ' M' 
 
ERYSIPELAS. 
 
 415 
 
 on the face. The skin is red, shiny and swollen ; the patient has a 
 sense of pain and of burning in the part. 
 
 The disease is ordinarily preceded by a severe chill and high 
 fever; if the face be the part affected, there may occur also vomit- 
 iiv', delirum and even stupor. The symptoms become more severe 
 when the inflammation appears in the skin. 
 
 The appearance of the skin varies somewhat according to the 
 part affected ; but there is always this characteristic feature, that 
 the inflamed skin is sharply marked off from the healthy skin by 
 the difference in color. The outer layer of the skin is often raised 
 in the shape of small blisters, whose contents may be watery or 
 niav contain matter. After a time these blisters dry into black 
 
 scabs. 
 
 When the inflammation subsides, the skin loses its red color, 
 but remains swollen for a considerable time ; the hairs of the 
 affected part fall out, but grow again subsequently. Sometimes a 
 series of boils and abscesses follow in the wake of erysipelas, and 
 at times a considerable part of the skin mortifies and is removed 
 by suppuration. 
 
 Erysipelas occurs either as scattered cases which apparently 
 have no connection with one another, or in epidemics. In the 
 latter form it is especially apt to attack patients who are suffering 
 from wounds, injuries or surgical operations. Until the introduc- 
 tion of certain recent improvement in methods of surgical dressing, 
 erysipelas was the scourge of hospitals. It often happened that 
 the disease would sweep an entire ward of surgical patients, attack- 
 ing every one that had been operated upon ; many cases which 
 would have recovered easily from the effects of the operation died 
 of the erysipelas. 
 
 Aside from the occurrence of this disease in the wards of 
 hospitals, it is frequently met with in private practice among those 
 who have not been exposed to contagion. These are the so-called 
 sporadic or scattered cases. In these cases erysipelas occurs most 
 frequently in the face ; it has been ascertained that twenty cases of 
 facial erysipelas occur to one case of the disease in other parts of 
 the body. It is especially apt to begin on the side of the nose ; 
 often commencing as it seems in some scratch on the mucous mem- 
 brane of the nostril, or in a sore of the nostril or lip. The skin 
 just under the eye, extending to the side of the nose, becomes 
 somewhat painful and itchy ; in a few hours the redness appears 
 
 m 
 
 
 11 .' 
 

 m 
 
 t^i 
 
 416 
 
 UISKASKS OK THK SKIN. 
 
 accompanied by the symptoms of constitutional disturbance — chill, 
 fever, vomiting, etc. — detailed above. The redness and swcllin^j 
 extend over a considerable part of the face, often causing great 
 deformity for the time being. One or both eyes will be closed 
 entirely by the enormous swelling of the lids; the nose, too, is 
 very much thickened, and the nostril is thereby so much diminished 
 in caliber that the patient is often compelled to breath entirely 
 through the mouth. In many cases the inflammation extends 
 upward over the scalp, and may cause great danger to life by 
 attacking the membranes of the brain. Much or all of the hair 
 may be lost in this disease, but the baldness is only temporary. 
 
 The symptoms of inflammation begin to subside on the fourth 
 or fifth day, and in a few days more the skin usually resumes its 
 natural condition, except that the outer skin peels off in large flakes. 
 Sometimes an affection of the eyes remains for a considerable 
 period after the inflammation of the skin has subsided. 
 
 This is the usual and favorable termination of facial erysipelas. 
 But it sometimes happens in erysipelas of the face, and frequently 
 when the disease affects other parts of the skin, that the inflaniiiKi- 
 does not subside so quietly. The redness and pain may diminish 
 considerably, but the swelling remains ; and it will be found that the 
 skin has a peculiar soft, doughy feel; if the finger be pressed firmly 
 on the part a depression remains for a number of minutes after its 
 removal. These symptoms generally indicate that matter has 
 formed in tlic skin ; in this case recovery will not take place until 
 the skin be opened and the matter permitted to escape. This is 
 absolutely necessary, since otherwise the pus will burrow under the 
 skin, and even downward between the muscles, resulting in a con- 
 dition which may seriously impair the usefulness of a limb, or even 
 cost the patient his life. Even when promptly opened, the abscess 
 (collection of matter) may run a long and tediou;i course, and cause 
 mortification of the skin and of the muscles underneat! ^oii 
 times in spite of all treatment, it ultimately exhan ' ' -trengtli 
 of the patient, and causes a fatal result. 
 
 Erysipelas of the face often occurs several tii in tli- sa.ne 
 individual ; in fact, there are those who suffer from it .ilm' 4 every 
 year during the spring months. In general, erysipelas is uk^h' prev- 
 alent during the spring and fall than at any other times of the 
 year. 
 
 Wf 
 
KRYSIJ'ELAS. 
 
 417 
 
 Treatnivnf, — The treatment must always be adapted to the 
 piiticiit ; and the constitutional treatment is, therefore, of far more- 
 consequence than the application of remedies to the inflamed 
 
 skin. 
 
 if the individual be at the beginning of the attack somewhat 
 ililiilitated, or if he be evidently much exhausted by the onset of 
 tlir disease, it is extremely important that his strength should be 
 sustained in every possible way. For this purpose we rely upon 
 iron and quinine. The following prescription may be given: 
 
 One ounce. 
 
 One drachm. 
 
 Half an ounce. 
 
 Two ounces. 
 
 To make four ounces. 
 
 Tincture of the chloride of iron, 
 
 Sulphate of quinine. 
 
 Tincture of nux vomica, 
 
 Syrup of orange peel. 
 
 Water, 
 
 Mix. and take a tcaspoonful in water every four hours. 
 
 Sometimes the pain is so intense that it becomes necessary to 
 ;iclniiiiister opium. Twenty drops of laudanum may be given every 
 tliric or four hours until the pain is somewhat allayed. 
 
 For application to the skin itself one of the best remedies is 
 the following : 
 
 Tincture of opium, . . . . One ounce. 
 
 Liquor plumbisub acetatis (lead water), - Five ounces. 
 
 Mi.x and apply by saturating soft cloths with the lotion and 
 laying them upon the inflamed skin. 
 
 \\Trious measures have been tried to prevent the spread of the 
 disease, for one of the unpleasant features of erysipelas is that the 
 inllamniation shows an inclination to extend indefinitely over the 
 skin. In order to limit the inflammation, it was formerly the habit 
 to draw a line around the advancing disease with a stick of lunar 
 caustic. Although success was claimed for this practice, yet it was 
 finally abandoned. In more recent times, several other measures 
 liavc been proposed and used to accomplish the same result ; 
 amuiit^ these is the injection of a three per cent, solution of carbolic 
 .icid at several points in the skin in front of the advancing inflam- 
 niatioii ; this is done by means of a hypodermic syringe, and the 
 process must be repeated two or three times within a couple of 
 lays, if the inflammation be not arrested. This measure should 
 be carried into execution only by a physician, and it must be 
 
 
 
 h:Si^^' 
 
4i8 
 
 DISEASES OF THE SKIN. 
 
 is 
 
 
 admitted that its utility in limiting the spread of the disease is 
 very doubtful. 
 
 In the early stage of the inflammation, the application of 
 cloths wrung out in ice water, or of the ice itself, will often be 
 grateful to the patient, though it has probably no influence in 
 arresting the disease ; after the first day or two, cloths w ung out 
 in hot water will usually be found more agreeable to the patient 
 than the ice. 
 
 Redness— (Erythema). 
 
 Several varieties of erythema are recognized, all characterized 
 by redness, without sivclliug of the skin. In simple erythema there 
 is a limited redness, occurring in spots or blotches, over which the 
 skm feels hot, and causes a somewhat painful sensation. These 
 red spots pers^s^ for some hours or days, though in exceptional 
 cases they disappear rapidly and reappear in other locations — 
 resembling the familiar " nettle-rash " in this respect. 
 
 Several varieties of erythema are occasionally found in wnich a 
 certain amount of swelling also occurs. The form which is called 
 erytJiana inidtifornic appears as spots and pimples from the size of 
 a dime to that of a quarter; these cause some itching and a burn 
 ing pain. The spots are almost invariably located on the back of 
 the hands and of the feet, or on the forearm and on the leg. They 
 last from two or three days to two weeks, and then disappear spon- 
 taneously. 
 
 The different forms of erythema occur almost e.xclusively in 
 individuals of rheumatic tendencies. Such persons are apt to 
 suffer at short intervals from repeated attacks of the rash in various 
 parts of the body. The disease occurs with especial frequency 
 late in the spring and early in the fall, and is more apt to affect 
 individuals who have not yet attained the twenty-fifth year, than 
 those in more advanced life. 
 
 While erythema exhibits this marked preference for rheumatic 
 individuals, it may ^>^ brought on in others by errors of diet and 
 by exposure to cold ; it occurs, also, wheiever the skin is irritated 
 by acrid discharges. It seems to occur, also, with considerable 
 
NETTLE-RASH — URTICARIA. 
 
 419 
 
 frequency in dibilita'iied individuals, and in those who suffer from the 
 green sickness and from dyspepsia. 
 
 Treatmetit, — In most cases the inconvenience caused by 
 erythema is so trifling that the individual prefers to endure the 
 disease rather than be troubled with treatment. Yet in every 
 case the patient should take such measures, by attention to his 
 general health, as will prevent the recurrence of this annoying 
 affection. If debilitated he should take a tonic, consisting of 
 quinine and iron, according to the follo>Ying formula : 
 
 Reduced iron, _ _ - - Twenty grains. 
 
 Sulphate of quinine, - - - Thirty grains. 
 
 Extract of nux vomica, - - Four grains. 
 
 Mix and make tM'enty pills ; take one morning and night. 
 
 If the patient be inclined to rheumatism, he should adopt the 
 
 treatment which is recommended in the discussion of that disease. 
 
 Locally it is rarely necessary to make any applications ; yet, 
 
 if the pain and sensation of burning be severe, one of the following 
 
 lotions may be applied : 
 
 Laudanum, .... Half an ounce. 
 
 Lead-water ----- Four ounces. 
 Mix and apply by means of soft cloths, which may be bound upon 
 the affected part. 
 
 If this fail to give relief, the ibllowing mixture may be used: , 
 Boracic acid, - - - . Four drachms. 
 
 Alcohol, - - - - - Eight ounces. 
 
 This lotion may be applied in the same way as was directed 
 for the preceding. 
 
 Nettle-rash— (Urticaria . 
 
 Nettle-rash, also called hives, seems to be somewhat allied to 
 the rash just described, erythema. It appears in the shape of 
 elevated patches, or " wheals," which are of irregular shape, flat 
 upon the top, hard, and usually of a pale red color ; in some cases, 
 however, the elevated portion of the skin is whiter than that which 
 sunounds it. In general, the larger ones are light in the middle 
 and red at the circumference, while the smaller ones arc pale red. 
 
 !» .1 
 
 \i ! 
 
 i 
 
 \ 'i.U 
 
 fi! 
 
 I'M 
 
'^ J 
 
 \% 
 
 ^ i 
 
 
 Siiilij 
 
 ] ' 
 
 !r 
 
 1 
 
 
 
 
 i 
 
 * 
 
 1 
 (1 
 
 
 
 
 ' 
 
 u 
 
 ii 
 
 i 
 
 i 
 
 
 1 
 
 420 
 
 niSEASKS OF THE SKIN. 
 
 The rash may also appear in the shape of stripes, either straight 
 or of a serpentine shape. These patches itch intensely, and may 
 be accompanied by some burning pain. 
 
 The rash may appear on any part of the body ; when it is 
 developed on the face the skin may swell enormously, so as to alarm 
 the individual extremely. In most cases there is no constitutional 
 disturbance aside from the irritation caused by the itching ; in sonic 
 cases there is, on the other hand, slight fever. 
 
 Nettle-rash in the adult differs somewhat from the same rash 
 as it appears in the child. In the adult the wheals are well marked 
 and disappear completely, leaving no trace of their presence. In 
 the child the wheals arc usually not so distinct, and are often fol- 
 lowed by the appearance of little pimples. These may persist for 
 days and are called by a separate name — lichen tirticntus. 
 
 The wheals rarely persist for more than a few hours, and often 
 disappear in a comparatively few minutes. The rash usually ap- 
 pears in the morning, disappears before n-^on, and perhaps is seen 
 agian once or twice in the course of the day. It is apt to recur on 
 the following day, and perhaps daily for a week. 
 
 Nettle-rash occurs most frequently in women and children, li 
 is often the result of some indiscretion in diet. Oysters, fish, 
 pickles, honey and strawberries are among the articles which seeni 
 especially apt to induce an attack of urticaria. Certain medicines 
 also occasion nettle-rash in some individuals. Thus it has been 
 known to follow the use of turpentine, copaiba, chloral and mor- 
 phine. Some individuals learn by experience to avoid certain arti- 
 cles of food and certain drugs, knowing the indulgence in them is 
 followed by an outbreak of nettle-rash. 
 
 Urticaria also follows the irritation caused by vermin in the 
 clothing and the itch. In fact, long-continued irritation of the skin 
 from any cause may induce an attack in an individual predisposed 
 to it. 
 
 Nettle-rash also appears as an accompaniment of several con- 
 stitutional diseases ; among these affections are catarrh of the stom- 
 ach and of the bowels, jaundice and Bright's disease of the kidneys. 
 It has also been observed during the course of typhoid fever, of 
 rheumatism and of intermittent fever. 
 
 Treatment, — The treatment of nettle-rash will depend alto- 
 gether upon the cause. If it have resulted from eating oysters, 
 shell fish, or the like, the most expeditious method of treatment 
 
NETTLE-RASH — URTICARIA. 
 
 421 
 
 consists in an emetic. For this purpose a teaspoonful of mustard 
 in a glass of hot water may be given. If it can be traced to any 
 derangement of the internal organs, such as catarrh of the stomach, 
 the latter must, of course, receive appropriate treatment. If none 
 of these causes be present, a careful search for bed-bugs, fleas and 
 oiher skin irritants, should be instituted. While an acute attack of 
 urticaria is in most cases easily disposed of, the chronic form in 
 which the individual is tormented at short intervals and for days at 
 a time with frequent attacks of nettle-rash, is a very troublesome 
 affection. It is often impossible to cure such a nettle-rash until some 
 disorder of the liver, or stomach, or uterus, which may be present, 
 is permanently relieved. In every case the patient should for sev- 
 eral days use only bland diet, especially milk, starchy articles, such 
 as arrow root, corn-starch, and the like, and should avoid eating 
 much meat or the use of condiments. He should also keep the 
 bowels active by means of saline laxatives, such as the ordinary min- 
 eral waters, the citrate of magnesia, or epsom salts. 
 
 Numerous remedies have been recommended for the relief 
 of nettle-rash. Among these are the following : 
 
 Sulphate of atropia, - Two grains. 
 
 Distilled water, - Half a drachm. 
 
 Glycerine, - - Half a drachm. 
 
 Gum tragacanth, - Enough to make twenty pills. 
 Take one morning and night. Another prescription is the .ol- 
 lowing : 
 
 Strychnine, - . _ - _ One grain. 
 
 Peppermint water, - - - - Six ounces. 
 Take a teaspoonful twice daily. 
 
 In most cases it will be desiraole for the patient to take Fow- 
 ler's solution internally and to employ alkaline baths. The pre- 
 scription may be written as follows : 
 
 Fowlers solution, . - - Three drachms. 
 
 Syrup of orange peel, - - Two ounces. 
 
 Water, ----- Two ounces. 
 
 Mix and take a teaspoonful before meals. 
 
 An alkaline bath is made by adding from five to ten ounces of 
 the bicarbonate of soda, or four ounces of borax to an ordinary 
 bath containing twenty-five gallons. The patient may He in this 
 for fifteen or twenty minutes, the water being kept at a temperature 
 
 as 
 
 MA 
 
 ■M 
 
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 422 
 
 DISEASES OF THE SKIN. 
 
 of about 90 degrees F. In the intervals between the baths, one 
 of the following lotions may be applied to the itching skin : 
 
 Dilute hydrocyanic acid, - - One drachm. 
 
 Solution of the acetate of ammonia, - Two ounces. 
 
 Rose water, . .. - - Four ounces. 
 
 Soft cloths may be wet with this and applied to the skin. 
 
 Cyanide or potassium, . _ . Five grains. 
 
 Cold cream, _ . - _ - One ounce. 
 
 Mix and apply directly to the skin. This is an extremely 
 poisonous mixture, and should be carefully guarded from careless 
 hands ; it would be better to keep it in a dark place. 
 
 Benzoic acid, - _ . . Fifty grains. 
 Water, . . _ . - Six ounces. 
 
 This may be applied upon moist cloths. 
 
 A similar course of treatment may be employed for children ; 
 out it is usually necessary to use an extremely bland ointment, 
 since the child's skin is especially tender. For children the follow- 
 ing lotion may be used : 
 
 Oxide of zinc. 
 Calamine powder. 
 Glycerine, - - - 
 Rose water, 
 Apply by means of soft cloths. 
 
 Two drachms. 
 Half an ounce. 
 Two ounces. 
 Four ounces. 
 
 Lupus. 
 
 This name, which means " wolf," is applied to a disease which 
 attacks the skin in early life, lasts for years, and finally destroys a 
 considerable portion of the skin. 
 
 It begins as small yellow or red points which project some- 
 what above the surface of the skin, and are usually arranged in 
 groups. They occasion no itching or pain. After a time those 
 points become ulcerated — that is, raw — at the top ; this ulceration 
 slowly increases in extent and often includes several of the pimples 
 iii vvhich the disease began. After the ulcer has attained a certain 
 size it begins to heal at one side, while it is constantly extending 
 
LUPUS. 
 
 423 
 
 in other directions. The scar which is formed as the ulcer heals is 
 at first red, but gradually becomes white and shiny. 
 
 This form of lupus usually begins during childhood, and 
 although it may affect any part of the body it is especially common 
 on the face. Its favorite seat is at the angle of the nose, or just 
 below the eye ; it may also begin around the ear. As the disease 
 progresses, the nose — if this be the part first affected — is gradually 
 destroyed ; the sore becomes covered with thick dark crusts, which 
 often close the openings of the nostrils. Bleeding from the nose is 
 an occasional symptom. The disease spreads backward along the 
 nostrils, and may affect the palate as well. The disease may also 
 attack the upper lip as well as the nose ; the lip becomes very 
 thick and everted, so that the patient loses control of the lips to a 
 certain extent and cannot articulate distinctly, nor take his food 
 with comfort. In time the gums are attacked, become soft and 
 bleed easily ; finally the teeth are loosened and fall out. In bad 
 cases the entire cavity of the mouth is a mass of ulcers. The 
 disease may progress and attack the larynx, in which case the voice 
 becomes hoarse or is altogether lost. 
 
 Lupus may affect other parts of the body also ; next to the 
 face, the legs are most frequently the seat of the disease. We 
 sometimes see cases in which the leg, almost all the way from the 
 knee to the ankle, is covered with lupus scars, composed of thin, 
 smooth, glistening skin, while somewhere on the surface there will 
 be an open ulcer surrounded by the characteristic pimples. 
 
 Lupus may also affect the eyelids, the ear and the genitals. It 
 rarely occasions any considerable loss of substance — that is, ulcer- 
 ation — until it has existed for several years. 
 
 No one but a practiced physician will be able to distinguish 
 lupus from several other affections which present an appearance to 
 that of this disease Syphilis often causes ulcers which can scarcely 
 be distinguished by their appearance, though the distinction can 
 be made by the duration of the disease, for syphilis progresses far 
 more rapidly than lupus ; in a few months syphilis can cause an 
 ulcer as large as that which would be produced by lupus in as many 
 years. In other cases it becomes very difficult to distinguish lupus 
 from a form of cancer which affects the skin. The recognition of 
 ihc disease, therefore — the diagnosis, as it is technically called 
 can be made by a physician only, and usually only by one especially 
 familiar with diseases of the skin. 
 
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 s (t 
 
 1^ 
 
424 
 
 DISEASES OF THE SKIN. 
 
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 One ounce. 
 One ounce. 
 Two ounces. 
 
 Four drachms. 
 Two drachms. 
 Four ounces. 
 
 Treatment. — In many cases sufferers from lupus are evi- 
 dently scrofulous, and need the treatment which is required by 
 scrofulous patients. For this purpose cod liver oil may be given, 
 a teaspoonful at first, the quantity being gradually increased to a 
 tablespoonful or two three times a day. Children may also take 
 with advantage the following prescription : 
 
 Syrup of the iodide of iron 
 
 Glycerine, _ . . _ 
 
 Water, 
 
 Mix, and take a teaspoonful after meals. 
 
 If the individual be not of a scrofulous habit, he may take the 
 following prescription : 
 
 Iodide of potassium, - - - 
 
 Fowler's solution, - - - 
 
 Syrup of sarsaparillc., 
 
 Mix, and take a teaspoonful before meals. 
 
 The most important of the treatment is usually the local appli- 
 cations. These vary according to the severity of the case. If 
 there be but little ulceration, the mercurial ointment may be 
 applied by smearing it upon soft cloths which are then laid upon 
 the diseased surface. This should always be tried in the treatment 
 of lupus in children. If this do not succeed, the following mixture 
 may be prepared : 
 
 Iodine, ------ One drachm. 
 
 Iodide of potassium, - - - - Two drachms. 
 
 Glycerine, ------ Three ounces. 
 
 This may be painted upon the ulcerated surface and its vicinity 
 three times a day. 
 
 Another valuable application is chrysophanic acid, which may 
 be used in the form of an ointment ; 
 
 Chrysophanic acid, - - - - Two drachms. 
 
 Vaseline, - ----- One ounce. 
 
 This may be applied directly to the ulcerated surface. 
 
 Cases are found in which all these applications prove ineffectual. 
 In such instances there are several measures to be employed, any 
 one of which can usually be relied upon to secure a good result. 
 The first of these is the use of what is called the " sharp spoon," 
 an instrument by which the diseased surface can be thorou^^hly 
 rasped and the tissue removed. Such treatment must, however, 
 be used only by the physician. 
 
IMPETIGO. 
 
 425 
 
 Mollusoum. 
 
 This affection is an enlargement of the sebaceous or oil glands 
 of the skin, which become distended by an accumulation of matter 
 in their cavities. These distended glands may become as large as a 
 pea or even as a hazel nut ; the top is flattened and the center usu- 
 ally somewhat depressed. When the tumor is compressed a whit- 
 ish cheesy mass — the accumulated secretion of the gland — escapes. 
 
 These little tumors occur especially on the face, on the eye- 
 lids, on the neck and on the hands- sometimes they are solitary, but 
 are often arranged in groups. They usually occur in children, and 
 have been supposed to be contagious, since the occurrence of one 
 on the hand of a child is apt to be followed by the appearance of 
 similar growths on the skin of its playmates. Yet numerous 
 efforts to inoculate an individual with the contents of these tumor*; 
 have failed, and it seems doubtful whether they are really con- 
 tagious. 
 
 Ti'eatnient. — In many cases these little tumors wither away 
 spontaneously, in other instances they become inflamed and mat- 
 ter is formed around them, as a result of which they are ultimately 
 destroyed. They can be readily removed in any one of several 
 ways ; their contents may be squeezed between the thumb nails, 
 and the interior of the sac can be destroyed by touching it with a 
 stick of lunar caustic, or the little tumor maybe snipped out with a 
 pair of scissors. 
 
 vl 
 
 Impetigo. 
 
 This affection consists in a rash composed of little blisters full 
 of matter. It attacks children almost exclusively. The rash 
 occurs chiefly on the face and head and after these parts most fre- 
 quently on the hands. The pustules vary in size from that of a 
 pin's head to that of a pea. They are usually scattered and quite 
 distinct from one another, though sometimes running together and 
 making a blister as large as a dime. The matter soon dries up into 
 a yellow scab, which projects above the surface and looks as if it 
 were stuck onto the skin. The skin around the pustules is not red 
 nor swollen. 
 
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 1! y i 
 
 w, I 
 
 426 
 
 DISEASES OF THE SKIN. 
 
 ■ ! 
 
 The disease is usually ushered in by a slight fever ; aside from 
 this there is no constitutional disturbance. Each of these little pus- 
 tules runs a definite course lasting eight or ten days; at the end of 
 this time the scab falls off leaving a red surface, which after a few 
 days has entirely healed. 
 
 The disease occurs in consequence of general disease such 
 as small-pox and child-bed fever ; but is more frequently in- 
 duced by external irritation of the skin, such as is caused by the 
 itch mite and by lice. It may also result from the application of 
 irritating substances, such as croton oil. In bad cases which are 
 long neglected, the removal of the scab may be followed by the 
 formation of deep and obstinate ulcers. In some cases the irrita- 
 tion caused by this rash leads to violent scratching, as a result of 
 which eczema is developed. 
 
 Tfeatment, — The scabs may be removed by oiling the skin 
 with sweet oil, or by soaking the patient in a warm bath. After 
 they have been thus removed, the following ointment or lotion 
 should be applied night and morning for three or four days, to the 
 raw surface beneath : 
 
 Ammonia (chloride of mercury), 
 
 Simple ointment; . - - 
 Or the following lotion may be used : 
 
 Sulphate of zinc, - - . 
 
 Corrosive sublimate, 
 
 Water, 
 
 Another good application for this purpose is the ordinary 
 diachylon ointment. 
 
 The pustles of impetigo are contagious ; that is, when the 
 matter is communicated to another individual, or to other parts of 
 the skin on the same individual, similar pustles are formed. This 
 fact should be remembered in handling and treating these cases. 
 
 Five grains. 
 One ounce. 
 
 Eight grains. 
 Six grains. 
 Four ounces. 
 
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 II 111* 
 
 Ecthyma. 
 
 Ecthyma differs from impetigo in the size of the pustules, and 
 in the fact that the skin around them is inflamed and swollen The 
 pustules are as large as the finger nail or even more extensive. 
 
ECHTYMA. 
 
 427 
 
 They are covered by thick, dark crusts, which adhere firmly to the 
 sore underneath, and when removed leave red, raw patches. The 
 skin around the crust is thickened, elevated, red and painful. 
 
 These sores may develop anywhere upon the body, but are 
 especially often met with on the lower limbs. The disease usually 
 occurs in poorly nourished individuals ; in fact it is rare among the 
 better classes of people. In many cases disease results from the 
 presence of parasites in the clothing or in the skin ; indeed the 
 majority of cases of eczema are due to the itch or to body-lice. 
 
 Treatment, — In every case attention should be directed to 
 the condition of the clothing and of the skin ; the possibility of the 
 occurrence of parasites, even when unsuspected, may not be for- 
 gotten. The removal of these will be in such instances sufficient to 
 cause the ecthyma to disappear. 
 
 In case no parasites can be detected and the individual ap- 
 pears debilitated, tonics should be administered, and regular evac- 
 uations of the bowels should be secured. For this purpose the 
 following prescription may be given: 
 
 Sulphate of magnesia, - 
 Sulphate of iron, 
 Dilute sulphuric acid, - 
 Infusion of quassia, 
 
 Mix, and take two teaspoonfuls before meals. 
 
 If the patient exhibit signs of scrofula, he may take in addi- 
 tion a teaspoonful of cod liver oil after meals. 
 
 For the local treatment of the sores the following plan may be 
 adopted: The scabs should first be removed by immersing the 
 patient for fifteen or twent)- minutes in a warm bath, whereby they 
 become softened and can be more readily detached. The ulcers 
 which are left can then be dusted with powdered iodoform twice 
 daily, until they have lost the original foul appearance, and show a 
 clean red base. Instead of the iodofo m the following formula 
 may be used for the same purpose: 
 
 Powdered starch, - - - - One ounce. 
 Glycerine, - _ . _ _ Three ounces. 
 Water, ------ Four ounces. 
 
 Boil these together, and when the mixture is nearly cold, add 
 
 Three drachms. 
 Forty grains. 
 One drachm. 
 Eight ounces. 
 
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428 
 
 DISEASES OF THE SKIN. 
 
 one ounce of the tincture of iodine. After the sores are cleansed 
 they may be dressed twice a day with the following: 
 
 Mercurial plaster, One ounce. 
 
 Soap plaster, - ... - One ounce. 
 
 Mix, and apply upon soft cloths. 
 
 Another excellent ointment for these sores is the following: 
 
 Camphor, 
 Pitch, - 
 Yellow wax. 
 Red oxide of lead, 
 Olive oil, 
 
 Half a drachm. 
 Four drachms. 
 Ten drachms. 
 Two ounces. 
 Four ounces. 
 
 These are to be melted together and applied upon cloth. 
 
 Lichen. 
 
 i^ll ! 
 
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 This is a very frequent disease in childhood, and one which 
 gives parents as well as children much annoyance. It consists of a 
 rash of small pointed pimples about as large as millet seeds, which 
 are usually found on the outer surfaces of the limbs and on the 
 back, though the rash may extend over the entire body, including 
 the face. 
 
 Lichen is characterized by its extreme itchiness, a feature 
 which gives the patient an amount of annoyance and torment quite 
 out of proportion to the apparent insignificance of the eruption. 
 Sometimes the rash is localized in limited parts of the body ; thus 
 it may appear on the back of the hands only ; at other times it 
 affects the wrists and the front of the forearms. 
 
 Sometimes the pimples become considerably larger, and flat- 
 tened upon the top. These pimples are extremely uncomfortable, 
 since they cause the patient to scratch the skin incessantly. When 
 these pimples disappear, they leave brown stains upon the skin 
 much resembling freckles. This variety is somewhat unusual, and 
 from the flatness of the pimples is called lichen planus. 
 
 The rashes which often appear upon children during nursing 
 or teething, and which are known by various popular names — 
 "red gum," "tooth rash," etc., — are forms of lichen. Another 
 common variety of lichen is what is known as " prickly heat," with 
 which all are familiar. Still another variety is seen in the form of 
 
li m 
 
 FISH-SKIN DISEASE. 
 
 429 
 
 pimples around the hairs on the arms and legs. This form of the 
 disease seems to result from insufficient bathing, but causes the 
 patient no annoyance. 
 
 The treatment of lichen varies extremely. In nearly all cases, 
 except the " prickly heat," it will be found that there is some de- 
 rangement of the internal organs, upon which the skin rash depends. 
 Thus the rashes which appear upon children during nursing, are 
 usually due to an impropt r quality of food ; they occur especially 
 often upon bottle-fed children and upon infants who are but poorly 
 cared for. 
 
 In every case it will be necessary to see that the digestive 
 organs are kept in good condition ; the diet should be bland and 
 unirritating, consisting of milk, eggs and vegetables, to the ex- 
 clusion of meats and condiments. Regular evacuation of the bowels 
 should be secured by the use of some saline cathartic, such as a 
 tcaspoonful of the citrate of magnesia. 
 
 For the treatment of the skin itself the patient may have an 
 alkaline bath. This may be prepared by adding six ounces of 
 baking soda to twenty gallons of water, which is to be kept at a 
 temperature of 90 deg. F. This bath may be repeated morning 
 and night. In obstinate cases the following formula may be used : 
 
 Precipitated sulphur, - - - Two ounces. 
 
 Hyposulphite of soda, - . . One ounce. 
 
 Dilute sulphuric acid, - - Half an ounce. 
 
 Water, - - - - One pint. 
 
 Mix, and apply to the skin by means of a soft cloth three or four 
 times daily. 
 
 In many cases it will become necessary to administer arsenic 
 in some form ; the most convenient and desirable will be Fow- 
 ler's solution, which may be given in the following prescription : 
 
 Fowler's solution, _ . . Three drachms. 
 
 Tincture of the chloride of iron, - Six drachms. 
 
 Tincture of quassia, - _ - To make four ounces. 
 Mix, and take a teaspoonful before meals. 
 
 Fish-skin Disease. 
 
 This affection, technically known as icthyosis, is so called 
 because the skin is arranged in the shape of large crusts, sometimes 
 overlapping one another, and thus resembling slightly the scales of 
 
u 
 
 \l ■ ' 
 
 430 
 
 t DISEASES OF THE SKIN. 
 
 k I: 
 
 a fish. In many cases this resemblance to fish scales is rather 
 imaginary ; the actual appearance of the skin suggests rather ;i 
 layer of dried mud which has been caked upon different parts of 
 the surface. These cakes or scales project somewhat from the 
 surface of the skin, and are thickest and most abundant upon the 
 outer surfaces of the legs and of tlie arms. Sometimes only a 
 limited portion of the skin will be affected ; at other times almost 
 the entire body, trunk and limbs present this remarkable appear- 
 ance. 
 
 Cases of fully developed icthyosis are rare ; but a milder form 
 of the affection, which is known as xeroderma, or parched skin, 
 is not uncommon. In these cases the skin does not present the 
 dirty appearance characteristic of the fish-skin disease, but looks 
 simply dry and parched ; the individual perspires very little, and 
 the skin is easily chafed. The sensibility of the skin is apt to be 
 impaired in this disease. 
 
 Icthyosis is a congenital disease ; that is to say, it is devel- 
 oped in the infant soon after birth without the occurrence of any 
 perceptible cause. Yet it often occurs in individuals wliose 
 parents have never suffered from a similar affection. 
 
 Treatment. — The disease is, so far as known, absolutely 
 incurable. Yet much can be done to relieve the discomfort attend- 
 ant upon it and to prevent further progress. For this purpose the 
 skin may be kept soft and flexible by means of free itpplication uf 
 sweet oil or lard, and by frequent alkaline baths, each of which 
 shall contain six or eight ounces of baking soda. The excessive 
 use of soap should be avoided, since it tends to aggravate the 
 condition. 
 
 Enf,- 
 
 
 I ' > i 
 
 id I 
 
 Leprosy. 
 
 This disease has at the present time an historical interest rather 
 than immediate practical importance; in the United States espe- 
 cially the disease is very rare, so that a case of it is an object ol 
 extreme interest to physicians. Nearly all the cases of leprosy 
 which are observed in the United States have been imported direct 
 from some of those localities where the disease still exists ; the 
 great majority of cases observed in the northern part of the 
 
 feli 
 
LEPROSY. 
 
 431 
 
 United States, at least, occur in Swedes, Norwegians and Danes 
 will) have contracted the affection in their mother countries. 
 
 It seems to be generally agreed that the disease known as 
 leprosy to-day is the same as the leprosy of the Scriptures. Yet 
 it is probable that the term leprosy, as used in the Bible, included 
 several distinct diseases of the skin. Thus several individuals are 
 described as being "as white as snow;" since this appearance is 
 not presented by leprosy, but is a frequent occurrence in psoriasis 
 (" dry tetter") it seems probable that the latter affection was desig- 
 nated. 
 
 The disease now known as leprosy has certainly been in exist- 
 ence and has been recognized as such since 1500 K. C. The first 
 accotmts that we have of it indicate that it originated in Egypt. In 
 Persia the disease was known in the sixth century li. C. ; it seems 
 to have appeared first in Greece and Italy in the first century B. C. 
 From these countries it spread over the greater part of Europe; 
 for a long while — several centuries — it was quite common in the 
 Italian Peninsula; it seems to have migrated with the Romans to 
 Spain, where it flourished for hundreds of years, and can indeed 
 be found at the present time. In the fifth century of the Christian 
 era leprosy was a common disease in Germany, Switzerland and 
 Flanders. In the twelfth century the disease was a familiar one in 
 England, Scotland and Ireland. 
 
 In most of the countries named leprosy gradually disappeared, 
 so that it is now a comparatively rare disease, except in Spain ; 
 but in Sweden and Norway, where it seems to have made its 
 appearance later than in other European countries, there is still a 
 considerable number of cases. It is supposed that the Crusaders 
 were the agents in bringing back a considerable stock of the disease 
 from Palestine. 
 
 At the present day leprosy is common in certain parts of 
 South America — Uruguay, and Guiana for example — in Mexico, 
 especially among the Indian races ; in certain other parts of Central 
 America and in Brazil. The disease is also found at the eastern 
 end of the Mediterranean Sea, along the shores of the Red Sea, 
 and at points around almost the entire coast of Africa ; it is found 
 in Abyssinia, in Soudan, at the Cape of Good Hope, in Sene- 
 gambia, in Morocco and Algiers. In the southern part of Asia 
 the disease is also quite prevalent ; the various provinces of the 
 British Empire in the East Indies contain many cases of it; thus 
 
432 
 
 DISEASES OF THE SKIN. 
 
 within two years two hundred and twelve cases of leprosy were 
 treated in the hospital at Madras. In numerous islands of the 
 Pacific the disease is also at home, notably in the Sandwich Islands ; 
 and it seems to have been transported thence to Australia, where 
 it was unknown until 1848, but is now quite prevalent. 
 
 Many cases of leprosy are found also in Japan and in Chin.-' 
 where hospitals for the reception of sufferers from this disease iire 
 constantly full. 
 
 Cause. — Until quite recently the vast amount of study and 
 research which had been expended in studying the nature and 
 cause of leprosy seemed to have proved fruitless. It was ascer- 
 tained that certain climates, insufficient and injudicious diet, imper- 
 fect sanitary regulations, all contributed to the development of 
 the disease. It was found that leprosy occurred chiefly on the 
 sea coast, and was rare in the interior, especially in mountainous 
 regions ; yet this was true of cold as well as of warm climates. It 
 was assumed that the disease might be contracted from the con- 
 sumption of stale fish, since it occurred with especial frequency 
 iimong those whose diet consisted largely offish. In some regions 
 turtles were held responsible for the occurrence of the disease ; in 
 others the affection was ascribed to the fat of hogs. Yet these 
 were mere assumptions, and have never been supported by facts 
 of observation. 
 
 It was also ascertained beyond question that there was a 
 decided hereditary tendency to the di;-oase, since it occurred far 
 more frequently in the children of leprous parents than in others. 
 
 In ancient times leprosy was regaiJcd as highly contagious; 
 the sufferer.s from it were distinguished by a particular garb, and 
 were not allowed to come into contact with other people. In some 
 parts of Germany, during the middle ages, leprosy patients wore 
 bells attached to their clothing, so as to warn others of their 
 approach ; they were permitted to go out of their hospitals at niiyht 
 only. They wore black clothing, and a broad white band on the 
 hat ; they carried a cane, with which they pointed out objects that 
 they wished to bu>', since it was unlawful for them to touch anything 
 that could be used by a healthy person. In other places it was the 
 custom whene .er an indivic''. u contracted the disease to announce 
 the fact with religioi . ceremonies ; at the conclusion of this for- 
 mality, a shovelful of earth was thrown upon his feer as a sign that 
 the persc.i was dead to the church and to tb ^ world ; begging was 
 
 Mj 
 
 h- ''' 
 
LEPROSY. 
 
 433 
 
 the only occupation permitted to the leprous patient. Haeser states, 
 in his " History of the Epidemic Diseases," that the city of Harlem 
 had the right to grant to healthy people the privilege of wearing 
 the costume of leprosy patients in order that they might carry on 
 the occupation of begging undisturbed. 
 
 In the last century or two the contagiousness of leprosy has 
 been much doubted, and it seems with reason ; for many cases of 
 the disease have occurred in different parts of the world in perfectly 
 healthy communities, where they have been permitted unrestrained 
 personal freedom, yet so far as known no instance has ever been 
 observed in which the disease has been communicated by such 
 individuals ; whence physicians have been inclined to the belief that 
 leprosy is really not contagious. 
 
 Such a conclusion neglects the fact, however, that in order that 
 a disease shall be contagious there must not only be something 
 capable of being transmitted from one individual to another, but 
 also an individual capable of receiving such contagious material. 
 It is doubtless true that leprosy is for all practical purposes not con- 
 tagious, since people nowadays are not susceptible to this particu- 
 lar contagion. Yet, that the disease can be communicated by con- 
 tact is abundantly proven by numerous instances which have been 
 observed in recent years in the various countries where the disease 
 is still prevalent. Hansen, for example, reports two cases in Ber- 
 gen, Norway, in which two nurses employed in the leprosy hospital 
 contracted the disease from patients. Another individual, whose 
 occupation brought him into frequent contact with leprosy patients, 
 acquired the disease ; shortly afterward his wife also became 
 affected. After the husband died, the wife married again, and her 
 second husband became afifected with the disease. 
 
 Milroy reports that a white boy stuck himself with a needle 
 with which a leprous child had previously played, and that the 
 former soon afterward exhibited signs of the disease. Yet that 
 the disease does not always result from contact with afflicted indi- 
 viduals, is shown by such instances as the following : Koebner 
 treated a patient 19 years old, sick with leprosy, whose father 
 remained quite healthy, although he had been married to two 
 women, each suffering from the disease. 
 
 Sumptonis. — For some time, amounting perhaps to months, 
 the ouhreak of leprosy is preceded by general debility, emaciation 
 and weakness. The onset of the disease is marked by fever, which 
 
 
 
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 1. 1 
 
 i';:,i 
 
 434 
 
 DISEASES OF THE SKIN. 
 
 lasts usually only two or three weeks. When the fever ceases an 
 eruption appears upon the skin. This eruption takes the form of 
 pimples somewhat resembling warts, though not fissured like the 
 latter. These pimples or tubercles, as they are called, usually ap- 
 pear first on the eyebrows and soon afterwards on the face, the ears 
 and the lower extremities. At first they are scattered, but soon 
 become thickly crowded together, so that the entire surface of the 
 skin, on the face and hands particularly, becomes a mass of little 
 tumors or tubercles. After a time similar tubercles appear in the 
 mucous membrane of the mouth, the throat and the eyes ; they 
 may also spread to the larynx, causing hoarseness, cough and loss 
 of voice. The result of ti .e growths is a most repulsive and 
 loathsome appearance of the face — an appearance which has been 
 described as like that of a lion, though the resemblance does not 
 seem especially striking. 
 
 Although leprosy is commonly referred to and described as a 
 disease of the skin, it is really a constitutional affection. For it 
 attacks not only the skin and the mucous membranes, but also the 
 internal organs. The nerves, especially in the 'extremities, are so 
 diseased that the patient after a time loses the sense of touch. The 
 muscles and other tissues, especially those constituting the joints, 
 .-re gradually eaten away and destroyed. The result of this is that 
 the joints of the fingers and toes dry up and drop off; in fact the 
 patient may lose in time an entire foot or hand. 
 
 The internal organs, including the brain and the organs of 
 digestion, are also attacked by the disease; and the result is sooner 
 or later necessarily fatal. 
 
 The duration of the disease is usually several years, rarely 
 more than ten or less than three. In many cases death results 
 from some acute affection — inflammation of the lungs, brain, bowels, 
 or kidney.s — which has nothing to do directly with the leprosy. 
 But these leprous patients are found to be unusually susceptible to 
 other diseases. Cases are known in which the patient recovers 
 spontaneously, the tubercles gradually disappearing; in some 
 instances the disease reappears after an interval of several months, 
 and may then lead to a fatal termination. 
 
 There is a second form of leprosy called ancesthetic leprosy, 
 because the nerves are early affected, and the patient soon loses 
 the sense of touch. In these cases the tubercles of the skin appear 
 in small numbers or not at all. Considerable portions of the skin 
 
yj^'S), .:S 
 
 BARBADOES LEG. 
 
 435 
 
 may become quite devoid of sensibility, so that the individual may 
 be cut or burned in those parts without suffering pain. This form 
 of the disease is less frequent than the other and lasts a longer 
 time ; patients have been known to suffer from twenty to thirty 
 years with this disease before death put an end to their sufferings. 
 
 Tt'catitient. — Nearly all the remedies known to physicians 
 have been used in the treatment of leprosy ; but none of them are 
 capable of curing or even arresting the disease. At different times 
 various remedies have been vaunted as successful; but further trial 
 has in every case shown the fallacy of this belief. The latest can- 
 didate for favor is cliauimoogra oil ; it remains to be seen whether 
 this will prove more effectual than other remedies which have been 
 tried and abandoned. 
 
 In the last few years it has been discovered that the tissues 
 and organs of leprosy patients always contain a certain minute 
 vegetable parasite ; that this organism is found all through the 
 body wherever the tissues are diseased. It has not yet been proven 
 l''at this parasite causes the disease, though it seems highly prob- 
 tblc ; nor it is yet known from what source this plant is derived, 
 nor how it gets into the body. 
 
 Barbadoes Leg. 
 
 This affection, which is also called " elephant leg," and techni- 
 cally ilcpliantiasis, consists, as the name implies, in an enormous 
 enlargement of the leg. This enlargement consists at first and in 
 large part merely of a thickening of the skin. It may occur also 
 ill other parts of the body than the leg, and affects especially often 
 the genital organs of both sexes. Sometimes a similar thickening 
 of the skin is observed in the female breast, in the ears and the 
 scalp. 
 
 The disease occurs over the entire world, but is most fre- 
 quently found in tropical regions. Among these localities is the 
 Island of Barbadoes — from which the affection derives one of its 
 names — Brazil, Japan and the East Indies. In Europe elephan- 
 tiasis occurs most frequently in France and in Ireland. 
 
 The disease rarely occurs before puberty, and most frequently 
 begins before the age of 30 years. 
 
43<5 
 
 DISEASES OF THE SKIN. 
 
 When the disease occurs upon the leg this member becomes 
 enormously swollen, smooth and shiny ; but there is not usually any 
 evidence of inflammation or pain. After a time the skin becomes 
 rough and covered with small pimples ; the extreme size of the 
 limb renders the patient unable to walk. In the course of the dis- 
 ease there finally occur extensive ulcerations of the skin which 
 resist treatment most obstinately. 
 
 Trenfnienf, — The disease may last for years without serious 
 impairment of the patient's health ; but in many cases the tissues 
 of the leg become mortified, and are often attacked by erysipelas 
 which may end the patient's life. 
 
 In the beginning of the illness the patient may be much im- 
 proved by rest in a recumbent position, and by wrapping the 
 limb in cloths wrung out in hot water. Yet the most reliable and 
 most rapid means for reducing the swelling is the bandage of iiuiia 
 rubber termed " Martin's bandage." When this is worn the patient 
 can continue his occupation without interfering with the cure of 
 the affection. 
 
 In cases where the disease affects the face or other parts that 
 cannot be subjected to the pressure of a rubber bandage, adxaii 
 tage may be derived from the use of the following lotion : 
 Iodine, . _ _ - - One drachm. 
 
 Glycerine, ----- Three ounces. 
 Mix, and apply to the thickened skin. 
 
 Advantage may also be derived from the use of the oiiitmcut 
 of the iodide of potassium. 
 
 rv 
 
 Pemphigus. 
 
 This disease is characterized by the occurrence of oval-shaped 
 blisters, which may vary in size from that of a bean to that of a 
 walnut. Each blister contains at first a watery-looking fluid; in a 
 short time the fluid becomes milky and then dries up, leaving a small 
 scab. These blisters may occur singly or in groups, and are found in 
 all parts of the body, and even on the mucous membranes of the mouth. 
 When the scabs are removed there remains either a raw surface or a 
 dark spot, but never a scar. 
 
 The outbreak of the eruption is accompanied with a cinll, 
 fever, headache and sleeplessness; the skin is the seat of a burn- 
 
PKMPHIGLS. 
 
 437 
 
 \nrt sensation, which is sometimes followed by extreme itchings. 
 There is rarely any considerable pain unless large areas of the skin 
 are attacked at once. 
 
 Pemphigus occurs with especial frequency in children, and 
 oftcncst in children of debilitated constitutions ; yet the disease is 
 sometimes observed in adults also. Several successive groups of 
 blisters are observed on the same patient, one set appears after 
 another has dried up. The duration of the disease varies extremely. 
 Sometimes it runs a rapid course, and is concluded in two to three 
 weeks ; in other cases it may persist for months or years. 
 
 When the disease becomes chronic, the patient is almost always 
 reduced to a debilitated condition. In this state he is very apt to 
 suffer from other diseases, especially inflammation of the kidnej's. 
 
 Pemphigus is one of the few skin diseases which sometimes 
 results fatally. .These fatal cases usually occur in poorly-nourished 
 and scrofulous children. 
 
 This disease is often observed in new-born children, where it 
 is found in large watery blisters on the palms of the hands and the 
 soles of the feet. Under these circumstances, it is almost without 
 exception an evidence of syphilis ; one or the other of the parents 
 having suffered from this disease. This form of pemphigus will 
 be discussed under the head of syphilis. 
 
 Ttu'Otinent. — In many cases it becomes necessary to use con- 
 stitutional treatment, since the individual's general health requires 
 improvement. For this purpose it will be well to administer the 
 following prescription : 
 
 Sulphate of quinine, 
 
 Tincture of the chloride of iron, 
 
 Syrup of orange peel, - 
 
 Water, .... 
 
 Mi.\,and take a te ispoonful before meals 
 
 tor an adult, and should be diminished for children. 
 
 The rash can be in most cases readily relieved by the use of 
 arsenic, which can be given in Fowler's solution, as follows : 
 I'owler's solution, - - - - Two drachms. 
 
 Water, ------ Four ounces. 
 
 Mix, and take a teaspoonful four times a day. 
 
 The comfort of the patient will be much enhanced, in those 
 cases in which the eruption is extensive, by immersion in a \\an« 
 
 29 
 
 One drachm. 
 Six diachms. 
 One ounce. 
 To make four ounces. 
 This is the proper dose 
 
 if . 
 
 IH" 
 
 el 
 
 \ 
 
 •S^> O 
 
438 
 
 DISEASES OF THE SKIN. 
 
 bath. This bath may consist simply of warm water, or there may 
 be added to it eight ounces of the bicarbonate of sodium. In the 
 skin hospital at Vienna, patients suffering from pemphigus arc 
 placed in baths prepared for the purpose, and are allowed to remain 
 there for days or weeks until the formation of blisters ceases. The 
 water is frequently changed ; the bath is provided with coverings, 
 and with a water pillow ; the patient takes his meals in the bath, 
 and, in fact, does not leave it until the cure is complete. Not 
 the least of the advantages of this permanent bath is the complete 
 relief from the itching which otherwise torments the patient ex- 
 tremely. If it be impossible to employ such a bath, the patient 
 should be wrapped in wet sheets, and the sore spots on the skin 
 may be dressed with the diachylon ointment. Sometimes the 
 sores are extensive and foul, and emit an offensive odor ; in this 
 case, there may be applied to them cotton-wool which has been 
 soaked in a five per cent, solution of carbolic acid in water. 
 
 Prurigo. 
 
 This is, in America, a rare disease, though in certain parts of 
 Europe it is most frequent and troublesome. It consists of small 
 elevations or pimples, from the size of a pin's head upward, and of 
 a pale red color. These pimples are very hard, and occasion an 
 intolerable itching. They occur chiefly on the lower limbs, espe- 
 cially below the knees ; in obstinate cases they are also found on 
 the arms and on the trunk. 
 
 At first the disease consists simply in this rash, but as time 
 elapses the constant scratching results in an inflammatory thicken- 
 ing of the skin which becomes hard and feels like a board. Another 
 result of the constant scratching is atliscoloration of the skin, which 
 assumes a brown color. The rash, in the early stages, can be felt 
 before it is seen ; it is only after it has endured a considerablt! time 
 that the pimples become sufficiently large to be seen. 
 
 In the course of time the glands in the groin and in the arm- 
 pits, if the arms also be affected, become enlarged and hardened, 
 A frequent result of the scratching is eczema of the leg, the result 
 of which is to increase still further the thickening of the skin and 
 the enlargement of the glands. 
 
 As to the cause of this disease, there is no definite inforina- 
 
PRURIGO. 
 
 439 
 
 tion ; it has been supposed to result from improper nourishment, 
 and from various affections of the nervous system ; it is also 
 observed that the children of consumptive parents are more fre- 
 quently affected than in those of others. Scrofulous children who 
 suffer from eczema (as they so often do) are very apt to have 
 prurigo of the skin in consequence. 
 
 The disease is, in most cases, congenital; that is to say, the 
 child manifests the beginning of it in the first year or two of 
 life. If treated early, it is often possible to cure the disease per- 
 manently ; but if allowed to go untreated until the child becomes 
 10 or 12 years old, the disease often resists all remedies. 
 
 Among children, prurigo occurs in all classes of society, the 
 well-to-do as well as the poor. Among adults, on the other hand, 
 it is confined almost exclusively to the poorer classes ; this fact 
 alone indicates that the persistence of the disease is favored by 
 neglect of sanitary conditions — a fact which is also illustrated by 
 other features of the disease. 
 
 Tveiltmetlt. — The treatment of the disease must always 
 begin with strict attention to the sanitary surroundings of the 
 patient. It will be necessary to give him the best nourishment and 
 care. Some cases have been much improved by residence at the 
 seaside. 
 
 As for the remedies to be used, reliance is chiefly placed upon 
 arsenic. This maybe given in the following prescription: 
 
 Fowler's solution, - - One and a half drachms. 
 
 Wine of iron, - - - Two ounces. 
 
 Simple syrup, - - One ounce. 
 
 Water, - - - - One ounce. 
 
 Mix. and take a teaspoonful after meals. 
 
 In the local treatment of the rash it becoi»r-e neces9«*r to 
 employ some means to relieve the intense itchin;;. For thi- f>ur- 
 pose alkaline baths a e useful. These may be made by addmg 
 eight ounces of the bicarbonate of sodati eighteen or -" nty gal- 
 lons of water. Sometimes much relief can be ( ht ifn , by oiling 
 the skin. For this purpose wc ni.i\ use either weot , ' or 
 
 cod liver oil, or the following:: 
 
 Pcrchloridc of mercur\-, 
 Dilute hydrocyanic acid, 
 Fmulsion nf almonds. 
 
 One gr. m. 
 One drachm. 
 Five ou 
 
440 
 
 DISKASES OK I'UE SKIN. 
 
 A simpler and often very efficient application to the skin is the 
 following: 
 
 Chloroform, ----- Two drachms. 
 Glycerine, ----- One ounce. 
 In adults the affection is usually incurable ; the most that can 
 be done is to relieve the itching and irritation of the skin. Yet the 
 disease involves no danger to life, and need occasion no anxiety on 
 that account. 
 
 I I, 
 
 i- L 
 
 I' I 
 
 11''' ^ 
 
 ill' 
 
 fffl 
 
 Itching —(Pruritus). 
 
 Itching of the skin is a symptom of numerous conditions and 
 diseases ; in fact, most of the skin affections are accompanied by 
 more or less itching. It is only those which are dependent upon 
 constitutional tainis — such as scrofula and syphilis — which arc 
 rarely accompanied by itching. 
 
 In most cases in which itching is felt at any part of the skin, 
 a cause can be readily discovered in some local irritation. This 
 may consist in parasites, such as the itch mite ; or it may e.vist 
 nierely in the form of an inflammatory rash. Yet there are many 
 cases in which intense and obstinate itching occurs in certain lim- 
 ited parts of the body, for which no cause for the sensation can be 
 discovered. We are all familiar with an occasional itchy sensation 
 lasting but a moment or two, which leads us to look intently at 
 some part of the skin, but without finding anything unnatural in 
 the appearance of the skin. Now, in some individuals, this itchy 
 sensation persists for days and weeks, localized in some limited 
 part of the skin, and yet unaccompanied by any rash or by cUiy 
 unnatural appearance of the skin or its surrounJings. It is thi^ 
 condition which is designated by the term pruritus. 
 
 This symptomatic itching is often most intense and anno\ing, 
 so that it may make life wretched for an individual who is appar- 
 ently in perfect health. In many cases the sensation is limited to 
 certain parts of the skin, to be presently described ; in other in 
 stances it is felt over a large surface, or even the entire bod\-. This 
 is especially apt to be the case with elderly people, so tlial the 
 disease is often called pruritus senilis — the itching of old age. In 
 some individuals this condition exists during the winter, while they 
 
ITCIIIN'C; — I'KUklTLS. 
 
 441 
 
 ,iii' free iVom it in warmer weather. In some cases doubtless, this 
 itching of the skin is favored by wearing flannel, yet it may occur 
 during the winter in persons who avoid the use of this article. In 
 still other cases the tendency to itch is greater during warm weather; 
 in these cases there seems to be no more apparent cause than in 
 the former instance. 
 
 Although this itchy feeling may be felt over a considerable part 
 of the body, or even over the entire skin, yet the cases are far 
 more frequent in which the sensation is limited to certain small 
 parts of the body. The parts most frequently affected are the geni- 
 tal organs of both sexes, the palms of the hands, the soles of the 
 feet and the skin between the thighs. 
 
 In these situations the itching is not constant, but occurs in 
 paroxysms, during which the patient is completely unfitted for 
 active employment, and is compelled to retire to the privacy of his 
 apartment and devote his entire attention to the relief of the itch- 
 ing. The attempt to relieve this feeling by rubbing or scratching 
 the skin, merely aggravates the difficulty and often induces the 
 appearance* of other symptoms as well. Thus one of the first 
 effects is eczema of the part, accompanied by deep fissures and 
 furrows in the skin ; in women, itching about the genitals often 
 causes unnatural sexual excitement. This itching in these parts 
 occurs in women with especial frequency during the change in life; 
 it is also a frequent occurrence in those who suffer from disorders 
 of menstruation and from diseases of the ovaries. It often 
 accompanies diseases of the womb and of the vagina, and is a 
 frequent result of the " whites;" when the latter condition has once 
 existed the itching may last for a considerable time, even after the 
 discharge has ceased. 
 
 In nearly all these cases the paroxysms of itching occur 
 especially at night when the patient has become warm in bed. 
 Itching between the thighs is often caused by the piles. 
 
 .\niong the general conditions which are accompanied by 
 itching over a large part of the skin, are chronic Bright's disease of 
 the kidneys and diabetes. The same symptom frequently accom- 
 panies diseases of the liver which cause jaundice, catarrh of the 
 stomach and inflammations of the womb. In all those cases in 
 which a careful search fails to reveal the presence of lice or 
 other local causes, the patient should be at once examined, to 
 ascertain the existence of one or another of these conditions. In 
 
 
442 
 
 DISEASES OK rHK SRIN. 
 
 •■kU] 
 
 i '« 
 
 J I 
 
 m 
 
 every case it should be remembered that itching will be followed 
 sooner or later by a rash on the skin, caused by incessant scratch 
 injf ; care must be taken not to mistake this rash, which is thi 
 result of the itching, for the cause. The first item in the treatment 
 of pruritus, whether it be confined to a part or spread over thr 
 entire skin, is an attempt to ascertain the cause. This is a far 
 more troublesome undertaking in many cases than one might 
 suppose. The first object of suspicion must always be animal 
 parasites ; even in our first families bed-bugs, fleas, and other 
 vermin are occasionally found ; the constant intercourse with other 
 people upon the streets, in public vehicles, etc., frequently leads to 
 the introduction of these parasites where they are least expected. 
 
 When the itching is constant, not occurring in paroxysms, but 
 increased at night by the warmth of the bed, it should excite sus- 
 picion of scabies or the " itch," and should lead to a careful search 
 of the skin between the fingers, on the wrists, and about the genitals. 
 Itching between the shoulders and on the back is often caused by 
 body lice; itching at the back of the head in children by head 
 lice. Itching between the thighs is often caused by eczema of 
 these parts, and in children by thread worms. Itching which 
 occurs suddenly and ceases abruptly, felt here and there about the 
 body, especially at night, but accompanied by no perceptible rasii. 
 may be due to any one of several causes — disorders of men- 
 struation or of the womb in women, nettle-rash, or one of the 
 general conditions which have been already mentioned — Brighl's 
 disease, diabetes, etc. 
 
 In case any of these causes can be discovered to explain the 
 itching, the treatment will naturally begin with the removal of the 
 cause, so far as this is possible. In addition, it is necessary to 
 employ remedies which will temporarily, at least, allay the itching, 
 since this will otherwise provoke scratching, and the scratching will 
 result in several additional difficulties, such as eczema. 
 
 To allay the itching the patient may take warm alkaline baths 
 once or twice a day. For this purpose four ounces of borax may 
 be dissolved in twenty gallons of warm water. In some cases bet- 
 ter results will be achieved by dissolving three ounces of sulphurated 
 potash in the same quanity of water. In many cases of itchini; 
 without appreciable cause, such as the itching of old persons aiui 
 that form of itchiness which occurs in many individuals in winter, 
 
 I'n i , 
 
ITCHINC. — PRURITUS. 
 
 443 
 
 relief can be obtained by an acid bath made by adding one ounce 
 of muriatic acid to twenty gallons of water. Several remedies 
 have been found useful as applications to the skin for the relief of 
 itchi.ig. The following formula; are given as examples : 
 
 Half an ounce. 
 Four grains. 
 Eight ounces. 
 
 Two drachms. 
 Four drachms. 
 Eight ounces. 
 
 Borax, - - - - - 
 
 Sulphate of morphia, 
 
 Rose water, - - - - 
 
 Mix and apply by means of a soft cloth. 
 
 Dilute hydrocyanic acid, 
 Borax, ----- 
 Rose water, - - - - 
 This is often especially useful in the itching of elderly people. 
 
 Cyanide of potassium, - - - Four grains. 
 Glycerine, ----- Two drachms. 
 Simple ointment, - - - - Two ounces. 
 
 When the skin is especially irritable the following mixture 
 may be used : 
 
 Extract of belladonna, - - - One drachm. 
 Dilute hydrocyanic acid, - Two drachms. 
 
 Glycerine, ----- Two ounces. 
 Water, ------ Four ounces. 
 
 Another formula which is often useful is the following : 
 
 Camphor, 
 Oxide of zinc, 
 Powdered starch, 
 
 One drachm. 
 One ounce. 
 One ounce. 
 
 Mix and dust upon the part. 
 
 Borax, - . - - - 
 
 Carbonate of soda, - - - 
 Dilute hydrocyanic acid, 
 
 Glycerine, - - . . 
 
 Water, - - . - 
 
 In all cases of obstinate itching care should be taken that 
 the clothing over the part is as unirritating as possible ; hence no 
 flannel should be worn next the skin, and the underclothing 
 should be frequently changed, especially if the individual perspire 
 freely. 
 
 One drachm. 
 Two drachms. 
 One drachm. 
 Two ounces. 
 Four ounces. 
 
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IMAGE EVALUATION 
 TEST TARGET (MT-3) 
 
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 WEBSTER, N.Y 14580 
 
 (716) 872-4503 
 
 

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 444 
 
 DISEASES OK THE SKIN. 
 
 Condylomata. 
 
 . i I 
 
 i 
 
 w. 
 
 These are small tumors, often looking like exaggerated warts. 
 These are two varieties, which it is important to distinguish from 
 each other, because of the difference in their nature. 
 
 The first of these varieties is composed of slender pointed 
 projections of the skin, which usually rise not more than a quarter 
 of an inch above the surface of the skin, but may attain a much 
 greater length. They occur usually in groups, but sometimes 
 separately. They are covered with natural skin, and present no 
 differences in appearance from the rest of the skin. They are 
 found almost exclusively around the orifices of various openings of 
 the body, especially around the vagina and rectum ; they are 
 located usually at the junction of the skin and mucous membrane. 
 
 This variety of condyloma, called the pointed condyloma, is 
 caused by irritating discharges, or by lack of cleanliness. They do 
 not necessarily indicate any venereal disease, though they are 
 especially often found in those addicted to excessive indulgence 
 They may occur as a result of a simple leucorrhcea, or even with- 
 out this cause. 
 
 The treatment consists simply in snipping them off with a pair 
 of scissors, and in applying a stick of lunar caustic to the base after 
 removal. This plan answers perfectly well, except where the con- 
 dylomata are arranged in large groups, so as to cover a considerable 
 surface. In this case removal with the scissors is apt to be followeci 
 by considerable bleeding, and the matter should not be undertaken 
 by any but a professional hand. 
 
 The other variety of condylomata is composed of tumors 
 which differ from the preceding in their shape, size and nature. 
 They are flat upon the top, usually reddish or brownish in color, 
 and seem to be divided upon their surface into numerous pieces b_\- 
 furrows. They occur around the mouth, nose, and genitals ; tlu\' 
 are apt to secrete a thin, watery fluid, and sometimes produce con 
 siderable matter. These condylomata are of syphilitic origin, and 
 are highly contagions. Extreme care should be taken, therefore, to 
 prevent the entrance into the body of another personal dischaij,'e 
 or matter from these tumors. 
 
 The treatment of the syphilitic condylomata consists first in 
 careful attention to cleanliness, and second, in the treatment appro- 
 
SWEAF KASH — MILIARIA. 
 
 445 
 
 priate to syphilis. The latter part of the treatment will be dis- 
 cussed in the chapter on syphilis. Cleanliness may be attained by 
 frequent washing and by dusting upon the parts the powder of 
 calomel or powdered iodoform. In either case the tumors should 
 be covered with cotton, which may be fastened by means of a 
 bandage or adhesive straps. 
 
 Sweat Bash — ( Miliaria). 
 
 At any season of the year, but especially in the spring when 
 the weather becomes warm, there may often be seen numerous 
 minute watery blisters, not so large as pin heads, .scattered over 
 various parts of the body. This eruption may be limited to a small 
 part of the skin such as the hand, or may be visible over the entire 
 person. The rash causes no further annoyance than a slight itching 
 sensation which is not usually enough to induce violent scratch - 
 
 This rash consists merely in a stoppage of the sweat glands. 
 These arc minute bodies situated in the substance of the .ikin and 
 opening upon the surface by a very fine spiral tube or duct. Under 
 ordinary circumstances the secretion of the gland — the perspiration 
 — escapes upon the surface so soon as it is formed ; but in certain 
 conditions of the skin these tubes become stopped up, and the per- 
 spiration collects in the little ducts so as to distend them and form 
 the minute blisters above described. 
 
 This condition occurs usually after the patient has been per- 
 spiring profusely, and is therefore most frequently observed in the 
 late spring or early summer months ; yet it mav occur at any tini* 
 luring the year, in winter as well as ii\ summer. 
 
 In most cases the blisters do not increase in size beyond that 
 of a pin's head ; sometimes, however, they run together so as to 
 niiike vesicles an eighth or a quarter of an inch in diameter. After 
 a time the outer skin dries and peels off. For this reason the con- 
 dition is often mistaken for eczema ; but it can always be distin- 
 j;iiisheil by the fact that there is no watery discharge, or " weeping," 
 sucii as is always found in eczema. 
 
 Tfeuttneut. — This condition usually occurs in debilitated 
 individuals, and the treatment must, therefore, be directed to the 
 
 '^:\ 
 
446 
 
 DISEASES OF THE SKIN. 
 
 improvement of the general health. In some cases the patient is 
 decidedly gouty or rheumatic, and should have the treatment 
 specified in the chapters on these diseases respectively. Generally 
 speaking, it will be beneficial to administer some remedy which 
 will increase the secretion of urine, such as the following : 
 
 Acetate of potash, - - Three drachms. 
 
 Sweet spirits of niter, - - Two ounces. 
 
 Water, - _ . . - Two ounces. 
 
 Mix, and take a teaspoonful every four hours. If the patient be 
 very weak he should have a tonic remedy, such as the following 
 prescription : 
 
 Tincture of the chloride of iron, - - Six drachms. 
 
 Compound tincture of gentian, - - To make four ounces. 
 Mix, and take a teaspoonful in water before meals. 
 
 The skin should be soothed by the application of vaseline, and 
 advantage may be derived from the use of an alkaline bath, such 
 as is made by the addition of six ounces of the bicarbonate of 
 sodium to the water. Afterwards it may be advisable to use an 
 astringent ointment, such as the diachylon salve. 
 
 Piebald Skin. 
 
 
 
 :S 
 
 This condition, which is known as lettcoderma, consists in 
 an irregular, spotted, or patchwork coloring of the skin so that 
 large brown spots occur in the midst of skin of the natural color, 
 or unnaturally white spots are observed surrounded by natural 
 skin ; sometimes both variations from the natural color will bo 
 found side by side ; a very white spot will be surrounded by .i 
 margin of unusually dark skin. Sometimes these spots art- 
 arranged symmetrically on both sides of the body. It is often found 
 on the backs of the hands and on the neck. 
 
 This appearance of the skin is all the more remarkable when 
 it occurs, as it often does, in negroes ; in these cases light or even 
 perfectly white spots of different sizes are found on the body, and 
 often on the face. 
 
 The disease occurs among whites chiefly during or after resi- 
 dence in a torrid climate. It can generally be relieved in the course 
 
PITYRIASIS. 
 
 447 
 
 of time by the use of tonics and electricity to the spine. If there 
 be patches of unnaturally dark skin, these can sometimes be 
 removed by the daily application of the following : 
 
 Corrosive sublimate, - . . Two grains. 
 
 Water, ------- One ounce. 
 
 This may be rubbed over the spot by means of a soft cloth or piece 
 of flannel ; the application should not last more than two or three 
 minutes nor be made more than once per day. In fact, it is neces- 
 sary to be extremely cautious in the use of this powerful remedy 
 on the skin, as well as elsewhere. 
 
 Allied to this condition is that which is called, technically, albi- 
 nismus. This consists in an absence of the natural coloring matter 
 over the entire body ; an individual thus affected is called an albino, 
 a term derived from the Latin word albus, which means white. 
 Such individuals have a milk-white skin, silvery hair and pink 
 eyes ; the same condition is observed in white rabbits. The 
 curious fact about this is that a member of the negro race is some- 
 times a perfect albino — a " white negro " — while his brothers and 
 sisters may be as dark as the average African. 
 
 Pityriasis. 
 
 This term is applied to two different diseases ot the skin ; one 
 of these, which is caused by a parasitic plant, has been described 
 under the head of tinea versicolor. The other is a somewhat rare 
 disease which consists in an excessive shedding of scales from the 
 skin. It often begins as a single red scaly spot on some part of 
 the body and spreads rapidly, so as to cover the entire surface in a 
 comparatively short time. The skin becomes extremely red and 
 covered with scales lying one over another in large flakes. These 
 scales are gradually thrown off, sometimes as large pieces of skin ; 
 underneath the skin remains red and tender but not raw. The 
 skin is much less flexible and soft than in the natural state, so that 
 the movements of the patient's limbs are impeded ; he cannot bend 
 the knee nor the elbow with the same freedom as before. 
 
 The disease seems to be the result of defective nutrition • yet 
 it is not ascertained in what this defect of nutrition consists. The 
 
 )-\\ 
 
448 
 
 DISEASES OF THE SKIN. 
 
 affection is extremely obstinate, and may last for years. Some cases 
 seem to have been incurable. 
 
 Tt'eattnent, — In every case the patient's general condition 
 must be built up, and his strength supported by tonics. For this 
 purpose the following prescription may be employed : 
 
 Fowler's solution, ... Two drachms. 
 Tincture of nux vomica, - Si.x drachms. 
 
 Compound tincture of cinchona, - To make four ounces. 
 Mix and take a teaspoonful before meals. 
 
 The patient's skin must be kept soft by some ointment ; for this 
 purpose cod liver oil will be found useful. In recent years success 
 has been obtained by the use of the glycerolc of the acetate of lead. 
 This should be spread upon soft cloths, and these wrapped around 
 the patient's limbs, where they may remain until it becomes neces- 
 sary to renew the ointment. It may be necessary to persevere in 
 this treatment for several months before a cure is effected. 
 
 Bupia. 
 
 I 
 
 This term was formerly applied to a variety of affections in 
 which a thick crust or scab was formed upon the surface of the skin. 
 In recent years the terrri is limited to one eruption, which begins as 
 small blisters containing a watery fluid. In a few days this fluid 
 becomes mixed with matter and with blood, after which the blisters 
 dry into dark, thick scabs. If these scabs be removed there is found 
 beneath a raw, ulcerated surfnce, bounded by ragged and prominent 
 edges. But in the ordinary course of the disease the scabs do not 
 fall off when first formed. The first scab is raised from the rawsm- 
 face by the formation of a second one beneath it. This second and 
 lower r.cab is larger in extent than the first, and is in turn rcpl.icud 
 by a third larger than itself. Thus there accumulate a scries of scabs 
 one above another, the entire mass presenting a conical shajjc 
 
 These may occur at some limited part of the body or they may 
 be scattered pretty generally over the entire surface. In this latter 
 case the patient is exceedingly uncomfortable, and is unable to rest 
 in any position without pain. 
 
 Treafineuf. — This disease is always oi syphilitic origin. Tlie 
 patient has acquired the disease usually at least eighteen months or 
 
SEHOKKIIOEA. 
 
 449 
 
 two years previously. In most cases his general health is greatly 
 impaired, and he may have some other symptoms of syphilis. The 
 til.' itment consists in supporting the powers of the individual, in the 
 administration of tonics and of those remedies which are known to 
 counteract the effects of syphilis. Locally it is necessary to soften 
 and remove the scabs by immersing the patient in a hot bath for 
 fiftern or twenty minutes. Then the ulcers which are left after re- 
 moval of the scabs may be dressed by dusting them with powdered 
 iodoform. 
 
 Seborrhoea. 
 
 By this term is designated an unnatural secretion from the 
 sebaceous or oil glands of the skin. This variation from the 
 natural secretion consists sometimes merely in an excessive quan- 
 tity. In this case the skin is constantly covered with a thin layer 
 of oil, and is usually shiny in consequence ; the hair too is apt to 
 be constantly moist and glistening from excessive secretion of the 
 ;^dands at the roots of the hairs. In other cases the secretion is 
 dried into scales or plates of a dirty white color, which lie upon 
 the skin, and when removed leave a reddened surface. These 
 scales have a greasy feel to the finger, and often a somewhat 
 strong odor. This condition is exceedingly common upon the scalp, 
 where it constitutes the affection known as " dandruff" or "scurf" 
 in the head. 
 
 In the third form of seborrhoea the secretion of the oil glands 
 takes the shape of small plugs, which distend the orifice of the 
 Ljland ; in this case the skin feels harsh and dry and somewhat 
 rough like a file. 
 
 Seborrhoea occurs with especial frequency on the face and on 
 the scalp, though it may be found on other parts of the body, 
 ll is liable to be mistaken for eczema, since the crusts produced are 
 often thick and scaly ; but, whereas the removal of the crusts in 
 ec/ema leaves a reddened and somewhat raw surface, the removal 
 of the same in seborrhoea shows no rawness, but merely a redness 
 of the skin underneath. 
 
 Tfcatment. — In almost all cases it is desirable to give tonics 
 
 >i ':* i 
 
450 
 
 DISEASES OF THE SKIN. 
 
 m 
 
 and arsenic. For this purpose the following prescription may be 
 ordered : 
 
 Arsenious acid. . . . . Half a grain. 
 
 Sulphate of quinine, - - - Thirty grains. 
 
 Extract of gentian, ... Twenty grains. 
 
 Mix, and make twenty pills. Take one half an hour before meals. 
 At the same time the crusts may be removed by rubbing the 
 skin with oil, and the following lotion may be applied : 
 
 Oxide of zinc, .... - Three drachms. 
 
 Glycerine, . . . . - Two ounces. 
 
 Lead water, ----- Two drachms. 
 
 Lime water, - - - - Six ounces. 
 
 Mix and apply to the surface upon soft cloths. 
 
 ■I 
 
 Inflammation of the Skin. 
 
 i'- 
 
 The various skin eruptions which have been described are forms 
 of inflammation of the skin. There occur in addition several 
 varieties of inflammation in the skin, which are not recognized as 
 distinct diseases, but are included under the general name (/er- 
 matitis (inflammation of the skin). 
 
 Among the various causes which may induce inflammation of 
 the skin, are exposure to heat and cold, including the various 
 degrees of burns and scalds. These belong properly in the domain 
 of surgery and will be discussed under that head. Aside from 
 these, the more common causes of inflammation in the skin are 
 various poisonous substances, which are apt to come into contact 
 with the individual. Many of these induce eczema, as has been 
 already described. Some others, however, cause a diffuse redness 
 and swelling of the skin accompanied with a burning sensation and 
 sometimes extreme pain. Among these is the poison derived from 
 the so-called poison ivy. This eruption begins with a burning and 
 tingling feeling, which is soon followed by redness, swelling, and 
 the development of numerous small blisters This burning sensa- 
 tion, together with the accompanying desire to scratch, often gives 
 the patient extreme annoyance and even distress. These feelings 
 may persist for a long time even after a slight exposure to the 
 
INFLAMMATION OF THE SKIN. 
 
 45 « 
 
 poison. Some persons suffer from this eruption even without 
 coming into actual contact with the plant itself; it is sufficient for 
 them to pass thiough a region where the ivy grows, to have an in- 
 llammation of the skin. This eruption may also be produced in 
 some individuals by the dried plant, and has been known to occur 
 in those who had handled evergreens for decoration in the winter ; 
 in this case, the cause was presumably some of the dry ivy which 
 had become mixed with the evergreens. 
 
 This poison ivy is a very common plant, which closely resembles 
 the ordinary woodbine. From this the ivy is, however, readily 
 distinguished from the fact that it has but three leaves on each stem, 
 while the woodbine has five. Another plant which may cause a 
 severe inflammation of the skin, is the poison oak, which is also 
 called poison sumach and swamp sumach. Some people are also 
 susceptible to the ordinary sumach, which induces in them a decided 
 inflammation of the skin, though this is less violent than that caused 
 by the poison sumach of the swamp. These may be distinguished 
 from each other according to Dr. Bulkley, as follows : The poison 
 sumach is a plant six to eighteen feet high ; the leaves are dark green, 
 pointed, shiny and smooth on the edges, which are not notched, 
 they are arranged in pairs of four to six on opposite sides of the 
 middle stem with one at the end. The harmless sumach has many 
 more leaflets on each side. The flowers are very small and green- 
 ish, and the berries greenish white or yellowish ; the berries of the 
 harmless variety are always of a crimson red. The young shoots 
 are purple or green clouded with purple and marked by orange 
 colored dots which turn grayish. 
 
 In all forms of inflammation of the skin from external poisons, 
 the object is to relieve the burning and itching. For this purpose 
 several prescriptions may be employed, as follows : 
 
 :n 
 
 Borax, . . _ . _ 
 
 Two drachms. 
 
 ss 
 
 Glycerine, . . . . - 
 
 Two ounces. 
 
 id 
 
 Water, 
 
 Two ounces. 
 
 ni 
 nd 
 nd 
 
 Mix and apply to the inflamed skin. Or, 
 
 
 Oxide of zinc, _ - - - 
 
 Two drachms. 
 
 Lead water, - - - - - 
 
 One drachm. 
 
 ia- 
 
 Wine of opium, - - - - 
 
 Four drachms. 
 
 'CS 
 
 Rose water, - - - - - 
 
 Four ounces. 
 
 he 
 
 
 
 V.'.] JJ' ' "it. 
 
 i-m 
 
^1! 
 
 45^ 
 
 DISEASES OK THE SKIN. 
 
 If the burning and itching be intense, the surface may be dusted 
 with this powder : 
 
 Camphor, . - . - 
 
 Oxide of zinc, . . - 
 
 Starch, ----- 
 This is to dusted thickl>- upon the skin. 
 
 Camphor, . - - . 
 
 Borax, ----- 
 
 Alcohol, - - - . 
 
 Glycerine, . . . - 
 
 Rose water, - . - - 
 This should be applied to the skin upon soft cloths, and changed a>. 
 often as the cloths become dry. 
 
 Freckles. 
 
 Half a drachm. 
 One ounce. 
 One ounce. 
 
 One drachm. 
 Two drachms. 
 Two ounces. 
 Two ounces. 
 Four ounces. 
 
 m 
 
 Freckles consist in the deposit of an excessive amount of pi^^- 
 ment (the coloring matter of the skin) in irregular patches. This 
 deposit is favored by exposure to the sun, and to excessive licit 
 without sunlight; yet there is a predisposition of the individual to 
 this irregular pigmentation, as is evident from the fact that some 
 persons never have freckles, no matter how much they may be 
 exposed to the sun's rays. 
 
 Tt'eafm4"nt. — It is sometimes possible to remove freckles by 
 the daily application of the following solution : 
 
 Corrosive sublimate, - - Two grains. 
 
 Water, ------ Two ounces, 
 
 This may be gently rubbed into the skin at the discolored 
 part by means of a piece of flannel. Yet this remedy should be 
 used with extreme caution since it is a most violent poison. 
 
 I' I'i '5 
 
 ml h 
 
 Lioe. 
 
 In addition to the vegetable parasites of the skin, which have 
 been described as causing various eruptions such as favus, ring- 
 worm and the like, there are numerous animals which live in the 
 vicinity of the skin and pasture upon it. Some of these arc com- 
 
MCE. 
 
 453 
 
 parativcly uncommon, and need be only mentioned here. Such is 
 the IcptHS autumualis, ii red or yellowish insect which lives upon 
 \ arious kinds of {^rain, but seizes the opportunity of burying its 
 head in the human skin whenever the occasion offers. The bite of 
 the insect occasions considerable trouble to harvest hands in vari- 
 ous parts of the world, since it causes severe itching and consider- 
 able swelling of the skin. 
 
 More familiar parasites are the common bed-bug and the flea. 
 In the United States the flea is associated in the popular mind 
 with the dog and cat, but in many parts of Europe the flea is a con- 
 stant inhabitant of the bed-chamber and even of the body linen. 
 
 In this country the physician finds as the most frequent animal 
 parasites of the skin three varieties of lice. Each of these varieties 
 i.: cluiracterized by certain features of size and shape and by its 
 habits. 
 
 The largest of the three is the body louse {pcdiculus vcsti- 
 mciiti). This animal lives altogether in the clothing, and hence 
 when its presence is suspected it does not suffice to examine the 
 body simply in order to detect it. Search should always be made 
 in the creases and folds of the underclothing, especially in those 
 parts where it rub closely upon the person ; thus they are espe- 
 cially liable to be found around the shoulders and under the arms, 
 around the hips and between the thighs. 
 
 The presence of these parasites is indicated by the intense 
 iiching and by the occurrence of minute red spots or small dried 
 flakes of blood. The irritation caused by the parasites results in 
 scratching, which then induces the development of pimples. 
 These arc irritated, their tops scratched of, and there finally results 
 an extensive rash on the skin, which may become so serious that 
 the origin of the difficulty is not suspected. 
 
 Body lice are usually found first around the neck and 
 shoulders ; and the rash induced by them consequently appears 
 first in these parts. Subsequently, however, the animals find their 
 way over the entire body, and the skin may accordingly exhibit 
 their effects throughout its entire extent. 
 
 Trrfftment. — So soon as the existence of body lice is dis- 
 covered, all the clothing worn by the patient should be put into an 
 oven and kept at a temperature of at least 225 degrees F. for two 
 or three hours. This will be sufficient to destroy the mature 
 
 •:l 
 
 30 
 
\l 
 
 > 
 
 i 
 
 i ^ k 
 
 « ■i'i'l 
 
 ■ • 
 
 '» 'v^'' 1 
 
 
 P if |i 1 
 
 
 ■ mill 
 
 !*■ 
 
 454 
 
 DISEASES OF THE SKIN. 
 
 Two grains. 
 One drachm. 
 One ounce. 
 Four ounces. 
 
 animals, though it may not annihilate the nits, which arc also fouml 
 upon the clothing. To accomplish this latter object the under- 
 clothing and the linen should be subsequently boiled ; and it will 
 be better to repeat this process again during the course of a week. 
 As for the body of the patient himself nothing further is ncccK il 
 than a hot bath. After this, and the removal of the cause, tiic 
 rash on the skin will subside spontaneously. This species of \(.n\<c 
 does not inhabit the hair, and, therefore, need occasion no an.xicty 
 as to the condition of the head. In order to prevent the return of 
 any of the parasites which may have escaped the efforts made for 
 their destruction, the following ointment may be rubbed upon the 
 skin : 
 
 Perchloride of mercury, - 
 
 Chloride of ammonium, - 
 
 Alcohol, - - - - - 
 
 Rose water, - - - - 
 
 The /n'a(/ louse is smaller than the former and lives exclusively 
 on the scalp ; three or four are often found on one hair, the li)\ve>t 
 being the oldest. These lice may extend their depredations some- 
 what outside of the hairy part of the scalp, and may invade the 
 neck and even the face. The irritation caused by them is often sufti- 
 cient to induce eczema of the scalp ; in every case of this disease 
 search should be made for these animals as the possible cause. 
 
 The nits or eggs of the head louse are firmly attached to the 
 hair, so that they cannot be removed by combing, nor, indeed, in 
 any way without destroying them. These hatch in about nine 
 days ; hence the head may be thoroughly cleansed of all the 
 mature animals to-day, but be thickly populated again by the end 
 of the week. 
 
 Trefifment, — The lice can be removed by careful combini,^ 
 with a fine-tooth comb. The nits can be destroyed by any one nf 
 several agents. It is not necessary to cut off the hair to accom- 
 plish this. 
 
 One of the speediest ways for eradicating both the mature lice 
 and the nits from the head consists in the application of kerosene oil. 
 The head and hair should be thoroughly shampooed with this oil 
 three times in the course of the day, and the head should be bound 
 up in a towel during the intervals. At the end of twenty-four 
 hours the head and hair may be thoroughly washed with soap and 
 
 Mt 
 
LICE. 
 
 455 
 
 1 
 
 water. The towel which has been used to cover the head should 
 be baked thoroughly in the oven. 
 
 In carrying out this plan, extreme care should of course be 
 taken to keep lights and fires away from the individual's head. 
 Several serious accidents have followed the neglect of this simple 
 precaution. 
 
 Those who may deem kerosene oil too unpleasant and irrita- 
 ting,' for application to the head, may use the following substitute : 
 An mincc of stavcsacre seeds may be bruised in a mortar or in a 
 cup, into which there may then be poured half a pint each of alcoh'~'i 
 and water. The vessel is then thoroughly shaken and allowed t«» 
 stand covered for half an hour, at the end of which time the 'iquid 
 Tiay be rubbed into the scalp and onto the hair. This shan.^ooing 
 may be repeated three times during the day ; on the following d.i) 
 the hair is washed wiui b>..ap and water. 
 
 If this m-^asure prove unsuccessful, the hair may be washed 
 with a solution of corrosive sublimate, three grains of which arc 
 dissolved in six ounces of water. Yet it must be repeated that 
 this substance cannot be used by an inexperienced person without 
 some danger. 
 
 The third variety of louse which makes its home on the human 
 body is the one known as the pcdicnlus pubis, vulgarly known as 
 the " crab louse. " This animal inhabits the hair on all parts of the 
 body except the head. It is more frequently found, therefore, in 
 the hair of the genitals, but also inhabits the beard and the eye- 
 lashes. In the latter situation it is a frequent cause of a disease of 
 the eye, which is manifested by the formation of thick crusts along 
 the edges of the lids. Close inspection shows that these crusts con- 
 sist largely of the lice themselves, which cling so closely to the hairs 
 that they are detached with great difficulty. 
 
 These lice may be destroyed by kerosene oil. They are also 
 destroyed by the common vicrciirial oint'.neut, though this should 
 be used with caution in order not to provoke salivation. Perhaps 
 the most convenient way is the use of the ordinary " insect pow- 
 der. " By blowing this powder freely upon the parts two or three 
 times a day the animals are destroyed and may be washed off sub- 
 sequently with soap and water. 
 
 The irritation caused by lice, whether on the body or the head, 
 often results in swelling of the glands near the irritated part of the 
 skin, Thus their presence in the hair of the head often causes the 
 
 • i! 
 
 
 m 
 
 p: 
 
 ' 
 
 \w 
 
 r^.M iK! 
 
 I'll 
 
 u r 
 
 I;H 
 
 
 1 'I 
 
 MA 
 
 
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 ■ 'y * ■ 1 
 
 
 Wk 
 
 %v' ' • 
 
 .;.ii 
 
 
 i\- ' ■ . 
 
 4 
 
 ■if 
 
456 
 
 DISEASES OF THE SKIN. 
 
 it 
 
 ( ■ 
 
 il i 
 
 appearance of lumps at the back of the neck, especially in scrofu- 
 lous and ill-nourished children. These lumps may proceed to the 
 formation of abscesses and boils. On other parts of the body, too, 
 such lumps may form and discharge matter profusely. So soon as 
 the cause of irritation — the lice — is removed, these abscesses sub- 
 side. 
 
 After an individual has been afflicted for a considerable time 
 with body-lice, and has relieved himself by violent scratching, the 
 skin presents numerous discolored spots and lines of a darker luic 
 than natural. These dark spots persist for some weeks after the 
 cause of the irritation has been removed, but ultimately disappear. 
 
 The fact that lice are often found in and around the abscesses 
 which result from the irritation of the skin, gave rise in former 
 times to various fables, which were believed by the medical pro- 
 fession as well as by the people. Thus Aristotle taught that Hce 
 were produced in the flesh of the individual, and that they came 
 out to the surface through these abscesses. It was asserted that in- 
 dividuals sometimes died through this production of lice in their 
 bodies out of the injurious humors that were circulating in the 
 blood. It was believed that the Danish King Snyo, for instance. 
 died of this disease. Lice are, however, air-breathing animals, and 
 cannot, of course, exist under the skin. They are found only upon 
 the surface of the skin, or upon the garments covering the skin, 
 where they have opportunities for breathing. 
 
 > I 
 
 Corns. 
 
 Corns are one of the evils which seem inseparable from modern 
 civilization. They consist of a thickening of the horny layer of 
 the skin with an excessive development of blood vessels and ncr\ es 
 in the deeper parts. They result from long-continued pressure 
 upon the skin, usually upon the feet, since these are the parts of 
 the body most frequently exposed to continuous pressure. The 
 corn is ordinarily the product of an improperly-made shoe, whicli 
 causes pressure either directly upon the skin at some particuhir 
 part of the foot, or compresses the toes so that they rub aq^ainst 
 one another. While such shoes are generally too small, tlie\- may 
 be in some cases abundantly large, except at some particular point. 
 
CORNS. 
 
 457 
 
 Corns are ordinarily spoken of as hard and soft. These are 
 essentially the same, differing only in the rapidity and extent of 
 their formation. 
 
 Tt'Pdtnietit, — The most troublesome corns cease to give any 
 annoyance, and finally disappear, if only such shoes be worn as 
 afford ample room for the foot. Yet this plan is rarely followed, 
 and it becomes necessary to devise some means for removing the 
 cjrowth outright. There are several means for removing corns. 
 The first of these consists in relieving the tender part from pressure. 
 by w'u.iring over the toe a piece of felt or doeskin with a hole in 
 the center large enough to receive the corn. This felt or doeskin 
 is made adherent by some form of sticking plaster, and is thus 
 attached to the skin in the proper position ; or even without 
 bcini^ made adhesive itself, it may be held in position by narrow 
 strips of adhesive or " sticking " plaster. In this way the corn is 
 protected from the pressure of the shoe, the projecting part can be 
 readily removed with a sharp knife or razor, and in the course of 
 time the corn disappears. 
 
 Another method consists in the use of lunar caustic. The 
 foot is soaked for a quarter of an hour in warm water, after which 
 as much of the corn is cut away as can be, without causing it to 
 blccil The surface is then rubbed thoroughly with a stick of lunar 
 caustic, after which the toe is covered with sticking plaster. At 
 the end of one or two weeks a thick scab is loosened from the toe, 
 with which the corn is usually brought away. In using this method 
 the foot should be rested for some hours after the application of the 
 caustic; hence this should be applied in the evening before retiring. 
 
 Another method, which is extensively practiced by the pro- 
 fessional corn doctors, consists in scraping around the corn and down 
 on cither side of the " core " until the point is reached ; the entire 
 mass can then be extracted without causing pain. In order to 
 accomplish this, the operator must have a special instrument as 
 well as considerable experience. 
 
 Another method, which is that commonly employed in the 
 application of the patent remedies for the cure of corns, consists in 
 the use of some material which will soften the outer layer of the 
 skin, such as potash or acetic acid. These substances arc made up 
 into the form of a paste, which is applied to the thickened skin every 
 night for four or five nights ; by this time the skin is well softened, 
 
 :?i 
 
 i 
 
 •uM 
 
458 
 
 DISEASES OF THE SKIN. 
 
 EM 
 
 ii, 
 
 (• i 
 
 :i «i 
 
 and when the foot is soaked in warm water for fifteen or twenty 
 minutes the mass of thickened skin can be readily detached. 
 
 In the treatment of corns it should be remembered that the 
 painful spot is right under the " core ; " it is here that the skin is 
 thickest and hardest, and it is under this core that the greatest 
 tenderness exists. Hence in cutting corns we should not pare 
 the outside and leave the core, since thereby the corn is rendered 
 extremely sensitive to pressure ; the object should be always to 
 dig out the central part, the core, and leave the external part of 
 the mass as a protection. 
 
 Suffering from corns can also be diminished by the use of 
 different pairs of shoes on successive days ; since no two shoes will 
 press in exactly the same place, the skin is relieved from pressure 
 for several days at a time. 
 
 The soft corns which occu.- between the toes, may be treated 
 in the same way as the hard corn. Sometimes the annoyance from 
 them can be much diminished by daily washing with spirits of 
 camphor, and by wearing pieces of cotton between the toes ; relief 
 may also be obtained by the employment of pieces of felt or doc- 
 skin with holes cut through the middle, so that the corn is relieved 
 from pressure. 
 
 1 \~:i 
 
 Mother's Marks. 
 
 V, m 
 
 uiV 
 
 iv^ 
 
 1 .4i 
 
 Mother's marks or naevi are congenital discolorations of the 
 skin. They are of two varieties: first, there is the simple increase 
 in the coloring matter of the skin, constituting what is known as a 
 i/io/i\ These moles are often supplied with hairs of unusual size and 
 length, whereby the disfigurement of the skin is much enhanced. 
 The other variety is the reddish discoloration of the skin, which is 
 variously known as wifie mark and claret stain. This reddish 
 color is due to an unnatural size of the blood vessels in the skin at 
 the given point. Sometimes this enlargement of the vessels i; 
 quite limited, making merely a reddish point ; at other times the 
 vessels over a considerable part of the skin are enlarged and dilated, 
 so that the entire side of the face or neck exhibits an intense red 
 color. 
 
 These birth mark?, are associated in the popular mind with 
 numerous curious fables. Every deformity of a new-born child, 
 
MEDICINAL RASHES. 
 
 459 
 
 whether it consists merely in a discoloration of the skin or in more 
 serious departure from the natural condition, is explained by sup- 
 posing that the mother during her pregnancy had witnessed some 
 scene or beheld some object, the sight of which had impressed 
 itself upon her memory and upon the body of her unborn child. 
 These wine marks, so called, are attributed to such causes ; in one 
 instance the mother asserts that she had, a few months previous to 
 the birth of the child, seen an individual with blood on his face, 
 exactly in the location in which the discoloration subsequently 
 appeared on the face of her child. 
 
 It is needless to say that there is no foundation whatsoever 
 for such explanation of these deformities. These fables are merely 
 evidences of the curious fancies which have always been invented 
 to explain the unknown. 
 
 In consequence of the superstitious ideas associated with the 
 origin of these mother's marks, there has prevailed a belief that 
 these deformities should not be corrected lest some harm should 
 happen to the individual. This, too, is a mistaken idea, as has 
 been often demonstrated by the removal of such marks. There is 
 no objection on this score to removing mother's marks ; but there 
 is often considerable difficulty in the execution of this plan. Vari- 
 ous procedures have been devised and carried out by surgeons for 
 the relief of this condition, but until recently, all of them have 
 required some interference by means of the knife or of caustic. 
 It is, however, now possible to remove many of these mother's 
 marks without injury to the patient, but such measures can be suc- 
 cessfully carried out only with the apparatus and skill of the 
 
 surgeon. 
 
 Medicinal Bashes. 
 
 Quite a number of the remedies in common use are capable, 
 when taken in excess, of exciting eruptions upon the skin. Promi- 
 nent among these ^s the bromide of potassium. This remedy is 
 taken for a long time in the treatment of various diseases, among 
 them epilepsy and persistent wakefulness. After the use of the 
 drug for several weeks or months, according to the susceptibility of 
 the patient, there appears a rash upon the face, shoulders and 
 
 1 1 ■' 
 
 %m 
 
 1 1 xM 
 
 K\\M 
 
46o 
 
 DISEASES OF THE SKIN. 
 
 |i 
 
 breast. This rash is caused by the inflammation of the sebaceous 
 glands in the skin, and cannot be distinguisheH from the common 
 acne or pimples upon the face. If the medicine be discontinued, 
 the rash usually subsides in the course of a few weeks. If it 
 becomes necessary to continue the use of the bromide, the appear- 
 ance of the rash may be avoided by administering Fowler's solu- 
 tion at the same time. For epilepsy, for instance, the following 
 prescription may be ordered : 
 
 Bromide of potassium, 
 Fowler's solution, 
 Syrup of orange peel. 
 Water, 
 
 One ounce. 
 
 One and a half drachms. 
 
 Two ounces. 
 
 Two ounces. 
 
 Mix, and take a teaspoonful four times a day. 
 
 If the rash which is produced by the bromide of potassium be 
 not treated, it is apt to result in the production of large blisters 
 containing matter — the condition known as ecthyma. This results 
 in part from the itching of the skin and the consequent scratching 
 by the patient. 
 
 The iodide of potassium is also a frequent cause of a skin erup- 
 tion. It is important to bear this in mind, because the failure to 
 remember it, and to recognize the nature of the rash, sometimes 
 leads to serious errors of diagnosis, for the iodide of potassium is 
 taken for months at a time in the treatment of syphilis ; now thi^; 
 disease causes, among other things, several eruptions on the skin, 
 and it has sometimes happened that a patient has persisted for a 
 long time in the use of iodide of potassium to remove a rash which 
 he supposed was due to syphilis, but which was really the effect of 
 the remedy itself. 
 
 The rash produced by the iodide of potassium is very similar 
 to that caused by the bromide, and resembles, therefore, the com- 
 mon acne. 
 
 Arsenic causes certain derangements of the skin, when brought 
 in contact with the person repeatedly and persistently ; thus many 
 of the workmen employed in the manufacture of dyes and of arti- 
 cles in which these dyes are freely used, such as wall paper, are 
 apt to suffer from severe inflammation and ulceration of the skin. 
 It may also induce a hardening of the skin, when taken to excess as 
 a medicine. 
 
 Copaiba also causes a rash on the skin when taken to excess, as 
 it often is in the treatment of gonorrhea. This rash causes a 
 
:^ 1^1 
 
 THE NAILS. 
 
 461 
 
 reddish eruption composed at first of pimples simply, which maybe 
 followed by blisters of considerable size and by swelling of the 
 skin, such as occurs in nettle-rash, 
 
 Tar and the various substances which are made from it also 
 cause an eruption on the skin. 
 
 Arnica often induces eczema of the skin when applied to 
 bruises, sprains, swellings and the like. 
 
 1 U\ 
 
 The Nails. 
 
 The nails are merely thickened pieces of skin, being made from 
 the same materials and arranged in essentially the same way as the 
 outer parts of the skin in general. The nails are subject to a number 
 of diseased conditions. They are often affected when the skin is the 
 scat of a rash. Thus in psoriasis (dry tetter) the nails of the hands 
 and perhaps of the feet also are affected ; they become speckled, 
 whitish, irregular and brittle ; sometimes the free edge is split up 
 into several distinct layers. 
 
 In ichthyosis (fish skin disease) the nails are apt to be thickened 
 and dull. In lichen they are also affected. 
 
 In syphilis the nails are often deformed, and their beds become 
 the site of inflammatory processes. 
 
 In scrofula the nails are often marked with distinct lines, and 
 maybe thickened ; in consumption they are often club-shaped and 
 arched. A similar arched appearance is often presented by the 
 nails in cases of heart disease. 
 
 Another cause of difficulty in and around the bed of the nail 
 is the occurrence of parasitic growths, like those which cause ring- 
 worm on the skin. In this affection the nail becomes somewhat 
 thickened and raised. The cause of the difficulty is usually indi- 
 cated by the occurrence of ringworm elsewhere on the skin. 
 
 higroxi'ing toe-nail is a troublesome affection, which is apt to 
 follow the compression of the foot by tight boots. At times the 
 nail is really not at fault, the flesh at the side being merely forced 
 over and against it by the pressure from without. In these cases 
 the nail retains its natural flat shape, and is not tender upon pres- 
 sure. 
 
 In other instances of ingrowing toe-nails the difficulty lies really 
 in the nail itself. In these cases the bed of the nail has been irri- 
 
 ■ 
 
 t.v iil 
 
 i ', 
 
 ! ; 
 
 •i 
 
 Vi^tt: 
 
 \, uii> 
 
462 
 
 DISEASES OF THE SKIN. 
 
 ;U:i 
 
 ■i i' 
 
 tated for a long time by pressure. As a result, the nail is thickened 
 and its shape essentially changed ; for instead of being flat, with a 
 simple depression at the sides, the nail is usually thickened and 
 raised in the middle, while the sides are directed downward and 
 grow deeply into the flesh. In these cases pressure upon the nail, 
 especially upon the end, causes pain. 
 
 After a time the constant irritation of the flesh, caused by the 
 sharp edge of the nail, excites inflammation of the skin, which may 
 proceed to ulceration. A considerable surface along the side of the 
 nail may become raw and covered with matter. Under these cir- 
 cumstances the toe is very painful, and the shoe cannot be worn 
 without e.xtreme annoyance. 
 
 Treatment, — The treatment of this condition must depend 
 upon the degree to which the inflammation and ulceration have pro- 
 gressed. In the early stages, that is, when the skin alongside of 
 the nail is merely red and tender, it will usually be sufficient to wear 
 only shoes which afford ample room for the toe. It is important to 
 see that the shoes are not simply wide enough, but that they also 
 are made so as not to press upon the toe from above. 
 
 If there be already some ulceration at the side of the nail, the 
 skin should be gently pulled away from the edge of the nail and 
 the groove should be washed out thoroughly with water ; it will 
 often be possible to discover small fragments of the nail which have 
 broken off" and are lodged in the groove, where they keep up a con- 
 stant irritation and provoke a profuse discharge of matter. These 
 should, of course, be removed. A little vaseline should then be 
 smeared upon a small piece of cotton wool and gently inserted 
 between the edge of the nail and the skin. This dressing should 
 be renewed at least once every day, the part being washed at the 
 same time. If care be taken to avoid further pressure by the shoe, 
 recovery will usually take place by this simple means. If not, nar- 
 row strips of adhesive plaster should be so applied around the toe 
 as to hold the skin at the side of the nail away from the edge of the 
 nail itself. 
 
 If all these measures fail, the edge of the nail may be removed 
 to such an extent as to aff"ord the skin suflficient room. This is an 
 operation which should be performed only by a surgeon. 
 
DIET IN DISEASES OF THE SKIN. 
 
 463 
 
 DIET IN DISEASES OF THE SKIN. 
 
 The physician is constantly asked by patients suffering from 
 skin diseases, what they shall eat and what they shall not eat. 
 Probably no other class of patients is so deeply impressed with 
 the idea that their diseases are due to impurities of the blood, and 
 that extreme care should be taken to avoid the use of certain arti- 
 cles of food. Most of these patients have theories and hobbies as 
 to the diet which it is proper for them to take and to avoid ; and 
 most of them seem to believe that dieting consists in the avoidance 
 of food so far as possible. 
 
 It is true that the diet can be made to exercise considerable 
 influence upon diseases of the skin as well as upon diseases of the 
 internal organs ; but it is not especially necessary to regulate the 
 food in diseases of the skin, with certain exceptions to be presently 
 mentioned. 
 
 In every case it should be remembered that the plan of diet- 
 ing does not mean to reduce the patient to the verge of starvation, 
 but simply to grant him such articles of food and in such quantities 
 as will, in the opinion of the physician, tend to restore his bodily 
 functions to their natural condition. In most cases the patient 
 needs to be built up rather than torn dox'in ; for most diseases of 
 the skin, even those of local origin, such as ringworm, indicate that 
 the patient is in a more or less debilitated condition, since these 
 diseases do not ordinarily occur in persons of the most robust 
 habits. 
 
 There are certain affections of the skin which are provoked 
 and aggravated by indulgence in particular articles of diet ; the 
 patient soon learns to discriminate for himself upon this point ; he 
 soon discovers what articles of food are especially apt to provoke 
 the outbreak of his complaint. Thus the sufferer from nettle-rash 
 early ascertains that he has an attack of the disease whenever he 
 cats strawberries, or oysters, or shellfish, or whatever his particular 
 weakness may be. 
 
 Aside from these personal peculiarities, there are certain prin- 
 ciples which apply to patients affected with chronic diseases of the 
 skin. In most cases the appetite is a reliable guide, though it 
 sometimes needs direction. 
 
 
 \t ; 
 
 
; >?: 
 
 464 
 
 DISEASES OF THE SKIN. 
 
 To begin with, it must be remarked that much of the difficulty 
 from errors of diet arises not so much from the nature of the sub- 
 stances eaten, as from the imperfect and careless way in which they 
 are eaten. In our country especially, rapid eating and hurried 
 chewing are prevalent habits, which are responsible for many diffi- 
 culties of other organs than the stomach. For digestion really 
 begins in the mouth ; here the food is not simply divided into 
 small particles, so that it can be acted upon by the juices of the 
 alimentary canal, but it is also mixed with the saliva, which effects 
 certain changes in it. If the chewing be imperfectly performed, or 
 if the saliva be but slightly mixed with the food, there will result 
 first derangement of the stomach, and subsequently derangements 
 of other organs. For the ill effects are not limited to the stomach 
 alone. If this do its work but imperfectly, additional labor is 
 required of other organs to piece out the work of the stomach ; 
 while at the same time these other organs are supplied with imper- 
 fect blood, since the stomach does not digest and take up the food 
 in a natural way. It is evident, therefore, that one of the first 
 requisites for the diet of a patient affected with skin disease is that 
 the food shall be easily digested. The patient's own sensations will 
 usually indicate to him when he has indulged in indigestible food. 
 
 As to the quantity of food which should be taken, it may be 
 said that but very few of the skin diseases are caused or aggravated 
 by excessive indulgence in food. Patients with acne are perhaps 
 the only ones whose complaint is aggravated by simple over-indul- 
 gence. Such patients should avoid hot drinks and soups, since 
 these provoke flushing of the face and favor the development of the 
 rash. It is well for them to avoid desserts, since these are usually 
 just so much more than the individual requires or loally desires. 
 
 A prevalent habit, which probably contributes largely to the 
 prevalence of indigestion, is the habitual use of large quantities of 
 liquids with the meals. Aside from the injury which may result 
 from alcohol or tea or coffee in excess, it is not desirable to fill the 
 stomach with any liquid, however harmless, during the process of 
 digestion ; since the stomach juices are thereby diluted and weak- 
 ened and the process of digestion is, to say the least, retarded. 
 This is especially true if the liquids taken be cold, since the effect 
 of chilling the stomach is also to arrest the digestive process. 
 
 Patients with eczema are apt to dislike and avoid fatty food. 
 It has been ascertained that the use of fats in the food generally 
 
 ' il i- ^ 
 
 lU . 
 

 DIET IN DISEASES OF THE SKIN. 
 
 465 
 
 exercises a good influence upon the course of the disease ; hence it 
 is desirable that such patients take a moderate amount of fat with 
 their food, even though they do not crave it. These patients with 
 eczema are apt to eat vegetable food by preference, especially the 
 starchy substances, such as rice, arrow-root and oat meal. It is 
 well for them to bear in mind the popular idea that " oat meal is 
 icating," since there seems to be some foundation for this idea in 
 fact. 
 
 One of the most frequent causes and one of the most constant 
 means in prolonging the various diseases of the skin, is indulgence 
 in fermented liquids. These generally exercise a decided influence 
 in originating and in prolonging diseases of the skin. A patient 
 suffering from such disease should, therefore, abstain from the use 
 of beer, ale, wine, whisky, cider, etc., unless his condition is so 
 debilitated as to require some of these liquids to increase and 
 support his strength. 
 
 Especial care must be taken in the food of infants who are 
 ifflicted with diseases of the skin. The great bane of infancy 
 among skin affections is eczema. This is doubtless often caused by 
 a poor quality of food, whether this food be artificial nourishment 
 or the milk from a debilitated mother. In every case of eczema in 
 an infant, the attention should be directed to the matter and manner 
 of nourishment of the child ; the mother should scrutinize carefully 
 her own condition ; should see that she eats only suitable food and 
 avoids articles which she knows to be harmful, even though she 
 have a craving for them. She should also endeavor to avoid any 
 mental disturbances, excitement or emotion of any sort, undue sex- 
 ual indulgence, and she should secure sufficient rest by retiring in 
 due season at night. 
 
 Another habit which may assist in the development of eczema 
 is the practice of giving the child the breast too frequently. The 
 custom is almost universal of using the breast to soothe a crying 
 infant ; this is usually a successful device, but it exerts a most 
 injurious influence upon the child's digestion, and promotes the de- 
 velopment of several skin diseases, especially eczema. As will be 
 observed under the appropriate heading, the child should not have 
 the breast, even in the early weeks of life, oftener than once in two 
 hours ; and as time passes this interval should be lengthened, in 
 the interests of the child as well as of the mother. 
 
 Doubtless another factor in the production of eczema in nurs- 
 
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 m 1 r 
 
 466 
 
 DISKASES OF THE SKIN. 
 
 ing infants is the use of fermented liquors by the mother. It is well 
 ascertained that the use of such liquors promotes the occurrence of 
 eczema in adults and in infants through the mother's milk; hence, 
 unless the mother's general condition is such as to absolutely re- 
 quire the support which can be given only by fermented liquors, 
 it is advisable that she avoid these, in spite of the counsels and re- 
 monstrances of friends. 
 
 Eczema is especially frequent among artificially nourished or 
 " bottle-fed" infants. It is often impossible to relieve an infant 
 from eczema until its diet be radically changed. Directions for the 
 feeding of infants will be found in the section on " diseases of wo- 
 men and children. " It is scarcely necessary to remark, that the 
 habit of feeding suckling infants with scraps from the table, pieces 
 ofcake" which won't do him any harm," sips of tea and coffjc, 
 and the like, should be avoided even when the child is perferj\- 
 healthy, in the hope of keeping hmi so. It is all the more necessary 
 when the infant is afflicted with a disease of the skin. 
 
 Much might be said also as to the hygiene of the skin during 
 the existence of ailments affecting it. The popular idea that bath- 
 ing is a ways desirable in all diseases of the skin, is a mistaken one; 
 some o these diseases, especially eczema, are greatly aggravated 
 and prolonged by frequent contact of the skin with water. Vet 
 certain diseases, especially psoriasis, are certainly benefited by fre- 
 quent bathing, especially at the sea shore. In fact everything 
 which tends to increase the activity of the skin — muscular exercise 
 in the open air, sunlight, fresh air in the bedroom, etc. — is 
 highly desirable and important in the treatment of chronic diseases 
 of the skin. 
 
 Dr. Fox gives the following directions as to diet in skin dis- 
 eases : 
 
 First. — A distinction must be made between the diet of the 
 private and the hospital patient. The latter often requires to bo 
 well fed and his disease then speedily goes ; the former, on the 
 other hand, often needs to have a check put on the quantity and 
 quality of his food. 
 
 Second. — In children, skin diseases may arise directly from 
 defective alimentation, as in the case of eczema ; and it is fre- 
 quently the case that the child who is the subject of eczema or of 
 psoriasis, has not a sufficient supply of milk, either from excessive 
 dilution or otherwise. 
 
DIET IN DISEASES OF THE SKIN. 
 
 467 
 
 Third. — The regulation of the diet, setting aside the question 
 of quantity or quality, is as a rule needed not so much to directly 
 iiillucnce skin disease as certain states of the general health, which 
 modify the particular disease present ; for instance, to meet espe- 
 cially, dyspeptic, gouty and rheumatic conditions, but particularly 
 tlic former. 
 
 In dyspepsia, in connection with eczema, acne, psoriasis or 
 congestion of the face, it is advisable, especially if the urine be 
 very acid, to avoid sugar, tea, coffee, alcoholics, beer, raw vegetable 
 matter, unripe or uncooked fruit, veal, pork, seasoned dishes, 
 pastry and the coarser kinds of vegetables, but especially all 
 articles whose use is followed by heat or flushing of the face, and 
 by flatulence and the like. Milk, the common meats, light kind of 
 b 'cad and some very light wine should be the diet of dyspeptic 
 patients whose skins are at all in a state of irritation. In very 
 many cases the stomach is at fault at the outset, and a careful 
 regulation of the diet is of the utmost importance as an aid to 
 the other means adopted to correct faults in other parts of the 
 system. 
 
 In gouty subjects much the same line of treatment is to be 
 pursued. As regards stimulants, hock, a good light claret or 
 whisky and water are the best beverages. 
 
 In scrofulous patients the diet should consist of as much fatty 
 matter as possible. 
 
 Fourth. — In children who suffer from ringworm it is desirable 
 to give plenty of fatty food by means of milk, cream, eggs, and 
 fat meat, if they can be persuaded to eat it. 
 
 Fifth. — In syphilis the greatest care should be taken to avoid 
 everything beyond the most moderate use of stimulants ; their 
 abuse in this disease is a source of the greatest aggravation. 
 
 Sixth. — In all cases in which the onset or early stage of a skin 
 disease is accompanied by fever, however slight, stimulants should 
 be avoided, and the plainest and simplest diet ordered. In marked 
 cases of this kind a milk diet for a while is often found to be very 
 beneficial. 
 
 Seventh. — In some cases in which the disease is accompanied 
 by flushing of the skin, this condition is much increased by the 
 consumption of food, especially if dyspepsia exist, in consequence 
 of the sympathy existing between the stomach and the skin of the 
 part affected. This state of things is especially marked in such 
 
468 
 
 DISEASES OF THE SKIN. 
 
 r 
 
 i « .r i 
 
 !| 
 
 ^iH;: 
 
 i ' ? 
 
 diseases as acne, congestion of the face and sycosis (barbers' itch). 
 Stimuhints must be avoided, unless they be diluted with some alka- 
 line water. The use of a diet appropriate to the dyspepsia must be 
 rigorously enforced. 
 
 Eighth. — It is said that psoriasis requires an ample meat diet; 
 but the patient must be dieted, and not his disease. That is, the dirt 
 should be plain and nutritious and adapted to the constitutional 
 peculiarities, according to circumstances. 
 
 Ninth. — In all cases where a skin disease has become chronic, 
 and where there is debility, the patient should be allowed a full 
 unstimulating diet. 
 
 At the well-known hospital for diseases of the skin, Blackfriars, 
 London, the following directions are issued, to be observed by pa- 
 tients: 
 
 Remove flannel from next the skin affected, or line it with soft 
 linen. Wash with warm water, and, as regards diseased skin, not 
 more frequently than cleanliness requires. 
 
 Avoid using soap of any kind to the affected parts. To cleanse 
 the diseased skin, substitute instead of soap a paste or gruel made 
 of bran, oat meal, linseed meal, arrow root, or starch and warm watrr. 
 Rinse off with warm water or warm milk and water; and employ 
 yolk of an egg and warm water to ci^t^.iSe the scalp. 
 
 Dry the skin with soft linen, and smear it lightly with the oint- 
 ments or liniments, or dress wounds with the same spread thin upon 
 lint or linen. Afterward apply the bandages evenly should they 
 be required. Bathe the affected part by means of a sponge or rag 
 with the lotions or embrocations, or paint them over with a camel's 
 h, ir brush, not more frequently than directed by the physician. 
 
 Rinse the mouth with water, and brush the teeth after taking 
 the medicines, and observe that neither more nor less than the dose 
 ordered is taken. 
 
 At the same institution the following rules of diet for patients 
 are observed : 
 
 For breakfast — Bread and milk, rice, milk or porridge instead 
 of much tea, coffee or cocoa — with or without eggs, and bread 
 and butter, or a little animal food. 
 
 For dinner — Plain roast or boiled fresh meats, fish or poultry 
 plainly cooked, egg or farinaceous (starchy) puddings, potatoes, 
 and few other vegetables, plain boiled rice. 
 
 For supper — Milk and water, or gruel or other farinaceous 
 
KELOID. 
 
 469 
 
 food, witli bread and butter, a little cream cheese or poached 
 
 Beverages — Harley water, toast and water, thin gruel beef 
 tea, soda, potash or seltzer water. 
 
 N. H. — To be avoided — Salt meats, soups, sweets, acids, fruits, 
 pastry and raw vegetables. 
 
 No malt liquors wine or spirits are to be taken without the 
 sanction of the medical officers of the hospital. 
 
 Keloid. 
 
 This is a somewhat rare affection, consisting of a scar-like 
 growth which appears \r. l.c shape of white shiny streaks. The 
 surface is usually very smooth and covered with minute hairs. At 
 first the skin is soft and elastic, but afterward becomes hard and 
 painful. 
 
 The tumor begins with a circumscribed discoloration of the 
 skin, which is surrounded by a red ring. In a short time an itching 
 sensation or even positive pain is occasioned by pressure; it some- 
 times happens that the patient's attention is first called to the 
 growth by a painful feeling resulting from the pressure of the 
 clothing. 
 
 Keloid grows slowly ; in the course of time the central part 
 becomes sunken, while here and there narrow streaks may be 
 elevated. It appears most frequently on the breast, the neck, and 
 the back, though it may be found on any part of the surface. The 
 growth is rarely observed before puberty. It is said to occur in 
 tropical countries and among the negroes. 
 
 As to the nature of the growth, nothing definite is known. In 
 some cases it appears to be merely the beginning of a cancerous 
 formation, while at other times the keloid seems perfectly harmless, 
 and may even result in a spontaneous cure. 
 
 Tveufnmnt. — The cases which have thus far been observed 
 li;ive shown themselves very obstinate against treatment. In most 
 instances the attempt has been made to remove the growth either 
 by the knife or by the use of corrosive substances. If the growth 
 occasions no pain, it is better to avoid irritating it by such treat- 
 ment and simply to protect it by a bandage, so that it will not be 
 irritated by the clothing. 
 3» 
 
 f: V. 
 
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 DISKASKS OK TIIK SKIN. 470 
 
 Fatty Tumors. 
 
 ritoic fiC(|U(Mitly oi-.ciir sin. ill tumors of the skin, wliicli ;iic 
 ootnposfil incic'Iy oCr.it. llicy aw of course of" no cspriial < onsc 
 quiMUc, rxct'pt as thr\' .ilVcil p<'rstuial appearance. \\ is, liowcvci , 
 important to roi'0};ni/e them iv okIit to ulicve tlu' mind ol llu' 
 patii'nt iVoin uniu'ci'ss.iiy .inxietN' and ippr<h<iision, 
 
 A tumor loniposrd simpi)- ol ("at is ncvt-i iiainlul ; tin- skin 
 over it is ntit red nor in .my w.iy chan^jed from its n.itur.d .ippc.n 
 ance. Tlu* sinf.uc is usu.illy rounded .md c.m often l)e sep.u.ilid 
 into lolxs ; iiuleed, we e.m see without touehinjj the tiimtu' tli.il It 
 is tlividi'd into p.irts by furrows wljich tr.iverse it in iliflereiit diK ( 
 tions. 
 
 These tnmoi are most fretpiently found after the thirtietli yen 
 t»f life ; tliey m.iy, Innvever, be met with in yonnj^er p<'rsons, .iml 
 are sometinu's evi"n bom with thi" indiviibial. Tiiey seem (d 
 result, in some inst.mces, I'rom .1 blow or .1 wound. Tiiey are nmsi 
 freipientl)- fouiul on the shouldeis ami the hips, more rarely on 
 other parts of the body ; sometinu's numerous tumors arc observed 
 on the s.une individu.d. 
 
 Tiwofnii'llt, Si^ tout; ,is the tumor occ.isions tlie p.ilicnt lui 
 .inno\ .nice, it need not b(" intiMleu'd wiUi ; it will never eiulaiUMi 
 his life or he.dlh. it, howexci , it be situ.ited on the f,u:e or olliei 
 part of the bi>d)', whi-re it constitut(~s .1 deformit)', the tiunor ni.iy 
 be removed \\itlu)ut li.uigcr b)' .1 sui^ic.il operation. 
 
 
VENEREAL OK PRIVATE DISEASES, 
 
 Hy this naiut; arc (lcsi};iiiit((l tliifc discasrs ul\i( li arc usually 
 .i((|iiiic(l l)y (lie iiii|nirc iiitcicoiirsc of the sexes: Ik n< c llie iiaiiic, 
 iVoin I'liiiis, till! inylliiial (iiuUlcss of I.ovr. 'Ihcse tlire(! dis- 
 eases are: Sypliilis, cliaiicroid or venereal ulcer, and {^jnorrhca. 
 
 Pox (Syphilis). 
 
 Murl) lime and lalxtr liavc been ixpendcd l)y incdieal histori- 
 ans in ascertaining; the dale and location of the earliest rnanifesta- 
 lion of this disease. It is oiii; of those contai.;i<Mis diseases wilic.h 
 ,irc .u(|iiircd only by conlat t with an individual alrea<ly subject to 
 llic allcclion ; and this individual must be, moreover, a human 
 .miin.il, sinci; man is the only one of all known cicitures who is 
 susceptible to this tliseasi . l'"or man)' years expcriuKntcrs have 
 busied themseU'es with tile attempt to inoculate the lower animals 
 with syphilis: at first the ordinary domestic animals — doj.;s, 
 rats, rabbits, and tlu; like — werir employed for the pur[)ose ; and 
 .liter iiuuunerable failures to inoculate thest; animals with syphilitic 
 material from human subjects, it was deemed possible that the 
 nmnkey mij.;ht be a more favoral)le object for the pur|)ose, because 
 lit his greater ri'scnd)lance to the human animal. One or two 
 observers have, at different times, re|)orte(l tli.il tliey havtr suc- 
 eeoiled in inducin;^ this disease in nionkiys by inctctdation with the 
 syphilitic poison from human p.itii-nts, but the almost unanimous 
 testimony of oxperimenti'rs is, that the monkey, notwithstanding 
 his intimate relationship to man, is ncvcrtliclcss not susceptible 
 to this curse of tiic human fanuly. 
 
 The attempt to fix the date and locality at wliich the disease 
 ori^nnated. has not met v;ith tnucli success. It seems certain that 
 
 471 
 
 
 f 
 
 f.*i^^'^ 
 
472 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 '\J. 
 
 'i ' v. 
 
 M- 
 
 ( ( IS 
 
 . ! ''.1 
 
 Ifff. 
 
 the disease was known in the time of Moses, since in the Fifth 
 Book of Moses an ailment is described which was apparently a 
 manifestation of syphilis. It is quite certain that the disease was 
 known to physicians several centuries before Christ ; and it has 
 been ever since one of the recognized affections of human patients. 
 It seems also quite certain that syphilis was present amonj^ the 
 ancient tribes of America, before the invasion of the continent by 
 the whites. 
 
 In the middle ages syphilis was extremely prevalent, so that 
 at the end of the fifteenth century the disease ravaged the popula- 
 tion of Europe like an epidemic of small-pox. 
 
 With occasional slight exceptions, syphilis is known wherever 
 man has set his foot. In a few remote and isolated spots syphilis 
 is still unknown, or has been introduced within the last few decades. 
 The following account of the geographical distribution of syphilis 
 is taken largely from Zeissl's text book of syphilitic diseases. 
 
 The disease is more prevalent on the shores of the East and 
 North sea and in Jutland, and around the shores of the Medi- 
 terranean, than in certain parts in the interior of the Euroj^ean 
 Continent. 
 
 In the Faro Islands, on the other hand, syphilis was unknown 
 until the year 1844 ; and in Iceland the disease was not found 
 until quite recently. This latter fact is very remarkiible, since 
 between two and three hundred ships from different parts of Europe 
 visit Iceland every year, and many of them remain in the harbors 
 during the entire summer. There is evidently opportunity enoui;ii 
 for the communication of the disease to the inhabitants of the island, 
 since sailors furnish probably a larger percentage of sufferers from 
 syphilis than any other class of society. 
 
 The disease is prevalent throughout Europe, especially in the 
 capitals. Certain provinces arc I'speciallj- afflicted ; anions.^ these 
 are Galicia, Iberia and the provinces around the Adriatic. 
 
 In Southern Asia — Palestine, Arabia and Persia — syphilis 
 prevails to an unusual extent. It is especially frequent among those 
 people who are brought into contact with Europeans. In Syria the 
 disease has been known only since an invasion by Turkish troops. 
 
 In Australia, and most of the islands of the Pacific, the disease 
 has been introduced by white settlers. During the latter half of 
 the last century many of the Pacific islands were devastated by 
 syphilis obtained from the sailors of Captain Cook's expedition. 
 
POX — SYPHILIS. 
 
 473 
 
 Syphilis is especially virulent and deadly when it is introduced 
 into a community for the first time. This has been well illustrated 
 in the history of the Sandwich Islands. For some time after these 
 islands had received a considerable white population syphilis remained 
 almost unknown, so far, at least, as the natives were concerned ; 
 but as the islands acquired commercial importance, and were more 
 frequently visited by vessels, the disease was introduced by sailors 
 among the native population. The result was a frightful epidemic 
 of syphilis, in which many lives were lost and many individuals 
 mutilated for life. The white population, however, suffered no 
 more from it than the whites of Europe or America — showing the 
 (liffcr';nce between the effects of the disease when freshly intro- 
 duced to a people unacquainted with it. 
 
 In America syphilis seems to be extensively distributed It is 
 most virulent and frequent in Mexico, Central America and some 
 (if the islands of the West Indies. It is also frequent in several of 
 the countries of South America. 
 
 It appears, therefore that syphilis is one and the same disease 
 over the entire world. It is communicated wherever introduced, 
 without regard to differences in race or color. It is however 
 noteworthy that in Iceland and Central Africa the disease finds no 
 foothold. It would seem at first as if its absence from the inhabit- 
 ants of Central Africa might be due to the absence of exposure to 
 the disease, since but few whites ever penetrate this region ; but 
 the *;ict is, that the negroes of the interior of Africa are in constant 
 communication with those of the coast, and that these latter are 
 afflicted with syphilis to a great extent. 
 
 As to the influence of climate upon the virulence of S3'philis 
 but httle information has been acquired. It is by some maintained 
 that the course of the disease is milder in warm climates than in 
 ':older ones ; yet this seems to be by no means established. It 
 seems, however, to '-":' the fact that syphilis runs a milder course 
 in those regions where the climate is uniform and even, while its 
 course is more severe — other things being equal — in countries 
 where the climate exhibits sudden and extreme changes of tempera- 
 ture and of moisture. 
 
 Yet the extent and severity of syphilis 's determined largely 
 by tlic social and sanitary conditions of a people. The most 
 favorable conditions of climate are powerless to prevent the preva- 
 lence (if syphilis where filth, poverty, ignorance and a neglect of 
 
r;li 
 
 i >n 
 
 i i 
 
 ?i! 
 
 I I 
 
 k I 
 
 474 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 sanitary regulations prevail. This is brilliantly shown in the east- 
 ern provinces of Austria. Although this region enjoys a wonder- 
 fully mild and beautiful climate, thanks to the filth and ignorance 
 of the inhabitants, syphilis prevails to an appalling extent. The 
 young men go to other countries as soldiers or sailors, and bring 
 syphilis with them on their return, and, of course, communicate it 
 in their homes. 
 
 Another feature which promotes wonderfully the spread of 
 syphilis is an unsettled condition of society. It is notorious that a 
 political upheaval — such as a war or revolution — is followed by 
 marked increase in the extent and severity of syphilis. This has 
 been often and amply shown, though never more strikingly than in 
 the hisitory of France, from the time of the Revolution to the battle 
 of Waterloo. 
 
 The moral culture of a people has, of course, considerable 
 influence upon the prevalence of the disease ; though just what that 
 influence is, it is somewhat difficult to say, since the centers of civ- 
 ilization — the European capitals — are, without exception, hotbeds 
 for the propagation of syphilis. Doubtless the dissemination of 
 the disease is favored also by the high-pressure method of li\in", 
 which is now so fashionable throughout the world, especiallj- in 
 America. The necessity of attaining a certain rank and standing; in 
 society before entering upon matrimony, acts, of course, as an 
 agency in spreading the disease among young people of both 
 sexes. 
 
 The course of syphilis is divided, for convenience, into several 
 stages or periods; these are usually designated primary, secondary 
 and tertiary. The prima ty stage begins with the first manifestation 
 of the disease, which is, in almost all cases, a sore at the point of 
 contact with the diseased individual from whom the contagion was 
 obtained. This sore usually occurs upon the genitals, but may be 
 found upon any part of the body. The next most frequent point of 
 infection is the mouth, and after this the nipples of women. 
 
 This sore, and the swelling of the neighboring glands which or- 
 dinarily accompanies it, lasts without other symptoms from throe 
 to six weeks. At the end of this time other symptoms make them- 
 selves manifest, marking the beginning of the second stage of the 
 disease. 
 
 The secondary period begins from the seventh to the twentieth 
 week of the disease. Its onset is indicated by an eruption on the 
 
 
POX — SYPHILIS. 
 
 475 
 
 skin and by sores in the throat and mouth. After this the glands 
 swell in different parts of the body, and there may appear later any 
 one or more of several eruptions which are characteristic of this 
 disease. 
 
 The tertiary, or third stage of syphilis, manifests itself at or 
 after the sixth month by the occurrence of lumps in the skin and in 
 the bones. Several eruptions are also observed on the skin during 
 this stage of the disease. The duration of this period is very in- 
 definite ; in some cases most of the symptoms disappear in eighteen 
 months or two years. But unless the circumstances be peculiarly 
 favorable the individual is rarely entirely relieved from manifesta- 
 tions of the disease for several years after this period, and even then 
 has no assurance that he will be spared further attacks. It is cus- 
 tomary to speak of the secondary and tertiary stages of the disease 
 as constitutional syphilis, because the symptoms constituting these 
 stages show that the syphilitic virus or poison has been taken into 
 the system and has modified the vital functions of the individual. 
 The sore through which the syphilitic material enters the body and 
 which constitutes the first evidence of syphilitic infection is called 
 the " primary sore " or chancre. 
 
 Hijmptoms. — In order that an individual shallacquire syphilis 
 it is necessary first that he come into contact, direct or indirect, 
 with an individual already affected with the disease. By indirect 
 contact we mean that some of the secretions from a diseased indi- 
 vidual may be brought to a healthy one through the medium of 
 some inanimate object, such as a pipe or a towel. Many instances 
 are on record in which the disease has been acquired in this way. 
 A man has for example smoked a pipe which had been recently 
 held between the lips of a syphilitic person, and has in this way 
 taken into his mouth some of the contagious material which was 
 present in the saliva of the latter individual. So, too, a towel 
 which has been employed by a person suffering from some of the 
 syphilitic eruptions on the skin, may contain in its meshes the con- 
 tagious virus, and when applied to the skin of a second person may 
 deposit some of this poison upon him. It is of course needless to 
 enumerate all of the ways in which the contagion of syphilis may 
 be thus indirectly transferred, and through which a person may in- 
 nocently acquire this formidable disease. 
 
 But this alone does not suffice to communicate syphilis ; for 
 the virus is incapable of penetrating the skin or mucous membranes 
 
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 li 
 
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 ■!• 
 
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 476 
 
 VENEREAL OK PRIVATE DISEASES. 
 
 SO long as these arc uninjured and perfect. In order that the poison 
 may be taken up into the system, it is necessary that there be some 
 opening through the skin or mucous membrane ; that is, that tlu' 
 outer or horny layer of the skin should be scratched off or perfor- 
 ated. Yet the slightest opening through the skin — a scratch with 
 the nail or even the prick of a pin — is sufficient to afford access of 
 the virus to the body. It is evident, therefore, that the only 
 security against infection consists in absolutely avoiding all contact 
 with the diseased individual. Physicians are in the habit of touching 
 and handling syphilitic sores, both primary and secondary, and they 
 are usually enabled to do this with safety — always, indeed, so long 
 as there are no cracks nor abrasions on the fingers. Yet it occasion- 
 ally happens that a physician acquires the disease through exami- 
 nation of an individual with the fingers ; and this is especially apt 
 to occur in cases where he is not aware of the" fact that his patient 
 is syphilitic, since under these circumstances he is not so careful to 
 inspect the condition of the skin on his finger before bringing it in 
 contact with the surface to be examined. So, too, the kiss of a 
 syphilitic individual involves no terror to a healthy person, so lon;^ 
 as the mucous membrane of the latter's lips and mouth is perfect 
 and uninjured ; yet since there are often, or nearly always, sliyln 
 fissures and abrasions on the lips, it frequently happens that tJK 
 disease is communicated simply by a kiss. 
 
 The most frequent method of communication is, of course, bj- 
 sexual intercourse. For if the disease manifest itself anywhere on 
 the bod\', it is jiretty certain to appear on the genitals ; the soiucc 
 of the infection is, therefore, provided by the organs of the dis- 
 eased individual. Since the act is almost always accompanied by 
 more or less severe abrasions of the parts, it probably rarely haj)- 
 pens that a healthy individual escapes contagion if he intlulgc in 
 intercourse with a diseased person. This statement applies, of 
 course, to those stages of the disease in which syphilis is corta- 
 giour. ; as will be hereafter described, there is a time in the history 
 .syphilitic individual — the so-called tertiary period — when 
 -l.^e seems to have expended its force, at least so far as com- 
 ni'iiy is concerned ; during this period the individual is 
 ! : »'. . ever, capable of communicating the disease. 
 
 Hull syphilis can be and is communicated from one individual 
 to another has been amply proven by direct inoculation as well as 
 by the observation of patients. In the last half century there have 
 
 
)f 
 
 IS 
 
 POX — SYPHILIS. 
 
 477 
 
 been found numerous physicians who were sufficiently devoted to 
 tlie cause of science to submit themselves voluntarily to inoculation 
 with syphilis in order to decide certain disputed points ; and there 
 have been instances in which patients also have undergone a like 
 inoculation. 
 
 After exposure to syphilitic contagion — that is after contact 
 with a syphilitic individual — several days or weeks may elapse 
 before evidences of the disease are manifest. If the infection have 
 taken place through the skin or mucous membrane of the genitals 
 — the usual mode — a slignt abrasion or scratch may be the only 
 sis^n that there has been a possibility of contagion. In many cases 
 the patient does not observe anything wrong with the parts for two 
 or three weeks after exposure ; in other instances he may notice a 
 slight sore, which perhaps heals in a few days without treatment, 
 or in other cases resists somewhat obstmately the ordinary house- 
 hold means. At the expiration of two or three weeks the patient's 
 attention is usually attracted to a small shallow sore, which is not 
 particularly painful, in fact often gives him no physical annoyance 
 whatever. But if the sore spot on the skin be gently pressed 
 between the finger and thumb, it will be noticed that this piece of 
 skin is rr/'j' hard ; one gets the same sensation through the finger 
 as is given by compressing the point of the nose. This means 
 syphilis. There are, it is true, cases in which the skin surrounding 
 a sore that is not of syphilitic nature is somewhat hard ; yet, in the 
 [.i;reat majority of cases, it will be found that such a sore will be fol- 
 lowed, in a few weeks, by all the signs of constitutional syphilis. 
 
 Aside from this hardness the primary sore of syphilis — the 
 chancre — does not present any marked symptoms. It is usually 
 of small extent not more than a quarter, or at most a half, inch in 
 diameter, and often smaller than this ; there is but little matter 
 secreted by it, and it does not occasion any particular pain. In 
 fact, were it not the harbinger of one of the most dreadful diseases 
 with which we are acquainted, this sore would be quite an insignifi- 
 cant affair. It is not nearly so large nor so troublesome as the 
 other sore which is often obtained from impure intercourse — the 
 venereal uleer or chancroid, to be presently described. 
 
 Soon after the sore makes itself manifest, it will be observed 
 that the glands in the groin — on one or both sides of the body — 
 arc somewhat enlarged, and very hard. In the healthy individual 
 the glands in the groin can usually be felt only upon somewhat firm 
 
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 478 
 
 VENEREAL OR PRIVATE DISEASES. 
 
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 pressure ; and even then they feel about the size of beans. So 
 soon however as the syphilitic sore is developed upon the genitals, 
 these glands in the groin become much larger, so that they can be 
 felt upon the slightest touch, and may even be visible to the eye as 
 enlargements under the skin. 
 
 Sometimes it is possible to trace a thick, hard cord whicii 
 begins somewhere in the vicinity of the sore, and passes aloii^ 
 the parts into the enlarged glands in the groin. This string marks 
 the position of the /jm/'a/ /lie vessel, that is the channel along whicli 
 the poison has passed from the sore to the glands in the groin. 
 
 This sore or cancer is very obstinate, and may resist all treat- 
 ment for several weeks. This is, however, a matter of slight con- 
 sequence, since it rarely gives much pain, as has been already 
 remarked. 
 
 While the primary sore of syphilis is usually situated upon tin- 
 genitals, it may be found in other situations. Perhaps the most 
 frequent location next to that mentioned is the lip, where it appears 
 almost invariably as the result of a kiss. It may be well in this 
 connection to enter a most emphatic protest against the almost uni- 
 versal habit of submitting children for promiscuous kissing to 
 strangers as well as to friends, for syphilis is not confined to the out- 
 casts from society nor to the lower classes ; it finds its way into the 
 very best society, and is no respecter of persons, of innocence, nor 
 of youth. This habit of indiscriminate kissing is as repulsive as it 
 is useless and dangerous, and many a life has been blighted in child- 
 hood or even infancy, by a kiss which was given and taken only 
 out of regard for this useless custom. It is well, too, to remember 
 that the susceptibility to the disease does not cease with infanc}- ; 
 that a flirtation which proceeds to the kissing point may ruin a girl's 
 happiness for life. It has fallen to the lot of every physician who 
 practices in a large city, to see cases in which young and innocent 
 girls have contracted the disease by simply permitting a kiss. It 
 would be supposed that a man who knew himself to be suffering 
 from the disease would carefully abstain from kissing, simply for 
 the sake of the other person ; but some of these individuals are not 
 aware of the fact that they can communicate the disease in this 
 way ; others doubtless think themselves cured, and while aware 
 that syphilis can be communicated by a kiss, do not suppose tlmt 
 they are in a condition to thus communicate the disease. Then 
 
 ¥ 
 
POX — SYPHILIS. 
 
 479 
 
 there are, of course, some who are perfectly regardless of the 
 interests of others, and take no precautions at all in the matter. 
 
 We have just called attention to the fact that children, or even 
 infants, sometimes contract the disease from the kisses bestowed by 
 adults. It should also be remarked that there is danger for the 
 adults as well, though not so frequently perhaps as in the former 
 way, for children are sometimes born with syphilis derived from 
 their parents, and in many cases they can communicate the disease 
 as thoroughly as the most abandoned rake. It is from such chil- 
 dren that wet-nurses frequently contract the disease. In this case 
 the primary sore of syphilis appears on the nipple of the nurse. 
 
 Occasionally the chancre is observed upon the cheek, the tongue 
 or the finger. In fact, it may be found wherever there has been 
 contact with a diseased person. 
 
 In women the primary sore is often located on the e.xternal 
 genitals, where it can readily be detected by the eye ; but in other 
 cases the sore is situated in the vagina, or at the mouth of the 
 womb. In this situation it will be discovered only by a care- 
 ful examination by a physician ; indeed, there arc instances in 
 which the sore is located at some point inaccessible to the eye. 
 riiis is a point to be remembered in private practice as well as in 
 the treatment of prostitutes, for it constitutes one argument — a 
 small one perhaps — against the legalization of prostitution. For 
 it is evident that if a woman's freedom from this disease can be 
 assured only after the most careful and searching examination by a 
 physician, the ordinary hasty and incomplete examination gives no 
 security of her harmlessness, notwithstanding the physician's cer- 
 tificate to that effect. In fact, in the European capitals where 
 prostitutes are licensed, cases are frequently met in which the dis- 
 ease has been communicated by a woman who had submitted 
 to the usual examination and had been pronounced free from 
 syphilis. 
 
 The primary sore usually lasts at least a month and moie fre- 
 quently two, three or four months before it is entirely healed ; 
 indeed, instances are known in which the sore persisted for six 
 months and even a year before healing. Even after the skin has 
 grown over the sore, the characteristic hardness of the part — to 
 which attention has been already drawn — persists for some weeks 
 or months. 
 
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 480 
 
 VKNEREAI. OK PRIVATE DISEASES. 
 
 So soon as the first rash appears on the skin, usually six or 
 eiLjht weeks after the contraction of the disease, the sore and the 
 hardened base around it become smaller and show sip^ns of disap- 
 pearing. The site of this sore is marked by a scar which usually 
 persists for years. 
 
 As a rule an individual acquires a chancre — that is, syphilis — 
 but once in a lifetime, no matter how many times he may be exposed 
 to contagion. The reason seems to be that the disease in most 
 cases remains permanently in the system. Yet it must not be 
 inferred that syphilis is an incurable disease ; on the contrary, 
 instances enough are known in which the patient recovered under 
 treatment so as to be entirely free from all subsequent manifesta- 
 tions of disease ; indeed, they have in some cases given the best 
 possible proof tiiat they were cured, by going and contracting the 
 disease a second time. Zeissl, the great Viennese authority of 
 syphilis, has himself seen almost a score of cases in which the dis- 
 ease had been contracted twice by the samo individual. 
 
 As occasional means for the transfer of the syphilitic material, 
 there should be mentioned childbirth, surgical operations, den- 
 tistry, and the use of a common toilet room. While these means 
 are sometimes instrumental in communicating the disease, yet such 
 instances are doubtless infrequent. 
 
 The glands lying next to the primary sore become enlarged 
 and slightly tender soon after this sore makes its appearance. If 
 the chancre be located on the genitals — the usual situation — the 
 glands in the groins are the first to become swollen ; if the primary 
 sore be located on the lip or cheek, or in the mouth, the glands at 
 the angle of the jaw and at the side of the neck become enlarged ; 
 when the sore is located on the nipple the glands under the arm 
 become enlarged. 
 
 These glands, although swollen, are not usually very tender 
 and rarely suppurate or produce matter. In the course of a few 
 weeks the glands become swollen throughout the body; even if the 
 sore be in the usual situation it will be found that the glands of the 
 neck are somewhat enlarged. This enlargement of the glands is 
 one of the most persistent symptoms of syphilis, and one which 
 may betray the individual to an expert physician long after the 
 skin eruptions and the usual signs of syphilis have disappeared, 
 
 -i nl 
 
SECONUAKV SVFHILIS. 
 
 Secondary Syphilis. 
 
 4S1 
 
 The spread of the syphilitic poison through the system is mani- 
 fested by a series of symptoms which culminate in the appearance 
 of a rash upon the skin. This rash usually appears from six to 
 eight weeks after the disease has been contracted. For a few da)s 
 before the appearance of the rash the patient suffers from general 
 indisposition, lassitude, wandering pains in the joints and in the 
 licad, fever, loss of appetite and of sleep, and often profuse perspi- 
 ration. In many cases the symptoms are vague and indefinite like 
 those just mentioned, and the patient may have no suspicion as to 
 the cause of the difficulty. In some instances, however, there oc- 
 curs agoni/'Hg pain in some of the bones ; sometimes the patient 
 has a mo t violent headache which renders him almost or quite 
 delirious. 
 
 If the individual has already some constitutional taint, such as 
 rheumatism, gout or tuberculosis, the outbreak of constitutional 
 syphilis may be accompanied by an attack of rheumatic or gout)- 
 pain. If the individual be poorly nourished or exhausted by exces- 
 sive mental or physical exercise, or by the use of alcoholics, the 
 appearance of the constitutional symptoms of syphilis is hastened 
 so that the rash may become visible at the end of a month. 
 
 After the symptoms above described — headache, fever, etc. , — 
 have lasted for several days, the rash appears in the shape of deli- 
 cate red spots, usually from a quarter to half an inch in diameter. 
 Simultaneously with the appearance of this rash the fever and 
 accompanying symptoms subside. 
 
 The rash — which is called the syphilitic roseola — consists en- 
 tirely of these red or brownish-red discolorations of the skin. There 
 is, therefore, properly speaking, no eruption at this time — nothing 
 which is elevated above the surface of the skin. Indeed, the skin 
 remains perfectly smooth and even, and is changed in nothing except 
 its color. 
 
 This roseola is more distinctly seen on the sides of the chest 
 and on the neck ; and it is usually more distinct when the individ- 
 " ual's skin is somewhat warm. This rash may escape a careless 
 scrutiny; indeed, there are cases in which the patient himself is not 
 aware of its existence until his attention is directed to it by the 
 physician. 
 
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4S2 
 
 VKNERKAL OR PRIVATE DISEASES. 
 
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 This is usually the first, though not the only skin eruption which 
 appears as a manifestation of constitutional syphilis. It will be use- 
 less to describe in detail the eight or ten varieties, since these can 
 be recognized, not from any description, but only from long practi- 
 cal observation. It will suffice to say that they resemble the differ- 
 ent varieties of skin eruptions which have been described in the 
 section on skin diseases. Many of them have white scales like 
 psoriasis (dry tetter) ; some consist of pimples like the common 
 acne ; 'some appear as little blisters containing matter; others are 
 composed of watery blisters ; and one causes the formation of thick 
 scabs upon a raw surface — the last named has been already described 
 on a previous page under the name of r/t/>ia. 
 
 There are certain peculiarities as to the location of the syphil- 
 itic rash. Thus one of them is especially apt to occur on the palms 
 of the hands and on the soles of the feet, so that the nature of the 
 disease can often be recognized just from its location. 
 
 Another feature which is often of service in distinguishing the 
 syphilitic eruptions from those of similar appearance which are not 
 syphilitic in their nature, is the absence of itching. The eruptions 
 of syphilis rarely cause any itching, while the non-syphilitic erup- 
 tions which may be mistaken for them — such as psoriasis, prurigo 
 and eczema — are accompanied by more or less intense itching. 
 
 The skin is not the only part of the body in which the syi)liilitic 
 infection is manifested. The mucous membranes are also the seat 
 of disease at an early period of syphilis. The throat and the mouth 
 are almost always affected within the first few months after the dis- 
 ease has been contracted. In fact, there are cases in which no rash 
 occurs upon the skin until long after the throat has become sore ; 
 such cases have been occasionally mistaken fc. luilr. attacks of diph- 
 theria. These sores in the throat consist of vvliLish patches, vary- 
 ing in size from a pin's head to half an inch or more in diameter. 
 They occur on the tonsils, on the roof of the mouth, on the sides 
 of the tongue where it presses against the teeth, and in the groove 
 between the lip and the gum. In many cases one sees nothing un- 
 natural — unless, perhaps, a slight redness of the throat — upon 
 looking into the patient's mouth ; and if the examination be not 
 carried further, it might readily be supposed to be a simple and 
 innocent one. In such cases the examiner should always turn the 
 lip out so that he can inspect the base of the gums and the inner 
 
SECONDARY SYPHILIS. 
 
 483 
 
 surface of the lip. The trouble will often be rewarded by the appear- 
 ance of small white patches surrounded by a reddish border. 
 
 It should be said, however, in order to allay undue and unjust 
 suspicion that patches of similar appearance may be present in the 
 mouth of an individual who is not syphilitic. The distinction be- 
 tween the syphilitic sores and those from other causes can be made 
 only by the practiced eye. 
 
 These sores appear with especial frequence, and are unusually 
 obstinate in individuals who do not attend carefully to the cleanli- 
 ness of the mouth and teeth. They are apt to be obstinate also in 
 those who use tobacco in excess. 
 
 Another manifestation of syphilis, which often appears within 
 a few months after the contraction of the disease, is the occurrence 
 v)f small moist tumors called condylomata. In a previous chapter 
 we ha'(. described the pointed condylomata, which are merely 
 larj;c warts, usually caused by some irritation of the skin, but not 
 due to syphilitic infection. The condylomata which occur as a 
 part of syphilis, however, are not pointed, but Jlat ; they do not 
 look so much like warts as the other variety. They consist of 
 broad, flattened tumors, usually raised a quarter of an inch or so 
 above the surface, and covered with skin or mucous membrane, 
 rhc surface is often moist and sometimes ulcerated. 
 
 These tumors occur especially often at the places where the 
 skin and the mucous membrane are joined; their favorite location 
 is therefore around the orifice of the vagina, around the rectum 
 and in the vicinity of the mouth. Syphilitic individuals often 
 ha\c minute tumors, looking like simple pimples, in the corners of 
 the mouth ; these may be so small and insignificant as to attract no 
 attention. The fact is, however, that these tumors or condylomata 
 arc extremely contagious; the least matter or discharge from their 
 surface conveys the disease either to a healthy individual or even 
 to an adjacent portion of the same person. That is to say, that if 
 one of these tumors be located in a fold of the skin, so that its top 
 comes in contact with the skin on the opposite side of the groove 
 a second tumor will soon be developed at the point of contact If 
 one of these condylomata grows upon the inside of the thigh, a 
 second one will in all probability be developed at a corresponding 
 point on the other thigh. 
 
 In consequence of this fact — that new tumors are caused by 
 the discharge from any one — it happens that these condylomata 
 
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 H:i:t I lilt' '-■• 
 
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 484 
 
 VENKkEAL OK PRIVATE DISEASES. 
 
 are almost always found in groups, and rarely alone. They ma\ 
 occur on all parts of the body where there are large oil ^jlands ;uul 
 hair follicles. They are found on the genitals especially, on the 
 inner surface of the thighs, in the groins, under the arm, at tin- 
 corner of the mouth and of the nose, at the back of the neck, in 
 the ear, on the breast in women, and between the fingers ;uui 
 toes. 
 
 These tumors are more frequently found in women than in 
 men who suftcr from syphilis ; this seems to result from the fact 
 that a lack of cleanliness favors the development of these tumors, 
 and that it is possible for women to be more filthy than men in 
 their personal habits. 
 
 The skin eruptions in syphilis sometimes take the form nf 
 ulcers, which may or may not be covered by thick scabs. Thi> is 
 especially apt to occur in poorly nourished individuals and in those 
 who are neglectful in the care of the person. These scabs are some- 
 times so thick and numerous as to interfere seriously with the 
 movements of the limbs and with the wearing of the clotlies. 
 When these ar, removed there remain large foul ulcers, which aie 
 apt to be very painful in consequence of the irritation to which 
 they are subject from the clothes. When these ulcers heal tliey 
 leave large scars which, for a time at least, exhibit a dirty brown 
 or copper color. This peculiar color sometimes serves for tlie 
 detection of syphilis, even after the symptoms of the disease Iiave 
 subsided. 
 
 Another manifestation of the disease consists in the appear- 
 ance of lumps in and under the skin. These must not be mistaken 
 for enlarged glands, which occur in a few weeks after the con- 
 traction of the disease. These lumps appear in the skin on all 
 parts of the body, though especially often on the skin of the head 
 and face, on the forehead, nose and lips, on the shoulders and 
 thighs. These lumps, which may reach the size of hazel nuts, or 
 even larger, disappear under appropriate treatment without causiiiL,^ 
 trouble, but if not treated promptly they are apt to result in the 
 formation of ulcers, which may occasion the patient considerable 
 pain and annoyance. 
 
 Another manifestation of syphilis, which often occurs at the 
 same time with the appearance of these lumps on the skin of tiie 
 heatl, is falling out of the hair. The hair becomes dull, loses its 
 natural luster, and comes out upon very slight contact. Sometimes 
 
SECONDARY SYPHILIS. 
 
 485 
 
 whole bunches of it will be drawn out by the comb or even by a 
 stiff brush. The individual may become quite bald, though the 
 skin of the head is found to be covered wjth thick scales. Some- 
 times the loss of hair affects the eyebrows and eyelashes, the beard, 
 and even the entire surface of the body. This loss of hair usually 
 liappens only in individuals who are in a debilitated condition, 
 cither from the ravages of the syphilis itself or from some other 
 impairment of the health. Under appropriate treatment the 
 jiatient's general condition can be readily improved, after which 
 the hair grows again as luxuriantly as before. 
 
 Another manifestation of the syphilitic poison is a disease of 
 the nails. Properly speaking, the disease affects the skin around 
 the nails and the surface upon which they lie — the bed of the nails. 
 The skin surrounding the nail becomes red, swollen ?.nd painful ; 
 in many cases ulceration results, so that considerable matter is 
 formed and escapes at the sides and from under the nails. This 
 disease affects the toes as well as the fingers ; the fact occurs more 
 frequently on the former than on the latter. 
 
 In consequence of this affection the nails become ineven, 
 knotty, deformed and discolored ; they are usually loosened and 
 drop off, though new nails grow again when the ulceration of the 
 surrounding skin ceases. These new nails are not usually so regu- 
 lar and natural in appearance a; the former ones were. 
 
 Syphilis also causes p disease of the nails themselves, without 
 affecting the skin around them. In consequence of this disease the 
 nails become discolored and deformed ; they are dotted over with 
 white or brown specks, and the free edge uf the nail is often broken 
 off. 
 
 Such are, in brief, the aifections of the ski.i and mujous mem- 
 branes which occur during the first six or eight months after an 
 individual has contracted syphilis. The number and extent of these 
 eruptions, and the injuries inflicted upon the individual in conse- 
 quuncc, depend largely upon the person's general health and con- 
 dition, and upon the treatment pursued. If the subject of the 
 disease has always enjoyed robust health and taken care to keep 
 himself in good physical condition, he may escape most of the 
 affections which have been described in these pages. If in addi- 
 tion lie place himself under appropriate and skillful treatment his 
 chances for suffering but slightly frony' these affections are very 
 good. When properly managed an individual enjoying good health 
 
 3a 
 
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 mm 
 
 486 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 in other respects need suffer, during the first six months, almost no 
 other affection of the skin or mucous membranes than a soreness 
 of the throat and the simple rash on the skin which has been 
 described under the name of roseola. 
 
 The serious affections of the skin occur chiefly in persons of 
 poor constitution and in a debilitated condition. Generally speak- 
 ing it is therefore true that syphilis creates far more havoc amoii^r 
 hospital patients than among those of the better classes who me 
 met with in private practice. 
 
 While these affections are manifesting themselves on the skin of 
 the syphilitic individual, other changes are frequently taking place in 
 the internal organs, and it is these which constitute the danger of 
 the disease. The eruptions which appear upon the skin arc often 
 very annoying, and sometimes give the patient much bodily dis- 
 comfort ; but they rarely, if ever, are sufficiently serious to threaten 
 his existence, or even to interfere with the perfect performance of 
 his bodily functions. But the changes which occur in the internal 
 organs, though not so readily discovered as the rashes upon the 
 skin, are none the less real and are far more serious. 
 
 It is beyond our province here to attempt any description of 
 the diseases of the internal organs which are caused by the presence 
 of the syphilitic poison in the body, yet a i^w of them are so 
 important that brief reference must be made to them. 
 
 One of the first of these consists in the impoverishment of the 
 blood. This is manifested by the pallor, lassitude and loss of 
 strength which the individual suffers, usually within the "irst three 
 or four months after contracting the disease. This pallor and 
 impairment are sometimes so great as to unfit the individual ior the 
 performance of his usual duties, and even to confine him to the 
 house or to the bed. 
 
 Sometimes the syphilitic poison affects the brain, resulting in 
 the growth of tumors, which press upon this organ and prevent Ire 
 performance of its usual functions. The resulting symptoms vary 
 with the part of the brain affected ; sometimes the individual suffers 
 a stroke of " apoplexy" or paralysis ; at otaer times the movements 
 of the eyes are impaired so that the individual has a persistent 
 squint, or inability to move the eyeballs in the natural way. Thus 
 it may happen that the patient is unable to turn one of his cjes 
 inward toward the nose, or outward in the opposite direction. 
 Sometimes the upper lid droops and the patient is unable to open 
 
 J 
 
SECONDARY SYPHILIS. 
 
 487 
 
 the eye as widely as before. There may also be a ditference in the 
 size of the pupil. 
 
 At other times the power of motion and the feeling of the skin 
 are impaired. The patient may have certain spots on the body 
 which arc quite numb, and in which he has no feeling In fact, 
 there is no limit to the number and variety of the ailments which 
 may affect different parts of the body and different organs, as the 
 result of infection by syphilis. The disease may affect all the dif- 
 ferent organs and tissues, and may result in a grcjit variety of 
 disorders which often simulate other diseases, and whose nature 
 may not be for a long time suspected, 
 
 A frequent manifestation of syphilitic infection is the occur- 
 rence of pains similar to those of rheumatism, which may be felt 
 in any part of the body, but are especially liable to affect the legs 
 between the knee and the ankle. Sometimes these pains are 
 extremely acute, and render the patient restless and miserable; he 
 is unable to obtain the necessary sleep by day or by night. 
 
 Sometimes these pains are accompanied by a perceptible swell- 
 ing and thickening along the shin-bone ; in this case the bone 
 itself is tender upon pressure. The thickening and swelling may 
 extend along the entire course of the bone, from knee to ankle, or 
 may be perceptible only at certain points of the bone; sometimes 
 lumps of considerable size, even as large as a hickory nut, are to be 
 found at one or more points of the bone. 
 
 These pains are sometimes erroneously regarded as rheumatic ; 
 but from rheumatism they are readily distinguished by the fact that 
 they are much zvorsc at night, while the rheumatic pains do not fol- 
 low this rule. Rheumatism moreover is usually worse during a 
 chani^e in the weather, and during rainy weather, while the syphil- 
 itic pains do not thus vary. 
 
 Hereditary Syphilis. — Syphilis is one of the diseases which is 
 known to be transmitted from parent to child. It may be mani- 
 fested in the child at the time of birth, or may become evident 
 some months, or even years, afterward. The symptoms of syphilis 
 derived from the parents — and therefore called hereditary or con- 
 genital syphilis — vary somewhat according to the stage of the dis- 
 ease with which the parents were affected at the time of conception. 
 Syphilis is a frequent cause of abortion and miscarriage, and in 
 general it is true that the chances of abortion are greater if concep- 
 tion take place soon after the disease is contracted than if it be 
 
 I . ik 
 
 ' '. itl 
 
 ■■,^M■ 
 
1: 
 
 : I 
 
 486 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 I ,: 
 
 m ':■ >' 
 
 postponed until a later period. If conception occur during the 
 existence of the primary sore, or during the presence of the sec- 
 ondary symptoms — that is, within six or eight months after the 
 disease is contracted — abortion almost invariably occurs ; and if a 
 pregnant woman contract the disease during the first six or seven 
 months of her pregnancy, a miscarriage usually results. Thus it 
 often happens that a woman will suffer two, three or four abortions, 
 and finally bring into the world a living child at full term. In these 
 cases it is usually observed that the later children are retained in the 
 womb a longer time than t'lC/se which were conceived immediateh- 
 .".fterthe disease was contract-cl. Thus the first abortion may occur 
 at the third month, a second ai tnc fourth or fifth month, a third al 
 the sixth or seventh, and so on In other words, the ability to 
 retain and nourish the foetus to the full term increases when tlie 
 virulence of the syphilitic poison wears itself out. 
 
 The symptoms of congenital syphilis which appear at or after 
 biith, are usually seen on the skin and mucous membranes. Some- 
 times the child is brought into the world with a rash upon the skin, 
 consisting of large blisters which may contain watery fluid, or may 
 have pus (matter) in them. Such children are often born dead, 
 though they may have lived until within a few days or weeks of 
 birth, and if they are born alive, they rarely live more than a few 
 weeks. 
 
 Many children born with the syphilitic taint are apparently 
 healthy at the time of birth, and remain so for several weeks. 
 
 The appearance of the symptoms usually occurs within three 
 months after birth, occasionally some weeks later. There are cases 
 in which the first symptoms appear at or subsequent to puberty. 
 
 As to the source of the infection, it seems well established 
 that the child can be tainted with syphilis by either the father or 
 the mother. In the majority of cases it is apparent that the dis- 
 ease is derived from the father. And in general it is true that the 
 more recently the father has suffered from the disease, the more 
 probable is the outbreak of virulent syphilis in the ciiild wiiich lie 
 begets. Yet it must be remembered that the father communicates 
 the disease to his child in the act of propagation, not by the contact 
 of his person, but because a part of his body enters into the com- 
 position of the fcetus. This explains the fact that a man who has 
 no symptoms whatsoever of syphilis, and who may have been appar- 
 ently free from the disease for months or even years, begets, ne\ cr- 
 
SECUNDARV SYPHILIS. 
 
 489 
 
 thcless, a syphilitic child. The fact is that the disease is still present 
 in his system, thou<jh it may have been so controlled by treatment 
 and by sanitary measures that it does not manifest itself in his own 
 person. Many a man who has long been free from the signs of 
 syphilis and congratulates himself that he is entirely cured of the 
 dise.'ise, has been horrified to find that the skin eruptions and other 
 ailments which affect his new-born child, are due directly to the 
 taint derived from himself, which he supposed had been long before 
 eradicated from his system. 
 
 Another curious feature in the matter — which is, however, 
 explained by the fact just stated — is that the mother may remain 
 entirely free from syphilis even though she bears several syphilitic 
 children. This results from the fact that the wife contracts the dis- 
 ease only when the husband has some eruption, either on the skin 
 or on the mucous membranes. Months may elapse at a time during 
 which the man remains free from these eruptions and from sores 
 in the mouth, etc. ; and during this time he does not communicate 
 the disease to another individual unless some of his blood be trans- 
 ferred to that person. Contact alone, no matter how intimate it 
 may be, does not, therefore, transfer the disease ; and the wife 
 remains free from syphilis, although as the result of that intimate 
 contact the fcetus exhibits the syphilitic taint derived from the 
 father. 
 
 It may thus happen that a woman bears syphilitic children to 
 one husband, and In after years brings into the world healthy chil- 
 dren by a second husband; for the disease is entirely a ///j/^vVrt/ 
 one, and leaves no trace upon the woman unless it be communi- 
 cated directly to her person. 
 
 Another curious feature about the diease is, that a woman may 
 contract syphilis from her own child ; for the infant is apt to 
 develop in the first few weeks of life certain sores in the mouth, 
 which arc due to the syphilitic taint, and arc just as capable of 
 communicating the disease as the sores found in the mouth of an 
 adult who has contracted the disease in the usual way. If the 
 mother have some crack or abrasion on the nipple — and few 
 mothers escape these annoyances — the disease will almost cer- 
 tainly be communicated from the child to the mother by the act of 
 nursing. Hence this curious state of affairs: As the wife of a 
 syphilitic man, and as the mother of a syphilitic child, during the 
 nine months of pregnancy a woman may escape infection ; and yet 
 
 I5|! -: 
 
 M. 
 
 \ij^''*> 
 
mxwm 
 
 490 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 as the nurse of her own child sne falls a victim to the disease. Yet 
 it is true that such women seem to have a certain protection against 
 infection by their own children. Cases are known in which a 
 syphilitic child has been nursed by its own mother and the latter 
 has shown no signs of the disease, yet the same child has after- 
 ward communicated syphilis to a healthy wet-nurse. Hence it has 
 been supposed that a woman who carries in her womb the child of 
 a syphilitic father does really experience a mild attack of the dis- 
 ease, and that this attack may be so mild as to escape attention, 
 while it is sufficiently intense to protect the mother from subse- 
 quently contracting the disease. The whole subject of the relation 
 of the parents to syphilis i' the child is summed up by Professor 
 Neumann in the folio virr; 'ids : 
 
 First — Syphilis occurs in the child the earlier if the father have 
 contracted the disease a*" or .ibcit the time of conception; yet 
 fathers suffering from advanced syphilis can also beget syphilitic 
 children. 
 
 Second — Appropriate treatment applied to the father, or after 
 conception, to the mother, usually exerts a favorable influence in 
 protecting the foetus from syphilis. 
 
 Third — A child acquires syphilis from the mother in most 
 cases only when she has recently contracted the disease. It seems 
 that if she become syphilitic after conception, she is not likely to 
 communicate the disease to her unborn offspring. 
 
 Fourth — If both parents are suffering from syphilis at the time 
 of conception, the child exhibits the most intense forms of the 
 disease. 
 
 Fifth — The communication of syphilis from parents to their 
 children is the rule, although exceptional cases occur in which the 
 offspring are born healthy, notwithstanding the syphilis of the 
 parents. (In these cases the syphilis of the parents is almost always 
 of ancient date, so that it has worn itself out in their bodies and is 
 no longer communicable.) 
 
 Sixth — Hereditary syphilis is generally communicated to the 
 child by the father. Mothers who bear syphilitic children generally 
 remain apparently healthy (when the syphilis is derived from the 
 father) ; yet since such mothers are not usually infected by nursing 
 their own syphilitic children, we must suppose that they have 
 really experienced a slight attack of the disease which did not 
 make itself sufficiently prominent to attract attention. 
 
 Among 
 infants are 
 been alreadj 
 of the hand 
 chiefly arou 
 thickening a 
 These latter 
 from " snufllc 
 membrane, tl 
 he make cons 
 As the c 
 the peculiar 
 derangements 
 Sj'philis ! 
 of the head j 
 prominent, esj 
 the eyebrows 
 in many cases 
 skin between I 
 consequently c 
 from looking 
 revolved about 
 base of the nc 
 upward. In c( 
 upper part of t 
 usually somewl 
 has been descri 
 forehead and th 
 intervening spac 
 's apt to be sh( 
 the eyes, so tha 
 In many cases t 
 some catarrh. 
 
 Another fea 
 is the peculiar si 
 edge of such a t 
 the sides extend 
 being " cb ,el-sh 
 Ano ,er aff 
 obstinate affecti 
 
SECONDARY SYPHILIS. 
 
 491 
 
 Among the symptoms which mark the hereditary syphilis of 
 infants are various eruptions on the skin, to which reference has 
 been already made. Sometimes the rash affects merely the palms 
 of the hands and the soles of the feet ; at other times it occurs 
 chiefly around the buttocks ; in other cases it is manifested by 
 thickening and a discharge from the mucous membrane of the nose. 
 These latter cases are those in which the child suffers extremely 
 fvom " snuffles " ; in consequence of the thickening in the mucous 
 membrane, the infant is unable to breath through the nose unless 
 he make considerable effort and noise. 
 
 As the child grows older the syphilitic taint is manifested by 
 the peculiar shape of various bones in the body, as well as by 
 derangements in different organs of the body. 
 
 Syphilis shows itself in these children especially in the shape 
 of the head and of the nose. The forehead is apt to be quite 
 prominent, especially the upper part, while the lower part above 
 the eyebrows is somewhat sunken. The bridge of the nose seems 
 in many cases entirely absent, so that there is no elevation of the 
 skin between the corners of the eyes. The point of the nose is 
 consequently considerably elevated ; in fact, the impression derived 
 from looking at such a nose is as if the entire organ had been 
 revolved about an axis running through the nostrils, so that the 
 base of the nose is turned backward and the tip of the organ 
 upward. In consequence of this shape of forehead and nose, the 
 upper part of the face looks in profile bow-shaped. The mouth is 
 usually somewhat sunken and the chin prominent ; the entire face 
 has been described as " concave" — that is, the upper part of the 
 forehead and the chin are the two most prominent points, while the 
 intervening space is hollowed out. The nose of such an individual 
 is apt to be short, thick and broad, and it widens rapidly toward 
 the eyes, so that the base of the nose attains an extreme breadth. 
 In many cases these individuals suffer from obstinate and trouble- 
 some catarrh. 
 
 Another feature which is characteristic of secondary syphilis 
 is the peculiar shape of the middle teeth in -the upper jaw. The 
 edge of such a tooth ''> usually hollowed out in the middle, while 
 the sides extend dov n into points ; hence the tooth is described as 
 being " ch -.el-shaped. " 
 
 Ano ler affection which is due to congenital syphilis, is an 
 obstinate affection of the eyes. This does not usually manifest 
 
 \< 
 
 'V 
 
 :vt'-5;^ki 
 
 m 
 
 Msd 
 
492 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 itself until the period of puberty. The front of the eyes becomes 
 somewhat white and opaque, or as the patient describes it, there is 
 a "scum over the eye." The sight may be for a time almost lost, 
 but is recovered again usually under proper treatment. In many 
 cases the second eye is affected soon after the first, or after recov- 
 ery in the first eye. 
 
 The subjects of hereditary syphilis are susceptible also to 
 paralysis, and to other manifestations of disease in the brain ; 
 these may be manifested in childhood, and may occur without 
 apparent cause. These children are also subject to various 
 deformities of the bones, and to disease affecting the bone struc- 
 tures. Thus these children are frequently afflicted with caries or 
 necrosis — diseases which consist essentially in the mortification of 
 the bone, as a result of which the skin and flesh over the bones 
 become ulcerated and produce matter. These affections arc very 
 obstinate, and may last for a considerable time unless the cause of 
 the disease (syphilis) be recognized and appropriate treatment be 
 employed. 
 
 Tveatment, — Syphilis is practically an incurable disease. 
 By this it is not meant that individuals once affected with syphilis 
 never recover entirely from its effects or never cease to manifest 
 evidence of its presence in the system. It is meant simply that 
 the cases in which recovery occurs do not constitute the majority; 
 on the contrary, they form a small minority. It is always possible, 
 except in very much debilitated individuals, to cure the usual 
 manifestations of the disease on the skin, mucous membranes and 
 in the bones; and in many cases it is possible to relieve serious 
 symptoms, such as paralysis, which result from syphilitic disease of 
 the brain. In fact, the physician who is called to a case of paralysis 
 or apoplexy is always rejoiced to find that the patient has had 
 syphilis, since he knows that if the disease be caused by some 
 change in the brain due to syphilis, the chances for the patient's 
 recovery are much better than is otherwise the case. 
 
 While it is thus usually possible to cure the different outbreaks 
 of syphilis, as they occur from time to time, the physician is never 
 certain that the poison is completely eradicated from the patient's 
 system. The individual may enjoy months and years of uninter- 
 rupted health; he may be entirely free from even the slightest 
 manifestation of the disease ; and yet five, ten, or even twenty 
 
SECONDARY SYPHILIS. 
 
 493 
 
 years afterward, he may be afflicted with an ailment which points 
 unmistakably to the syphilitic poison as the source of the difficulty. 
 Perhaps the most critical test of a man's freedom from syphilis is 
 to be found in the condition of his children, for it often happens 
 that the man himself may remain for a long time quite free from 
 all evidences of the disease, and yet, at the end of that time, may 
 bct;ct children who illustrate the fact that the sins of the father are 
 visited upon the children. 
 
 In view of this practical incurability of syphilis, or rather of 
 the impossibility of determining that a man who has once contracted 
 the disease is completely free from it, the question naturally arises, 
 whether an individual who has once suffered from syphilis is justi- 
 fied in marrying at all. This question has been the subject of much 
 observation and thought on the part of tncdical men, and opinions 
 still vary because the facts observed in different cases also differ. 
 There can be no doubt that the prevalence of the disease would be 
 restricted if all men — and women too of course — who have once 
 suffered from the disease, would refrain from marriage and from all 
 unnecessary personal intercourse and contact with others. Yet 
 this plan could not and of course would not be adopted ; such a de- 
 mand on the part of society would hardly be justifiable, since many 
 cases do occur in which individuals recover so completely from the 
 disease as to be quite free from it themselves and to beget children 
 who exhibit no evidences of the poison. 
 
 Since, therefore, such individuals can not be asked nor com- 
 pelled to refrain from marriage, the important question is, ^wder 
 what conditions may such a man feel justified in marrying ? 
 
 To answer this question we must realize the risk which every 
 man who nas once had syphilis imposes upon a woman and upon 
 unborn children by assuming the marriage relation. It must be 
 remembered that the ability to communicate the disease does not 
 cease when the primary sore is completely healed. It must be 
 borne in mind, that for some weeks or months during the first year 
 after contracting the disease, the touch of his lips is often sufficient 
 to communicate the disease. Furthermore he does not know at 
 what time in subsequent years sores may break out in his throat or 
 mouth, or about the genitals, which are just as virulent and con- 
 tagious as the original primary sore. If a man bears all these 
 thinc^^s in mind ; if he realizes that his most affectionate caress may 
 deal disease and even death to an innocent and trusting woman; if 
 
 Ifl'- 
 
 if V 
 
 ^ri\.''i '■•■i 
 
 
494 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 he remember further, that his children and hers may rise up to curse 
 the day and the man by whom they were brought into a world 
 of disease, ..e will listen with more patience to the warning which 
 the accumulated experience of medical men pronounces most em- 
 phatically for all those who have once suffered from syphilis. 
 
 It may be safely asserted that under no circumstances should 
 an individual marry within two years after the last manifestations 
 of syphilis have disappeared. And even at this time he shoiiUi 
 not take the risk unless his general health is such as to encouraj^c 
 him in the belief that there is none of the poison lurking unseen in 
 his system. This period will, in most cases, be at least three years 
 after the disease was contracted. 
 
 In order to determine so far as possible his freedom from the 
 disease, the patient should of course submit himself to the most 
 careful medical examination. More than that, he should, from the 
 very beginning of the disease, keep himself under constant super- 
 vision by the best medical man at his service. The chances are 
 great that if treatment be discontinued so soon as the first manifesta- 
 tions of the disease have disappeared, subsequent outbreaks of 
 syphilis will occur. In order to secure the greatest possible assur- 
 ance of success in getting rid of the poison, both treatment 
 directed against the disease and the most careful attention to the 
 general health should be maintained for months after the disap- 
 pearance of the symptoms. By this it is not intended that the 
 patient shall take medicine regularly every day during the entire 
 time ; in fact experience has shown that the best and speediest 
 results are obtained by omitting medicines for a time and resum- 
 ing them subsequently at intervals, but it is meant that the patient 
 shall remember that the first object of his existence is to do every- 
 thing possible to rid himself of the syphilitic poison. This will 
 include the most careful attention to the ordinary rules of health, 
 good diet and proper exercise. For it is abundantly shown that 
 syphilis is the more dangerous and persistent as the general health 
 of the body becomes depreciated. The worst cases of the disease 
 are found in those who, either from hereditary taint or neglect, 
 have become reduced in their general health ; the ravages of the 
 disease, even including the primary sore, are much less in healthy 
 and robust individuals. 
 
 If the patient conscientiously observe the principles laid down 
 in these lines ; if he regards it as a duty to keep himself under the 
 
SECONDARY SYPHILIS. 
 
 495 
 
 direction of his physician so long as the least symptom of the dis- 
 ease remains ; and if he have the moral courage and the self-con- 
 trol — the regard for the happiness of others which he would have 
 them observe toward him under like circumstances — he may console 
 himself with the assurance that, sooner or later he may, with a clear 
 conscience, follow the natural instinct of a man and marry. Yet it 
 must be admitted that even then there remains a possibility that 
 disaster may follow ; and in this case, if he have the least spark of 
 manhood, the least grain of affection for his wife and children, he 
 will regret with the keenest remorse that he did not choose the 
 wiser, though perhaps less blissful lot, and remain single. Surely 
 nothing could inspire a man with more bitter regret than to see in his 
 own wife and family the results of his selfish course manifesting 
 themselves by the most loathsome and incurable of diseases. Such 
 sights are unfortunately common in the observation of physicians. 
 
 That an individual who is still suffering from syphilis should 
 most carefully avoid all contact, direct or indirect, with other per- 
 sons, seems so self-evident, that a statement of the fact appears 
 unnecessary. Yet it is unfortunately the actual fact that such indi- 
 viduals are extremely careless, and even criminally negligent in 
 distributing promiscuously the poison which emanates from their 
 own persons. 
 
 The prevention of syphilis has occupied a great deal of atten- 
 tion on the part of law-makers as well as of medical men. The 
 matter rests, of course, chiefly with the individual, since in the 
 vast majority of cases the disease is contracted through the gratifi- 
 cation of the sexual appetite. Since it seems impossible for men 
 to lestrain themselves from the unlawful indulgence in such gratifi- 
 cation, the attention of those interested in preventing the disease 
 has been chiefly directed to the regulation and supervision of pros- 
 titutes. 
 
 This question has, of course, a moral aspect, which should be 
 considered before the means for executing it are discussed. It is 
 not our purpose to consider this moral side of this question ; it may 
 however be proper to state that, from the medical point of view, 
 the attempt to restrict the spread of syphilis by official inspection 
 and regulation of prostitutes has not been particularly successful. 
 It would be out of place to state in detail the reasons why tkis plan, 
 which is apparently so complete, has failed. Yet the experience of 
 Paris, Berlin, Vienna and other European capitals, has proven the 
 
 I 
 
 i I,, 
 
496 
 
 VKNKRKAL f)R PRIVATE DISEASES. 
 
 inefficacy of this procedure in limiting the prevalence and spread 
 of syphilis. In this country this method has not received the sanc- 
 tion of public opinion, and has not been carried into effect to any 
 great extent ; yet we are thus far, as a community, less afflicted 
 with the disease than most of the peoples of Europe. 
 
 Various plans have been proposed for protecting the individual 
 from contracting the disease during intercourse. Without mention- 
 ing these, it may suffice to say that no reliance whatsoever can be 
 placed upon any of them. The force of this statement becomes 
 apparent without detailed discussion, when we remember that tlie 
 disease is communicated by any discharge from the body, and by 
 the matter contained in any sore of the individual suffering from 
 the disease. Thus instances are known in which the disease has 
 been communicated by the scratch of a finger nail, there havins^ 
 been a syphilitic disease around the nail at the time, some of the 
 matter from which had been introduced into the skin by means of 
 the nail. 
 
 It has been proposed to cut out the primary sore so soon 
 as it becomes visible, in the hope that by removing this portal 
 of infection the syphilitic poison might be prevented from getting 
 into the body. This plan has been carried into effect in a large 
 number of cases by different physicians. The results reported 
 are almost unanimous in proving that this method is quite ineffec- 
 tual in preventing the virus of syphilis from entering the body ; 
 since in nearly all cases the disease has been manifested in just the 
 same way subsequently as in those cases in which the primary sore 
 has not been cut out. The operation is a trifling one, and it may be 
 well in every case to give the patient the benefit of the possibility, 
 but the fact is that the primary sore does not exhibit the character- 
 istic of a syphilitic sore until after the poison has entered the body. 
 Hence, although the sore in the skin may be completely removed, 
 it is already too late to prevent the access of the virus into the 
 system. 
 
 The treatment of the disease should in no case be undertaken 
 by the patient himself; his ability to manage the affair ends with 
 the first manifestation of the di.sease. It is only proper to empha- 
 size with all the weight of medical experience, that the only proper 
 treatment of syphilis consists in a careful avoidance of exposure to 
 it. This is not a mere question of morals or of religious observ- 
 
f%^- y: 
 
 SK'-dNDAKV SVniILIS. 
 
 497 
 
 ancc ; it is a matter whicli underlies the happiness of the com- 
 munity, individual and collective. 
 
 " Me, therefore, who exposes himself to venereal disease docs 
 iKit endanj^er alone his own health, peace and happiness, but 
 assumes a risk for posterity which is criminal on his part. The 
 physician alone can understand the terrible nature of this disease, 
 and could the people but see a tithe of what is witnessed by a 
 physician who practises in this line, there would be such a wave of 
 popular feeling and action that if it could not sweep prostitution far 
 from till" habitation of enlightened man, would at least restrain its 
 ravages by sanitary laws even more stringent than those applied to 
 ^mall-pox and other contagious diseases. The opinion is strong 
 among many medical men, that the person who communicates 
 ^'cnercal disease should be punished as severely by the law, as he 
 who would voluntarily spread small-pox, commit arson, or murder. " 
 
 —B/i/i-ZO'-) 
 
 Wherever it is possible the patient should place himself under 
 the care of a ])hysician, and not attempt to treat himself. I"\m- in 
 no other disease is it more important to remember that treatment 
 is always directed to the patient and not to the disease ; and the 
 treatment in cases of syphilis varies extremel)', according to the 
 condition of the patient and his ability to withstand the ravages 
 of this formidable affection. Since many sufferers from the dis- 
 ease are unable to place themselves under the immediate care of a 
 physician, the general plans of treatment will be outlined here. 
 It must be again remarked that the various manifestations of 
 the disease are so numerous and so different that they can be 
 recognized only after long observation and experience with such 
 cases. 
 
 TrcntiHcnt of the Primary Sore or Chancre. — The first 
 thing to be ascertained is, whether the sore is really syphilitic or 
 not. The treatment will vary greatly according to the nature of 
 the sore, for several varieties of sores or ulcers often appear u\nm 
 the genital organs ; some of these are derived by contagion, others 
 arc perfectly innocent and harmless. It is, of course, impintant 
 to distinguish the latter from the former, for the course and dura- 
 tion of the contagious sores can be materially modified by treat- 
 ment. On the other hand, the simple and innocent sores are only 
 ai^^gravated, prolonged, and made worse by the treatment which is 
 adapted to the contagious ulcers. 
 
 't i' 
 
 IV- \ 
 
 iti- 
 
 
 
«:'V 
 
 498 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 The primary sore or chancre of syphilis cannot be distinguished 
 during the first few days of its existence from several other sores. 
 It is well, therefore, to adopt certain measures of treatment whicli 
 are applicable to them all. If any sore or pimple appear on the 
 genital organs after exposure to the possibility of infection, the 
 spot should be at once cauterized lightly. This may be done by 
 touching the sore with a stick of lunar caustic. Considerable care 
 should be exercised not to allow the caustic to touch the healthy 
 skin around, and not to press it too deeply into the skin, for in 
 these ways a large and ugly sore may be made where only a simple 
 and innocent one existed. It will be best to apply this caustic 
 lightly at first, so as to touch the entire sore surface. A small 
 piece of fine lint, on which vaseline is spread, may then be placed 
 over the spot, and held in position by strips of adhesive plaster, 
 or in any other convenient way. In twenty-four hours the surface 
 which was white after the caustic had touched it comes away in 
 pieces accompanied with considerable matter. When this has 
 occurred, it may be well to touch the surface once more, and dress 
 it as before. ' In most cases it is not advisable to employ any fur- 
 ther cauterization. 
 
 In a few days after the sore has been thus burned, it will heal 
 entirely if it be not of a contagious nature. If, however, it be a 
 true chancre, it will remain open for some days or even weeks. If 
 this be its nature, the patient will soon observe that the base — that 
 is the skin surrounding the sore — becomes very hard and elevated 
 above the general surface of the skin. Under such circumstances 
 it may be advisable to cut this sore and its hardened base out 
 entirely ; for, although there is but little probability of preventing 
 constitutional syphilis by this procedure, yet it may be well for the 
 patient to have the benefit of the doubt. Furthermore the wound 
 which is left by the removal of the chancre often heals more 
 rapidly than the sore itself would if it were allowed to remain. 
 
 In some cases it will be found, after the sore has been cauter- 
 ized as already directed, that it remains obstinately open, althouj^h 
 its base does not become hard and raised as in the former case. 
 The sore is quite shallow, surrounded by a red line and covered 
 with a dirty white layer of matter. This so:e will probably be not 
 the chancre of syphilis, but the venereal ulcer. This ulcer and the 
 treatment appropriate for it will be described in subsequent pages. 
 
 There is a third form of ulcer which frequently appears upon 
 
SECONDARY SYPHILIS. 
 
 499 
 
 the sexual organs; this is the true herpes, or " fever blister," pre- 
 cisely similar to the fever blister which often appears on the lips. 
 It often results in the formation of shallow ulcers which for a day 
 01" two closely resemble the venereal ulcer. If the patient has a 
 guilty conscience, these ulcers may frighten him into the belief that 
 he has contracted the disease. If, however, he abstain from 
 further treatment than a single cauterization with lunar caustic, and 
 then await developments, he will see that in three or four days the 
 ulcer has healed entirely. 
 
 If the patient have a true chancre — and he may rest in that 
 belief if it persists for two weeks after the use of the lunar caustic, 
 and if the skin around it becomes thickened and hard ; if he be 
 satisfied from these signs that the sore is of syphilitic nature, he 
 may dress it simply by dusting upon it powdered iodoform. This 
 will be found the most serviceable of all dressings for contagious 
 sores on this part of the body. 
 
 The iodoform may be applied by simply sprinkling it upon the 
 part from the point of a knife-blade until the sore is thickly cov- 
 ered with the powder. This substance is not of the nature of a 
 caustic, and occasions no pain ; a very slight smarting, which lasts 
 but a few minutes, is the most serious effect to be anticipated. 
 After the sore is covered with the powder, a piece of lint or of 
 cotton wool may be laid over it so as to keep the powder from fall- 
 ing off; and this lint or cotton may be bound on by means of adhe- 
 sive plaster. 
 
 This ioJoform dressing may be renewed morning and night ; 
 in a few days the surface of the sore, no matter what its nature may 
 be, will be clean and red, and look as if it were healing. 
 
 The sole objection to the use of iodoform is the fact that it has 
 a most pungent and by no means pleasant odor. For this reason 
 the patient should be extremely careful in handling it, not to get 
 any of the powder upon his fingers or clothing. The odor will 
 attract attention, and excite the curiosity of the inquisitive ; and 
 for tliOie who have had a similar experience, the odor of iodoform 
 suffices to betray the patient's secret. This odor can be obscured 
 to a great extent by the use of the attar of roses, two drops of 
 whiLh are usually sufficient to mask the smell of a drachm of the 
 drug. 
 
 Sometimes the sore gives considerable pain and uneasiness ; in 
 
 i 1m: 
 
 \y.a 
 
500 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 S 8 d 
 
 this case it may be dressed for a few days, until it becomes less irri- 
 table, with the following ointment: 
 
 Wine of opium, - - - - Half an ounce. 
 
 Simple ointment, - - - - Eight ounces. 
 
 This may be spread upon lint or soft cloth, and laid upon the 
 surface, where it is kept in position by adhesive straps. Instead of 
 this, the following lotion may be found more soothing: 
 
 Wine of opium, - - - - Four drachms. 
 Lead water, . . _ _ Four ounces. 
 
 Mix and apply upon soft cloths. 
 
 By means of one or another of these applications, the chancre 
 can be finally healed. Soon after this occurs, if not before, the sore 
 has become entirely healed, the first manifestations o( cousfitN/uvid/ 
 sypJiilis appear and aemand attention. It is sometimes possible to 
 avert some of these manifestations by beginning constitutional 
 treatment early ; but in nearly all cases the eruption on the skin and 
 the soreness of the throat appear, no matter how early treatment 
 may be begun. 
 
 As is generally known to the public, there are two remedies 
 which are commonly used in the treatment of syphilis by all phy- 
 sicians. It matters not how emphatically a medical man may 
 protest that he does not use any mineral remedies ; that he 
 employs only vegetable substances ; the fact is, that without nier- 
 ciiry and the iodide of potassium syphilis would be to-da\- as 
 intractable as it was five hundred years ago, when it devastated 
 certain countries in Europe like a plague. 
 
 There is, of course, a popular hue and cry against mercury; 
 in fact, this objection to the use of the drug has become such a 
 strong prejudice that many physicians are careful to conceal the 
 fact that they employ mercury in the treatment of syphilis. This 
 objection has sprung from the abuse of mercury, which was so 
 common among medical men a century ago. There is no doubt 
 that many individuals have been injured seriously and permanently 
 by the preparations of mercury administered by their physicians; 
 but this does not alter the fact that mercury, properly used, is one 
 of the most valuable drugs, as well as one of the most innocent 
 remedies that we possess. The excessive use of this substance 
 and the abuses that accompanied it, caused physicians to employ 
 more caution and to study its effects more carefully. The result is 
 
SECONDARY SYPHILLS. 
 
 501 
 
 that it is now possible to employ the various medicines containing 
 niorcury without the least danger of causing any injury to the 
 patient. This successful and safe use of mercury requires skill and 
 experience on the part of the prescriber. It follows therefore that 
 the non-professional person cannot be too cautious in administering 
 any preparation of mercury, and that with the exercise of all pos- 
 sible caution he is very apt to inflict damage. There are no rules 
 which can be laid down for the use of mercury, which will apply to 
 all cases. Hence only an outline of treatment will be given in this 
 work. 
 
 Mercury may be administered in any one of four • ays. The 
 most usual and convenient mode of administration is by the stom- 
 ach, in the shape of pills, or of liquid preparations. Yet this 
 method is not always practicable, since some of the forms of mer- 
 cury are apt to cause irritation of the stomach and bowels. In 
 such cases it is customary to resort to the second method — the use 
 of mercury by anointing the skin with ointments containing the 
 drug. This method has certain advantages, but is extremely 
 tedious, wearisome and unpleasant. In other cases the drug is 
 administered by hot air baths impregnated with the vapor of mer- 
 cury. The fourth method consists in the injection of some form of 
 the drug under the skin. 
 
 The only one of these methods which can be entrusted to the 
 non-professional is the usual one, which consists in taking mercury 
 in the shape of medicines by the stomach. For this purpose one 
 of the following prescriptions may be employed : 
 
 Red iodide of mercury, 
 Extract of gentian. 
 Extract of nux vomica, 
 
 - One grain. 
 One scruple. 
 
 - Four grains. 
 
 Make twelve pills, and take one after meals morning and night. 
 Another form is the following : 
 
 Bicyanide of mercury, - - - One grain. 
 
 Quinine, _-...- Twenty grains. 
 Extract of gentian, - . _ . Twenty grains. 
 
 Mix, and make twenty pills ; take one morning and night. 
 
 This latter prescription is especially useful in those forms of 
 syphilitic skin eruptions which are characterized by the presence of 
 
 ■■ i ' 
 
 "Irr 
 
 iji r 
 
 .VI 
 
i,Li 
 
 502 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 Bicloride of mercury, 
 Extract of gentian, 
 Extract of nux vomica. 
 
 scales or of pustules. In other cases it may be well to use the fol- 
 lowing prescription : 
 
 Half a grain. 
 
 - Twenty grains. 
 
 Four grains. 
 
 Mix, and make twenty pills ; take one three times a day after 
 meals. 
 
 Whenever the patient takes mercury in any form whatsoever, 
 he must keep his attention fixed upon the condition of his mouth ; 
 for the earliest manifestations of ;0 injurious effects of the drug 
 occur in the shape of an excessive secretion of saliva, and of 
 sponginess and bleeding of the gums ; in fact, the teeth may become 
 loosened and fall out. This is the condition known as " salivation." 
 Until this occurs the patient may rest assured that the drug has not 
 been taken in excess, nor in such quantities as to do him harm. 
 
 It is, of course, desirable to avoid salivation; and this can be 
 easily accomplished if the patient will take pains to keep the mouth 
 clean, and to note every day whether or not he experiences the least 
 tenderness in the gums when the teeth are firmly pressed together. 
 He should be scrupulously careful to use the tooth brush at least 
 twice a day ; should rinse the mouth out after eating and after taking 
 the medicine ; and he should avoid excess in the use of tobacco, 
 since this irritates the mucuous membrane of the mouth, gind predis- 
 poses to salivation. So soon as the patient feels the least tenderness 
 when he presses the teeth firmly together, he should discontinue the 
 nse of the drug or medicine which contains mercury for at least ton 
 days. The tenderness in the mouth will usually subside in two or 
 three days after the mercury has been stopped ; and a week subse- 
 quently he may resume the use of the pills again. In fact it is desir- 
 able to stop the use of any medicine which may be employed in the 
 treatment of syphilis after it has been faithfully used for five or six 
 weeks, even though no symptoms be produced by it ; for experi- 
 ence has shown that the best results arc obtained by giving the 
 patient an intermission of a week or ten days occasionally, after 
 which the medicines may be resumed. 
 
 Mercury is extremely valuable, in fact indispensable, in the 
 treatmentof those forms of syphilis which occur during the first five 
 or six months after the disease has been contracted. It is durin^j 
 this time that certain rashes appear upon the skin, in the treatment 
 of which mercury is especially valuable. 
 
SECONDARY SYPHILIS. 
 
 503 
 
 After the expiration of six months mercury iS not so frequently- 
 employed nor required. After this period, reliance is placed upon 
 the iodide of potassium. This remedy may be used with far more 
 freedom than mercury, since it may be employed in excessive doses 
 without causing any other ill effects than a rash upon the skin. The 
 iodide of potassium is especially valuable in the treatment of syph- 
 ilitic affections of the internal or onus. Thus one of the most frequent 
 and annoying symptoms of secondary syphilis \% pains in the bones, 
 felt especially at night. This symptom can be relieved only by ihe 
 iodide of potassium. By the use of this drug these pains, which 
 often deprive the patient of sleep, and hence impair his strength 
 materially, can be speedily and surely relieved. 
 
 The iodide of potassium is almost always taken in solution. Its 
 efficacy seems to depend chiefly upon the iodine which enters into 
 its composition ; hence it is customary to prescribe some iodine at 
 the same time with the iodide of potassium. The following formula 
 proves very agreeable and efficient : 
 
 Iodine, - . . _ _ 
 
 Iodide of potassium. 
 
 Syrup of sarsaparilla, 
 
 Mix and take a teaspoonful after meals. 
 
 The sarsaparilla is used in this prescription, not for any effect 
 of the drug upon the disease, but merely because it forms a pleasant 
 medium for administering the iodide of potassium and the iodine. 
 
 In most cases it is desirable that the patient should take both 
 mercury and the iodide of potassium for a considerable time. The 
 following prescription may therefore be administered so soon as it 
 becomes evident that the patient has contracted syphilis, though in 
 most cases the benefits of the iodide of potassium become evident 
 only after several months have elapsed, 
 
 Bichloride of mercury, - One grain. 
 
 Iodide of potassium, - - Four drachms. 
 
 Syrup of sarsaparilla, - 
 
 Water, _ . _ _ Each two ounces. 
 
 Mix and take a teaspoonful after meals. 
 
 It is the practice of many eminent physicians in this depart- 
 ment of medicine to begin the treatment of syphilis by rubbing 
 mercurial ointments into the skin. The disadvantages of this 
 method are the trouble and time necessary to accomplish the rub- 
 
 Eight grains. 
 One ounce. 
 Eight ounces. 
 
 n 
 
504 
 
 VENEREAL OK PRIVATE DISEASES. 
 
 bing, and the unpleasantness to the patient. Yet in some instances 
 it is necessary to administer remedies by some other means than as 
 medicines to be taken into the stomach, for some individuals cannot 
 endure the preparations of mercury upon the stomach ; they are 
 troubled with vomiting and diarrhea whenever these medicines arc 
 taken. 
 
 In order to rub mercury into the skin a preparation is made in 
 the shape of an ointment. For this purpose the ordinary mercurial 
 salve is used. 
 
 The patient should take a warm bath and wash himself thor- 
 oughly with soap ; these baths should be repeated after every fifth 
 or sixth time that the salve is rubbed into the skin. As much of 
 the salve is taken into the hand as will comfortably fill the palm — 
 say a quantity as large as a hickory nut. This should be spread 
 around upon the hand and then rubbed into the skin. It is well for 
 the patient to anoint himself in this way in a well -ventilated room 
 at such hour of the day as will permit him to rest for an hour or 
 two afterward. The patient should select different parts of the skin 
 for the inunction (as the rubbing process is called) on successive 
 days. Thus he may on the first day rub the sa'"e into the inner 
 surface of both thighs ; on the second day the inner surface of botli 
 legs (below the knees); on the third day the front of the bocl\ , 
 chest and abdomen (avoiding the nipples and armpits); on the 
 fourth day he may anoint the loins and the sides of the chest ; on 
 the fifth day the back, and so on. The object of this change is the 
 avoidance of unnecessary irritation of the skin. After he has gone 
 over the entire body in this way (excepting, of course, the head), 
 he may begin again with the thighs. 
 
 It will be well for the patient to make these inunctions in ;i 
 warm room, so that the skin may be active and the ointment may 
 penetrate thoroughly into the pores. In rubbing he should so far 
 as possible rub in the direction of the hairs, so as to avoid irritation 
 of the skin. 
 
 These inunctions m^y be continued until the syphilitic rash tor 
 which they are used has disappeared ; this usually occurs by tlie 
 time twelve or fifteen inunctions have been made. It must not be 
 forgotten that whenever a patient is using mercury as a remedy lie 
 must alzvays watch carefully the condition of the mouth, and must 
 stop the use of the drug so soon as the slightest tenderness of the 
 gums upon pressing the teeth together is observed. He will also 
 
SECONDARY SYPHILIS. 
 
 505 
 
 .emember that unpleasant symptoms in the mouth can be avoided 
 to a great extent by careful cleansing of the teeth and rinsing of 
 the mouth ; it may be advisable also to harden the gums and the 
 mucous membranes by frequently rinsing the mouth with brandy 
 and by using one of the following gargles : 
 
 Alum, ----- Two drachms. 
 
 Chlorate of potash, - - - Three drachms. , 
 Water, - - - - - Half a pint. 
 
 Or a gargle of tannin solution may be used, after the following 
 formula : 
 
 Tannic acid, - - - . One drachm. 
 
 Tincture of opium, . - . Twenty drops. 
 Water, . . - _ . Ten ounces. 
 
 These inunctions are especially valuable in those skin eruptions 
 in which scales are formed ; for cases in which syphilis is mani- 
 fested in affections of the eyes ; in congenital syphilis; and in short, 
 wherever it is desirable to secure the effect of mercury rapidly. 
 
 The oleatc of mercury constitutes an admirable ointment for 
 inunctions in syphilis ; it is said to be absorbed and to produce the 
 effect of the mercury more speedily than other ointments. 
 
 One of the troublesome symptoms of syphilis during the first 
 few months after the disease is contracted, is the occurrence of 
 sores in the throat ; these may also be present at subsequent 
 periods, even several years later. This difficulty is often over- 
 looked by the patient, who imagines that he has simply an ordinary 
 sore throat from cold. Yet if the throat is carefully inspected there 
 will be seen not only a general redness, but also numerous white 
 patches scattered here and there upon the tonsils and in the mouth. 
 
 The treatment of this sore throat consists in touching the sores 
 occasionally with a stick of lunar caustic ; this may be repeated if 
 necessary on the third or fourth day subsequently. Meanwhile the 
 patient should use a gargle consisting of borax or the chlorate of 
 pota; h, as follows : 
 
 Borax, . - . . . Three drachms. 
 
 Water, - - _ . _ Eight ounces. 
 
 A strong solution of alum will also be beneficial. 
 
 It must not be forgotten that the patient should always take 
 constitutional treatment, as already described, whenever he has a 
 manifestation of syphilis in the throat or elsewhere. If he use 
 local applications alone, he will perhaps fail to heal the sores, or at 
 best will succeed after long and tedious effort. 
 
 ii 
 
 
 
I' 
 
 506 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 Two grains. 
 One drachm. 
 Half a drachm. 
 Two ounces. 
 One ounce. 
 One ounce. 
 
 The small tumors, condylomata, will sometimes disappear by the 
 use of the constitutional treatment, without local application ; but 
 it is advisable to place cotton wool around them and in the folds of 
 the skin where they are usually situated. Their disappearance can 
 be hastened by using in addition to medicines taken internally, 
 some remedy which is applied directly to them. For this purpose 
 we may use the following mixture: 
 
 Corrosive sublimate. 
 
 Alum, - - _ ■ 
 
 Camphor. . _ .. _ 
 
 Alcohol _ . - . 
 
 Glycerine, _ . _ - 
 
 Water, - ... - 
 
 The condylomata and the skin surrounding them should be 
 carefully washed, and the above lotion applied by means of cotton 
 wool or a soft cloth which is dipped into the lotion and then dabbed 
 upon the tumors. If the tops of these little tumors be ulcerated it 
 will be better to employ the following wash : 
 
 Corrosive sublimate, - _ - One grain. 
 
 Alum, - - - - - One drachm. 
 
 Alcohol, ------ One-half ounce. 
 
 Ether, ....-- One-half ounce. 
 
 Collodion, - - , . . One-half ounce. 
 
 After the condylomata have been washed and dried this liquid 
 should be applied with a camel's hair brush. 
 
 In all dressings of syphilitic sores it should be remembered 
 that the matter from these sores is highly contagious and can com- 
 municate the disease ; therefore it is very important that all cotton, 
 lint, cloth and the like, which has been in contact with the sores, 
 should be burned immediately when removed from the skin, and 
 care should betaken that the brushes and instruments used for the 
 same purpose be kept apart from everything else, to prevent the 
 possibility of accidental contagion. 
 
 Hi 
 
 Soft Chancre— (Venereal Ulcer.) 
 
 As has been already stated, there are at least three kinds of 
 sores which appear upon the genitals. One of these is the primary 
 sore of syphilis — the chancre — which is characterized by its indo- 
 lent course and by the hardness which surrounds the sore. This 
 
SOFT CHANCRE — VENEREAL ULCER. 
 
 507 
 
 variety of ulcer is almost invariably followed by constitutional 
 s\ philis — that is, by a disease which affects the entire body, may be 
 manifested in any or all of the organs, may be communicated by con- 
 tact even years after the sore has healed, and is transmitted to the 
 individual's children. 
 
 There is a second sore which is also usually found upon the 
 Ljcnitals, where it is produced by impure sexual contact. This sore 
 — which is technically called -a chancroid or soft chancre — is en- 
 tirely different from the chancre after the first week or ten days, 
 though during the first few days it may be impossible even for a 
 practiced eye to say which of the two varieties it is. It is, how- 
 ever, important that the distinction between the two should be 
 made, for the venereal ulcer is in the vast majority of cases a locals 
 and HotTn constitutional affection; the poison does not seem to enter 
 the system, or if it does, it exerts no injurious effect upon the body 
 generally. After the sore is healed, the individual is just as sound 
 in every respect as he was before he contracted the disease ; he 
 need feat no subsequent manifestations of the affection, and his 
 children will show no evidence of hereditary taint derived from this 
 disease. 
 
 It is not necessary to enter into any discussion upon the differ- 
 ent views which have been in times past entertained by medical 
 men as to the nature of the respective venereal poisons. It will 
 suffice to repeat what has been already stated, that while the chan- 
 cre — the /^rtr^ chancre — is almost invariably the first symptom of 
 constitutional syphilis, the venereal ulcer or soft chancre is very 
 rarely followed by any evidences of constitutional infection. 
 
 The soft chancre or venereal ulcer is chc.racterized by a sharp, 
 abrupt edge, which often seems to have been cut out with a punch, 
 so regular and steep is the border of the ulcer. Sometimes this 
 edge is undermined so that a little border of skin projects from the 
 .side over the ulcer. The depth of the uher varies extremely, being 
 sometimes quite shallow, and at other times deeply excavated. 
 The bottom is covered with a grayish or'dirty yellow layer which is 
 composed of matter. In a few days there is usually consi ierable 
 discharge of matter or pus from the ulcer — a point of difference 
 between the soft and the hard chancre, since the latter rarely dis- 
 cliarges matter in considerable quantity. 
 
 There are two features by which the soft chancre can usually be 
 distinguished from the hard chancre or primary sore of syphilis. 
 
 ', A\ 
 
 1 ( 
 
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 u 'Ml 
 
 II 
 
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 $08 
 
 VENERKAL OR PRIVATE DISEASES. 
 
 The first and most important point of distinction is, that the skin 
 around the soft chancre is not hardened nor elevated; the sore 
 appears to be simply an excavation in the skin, without any swell- 
 ing around it, as is the case in the hard chancre. This is one of the 
 symptoms which is relied upon chiefly by physicians in predicting,' 
 whether or not the sore will be followed by constitutional syphilis. 
 If two or three weeks elapse without the production of any harden- 
 ing around the sore, it may be confidently expected that the dis- 
 ease will remain a local one, without any infection of the blood. 
 
 Another feature characteristic of the soft chancre is the early 
 period at which it appears after impure contact. This sore is some- 
 times apparent within 24 hours after exposure, while several days 
 commonly elapse before the true chancre is seen, and two or three 
 weeks pass before the chancre becomes well developed. 
 
 A third feature which is quite characteristic of the soft or vene- 
 real ulcer, is the fact that several of these sores usually appear at 
 the same time. Sometimes there may be a dozen or more situ- 
 ated near each other, or scattered about on different parts of the 
 genitals. If the infection be a hard chancre, on the other hand it 
 rarely happens that more than one sore is discoverable. Further- 
 more, it will often be observed that new sores appear in the neigh- 
 borhood of a soft chancre ; this seems to result from the escape uf 
 the matter from the original sore into cracks or abrasions of the 
 neighboring skin ; for wherever this matter enters the skin a new 
 sore is produced, which resembles, in all particulars, that which was 
 contracted during the venereal contact. The hard chancre, en the 
 contrary, does not produce similar sores in its vicinity ; even when 
 the matter from it is intentionally inoculated in the skin of the indi- 
 vidual, no such sores are produced. 
 
 This fact may often aid the uninitiated individual in distinguish- 
 ing between the hard and the soft chancre. It may be stated in 
 general, that if only one sore makes its appearance within a week 
 after exposure, it is in all probability the hard chancre, the fore- 
 runner of constitutional disease ; while if numerous sores arc 
 formed within a few days, they are in all probability chancroid;, 
 and will not be followed by a disease of the blood. 
 
 This fact that the soft chancre can be reproduced in different 
 parts of the same individual by transferring the matter from the 
 original sore, while the hard chancre is not so reproduced, has 
 been often used by physicians in deciding a doubtful case. The 
 
SOl-r CHANCkK — VENEKliAI, UlAKK. 
 
 509 
 
 plan consists simply in inoculating the individual at different points 
 of the skin with matter from the sore ; if a new sore similar to the 
 oritjinal one is produced at each of these points, the disease is the 
 venereal ulcer and not constitutional syphilis ; if on the other hand 
 these inoculations are not followed by the production of similar 
 sores, the disease is probably hard chancre, which will be followed 
 by general disease of the system. This artificial inoculation has 
 sometimes been carried to extremes ; thus one physician produced 
 ()\Lr 8,000 sores on his own body by inoculating himself with the 
 matter from a soft chancre. 
 
 Soft chancres may appear on any part of the body ; they are, 
 of course, most frequent on the genitals of both sexes, but may also 
 be found upon the tongue, the lips, the nipples, etc. When they 
 occur in and around hair follicles, they often produce sores which 
 resemble boils. When they are located in parts where the skin is 
 loose — as in the web between the fingers — the soft chancres are 
 often surrounded by a swollen base which may resemble the hard- 
 ness of the true chancre ; yet this base is never so hard and firm as 
 that which surrounds the hard chancre. 
 
 Bubo. — This affection — vulgarly known as "blue -ball" — is 
 an incident in the course of a soft chancre. It consists in an inflam- 
 mation of one or more of the glands in the groin, wiiich is due to 
 the absorption of the matter from the sore. This matter travels 
 along the little channels which are known as /j'm/>/iaiic vessels, until 
 it comes to the gland, where it is stopped and excites an inflamma- 
 tion ; sometimes indeed a red line can be seen along the skin from 
 the sore to the vicinity of the gland, indicating the course of the 
 lymphatic vessel. 
 
 riie swelling of the gland rarely appears before the second 
 week after the formation of the sore. It may be ushered in by 
 shivering and fever, accompanied by tenderness in the groin ; but 
 in most cases the attention of the patient is first attracted by stiff- 
 ness and pain felt in the groin upon walking. When he examines 
 the tender spot he finds a little lump or tumor, which is quite pain- 
 ful upon pressure. This tumor rapidly increases in size and occa- 
 sions the individual great pain, especially when he walks or indulges 
 in other exercise ; in a week or ten days the swelling and pain are 
 so great that he is compelled to keep the recumbent posture as 
 much as possible. The skin over the swollen gland becomes red 
 
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 " ''M 
 
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 ,1 
 
 11.^1 
 
 >' f 111 I' » 1 
 
 510 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 and tender, and if the inflammation be severe, the skin often 
 assumes a livid or bluish color. 
 
 In rare cases the swelling will gradually subside without further 
 difficulty; but in the vast majority of instances it will be observed, 
 within two or three weeks, that the central part of the swelling is iiut 
 hard as before, but has become quite soft and less painful. This 
 softness is due to the formation of vuxttcr in the tumor ; and notliinj^ 
 can be done after this except to open the abscess without delay. 
 Patients often make a mistake in refusing to have the swelling; 
 opened, thinking that they can thereby avoid the unpleasantness as 
 well as the pain. In this they are greatly mistaken, since if the 
 tumor be not opened it will break of itself. It is. therefore, far 
 more desirable, in every way, to have the abscess opened pruiuplly: 
 1st, because the pain is thereby relieved and the patient saved sev- 
 eral days, or even weeks of suffering ; and 2d, because the abscess 
 will be smaller and easier to heal if the matter be let out early. l-Dr 
 when the abscess is permitted to break spontaneously there is always 
 produced a ragged sore with undermined edges, which often needs 
 trimming with the scissors before it can be persuaded to heal. 
 
 After the buboes are finally healed, the individual need e.xpcct 
 no further difficulty from the venereal ulcer. In most cases the ulcer 
 is healed in two to six weeks ; but the bubo may remain open for 
 months unless carefully treated. 
 
 Physicians distinguish several varieties of soft chancre, accord 
 ing to the characteristics of the sore itself. Thus we recognize a 
 phagedenic ulcer, which is characterized by its tendency to proi^ress 
 and extend indefinitely. This ulcer sometimes causes extensive de- 
 struction of tissue, and even the loss of a part of the genital organs. 
 It is accompanied by extreme pain and tenderness. This variety 
 occurs with especial frequency in debilitated individuals, particularly 
 those who are afflicted with scrofula or tuberculosis, and those 
 who are addicted to excess in drink. 
 
 The serpiginous ulcer is so called because of its form ; it hi 
 in the center, but progresses irregularly around the edges. It 
 apt to spread with extreme rapidity, and to cause great destruction 
 of the organs attacked. This, like the former variety, uccurs 
 chiefly in individuals suffering from depraved constitutions. 
 
 The venereal ulcer, unlike the hard chancre of syphilis, can 
 be communicated to the lower animals, where it produces sores 
 similar in appearance, and in other characteristics, to those found 
 upon the human subject. 
 
LOFT CHANCRE — VENEREAL ULCER. 
 
 511 
 
 Such are the characteristic differences between the primary sore 
 of syphilis and the venereal ulcer. As has been stated, these dif- 
 ferences are visible usually only after several days have elapsed 
 since exposure to contajfion. At the very beginning it is impossi- 
 ble to say positively which of the two diseases — syphilis or the 
 venereal ulcer — is present. In every case the sore is apt to be^in 
 as a i)iniple, which merely causes a sli^dit itching for a time until the 
 top is scratched off, leaving the bottom of the ulcer exposed to 
 
 view. 
 
 Ti'eatineilf. — The treatment of a venereal ulcer is always a 
 purely local one ; that is to say, it consists in applications which 
 arc intended simply to heal the sore and to prevent, if possible, the 
 formation of a bubo. There is in this disease no infection of tin- 
 system, and hence no necessity for agents which shall " purify the 
 blood." In fact, no medicines need be given internally in this dis- 
 ease, so far, at least, as the affection itself is concerned. It some- 
 times becomes necessary to administer remedies which shall build 
 up the patient's health and thus prevent the sore from enlarging ; 
 but these remedies are not intended to exercise any influence in 
 counteracting the poison, since this poison does not remain in the 
 blood nor cause any constitutional dis(;ase. 
 
 The local applications vary according to the condition of the 
 sore itself, as well as the general health of the individual. 
 
 If ,1 suspicious pimple, which causes considerable itching, be 
 discovered on the genitals within a few days after impure contact, 
 it will be advisable to cauterize it thoroughly once with lunar 
 caustic. 
 
 If the matter be not discovered until the sore is already ulcer- 
 ated, one of the following plans should be pursued: 
 
 If the patient be in good general health, the ulcer should be 
 H»oroui:;hly cauterized once either with lunar caustic, nitric acid or 
 carbolic acid. It will be better for any other than a professional 
 II 1 to employ the lunar caustic for this purpose, since the acids 
 named are liquid and cannot be so easily controlled ; unless extreme 
 care be taken, these acids will run over the sore and destroy the 
 sound flesh around, making an extensive and painful ulceration. 
 
 After th sore has been cauterized with lunar caustic, it may 
 be dressed for twenty-four hours with a little vaseline spread upon 
 lint. At the end of this time the cauterized surface will come 
 away as a dirty white or grayish layer, leaving a red base. This 
 
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 llp- 
 
 4 
 
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 51; 
 
 VLNEKEAF, OR PRIVATE DISEASES. 
 
 may now be dressed by pouring upon the sore powdered iodoform, 
 over which a piece of soft rag may be applied. At the end of 
 twenty-four hours the sore may be washed and closely inspected. 
 The bottom of it should now be uniformly red and clean; if grayish 
 patches be noticed which stick closely to the bottom of the sore, 
 the ulcer should be cauterized a second time ; that is, those pprt.s 
 which are still covered with grayish matter should be burned again. 
 It will not be necessary to cauterize the entire base if the surface 
 generally be clean and red. In all cases the cautertzation should 
 be done, not by the patient himself, but by a second individual ; 
 because the application of the caustic causes considerable pain, 
 and the patient himself will flinch and fail to apply the caustic 
 thoroughly to all parts of the sore. 
 
 On the second day the iodoform dressing maybe renewed; 
 this will indeed constitute the best dressing for the entire duration 
 of the sore. The iodoform maybe .pplied morning and night; 
 since it is a solid, and comparatively insoluble, it lasts for sevcril 
 hours. The one objection to the use of iodoform is its unpleasant 
 odor, which clings to the firgers and the clothing for hours. The 
 patient must, therefo"e, 'ie careful that the powder touches no part 
 of his person except the sore. It may be advisable to apply the 
 iodoform only at night and wash it off in the mo.ning, since the 
 odor will thereby be less perceptible during the day. Or, better 
 still, the odor of the iodoform may be masked by adding two drops 
 of the attar of roses to every drachm of the drug. 
 
 If the sore be thoroughly cauterized at first, as has been 
 directed, and the patient be in good condition, the ulcer will usually 
 heal under this simple treatment in one or two weeks. If, however, 
 it be not thoroughly cauterized at first, it may last a much longer 
 time and finally require to be cauterized again before complete 
 healing occur. 
 
 After it becomes evident that the ulcer is healing, that is, ;.fter 
 the bottom has become and remains clean and red, and the sore is 
 observed to become shallower day by day, it will be necessary to 
 use only a simple salve of carbolic acid or vaseline. The iodoform 
 does no harm, and the substitution of the vaseline or carbolic acid 
 ointment has merely the advantage of dispensing with the odor of 
 
 ioJuform. 
 
 If the patient be debilitated, and suffer from scrofula, tuber- 
 culosis, or any other constitutional taint which interferes matcri- 
 
SOFT CKANCRli — VENEREAL ULCER. 
 
 513 
 
 ally with his general health, it becomes necessary to administer 
 some remedies which shall improve his condition. This is an 
 important part of the treatment ; without it great difficulty will be 
 experienced in preventing the ulcer from spreading extensively and 
 destroying considerable skin. Such individuals should take the 
 following prescription : 
 
 Tincture of the chloride of iron, - Si.x drachms. 
 
 Tincture of nux vomica, - Five drachms. 
 
 Compound tincture of gentian, To make four ounces. 
 
 Mix, and take a teaspoonful in half a wintglassful of water before 
 meals 
 
 Th'.. local treatment in such ''ases must be conducted with 
 caution, for in such individuals the use of caustic will cause 
 severer effects than in robust persons. During the first few days 
 it will be bet-xr not to cauterize the sore, but simply to dress it 
 with the oiutincnt of mtrcnry, which should be applied upon a 
 soft rag. After a few days the sore will probably be clean and 
 red if the internal treatment have also been followed. If the 
 progress of the ulcer be not satisfactory the patient should take 
 cod liver oil — a teaspoonful after meals ; in these cases it may 
 also be necessary to cauterize the sore with lunar caustic. These 
 individuals require the most careful management, and should always 
 place themselves in the hands of a pbysician. 
 
 In every case of venereal ulcer it should be remembered that 
 a bubo may result, and this constitutes one of the worst, if not 
 the worst, fec^ture of the case ; care should, therefore, be taken to 
 avoid the occurrence of buboes. The most important measure to 
 secure this result consists in the careful avoidance of unnecessary 
 eflort on the part of th-j patient, as well as in the improvement of 
 the general liealtii, A patient suffering from venereal ulcer should, 
 therefore, be upon his feet as little as possible ; should ride and 
 not walk whenc/er he can in performing his daily duties. At the 
 first sign of tenderness in the groin the patient should take to his 
 bed, or at least keep the recumbent posture. He may rest assured 
 that the occurrence of a bubo terminating in an abscess is almost 
 ^levitable. 
 
 The next most important measure for the prevention of buboes 
 consists in attention to the general health. Among individuals 
 who are in robust health at the time when they contract the dis- 
 ease, buboes are far less numerous, and their effect far less severe 
 
 «f'i 
 
 m 
 
 U !■' 
 
 >■ nl 
 
 ' "tW[\<, 
 

 
 !l' 
 
 
 514 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 than among those whose general condition is unsatisfactory. It is 
 therefoic advisable for the patient to use a generous diet, to ha\e 
 plenty of sleep and to enjoy the best possible conditions for tlic 
 maintenance of health. 
 
 Various remedies have been employed and recommended in 
 order to prevent the formation of matter in the bubo. The most 
 frequent remedy consists in painting the skin over the bubo with 
 the tincture of iodine, or by applying a tight bandage around the 
 waist and the thigh so as to compress the bubo. In recent years it 
 has been claimed that the sulphide of calcium, when administered 
 internally, will also prevent the formation of an abscess. Yet we 
 have no definite grounds for believing that any or all of these 
 remedies combined have any marked efifect in preventing the 
 formation of matter. 
 
 After it becomes evident that matter is forming — a condition 
 which is made manifest by a softening in the middle of the swelling 
 and perhaps by blueness of the skin — there remains but one thin<^ 
 to be dor.e : the bubo must be opened ; the sooner this is done the 
 better ; the pain is thereby relieved and the abscess will heal far 
 more readily and easily than if the bubo be allowed to break 
 of itself. 
 
 After the bubo has been opened it should be carefully washed 
 out three or more times a day, according to the amount of dis- 
 charge. E.xtreme care should be taken that all the matter be 
 removed at every dressing ; for this purpose a small syringe with a 
 narrow point may be employed in order to inject the water into alt 
 the crevices of the abscess. After it has been thoroughly cleansed, 
 powdered iodoform should be dusted into the cavity. A still better 
 way is to pack the cavity full of gauze, such as surgeons use, which 
 has been saturated with iodoform powder. If this cannot be pro- 
 cured, some fine lint may be impregnated with iodoform by rub- 
 bing the powder thoroughly into the cloth ; this is then cut into 
 narrow strips, say half an inch, wide and tucked mto the cavity ; 
 it should be packed tightly down so as to bring the gauze in contact 
 with the raw surface. 
 
 One of the most important items in the treatment of bubo is 
 that the patient should remain quiet ; H he can maintain the recum- 
 bent posture, so much the better. At any rate the healing of the 
 wound will be very slow and troublesome unless the patient avoid 
 walking and standing. 
 
 I^i % 
 
 |,1, i <HH|t| 
 
CLAP — GONORRHOiA. 
 
 515 
 
 Clap— (Gonorrhoea.) 
 
 Gonorrhoea consists in an inflammation of the mucous mem- 
 branes of the genital organs in male or female, accompanied by a 
 discharge of matter or pus. In males the matter comes from the 
 inside of the passage to the bladder — a channel called the urethra. 
 In females the inflammation and discharge are located in the vagina 
 as a rule, though it may also spread to the urethra. This inflamma- 
 tion is excited, in the vast majority of cases, by contact of the 
 parts with the organs of another individual who is already suffering 
 from the disease. In almost all cases, therefore, it results from 
 impure intercourse. For a long time it was supposed that this was 
 the only possible source of the discharge, so that the existence of 
 a tronorrhcea was regarded as positive proof that the affected indi- 
 vidual had indulged in such intercourse. For practical purposes we 
 may still adhere to this rule ; yet there are cases in which it is neces- 
 sary to bear in mind that the disease may originate without impure 
 contact, or even without any indulgence whatsoever in sexual inter- 
 course. For it is now well ascertained and understood that 
 a man may contract the disease from a perfectly pure woman, 
 even from his own wife. The circumstances under which this 
 annoying accident may occur are these : The discharge from the 
 genitals at the menstrual period is, in some women, even though 
 they be suffering from no disease of the parts, extremely irritating. 
 As a result of this it sometimes happens that intercourse during the 
 menstrual period will be followed by {i^onorrhoea of the severest 
 type. Some women, too, who suffer fi ' ;i the whites (leucorrhoea) 
 cause the disease to appear in men who have intercourse with them ; 
 this seems to result from the irritating nature of the discharge with 
 which such women are affected. Then, again, gonorrhoea may arise 
 from simple excess in sexual indulgence, that is, from frequent 
 repetition of the act within the course of a few hours. The physi- 
 cian is sometimes called in by the husband of a few weeks' stand- 
 ing to determine whether or not the bride has communicated the 
 gonorrhoea which has attacked him in the second week of his 
 wedded life. In such cases no rash decision or action should 
 ever be permitted until the situation has been explained to the 
 irate husband, who is apt to feel himself outraged in feelings as 
 well as in person. In the great majority of such cases it will be 
 
 I' ■ if 
 
 m 
 
 I ! 
 
 1 
 
 % 
 
 ^\\\ 
 
 !?, 
 
 in>a 
 
 :1f:. - 
 at,.-. 
 
510 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 found upon close examination that the disease is merely the result 
 of the youthful husband's impetuosity. 
 
 While, therefore, we must always remember the possibilit}' 
 that gonorrhoea may be contracted in other ways than by impure 
 sexual intercourse, yet we may lay it down as a general principle, 
 that this latter is the almost invariable source of the affection. 
 
 SifniptOina. — For a few days after indulgence in suspicious 
 intercourse, no signs of disease will be manifest. Usually at some 
 time between the fourth and eighth days after exposure the patient 
 notices an itching at the end of the penis, usually accompanied by 
 a slight burning sensation upon passing water. After this has 
 lasted a few hours, there will be noticed a slight discharge from the 
 urethra, which at first appears only in drops. This discharge is in 
 the beginning of a watery or milky appearance, but in the course of 
 a day or two after its commencement it becomes quite yellow and 
 creamy. If the inflammation be severe, the matter often has a 
 greenish tinge, and there may even be a few drops of blood mixed 
 with it. By this time the passage of urine causes a severe scaldinii 
 pain, which soon becomes so acute thac the patient dreads the 
 necessity for passing his water ; his distress is aggravated by the 
 fact that he feels the desire to urinate more frequently than is the 
 case in health. 
 
 In the majority of cases, the inflammation extends only two to 
 four inches up the urethra ; this part of the organ is apt to be 
 quite tender upon pressure and the orifice of the urethra at the end 
 of the penis is usually red and swollen. The pain during the pas- 
 sage of the water is felt most keenly at the point about an inch 
 from the end of penis, though it must not be supposed that the 
 disease is limited to this part of the urethra. If the inflammation 
 extend further back along the urethra, the patient usually suffers 
 considerable pain and a sense of heat around the neck of the 
 bladder ; there is also apt to be a considerable discharge of blood 
 at the end of the act of urination. This discharge of blood is apt 
 to alarm the patient unnecessarily, as the appearance of blood 
 from the inside of the body usually does. He should, however, 
 feel assured that this blood does not indicate that his disease is . 
 especially severe, since it merely comes from the inflamed mucous 
 membrane, just as a patient suffering from severe catarrh of the 
 nose often observes a little blood in the discharge upon iiis hand- 
 kerchief. 
 
CLAP — GONORRHCEA. 
 
 S17 
 
 One of the most troublesome and painful incidents of gonor- 
 rhea is the obstinate tendency of the penis to erection. This 
 happens without any provocation whatsoever, and is especially fre- 
 quent at night. In consequence of the inflamed condition of the 
 parts, the increase in size of the organ renders an erection ex- 
 tremely painful. This condition is commonly termed chordee. In 
 consequence of the pain the patient's rest is broken, so that his 
 health and strength are thereby seriously impaired; in fact chordee 
 is one of the most painful and annoying features of the disease, 
 though it does not indicate any particular gravity. 
 
 The other feature of gonorrhoea which renders' the affection a 
 troublesome one is the necessity for a frequent evacuation of the 
 urine. The bladder is so irritable that the patient cannot retain 
 liis urine as long as usual ; in fact he is sometimes compelled to 
 pass his water every two or three hours every hour, or even every 
 half hour If he fail to do so, or for any reason is unable to empty 
 the bladder, he experiences the most severe pain in and around the 
 root of the penis and a most intolerable and irresistible desire to 
 empty the bladder. When we remember that the passage of the 
 urine along the inflamed urethra is accompanied by sharp pain, we 
 can readily appreciate the unpleasantness of the situation. 
 
 Several complications may arise in the course of a gonorrhoea ; 
 the most common of these are inflammation of the testicle and a 
 swelling of the end of the penis. The former complication rarely 
 happens until the fourth or fifth week of the disease. It is indi- 
 cated by pain and swelling of the testicle, while the skin over this 
 organ becomes red. This condition of the testicle is extremely 
 painful, since unless the organ is supported by a bandage or other- 
 wise the patient experiences a sense of dragging in the groin 
 which is sufiicient to compel him to lie down, and even make him 
 faint. In addition to this the testicle is extremely tender, so that 
 the pressure of the clothing is sufiicient to keep up constant pain. 
 
 The swelling at the end of the penis occurs in most cases of 
 gonorrhcta, especially in those in which the patient neglects to keep 
 tile parts clean. Unless he is careful to pull the foreskin back and 
 wash the part thoroughly every day, matter collects under and 
 around the foreskin and occasions irritation of the organ. There 
 may also be some swelling of the parts from the spread of the 
 inflammation to the tissues of the penis outside of the urethra. 
 This swelling maybe inconsiderable, and occasion only slight puffi- 
 
 34 
 
 ll 
 
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 :,m:ii 
 
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 itm^ 1 
 
 518 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 ness of the foreskin ; but in some cases this skin is so enormously 
 swollen that it cannot be moved in the natural way. If the skin be 
 once drawn back, while in this swollen condition, the patient is 
 often unable to bring it forward again — a condition technically 
 known di% paraphimosis. This condition occasions the patient con- 
 siderable pain and great alarm ; it is in fact a matter to be attLiulcd 
 to, since, if not relieved, the skin may ulcerate or even mortify, so 
 that serious loss of tissue may occur. This dangerous condition of 
 the foreskin will be recognized through the fact that the skin 
 behind the end of the organ is drawn tightly around the penis like 
 a string. 
 
 Sometimes there occurrs in gonorrhoea a complication similar 
 to that which regularly happens in connection with the venereal 
 ulcer — a bubo. The glands in the groin become swollen and 
 painful, and may even proceed to ;.he formation of matter. This is 
 a comparatively rare complication of gonorrhcea, and happens 
 almost always only in individuals who are suffering from a debili- 
 tated condition of the system, o'r who neglect to keep quiet as 
 much as possible during the course of the disease. 
 
 In women the symptoms of the disease are quite different in 
 many respects from those observed in men. These differences 
 result from the fact that in women the inflammation affects primarily 
 and chiefly the vagina, and not the urethra as in the male. Hence 
 it happens that women do not usually experience the same pain and 
 difficulty in passing water as men who are afflicted with the disease ; 
 and furthermore the channel from the bladder is so short in the 
 female, and its calibre so large, that even when this passage also 
 becomes affected, as it sometimes does, there is less pain and sore- 
 ness about the bladder. 
 
 In many cases gonorrhoea seems to affect only the vagina in 
 women ; this part becomes inflamed, hot, tender to the touch, and 
 to the eye seems red and swollen ; the external parts surrounding 
 the orifice of the vagina may also become greatly swollen. This 
 condition is accompanied by considerable pain, often felt in the 
 back and thighs. After a day or two a discharge begins to issue 
 from the vagina, at h ^t somewhat thin and yellowish, then 
 becoming thick and greenish. 
 
 If the disease spread to the passage into the bladder — the 
 urethra — the woman experiences, though in a less intense degree, 
 many of the symptoms which have been described as occurring in 
 
CLAP — GONORRHCEA. 
 
 519 
 
 tlic male. There is a frequent desire to empty the bladder, and 
 the act is accompanied by considerable smarting and burning pain. 
 If the inflammation remain limited to the vagina, gonorrhcea is not 
 an especially serious disease in the female. But in some cases the 
 inflammation extends upward into the womb and may even pro- 
 ceed from the womb along the tubes which lead to the ovaries — 
 the fallojjiau tubes. In this case the affection becomes a grave 
 one ; it may even cause death within a few days, and in other cases 
 induces long and obstinate diseases of the womb which may render 
 the patient's life miserable for years. Sometimes the discharge 
 become much diminished but does not cease entirely ; these are 
 then cases of leucorrhcea, or " the whites. " It must not, how- 
 ever, be supposed that all cases of " the whites " have begun as 
 o-onorrhcEa, since there are many other causes, especially diseases 
 of the womb, which frequently produce a white discharge from the 
 
 vagina. 
 
 Gonorrhoea usually lasts four or five weeks. It is possible, if 
 
 the patient place himself under treatment immediately upon detect- 
 ing the disease, to cut short the course of the affection to two weeks 
 or even ten days. In most cases, however, the inflammation lasts 
 six or eight weeks; and in many instances the discharge continues for 
 months, or even years. In these instances the inflammation is not so 
 severe as it was at first ; there is no pain upon making water, nor is 
 the individual troubled with the erection at night, which constitutes 
 such a painful feature of the disease during the first month. The 
 discharge is slight in quantity, and usually of a thin, watery ap- 
 pearance ; this discharge is generally observed only in the morning 
 upon rising, and is not visible at any time during the day. This 
 obstinate affection is called the gleet, and is one of the most annoy- 
 \\\g and discouraging features connected with gonorrhoea. The 
 gleet occurs far more frequently in men than in women, a fact 
 which is easily understood when we remember the structure of the 
 genital organs in the two sexes. For in the male the urinary 
 passage is long and narrow, and the escape of the discharge is 
 impeded by various anatomical peculiarities of structure ; in woman, 
 on the other hand, the matter finds free exit, and is not retained as 
 in the male. Hence the obstinate and chronic forms of the disease 
 are less frequent in the female than in the male. 
 
 Ti'i'tituient, — When properly and carefully treated, gonor- 
 rhcea is a by no means serious affection. Yet practically, it is one 
 of the gravest diseases to which men are subject. This serious 
 
520 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 ii ' 
 
 i tt 
 
 character of the affection is largely due to the carelessness and 
 neglect of patients. Most men pay but little attention to a gonor- 
 rhcea, or at least but little attention compared with what the affec- 
 tion really demands. Patients do not permit the disease to inter- 
 fere with the performance of their daily duties ; they regard it as 
 something to be endured for a few weeks, and seem to think that 
 it will take care of itself, and that recovery will necessarily occur 
 without any particular care or attention on their part. 
 
 It cannot be too emphatically stated that gonorrhoea, when 
 neglected, is a most serious and dangerous affection ; for it is apt to 
 induce not simply the various complications which have been 
 already mentioned as occurring in the course of the disease ; if 
 these were all the danger to be apprehended, the patient niit^lit 
 feel reasonably sure of ultimate recovery. But the most serious 
 result of gonorrhoea — one that happens almost always in cases in 
 which the discharge has been permitted to continue for several 
 weeks or months — has not yet been mentioned ; this danger is the 
 formation of a stricture of the tirethra. This affection will be 
 described in the appropriate chapter ; it will suffice to say here that 
 strictures are, in the vast majority of cases, the results of gonorrhceT ; 
 and that they constitute a serious menace to a patient's comfort, and 
 even to his life. The stricture develops insidiously, rarely show- 
 ing itself within two years after the gonorrhoea, and sometimes 
 causing no trouble until five, ten or even more years have elapsed. 
 Yet a stricture is none the less certain to cause the patient much 
 pain and annoyance in the later years of his life. Many a man has 
 died of a stricture which was the result of a gonorrhoea contracted 
 twenty, thirty or forty years previously. These facts are men- 
 tioned hereto emphasize the possible gravity of gonorrhtea, and 
 hence to impress upon the patient's mind the importance of the 
 most careful attention in the treatment of this affection. It will ncjt 
 do to suppose that the disease will be all over in a few weeks any 
 how, and that it is not worth while to trouble one's self particularly 
 about the treatment. A patient suffering from gonorrhoea should 
 never lose sight of the fact that, however well he may feel, he is 
 the subject of a serious disease which may render his life miserable 
 and even cause his death. 
 
 The first item of treatment is bodily rest. The prime importance 
 of quiet during the early stages of gonorrhoea can not be over- 
 estimated, and is not generally appreciated, even by physicians. 
 
 m 
 
CLAP — GONORRHCEA. 
 
 521 
 
 Patients continue their usual employment, even when this compels 
 them to be upon their feet, and even to perform hard manual labor. 
 It may safely be said that if a patient works hard, he cannot expect 
 to recover from gonorrhoea in a short time. The importance of 
 bodily rest has been often impressed upon the writer by observing 
 cases in which men suffering from the disease had sustained some 
 accident or injury which compelled them to keep their beds. In 
 such cases gonorrhoea usually subsides in a few days under the 
 most simple treatment, although up to the time of the accident the 
 disease may have been quite severe and obstinate. 
 
 Another item of extreme importance in the treatment of gon- 
 orrhcea is the careful avoidance of everything which can cause 
 sexual excitement. Unless a man can refrain from all indulgence 
 of the sexual appetite he cannot expect that an inflammation affect- 
 ing the sexual organs can be soothed into recovery. 
 
 A third object to be attained is the regulation of the diet so as 
 to render the urine as unirritating as possible. It is therefore de- 
 sirable to avoid stimulating food such as meats and condiments, and 
 it is absolutely necessary to abstain from beer, wines and liquors. 
 Indulgence in a slight carouse has often caused a gonorrhoea which 
 had been nearly cured to return in full force on the following morn- 
 ing. The patient must therefore make up his mind at the very be- 
 ginning of the disease that he must be a teetotaler not only until 
 the discharge has ceased entirely, but even for two or three weeks 
 afterward. 
 
 The diet should consist of bland, unirritating articles such as 
 milk, eggs, starchy and vegetable food, and plainly-cooked meat in 
 small quantity. Tea and coffee may be used in moderate quantity 
 without aggravating the difficulty. 
 
 If the urine can be made unirritating, the patient's suffering 
 will be much diminished, and his recovery correspondingly 
 hastened. To accomplish this he should take a great deal of liquid 
 diet ; he should drink water freely, especially son. alkaline water. 
 It is also beneficial, though not absolutely necessary for him to 
 take certain bland liquids, such as flax-seed tea or slippery-elm tea. 
 These articles are unpleasant to most palates, and need not be 
 taken unless agreeable to the patient ; but it is his duty to himself 
 to take an abundance of water, and he will find advantage in using 
 some effervescing drink, such as soda water, or some alkaline 
 mineral water. 
 
^i '■ 
 
 522 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 If the measures which have been already mentioned — rest of 
 the body, avoidance of all sexual excitement, the use of a bland 
 diet and care in drinking plenty of water — if these measures were 
 faithfully and conscientiously observed, most cases of gonorrncjua 
 would recover within two to three weeks without further treat- 
 ment. 
 
 Yet many patients are unable to take the time necessary for 
 following out these directions. The requirements of their business 
 prevent them from remaining in bed for two weeks. Yet tlicy 
 should be careful and refrain from all exercise or excitement wher- 
 ever it is possible so to do. 
 
 For such persons it becomes necessary to employ certain medi- 
 cines. These medicine j are taken not for the purpose of " purifying 
 the blood," since gonorrhoea is not a disease of the system, but 
 merely a local inflammation in the urinary passage ; the object of 
 these medicines is to render the urine less irritating and to soothe 
 the mucous membrane of the urethra. To accomplish these ends 
 two drugs have been for many years almost universally employed ; 
 these two drugs are copaiba and ciibebs. Both of these medicines 
 have one extremely unpleasant feature — their nauseating taste. 
 To overcome this, many devices have been employed ; the most 
 successful is the use of gelatine capsules, by means of which the 
 taste of the medicine can be concealed and yet the good effects of 
 the drug can be obtained. These capsules come already prepared 
 and can be obtained at the drug stores. The taste of copaiba can 
 also be partially concealed by the use of the following prescription: 
 
 One ounce. 
 Two ounces. 
 Two ounces. 
 One ounce. 
 
 Balsam of copaiba, - - - 
 
 Peppermint water, - - . 
 
 Compound spirits of lavender, - 
 Mucilage of gum arable, - 
 
 A tablespoonful may be taken three times a day. 
 
 The good effects of this drug are most apparent during the 
 first week or ten days of the disease ; at the end of this time, 
 unless the patient has neglected to observe the precautions which 
 have been already mentioned, the smarting pain during the passage 
 of the water will have ceased. After this stage is reached, that is 
 when the smarting is no longer felt, the copaiba will not accomplish 
 so much good, and may be discontinued. Indeed the drug maybe 
 Stopped earlier, or the dose of it diminished if the patient com- 
 
CLAP — GONORRIICEA. 
 
 533 
 
 plain of sickness at the stomach ; for copaiba is apt to cause loss of 
 appetite and nausea. 
 
 After the use of copaiba is discontinued, the patient should take 
 some alkaline remedy, in order to keep the urine bland and unirrita- 
 ting. If he prefer, he may employ some of the usual mineral waters 
 which are kept on sale in the drug stores. A less expensive and 
 pleasant, though equally efficient remedy, consists in dissolving one 
 or two teaspoonfuls of baking soda in a glass of water. This may 
 be taken four or five times a day. 
 
 If the discharge be still profuse at the end of eight or ten days, 
 the patient may and should employ injections into the urethra. 
 These should not be used during the first weeks of the disease, since 
 they will only aggravate the inflammation. Much unfounded preju- 
 dice exists as to the use of injections. They have been charged with 
 causing many of the evils that accompany the disease. It is certainly 
 true that in ignorant and unskilled hands injections can cause and 
 have done much mischief. Patients who treat themselves without 
 consulting a physician, and those still more foolish individuals who 
 patronize advertising quacks and "specialists, " frequently suffer much 
 unnecessary pain and injury. A favorite device of such individuals 
 is to stop the discharge in a few days, thus displaying their extraor- 
 dinary skill to the admiring patient. The fact is that it is a very 
 simple matter to stop the discharge of gonorrhcea by using a suffi- 
 ciently strong injection ; but this measure will certainly be followed 
 by inflammation of the testicle, and possibly by a stricture. Although 
 .^uch injury can be done by the improper use of injections, yet it is 
 no less c'ji\:ain that when properly used these measures constitute a 
 most important and even essential feature of the treatment of gon- 
 orrha^a. 
 
 So soon as the acuteness of the pain and the smarting have 
 subsided — and this usually takes place, if the patient has been 
 cautious, at the end of eight or ten days or even sooner — the 
 following injection may be used : 
 
 Sulphate of zinc, - - . 
 Laudanum, 
 
 Glycerine, - - . - 
 Water, .... 
 
 This may be used as an injection four times a day. 
 
 The patient must always be instructed as to the method of 
 using an injection. In the first place, it is important that he secure 
 
 Eight grains. 
 One ounce. 
 Three ounces. 
 Four ounces. 
 
i'. I I 
 
 524 
 
 VENEkEAl, OR PRIVATE DISEASES. 
 
 
 
 
 the proper syringe. The articles which arc commonly sold for the 
 purpose arc made of glass and have a long, thin nozzle ; nothing 
 less appropriate could be devised. The only syringe in the market 
 which can be recommended is the one universally employed in the 
 large German hospitals ; it is made of hard rubber, with a conical 
 end, and holds about half an ounce. 
 
 When the patient is about to take an injection he should first 
 pass his water, and should then inject the urethra with simple warm 
 water of a temperature which feels agreeable ; after this he may fill 
 the syringe with the medicine, inject it and hold it in the urcthr.i 
 for three or four minutes. In using the injection the piston of tlic 
 syringe should be gently though firmly pressed. If too nuicli 
 force be applied the urethra will be forcibly distended and tlio 
 inflamed membrane damag£d ; if not enough force be used, on tiie 
 other hand, the fluid will not come into contact with the inflamed 
 surface throughout its whole extent. Probably the best guide as 
 to the amount of force to be used is the feeling of the patient liim- 
 self ; he should use sufficient force to cause a slight feeling of 
 uneasiness, but not enough to provoke pain. There is no danger 
 of forcing the fluid into the bladder, as many suppose. 
 
 This injection should be used for five or six days. If at tlic 
 end of this time the discharge has decreased considcrabl)-, the 
 strength of the injection may be increased by employing the fol- 
 lowing prescription : 
 
 Sulphate of zinc, 
 
 Alum, - _ . - 
 
 Glycerine, . . - 
 
 Water, . _ . 
 
 This may be injected as before. 
 
 The various complications of gonorrhoea also require treat- 
 ment. First among these is the condition which has been already 
 described as cJiordcc. This is an extremely painful incident of the 
 affection, and one which probably undermines the patient's strength 
 more than anything else, since it interferes so seriously with his 
 rest Chordee can generally be relieved at once by using the fol- 
 lowing prescription : 
 
 Bromide of potassium, - - One ounce. 
 
 Syrup of orange peel, - - One ounce. 
 
 Water, ----- One ounce. 
 Dissolve thoroughly and take a teaspoonful in a little water half an 
 
 Twelve grains. 
 Twelve grains. 
 Three ounces. 
 Three ounces. 
 
CLAP — GONORRHCEA. 
 
 525 
 
 hour bekfore rctirinfj. If the patient be awakened during the nifjht 
 by the pain, ho may repeat the dose. The ointment of mercury 
 ni;iy be rubbed along the under surface of the organ every night 
 ami morning. If the irritation extend to the bladder, and cause 
 frequent desire for making water, the following prescription may 
 be taken every four hours during the day : 
 
 Four grains. 
 Four drachms. 
 Four ounces. 
 
 Extract of hyoscyamus, 
 Bicarbonate of potash. 
 Camphor water, 
 
 Take a teaspoonful every three or four hours during the day. 
 
 In all cases care should be taken to secure regular evacuations 
 fi'Din the bowels. It will often be found that the severity of chor- 
 dae and the frequent inclination to pass water will disappear if a 
 free movement of the bowels be secured at least once every day. 
 For this purpose the patient may take a tablespoonful of the liquid 
 citrate of potash, or a teaspoonful of the " compound licorice pow- 
 der." If constipation occur, it will be better to relieve the rectum 
 by a copious injection of warm water than to take a strong cathar- 
 tic ; for the latter would result in severe straining at stool which 
 causes congestion of all the organs in the pelvis, and tends to aggra- 
 vate the inflammation in the urethra. 
 
 The inflammation of the testicle does not usually occur until 
 the third or fourth week of the disease. The best means for pre- 
 venting this painful and serious accident are absolute rest, the 
 avdidance of sexual excitement, and care in the employment of 
 injections. No medicines can be taken with the hope of preventing 
 this complication. The beginning of this affection is indicated by 
 the occurrence of pain in the testicle, and by a sense of weight and 
 drag^nng in the groin. So soon as it becomes evident that the 
 inflammation has begun, the patient should remain flat uoon his 
 back, if possible, keeping the testicle supported by a band of adhe- 
 sive plaster, upon which the organ may rest. If he be compelled 
 to remain upon his feet, the testicle should be carefully supported 
 by a bandage. The so-called " suspensory bandages" sold in the 
 shops are mostly worthless ; if the patient have a soft handkerchief 
 and a little ingenuity, he can devise a bandage which will answer 
 the purpose. The point is simply that the testicle should be sup- 
 ported by the bandage so that none of its weight is suspended in 
 the natural way. The organ should, therefore, be held closely 
 
i:!li 
 
 4f.' 
 
 |ij . «(}, 
 
 :(i: 
 
 ii \i .: 
 
 'ii 
 
 V, 
 
 :i 
 
 526 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 i-.gainst the body. Some soft cotton should be placed between the 
 skin and the handkerchief or bandage, so as to protect the inflamtd 
 organ from injury. During the early days of the inflammation but 
 little can be done to arrest its progress. The patient should remain 
 quiet, as has been already directed, and the inflamed organ should 
 be wrapped in soft cloths wet with hot water. If the pain be 
 severe', the patient may take twenty drops of laudanum in water 
 every four hours. After the acuteness of the inflammation has sub- 
 sided, that is, after the pain and tenderness are somewhat dimin- 
 ished, the organ may be wrapped in straps of adhesive plaster. It 
 is scarcely possible to direct in words how this strapping should be 
 done. It may be said in general that strips of plaster about five- 
 eighths of an inch wide and eight inches long may be prepared ; 
 the testicle is then rirmly grasped and forced downward from the 
 body until the skm over it is tightly stretched ; one strap is then 
 passed around at the upper end of the organ so as to hold it firmly 
 in position. The other straps are then applied from above down- 
 ward, each one overlapping slightly the one next above. This 
 operation must be done with great care, and should always be per- 
 formed by a physician. 
 
 The swelling of the glands in the groin is an occasional 
 incident in this disease. A slight amount of swelling is not in- 
 frequent in any case of gonorrhoea, and the lumps in the groin may 
 even become somewhat tender, especially if the patient is con- 
 stantly feeling and pinching them to see how much it hurts. But 
 at times one or more of these glands in the grcin become actually 
 inflamed ; " lump of considerable size forms, tender upon pressure, 
 and causing acute pain especially when the patient walks or stands. 
 
 In every case the first intimation of inflammation in a gland of 
 the groin should be the signal for the patient to take to his bed and 
 remain there. The treatment of the enlarged gland is just the same 
 as that of dubo, which has been described in connection with the 
 venereal ulcer. 
 
 aieet. 
 
 By this name ib designated : chronic discharge from the 
 urethra, which occurs as the equel to gonorrhoea. In many cases 
 the discharge does not cease after the gonorrhcea has lasted four or 
 five weeks ; it becomes gradually less and finally a; lunts only to 
 
 "I 
 
 :ff *,:,* .!« 
 
GLEET. 
 
 527 
 
 a few drops in the course of the day. These drops are thin and 
 watery, and the discharge occasions the patient no other annoyance 
 than the mental anxiety and uneasiness. 
 
 In man)'^ cases the discharge will be noticed only when the 
 patient lises in the morning. There is no pain when the bladder is 
 evacuated, no frequent desire to pass the water, in fact nothing 
 wrong except the slight watery discharge. This is, however, most 
 obstinate and difficult to get rid of; it frequently lasts for months, 
 and in many instances even years may elapse before the patient may 
 become entirely free from this last vestige of his indiscretion. 
 
 One of the uncomfo-table features about gleet is the fact that 
 excesses of various kinds are apt to increase the discharge so that 
 its quantity becomes almost as great as during the original 
 gonorrhoea. This is especially often the case after excessive sexual 
 indulgence, but it may also follow immoderate use of liquors, 
 especially of beer, or even physical or mental exhaustion from over- 
 work. After the discharge has thus broken out a few times it 
 becomes extremely difficult to check it completely. 
 
 One of the popular misapprehensions with regard to gleet is the 
 general belief among young men that the watery liquid which 
 escapes from the urethra is the seminal fluid. Such men are tor- 
 mented with the idea that they have " emissions," and in conse- 
 quence often become despondent and melancholy. A positive 
 opinion can be, in every case, made by a microscopic examina- 
 tion of these drops of fluid. In the majority of cases it will be found 
 that the fluid does not come from the organs of generation, but is 
 merely the continuation of the inflammatory discharge of gon- 
 orrlicea. 
 
 Treatment. — The treatment of gleet should never be under- 
 taken by the patient himself. It is in fact, even in the hands of the 
 ordinary physician, a most obstinate and puzzling affection. Cases 
 frequently run for years under treatment of various kinds, and fail 
 to improve until they come into the hands of one who has devoted 
 especial attention in the most scientific schools to this class of 
 diseases. It is scarcely necessary to say that such properly edu- 
 cated and competent physicians vc7'er advertise, since no medical 
 man who can attain an honorable position ever resorts to means 
 which arc practiced only by quacks. 
 
 Gleet often depends upon the existence of a stricture, and can 
 be relieved only when the stricture has been cured. At other 
 

 Ifrll 
 
 528 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 times there is an ulcerated spot somewhere in the course of the 
 urethra from which the discharge comes. In still other cases there 
 is a chronic inflammation of the gland situated at the neck of the 
 bladder called X.\\c prostatf gland. In none of these cases can any 
 benefit be derived from injections into the urethra. The detection 
 and treatment of stricture in the urethra requires a most expert and 
 experienced surgeon ; the detection and treatment of an ulcerated 
 spot requires the use of special instruments whereby the surgeon is 
 enabled to see the entire surface of the urethra, even into the 
 bladder ; an inflammation of the prostate gland can be recognized 
 and treated only by the physician. We shall therefore refrain fmm 
 giving descriptions and direction^ vvhich would be unintelligible 
 and impracticable to any one but a physician. 
 
 In many cases the patient suffering from gleet is in a weak and 
 debilitated condition, and will be benefited materially by tonics. 
 In fact cases occur in which the gleet breaks out afresh whenever 
 the individual becomes exhausted and disappears without further 
 ';reatment when his general health is improved. Such patients will 
 derive benefit frcin the following prescription : 
 
 Tincture of the chloride of iron, - Six drachms. 
 
 Tincture of nux vomica, - - Six drachms. 
 
 Compound tincture of gentian, - To make four ounces. 
 
 Mix and take a teaspoonful in half a wineglassful of water 
 before meals. 
 
 The treatment of gonorrhoea in the female varies somewhat in 
 details, but follows the same general principles. If the inflammation 
 affect the vagina only it will not be necessary or advisable for the 
 patient to take any medicine internally. She should take a hot hip 
 bath four or five times a day, remaining in the bath fifteen or twenty 
 minutes each time. She should also use an injection after the fol- 
 lowing formula : 
 
 Alum, ----- Four drachms. 
 
 Glycerine, ----- Four ounces. 
 
 Water, -.._._ Four ounces. 
 
 Half of this may be injected into tlie vagina at the conclusion 
 of the hip bath. At night a tampon may be intioduced, saturated 
 with the following lotion : 
 
 Tannin, - . - . . Four drachms. 
 
 Glycerine, . - - - - Two ounces. 
 
 Water, - . . . . Two ounces. 
 
 A piece of cotton as large as a small lemon may be saturated 
 
 I , 
 
GLEET. 
 
 529 
 
 with water and squeezed dry ; a piece of string is then tied around the 
 middle of this, and it is then thoroughly saturated with this lotion. 
 The tampon thus prepared may be introduced high up into the vagina 
 and allowed to remain during the night ; it is to be removed in the 
 niurning by means of the string, which should project from the 
 vagina. 
 
 If the inflammation affects the urethra also, the same measures 
 should be adopted for rendering the urine unirritating as hav: been 
 recommended in the treatment of gonorrhoea in the male. It will 
 be advisable to administer copaiba and to drink water freely. The 
 uruic may be kept bland by the use of mineral waters, or by dissolv- 
 ing a teaspoonful of baking soda in a glass of water, as before men- 
 tionetl. 
 
 There are certain facts to be borne in mind whenever a patient, 
 male or female, suffers from gonorrhcea. First, it should never be 
 forgotten that the matter composing the discharge is highly conta- 
 g' , "ot only when it comes in contact with the genital organs of 
 &n'.>t!n.; individual, but also for other mucous membranes of the 
 patient himself as well as of others. Thus it sometimes happens 
 that some of this matter is introduced into the rectum, causing a 
 severe inflammation of this organ. In some instances it has been 
 known to cause a violent inflammation of the nose, having been 
 introduced into the nostrils by means of handkerchiefs soiled with 
 the discharge. But the most susceptible of all the mucous mem- 
 branes of the body is that of the eye ; and this is the one which is 
 most frequently inflamed by the contact of gonorrheal discharge. 
 The patient neglects to wash his hands carefully after performing 
 the necessary manipulations of the diseased organs ; or he- care- 
 lessly rubs his eyes even before he has washed his hands, and thus 
 introduces some of the matter into the eye. In some instances the 
 contagious matter is conveyed by towels which have been used by 
 the patient about the genital organs and are subsequently employed 
 to dry the face. 
 
 The patient cannot be too careful to avoid every possibility of 
 conveying the matter from the urethra to the eyes, for if the latter 
 become inflamed there will result almost certainly a serious defor- 
 mity of the eye, and in many cases partial or complete loss of sight. 
 This inflammation of the eyes produced by the contact of gonor- 
 rheal matter, is one of the severest and most rebellious diseases 
 which the eye -surgeon is called upon to treat. The sight may be 
 
 ,' ■, 'It' 
 
 ^ ■' niiiii 
 
 -,<: » 
 
I, I 
 
 5 30 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 m 
 
 \p\ 
 
 completely lost in a day or two, and there is no means for restoring 
 it in such a case. 
 
 It seems scarcely necessary to remark that a patient suffering 
 from gonorrhoea should carefully abstain from sexual indulgence 
 until several weeks have elapsed after the cessation of the discharge. 
 His own welfare, as well as that of the other individual concerned, 
 demands that he shall be strictly continent until there is no further 
 possibility of communicating the disease. 
 
 Impotence. 
 
 An inability to perform the sexual act is one of the commonest 
 derangements of the genital organs in the male. It is due either 
 to some unnatural formation of the parts, or to deficiency in the 
 power of erection, or to some disease in those organs where the 
 esser.tial part of the male fluid is secreted. 
 
 In order that a man shall be capable of propagation, it is 
 necessary that certain microscopic elements, called spermatoziHx, 
 shall be produced in his body and shall reach the womb of the 
 female. It is evident, therefore, that an inability to propagate may 
 be due to defects in any one of three ways : 
 
 First — There may be some disease of the testicles, as a result 
 of which the spermatozoa are not produced, or are but imperfectly 
 formed, so that they are incapable of performing their functions 
 when they arrive in the genital canal of the female. 
 
 Sicond — There may be some impediment or obstacle to the 
 escape of the male fluid, so that it cannot be projected in the usual 
 way. 
 
 Third — There may be an inability of the male organ to assume 
 the changes of form and position necessary for the proper perform- 
 ance of the sexual act. 
 
 It would be extremely interesting to follow in detail the rela- 
 tion and connection between the sexual organs and the other narts 
 of the body, especially of the brain, for these organs are connected 
 by a delicate and complicated nervous apparatus with the brain, 
 so that they are largely under the influence of the mind. It is, of 
 course, a familiar observation, that while no exercise of the will can 
 affect the digestion or the beating of the heart, yet the manifesta- 
 
 n 
 
 
IMPOTENCE. 
 
 531 
 
 tions of sexual activity can be provoked by voluntary effort 
 through the influence of the imagination. 
 
 While it is out of our province to enter into any detailed 
 discussion upon this point, we can merely point out some of the 
 most important facts for practical application. 
 
 First — It is a fact that certain diseases of the nervous system 
 manifest themselves early in their course by interference with the 
 genital functions. A patient who is suffering from locomotor ataxia 
 or diabetes usually loses the power as well as the desire for sexual 
 gratification ; sometimes, indeed, this loss of sexual power is one 
 of the earliest symptoms of the disease. 
 
 Just as the influence of the mind is powerful in inciting the 
 individual to sexual excitement and gratification, so it may be 
 equally powerful in restraining the natural manifestations of sexual 
 power, even though there be nothing wrong with the genital organs 
 themselves. None of the bodily functions are so completely under 
 the influence of the mind as this one. The most curious and 
 remarkable instances are recorded in the annals of medicine, show- 
 ing how a sudden emotion or a sudden conviction can render a man 
 impotent for the time being. It would be out of place to record 
 upon the pages of a popular work incidents illustrating the facts 
 upon this delicate topic. But one point should be emphasized in 
 this connection, namely, that impotence is often a disease of the 
 imagination and not of the genital organs. Every physician who 
 has had much experience in this department of medicine knows how 
 many cases there are in which the patient fails to perform the act 
 merely from lack of confidence ; and hov/ many instances occur in 
 which the use of some mysterious remedy, or the application of 
 instruments in parts of the body which are to the patient myste- 
 rious, results in perfect cures of impotency, even though these 
 medicines and these i istruments have really not affected the 
 indi- idual in the least. The fact is that these patients suffer from 
 diseased imagination, and not from diseased sexual organs. They 
 have in many cases failed during the first attempt at sexual 
 congress, and have in consequence become so thoroughly dis- 
 heartened and demoralized that they believe themselves to be im- 
 potent, and are afraid to repeat the experiment. The difficulty is 
 increased by the privacy which always surrounds sexual matters ; 
 a man who suspects himself to be impotent does everything in his 
 
 
 .r> ^. 
 
It^ 
 
 I 
 
 t'-lB , ''♦-2 I ^ fi I 
 
 532 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 power to conceal his supposed condition from others, and hence 
 du^s not get the benefit of the experience of other men. 
 
 For the benefit of such individuals, and indeed of all who are 
 suffering in secret from doubts and fears as to their own sexual 
 capacity, it should be stated that very few men meet with com- 
 plete success in their maiden efforts in this direction. The excess 
 of emotion is usually such as to defeat its own object ; but this 
 defect disappears with time and experience. No man, no matter 
 how often he may have failed, should believe himself incapable of the 
 perfect performance of this function until he has been carefully ex- 
 amined by a physician. The fact is that cases of impotence arc 
 rare, except in those who have exhausted their powers by excessive 
 indulgence. Nearly all of the cases in which persons inexperienced 
 in this matter fancy themselves impotent, are merely instances of 
 diseased imaginations, which are easily improved and cured with 
 or without medicine. 
 
 There is also a form of impotence which depends upon actual 
 disease of the genital organs and of their appendages. Such disease 
 is caused by sexual excesses, by masturbation, by deterioration of 
 the general health, by nervous exhaustion, and may follow attacks 
 of gonorrhoea. Then, again, there are cases which are caused by 
 some deformity of the genital organs. This deformity may be con- 
 genital — that is, a defect of development which was present at 
 birth — or it may be acquired. Thus it sometimes happens tliat 
 wounds or injuries to the part occasion such change as renders the 
 sexual act impossible. 
 
 It is unnecessary, and would be improper, to enter into the 
 details for recognizing the cause in each particular case of impo- 
 tence, or to outline the treatment to be adopted. When this 
 condition actually exists ; when the individual is convinced that the 
 obstacle to the successful performance of the sexual act is not a mere 
 effect of the imagination, nor the result of excessive timidity or 
 anxiety on his part, he should, at any cost, place himself in the 
 hands of a competent physician. 
 
 Sterility in the Male. 
 
 Every man who is really impotent — that is, incapable of per- 
 forming the sexual act — is of course sterile, incapable of begetting 
 offspring ; but there are also individuals who are apparently in the 
 
STERILITY IN THE MALE 
 
 533 
 
 perfect enjoyment of sexual power, and yet who arc incapable of 
 propagation. Such instances are more frequent than has been gen- 
 ii. illv supposed. The popular impression is that a failure to beget 
 cliiUlren is due to a fault of the wife. The husband usually escapes 
 suspicion, unless his pas' life has been such as to encourage a doubt 
 of sexual capacity on his part. Many a woman bears unjustly one 
 of the greatest stigmas that can be attached to her — that of bar- 
 renness. 
 
 Sterility on the part of the male is just as certain, though not 
 so frequent a condition, as barrenness of the female. The affection 
 may result from any one of several causes, and these causes are of 
 such common occurrence that about one case in six in which mar- 
 liasfcs are unfruitful is found to be due to the fault of the hus- 
 band, 
 
 it would be out of our province to enumerate all the causes 
 which may result in sterility in the man, and just as foreign to our 
 purpose to mention the treatment which is necessary for the relief 
 of this condition. Sometimes it is quite possible to cure the affec- 
 tion, though recovery is not so frequent in these cases as in those 
 in which there is simply inability to perform the act. The causes 
 which result in actual sterility are in most cases beyond the reach of 
 medicines or of surgical operations. A few causes may be men- 
 tioned here ; these are cases in which the active ingredients of the 
 male fluid — xXxe spermatozoa — are absent from this fluid tem- 
 porarily. 
 
 This condition occurs frequently in those who have been 
 addicted to excessive sexual indulgence for years. Tn such cases 
 the sexual power is apparently not impaired, though the capacity 
 fur propagation is lost. In many of these cases of confirmed 
 debauchees this condition is followed in a short time hy actual impo- 
 tence — that is, inability to perform the sexual act. 
 
 In other cases the absence of spermatozoa is a merely tempo- 
 rary one which may be t^ue to excesses of -hort duration : fw 
 cause is nervous exhaustion, which may occur in a perfectly c ,u- 
 ncnt individual who has never been addicted to excessive ■<<;.\ual 
 indulgence. In such cases the sexual capacity retur?^* when tl»« 
 condition upon which it depends is removed by rest and treatm-jftt. 
 It has been already mentioned that certain diseases of dt^rierent 
 nrt^^ans in the body are apt to cause sexual incapacity. \ arious 
 diseases of the nervous system are especially often accompanied 
 
 35 
 
Pt 
 
 \\! 
 
 E ' r 
 
 > ^ 
 
 k?i' ill .| 
 
 
 534 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 with this symptom ; and diseases of the kidney are also apt to be 
 followed by loss of sexual power. One of the most frequent of 
 these general diseases which has this depressing effect upon the 
 fornLition of spermatozoa, is consuviption. The interference with 
 sexual power seems to occur before the disease hab made serious 
 inroad upon the patient's health. 
 
 The use of certain stimulants in excess is also followed by this 
 loss of sexual capacity ; among the agents which are now so com- 
 monly abused are morphine and chlcral. 
 
 In every case in which doubt exists whether the fluid actually 
 contains the elements necessary to propagation, the matter can be 
 solved at once by submitting this fluid to microscopic examination. 
 This is in fact the only way to ascertain whether the barrenness of 
 a marriage is to be charged to the husband or to the wife. 
 
 Seminal Emissions— (Spermatorrhoea.) 
 
 This affection is the greatest bugbear of young men. It is 
 the source of immense revenue to self-styled " specialists " and 
 others who advertise in the daily press their ability to cure the 
 disease, and present a most appalling and gloomy picture of the 
 present condition and future misery of individuals who suffer from 
 seminal emissions. There are probably comparatively {kiw young 
 men who have not at some time been alarmed by reading the 
 newspaper advertisements, pamphlets and handbills with which the 
 country is flooded, offering relief in the name of pure philanthropy 
 and humanity to the thousands of young men who must otherwise 
 go down to a wretched and early grave. These pamphlets and 
 circulars emanate generally from " victims of self-abuse," who have 
 after long years of unsuccessful treatment at the hands of physicians 
 discovered accidentally a sure cure for the affection, which they are 
 willing to impart — for a consideration. V 
 
 The business of these men would be destroyed, and much 
 unhappiness, misery and despondency would be avoided by young 
 men generally, if the actual facts with regard to seminal emissions 
 were known to the public. 
 
 The fact is that seminal emissions occur naturally in men in 
 good health who do not indulge in sexual intercourse. Witb'n a 
 
 K 
 
SEM'ivAl- EMISSIONS — SI'l-:KMATORRHa:A. 
 
 535 
 
 certain limit it is perfectly natural and healthy for the fluid to 
 escape without the usual provocation. The question then arises. 
 what is the limit at which these emissions cease to be healthy and 
 become injurious ? It would be a source of much satisfaction to 
 the writer, as well as to other physicians, if there were some fixed 
 law by which this question could be answered. But there is no 
 such law ; indeed, when we consider the matter, it is evident that 
 there can be no rule which shall apply to all individuals. It is 
 impossible to state definitely just how much beefsteak a man should 
 cat or can eat without injury ; he can easily ascertain for himself 
 bv experiment. So it is with regard to the frequency of seminal 
 emissions ; the interval which elapses between them varies ex- 
 tremely in individuals who remain nevertheless in equally good 
 health. Some men sufter such an emission once in two weeks, 
 while others have several in a week, and yet maintain perfect health. 
 
 While we cannot, therefore, predict just how many emissions 
 can be borne without injury to the health, we can say whether they 
 are injuring any given individual. They cannot be accused of any 
 injurious effect unless they are followed by headache, backache, 
 sleeplessness, mental depression, and bodily lassitude. Even in 
 these cases it is quite possible that other causes, such as excessive 
 devotion to business or pleasure, are largely responsible for the 
 symptoms just mentioned ; in every case the patient should take a 
 calm and reasonable view of the matter, and not jump to the con- 
 clusion that his health is being undermined by seminal emissions when 
 there are actually other causes which are in themselves sufficient to 
 account for his difficulties. It is a fact that seminal emissions may 
 be a result as well as a cattse of general debility ; and much effort 
 is sometimes wasted in attempts to cure seminal emissions, which 
 should be directed to improvement of the general health, since 
 this improvement would be the surest way of checking the symp- 
 toms complained of. 
 
 The occurrence of these emissions by day is always a symptom 
 of disease, either in the sexual organs themselves or elsewhere in 
 the body. If they be provoked by slight excitement or irritation 
 of the skin, or by lascivious thoughts, it is highly probable that 
 the difficulty originates in the sexual organs themselves. 
 
 Most cases in which the patients believe themselves to be 
 afflicted with seminal emissions by day, are really not cases of 
 spermatorrhoea at all. Unless the discharge be accompanied by 
 
 'i: : ill:. ;•!,;, 
 
 V 1 r 
 
 I. 1 
 
 ,.,.!■; 
 
 i 
 
 " li -'rs ' 
 
 ! >H 
 
 

 .!.■-' 
 
 536 
 
 VKNEKKAI, l)K I'KIVAIK DISKASES. 
 
 the usual symptoms, it is highly probable that the fluid which 
 escapes is not the seminal fluid at all, but merely an increased secre- 
 tion from the urethra and from the prostate gland. The question 
 can be decided at once by submitting the fluid to microscopical 
 examination ; until this is done the patient should remember that 
 the probabilities are against the supposition that this fluid is the 
 true seminal discharge. It should also be remembered that in cer- 
 tain conditions of the general system seminal emissions occur as a 
 rule, and have no other significance than that of a symptom of the 
 disease. It is not uncommon for patients who are recovering from 
 exhausting diseases — such as the infectious fevers, small-po.N, 
 typhoid fever, etc., — to have emissions by day as well as by night. 
 These may occur at short intervals for several weeks and yet dis- 
 appear permanently when the patient finally recovers his health. 
 
 One of the most frequent complaints which are made to ph) 
 sicians by young men in connection with this matter, is that they 
 sufier seminal losses during the evacuation of the bowels. It 
 should be stated that the fluid which the patient regards as scnicn 
 is rarely of this character ; in most cases it has nothing to do what- 
 soever with the seminal fluid. Such patients complain that tliis 
 discharge is more frequent and profuse when the bowels arc con- 
 stipated — a fact which of itself indicates the harmlessness of the 
 symptom. 
 
 Syniptonii*, — Although the symptoms of true spermatorrhu;a 
 vary according to the general condition, disposition and age of the 
 patient, yet the general course is somewhat as follows : 
 
 Among the earlier symptoms which indicate that the pollutions 
 are becoming more frequent than is compatible with perfect hcallh, 
 are pain in the small of the back, pain in the head, a sense of fatigue 
 and inability for exertion, and a certain incapacity for mental effort 
 As the emissions increase in frequency, the patient observes a dimin- 
 ished capacity for sexual enjoyment ; the general symptoms are made 
 worse, and include dizziness, weakness of sight, trembling in the 
 limbs, a sense of weight in the chest, palpitation of the heart, and 
 signs of dyspepsia. After a time he begins to have emissions by 
 day also, and he now usually becomes the prey of despondency. 
 His mental depression may be so grea* that his thoughts are con- 
 stantly directed to the one subject — a condition which aggravates 
 the difficulty. His gait becomes unsteady ; he feels wandering 
 pains in various parts of the body ; his rest is disturbed by frJLjhtful 
 
 .-«U.J*.i 
 
SEMINAL EMISSIONS — SPEkMATORKHa<;A. 
 
 537 
 
 dreams ; he shuns society, because he imagines that others see and 
 recognize the cause of his difficulty. In fact, his mental condition 
 ;ij)])i()aclies finally a niiki typo of insanity. It must be said, how- 
 ever, that there but few, if any, cases in which insanity can be traced 
 to excessive seminal losses. There are numerous instances in which 
 an individual suffering from seminal emissions has become insane, 
 and such cases are commonly ascribed to the seminal losses. A 
 closer scrutiny of the case usually shows that the patient had a ten- 
 dency to nisanity, ami that the seminal losses are to be regarded 
 rather as one of the symptoms of the general nervous depression 
 which resulted in insanity — as an effect, therefore, rather than as 
 the cause of his mental derangement. Certain it is that those who 
 have inherited a disposition to certain nervous diseases — epilepsy 
 .iiul insanity for instance — are far more frequently affected with 
 seminal emissions than others. 
 
 ('(fuse. — Spermatorrhoea is not usually a separate disease by 
 itself, but is a symptom of several affections which may be located in 
 the genital organs or may affect other parts of the body, especially 
 the nervous system. In most cases it is simply a nervous disease, 
 and is accompanied by numerous other symptoms which indicate fee- 
 bleness of the nervous system. The subject of it is commonly of a 
 nervous, excitable temperament ; and as first pointed out by an 
 eminent French physician, he has usually suffered in earlier life 
 from some manifestation of weakness in the genital or urinary 
 organs, such as inability to retain the urine. It has been noted that 
 children afflicted in this way often suffer in later life from weakness 
 of the genital organs. 
 
 Among the causes which predispose to this affection is con- 
 stant indulgence of the imagination in licentious thoughts. This 
 especially when combined with unsatisfied sexual excitement, in- 
 duces an irritability of the organs which finally results in the ascape 
 of the seminal fluid upon slight provocation. 
 
 Spermatorrhoea is most frequently induced by the habit of self- 
 :ibusc. When this habit is stopped the individual usually suffers 
 from inxoluntary emissions instead of those which he had formerly 
 excited voluntarily. 
 
 It must not, however, be supposed that every individual who 
 has once indulged in this habit must suffer from incontinence of 
 semen afterward. In many cases the habit is practiced to only a 
 limited extent and is not followed, to any particular degree, by 
 
 iS'lr^.iP 
 
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 Photographic 
 
 Sciences 
 Corporation 
 
 73 WEST MAIN STREET 
 
 WEBSTER, NY. MS80 
 
 (716) 873-4503 
 
 

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 538 
 
 VENEREAL OR PRIVATE DISEASES. 
 
 seminal emissions ; that is, these emissions do not occur with more 
 frequency than is natural for individuals who have not practiced 
 self- abuse. 
 
 There are several causes which may act in exciting seminal 
 emissions in cases where no disease of the sexual organ;** exists. 
 Sometimes an unusual formation of the organ is a source of con- 
 stant irritation which provokes seminal emissions. One of the 
 most frequent of these is an unnatural tightness of the foreskin, 
 whereby the secretion formed beneath it cannot escape, and being 
 retained irritates the inner surface. An unnatural narrowness of 
 the urethral opening may also cause constant irritation and seminal 
 losses. 
 
 Cases have been known in which spermatorrhoea has followed 
 several ordinary derangements of the rectum ; thus piles, fissuiLs, 
 worms and skin eruptions in these parts have all been known to 
 cause seminal losses, which disappeared when the orii^inal affection 
 was removed. Habitual constipation may also cause the same 
 effect by constant pressure upon the parts. 
 
 Treatment, — In all cases of involuntary seminal losses 
 certain rules of hygiene and of moral conduct must be complied 
 with. The diet should be bland, easily digestible, and yet 
 nourishing ; in fact particular care should be taken that the 
 patient is provided with abundant food of the best quality. He 
 should take but little food in the evening, and should carefully 
 avoid the use of liquors. The bladder should be emptied before 
 retiring, and the patient should sleep upon a hard mattress — hair, 
 for instance — without much covering. The emissions occur with 
 especial frequency in the early morning hours ; hence the patient 
 can often prevent them by setting an alarm-clock, which shall 
 awaken him about an hour before the time at which the accident 
 usually occurs. If the patient will then empty the bladder the 
 liability to seminal loss will thereby be much decreased. 
 
 The attention should also be directed to the general state of 
 the bodily health ; care should be taken to secure abundance of 
 air and exercise, and to interest the mind in some pursuit which 
 will divert the attention from sexual matters. Perhaps the most 
 important item in the treatment of spermatorrhcua, generally 
 speaking, consists in persuading the patient to devote his oiitiic 
 energies to some occupation which will leave him no time, ami but 
 little energy for thinking about his condition. 
 
SEMINAL EMISSIONS — SPERMATORRH'EA. 
 
 539 
 
 Yet it should not be forgotten that since seminal losses are 
 oftentimes a mere sign of general debility, excessive exercise may 
 aggravate rather than benefit the difficulty. The patient should 
 never push his employment to an extent which causes him to feel 
 exhau'^tcd. 
 
 The genital organs and the skin in the vicinity should be 
 carefully scrutinized, in order to detect and remove any of the 
 irritating causes which are known to induce seminal losses. In 
 some cases simple attention to cleanliness, and care .to avoid the 
 retention of any secretion under the foreskin will be sufficient to 
 remove the affection. In other cases an operation will be necessary 
 whereby a portion of the skin is removed — circumcision. At 
 other times it will be found that piles are keeping up constant 
 irritation, and that the removal of the piles will cure the affection 
 of the sexual organs. 
 
 Again, the entire difficulty may result from habitual constipa- 
 tion. Measures which cure this affection will also relieve the patient 
 of the seminal weakness. For this purpose the individual may 
 employ the usual mineral waters, or he may take a teaspoonful of 
 Rochelle salts in a glass of water before breakfast every morning. 
 If tliis does not suffice to secure regular evacuation of the bowels, 
 the following prescription may be employed ii. addition : 
 
 Extract of belladonna, . . . Four grains. 
 Extract of nux vomica, - - - Five grains. 
 Compound extract of colocynth, - Thirty grains. 
 
 Mix, and make twenty pills ; take one of these at bedtime. 
 
 A word may be added here with reference to the habit of self- 
 abuse. There is no denying the fact that this custom is alarmingly 
 prevalent among children of both sexes. Parents cannot be too 
 careful in supervising the habits of their children, for these often 
 acquire the habit of self-pollution without knowing what they do. 
 In fact, the habit is practiced in many instances at an age when the 
 child would not be supposed to be deriving any gratification from 
 it. It has even been practiced by infants in arms. Every associa- 
 tion of boys or girls, such as occurs in boarding schools, public 
 schools and the like, is a hotbed for the propagation and dissemi- 
 nation of this habit among innocent children. Every child who 
 is entrusted to the care of hired servants also runs a risk of con- 
 tamination. This is of course a matter for parents, guardians and 
 
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 M S'! 
 
 
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 ,■} 
 
 540 
 
 VENKRliAL OR PRIVATE DISEASES. 
 
 teachers of children to detect and to prevent ; it lies beyond tlic 
 reach of the physician. 
 
 A few words of information may, however, be comforting ami 
 profitable to parents who discover that their children have btn n 
 taught this habit. 
 
 In the first place, the evils which are popularly attributed to 
 the habit are grossly exaggerated. The medical profession has 
 been singularly lax in instructing the people as to the actual facts 
 in the case ; hence the popular information on the subject is derived 
 largely from the advertisements of quacks, whose interest is 
 furthered by exciting the fears and anxiety of those who have at 
 some time been guilty of the practice. From such sources people 
 have derived the belief that one who has been addicted to self- 
 abuse is marked as a victim for all sorts of nervous diseases, termi- 
 nating in insanity, imbecility and death. These ideas are essentially 
 erroneous ; for no instance is on record in which insanity or imbe- 
 cility could be traced positively to this habit. The numerous cases 
 in which self-abuse is practiced by insane, imbecile and epileptic 
 patients seem to be instances in which both the disease and the 
 habit of self-pollution are the results of a common weakness of tlie 
 nervous system, and not that either one is the effect of the other. 
 
 The injury which is to be expected from indulgence in the 
 habit of masturbation depends largely upon the e.xtent to wiiich 
 the habit is practiced, as well as the age .it which it was begun. 
 As has been stated, every healthy male suffers a discharge of semi- 
 nal fluid at stated intervals, no matter how continent he may he ; 
 and the frequency of these emissions may vary extremely without 
 exceeding the bounds of health or causing injurious effects. The 
 health of the individual is not impaired when the frequency of these 
 emissions is much increased by marriage ; nor is his general condi- 
 tion necessarily deteriorated if the emissions are made to occur 
 without marriage. Injury is to be expected when the habit is 
 acquired at an early age before the sexual powers are develoiud, 
 and hence before they are capable of sustaining the effort recinin d 
 of them in responding to the stimulation of se.xual e.xcitenunt. 
 Unfortunately in many cases, the boy becomes so addicted to the 
 habit that he is incapable of thinking about or devoting his ener- 
 gies to anything else. The result must necessarily be a stuntini; of 
 his intellectual powers. One other fact should be empliasi/ed, 
 namely, that the injury is simply the result of exhaustion of the 
 
SEMINAL EMISSIONS — SPERM ATORRHCEA. 
 
 541 
 
 vital powers ; and that this exhaustion results not from the loss of 
 the seminal fluid, but from the excitement incident to the escape of 
 the fluid. The most absurd and extravagant ideas prevail as to the 
 vital importance of the male fluid ; these ideas, derived chiefly from 
 the advertisements of" specialists," ascribe to this fluid the qualities 
 (if a vital essence. It is a prevalent belief that the loss of a single 
 drop of this fluid exhausts a man as much as the loss of a consid- 
 erable quantity of blood. Such ideas are, of course, absurd ; the 
 exhaustion which follows the loss of the seminal fluid is consequent 
 merely upon the intense excitement which accompanies the act. 
 This is the most intense and exhausting emotion of which the human 
 .mimal is capable ; and indulgence in it is naturally followed by a 
 corresponding degree of exhaustion. As a matter of fact, a semi- 
 nal emission induced artificially does not and cannot exhaust the 
 individual so much as natural intercourse ; but the trouble is that 
 while the number of emissions in the natural way is from the very 
 nature of things limited, there is no limit to the license which a per- 
 son may practice who grfitifies his sexual appetite by artificial 
 means. Hence masturbation is or may be more injurioi-.s than 
 sexual congress, simply because it is so easily and generally prac- 
 ticed to an excess that is impossiole in natural intercourse. 
 
 As for the treatment of masturbation no rules can be given. 
 The habit must of course be stopped as soon as possible ; yet the 
 best means of attaining this object vary extremely in different 
 cases. In some instances there may be room for the use of medi- 
 ciiir^ ; the child may be pale and feeble, and perhaps when the 
 j,'cneral health is improved, the practice of self-pollution may be 
 (i\ercomc. But in most cases the treatment will consist in engag- 
 ing the child's attention in some employment or recreation which 
 absorbs his thoughts and energies ; in encouraging him in the effort 
 to overcome the habit, and in extending the warmest sympathy 
 and supi)()rt. 
 
 " In some cases it may be absolutely necessary to employ 
 mechanical means for preventing the practice in individuals who 
 arc ton young to summon the moral strength necessary to over- 
 conic the habit. Various measures have been tried, such as tying 
 tile hands and feet. This is a harsh measure which is, moreover, 
 often unsuccessful. If any such mechanical means must be used, the 
 the most effectual is probably the application of a small Spanish fly- 
 blister plaster to the parts in such away as to keep them constantly so 
 tender that the child is restrained by pain from meddling with them. 
 
 ■ riil 
 
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 i1 I 
 
 542 
 
 VKNERF.AI, OR PRIVATE DISEASES. 
 
 These plasters need not remain long enough to cause the 
 actual formation of blisters ; it will suffice to keep portions of the 
 skin red and irritated, so that violent motion causes pain. The use 
 of these plasters for a few weeks will usually be sufficient to break 
 up the habit for a time ; care must however be taken that the child 
 does not resume the habit auer the blisters are discontinued. 
 
 Those who may have at an early period of their lives been 
 addicted to this habit, but have discontinued it, should be assured 
 that no serious results are to be anticipated in the future. Physi- 
 cians are occasionally consulted by young men who have become 
 thoroughly alarmed by reading the pamphlets circulated for 
 advertising purposes, in which it is asserted that numerous ills 
 of adult life are the direct consequences of the least indulgence in 
 this habit in youth. If any evil results, it will become evident long 
 before the individual becomes matured; he need have no apprehen- 
 sion on account of a previous indulgence for a short time in this 
 habit. 
 
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 2.— Iris, Olliiiry Mtwclr, iiiid Choroid. 
 
 6.— Artiticial Eye. 
 
 7.— View of tliu becomi pair of Optic Norvee. 
 
 1.— Vertloal Keotlon of the Kycball. 
 
 4.— External Muscles of the Eyeball. 
 
 8.— Lachrymal Apparatuc (the skin or the lids has 
 been removed i. 
 
 6.— Formation of Image on Ifrtina. 
 
 EYE. 
 
DISEASES OF THE EYE AND EAR. 
 
 DISEASES OF THE EYE. 
 
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 In order to understand the affections of the eye, even the 
 most frequent and simple ones, it is necessary to have some knowl- 
 cdj^c of the general structure and functions of the organ. While 
 it will be impossible to convey in words any accurate idea of the 
 intricate and delicate structures contained in the eye, yet the gen- 
 oral plan and principle of its formation are extremely simple and 
 interesting. 
 
 Every one who has even a slight acquaintance with the box 
 which a photographer uses, called the camera, can appreciate at 
 once the structure of the eye. The human eye is, indeed, arranged 
 upon precisely the same principles as the photographer's camera, 
 as will be evident upon slight comparison. 
 
 The photographic camera consists of a box blackened on the 
 inside, to which light is admitted only through an opening in the 
 front ; this opening is filled by a piece of curved glass, technically 
 called a double convex lens. At the side of the box opposite to 
 this lens is a frame made to carry a plate of glass. This plate oi 
 t^lass is coated with a layer of material — usually a compound oi 
 .silver in gelatine — which is sensitive to light; that is, whenever 
 the light falls upon the plate, this material undergoes a chemical 
 change. In taking a picture the object is placed in front of the 
 bo.K in such a position that the rays of light emanating from this 
 object are focused by means of the lens, that is, brought together 
 so as to make a picture upon the plate. In consequence of the 
 sensitive nature of the gelatine upon the glass plate to the action 
 
 S43 
 
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544 
 
 DISEASES OF THE KY+; AND EAR. 
 
 in*' 
 
 of li^ht, this picture is recorded upon the plate, makinjj the p/ioto- 
 
 The same principles apply in the formation of the picture in 
 the human eye. The eye is a spherical box or camera, blackened 
 on the inside and closed on all sides e.xcept in front, where a circu- 
 lar opening exists. Ri|^ht at this opening is a double convex lens 
 like that of the photographer's camera ; and at the back of the 
 eye is a sensitive plate, a layer of nervous tissue called the retina, 
 which is susceptible to the action of light just like the gelatine of 
 the photographer's plate. The rays of light coming from an object 
 in front of the eye are focused by means of the lens so as to make 
 a picture of that object upon the sensitive plate — the retina — at 
 the back of the eye. This picture e.xcitcs the nervous center in the 
 brain, so that the individual is conscious of the image on the 
 retina. 
 
 The essential parts of the eye — those absolutely necessary to 
 the perception of an object — are therefore the Avw and the retina. 
 If either of these be damaged so that it cannot perform its proper 
 functions, there can be no perception of objects by the eye. Yet 
 while these constitute the foundation of the eye, so to speak, there 
 are various other parts of the organ which are essential to perfect 
 vision as it exists in the healthy eye. We can understand these 
 parts by referring again to the photographer's camera. He em- 
 ploys lenses of different power, according to the distance of the 
 object which he wishes to picture upon the plate. If this object be 
 situated close to his camera, the photographer must have a stronger 
 lens — that is, one with a considerable curvature of the surface. 
 This is necessary in order that the picture shall be accurately 
 focused upon the plate at the back of the box. If the object be, 
 on the other hand, situated at a considerable distance, such as an 
 extensive landscape, the photographer uses a weaker lens — that is, 
 one which is not so curved. 
 
 Just so there must be a difference in the curvature of the lens 
 in the human eye at different times, for when we read small print 
 for instance, or examine objects situated close to the eye, the rays 
 of light must be strongly focused in order to make a perfect picture 
 on the retina ; and when we look at distant objects the rays of light 
 must be less strongly focused — 'that is, the lens must be flatter. 
 Now, it is impossible to arrange for the difference in the eye as is 
 done in the photographic camera, for in the latter case a stronger 
 
DISEASES OK THE EYE. 
 
 545 
 
 or a weaker lens is put into the opening of the box as occasion 
 n quires, several being kept on hand and changed according to the 
 oWjict desired. The eye is provided with only one lens ; but by a 
 nu>st delicate arrangement this lens can be made to change its shape. 
 It becomes more curved or flatter, according as the individual looks 
 at near or distant objects. Thus the same result is produced as if 
 the eye were provided with several lenses of different curvatures ; 
 that is, the objeci, whether near or far, is focused so as to produce 
 a perfect picture on the retina. 
 
 This change in the curvature of the lens is accomplished by the 
 contraction of a muscle — the ciliary muscle. Whenever we desire 
 to look at near objects this muscle contracts, causing the lens of the 
 eye to become more curved. We are not conscious of the effort at 
 first, nor are we aware that we actually change the form of the eye. 
 riiis is done unconsciously, like so many other movements of the 
 body. Hut after a time we become conscious that we are exerting 
 an effort ; thus if we look at small objects for a considerable time, 
 if we read fine print, for example, the eye becomes tired. This is 
 for the same reason that the arm becomes tired after long-continued 
 miiscuiar effort, or that the legs become tired from walking. Every 
 muscle must be rested after it has worked a considerable time, and 
 it indicates the need for rest by the feeling which we call fatigue. 
 So llic eye becomes tired when reading small print, simply because 
 the muscle which keeps the lens in a proper state of curvature has 
 become exhausted. 
 
 Another feature, which is common to the eye and to the photo- 
 t;ra|)liic camera alike, is an arrangement whereby the amount of 
 light entering the eye can be regulated — that is, increased or de 
 creased as occasion requires. The photographer regulates the light 
 which enters his camera by means of a black ring which he puts 
 over the lens, thus shutting out the light from the edge of the lens, 
 aiul permitting it to enter only through the middle portion. When 
 the light coming from the object is very intense, it is necessary to 
 put this black ring over the lens so as to shut out some of the light. 
 This is what the photographer calls stopping the lens. A precisely 
 similar arrangement is found in the human eye. The colored ring 
 in the front of the eye — the iris — is really a curtain, intended to 
 regulate the amount of light which passes through the lens onto the 
 retina. Whether blue, or brown, or black, it is so constructed that 
 no light passes through it. Any light which enters the eye must 
 
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 546 
 
 DISKASKS OF THE EYE AND EAR. 
 
 pass through the central opening in the iris — the pupil. Wheni\ir 
 the eye is exposed to a bright light, the iris closes somewhat, so ,is 
 to make the pupil smaller, and thus permit less light to pass into the 
 eye. Whenever the light is very dim, on the other hand, the iri-, 
 opens, so as to j)ermit more light to enter the eye. 
 
 This action of the iris in regulating the amount of light adniittci' 
 to the eye, is, like the action of the ciliary muscle, an unconscious 
 effort, which may even take place during sleep. 
 
 The closure of the pupil has also another object, for, in con- 
 sequence of the shape of the lens, it is necessary in looking at luai 
 objects, to permit the light to pass only through the central p.irt 
 of the lens ; if the rays enter through the edge as well as th. 
 middle of the lens, the image formed on the retina is blurred ; d 
 the individual sees indistinctly. Hence whenever we look at 1, ' 
 objects, when we read fine print for example, the pupil contracts 
 quite markedly ; if the eye be suddenly directed from near to dis- 
 tant objects, the pupil increases in size — a change which can In- 
 plainly seen if we watch a person who suddenly changes his c\ es 
 from a book that he is reading to look at a distant object. Tlii^ 
 occurs quite independently of the amount of light which enters 
 the eye ; it is intended to increase the distinctness of vision. A 
 simple experiment will illustrate the value of this action of the iris in 
 closing the pupil when we look at near objects. Let an individual 
 close one eye, and holding a pin by its point between the thumb 
 and finger, bring the head of the pin to within about ten inclKs 
 from the other eye. He will now see the pin head quite distinctly. 
 Let him then bring it gradually toward the eye gazing ste;idily at 
 tl:e head of the pin all the time, when it has been brought to within 
 a certain distance — usually within about three inches from the eye 
 — the image becomes indistinct, that is the pin's head seems 
 blurred. Let the person now take with the other hand a card w it); 
 a pin-hole in it, and bring this card close up against the eye so that 
 the pin-hole comes just in front of the pupil ; upon looking through 
 this pin-hole he will see that the head of the pin which was blurred 
 a moment before is now perfectly sharp and distinct. 
 
 This simple experiment shows how important the action of the 
 iris is in enabling us to see near objects distinctly. By looking 
 through the pin-hole we accomplish the same result as if we closed 
 the pupil to the size of the pin-hole, and are thus enabled to see 
 distinctly where we could not see were the pupil large. 
 
DISEASES OF THE EYE. 
 
 547 
 
 The form of the eye is maintained by means of stout mem- 
 branes — the outer coat of the eye — and by the fluids which 
 till its interior. The front part of this outer coat is made smooth 
 ,iiui transparent and is called the cortna. This part of the eye is 
 shaped \ery much like a watch glass ; it is its smoothness and 
 polisiied surface which give to the eye the brilliant luster so char- 
 acteristic of this organ. The interior of the eye is lined with a 
 laver of black material — the choroid — the object of which is just 
 the same as the object of the black layer in the photographer's 
 camera or in any other optical instrument — that is to absorb 
 str.i;,^i;ling rays of light so as not to blur the image formed by the 
 rays coming directly from the object. It is owing to this black 
 lining that the pupil of the eye appears blac!:, no matt' i what the 
 C()li)r of the iris may be ; for the pupil is merely an opening throu^-h 
 which wc look directly into the back of the eye ; >i since thi*^- L»ack 
 is made of black material which reflects but little light. ' is evident 
 that the pupil .nust appear to be bla :k. There are certain circum- 
 stav-f>s under which the pupil may appear red; those circumstances 
 occur when an individual happens to be standing facing a bright 
 lif,dit while the observer stands between him and the light. Under 
 such circumstances the pupil will suddenly flash out with a flammg 
 red color, as if the eye were of fire. This appearance is more 
 familiar in connection with the lower animals ; it is frequently 
 observed that the eyes of a dog or cat exhibit this brilliant red 
 color. This redness is simply a reflection from the retina, which 
 lies upon the black coat, the choroid, and has a brilliant red 
 color. 
 
 The retina is, as has been said, a layer of nervous tissue which 
 is sensitive to the action of light. Yet it is not equally sensitive 
 over its entire surface ; we are familiar with the fact that the sense 
 of touch is more acute on the ends of the fingers and on the lips 
 than in the middle of the back ; in the same way the sense of sight 
 — that is, sensitiveness to light — is most acute at a little spot 
 directly opposite the pupil. This place is called the ycllozv spot of 
 the retina, and is the point upon which the picture must be made 
 in order that we shall see objects distinctly. The rest of the retina 
 is susceptible to light, though less so than this central yellow 
 spot. Hence when images of objects are formed upon other parts 
 of the retina than the yellow spot, they are somewhat indistinct; 
 we can readily appreciate this fact by looking intently at some 
 
 36 
 
'11 
 
 
 Hi 
 
 548 
 
 DISEASES OF THE EYE AND EAR. 
 
 small object on the wall a few feet distant. This small object is 
 seen quite distinctly but other objects on either side of it are but 
 imperfectly seen. In consequence of this arrangement, it follows 
 that the eye must be directed toward any object which we desire 
 to see distinctly. This necessitates some arrangement for moving 
 the eye quickly and easily, in order to view successive objects witli 
 great rapidity. Hence the eye is made movable in its socket, and 
 is provided with a series of muscles wlio",e function it is to revolve 
 the eye and thus enable the individual to view different objects in 
 quick succession. In this way the pictures of different objects, 
 located in various directions from the individual, can be readily 
 formed upon the yellow spot, and thus distinctly seen. 
 
 It has been several times stated that pictures are actually 
 formed upon the retina, just as they are formed in the photog- 
 rapher's camera. This statement can be easily verified by remov- 
 ing an eye from a freshly-killed animal — a sheep or bullock. If 
 the outer white coat be cut carefully away at the back of the eye, 
 so as to leave the inner coat intact, and the eye then be taken in a 
 dark room and the front of it — the cornea — turned toward a 
 window, a picture of the window-sash and frame will be seen dis- 
 tinctly upon the back part of the eye where the outer coat is cut 
 away. This is what happens in life ; every time that we sc ; an 
 object, an image of that object is actually formed upon the retina. 
 
 If, in the experiment just described, the picture in the eye be 
 carefully obser ed, it will be seen that the image is inverted, that 
 is, the upper pan of the sash appears to be the lower part in the 
 picture. This is also true of the image in the photographer's 
 camera , the picture of a person as formed upon the sensitive plate, 
 is really inverted, so that the individual seems to be sitting or 
 standing on his head. Much speculation has been indulged in at 
 various times in efforts to explain how it is that we seem to see the 
 objects in their proper erect position, though the pictures of them 
 on the retina are upside down. It is not necessary to enter into this 
 discussion ; but simply to remind ourselves that the infant learns to 
 appreciate the relations between the sense of touch and of sight 
 during the first months and years of his existence. Even if there 
 be no other explanation, we may readily assume that after the 
 child has learned by touching objects that they really stand erect 
 he will get into the habit of reg:;.rding them as erect, no matter how 
 the pictures are formed on the retina. 
 
DISEASES OF THE EYE. 
 
 549 
 
 The interior of the eye is filled largely with liquids ; one of 
 these, the so-called vitreous humor, occupies most of the eye, and 
 serves to keep the coats of the eye properly filled out. This is a 
 jelly-like substance, which is readily seen by cutting open the 
 freshly-extracted eye of an- animal. This vitreous humor is per- 
 fectly transparent, and in the natural condition of the eye offers no 
 impediment to the passage of light. But sometimes in diseased 
 conditions of the eye, minute bodies float in this vitreous humor. 
 These bodies seem to the individual to be outside of the eye, and 
 constitute the " specks " before the eyes, which annoy some people 
 extremely. 
 
 Another most important part of the optical apparatus is the 
 eyelids. Each of these is moulded out of a substance resembling 
 gristle into the form of a thin plate curved so as to fit over the globe 
 of the eye. These plates of gristle are covered by very fine skin 
 externally, and internally by a delicate mucous membrane called 
 the conjunctiva. A band of muscular fibres passes around the 
 opening of the eye ever the upper lid above and the lower lid 
 beneath, making a somewhat oval or elliptical figure. When these 
 muscular figures contract they draw the two lids together, thus clos- 
 ing the eye. From the borders of the lids there project the eye- 
 lashes, which give protection against the entrance of dust and other 
 foreign bodies. Just behind these hairs is a row of minute glands, 
 which produce a greasy material. This oily secretion is very 
 important, since it greases the edges of the lids, and thus prevents 
 the tears from escaping down the cheeks. 
 
 ■ This mucous membrane, or conjunctiva, covers the entire eye 
 as well as the under surface of the lids. It is a very important part 
 uf the eye, since the moisture which it secretes serves to prevent 
 friction between the eyelids and the globe itself. A considerable 
 part of this moisture is furnished by a gland — the lachrymal or 
 tear gland — which is located at the upper and outer part of the eye. 
 This gland is constantly producing a watery fluid, which under ordi- 
 nary circumstances is just sufficient to keep the eye moist and to 
 provide for the freedom of its movements. At the other end of 
 the opening between the lids — that is, at the end next to the 
 bridge of the nose — there are two small openings, one on each lid. 
 These are the openings of very fine hair-like channels which lead 
 into a larger tube or duct. This tube runs downward from the 
 inner angle of the eye into the nostril. These channels afford the 
 
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550 
 
 DISEASES OF THE EYE AND EAR. 
 
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 I 
 
 natural way of escape for the moisture which is constantly being 
 produced in the eye. It sometimes happens that this duct leading 
 from the eye to the nostril becomes inflamed and stopped up ; in 
 this case the tears — by which we mean simply the moisture con- 
 stantly produced in the eye — can no longer escape into the nose, 
 and, therefore, flow over the edge of the lids onto the checks. 
 
 We have thus mentioned the most essential points in the struc- 
 ture of the eye; and with a clear understanding of these points wc 
 can appreciate tie usual affections to which the eye is subject, ;is 
 well as the care and attention which should be bestowed upon 
 them. 
 
 Color-Blindness. 
 
 There is one other fact in regard to the eye which has recently 
 attracted much attention among physicians, and has become a mat- 
 ter of great importance in connection with public conveyances. Tliis 
 is the lack of ability on the part of some individuals to distinguish 
 properly between different colors — a condition technically known 
 as " color-blindness. " It seems at first incomprehensible that a 
 man who can see at all should not be able to distinguish colors per- 
 fectly. But the fact is that the ability to distinguish oui/ine is quite 
 distinct from the ability to recognize coior. It is a fact that one 
 man may see a bay horse just as distinctly as a second individual 
 can, yet the first may be unable to see any difference between a 
 bay horse and a black horse of similar outline — a diff"erence which 
 is of course plainly perceptible to most of us. To some individuals 
 ripe cherries are indistinguishable in color from the leaves which 
 surround them. This subject has been discussed in detail i.i a book 
 entitled " Color-Blindness," by Dr. Jeffries, of Boston, from which 
 the following facts and incidents are taken: 
 
 This defect of vision is often called " Daltonism," because a 
 noted chemist of the name Dalton was a sufferer from this defect, 
 and described very graphically the way in which different colors ap- 
 peared to him. To Dalton blood appeared of a color similar to that 
 called bottle-green; grass had a color almost identical with red ob- 
 jects. Green cloth — such as is used to cover tables — appeared of 
 a dull red color. " When this kind of cloth loses its. color, as other 
 
COLOR-BLINDNESS. 
 
 55« 
 
 people say, and turns yellow, then it appears to me a pleasant 
 green. Very light green paper, silk, etc. , are white to me. Colors 
 appear to me much the same by moonlight as they do by candle- 
 Ijirht. By lightning and electric light they appear as by daylight. 
 A light drab woolen cloth seems to resemble a light green by 
 
 day. " 
 
 Dalton's defect of vision led him into the commission of some 
 ludicrous mistakes. " Firstly, he. was a Quaker, and would not 
 wear the sword, which is an indispensable appendage of ordmary 
 court dress. Secondly, the robe of a doctor of civil laws was known 
 to be objectionable on account of its color — scarlet — one forbidden 
 to Quakers. Luckily, it was recollected that Dalton was afflicted 
 with the peculiar color-blindness which bears his name, and that, as 
 the cherries and the leaves of the cherry-tree were to him of the 
 same color, the scarlet gown would present to him no extraordinary 
 appearance. So perfect, indeed, was the color-blindness, that this 
 most modest and simple of men, after having received the doctor's 
 gown at Oxford, actually wore it for several days in happy uncon- 
 sciousness of the effect he produced on the street. " When asked 
 what color this gown appeared to him, Dalton pointed to some of 
 the evergreens outside of the window and said that, to his eye, the 
 colors were alike. The lining of the gown, which was pink silk, he 
 could not distinguish from sky blue. 
 
 A boy eleven years old, who was color-blind, saw a woman 
 passing by with a basket on her arm. He told his mother that the 
 woman had chickens in the basket, because he saw the red feathers 
 hanging out. These proved to be green leaves, with which the 
 woman had covered the butter which she carried in the basket. 
 
 A relative of this boy, who was in the navy, bought a blue uni- 
 form coat and vest, and trousers to match them ; the latter garment 
 proved, however, to be red. 
 
 " Six men — uncles, nephews and cousins — in one family, all 
 belong to the Society of Friends ; and their mistakes in selecting 
 articles of dress have been rendered especially conspicuous by the 
 preference which members of that religious body give to the least 
 brilliant and most unconspicuous colors. One of their number 
 provided himself with a bottle-green coat, intending to p'irchase a 
 brown one ; and selected for his wife, who desired a dark gown, a 
 scarlet merino. Another, who is an upholsterer, purchased scar- 
 let for drab, aiiu had to rely upon his wife and daughters to select 
 
 *:'1V? 
 
 I ■ ••> 
 
»" 
 
 III 
 
 
 552 
 
 DISEASES OF THE EYE AND EAR. 
 
 for him the fabrics needed in the course of his profession. A third, 
 who is a farmer, could not tell red apples from the surrounding 
 green leaves, except by their shape. All of them confounded red 
 with green, olive with brown, and pink with blue. One of the 
 younger men, whose profession requires him to deal much in col- 
 ored tissues, has found that the 'only way of telling the difference 
 between scarlet and green, or blue and crimson, is to take them into 
 a room lighted with gas or candles,' when the distinction which u;is 
 invisible by daylight becomes apparent." 
 
 " A post-office clerk in Prussia was found to be constantly in 
 trouble with the stamps. The accounts would come wrong. Some- 
 times there was not enough money in return for stamps sold, and 
 on other occasions there was too much. This made dishonesty on 
 his part less likely ; but it was incomprehensible how he would 
 make the accounts so entangled. At length it was discovered that he 
 was color-blind, and could not distinguish red from green stamps." 
 — Boston Medical and Surgical Journal, December 2^ , i8yy. 
 
 No doubt letters in the United States find their way to the dead 
 letter office as unpaid, from the color-blind senders putting on red 
 two-cent instead oi green three-cent stamps, since we all, from habit, 
 regard the color rather than the number on a postage stamp, espe- 
 cially when in haste. 
 
 Color-blindness is a congenital defect — that is to say, it is born 
 with the individual — in the majority of cases. In 1845, Dr. K.ule 
 reported color blindness in five generations of his own family. 
 Instances are also known in which this defect has resulted from dis- 
 ease and from injury. 
 
 It is interesting to observe that all physicians who have inves- 
 tigated the subject, find that color blindness is more frequent in 
 males than in females. 
 
 Within the last ten or fifteen years the attention of railway and 
 steamship authorities has been directed to this subject ; for it is 
 evident that since trains and ships are largely dependent for their 
 safety upon the accurate recognition of the colored lights employed 
 as signals, a failure on the part of engineers, switchmen, pilots, 
 etc. , to distinguish between red and green might be followed by 
 the most serious accidents. In fact, several catastrophes have been 
 traced to color-blindness on the part of such employes. Many rail- 
 way and steamship lines subject their men to examination as to 
 
COLOR-BLINDNESS. 
 
 553 
 
 their ability to detect colors ; and in Sweden such examination is 
 required bylaw, 
 
 In order to detect the color-blindness of an individual, it does 
 not suffice to simply ask him to uatnc the colors of different objects 
 presented to him, for he may have a perfectly accurate perception 
 of the color, and yet from lack of familiarity with the names, he 
 may designate this color by an improper name. Hence, the only 
 reliable method is to give him an opportunity for matching colors. 
 This is done by presenting to him a pile of worsted skeins of a 
 'freat variety of shades ; one of these, say a dark green, is put 
 aside, and the person is requested to select from the pile the other 
 skeins which seem to him to have the same color. If he have the 
 usual form of color-blindness, he will select red and scarlet among 
 other dark colors as similar to the green. 
 
 Dr. Jeffries presents the following recapitulation of the sub- 
 ject: 
 
 One male in twenty-five is color-blind in a greater or less 
 
 degree. 
 
 Of this defect they may even themselves be wholly uncon- 
 scious. 
 
 The defect is congenital. It exists in varying degrees. It is 
 lari,a>ly hereditary. It may be also temporarily or permanently 
 caused by disease or injury. It may exist in one eye ^nly. 
 
 It is incurable when congenital. Exercising the eyes with 
 colors and the ears with their names, helps the color-blind to sup- 
 plement their eyes, but does not change or increase their color 
 perception. 
 
 ILxperiment and experience show that we are forced to use red 
 and green marine signal lights to designate a vessel's direction of 
 motion and movements, and at least red lights on railways to 
 designate danger. 
 
 Form, instead of color, cannot be used for these purposes. 
 
 There are many peculiar conditions under which railway em- 
 ployes and mariners perform their duty, which render colored 
 signals, and especially colorea lights, difficult to be correctly 
 seen. 
 
 These signals can never be correctly seen by the color-blind. 
 There are such among railroad employes, officers, pilots and 
 sailors. 
 
 ■?' !, 
 
 % 
 
 tlil' 
 
 l|i» 
 
 ■■k 
 
 't'nis 
 
 mm'i 
 
554 
 
 DISEASES OF THE EYE AND EAR. 
 
 
 * 
 
 If 
 
 i 
 
 if' 
 
 There is, therefore, great danger from color-blindness. 
 
 Railway and marine accidents have occurred from it. 
 
 There is no protection but the elimination from the employes 
 of railways and vessels of all persons whose position requires per- 
 fect color perception, and who fail to possess this. 
 
 Care of the Eyes in Childhood. 
 
 In every civilized country there is at the present time a large 
 number of individuals who are totally or partially blind ; in a very 
 considerable portion of these cases the loss of sight occurred during 
 the early months or even weeks of life. It, therefore, becomes a 
 matter of much importance that the eyes should be carefully pro- 
 tected from the very hour of birth, since many of these case? of 
 blindness result simply from carelessness and ignorance on the irt 
 of the attendant. 
 
 One of the first points to be observed is the cleansing of the 
 eyes immediately afterbirth. The eyes should, indeed, be washed 
 before the rest of the body is cleansed. Warm water, perfectly 
 clean, should be used; a piece of clean, soft cloth, such as an old 
 cambric handkerchief, may be dipped in this water and used to 
 remove from the eyes the secretions which naturally adhere to 
 them. After this, the eyes should be gently dried ; no soap, nor 
 anything indeed but water, should be allowed to come into contact 
 with them. When the child's body and head are washed, care 
 should be taken to prevent any of the water from entering the 
 eyes. 
 
 It is necessary that the infant's eyes be protected from intense 
 and dazzling light. Since the child is unable to protect itself dur- 
 ing the first few weeks of life, .by moving its head or shading its 
 eyes, there is an especial demand for watchful care on the part of 
 the attendants. Furthermore the infant's eyes are not so well pro- 
 tected as the adult's, since the eyelids are thin and almost transpar- 
 ent and the eyelashes and eyebrows are but little developed Hence 
 care should be taken that the infant is not exposed so that the direct 
 rays of the sun can shine into its eyes. Yet it is not necessary to 
 fall into the opposite error of covering the face so as to keep out all 
 
 m 
 
CARE OF THE EYES IN CHILDHOOD. 
 
 555 
 
 light and air, or of keeping the room dark, since these practices 
 render the child's eyes unnaturally susceptible. 
 
 During infancy the eyes are also affected by the influence of 
 impure air. The child which is kept in hot, ill -ventilated rooms, 
 whether these be in the houses of rich or ooor, is apt to suffer from 
 affections of the eyes. 
 
 Yet the greatest danger to the eyes in infancy is the disease 
 called pnrident ophthalmia. This is an inflammation of the mucous 
 membrane covering the front of the eye, accompanied by a dis- 
 charge of matter. The inflammation is the result of impurities 
 which have entered the child's eyes during the passage of the head 
 through the vagina of the mother. It is, therefore, especially apt 
 to occur in infants born of women who are suffering at the time of 
 confinement from some discharge from the genitals. A woman 
 subject to obstinate leucorrhoea — "the whites" — is apt to com- 
 municate disease to her child. 
 
 The inflammation begins usually between the second and the 
 seventh days after birth. It begins by redness and swelling of the 
 lids ; a discharge at first somewhat thin and yellow, but afterward 
 thick and ropy, escapes from between the swollen lids. The first 
 effect of the discharge is merely to glue the eyelids together ; when 
 this occurs, matter collects behind the lids, so that when pressed 
 upon a gush of yellowish pus escapes. 
 
 When this condition occurs no time should be lost in summon- 
 ing the best medical assistance. Thousands of eyes have been 
 destroyed by the attempt to treat this disease with so-called "home 
 remedies." It should be understood that the eyes may be lost 
 beyond repair within twenty-four hours after the disease begins, 
 and that every moment is precious in arresting the affection before 
 irreparable injury is done. There is no disease of the eyes which 
 causes so much blindness as this, and the reason for this seems to 
 be the ignorance of the attendants in not recognizing the gravity 
 of the affection. In most cases, for two or three days after the eyes 
 become inflamed, the little patient is in the hands of the nurse or 
 the grandmother, who have unfailing remedies for all the ills that 
 baby flesh is heir to. At the end of these days it is found that the 
 eyes are becoming worse, and then the physician is called in. This 
 is, however, in many cases, too late to save the eyes. Until a 
 physician can be summoned the following treatment should be 
 adopted. 
 
 i 
 
556 
 
 DISEASES OF THE EYE AND EAR. 
 
 V'l 
 
 The child should be kept in a warm and somewhat darkened 
 room. The important point is to ircp the eyes clean. To accom- 
 plish this the first requisite — the only one which the attendant 
 should use — is warm water. The lids should be carefully separated, 
 care being taken to avoid any pressure upon the eyeball. This will 
 be best accomplished by having one person place the hand upon 
 the infant's head, so that the tip of the forefinger rests upon the 
 upper eyelid, which should then be gently drawn toward the eye- 
 brow ; the forefinger of the other hand is then placed in a similar 
 position with regard to the lower lid, which is in like manner drawn 
 downward. A second attendant then removes the matter with a 
 fine clean sponge, and afterward allows a stream of water to fall 
 gently upon the lids so as to wash out the eye most thoroughly. 
 This water should be caught as it escapes from the eye by a sponge 
 or in a cup held against the child's face. 
 
 It will be necessary to repeat this washing of the eye as often 
 as the matter collects under the lids ; this may be every hour, or 
 even every half hour. In the meantime it is well to wash the lids 
 gently, without opening them, with warm water, in the intervals 
 between the more thorough cleansing of the eyes. If the escape 
 of matter is not so profuse as to require frequent bathing, it will 
 be well to place upon the eyes a piece of soft cloth folded several 
 times so as to make a compress, and wet with cold water. This 
 may be frequently changed — say every fifteen minutes — in order to 
 prevent the cloth from becoming warm. 
 
 It is extremely important for all who come into contact, direct 
 or indirect, with the child, to remember that the matter which 
 escapes from its lids is extremely contagions. A single drop of this 
 matter introduced into the eye of a second individual, whether 
 child or adult, will cause a similar inflammation in the infected eye. 
 Hence it is necessary to observe the greatest precautions to prevent 
 the introduction of such matter into a healthy eye. The attend- 
 ants should be careful not to touch their own faces, nor rub their 
 own eyes, while they are handling tue infant or any of the cloths 
 used for its eyes ; they should wash the hands immediately after 
 touching the infant. The greatest care should be taken to prevent 
 the careless use by other persons of the towels, linen, sponges, etc., 
 which may have come into contact with the discharge ; indeed it 
 will be well to burn these articles so soon as they are no longer 
 required. 
 
1 
 
 CARE (JF THE EYES IN CHILDHOOD. 
 
 557 
 
 Wlien children have passed the age of infancy, and have begun 
 to use their eyes intelligently in the examination of surrounding 
 objects, the condition of the vision should be the object of atten- 
 tion and scrutiny on the part of the parents. It is a familiar fact 
 that the acuteness of vision varies extremely among adults, and that 
 certain defects of the eye — such as short-sightedness — can be so 
 completely remedied as to restore to the individual almost perfect 
 si<'^ht. Now, there exists among children just the same difference 
 in the acuteness of vision as is observed among adults, and many 
 defects of the eyes, which are so troublesome in after life, originate 
 in tlie failure of parents to appreciate these differences. Short- 
 sir^htccincss is an affection which does not force itself upon the 
 attention until the subject of it acquires considerable intelligence — 
 enough to observe the difference between his own eyes and those 
 of his companions. During childhood, therefore, it cannot be 
 expected that the short-sighted individual will discover his defect. 
 Parents should, therefore, always bear in mind the possibility of 
 these defects in the eyes, which do not show themselves by any 
 outward deformity, and can be discovered only by careful observa- 
 tion of the child. Many a child has been considered stupid and 
 dull, when his failure to equal his companions and schoolmates in 
 intellectual acuteness was merely due to some undiscovered defect 
 of the eyes which placed him at a disadvantage. Not long since a 
 boy of eight years was brought to a London physician noted for 
 his knowledge and skill in the treatment of diseases of the brain. 
 The mother complained that the child had never been so bright 
 nor quick to learn as other children ; he seemed unable to appre- 
 ciate the true relation of things, and was supposed to be suffering 
 from some disease or defect of the brain. The physician detected 
 at once that the child was suffering from an extreme degree of 
 short-sightedness, and was inclined to think that the apparent 
 stupidity of the child resulted merely from this defect of vision, in 
 consequence of which the boy was unable to see objects at a dis- 
 tance of more than five or six feet. Appropriate spectacles were 
 provided, and the immediate and marked change in the child's 
 intellectual habits proved the correctness of the doctor's opinion. 
 
 Children, as well as adults, may also be far-sighted, and there- 
 fore unable to peruse their books with any comfort, if at all. Many 
 afar-sighted child, when complaining that his eyes hurt him upon 
 studying, has been accused of laziness and indifference, when the 
 
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 1' VI 
 
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 m 
 
ll 
 
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 f 
 
 
 P; 
 
 1. 
 
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 j;: L' 
 
 Ha i 
 
 558 
 
 DISEASES OF THE F;YE ANO EAR. 
 
 fact was that the condition of his eyes rendered it impossible for 
 him to read for any considerable time, even half an hour, witliout 
 suffering pain. 
 
 These defects of the eyes escape notice for years, unless the 
 parents are aware of the possibility of such defects in children 
 and take pains to ascertain the condition of the child's eyes. Some- 
 times these defects are indicated by actual deformity in the shape 
 of a squint. In the great majority of cases a child acquires a squint 
 as the result of defect in the eyes — either short-sightedness or long- 
 sightedness. Hence, if the least inclination to squint is manifested, 
 the parent's suspicions should be at once aroused as to the proba- 
 bility of a defect in the eyes. The popular idea that squint results 
 merely from a vicious habit, such as the imitation of another child, 
 is incorrect; and hence the efforts to remedy the deformity by 
 harsh reproof or punishment are as unavailing as they are cruel. 
 
 It is extremely important that the cause of squinting should 
 be understood and appreciated ; for the condition can be remedied 
 and loss of sight prevented if the proper measures be employed 
 at an early stage, before the squint has lasted more than a few- 
 months. If the condition be allowed to exist for years on the 
 other hand, it becomes extremely difficult to restore the eye to its 
 natural position, and to prevent some impairment of sight ; for in 
 the course of time the vision in the squinting eye becomes less 
 acute, or may even be lost entirely. This results from the fact that 
 the individual acquires the habit of looking with the sound eye only, 
 to the neglect of the squinting eye, which loses the power of sight 
 just from lack of use. 
 
 While these defects of vision are sometimes born with the 
 child, they are far more frequently acquired during the early years 
 of life. A slight defect in the shape of the eye — constituting 
 short-sightedness or far-sightedness — may practically disappear, so 
 as to cause the individual no trouble if the eyes be properly man- 
 aged ; while on the other hand, it may be aggravated into a serious 
 impairment of vision if the child be improperly trained in the use 
 of the eyes. One of the worst features in the usual training of 
 children is the practice of teaching them to read and write at an 
 early age, such as four and five years ; for it should be remembered 
 that the eyes must be strengthened, like other parts of the body, 
 by the growth of the individual. It is just as unreasonable and 
 injurious to impose serious effort upon the child's eyes by teaching 
 
CARE OF THE EYES IN CHILDHOOD. 
 
 559 
 
 him to read early as to overtax his limbs by requiring him to carry 
 heavy burdens while his bones and muscles arc still soft and 
 tender. 
 
 The power of sight in later years is much influenced by the 
 time of life at which children are required to undertake close and 
 continuous effort with the eyes. For most children in this country 
 this time begins when the child is sent to school. In addition to the 
 fact that the eyes arc now used continuously and closely, there are the 
 tlisadvantagcs which result from the use of improper type in the 
 text books, and of improper illumination. Children should not be 
 permitted to use books printed in small and closely-set type, as is 
 so often the case in the school-books which they are compelled to 
 employ. Then, again, the illumination is rarely all that could be 
 desired. In many cases the quantity of light admitted to the school- 
 room is quite insufficient, requiring the closest attention and strain- 
 ing of the eyes. 
 
 One of the most important items, however, is the avoidance of 
 all those tasks which require close application of the eyes. The use 
 of text-books for instruction during the first years of school life, is 
 not only useless for the education of the child, but is often the 
 cause for serious impairment of vision in after life. The various 
 systems of ' object-teaching " and " kindergarten " obviate to a 
 certain extent the disadvantages of the system of text-books still in 
 common use in most of the public schools. Half a century ago 
 Beer said: " He who has taken the fruitless pains, as often as I have 
 done, to try and impress upon parents and friends in the most 
 friendly manner and upon the most convincing grounds the mis- 
 chievous effects upon the eyes of growing children, of the forcing- 
 house system of the present day, will still be disheartened to find 
 his well-intended counsel, based upon long experience and often 
 repeated, either entirely neglected or listened to only by a few. 
 Because people hold the imperfectly understood principle that chil- 
 dren should be constantly occupied, there is at all hours of the day 
 a master at hand. There is reading, writing, language-learning, 
 drawing, arithmetic, embroidery, singing, piano-playing without 
 end, until the persecuted victims are rendered pale, weak and 
 sickly, and to such an extent short-sighted or weak-sighted, that 
 finally medical counsel must be obtained. Of what avail is it to 
 many charming girls, many estimable women, that as children they 
 were regarded as prodigies, when the soundness of their eyes and 
 
S6o 
 
 DISEASES OF THE EVE AND EAR. 
 
 ':' it 
 
 I II 
 
 V !| 
 jl 
 
 r^ 
 
 I-' 
 
 ii ' ! 
 
 the acutencss of their vision have been sacrificed? I have seen 
 pictures worked upon a tobacco pouch in the so-called pearl stitch, 
 which were scarcely inferior to miniature paintin^j, and which I ex- 
 amined with much pleasure until I remembered the eyes of tlio 
 cmbroideress. In the present daily teachinj^ of children the work 
 most injurious to their sight is the constant piano practice from in- 
 graved notes; since the uniformity and the small size of these notes 
 are calculated to fatigue and weaken the strongest eyes, as any one 
 may ascertain by experiment. " 
 
 Professor Arlt, the famous eye surgeon of Vienna, comment- 
 ing upon these lines says: " If the illustrious Beer were now with 
 us, he would not fail to call our attention to the injurious print of 
 many books such as the stereotyped editions of Latin, Greek and 
 German classics, the pocket dictionaries, and thr; small maps which 
 require a magnifying lens to render the names of places readabk'. 
 Parents and teachers should be very careful that such books and 
 maps are not used by the children under their charge. The num- 
 ber of those who, in consequence of these books, have suffered in tiic 
 extent, duration and clearness of their vision, is not inconsiderable, 
 and I remember that I myself, when I had completed my school ed- 
 ucation, was no longer able to see a mountain an hour's journey 
 distant, and which in my thirteenth year I had seen from the same 
 place with perfect distinctness. " 
 
 Mr. Brudenell Carter, of London, in discussing the same sub- 
 ject, remarks : 
 
 " With regard to the actual conduct of the teachings, it must 
 be remembered that there is no reasonable doubt of the injurious 
 influence of premature exertion of the brain in retarding the 
 development of the body, the eyes of course included ; and I 
 myself entertain none that such premature exertion is at least 
 equally injurious to the mental faculties themselves. Many years 
 ago I wrote an essay upon the artificial production of stupidity in 
 schools, which had for its purpose to show the manner in which the 
 proceedings of teachers may defeat their supposed objects ; and 
 this essay has now been so often reprinted in this and other coun- 
 tries that I would fain hope that it may have induced some feu- 
 teachers to reconsider their ways. For the present purpose it is 
 sufficient to observe that any excess of school work implies ahiiost 
 of necessity an undue application of vision to near objects ; and 
 
CARE OF THE EYES IN CHILDHOOD. 
 
 S6l 
 
 that hence, when the eyes arc cither wti...ly or diseased, such excess 
 shtiuld be strictly prohibited. 
 
 " It is very worthy of note that, in the experience of eye sur- 
 peons, it is exceptional to meet with a child suffering; from defective 
 vision who has not, before the drfect was discovered, been repeat- 
 edly and systematically punished by teachers or school-masters for 
 supposed obstinacy or stupidity. The very reverse of this practice 
 is that which oujjht to obtain ; and apparent obstinacy or 
 stupidity should lead from the first to the question, 'Can he see 
 pirfcctly'? Children have an indefeasible claim upon their elders 
 for friendly and considerate treatment. If they are harshly or 
 unjustly dealt with, punished for errors which they cannot avoid, 
 or forced to undertake tasks, either mental or bodily, which are 
 beyond their >j\vers, they will suffer either in mind or body, or in 
 both. Unfortunately the work of teaching seems to exert a 
 destructive influence upon the imagination, using that word in its 
 true scientific sense , and the average school-master has often done 
 an amount of wrong which can hardly be repaired, before the sur- 
 geon has any opportunity of interposing to put the saddle upon 
 the right horse, and to assign the palm of stupidity to the peda- 
 jfogue inste.id of the pupil." 
 
 The same excellent authority says with reference to the selec- 
 tion of an occupation : 
 
 " In the choice of a profession for children the capabilities of 
 their eyes should never be left out of account. The state of a 
 youiij,^ man whose eyes refuse to perform his accustomed work may 
 be oven more painful than if he were blind ; and we should find 
 fewer persons in this condition if more care were taken to consider 
 tiic powers of the eyes before deciding upon an occupation. Eyes 
 which within a few years would fail an engraver, a goldsmith or a 
 w.itchmakcr, would last their possessor his lifetime if he were an 
 ai;riculturist, a gardener, or employed in many other callings. He 
 who has sound and normal eyes, may choose his occupation with- 
 out rcrcicMrce to them ; but he who is short-sighted or weak-sighted, 
 or wh(/SL eyes are inclined to be inflamed, must endeavor fully to 
 rciilizc the claims which an otherwise desirable calling will make 
 upon his sigrit, and to understand the different ways in which this 
 or that kind ot work may be injurious to him. 
 
 " It may pc;rhaf.>s be laid down as a general principle, that a 
 child who is simp.y short-sighted and who can employ his eyes 
 
 
I 
 
 mm 
 
 562 
 
 DISEASES OF THE EYE AND EAR. 
 
 continuously and with clear vision upon small objects, such as very 
 fine print, so long as it is near enough, may undertake work which 
 requires accurate and continued seeing. Experience teaches that 
 merely short-sighted eyes, when the short-sight has not reached a 
 very high degree, will bear without injury very fine and continuous 
 work In the higher degrees of short-sight, however, it is unde- 
 sirable to engage in any occupation in which the vision must be 
 directed by turns to near and to distant objects, since the latter 
 will require the use of lenses, which increase the strain thrown upon 
 the eyes by the former. 
 
 " Children who are the subjects of weak sight or far-sightedness, 
 and who either cannot see near and small objects clearly, or cannot 
 set' them for long together, or only by the aid of convex glasses, 
 should be dissuaded from engaging in occupations which will 
 demand from them the application of the eyes to uniform work 
 upon fine or small objects. The far-sighted individual can indeed 
 be greatly assisted by glasses, but these are not available in all 
 pursuits. 
 
 " Children who have often suffered from any of the various 
 forms of inflammation of the eyes which are incidental to early life, 
 especially if they show any tendency toward a relapse, cr if they 
 are still prone to irritation of the margins of the lids, should never 
 be allowed to undertake any kind of work in which they will be 
 exposed to dust, particularly woolen dust, to smoke, or to excessive 
 perspiration from fire ot heat. 
 
 " Even when the e^ es are of natural formation and acuteness, it 
 would be improper to forget how much the power of sustained 
 effort with the eyes is dependent upon the general vigor of the 
 muscular system. Girls of feeble frames and late development 
 should avoid on this account the more sedentary forms of industry; 
 and should rather find employment in work that is comparatively 
 coarse, than in sewing, embroidery, or the like. The caution herein 
 contained applies also in a still greater degree ".hen the eyes have 
 been weak or inflamed during childhood. 
 
 " In addition to the foregoing general principles, the whole edu- 
 cation of children with delicate eyes should be regulated with some 
 reference to their delicacy. For those who attend a day school, the 
 distance and manner of the journey and the protection to be afforded 
 upon the way require careful consideration, since various forms of 
 inflammation of the eyes arc caused or at least promoted, by 
 
WEAK SIGHT. 
 
 563 
 
 exposure to wet or vicissitudes of weather. In all day schools there 
 should be arrangements to allow the removal of wet or damp 
 clothing, and especially of wet or damp boots or shoes, before the 
 cliildrenarc suffered to se.tle down to their tasks. The atmosphere 
 of school-rooms and the clue supply of fresh air to them are matters 
 which probably will not be regarded until school boards and school 
 managers have no political or polemical questions left to dispute 
 about. " 
 
 IM 
 
 lil 
 
 Weak Sight 
 
 eness, it 
 
 stained 
 
 of the 
 
 opment 
 
 dustry; 
 
 iratively 
 
 n herein 
 
 es have 
 
 ole edu- 
 th some 
 lool, the 
 afforded 
 forms of 
 »ted, by 
 
 Under this term are popularly included a number of conditions 
 which originate in various ways. It is important that we should 
 recognize the fact that " weak eyes " may be weak from any one of 
 many causes ; and that many of these causes can be cured, or at 
 least relieved so as to render the patient comfortable, and his eyes 
 " strong. " 
 
 The vision of the natural eye includes an immense range, 
 beginning at a point about five inches from the eye and extending 
 to infinitf- distance, like that of the fixed stars. So long as the eye 
 remains in its natural condition it can be employed for vision con- 
 tinuously upon objects situated anywhere within this range. If the 
 individual become short-sighted or long-sighted to a considerable 
 degree there occurs, after a certain time, an indistinctness of vision 
 over some part of the natural range ; the sight becomes indistinct 
 either for distant or for near objects. In most cases there occurs for 
 some time before this mdistinctness of vision some pain, either in 
 the eyes themsc>ves or in the forehead and temples. This pain 
 increases if the effort to use the eyes be continued. There may 
 result a severe headache, followed perhaps by sickness at the 
 stomach, giddiness and palpitation of the heart. The symptoms 
 are sometimes so severe as to inspire a belief that the patient is 
 suffering from some disorder of the brain or of the stomach. Yet 
 if the actual source of the difficulty be suspected and corrected, 
 these symptoms, and with them the supposed disease of the brain, 
 subside. A good example is related by Mr. Carter : 
 
 " A young gentleman of good position, who was reading for 
 honors at his university, suddenly broke down with symptoms 
 which were attributed to some form of brain disease, and was 
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 DISEASES OF THE EYE AND EAR. 
 
 advised to give up his studies ^nd to go home. After a period 'if 
 rest, being no better, he sought advice in London, where the opin- 
 ion previously given was confirmed, and as a means of afifordiii;' 
 the most complete possible rest to his brain, he was advised to 
 make a voyage to Australia and back. He did so and returned in 
 the same condition. He was then considered to be incurable, was 
 told that he must abandon a career which had been opened to him 
 and a matrimonial engagement which he had formed. In a word 
 his whole life was blighted. Ultimately he was brought to mc, nut 
 from any idea that his eyes were at fault, but merely that I mii^^lu 
 examine their internal circulation in order to see whether this exam- 
 ination would throw any light on the state of the circulation in his 
 brain. I found his eyes healthy but somewhat short-sighted, and 
 on making inquiry into his symptoms, ascertained that they resolved 
 themselves into simple inability to read. As soon as he took up a 
 book he became giddy, and the giddiness brought on intense head- 
 ache, palpitation of the heart, and sometimes sickness at tlie 
 stomach. 
 
 " The case was of the simplest kind, the patient had never used 
 spectacles, and up to a certain point he had been able to read well 
 and easily. When he began to work for honors, and to read eit^lit 
 or ten hours a day, the muscles gave way ; and then, as the two 
 eyes were no longer directed to the same point, the patient ' saw- 
 double. * This in its turn produced giddiness, and the giddiness 
 produced headacJie and sickness by disturbing the circulation. 
 The strained muscles which had once given way, became prompt 
 to give way again when they were unduly called upon, and the 
 grave view which was taken of the symptoms by medical men filleil 
 the patient with alarm; as soon as he tried to read the old troubles 
 were brought back by fear and expectant attention. I assvued him 
 that he had no brain disease, tried to make him understand his con- 
 dition, prescribed spectacles to correct his short-sight, and told him 
 to wear them constantly and to read in them three times a day for 
 half an hour at a time. He was to report progress in three weeks; 
 and at the end of that time he returned cured. He could read 
 as much as he liked. He was going to be married the following; 
 week, and on returning from his wedding trip was to take up the 
 career which he had fancied closed to him forever. All these 
 pleasant anticipations were in due *'ihe fulfilled and the cure was 
 permanent and complete. " 
 
 f'f- ■ 
 
WEAK SIGHT. 
 
 565 
 
 The eyes may suffer in adult life from numerous causes, such 
 as improper illumination, excessive use, exposure to cold, and dis- 
 eased conditions of the body. 
 
 There is considerable misapprehension as to the proper light 
 required for the eyes. Sunlight is just as necessary and proper 
 for the eye as food is for the stomach ; but the eye can be injured 
 by excess as well as by deficiency of light, just as the stomach can 
 be by excess or deficiency of food. The eyes may be injured by 
 Inn"" exclusion from daylight, as occurs when they are bound up 
 for a long time, or when colored glasses are worn. In such cases 
 the eye acquires an unusual degree of acuteness so that the indi- 
 vidual can distinguish objects in what others would regard as total 
 darkness. If such eyes be restored to daylight, much caution 
 must be used to prevent injury. 
 
 A more frequent cause of injury to the eye is exposure to a 
 dazzling light, especially after leaving comparative darkness. 
 Many individuals have experienced serious impairment or even 
 loss of sight by looking directly at the sun, or by watching an 
 eclipse through a piece of glass which was not sufficiently obscured. 
 After looking at the sun there often remains an appearance like 
 that of a dark cloud, which becomes of a fiery color when the eyes 
 arc closed. Sometimes a permanent dark spot, corresponding; to 
 the position of the sun's image, remains in the eye. At other 
 times this dark spot gradually spreads over a considerable part of 
 the retina, so that the individual is threatened with total blindness. 
 Prof. Arlt says that he saw three cases of this kind after the eclipse 
 of the sun in 1851 . 
 
 Impairment of vision may occur likewise from the .sudden 
 reflection of bright sunlight into the eye by means of a mirror, as 
 is often done by children at play. The reflection of the sun from 
 the surface of snow or of the water has also occasioned serious 
 injury to the eyes. 
 
 Several considerations become evident from these facts. It is 
 to be remembered that the position of the eyebrows and the 
 arrangement of the lids is such as to protect the eyes from light 
 which conies from above, but to leave them unprotected from that 
 which comes up from below. Hence low windows are disadvan- 
 taLjeous, unless provided with blinds which draw up rather than 
 clown in order to shut off the light from the lower part of the 
 window. 
 
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 DISEASES OF THli EYE AND EAR. 
 
 Yet more difficulty is experienced in regulating artificial than 
 natural light. This occurs not simply from the feebleness of many 
 artificial lights, and from the fact that they are often but imperfectly 
 shaded, but also because the artificial lights produce a larger per- 
 centage of heat than is derived from the ordinary daylight. Gas 
 especially produces an excessive amount of heat in proportion to 
 the light furnished The heat has an injurious effect upon the eyes, 
 since it dries the fluids which moisten their surfaces and predisposes 
 to various inflammatory diseases of the eye. Various devices are 
 employed to shut ofi" so far as possible the heat rays which accom- 
 pany the light from artificial sources of illumination. A common 
 expedient consists in placing a bowl of glass containing water under- 
 neath the gas flame ; the water, while permitting most of the light 
 rays to pass through it, absorbs a large amount of the heat. This 
 absorption of the heat is still further increased if a little alum be 
 dissolved in the water. 
 
 Another device consists in surrounding the artificial light with 
 blue glass. Since the heat rays are found chiefly with the red light, 
 the blue glass, by intercepting all but the blue light, cuts off 
 most of the heat. 
 
 Another item of importance in the use of artificial light per- 
 tains to the position of the lamp. The ordinary lamp should be so 
 arranged that the flame is a few inches higher than the eyes, since 
 in this way the eyes are protected to a certain extent by the eye- 
 brows ; it should also be placed a little to one side, preferably the 
 left, in order that the light rays shall not fall directly into the eyes. 
 It is always advisable to have but one source of illumination, 
 whether this be natural or artificial. Thus the individual should so 
 arrange his work and himself that the light falls into his eyes from 
 only one lamp or gas jet ; by permit^^ing it to enter from several 
 sources the eye is more fatigued, not only because it receives an 
 undue amount of light, but also because it is .strained by the effort 
 to see distinctly in the presence of so much light. So, too, Mhen 
 it becomes necessary toward evening to employ artificial light, the 
 daylight should be excluded on the same principle. 
 
 The effort to read when the individual is unsteadily moving, 
 as happens in a carriage or in a railway car, is of course extremely 
 trying to the eyes, and should be avoided. 
 
FOREIGN BODIES IN THE EYES. 
 
 567 
 
 Foreign Bodies in the Eyes. 
 
 Icly 
 
 The dust everywhere present occasions a constant Irritation of 
 the eyes, especially in our large cities. Persons who are much 
 exposed to dust should frequently wash the eyes with cold water. 
 It is constantly happening that small bodies, such as particles of 
 wood, cinders, etc. are thrown violently against the mucous mem- 
 hnuic of the eye by the wind. The first effect is to cause a copious 
 secretion from the tear gland, accompanied by movements of the 
 lids, whereby the particle may often be dislodged. In this case 
 the patient experiences a sense of relief, though a certain amount 
 of burning may be felt in the eye for some hours afterward. 
 
 In other cases the particle lodges in the front of the eye, the 
 tonica; or it is carried upward beneath the upper Hd. Under these 
 circumstances the patient almost invariably rubs the lids — a most 
 objectionable practice, since it not only fails to afford relief to the 
 pain, but also serves to force the particle more firmly into the tissue 
 on which it rests, and thus renders its subsequent removal more 
 difficult. The lids should be kept apart, and the eye moved around 
 beneath them. In this w?y the particle is sometimes dislodged and 
 comes into view If it can be seen, it can best be removed by 
 nio'stening the corner of a soft handkerchief and applying it to the 
 object. If the particle be loose, it will usually adhere to the hand- 
 kerchief at once ; but no force should be employed to loosen it. In 
 many cases the fragment can be distinctly seen imbedded in the 
 cornea ; yet its removal can be effected only by a surgeon, provided 
 with instruments for that purpose. 
 
 In many instances the foreign particle lodges under the upper 
 lid, near its margin. In this case 't causes a constant rasping of the 
 eye, and yet cannot be brought into view. It can sometimes be 
 dislodged in the following way : The patient takes hold of the eye- 
 lashes of the upper lid and draws it away from the eye. He then 
 pushes up the lower lid with the other hand, so that its lashes may 
 swei.'p over the inner surface of the upper lid. Sometimes the par- 
 ticle will be found adhering to the lashes of the lower lid when they 
 arc bioiight down again. If this attempt fail, the loop of a fine 
 hair piu may be passed gently upward behind the upper lid, which 
 is meanwhile held away from the ball of the eye. Sometimes the 
 particle can be dislodged in this way. This must be done with care, 
 
 
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 DISEASES OK IIIE EYE AM) EAK. 
 
 since Otherwise the delicate surface of the eye may be damaged A 
 certain way for dislodginrj particles from this location consists in 
 tiiniiii^ tlic lid. This requires considerable skill and experience, 
 and can rarely be properly done by a non-professional hand. In 
 order to accomplish it, the patient is directed to " look down. " The 
 lashes of the upper lid are grasped between the thumb and finger t)f 
 one hand, and the lid is drawn gently downward and away from the 
 eye. Meanwhile a hair pin knitting needle, or other object of simi- 
 lar shape, is placed upon the upper lid, just behind the gristly part, 
 so as to make a hinge, around which the lid can be turned. Hy 
 means of the eyelashes, which are still grasped between the thumb 
 and finger of the other hand, the margin of the lid is drawn upward 
 and then backward, so as to fold the lid back on itself. The hand 
 may then be taken away, and the lid remains in this position. An\- 
 foreign body which may be present is at once detected, and may he 
 removed by the corner of a soft handkerchief. The lid can be re- 
 placed by simply drawing the lashes outward and downward again, 
 when it falls naturally into place. In every case in which a foreign 
 body has been present in the eye, and has caused much irritation, 
 there will remain for some time after its removal a feeling as if it 
 were still present. This feeling is often so strong that the patient 
 cannot be persuaded that the body has been removed, even thongl; 
 he may have seen portions of it. 
 
 The irritation consequent uoon the presence of a foreign body 
 may be allayed to a considerable extent by putting two or three 
 drops of fresh sweet oil between the lids. If the body be not 
 removed from the eye there will probably follow an inflammation 
 of the mucous membrane of the eye — \\\e. conjunctiva. This is 
 indicated by great sensitiveness to light, by redness of the eye and 
 a feeling as if there were sand or gravel in the eye. The treatment 
 of this affection will be given under an appropriate heading on a 
 subsequent page. 
 
 So long as the foreign body remains on the surface of the eye, 
 that is, does not penetrate further than the mucous membrane 
 which covers the globe, no serious impairment of sight is to be 
 expected. But these are by no means the serious cases. I'dr it 
 often happens, especially among those who work in metals or stone, 
 th;'*^ particles of these hard -substances will be driven with i;reat 
 force against the eye. In many cases these particles penetrate the 
 front of the eye, especially if they strike the transparent front — 
 
 {I 
 
FOREIGN I50DIKS IN THIi EYES. 
 
 569 
 
 the cornea. The injury inflicted depends upon the depth to which 
 the par xle penetrates. In some cases the force wuh which it 
 strikes is so much diminished by its passage through the hard 
 tissue of the cornea, that the particle penetrates no further, and 
 drops into the watery Hquid — the aqueous liiimor — which lies 
 between the cornea and the colored part of the eye, the iris. In 
 tliis case it may occasion no further damage ; perhaps a small, 
 white speck will mark the point at which it penetrated the cornea. 
 It may lie in this watery fluid for a long time without causing any 
 interference with the functions of the eye ; or it may in a short 
 time excite an infiammation of the iris, which is a serious affection. 
 In any case the services of a surgeon should be at once procured, 
 since the foreign body is a constant source of peril. 
 
 In other cases the particle strikes the transparent body which 
 fills up the pupil — the crystalline lens. So long as the lens is in 
 its natural condition it is perfectly transparent and colorless, so that 
 the pupil appears quite black. If, however, a particle of iron or 
 stone penetrate into the substance of the lens, there will generally 
 be seen after a few days a whitish speck somewhere in the ring of 
 the pupil. This speck is due to a change in the lens, whereby it 
 loses its transparency and becomes opaque. This change may extend 
 so as to involve the entire lens, in which case the pupil appears 
 white instead of black. The lens, being opaque, obstructs the 
 entrance of light to the back part of the eye, so that the individual's 
 sight is more or less impaired ; indeed he may become quite blind 
 ill this eye. Fortunately this condition is not necessarily perma- 
 nent. The lens can be removed by an operation, so that the light 
 will again penetrate to the back of the eye and sight will be 
 restored. 
 
 But the most serious of all these cases are those in which the 
 foreign particle passes into the interior of the eye. This is especially 
 dangerous if the fragment has entered the eye not through the 
 cornea, but just outside of the rim of the cornea, in the white part 
 of the eye. It often becomes necessary to remove such an eye 
 from the body. The reason for this lies in the fact — which has 
 been ascertained by long experience — that if the eye be permitted 
 to remain, the foreign body being still in it, there may result an 
 inflammation not only in the injured eye but also in the other one, 
 and that such an inflammation is apt to result in loss of sight. 
 Hence, at the very first signs of irritation in the injured eye, the 
 
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 DISEASES OK THE EYE AND EAR. 
 
 surgeon advises and even insists upon its removal. It will not do 
 to wait until the eye has become inflamed, for then it is usually too 
 late to save the other eye, even if the injured one be removed, it 
 is important that non-professional people should understanil the 
 gravity of the situation. It seems to most people quite unnccis- 
 sary and harsh to remove an eye which doesnot seem much affectL'd, 
 and many a man has acted upon this idea, has refused to permit 
 the removal of the injured eye, and has lost the sight of both eyes 
 in consequence. 
 
 Another class of injuries is those in which chemicals, such as 
 acids and alkalies, or quicklime, come in contact with the eje. In 
 every such case the assistance of an eye surgeon should be obtained 
 immediately. Until he arrives the friends may wash the eye 
 thoroughly with cold water, remove any particles that can be seen, 
 drop a little sweet oil into the eye, and then apply a cloth, such as 
 a soft handkerchief, which has been saturated with cold water. 
 
 No injury nor accident to the eye should be allowed to go 
 without the advice of a surgeon ; for, owing to the delicate structure 
 of the organ and the importance of vision, there is often no proixji-- 
 tion between the apparent injury and the actual damage infliclccl. 
 An injury which may seem to the uninitiated quite trivial may 
 actually involve most serious consequences for the patient's pros- 
 pects in life. People generally are accustomed to measure the 
 gravity of an injury by the amount of blood which flows and of 
 visible vlamage to the tissues ; but this rule does not apply at all to 
 injuries iflecting the eye. 
 
 Sight may be seriously impaired also by injuries inflicted in a 
 playful way. A case is recorded in which the sight was lost through 
 a trick which is exceedingly common. A man was sitting in a 
 chair, when another came in behind him, and clasping both hands 
 over his eyes, told him to guess who it was. The person strui;L;lcd 
 to free himself, the other tightened his grasp, and in the struggle 
 the eyes were permanently blinded by the fingers of the other 
 individual. 
 
 The eyes, like other organs in the body, are affected b\- dis- 
 eases which impair the general condition. An individual who is 
 suff'ering from some exhausting disease is apt to have some impair- 
 ment of sight, or at any rate, be unable to use his eyes to the 
 extent which is customary with him. There are also some diseases 
 which produce not only the general failure in the power of the 
 
SHOk r-SIClH TKUNKSS. 
 
 571 
 
 (•\ cs, but also changes which are peculiar to the disease in question. 
 riius oik; form of inflammation of the kidney, known as " Hright's 
 disease," is accompanied by serious changes in the nervous tissue 
 of the eye, the retina, which result in a decided impairment of 
 vision. Indeed, it has often happened that patients who were 
 attiially suffering from Bright's disease, though having no suspicion 
 of it, have consulted an eye surgeon to ascertain the cause of the 
 impairment of sight, and have been surprised to learn from him 
 tli.it the disease in the eye was merely a part and symptom of the 
 disease of the kidney. An affection of the spinal cord already 
 described, called locomotor ataxia, is also frequently accompanied 
 by disease of the eye, with or without serious impairment of 
 siKht. 
 
 There has been considerable dispute as to whether tobacco 
 sinoking is injurious to the eyes. There can be no doubt that the 
 smoke is irritating to the mucous membrane of the eyes ; but it 
 has been asserted, and is now pretty generally believed among 
 eve surgeons, that excessive smoking causes a disease of the retina 
 call atrophy, whereby the sight is seriously impaired. Yet it must 
 be admitted that, notwithstanding the increase in the prevalence of 
 this habit of smoking during the last half century, there scarcely 
 seems reason for believing that the affection which is supposed to 
 be caused by smoking has increased to a corresponding degree. 
 
 The same assertion has been made as to the relation between 
 the use of alcoholic beverages and the loss of sight. It has been 
 maintained that the excessive use of liquors results in atrophy of 
 tlie retina and impairment of vision. Yet the grounds for this 
 assertion are by no means so strong as for the belief that tobacco 
 can cause the disease. 
 
 V dis- 
 
 ho is 
 
 ipair- 
 
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 ;cascs 
 
 if the 
 
 Short-sightedness. 
 
 This condition, which is technically termed myopia, consists in 
 a limitation of the range of distinct vision to comparatively near 
 objects. The natural eye is so adapted that it can accommodate 
 itself so as to see objects situated at any distance which is more 
 than five or six inches from the eye. As has been already stated, 
 this power to see objects at different distances — far or near — 
 depends upon the power possessed by the eye of changing the 
 
 
572 
 
 DISKASKS in- TIIK KVK AND KAk. 
 
 i^ 
 
 curvature of the crystalline lens. In order that the object shall hi' 
 distinctly seen, a picture of it must be formed at the back of thf 
 eye upon the retina. This picture is formed by the focusin^f of 
 the rays of \\\!,\\t by means of the crystalline lens. When iIk' 
 object is situated at a distance from the eye, the lens is compaiii 
 tively flat ; when, on the other hand, it becomes necessary to view 
 an object situated only a few inches from the eye, the lens i-., 
 through the action of the ciliary muscle, made more curved. In 
 every case the curvature of the lens is such that the rays of liL;lit 
 are properly focused so as to produce a picture upon the retina. 
 If from any cause the picture is not properly focused upon tlu' 
 retina, the individual perceives only a blurred image. 
 
 Now, it is evident that the failure to focus the picture properly 
 upon the retina may result from either one of two causes : First, 
 the curvature of the lens may be improper — that is, the lens may 
 be too flat or too curved ; second, the retina may be situated too 
 far back or too far forward — that is, the eye may be too long or 
 too short ; for it is evident that a lens which can focus the rays so .is 
 to produce a definite picture on the retina in one eye, will have an 
 improper curvature for producing the picture in the second eye, in 
 which the retina is situated further back than in the first. This can 
 be readily illustrated by taking an ordinary sun- glass, which is ,i 
 lens shaped almost exactly like the crystalline lens in the cm. 
 This lens may be held so as to produce a perfect picture of the sun 
 — that is, a bright spot — on a sheet of paper held below it. If this 
 paper be now moved a little further from or a little nearer to tiic 
 lens, there will be seen upon it a large bright circle but not the bril- 
 liant image of the sun. 
 
 Now, the short-sighted eye is, in the majority of cases, too 
 long; that is to say, the distance from the lens to the retina is so 
 great, that the rays of light cross each other before reaching tin; 
 retina. If the retina could be moved a little further forward 
 toward the lens, the short-sighted eye would become a perfectly 
 natural one. In many, perhaps most cases, the short-sighted e\c 
 was in childhood a perfectly natural one ; but in consequence ot 
 improper use, straining of the muscles, etc., the eye has become 
 compressed and the back part — that is, the retina — has been 
 pushed further backward away from the lens, so that the eye be- 
 comes too long, in other words short-sighted. 
 
 It would be out of place here to discuss the various causes coa- 
 
 ' Vw1 I IJHWIIIIi.llJ.H- l J in lU 
 
SnOkT-SIGHTEUNliSS. 
 
 573 
 
 ccrncd in the proiliiction of short-sij^htcdncss, hut it is necessary 
 to make some remarks upon the practical apjilication connected 
 therewith. 
 
 A short-sighted individual has a certain range of vision in 
 
 # 
 
 which he sees objects quite as distinctly as those whose eyes arc 
 naturally formed. This range varies from about ten inches to six, 
 ci'^lit ten or more feet. His vision diflers from that of those with 
 natural eyes in two respects: First, he is able to see objects when 
 brought closer to the eye, as a result of which he can distinguish 
 smaller objects than other people can ; second, lie is unable to see 
 objects at a distance. The result of this i.s that the individual gets 
 ill the habit of bringing objects close to the eye, since by so doing 
 lie (lees not feel the same strain upon his eyes as when he looks at 
 tlicm at a greater distance. 
 
 Whenever an individual who can see near objects quite dis- 
 tinctly cannot distinguish objects at a distance, we may suspect that 
 he is short-sighted. The question can be easily settled by holding 
 before his eyes a concave Ictts. If his sight for distant objects is 
 improved by the assistance of this lens, the person is undoubtedly 
 short-sighted. 
 
 There are several popular beliefs respecting short sight, some 
 of which are quite enoneous. 
 
 First among these is the general impression that short-sighted 
 eyes are particularly " strong " eyes. This belief results from the 
 fact that short-sighted persons can distinguish smaller objects than 
 other people can, and that they can see in a less brilliant light than 
 others. A moment's tlvought shows, however, that both of these 
 characteristics result from the ability of short-sighted people to see 
 objects when held close to the eyes. For we know that the nearer 
 an object is to the eye the larger it appears. Now a person with 
 natural eyes can not see small print, for instance, at a distance less 
 than eight or ten inches; the short-sighted person, on the other 
 hand, can see the same print at a distance of four or five inches; 
 but at this distance it appears, of course, larger than it did at ten 
 inches. In the same way a person with natural eyes may fail to 
 distinguish very fine particles, such as minute pieces of sand or dust, 
 merely because he has to hold objects so far away from his eyes in 
 order to see distinctly. The short-sighted individual cannot see 
 these objects at the same distance — eight or ten inches — any bet- 
 ter tiian the person with natural eyes, but he has this advantage 
 
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 574 
 
 DISEASES Ol< THE EYE AND EAK. 
 
 over the latter, that he can brinj; the object much closer to his oyc 
 and still sec distinctly. Thus he is enabled to see smaller objects 
 than the person with natural eyes. 
 
 The ability to see distinctly in ,i 'aint li^jht 's -xplained in c\ 
 actly the same way. The nearer an object approaches the eye the 
 more li^ht enters the eye from it. Mence, the short-sij^hted iiuh- 
 vidual who can see distinctly at a distance of four or five inches i^ 
 able to recognize objects which another person, who is compelled to 
 hold them eij^ht or ten inches distant, can not see. The difference 
 lies not in ihe relative stren^ijth of the eyes, but simply in the fact 
 that the object appears brij.ihter because brought closer to tlic 
 eye. 
 
 Another popular impression regarding short-sighted eyes is 
 the belief that short-sight im;)roves as the person grows older. This 
 belief rests upon the fact that many short-sighted persons do not 
 require such strong glasses in middle life as they were compelled to 
 use in youth. This is often the case, but it depends not upon aii\- 
 inherent improvement in the condition of the eyes, but simply 01 
 the changes which naturally occur in the eye as the individual grows 
 older. Such persons often say that they " are not so short-sighted 
 as they were." They forget, however, that the measure of shoit- 
 sight is in seeing distant objects and not near ones. They will fiiui 
 that while they may be able to see small objects better witliout 
 glasses than they formerly could, yet they require glasses for dis- 
 tant objects just as before. 
 
 The one advantage which short-sighted people enjoy consists 
 in their freedom from the necessity of the ordinary spectacles 
 which most people require in advanced life. This freedom is due 
 simply to the defect in the eye, whi'rh counterbalances the second 
 defect consequent upon old api'c. As will be explained subse- 
 quently, the structure of the crystalline lens changes somewhat as 
 a person becomes older, so that he cannot increase its curvature as 
 he formerly did when looking at near objects. This change hap- 
 pens in the eye of a short-sighted person just as well as in that of 
 another; but whereas the latter is compelled to use glasses in orclcr 
 to counteract the defect in his lens, the short-sighted individual 
 does not require the glass, since the defect in his lens is already 
 counterbalanced by the defect in his eye which makes him short- 
 sighted. In consequence of these two defects, and their effect in 
 counterbalancing each other, it sometimes happens that a person 
 
 ■ h\ 
 
sii()kT-si(;im;uNi:ss. 
 
 575 
 
 vvlm 111 yo.itli iind c;ir\y life was coinpcllccl to wear glasses to correct 
 liis slii)rt-si{ihtcdncss, is able to yet alon^j without them in advanced 
 lifi Such people are said to have " wi)nilerful si^,dit," or, as it is 
 sdiiK'times expressed, " second-si^^ht. " 
 
 I'liis is the sole advantaj^e possessed by sliort-sif^hted people; 
 tlie disadvanta}j[es, on the other hand, resultinj; from the peculiar 
 formation of the eye constituting short-si^ht, arc numerous and 
 serious. In the lirst place, the eye cannot be used to the same 
 extent as the natural eye without pain, nor even without danj^er. 
 I'A'cn when protected by fjlasses, the short-si<jhti{l eye is constantly 
 in (laii{;;er of certain accidents, if the decree of short-si^ht be c(jn- 
 siderablc. After ccjntinued strain, such qs reading for a number of 
 hours, the eye usually becomes somewhat painful ; and it has 
 repeatedly happened that hemorrhage has occurred within the eye, 
 causing serious impairment of vision for a time, or even jiernia 
 ncntly. The sight may also be partially destroyed by what is called 
 " detachment of the retina," as a result of short-sightedness. 
 
 Another affection incident to short-sightedness is the change in 
 the position of the eye, called " squint," or technically straliisinus. 
 Tiiis is especially apt to occur if the degree of short-sightedness be 
 considerable. This can often be prevented by the use of appro- 
 priate glasses so soon as the first evidences of squinting are mani- 
 fested. 
 
 One of the unfortunate features about myopia is the fact that 
 t is progressive. As has been already stated, it is probable that 
 most of those eyes which subsequently become short-sighted, were 
 originally of natural shape, and that the defect has resulted from 
 pressure upon the eye. In many cases this increase in the length 
 of the eye progresses constantly as the individual becomes older, 
 so that his vision becomes more and more defective, and may even 
 fuially result in total blindness. It is, therefore, [extremely impor- 
 tant that the eyes of a short-sighted person should be submitted at 
 regular intervals to examination by a competent surgeon ; for if it 
 becomes evident that the disease is advancing, the greatest possible 
 care in the use of the eyes must be observed in order to arrest the 
 progress of the affection. 
 
 A short-sighted eye should always be looked upon as a weak 
 eye. It will not stand the same amount of wear and tear as a 
 natural eye ; it is liable to several accidents and dangers to which 
 other eyes are not subject. 
 
 > ) 
 
 M 
 
 W 
 
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 M 
 
 m 
 
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 57^> 
 
 DISEASES OK Till-: EYE AND EAR. 
 
 As to the causes of myopia we are not, as yet, fully informer!. 
 Certain it is that the affection is hereditary ; that is, it appears in 
 successive generations of the same family ; it seems to be probable 
 that children may be more or less short-sighted at birth. K.xamiii- 
 ations of the eyes indicate that such is actually the case. At aii)- 
 rate the tendency to this elongation of the eye — that is, a weak- 
 ness of the coats of the eye, so that they give way under pressure 
 — is certainly inherited. Short-sightedness is pre-eminently an 
 affection of civilization ; it is practically unknown among savatjc 
 races, as wc-Ii as among the lower animals. This fact is quite com- 
 prehensible when we remember that the affection results from the 
 excessive use of the eyes in gazing at small objects, and that it is 
 the employments of civilization which require the use of the eyes 
 in this way. 
 
 Numerous attempts have been made to ascertain which of the 
 elements peculiar to civilized life are especially important in induc- 
 ing the development of short-sightedness. The first attempts were 
 made in Germany, where short-sight is especially frequent. Dr. 
 Cohn, of Breslpu, examined the condition of the eyes in ten 
 thousand children in the schools of that city. Among these he 
 found one thousand who were short-sighted. Among the impor- 
 tant facts brought to light by his examination, and confirmed by 
 similar examinations which have since been made by others, are 
 the observation that the amount of short-sight steadily increases 
 from the lowest to the highest classes in the school; that is, both 
 the relative number of the cases and the degree of short-sight are 
 greater after the pupils have spent several years in the school. He 
 found further that the amount of short-sightedness was greater in 
 badly lighted and badly ventilated schools; and that it seemed 
 also to be increased among those pupils who were compelled to use 
 poorly constructed desks, which required them to stoop in the per- 
 formance of their tasks. 
 
 These observations of Dr. Cohn have been confirmed by 
 repeated examinations of many thousand pupils in public schools. 
 in various parts of the world. There is no question that improper 
 illumination and furniture of school-rooms have great iiitlurncc in 
 promoting the occurrence and progress of short-sightedness, This 
 is especially manifest in Germany, where the .schoc 1 buikliiigs arc 
 not always built with especial reference to the requi' enients of the 
 pupil, and where children are sent to school at an early age and arc 
 
'm 
 
 SHORT-SIGHTEDNESS. 
 
 577 
 
 ITS, arc 
 creases 
 s, both 
 v;\\t are 
 . He 
 ater in 
 seemed 
 1 to use 
 he per- 
 
 MU'ii by 
 
 schools. 
 
 iu[)ri'per 
 
 ueiice ill 
 
 Thi> 
 
 lilies are 
 
 ts of the 
 
 and are 
 
 kept closely confined many hours a day. In Germany, too, the 
 liLrcditary influence of short sightedness is especially manifested, 
 since educational requirements have there been severe during many 
 fenerations ; the tendency to short-sightedness is not only pro- 
 moted by the arrangement of the school-rooms, but is derived from 
 ancestors who have suffered in like manner. An eminent English 
 snrs^con, in discussing this question, says : 
 
 " For the prevention of myopia in schools there can be no 
 doubt that good and well-placed windows are essential, and that 
 fittings of judicious design would be useful ; but neither of these 
 will be effectual or will prevent children from drooping over their 
 work unless the matter receives the constant and vigilant attention 
 of teachers, and unless the sanitary state of the buildings, and the 
 time relatively given to work and to play, are such as to meet the 
 rc(]uircments of physical health. It is a curious illustration of the 
 essential mechanical character of certain minds, that the progress 
 of the myopia should, in Germany, have been referred to the 
 enforced convergence alone, and that better light and better fit- 
 tint^s should have been put forward as sufficient to bring about a 
 better state of things. Dr. Agnew, of New York, with more 
 practical knowledge and with deeper wisdom, pc inted out that a 
 feeble and easily extensible character of the coats of the eye would 
 be a condition largely dependent upon general debility ; and that 
 tlie treatment of this debility by food, tonics and exercise, as well 
 as by an ample supply of pure and often renewed air in the school- 
 room^, a judicious shortening of tasks requiring the close applica- 
 tion of the eye;- , and the use of books printed in bold characters, 
 wnuld be of great assistance in bringing about a much needed 
 reform. The robust faith of the average school-master in the 
 efficacy of what he calls teaching is probably not destined to survive 
 the time when a so.newhat better acquaintance with the nature of 
 mental operations will become diffused abroad ; and in the mean- 
 while, and with reference to the frequent sacrifice of l^.j ^iiysical 
 Mile of the development of the young it is not uninteresting to 
 recall the results of an experiment made some ten or twelve years 
 ago in the village school at Ruddington, in Nottinghamshire, under 
 the direction of the late Mr. C. Paget, so-netime M. P. for Not- 
 tint^ham. In this school Mr. Paget introduced a half-time system 
 as an experiment, to which only a portion of the children were 
 subjected, and which amounted to a substitution of garden work 
 
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i I 
 
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 m ; ^ 
 
 i'l 
 
 i 
 
 11 
 
 ll!! 
 
 inni' 
 
 578 
 
 DISEASES OF THE EYE AND EAR. 
 
 for about one-lialf of the ordinary school hours. The children wIki 
 were so treated, were found after a short period idtogether to nut- 
 strip in their school work those who devoted, or who were supposed 
 to devote, twice as much time to it. The prevention of the increase 
 of short-sij^ht in schools, is less in my judgment, an affair of desks 
 and fittings than of careful and judicious sanitation ; for I have 110 
 doubt that the optical conditions which would produce myopia in 
 weakly children would fail to do so in the robust. None the loss, 
 however, should these optical conditions, together with the lighting 
 and the distance of the work, receive a due share of attention; 
 although such mechanical matters must not be expected to super- 
 sede the necessity for the constant supervision of a directing intel- 
 ligence. " 
 
 When it is discovered that a child is short-sighted, the line of 
 treatment to be pursued is very simple. The evils to be appre- 
 hended result from the strain which the eyes are compelled to exei t 
 in order to see distinctly; and this strain is merely the consequence 
 of the lack of proportion between the curvature of the lens .uul 
 the depth of the eye. If we could change this proportion by 
 making the eye shallower ; that is, by bringing the retina for\v;irii 
 and somewhat nearer to the lens, we would obviate the difficulty. 
 This, of course, cannot be done ; the form of the eye cannot be 
 changed, but the other factor is a possibility — that is, we can chans^ve 
 the direction of the rays of light before they enter the eye so tliat 
 they shall be focused upon the retina. This is accomplished by 
 the use of spectacles, a concave glass being placed in front of the 
 eye. 
 
 T/te treatment of short-sightedness const 's, therefore, in tlu 
 use of spectacles. The object of these glasses is not to make the 
 patient see better than before. Indeed, the short-sighteii indi- 
 vidual will often complain at first that he can see better without the 
 glasses than with them. The benefit derived from the glasses is 
 simply that they compel the patient to held objects further from his 
 eyes ; by this means the eyes are relieved from the strain which is 
 the cause of danger for the future. 
 
 At first the patient will experience some inconvenience and 
 perhaps even discomfort in wearing spectacles. This is merely the 
 result of the pernicious habit which the eyes have so long main- 
 tained. It disappears in time, so that the patient feels much com- 
 fort in the use of his glasses, and much discomfort without them. 
 
SHORT-SIGHTEDNESS. 
 
 579 
 
 The effort required to accustom the eyes to the glasses is greater in 
 advanced years than in early childhood, since the habit of strain- 
 ing the eyes is of longer duration. It is especially desirable that 
 frjasscs shall be worn so soon as the short-sight is discovered, 
 which is almost always in childhood. For not only are the evils 
 which follow upon short-sight thereby averted, but the progress of 
 the affection may be entirely arrested ; hence after the individual 
 attains maturity he may, in many cases, unless he devote himself 
 to some profession requiring close application of the eyes, give up 
 the glasses entirely. 
 
 Another advantage in the use of glasses which is most 
 important, though scarcely appreciated, is their value in bringing 
 the individual into relation with the world. Those who have 
 natural eyes which take in the usual range of vision, cannot appre- 
 ciate the fact that the world of a short-sighted person extends only 
 ten or fifteen feet around him ; yet such is the fact. The immense 
 advantage derived from the use of the eyes in training the individ- 
 ual in a knowledge of external objects is lost, to a great extent, by 
 the short-sighted person. Instances illustrating this fact are known 
 to every surgeon who has much experience in the treatment of 
 diseases of the eye. Thus Mr. Carter says : " I once prescribed 
 glasses to correct the short-sight of a lady who had for many years 
 been engaged in teaching, and who had never previously worn 
 them ; her first exclamation of pleasurable surprise, as she put on 
 her spectacles and looked around her, was a curious commentary 
 on the state in which her life had until then been passed ; she said, 
 ' Why, I shall be able to see the faces of the children.' If we think 
 what this exclamation meant, and if we apply the lesson which it 
 teaches to other pursuits, we shall not '".lil to perceive that the 
 practical effect of myopia is to shut out the subject of it from a 
 very large amount of the unconscious education which the process 
 of seeing the world involves, and thus to occasion losses which can 
 hardly bo made up in any other way. Taken in detail, these losses — 
 tlic mere not seeing of this or that seeming trifle — may appear insig 
 nihcant ; it is their aggregate which becomes important. A young- 
 lady was lately brought to nic by her parents on account of the 
 way in which the effects of her myopia had forced themselves upon 
 tiicir notice during a continental tour. Two school boys were of 
 the ])arty, and they subjected their sister to an unceasing chorus of 
 ' Don't you see this ? ' and ' 13on't you see that ? ' and ' How stupid 
 38 
 

 S80 
 
 DISEASES OF THE EYE AND EAR. 
 
 I y- 
 
 ,,& ill » '- 
 
 you are ! ' until it became manifest to the elders that a state of 
 things which at home had always been accepted as a matter of 
 course was really a very serious evil. A distinguished man of 
 science, who is short-sighted in a high degree, and who did not 
 receive glasses until he was 19 or 20 years old, has often told me 
 how much he had to do in order to place himself upon the same 
 level, with regard to experience of quite common things, with man\' 
 of his normal-sighted contemporaries ; and it will be manifest on 
 reflection that the matters which are lost by the short-sighted, ;is 
 by the partially deaf, make up a very large proportion of the 
 pleasures of existence. I am accustomed on this ground to uii^rc 
 upon parents the necessity of correcting short-sight in their chil- 
 dren ; and I am •I'-e that a horizon limited to ten or even twcnt\- 
 inches, with no d! itinf perception of objects at a g'-eater distance, 
 has a marked tejidcncy to produce habits of introspection and 
 reverie, and of inatteni! ;• to outward things, which may lay the 
 foundation of grave defects of character. Landscape painters are 
 the only persons to whom a small degree of myopia can be useful. 
 I once accompanied a landscape painter on a sketching expedition, 
 and after a time asked him whether he intended to omit a certain 
 house from his drawing. He looked up with surprise and said, 
 ' What house ? there is no house there.' I at once understood a 
 curious haziness of aspect with which it was his custom to clothe 
 distant scenery in his pictures, and which was greatly admired by 
 many persons mIio mistook it for a skillful rendering of an uncom- 
 mon atmospheric effect ; in fact, it was only what the short-sighted 
 man saw always before .lim ; and I am sure he must himself have 
 been greatly puzzled by much of the praise which he received. 
 
 " The short-sighted child has no curiosity to explore a world 
 which he sees but dimly, and his habit is to curl himself up in a 
 corner and to pore over books. He is absolutely disqualified by 
 his defect from taking part in many games, such as cricket, foot- 
 ball, lawn tennis and the like, since all of them require distinct 
 vision of some distant object. The spectacles, therefore, assuming 
 them to be necessary in order to give the vision which is needed, 
 will enlarge the sphere of his activity rather than curtail it, and any 
 consciousness of their presence soon wears off under the influence 
 of daily use. The apparent danger to the eyes from them, in con- 
 sequence of falls or blows, is much in excess of the reality, especially 
 if the frames are so constructed so as to afford the greatest stability 
 
 It f' ■ 
 
KAK-SIGHT, 
 
 581 
 
 of position. Many short-sighted men habitually hun^ in specta- 
 cles, and take their share of falls with as little injury as their 
 neii^hbors ; while among the spectacled officers of the German 
 army, in the war with France, the number of instances in which 
 any wound was inflicted or aggravated either by the glasses or the 
 frames was exceedingly small." 
 
 Even when provided with proper spectacles, short-sighted 
 children manifest a disposition, from the force of habit, to bring 
 their books close up to the eyes, or to put their eyes close to their 
 work. It is, therefore, important to see that the child maintains an 
 erect attitude, and does not droop the head, since this stooping 
 keeps the eyes filled with blood and interferes with the breathing. 
 The care of short-sighted children includes, therefore, such atten- 
 tion and supervision as will enable them to get the greatest possible 
 benefit from the spectacles provided for them. It should be 
 observed that the books furnished the child are printed' in large, 
 clear type. 
 
 Another bad habit which is unconsciously practiced by short- 
 sighted persons, is the custom of reading by a dim light, such as 
 twilight or the light of a fire. They are especially prone to 
 this habit because they are able to read by a fainter light than 
 suffices for people with natural eyes. It is, therefore, desirable 
 that such children should be prevented from practicing this habit, 
 as they will otherwise almost certainly do. 
 
 One other point should be mentioned here, namely, the curious 
 popular impression that it is much better to go without glasses as 
 long as possible. Many people even take a considerable pride and 
 satisfaction in avoiding the use of glasses. Such a belief may lead 
 to the most disastrous results. In every case the use of glasses is 
 an absolute essential when the degree of short-sightedness is so 
 great as to cause the patient annoyance. 
 
 Far-Sight. 
 
 Short-sight, or mj-opia, results, as has been stated, from an 
 unnatural length or depth of the eye, whereby the retina is situated 
 too far behind the lens. There exists also a condition quite oppo- 
 site to this ; that is, the eye is not deep enough, is too shallow, 
 causing the retina to occupy a position unnaturally near to the lens. 
 
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 1 ^''i 
 
 
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 I 
 
 i! 
 
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 h: 
 
 m 
 
 582 
 
 diseasp:s of the eye and ear. 
 
 The result of this? improper formation of the eye is, in one respect, 
 similar to the effect of excessive depth of the eye ; that is, the range 
 of the patient's vision is not so great as that of a person with a nat- 
 ural eye. In this ^ase, however, the difficulty is not that the indi- 
 vidual is unable to see distant objects, but that he cannot distinguisli 
 near objects. His vision is good for everything which is not situated 
 within a few feet of the eye. This condition is, therefore, called /<?/- 
 stghtedncss, or long-sightedness. 
 
 These two opposite conditions of the eye, excessive depth in 
 the one case — near-sightedness — and unnatural shallowness in the 
 other case — far-sightedness — are often indicated to a certain extent 
 by the form of the eye. Thus an individual whose eyes are near- 
 sighted in a high degree, often has a peculiar staring expression, 
 which is found upon inspection to be due to a protrusion of the e\e- 
 balls Thi= protrusion seems to be due to the extreme length of 
 the eye frc ;n b- •' i. backward. The far-sighted individual, on the 
 other hand, has often unusually y?rt/ eyes, an appearance due to the 
 shortness vf. the eye from before backward. Just as near-sighted- 
 ness is technically calJed myopia, so far-sightedness is medicall\- 
 designated hypcrmetropia. 
 
 Fnr-sightedness — an unnatural shallowness of the eye — is more 
 apt to escape notice than near-sightedness. The near-sighted child 
 is apt to betray his defect of vision even to one who is not seeking; 
 to examine the state of his sight ; for he will often express his ina- 
 bility to see objects which are plainly discernible to his companions. 
 The far-sighted person, on the other hand, does not have so many 
 opportunities for revealing to himself as well as to others the exist- 
 ence of any defect of vision ; for he is enabled to see in the distance 
 as well as anybody else, and can distinguish ordinarily small objects 
 by holding them a little further from the eye than others do. 
 
 Since the defect of the far-sighted eye consists in its inabilit\ 
 to see near objects, it is evident that the defect will be detected 
 during the individual's efforts to read, write, or engage in other pur- 
 suits requiring close application of the eyes. Such eff'orts are apt 
 to be accompanied, even in early years, by fatigue and pain in tlie 
 eyes, which is often followed by a dimness of vision, since the eye 
 actually becomes unable to maintain the strain necessary for seeing 
 near objects. After resting a time the individual can again read with 
 perfect ease, but is again compelled, after a short time, to discon- 
 tinue the employment by the pain, weariness and .sense of effort in 
 the eyes. 
 
SQUINTING. 
 
 5«3 
 
 A curious feature about far-sightedness is, that the subject of 
 it sometimes acquires a habit which we would suppose would be 
 monopolized by «^rt!r-sighted individuals ; he habitually holds a 
 book at an unusually short distance from the eye ; in consequence 
 of this the friends often remark that the person is near-sighted, 
 though examination discloses the error of this belief. The explana- 
 tion seems to be that by bringing the object near the eye, clearness 
 of vision is increased, because the images formed upon the retina 
 are larger than when they are held further away. 
 
 If the person is required to employ the eyes upon fine work 
 constantly, these organs become red, irritable, bloodshot, and often 
 discharge a small amount of mucus. This discharge will be 
 noticed by the patient in the morning upon rising. The patient 
 will notice that the condition of his eyes is much improved by sim- 
 ple absence from his occupation for a day ; thus they are usually 
 much better on Monday after resting from work on Sunday. 
 
 It is, therefore, important that every person who has symp- 
 toms of this kind should ascertain by consulting a competent sur- 
 geon, whether or not the symptoms originate in this condition of 
 hypermetropia. Such individuals are very apt to content them- 
 selves with a remark to which they have been accustomed from 
 childhood, namely, that they " have weak eyes." This weakness of 
 the eyes can be easily remedied by the use of proper glasses. If 
 not remedied, the irritation and frequent inflammations will gradu- 
 ally result in serious disease of the eye which may prove exceed- 
 ingly obstinate to treatment. 
 
 The cure for far-sightedness, like that for near-sightedness, is 
 in the use of spectacles. In early life these spectacles may be 
 quite weak ; but in advanced life, when the crystalline lens of the 
 eye becomes hardened, it will become necessary for the patient to 
 increase the strength of the glasses. In this respect, therefore, 
 hypermetropia differs from myopia, since in the latter condition the 
 glasses required by the patient may be weaker than those which he 
 needed in childhood. 
 
 Squinting. 
 
 It is important that parents and teachers recognize the usual 
 cause of squinting. The most curious and absurd ideas prevail 
 with reference to this deformity. One of the commonest is, that 
 
 
584 
 
 DISEASES OF THE EYE AND EAR. 
 
 I- 
 
 squinting is merely a vicious habit which the child could avoid just 
 as well as not if he would. Acting upon this principle, parents arc 
 apt to stimulate the unfortunate child to better conduct by punish- 
 ing him, believing that in this way he can be induced to keep his 
 eyes straight. Another popular belief is that the habit of squint- 
 ing is " catching ;" and a child who is unfortunately afflicted with 
 this deformity i.. regarded as an object to be avoided just as mucii 
 as if he had ♦^'.le itch. 
 
 Both of these impressions are erroneous. The fact is, that 
 squintinr; is utterly beyond the control of the individual, and can- 
 not be corrected by punishment ; nor can it be communicated from 
 one individual to another. In fact, it would be quite impossible for 
 a p.-rson to acquire at will a habit of genuine squinting. 
 
 Squinting is, in the vast majority of cases, the result of defec- 
 tive formation of the eyes. It .nay result either from an undue 
 depth or an undue flatness of the eyes — that is, from myopia or 
 from hypermetropia. If the child be short-sighted, he is apt to 
 have that form of squint in which one eye turns outward ; if on the 
 other hand, he be far-sighted in a high degree he is prone to the 
 common form of squint in which one eye turns inward. In fact 
 about nine cases out of ten of this common form of squinting 
 occur in individuals who are " flat-eyed," that is, hypermetropic. 
 This deformity is usually manifested at about the time when the 
 child begins to use his eyes critically in the examination of exter- 
 nal objects — say from three to five years of age. When the habit 
 of squinting is first developed it usually seems to affect both eyes, 
 that is, the eyes turn inward alternately. Sometimes the child 
 looks with the right eye while the left is turned in toward the nose ; 
 at other times, perhaps while he is still looking at the same object, 
 he reverses the proceeding, directing the left eye toward the object 
 under inspection and rolling the right eye inward. For a consid- 
 erable time it seems to be a mere matter of accident as to which 
 eye is made to squint, but as time elapses it will be noticed that the 
 child neglects one eye or the other constantly, employing either tlic 
 left or the right eye for examining objects and permitting the other 
 to turn inward. 
 
 This is the time for action in correcting this deformity, for 
 when the individual has acquired the habit of using one persist- 
 ently to the neglect of the other, the sight of the latter undergoes 
 gradual impairment. Hence it frequently happens that if the squint 
 
 ' ■ .i\ 
 
THE SELECTION OF SPECTACLES. 
 
 585 
 
 be neglected until the person has reached adult age, the squinting eye 
 is almost completely blind, or at least practically worthless. This 
 impairment of sight results simply from disuse, just as an arm or 
 leg becomes gradually weaker if it be not used. By employing 
 proper measures to compel the individual to use both eyes, or rather 
 to permit him to see with both eyes without straining these organs, 
 the squint may be entirely avoided and the sight may remain per- 
 fecc in both eyes. It is, therefore, a matter of supreme importance 
 that a squint should be rectified at its very beginning. People 
 generally are inclined to think that the only disadvantage of a 
 squint is the impairment of beauty ; this is, of course, a matter of 
 considerable moment, especially in girls. But if this were all, the 
 squint might be neglected, since the eye can be straightened almost 
 anv time by a slight operation which involves no danger to the 
 patient nor to the eye. But no operation can restore the sight 
 which is lost by permitting the squint to persist for years. 
 
 By correcting the squint at its very beginning, therefore, we 
 not only prevent a serious personal deformity, but we also save the 
 si"^ht of an eye. With one eye a person can, it is true, see well 
 enough for all ordinary purposes, but it is a by no means comfort- 
 in"^ thought to be conscious that he has no reserve eye in case he 
 should, from any cause, lose the sound one. 
 
 The remedy for squinting lies, during its early stages, in the 
 use of glasses. It is often possible to correct a squint entirely, 
 before it has existed more than two or three years, by the judi- 
 cious employment of spectacles. The glasses act, of course, by 
 correcting the near-sightedness or far-sightedness upon which the 
 squint depends. 
 
 After the individual has been in the habit of squinting for 
 several years, it is rarely possible to correct the deformity entirely 
 by the use of glasses. Yet there should be no hesitation whatso- 
 ever in submitting the eye to an operation whereby it can be 
 straightened ; since, even though the sight of the eye be some- 
 what impaired, the vision can often be restored, at least so as to 
 make the eye practically valuable. 
 
 m 
 
 ■!.i':-i| 
 
 The Selection of Spectacles. 
 
 In selecting spectacles for cases of short-sightedness or far- 
 sightedness, it is always advisable to secure the advice of an eye 
 surgeon, if this be practicable, for there are certain principles 
 
586 
 
 DISEASES OF THE EYE AND EAR. 
 
 involved which can be understood and acted upon only after a 
 thorough acquaintance with the anatomy and the functions of the 
 eye. In fact the adaptation of spectacles is one of the most deli- 
 cate and trying duties of the surgeon. 
 
 Without entering into details which would he unintelligibji. to 
 one who is not thoroughly versed in the structure and functions of 
 the eye, certain hints may be given which have evident and prac- 
 tical value. 
 
 The most important point to be remembered is that the spec- 
 tacles should be so fitted tliat the eyes shall look through the ccnttr 
 of the respective glasses. It is, therefore, necessary to have the 
 frames made differently, according as the spectacles are designed 
 for viewing distant or near objects. For it is evident upon slight con- 
 sideration, and can readily be seen by observing the eyes of anotlicr 
 individual, that when a person looks at a distant object, the axes of 
 the two eyes are parallel ; while, when he looks at an object held 
 close to the face, the axes of the eyes are no longer parallel, but 
 are directed so as to meet at the object which is under examina- 
 tion. It is evident from this that the glasses which are intended 
 for assisting the eyes in viewing distant objects should be some- 
 what further apart than the glasses which are intended for viewing 
 near objects. One of the commonest mistakes which is made by 
 patients in buying their own spectacles is the neglect to observe 
 that the glasses are situated as already indicated. In some cases 
 it is true, one can correct this error by bending the frame of tlie 
 spectacles so as to bring the glasses a little nearer together or 
 further apart, as occasion requires ; yet it is a much better plan to 
 procure in the first place only such spectacles as are adapted to the 
 breadth between the eyes. Let it be remembered that when we 
 speak of the center of the lens we mean the thickest part (if the 
 glass be convex) and the thinnest part if the glass be concave, and 
 not the center of the frame which holds the lens. Every eye 
 surgeon constantly meets cases in which patients complain of dis- 
 comfort in wearing spectacles, sometimes so great as to compel 
 them to abandon the glasses ; and yet examination shows that the 
 fault is not in the strength of the lenses, but merely in the misfit of 
 the frame. The best way for ascertaining whether the frame is 
 properly adapted to the individual is, of course, by wearing the 
 glasses for a few hours. As this cannot always be done before 
 purchasing, the buyer should, before selecting the pair of spccta- 
 
TlIK SKLKCI'lON OF SPECTACLKS. 
 
 587 
 
 clcs. place them in position upon his nose and look at himself in 
 the mirror. If the spectacles are intended for distant vision, the 
 i)iipils of the eyes should be seen opposite the center of the lenses , 
 if the jfjasses are meant for reading, the pupils should be situated 
 a littk- outside of the center of the lenses. 
 
 A freciuent cause of discomfort in the use of spectacles is the 
 innocent practice of wearing another person's glasses. One member 
 of a family will frequently acquire a habit of using spectacles 
 intended for the eyes of another, and will wonder that they cause 
 so much discomfort. It should be remembered that spectacles 
 should be fitted with the same accuracy as shoes or gloves ; indeed 
 with more accuracy, since the eye is far more delicate and suscepti- 
 ble to the influence of strains than either the foot or the hand. 
 
 It should be remembered that the same individual may require 
 two pairs of spectacles for different purposes. Thus a short-sighted 
 person will usually require weaker glasses for viewing distant objects 
 thiui for reading. As the eye changes with the rest of the body in 
 advancing years, it will become necessary to change the spectacles 
 at intervals. A neglect to do this will, in many cases, cause much 
 discomfort and even pain. 
 
 As to the materials of the lenses themselves, the choice rests 
 between pebble and glass. In former times the pebble (rock crys- 
 tal) was much to be preferred. But in later years glass is made of a 
 quality so much superior to that of a half century ago, that there is 
 but little choice between the two except in one particular : this is 
 the t^'reator hardness of the pebble, as a result of which it is not so 
 liable to be scratched, and may last longer. Spectacles of pebble 
 may be wiped with a pocket handkerchief without injury, while 
 lenses of glass should be cleaned only with a piece of wash-leather 
 kept for the purpose. It is extremely important that spectacles be 
 kept with care, not only to avoid scratching by contact with hard 
 substances, but also to preserve the original shape of the frame. 
 The pasteboard cases which are commonly employed for the pur- 
 pose are rarely sufficiently stiff to resist the pressure to whi^h t-hcy 
 are exposed in the ordinary course of life. 
 
 If it be impossible to secure the services of a professional eye- 
 snrgcon in selecting the proper lenses, the individual should bear 
 in mind one or two points. The best way for deciding upon the 
 strength required in the lenses is to test them by means of the types 
 which are kept for the purpose by every dealer in optical goods. 
 
 4^ I' 
 
 
588 
 
 DISEASES OF THE EYE AND EAR. 
 
 11 I''! 
 
 It may be said in general that a short-sighted individual shuiiUl 
 select one of the weaker glasses which enable him to accomplish 
 the desired object, whether that be for viewing distant or near 
 objects ; a far-sighted individual, on the contrary, may select a 
 somewhat stronger glass for the same purpose. 
 
 As a person advances in years, the eye undergoes certain 
 changes which interfere somewhat with the performance of its 
 functions and deprive it of some of the powers which it possessed 
 in youth. These changes are just as natural to the eyes as the 
 changes which occur in the skin, the hair and the bones. The eye 
 becomes somewhat flatter, and the crystalline lens acquires a degree 
 of hardness which renders it incapable of undergoing the suiic 
 changes of form which it exhibited in early life. It will be renicm 
 bered that these changes of form occur when the eye is changed 
 from distant to near vision and conversely. When the person looks 
 at distant objects the lens is comparatively flat ; when the eye is 
 directed to near objects the lens is, by the action of the ciliary mus- 
 cle, rendered more curved. This change in form — which is tech- 
 nically called the accommodation of the eye — is necessary in order 
 that a picture of the various objects shall be accurately produced 
 upon the retina. 
 
 When the lens has become hardened and therefore less com- 
 pressible than it was in early life, this power of accommodation 
 whereby the eye can be adapted for viewing near objects is partially 
 lost. The individual, therefore, can no longer see objects held near 
 to the face with the same distinctness as he did twenty or thirty 
 years previously ; though his sight for distant objects remains jtist 
 as good as ever. At first he overcomes the difficulty by holding 
 objects somewhat further from the face ; but in the course of time 
 he is unable, even with this device, to read print of ordinary size. 
 Hence it becomes necessary for him to employ some artificial 
 means whereby the same effect can be produced as was formerly 
 brought about by the change in the shape of his lens. This is 
 accomplished by the use of a convex glass. 
 
 The age at which it becomes necessary for an individual to 
 employ glasses varies with many circumstances, though it may 
 be regarded on the average as between 40 and 50 years of age. 
 Some individuals, of course, are spared this necessity for a.nuicli 
 longer time, sometimes because their eyes are subject to defects 
 which are remedied by the change in the lens due to old age. In 
 
'^ 
 
 INFI-AMMATIUN OK THK EYE — CONJUNCTIVITIS. 
 
 589 
 
 every case it will be well for the individual to begin with weak 
 irjasscs, and chanj^c llieni for stronger ones as the progressing 
 change in the eye requires. 
 
 Inflammation of the Eye— (Conjunotivitis). 
 
 The term " inflammation of the eyes" is popularly applied to 
 an inflammation aflecting the mucous membrane which covers the 
 globe of the eye and lines the eyelids. • 
 
 SffiHptotHS, — The disease usually begins with a feeling of 
 grating in the eye, the patient generally supposing that some 
 particles of sand or other foreign matter have entered the eye. In 
 a few hours the eye becomes red, the redness usually beginning 
 at the part of the eye ne,\t to the lids. At the same time the 
 secretion from the surface of the eye is increased ; at first there 
 is an augmented discharge of mucus, which assumes a stringy 
 character; this collects especially at the innr angle of the eye and 
 forms little scabs along the edges of the lids. Upon awakening on 
 the following day the patient finds the lids glued together, and 
 experiences some difficulty in separating them. On the second 
 day the discharge from the eye will be observed to contain more 
 or less matter. By this time the entire front of the eye is of a 
 bright red color, except where the redness is concealed by patches 
 of a thick stringy secretion. The lids are usually somewhat 
 swollen, and in many cases the eye seems to be pufi"ed out — an 
 appearance due to the presence of watery fluid under the con- 
 junctiva, whereby this is lifted off from the globe of the eye. The 
 sight is not impaired except occasionally by the presence of a little 
 matter wliich can be readily wiped away. 
 
 In many cases both eyes are attacked simultaneously ; in 
 others one eye becomes inflamed a day or two in advance of the 
 other ; but in nearly all instances the disease will attack both eyes 
 before the patient recovers. 
 
 The cause of this inflammation seems to be, in many cases, 
 exposure to cold ; in other instances it results from the contact of 
 irritating substances. In still other cases the inflammation appears 
 to be epidemic, affecting a large number of persons in the same 
 community, and attacking every member of a family in succession. 
 
 m 
 
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 590 
 
 IHSI'.ASIIS or TIIK I'.VK AND KAK. 
 
 (■(Mijiinrtix itis is riiicly a sciioiis alTrclion, especially if pmp 
 rily healed ; when ne^leeleil it soimMimes spreads to the deeper 
 struct iiios ot the eye, causing tdccration «)r the cdiium and possiMy 
 intcrfcronee with si|;ht. 
 
 Tiwatnirnt. — Asa rule the patient recpiires no eonstitntion.il 
 tieatnuMit, since the local intlainmation is not commonly asstx i.iird 
 with symptoms of jM-neral ilistni hance. M IIk- patient l»e Iml ,ni>l 
 thirsty l»c shonid have a saline laxative, snch as a teaspoonlul n| 
 Koch("lle sills or o( the citrate of potash 
 
 The eyes may hi- hathed ev« ry honr or two with one ol llic 
 following lotions, c.ire heini; t.iken to allow .» little ol the solution 
 to llow into the ey(>s ,»t every application : 
 
 \lnm, ------- 'I'cii ^;rains, 
 
 W'atcM, ------ Two onnees. 
 
 If the c.«se he s(>\ en' the lollowiil}^ lotion may he employed 
 
 Ahim, ...... |'"i^jht jjrains. 
 
 Sulphate of zinc, . - . - Twoj^i.iins. 
 
 W'.vtcr, - - - . Two oimces. 
 
 In the inlerv, lis het ween the application of the lotion the eye 
 niay he washeil with water to secure the »"scape of the discli.uiM' , 
 the patient will derive much comlort from the application of .1 clolli, 
 svuh ,»s a soft h,mdkerchiel", so. d<ed in ct)ld water ,ind .dlowcd in 
 rest upon the eye. In makitii; such applications to the eyes, only 
 thin cloth should he uscil, and not more than threi' thicUMc-'-cs 
 shoukl he .ipplicil to the eye, since otherwise the heal prodmcd 
 may ai;i;r.i\ .(te the p.iin. 
 
 If there he much swelling; ,ind putViiu-ss of the conjuncliv.i ilie 
 the following; solution may he prep.ired . 
 
 Nitiate {i\ silvei , . - . . 'Two [grains. 
 
 W.iter, --.... Two ounces. 
 
 Two 01 three diops o\ this should he he dropped into the eye 
 morninj; and night. If this solution he used the ,dmn mixtiuc 
 .dn>ve j;iven is not required, hut the eye should he cleansed and 
 kept cool as directed .ihove. 
 
 In order to prevent the lids from sticking; toj^cther the cdjjfcs 
 may be sme.uetl with vaseline when the patient retires at niidit. 
 
 Chronic inflammation of t/ir rj'rs may result from an .unite 
 attack, but is more frequently caused by intense application of the 
 eye.s from over use in study, or in some employment requiring close 
 
 1 
 
 .m 
 
INII.AMMA ri(»N UK llll'; KVKS — < ()NJUN( irVITIS. 591 
 
 (ihscrv.ilioii. In nii'iiy (,;iscs jt is ajj|.p;ivat('»l l>y some dcfccl, sik li 
 ,is (.11 si|;lili'<liicss, which the p.iliiiit (hies nut stispccl. In most 
 lU'^Lxiri's it III (-.inn in (l(>liihtiit(*(l individuals, cspcciiilly in sctoriiloiis 
 I hildicn. 
 
 SifiHittoiHH. — riic (;yc is red and looks iriitaMc ; llicrc is a 
 (('il.nii nil i('.is<'d anionnl of 'aisccptiltility to liKl'*> ''" that the indi 
 viihi.il .ivnids ,1 l)ri(;lit lijdit .is miK h as possiMc. I'hc crjijc s 
 ,,| ihi' liil .lie red , tlirir is an increased sc(i(tion which (;atheis .it 
 l|l(' < i>l liei . ol llie ey<'. The person ( .iniiot read or .ipply the <yi- 
 ( niilniiiKiisI)' (or the Msiial lime without fi eliii}; that the eyes (Mow 
 V( I \' liied and Ix'l 
 
 'I'l't'flfnn'nt' — In most ( ases it hecomes necessary to improve 
 tlic '.lal( o( the patient's [jeiieral health Without sin h Ircitmeiil 
 till- |(i(al applications to the eyes remain iiiel(e< tiial. It will there 
 liiie '»e necess.iry to ex.imine » .inliilly the state of the patient's 
 liiiulioiis, and to prescrihc snc.li medicines as are nr-cessary to 1 ilieve 
 ,iiiy n rejMiiaiities of the system. II the patient he a •.crofiilons 
 (liilil, it will he .idvisalile to administer cod liver oil, a te;ispo(»ii 
 llll oj whi( h may he j;iven twii c a day. Such children will also he 
 Ik iielileil l»\' the lollowiiij^ prescription : 
 
 Syrup of the iodide <»! iron, - One ounce. 
 
 (ilyicrine, „ . - . - 1 wo ounces. 
 
 Mi.x anil Like a teaspoonfnl after meals. 
 
 (arc should also lie taken that the (;ycH are not strained hy 
 (NCiN-ave applii alion to line work. It may even he necessary for 
 tlirinilividii.il to chan};e his employment temporarily, so th.il the 
 (■\is in.iy secure the proper rest. ( J)iitiniioiis readiii};, ('specially 
 <>i line print, and all other close applications of the eyes, should he 
 
 .IVniiled 
 
 Unless the eyes are very irritahle, thir local treatment may con 
 sist ill the use of the following; ey(!-water : 
 
 Sulphate of zinc, - - - - 'Jwo grains. 
 
 Water, - . . . 'Jwo ounces. 
 
 Three 01 four drops of this may be dropped into the eye once 
 111 twice .1 (l.iy. If this does not cause improvement in a few days, 
 the lollowiii^ may be substituted : 
 
 Sulphiite of zinc, - - . - Two pjr.iins. 
 
 Alum, I'ive };rains. 
 
 Distilled water, - - . . 'Iwo ounces. 
 
 Mi.\ and drop into the eye as before directed. 
 
59; 
 
 DISEASES OF THE EYE AND EAR. 
 
 h n 
 
 The eyes may be washed frequently with cold water, and the 
 edges of the lids should be smeared with vaseline at night upon 
 retiring. 
 
 If there be much dread of light, these applications will probably 
 increase the irritation and should, therefore, be discontinued at 
 once. In such cases benefit is often derived from the application 
 of a small fly-blister, say half an inch square, to the temple. Instead 
 of the lotions above mentioned there may be used the following : 
 
 Yellow ointment of mercury, - Half an ounce. 
 
 Vaseline, _ . _ _ . Half an ounce. 
 
 A small portion of this, as large as two pin heads, ma" he placed 
 between the lids morning and night. 
 
 The treatment must be continued for several weeks or even 
 for months, before a cure can be expected. In many cases it will 
 be found that the surfaces of the lids are studded with minute red- 
 dish bodies, granulations. In these cases the affection will be far 
 more obstinate, and relief cannot be expected without the use of 
 some other measures than those indicated. These measures can. 
 however, be carried out only by the surgeon, and need not be 
 indicated here. 
 
 P 1 
 
 Purulent Inflammation of the Eyes. 
 
 Purulent inflammation of the eyes is marked, as the name indi- 
 cates, by a profuse discharge of pus or matter from the surface of 
 the eye. It usually occurs in two classes of patients : first, new- 
 born children; and second, in persons who are suffering with gon- 
 orrhoea. 
 
 This is one of the most formidable affections of the eye which 
 the surgeon is ever called upon to treat. When properly cared for, 
 it is the most readily controlled, but when neglected or improperly 
 treated, it is one of the most severe and disastrous of all the dis- 
 eases to which the eye is subject. Many a life has been blighted 
 in the first few weeks of existence by the destruction of the eyes a 
 disaster which might have been avoided if the affection had been 
 promptly and properly treated. 
 
 It will be seen, therefore, thit one who undertakes the treat- 
 ment of purulent inflammation of the eyes assumes an immense 
 
T 
 
 PURULENT INFLAMMATION OF THE EYES. 
 
 593 
 
 responsibility; and it is equally evident that no one who is not 
 thorout^hly familiar with the nature and treatment of the disease 
 should think of assuming such responsibility. 
 
 Symptoms, — In the child the inflammation begins between 
 the second and sixth day after birth. It is first noticed by the 
 nurse, who detects a slight running from the eyes, some swelling 
 and redness of the lids, and a gumming together of the lids during 
 sleep. After a time, often in a few hours, the discharge becomes 
 greatly increased in quantity ; it ceases to be watery and becomes 
 yellow and thick. The eyelids become much swollen and very 
 rod, the swelling being sometimes so great that the lids can 
 scarcely be separated. Many times the mucous membrane of the 
 eye — the conjunctiva — becomes puffed up anv;' separated from the 
 globe by an accumulation of watery fluid underneath. This swollen 
 conjunctiva may almost entirely cover the cornea, so that there is 
 but little to be seen in the eye except the red and inflamed con- 
 junctiva covered with matter. 
 
 The matter collects between the lids in large quantities, and 
 streams down the face when the lids are separated. The quantity 
 of matter which is formed and escapes from the eyes in severe cases 
 is most remarkable. 
 
 The gravity of the disease depends partly upon the severity of 
 the attack, but largely upon the promptness and skill with which 
 remedies are applied. If properly treated, recovery is almost cer- 
 tain. Yet there are cases in which the attack is so severe that one or 
 both eyes are destroyed within a few hours, almost before treatment 
 is begun. 
 
 In most of these cases, it will be ascertained on inquiry, that 
 the mother was suffering at the time of confinement from a puru- 
 lent discharge from the vagina, which may have been a genuine 
 gonorrhoea or merely an aggravated case of " the whites. " 
 
 Treatment. — The first requirement in treatment is to keep 
 the eye?, perfectly free from t/ie dtsc/targe. This is to be accom- 
 pHshed by frequent washing with warm water. In order to do 
 this, the child should be laid on the lap of the nurse, its head being 
 turned to one side or the other, according as the one eye or the 
 other is to be washed out. The lids are gently separated with the 
 thumb and finger, while a small stream of water is allowed to run 
 into the eye next to the nose, and to run out on the opposite side 
 
 r 1 
 
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 -i. j na 
 
594 
 
 DISEASES OF THE EYE AND EAR. 
 
 |i«< 1 
 
 into a sponge or basin held beside the head to receive it. This 
 must be repeated just as often as is necessary to prevent the accu- 
 mulation of matter between the lids. 
 
 This may be required every half hour, and should be attemltd 
 to by night as well as by day. The importance of this measmx- 
 cannot be over-estimated ; without it, no remedies can save the 
 eye in a severe case. 
 
 After the eye has been washed out, one of the following lotions 
 may be applied: 
 
 Alum, - _ - - Twelve grains. 
 
 Distilled water, _ . _ _ Two ounces 
 
 This should be i.^^ected gently into the eye with a small glass 
 syringe, the injection being repeated as often as is necessary to 
 check the secretion of matter. In severe cases this lotion may he 
 required every hour. As the discharge decreases in quantity, the 
 intervals between the use of the injection may be increased. 
 
 Two or three times a day the child should be seen b)- a sur- 
 geon, who will probably find it advisable to drop into the eye about 
 three drops from the following solution: 
 
 Nitrate of silver, - - - Five grains. 
 
 Distilled water, - - - One ounce. 
 
 This can be most conveniently applied by means of a dropping 
 tube, or it can be brushed upon the lids with a soft camel's hair 
 brush. The nitrate of silver solution is a powerful remedy, which 
 must not be carelessly employed by inexperienced hands. 
 
 Sometimes the edges of the lids and the skin of the cheek 
 under the eyes become sore from the irritating character of the 
 discharge ; this can be in a great measure relieved and prevented by 
 keeping the parts smeared with vaseline. 
 
 One of the unfortunate accidents which sometimes occur in 
 severe cases of purulent inflammation of the eyes in infants, is a 
 turning over of the upper lid, whereby the red and swollen mucous 
 membrane is exposed. This is a very unpleasant sight, and may 
 cause further trouble by the formation of sore and ulcerated places 
 on the lid. This is a troublesome incident in the affection, and 
 usually requires surgical interference for its removal. The matter 
 should not, however, be neglected, since it may result in serious 
 deformity of the lid if not promptly attended to. 
 
 The great danger in purulent inflammation of the eyes is, that 
 
tiONUKKHtEAL INFLAMMATION OF THE KYES. 
 
 595 
 
 the inflammation may extend to the deeper structures of the eye, 
 especially the cornea. So long as the conjunctiva — the mucous 
 membrane covering the eye — alone is afifected, there is no par- 
 ticular danger of impairment of sight. But it is impossible to say 
 how long the inflammation will be thus limited to the conjunctiva. 
 instances are known in which it has spread to the cornea within 
 twelve hours. The occurrence of this serious accident is indicated 
 by a grayness or haziness at the front of the eye. After a few 
 days, or even within twenty-four hours, a little hole or ulcer can be 
 detected at the spot, surrounded by a white margin. When the 
 inflammation subsides, the site of this ulcer will be marked by a 
 white opaque spot on the cornea. This is usually permanent, and 
 if it happen to be situated about the middle of the cornea — that 
 is, in front of the pupil — it may constitute a serious impairment of 
 vision. 
 
 }f'; I 
 
 t r 
 
 Oonorrhceal Inflammation of the Eyes. 
 
 )ccur in 
 
 Its, is a 
 
 mucous 
 
 md may 
 
 [d places 
 
 |on, and 
 
 matter 
 
 serious 
 
 is, that 
 
 This painful and dangerous disease results from the introduc- 
 tion of some of the matter of a gonorrhoea! discharge into the eye. 
 One who has seen many patients suffering from gonorrhoea, and 
 has observed how ignorant they are of the danger to the eye 
 involved by the disease, and how careless they are with reference to 
 the protection of the eyes, cannot wonder that so many eyes arc 
 seriously injured and even destroyed by this disease. 
 
 The patient who is suffering from gonorrhoea cannot be too 
 careful to avoid all possibility of contact of the urethral discharge 
 with the eve. The hands should be carefully washed every time 
 that they come into contact with the genital organs or with the 
 dressing used on these parts. Particular care should be taken with 
 regard to the use of towels. The towel which is used for drying 
 the hands should be kept separate from those used for the face. All 
 cloths and other dressing used about the genital organs should be 
 burned when soiled. 
 
 Sjfmptoms. — The evidences of inflammation in the eye begin 
 about one or two days after matter has been introduced. The 
 patient feels a sense of burning and itching in the lids, which causes 
 him to rub the eye. This feeling increases in severity, and is soon 
 accompanied by a watery discharge from between the lids. The 
 
 39 
 
 1 .,] 
 
 ill 
 
 t I 
 
 f 
 
 il'ii 
 
 1*1 1 
 
 
 h i\ 
 
596 
 
 DISEASES OF THE EYE AND EAR. 
 
 edges of the lids become red and swollen, and the entire surface of 
 the globe acquires a deep red color. Within twenty-four hours the 
 lids may have become so swollen as to close the eye completely 
 When they are separated there will be found an accumulation of 
 discharge, which now consists of yellow matter. Within a day or 
 two the eyes run profusely, the matter flowing over the lids onto 
 the cheeks. The edge of the lid and the adjacent skin of the cheek 
 become red and sore. 
 
 The eye is the seat of most intense pain, which suffices to pre- 
 vent the patient from sleeping. 
 
 The danger to be apprehended is the extension of the inflam- 
 mation to the deeper structure of the eye, causing ulceration of the 
 cornea. In severe cases the entire cornea — the transparent front of 
 the eye — becomes white and mortified, and may even dropoff in the 
 course of the affection. Yet sight may be seriously impaired or 
 lost without such extensive disease of the cornea, since if the cornea 
 be ulcerated even over a small surface, there will remain a white 
 opaque spot after the inflammation has subsided ; and if this spot 
 happen to be located just in front of the pupil, vision will be thereby 
 interfered with. 
 
 !l C 
 
 ; i '\ 
 
 Treatment. — It is extremely i.aportant that the treatment 
 of gonorrhoeal inflammation of the eyes be begun promptly and 
 energetically, for there is no other affection which attacks the 
 eye of the adult in which th.e most serious injury can be inflicted 
 in so short a time. In many cases the eye is irreparably lost within 
 twenty-four or even twelve hours after the discharge begins. 
 
 One of the most important items to be observed is the pro- 
 tection of the other eye from contagion, for the matter produced in 
 the inflamed eye is extremely contagious, quite as much so, indeed, 
 as that which flows from the urethra ; and the proximity of the 
 eyes renders transfer of the matter from the diseased to the sound 
 eye very easy. Several plans have been proposed for protecting 
 the sound eye. One consists in sealing the lids together with sev- 
 eral layers of collodion, re-enforced by narrow strips of adhesive 
 plaster. An ingenious device for protecting the sound eye with- 
 out interfering with the use of it, is thus described by Mr. Duller: 
 " It consists of a square piece of mackintosh, into the center of 
 which a watch-glass is fastened, and of three strips of adhesive 
 plaster. The mackintosh is trimmed to fit the nose and forehead 
 
GONOKKHCEAl. INFLAMMATION OF THE EYES. 
 
 597 
 
 of the patient, and should extend across one side of the forehead 
 about half an inch above the eyebrow, and downward nearly to 
 the tip of the nose, the nasal portion reaching a little beyond the 
 middle line. 
 
 " A strip of adhesive plaster about an inch in width, and long 
 enough to reach from just in front of one ear to a corresponding 
 point on the opposite side, is applied along the upper border of 
 the mackintosh. The second strip may vary in width according to 
 the height of the nose, and must be snipped in three or four places 
 in order that it may be auc-ipted to the uneven surface upon which 
 it rests, the lower part only slightly overlapping the edge of the 
 shield. For additional security, a third, the somewhat shorter strip, 
 is placed along the ridge of the nose. The eye in thus completely 
 protected by a waterproof shield, the upper and inner sides of 
 which are firmly adherent to the skin of the forehead and nose, 
 whilst the lower and outer borders are free, so that the eye is ex- 
 posed to the air almost as freely as when an ordinary shade is worn. 
 Moreover, the surfaces of the watch-glass being parallel, vision is 
 not interfered with and the patient is able to attend to the affected 
 
 eye. 
 
 " As the strips of adhesive plaster become softened in the 
 
 course of a few days, by the warmth and secretion of the skin, 
 
 they require to be renewed. This may be done as often as is 
 
 necessary without any difficulty or danger of infecting the healthy 
 
 eye. 
 
 Treatment. — A patient suffering from gonorrhceal inflam- 
 mation of the eye is usually in a depressed and debilitated condi- 
 tion, as the result of the sufferings which he has endured from the 
 gonorrhcea. The inflammation of the eye aggravates considerably 
 this condition. It becomes necessary, therefore, to administer 
 remedies which shall sustain and strengthen the patient. For this 
 purpose we may administer the compound syrup of hypophosphites, 
 a teaspoonful of which may be given three times a day. The diet 
 should also be generous in both quantity and quality ; yet the 
 gonorrhoea forbids the use of liquors unless these be dry wines. 
 It will be well to administer quinine regularly in the following pre- 
 scription ; 
 
 Sulphate of quinine, - - - One drachm. 
 
 Tincture of the chloride of iron, - Six drachms. 
 
 Peppermint water, _ - - Three ounces. 
 
 Mix, and take a teaspoonful in water before meals. 
 
598 
 
 DISLASLS OK THF, KYE AND KAR. 
 
 1 ! 
 
 The patient will probably suffer intense pain from the inflam- 
 mation in the eye ; this can be in part relieved by the applica- 
 tion of water dressings to the eye, as will be presently described. 
 Yet inmost cases it becomes necessary to administer opium in souk' 
 form. The most convenient and desirable way will be in the fol- 
 lowing prescription : 
 
 Sulphate of morphia, - Two grains. 
 
 Sulphate of atropia, - - One-eighth of a grain. 
 
 Water, _ - . . Two ounces. 
 
 A teaspoonful of this solution may be taken three or four times a 
 day, if necessary, to subdue the pain ; two teaspoonfuls ma\- be 
 taken at once at bedtime. 
 
 If there be much fever and thirst, with a coated tongue, the 
 following mixture may be given : 
 
 Bicarbonate of potash, - - Twenty grains. 
 
 Aromatic spirits of ammonia, - Half a drachm. 
 
 Water, ._..._ One ounce. 
 
 This may be taken in a wineglassful of water. 
 
 Locally, the most important item of treatment for the patient 
 and his friends to attend to is perfect cleanliness of the eye, that is, 
 its freedom from the discharge which will otherwise accumulate. 
 To accomplish this the eye must be carefully washed every half 
 hour, or as often as matter accumulates between the lids. lii 
 washing the eye, the lids should be separated and a stream of water 
 should be directed from a small syrin^, so as to remove any matter 
 which may have collected under the lids. 
 
 In the intervals between these cleansings of the eye, the patient 
 should apply a soft cloth, such as an old handkerchief, which in.iy 
 be folded to make three thicknesses, and should be kept wet with 
 ice water. This should be moistened afresh frequently, in order t(j 
 keep the parts cold. 
 
 A most important application is a solution of the nitrate of 
 silver. The strength of this solution, according to the sevcrit)- oi 
 the case, from ten to forty grains to the ounce of water. This 
 snould be applied to the lids in the following way : The lids are 
 separated, and their edges turned upward and downward respect- 
 ively, so as to expose as much surface as possible of the inflamed 
 conjunctiva. A soft camel's-hair brush is dipped in the solution of 
 nitrate of silver, and swept gently over the exposed surface. The 
 
GRANULAR LIDS. 
 
 599 
 
 brush is then rinsed in water and again passed lightly over the lids, 
 so as to remove the excess of the silver solution. This application 
 should be made just after the eye has been washed. In general, it 
 will be sufficient to apply the silver solution once in the day. In 
 stvcre cases it may be necessary to repeat the application twice in 
 the same day. No one but a surgeon should undertake the appli- 
 cation of nitrate of silver to the eye, since it is possible to inflict 
 serious damage by the improper use of so powerful an agent. 
 
 If it be impossible to secure the services of a professional man, 
 
 or if many hours must elapse before his arrival, it will be well for 
 
 the patient to use the following solution, which can be made in a 
 
 feu minutes in almost every household : Take as much powdered 
 
 alum as can be conveniently taken up on the point of a pen-knife, 
 
 and dissolve it in a tablcspoonful of water. Six or eight drops of this 
 
 may be dropped into the eye between the lids every half hour or 
 
 hour, after washing the eye with simple water. Or the following 
 
 lotion may be obtained at the drug store : 
 
 Sulphate of zinc, - _ - 
 
 Tincture of opium, - - - 
 
 Glycerine, . - . - 
 
 Water, 
 
 A few drops of this may be dropped into the eye every hour 
 at least. 
 
 Yet the patient must never lose sight of .the fact that the hope 
 of saving the eye depends upon the care in keeping it clean, rather 
 than the use of medicines or eye-water. 
 
 It is hardly necessary to say that the discharge from the eye is 
 as contagious for other individuals as for the other eye of the same 
 person, and that the greatest care should be used to avoid the possi- 
 bility of contagion. All cloths, brushes, etc., which have been 
 employed in the treatment of the case, should be burned when no 
 longer required. Towels and body linen which may have been 
 soiled by the discharge, should also be kept from possibility of con- 
 tact with other people. 
 
 Four grains. 
 Half an ounce. 
 Half an ounce. 
 One ounce. 
 
 Granular Lids. 
 
 This term is applied to a state of the eyelids, in which the 
 inner surfaces of the lids are studded with minute bodies about the 
 size of a pin's head, which may lie closely together over the entire 
 
6oo 
 
 DISEASES OK THE EYE AND EAR. 
 
 lid, or ,nay be scattered in different parts of it. During the early 
 stages of the affection these little bodies, called granulations, are 
 red and bleed easily upon pressure; but after a time they become 
 har 1 and white, and the mucous membrane between them becomes 
 shrunken and yellow. At the beginning of the disease the eye is 
 usually red, but in the later stages it becomes pale and somewhat 
 yellow. 
 
 These granulations arise as the result of a purulent inflamma- 
 tion of the eyes, or as the continuation of an ordinary inflammation. 
 In some cases they seem to result simply from the continued irrita- 
 tion of the eyes which occurs in a far-sighted individual who is 
 compelled to employ the eyes constantly in fine work. Granular 
 lids are not usually found among people in robust health and good 
 sanitary condition ; they are most frequently met with among 
 people who live in closely-crowded quarters, neglectful of sanitary 
 requirements. They are, therefore, more frequently seen among the 
 poorer classes, especially those whose general health is evidently 
 impaired. They may exist for a considerable time without giviiii; 
 any more annoyance than a slight sense of roughness in the lids, 
 and perhaps a little tendency of the lids to stick together in the 
 morning. In the majority of cases, however, there is increased 
 discharge from the eyes, and a constant feeling as if there were 
 sand in the eyes. The severity of these symptoms is increased by 
 exposure to a cold wifld, or to the glare of the sun as reflected from 
 snow or from the surface of water. 
 
 Symptoms, — The patient's attention is at first attracted by a 
 feeling of heat and fullness in the eye, and by a sensation as if there 
 were particles of sand or other foreign bodies constantly irritating 
 the surface of the eye. There is also increased sensibility to light, 
 and usually a discharge of watery liquid which causes the lids to 
 stick together in the morning. The edges of the lids are red and 
 somewhat thickened, and in advanced cases the upper lid is apt to 
 droop somewhat. 
 
 The little bodies which are situated in the inner surface of 
 the upper lid lie in contact with the cornea ; the constant move- 
 ment of the lid over the globe causes constant irri*^ation of the 
 cornea by the friction of the granulations. After a time this irritation 
 is shown by a cloudiness and whitish appearance of the cornea, 
 which is limited to that part of the eye covered by the upper lid. 
 
GRANULAR LIDS. 
 
 601 
 
 It 13 therefore only when this lid is raised, or when the patient 
 directs the eye downward toward the floor that this whiteness 
 becomes visible. After a time the surface of the cornea also 
 becomes uneven and rough, and ulcerations may be produced. In 
 many cases bright red streaks are seen across the upper part of the 
 cornea, consisting of blood vessels. 
 
 Occasionally the eyes troubled with granular lids become sud- 
 denly inflamed in a high degree ; the lids are then intensely red, 
 swollen and puffed, and may be kept spasmodically closed in con- 
 sequence of the excessive sensitiveness to light ; an attempt to open 
 them is extremely painful, and is accompanied by a gush of tears 
 which sweeps out strings of mucus. 
 
 Careful management and appropriate treatment usually suc- 
 ceed in removing the granulations, and as a result in restoring the 
 the clearness of the cornea, if the affection has been of only short 
 duration, we may hope for complete or almost perfect recovery in 
 every respect. The prospect is, however, worse in old cases ; the 
 mucous membrane of the eye becomes much changed in quality. 
 It is no longer red and soft, but becomes white and hard like a scar. 
 The result of this is frequently that the edge of the upper lid is 
 drawn inward toward the globe of the eye, so that the eyelashes 
 constantly rub against the surface of the cornea. The effect of this 
 irritation is, of course, to aggravate the condition of the cornea and 
 to diminish the prospects for ultimate recovery. 
 
 Trenttnent. — Few aff'ections of the eye are so obstinate and 
 troublesome in treatment as this granular condition of the lids. 
 Numerous plans of treatment have been employed with more or 
 less success, though none of them can be relied upon in all 
 cases. 
 
 It must be remembered that in the majority of instances the 
 patient's general condition is unsatisfactory ; he requires tonics, 
 judicious and generous diet and fresh air. These are just the 
 remedies which the majority of such patients cannot procure, since 
 these individuals are generally poor and are compelled to live in 
 poor sanitary relations. 
 
 The local treatment consists in the application of some sub- 
 stance which will destroy the granulations and restore the mucous 
 membrane to a healthy condition. For this purpose several difi'er- 
 eat remedies are used ; the most popular is perhaps the " blue 
 
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 r\i 
 
 M 
 
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 U^l.-J 
 
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 m 
 
 tlU^'"-' 
 
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 DISEASES OF THE EYE AND EAK. 
 
 i 
 
 Stone " or sulphate of copper. Every second day the h'd is turned 
 upward so as to expose the granular surface ; this is then carefully 
 dried and the granulations are touched with the sulphate of copier. 
 Nitrate of silver, the acetate of lead and other caustics of varyin^r 
 strength have been employed for the same purpose. It is not 
 necessary to enter into details of treatment, since success cannot 
 be expected in inexperienced hands. 
 
 In obstinate cases surgeons have sometimes resorted to a hold 
 and somewhat perilous expedient. This consists in sotting up a 
 severe inflammation of the eye by introducing into it a drop of matter 
 from a case of purulent inflammation of the eyes in another indi- 
 vidual. For this purpose the matter is taken from an infant suffer- 
 ing with purulent inflammation. In a day or two the eye becomes 
 the seat of a violent inflammatory process, which is, of course 
 carefully watched and controlled by the surgeon. In many 
 instances it is found that when the inflammation subsides the granu- 
 lations have disappeared. 
 
 This method will, of course, be undertaken only by a surgeon, 
 and, indeed, it is now not so popular with medical men as was 
 formerly the case. For within the last year experience has shown 
 that granular lids can be in a great majority of cases easily ..nd 
 rapidly cured by the application of a substance known di%jequirity. 
 This remedy is too powerful for harm as well as for good to be 
 entrusted to non-professional hands. 
 
 '. f 
 
 Inversion of the Eyelids. 
 
 This condition, technically known as trichiasis, frequently 
 occurs as the result of granular lids. The edges of the lids become 
 thickened, a condition which, in itself, tends to turn the lashes 
 inward toward the globe of the eye ; this tendency is aggravated 
 by the fact that the inner surface of the lid is drawn inward by m 
 granulations. 
 
 The first effect of this inversion of the lids is a; the 
 
 lashes rub against the globe of the eye. The result ihis posi- 
 tion of the hairs is first a severe irritation of the cornt... which 
 results in a haziness and opacity of this structure. The grt)wti nf 
 the hairs themselves is also impaired ; they become stunted and 
 
SCUM (JN THE EYE — PTKKVi.lL'M. 
 
 603 
 
 changed in the direction of their growth. After a time the hairs 
 bt cotnc brittle, and perhaps only a few stumps are left here and 
 iIkic to mark the position of the eyelashes. 
 
 Tt'eatnient, — Since the condition depends upon granulations 
 of the eyelid, it can be relieved only when these granulations have 
 bull removed. After this has been accomplished, measures may 
 be taken to remedy the condition and position of the eyelid. To 
 ctTt-ct a cure a surgical operation is usually required, hence it will be 
 unnecessary to discuss the treatment in detail. Tempt)rary relief 
 can, iiowever, be obtained by pulling out the eyelashes. To do 
 this the edge of the lid should be raised somewhat from the eye, 
 since the lashes which cause the irritation are often situated out of 
 si<'lit when the lid retains its natural position. When the edge of 
 the lid is thus raised there will often be seen a row of stumps pro- 
 jecting toward the surface of the eye. These should be pulled out, 
 one by one. Further than this it is not advisable for the non-pro- 
 fessional to go. 
 
 Sorun on the Eye— (Pterygium). 
 
 People are sometimes annoyed by observing a fleshy-looking 
 mass growing upon the corner of the eye ; in the course of time 
 this mass extends toward the center of the eye, assuming a trian- 
 giihir shape ; the point of the triangle extends gradually toward 
 the middle of the eye, and finally reaches the center of the pupil. 
 This constitutes what is popularly known as " a scum " on the eye ; 
 it has, however, no efifect upon the power of sight until it reaches 
 the cornea and extends in front of the pupil, in which case it inter- 
 feres somewhat, though not seriously, with vision. 
 
 In most cases the growth occurs at the inner half of the eye, 
 and only one is found in a single eye ; at times, however, one will 
 },'r()\v from either corner of the eye and the two meet in the center. 
 
 This scum appears almost invariably in middle or advanced 
 life, especially among those who have lived for a long time in "warm 
 climates. It is seldom seen in young persons. It grows very 
 slowly, and rarely attracts notice until it has reached the margin of 
 ' ■ cornea. 
 
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 lil 
 
 
 
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 f*H 
 
 
 
 Hh 
 
 HH 
 
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 WKim 
 
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 604 
 
 DISEASES OF THE EYE AND EAR. 
 
 Treat/ment. — This variety of scum over the eye is quite 
 harmless, and occasions no further annc vuncc than the deformity 
 induced by it. Most people, therefore, prefer to submit to its 
 presence rather than to undergo an operation for its rcnun 1! 
 Such an operation is quite devoid of danger to the patient, as will 
 to the eye ; and if the individual be young, the improvenv. nt in 
 the appearance of the eye warrants the operation. VViicnevcr the 
 growth reaches the middle of the cort'ea, so as to inter ire with the 
 sight of the eye, it is advisable to have it removed. 
 
 A smaller tumor affects the eyes of many persons and occa- 
 sions much unnecessary annoyance. This tumor consists of a 
 small yelU)wish knot, which is usually situated near the edge of tlic 
 cornea. The patient's attention is usually drawn to it by a ferliir- 
 of roughness upon closing the lid. This mass does no harm what- 
 soever, and may be permitted to remain without injury. If lis 
 presence annoys the vanity of the patient it may be seized with a 
 fine pair of forceps and snipoed off with the scissors. 
 
 Inflammation of the Cornea. 
 
 This disease is usually met with in children, especially amnn^i; 
 the poorly-nourished and under-fed. It may also occur in other* 
 as the result of a constitutional taint, such as scrofula or sy])hilis. 
 
 It is an obstinate and prolonged affection which usually lasts 
 several months. In most cases it begins in one eye and progresses 
 until it reaches a certain stage, when the second eye also becomes 
 affected. 
 
 Sffuiptoms, — Inflammation of the cornea generally begins 
 with a slight redness of the white of the eye at the edge of '.he 
 cornea. This redness ordinarily begins as several distinct patches, 
 which subsequently spread so as to run together. The eye becomes 
 very sensitive to light and irritable. 
 
 The cornea soon begins to look cloudy and white, and the 
 vision is correspondingly impaired. After a time the cornea, 
 instead of being clear and transparent as in the natural state, looks 
 like a window pan"* that has been breathed upon, or like a piece of 
 ground glass. T';ere is usually an increased amount of secretion 
 
INFLAMMATION OF THE CORNEA. 
 
 605 
 
 from the eye, and frequently much prain in c.nd around the 
 
 organ. 
 
 After lasting several months, the cornea gradually loses its 
 tinnatiir.il appearance, and in the course of a year or eighteen 
 months frequently exhibits a perfect recovery. In many cases, hovv- 
 cv(;r, the actiteness of vision is somewhat impaired, and there often 
 nniains a diffuse cloudiness of the cornea. In unfavorable cases 
 the inflammation proceeds so far as to cause ulceration of the cor- 
 nea, in uiiich case there remain permanently white spots in diflfer- 
 cnt parts of it. These cause moie or less interference with the 
 sJLdit of the eye, according as the dots are located in the middle 
 or at the edge of the cornea. 
 
 Ttu'«itmeilt, — In every case of inflammation of the cornea 
 the patient requires constitutional treatment. It is necessary to 
 ascertain carefully just what the defects in the patient's system may 
 l)c, ai'.d to employ those measures which are best adapted to the 
 relief of this condition. If the patient be a scrofulous child, he 
 should have a teaspoonful of cod-liver oil three times a day, and 
 fifteen drops of the syrup of the iodide of iron ; the latter may be 
 given in a teaspoonful of water after meals. 
 
 If the child have a syphilitic taint, it is necessary to employ 
 remedies which will cout.teract this virus. Y^r this purpose we 
 may rub a little mercurial ointment into the skin behind the ear 
 every right, keeping a strict watch upon the conditicm of the 
 patient's mouth to avoid salivalion. Internally we may administer 
 one of tne following prescriptions: 
 
 Syrup of the iodide of iron, 
 Glycerine, - . - _ 
 
 Water, - . . . 
 
 Mix anc. take a teaspoonful after meals. If this do not agree with 
 the child's stomach, we may order the following: 
 
 Iodide of potassium, - . _ Two drachms. 
 Citrat'^ of iron and quinine, - - Two drachms. 
 
 Six drachms. 
 One ounce. 
 Two ounces. 
 
 White sugar, 
 Water, 
 
 One drachm. 
 Four ounces. 
 
 A teaspoonful of this may be taken at meal-times. 
 
 Whenever the child is suffering from marked debility, more 
 benefit will be derived from residence in the country than from 
 
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 606 
 
 DISEASES OF THE EYE AND EAR. 
 
 medicines or applications to the eyes, for the improvement in the 
 general health is always followed by actual improvement in the con- 
 dition of the eye as well as by diminution in the distress e\])cri- 
 enced by the little patient. 
 
 As for the eye itself, but little can be done directly. If there 
 be great intolerance of light and profuse discharge from the oycs, 
 they may be washed several times a day with cold water and pro- 
 tected by a light bandage. The habit of wrapping the eye ti<;htly 
 in several folds of a handkerchief is a serious mistake, since the 
 condition of the eye is much aggravated by the heat of the bandage. 
 It will be better in al! cases to avoid the use of bandages, and to 
 protect the eyes by means of colored glasses. This is indeed abso- 
 solutely necessary if there be great sensitiveness to light. In mild 
 cases the blue glasses will afford sufficient protection and be least 
 unsightly ; but if the dread of light be excessive, the patient 
 should wear glasses of a neutral tint. The best form is the large 
 curved spectacle, whereby the eye is sufficiently protected from 
 light and wind, but is not heated. 
 
 If much pain be experienced in the eye, relief may be obtained 
 by making a fomentation as follows: 
 
 Extract of belladonna, - - . Sixty grains. 
 Dissolve this in a pint of boiling water ; saturate a piece of lint or 
 a soft handkerchief with the warm lotion, and apply it folded to 
 the eye. 
 
 Instead of this fomentation the following eye-water may be 
 used : 
 
 Sulphate of atropia, - - - - Two grains. 
 Distilled water, . _ - . One ounce. 
 
 Two or three drops of this may be dropped into the eye twice 
 a day. 
 
 Ulcers of the Cornea. 
 
 Ulcers in the transparent front of the eye, the cornea, result 
 from severe inflammations of the eye. They arc especially frequent 
 in those forms of inflammation which result from the contact oi 
 matter from a gonorrhctal discharge. There are, however, some 
 ulcers which originate without any previous severe inflammation of 
 the eye. These occur chiefly in children, and almost always in 
 
ULCERS OF THE CORNEA. 
 
 607 
 
 children of impaired health. They are especially common in the 
 so-called scrofulous persons. 
 
 Ulceration of the cornea is always accompanied by extreme 
 sensitiveness to light. So great is this susceptibility that the child 
 frequently shuns the sunlight, cannot be persuaded to go out and 
 play, '"^iid may even keep the head buried in a pillow or the eye 
 covered with the hand. 
 
 The ulcer begins as a slight cloudiness or haziness of the cor- 
 nea, which is soon found to surround a little hollow. This hollow 
 is the ulcer. It sometimes remains quite limited in extent, and 
 at other times spreads so as to acquire a diameter of a quarter 
 of an inch or more. The haziness around the margin of the 
 ulcer increases so as to constitute at times a considerable impair- 
 ment of vision ; for the cornea is of course more or less opaque, 
 and (Iocs not permit the light to pass through it. 
 
 There is always some increase in the secretion of the eye, and 
 the entire mucous membrane of the eye seems red and irritable. 
 
 The course and result of this affection varies much with the 
 cause and the condition of the i>atient. In the most favorable 
 cases the ulcers heal in the course of a few weeks under appropri- 
 ate treatment, leiiving only a minute white speck at the site of the 
 ulceration. In less favorable cases the ulcers resist treatment for 
 weeks, or even months, though finally healing. In the worst cases 
 the ulcer eats through the cornea, so that the watery fluid in the 
 front part of the eye escapes through the opening. As a result of 
 this the colored ring of the eye — the iris — lies in contact with 
 the cornea, and is apt to grow fast to the edge of the ulcer. If 
 this occurs there may result most serious difficulty, and even per- 
 manent impairment of vision. 
 
 Treatment, — In every case in which an ulcer of the cornea 
 occurs without injury to the eye, or without a previous severe 
 inflammation, the fault is to be sought in the impaired health of the 
 patient. Hence the treatment will be directed, first of all, to the 
 improvement of the general health. Many of the children are 
 decidedly scrofulous ; they need the best possible care n the way 
 of food, recreation, air and exercise ; their strength should also be 
 built up by the use of cod-liver oil and of the syrup of the iodide 
 of iron. Directions for the administration of these drugs have been 
 ivea in previous pages. 
 
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6o8 
 
 DISEASES OF THE EYE AND EAR. 
 
 I i] 
 
 The local treatment consists in means for relieving the sensi- 
 tiveness to light and for favoring the healing of the ulcer. For the 
 first purpose it will be well to put into the eye every day two or 
 three drops of the following solution : 
 
 Atropia, 
 Distilled water, 
 
 - Two grains. 
 
 - One ounce. 
 
 In order to promote the healing of the ulcer, it is advisable in 
 many cases to dust into the eye some powdered calomel. This is 
 done by taking a dry camel's hair brush, dipping it into the pow- 
 der, and then adroitly shaking it between the lids, which are mean- 
 while held apart by the fingers of the other hand. 
 
 Instead of the powdered calomel we may use an ointment 
 containing the yellow oxide of mercury : 
 
 Yellow ointment of mercury, 
 Vaseline, - - - - 
 
 One ounce. 
 One ounce. 
 
 Mix and apply a piece as large as a pea between the lids at 
 the angle of the eye. The movements of the lid will cause this to 
 spread over the eye and reach the ulcer. 
 
 It is highly important that no substance containing /^rtrt' should 
 come in contact with the eye when there is an ulcer on the cornea; 
 for the lead is deposited in and around the ulcer, making an un- 
 sightly mass which it is extremely difficult to remove. Hence no 
 eye-water should be used in a case of this sort without knowing that 
 it is free from lead. It is, therefore, necessary to avoid the so- 
 called eye-waters which are kept on sale in the drug stores. 
 
 If the white speck which is left after the healing of an ulcer be 
 located just in front of the pupil, it constitutes a permanent impair- 
 ment of sight, which cannot be remedied by any known means. If 
 it be located on the other hand somewhere near the edge of the 
 cornea, it need not interfere seriously with the sight of the eye. 
 But in every case the white speck constitutes a deformity, which 
 attracts notice from its pr' minent position. This spot can be con- 
 cealed, to a great extent, by tattooing with India ink. By this 
 means the appearance of the eye is very much improved, though 
 the impediment of vision, whatever it may amount to, remains 
 undiminished. 
 
Ii» 
 
 INFLAMMATION OF THE IRIS — IRITIS. 
 
 609 
 
 Inflammation of the Iris— (Iritis). 
 
 This is one of the most important affections of the eye, since 
 it may result in serious impairment of sight if it be not promptly 
 and properly treated. Inflammation of the iris arises first, fron: 
 some taint of the system, such as syphilis or rheumatism ; second, 
 from exposure to cold ; third, from an injury to the eye. 
 
 Sffinptoms. — One of the first symptoms noticed by the 
 patient is a dull aching pain in the eye ; this is often regarded by 
 the patient as neuralgia, since it is apt to extend upward on the 
 side of the head and downward along the side of the nose. 
 
 Another symptom is a certain sensitiveness of the eye to 
 iiirht, though this is not usually so marked as in the affections of 
 the cornea. 
 
 The appearance of the eye undergoes a change; this consists 
 in a certain vttidiUncss of the iris and of the watery fluid contained 
 in the front of the eye; by comparing the iris w'ith the one of the 
 sound eye, a decided difference in color is usually manifest. 
 
 There is usually also some dimness of vision, though this 
 mav not be noticed by the patient until his attention is directed to 
 the contlition of his sight. 
 
 The most important feature of the disease, however, and one 
 which is always present, is a contraction of the pupil. It will be 
 seen that the pupil of the affected eye is much smaller than that of 
 the opposite one, and that it does not change its size rapidly with 
 the amount of light which is admitted to it. Thus, if the hand be 
 held o\er the eyes for a moment and then removed, it will be ob- 
 served that the pupil of the sound eye is quite large at the instant 
 that the hand is removed, but rapidly decreases in size; the pupil 
 of the affected eye, on the other hand, is not perceptibly larger when 
 the hand is removed than it is subsequently, and it is constantly 
 smaller than the pupil of the other eye. 
 
 Treatment. — One of the important objects of treatment is to 
 lcr/> the pupil dilated, for the tendency of the disease is, as has been 
 said, to contract the pupil, that is to draw the iris toward the lens. 
 For it is to be remembered that the black opening which we call 
 the pupil is really filled up by a transparent body — the crystal- 
 line lens. Now when the iris is inflamed, if it lie in contact with 
 
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6io 
 
 DISEASES OK 'I'HK EYE AND EAR. 
 
 ! 1 
 
 this crystalline lens, as it does when the pupil is small, there is 
 danger that the two will grow together, that is, that the iris will hr- 
 come attached to the lens. This is a most serious accident, whicli 
 may occasion much injury to the eye subsequently. 
 
 The first object of treatment is, therefore, to keep the iris aw.iy 
 from the lens, that is to keep the pupil dilated. Fortunately this 
 can easily be done by the use of atropine. For this purpose 
 we employ the following solution: 
 
 Atropine, - . . _ . Two grains 
 
 Distilled water, _ . . _ One ounce. 
 
 Three drops of this may be dropped into the eye once or 
 twice a day, as occasion requires. The atropine exerts also other 
 beneficial effects ; it diminishes the irritability of the eyes and 
 affords the patient much relief. It is rarely necessary to employ 
 any form of opium to relieve the pain. 
 
 This part of the treatment is applicable to all varieties of iritis, 
 , whatever the cause may be. But the rest of the treatment vanes 
 according to the origin of the difficulty. Thus inflammation of the 
 iris results in many cases from syphilis. If the patient has e\er 
 suffered from this disease, he must be on the lookout for this 
 inflammation of the eyes as one of the possible manifestations of 
 the disease. 
 
 If the inflammation of the iris be due to syphilis, it is neces- 
 sary to employ not only the local remedies for use in the eye, but 
 also those medicines which are known to counteract the s\philitic 
 poison. For an extended discussion of this subject we must refer 
 the reader to the chapter on " Syphilis. " The following ointment 
 may be prepared : 
 
 Extract of belladonna, - - - Fifty grains. 
 Ointment of mercury, - - - One ounce. 
 
 These are to be rubbed together so as to make a perfect mix- 
 ture ; a piece as large as a hazel nut should then be rubbed into 
 the skin of the temple and forehead around the eye, and allowed 
 to remain during the night. 
 
 Syphilitic patients usually require tonics; for this purpose a 
 teaspoonful of syrup of hypophosphites may be taken after 
 meals. 
 
 It sometimi'3 becomes necessary in inflammation of the eyes 
 of syphilitic origin, to administer opiates in order to secure to the 
 
CATARACT. 
 
 6ll 
 
 patient the rest which he so much needs. He may take fifteen 
 drops of the deodorized tincture of opiun' three times a day, and 
 twenty drops upon retiring at night. 
 
 If the individual have never had syphilis, but is a frequent 
 sufferer from rheumatism, the treatment adapted to this condition 
 must be employed before we can hope to cure the inflammation of 
 the iris. 
 
 Cataract. 
 
 This is one of the most frequent and important affections of the 
 eyes in aged people, and may also occur in the young. It consti- 
 tutes the source of a " scum over the eye," though the scum is 
 really not over but in the eye itself. 
 
 A cataract consists in an opaque condition of the crystalline 
 lens. It will be remembered that the lens of the eye is, in the nat- 
 ural condition, perfectly transparent ; it lies just behind the col- 
 ored ring called the iris, and fills up the black opening in the 
 ring called the pupil. Yet so long as it remains healthy the lens 
 is quite invisible, and v hen we look into the eye we see no object 
 whatsoever filling up the pupil. 
 
 When from any cause the lens loses its transparency and clear- 
 ness and becomes opaque, it can be seen in the opening of the 
 pupil. This is what happens in the disease called cataract, which 
 may be defined, therefore, as an opacity of the crystalline lens. 
 
 Causes, — The opacity of the lens may be the result of any- 
 thing by which its nutrition is impaired. These causes may be 
 classified as follows : 
 
 It may occur as the result of old age ; in advanced life the 
 tissues of the body generally are not so well nourished as in earlier 
 years. Changes occur in numerous organs ; the bones become 
 more brittle ; the muscles are not so strong ; the skin is less abun- 
 dantly provided with fat ; the hair loses its color and often falls 
 nut. The opacity of the lens in old age is merely one of the changes 
 which seem to be due to the impairment of the powers of life ; this 
 variety is called "senile cataract," because an accompaniment ot 
 
 old A'^C. 
 
 Cataract may also result from some taint of the system where- 
 by the nutrition of the body is interfered with. One of the most 
 
 40 
 
 J 
 
 
 11 
 
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6l2 
 
 DISEASES OF THE EYE AND EAR. 
 
 frequent examples of this is the condition known as diabetes. A 
 patient suffering from d'-'betes is very apt to become partially blind 
 from an opacity of the lens — that is, cataract. 
 
 The lens may also become opaque in consequence of some dis- 
 ease of the other tissues in the eye, for when certain of these struct- 
 ures — especially the retina and the choroid — become diseased, 
 there results a disturbance of the nutrition of nearly all parts of the 
 eye. One of these results is an opacity of the lens. Cataract may 
 also be produced by an injury to the eye, such as a blow, even 
 though there be no wound. 
 
 Finally, cataract is sometimes congenital — that is, an infant is 
 born with opaque lenses. 
 
 Congenital Cataract. 
 
 The eyes of a child born with a cataract are usually poorly 
 developed and of small size. In some cases the child itself is 
 stunted and lacking in development of the body or of the mind, 
 or both. Congenital cataracts are seen witL especial frequency in 
 children who are born imbecile or idiotic. A more frequent form 
 of cataract in children comes on after birth, in well-developed as 
 well as in stunted children. It may not be discovered for some 
 months or years ; in some cases the child is afflicted with convul- 
 sions, which are not due, however, as is popularly supposed, to the 
 cataract. It seems more probable that both the convulsions and 
 the cataract result from some disease of the nervous system. 
 
 Mr. Hutchinson, of London, has shown that infantile cataract 
 is frequently associated with an imperfect development of the en- 
 amel on the teeth. " The incisors, the canines and the first molars, 
 are the teeth which suffer most ; and as a rule, with but very few 
 exceptions indeed, the bicuspids escape entirely. The contrast 
 between the clean, white, smooth enamel of the latter, and the 
 rugged, discolored spinous of the first molar, is often very strik- 
 ing. " 
 
 Cataracts occur from old age at any time after 35 or 40 years, 
 but usually between 50 and 60. The patient first notices a certain 
 haziness before the eye, accompanied by a corresponding impair- 
 ment of the sight. After a time a faint white body can be seen 
 
CONGENITAL CATARACT, 
 
 613 
 
 Ivintr in the pupil. This becomes gradually more distinct and 
 lar<fer so that finally the pupil is entirely filled with a white mass. 
 By this time the sight of the eye is practically lost, the patient 
 being able only to distinguish light from darkness. 
 
 Cataract follows an injury which impairs the nutrition of the 
 lens. Thus, if a particle of iron or stone, or other foreign body 
 penetrate the eye and enter the lens, a cataract will result within 
 ;i few weeks. So, too, a blow upon the eye may shake the lens 
 loose from its fastenings and result in the production of a cataract. 
 Sometimes a blow upon the back of the head, or a fall upon the 
 head, may result in an opacity of the lens. 
 
 Trentmt'ut. — Whatever the cause of the cataract may be, 
 there is but one plan of treatment — the removal of the lens. 
 There are, it is true, several operations, one or another of which is 
 preferred according the circumstances of the case ; but nothing 
 can be done by means of medicines for the removal or even the 
 arrest of a beginning opacity of the lens. 
 
 After the lens has been removed, the patient recovers the 
 sight of the affected eye ; for cataract impairs sight only by pre- 
 venting the entrance of light into the eye. After the opaque lens 
 have been removed, the light enters the eye again as before and 
 the patient sees again. This statement assumes that there is no 
 other disease in the eye itself than the cataract ; in many cases 
 other structures of the eye are also diseased ; in these instances 
 the removal of the lens may not restore the sight to the eye, since 
 the retina or the choroid may be so affected as to be unable to per- 
 form their usual office. 
 
 After the lens have been removed the patient sees but indis- 
 tinctly, for it will be remembered that in order that a person 
 shall see distinctly, it is necessary that a minute picture of the object 
 at which he looks shall be formed upon the retina, and that in 
 order to form this picture the rays of light must be focused by the 
 lens. When this is removed it becomes necessary to substitute 
 some other contrivance, whereby the rays can be focused so as to 
 meet upon the retina. This is accon lished by placing a lens 
 before the eye in the shape of spectacles. When the eye from 
 which the lens has been removed is thus provided with proper 
 spectacles, the individual can see in some respects as well as before. 
 He cannot, of course, adapt the eye to near and to distant objects 
 
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 614 
 
 DISEASES OF THE EVE AND EAR. 
 
 as can be done with the natural eye ; but his condition is far better 
 than before the removal of the lens. 
 
 The operation for the removal of a cataract is one of the most 
 delicate and critical of all surffcry. A slight error on the p.nt of 
 the operator, or — as is more frequently the case — an unfortunate 
 condition of the eye at the time of the operation, may cause an 
 inflammation which will result in the total destruction of the e)e. 
 It is, therefore, necessary that the very best and most prolicient 
 surfTeon be employed when so important an operation is to be per- 
 formed. 
 
 Injuries of the Eye. 
 
 The presence of a foreign body within the eye, however small 
 or insignificant this body may be, is an extremely serious matter. 
 It is therefore important to ascertain, as soon as possible after an 
 injury, whether any particle has lodged within the eye and is still 
 present there. 
 
 The symptoms which indicate that some such particle has 
 lodged within the eye, are : 
 
 Severe and continued pain in the eye, which resists the ordinary 
 remedies and is not proportioned to the apparent injury done. 
 
 An increase in the amount of inflammation e.xcited by the 
 original injury. 
 
 A gradual impairment of the sight in the aftected eye. 
 
 It has been said on a previous page, and can only be repeated 
 with emphasis here, that when a foreign particle remains in an eye 
 the patient is in danger of losing, not only the injured, but also tiie 
 soui i eye. Whenever the injured eye shows signs of inflammation, 
 when it secretes mucus freely and causes the patient considerable 
 pain, no time should be lost in presenting the matter to a compe- 
 tent surgeon. For if the trouble be allowed to continue indefinitely, 
 until the pain and irritation become so severe that the patient can 
 no longer bear it, it will probably be too late to save either the 
 injured eye or even the sound one. 
 
 Injuries from Gunpoivder, Small Shot, Percussion Caps, Toy 
 Pistols, Etc. — The most frequent injuries of the eye, wliicii are 
 brought to the surgeon in ordinary practice, result from contact 
 with the eye of some of the missiles just mentioned. In this country 
 
INJURIES OF THE KYELIUS. 
 
 615 
 
 the Fourth of July is a harvest time for eye surgeons as w«ll as for 
 (ithcrs. The toy pistols which have become so popular among 
 boys, occasion frequent injuries to the eyes. For not only may 
 fra-Miients of the different missiles be driven into the eye, but the 
 ';ini])le explosion in the immediate vicinity of this organ may occa- 
 sion damage by detaching some of its tissues. 
 
 The explosion of gunpowder near the eye may affect this 
 oi;,^aii in different ways. 
 
 The simple concussion may so shake the eye as to derange its 
 parts and impair sight. 
 
 The surface of the eye may be burned or scorched by the 
 flame so that serious disease and deformity result. 
 
 Grains of the powder may be driven with force sufficient to 
 penetrate the coats of the eye and lodge in its interior. 
 
 Trenttnent. — All loose powder should be at once washed out 
 of the eye in the following way : The lids are separated and raised 
 from the globe so far as may be gently done ; then a fine stream of 
 water is squirted over the eye and under the lids from a small 
 syringe. The front of the eye — the cornea — will probably be 
 stiiddcd with grains of powder which stick so tightly in the tissue 
 that they cannot be removed by the stream of water. These can 
 be detached by the dextrous use of a fine needle or other instru- 
 incni prepared for the purpose ; but this should always be left for 
 the experienced surgeon and never undertaken by any one who is 
 not a physician, since much injury can be done by unskilled hands. 
 After the eye has been thoroughly washed, a few drops of sweet 
 oil or a little vaseline should be inserted between the lids, and a 
 soft cloth saturated with cold water may be kept applied to the eye, 
 fresh water being used as often as is necessary to keep the part 
 cool. 
 
 
 • ^f< 
 
 1f»h 
 
 U,H\A 
 
 Injuries of the Eyelids. 
 
 The most common injury consists in a rupture of some of the 
 blood vessels in the tissue under the skin of the lids, resulting in n\ 
 escape of blood and swelling of the parts. This condition is wnat 
 is popularly known as " a black eye. " 
 
 The blood which escapes into the skin is at first red, but in the 
 course of a few days undergoes a change of color, becoming dark, 
 
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 DISEASES ()!• IIIK EYK AM) KAU. 
 
 then green, ;ind finally yellow, it usually entirely disappears in the 
 course of eight or ten days without treatment. 
 
 Tveatnwnt, — If cold can be applied to the part immediate ly 
 after the injury, the escape of blood may be limited consider, ibly 
 and the deformity repressed. This can be best accomplished by 
 applying ice directly to the eye, or by putting pieces of ic . in a 
 rubber bag or soft cloth, which may be bound over the eye if 
 this cannot be done at once, a cloth should be saturated witli jiol 
 water and pressed firmly upon the part. 
 
 If any advantage is to be derived from this measure it must ho 
 used as soon as possible after the receipt of the injury ; for the hlodd 
 escapes within comparatively few minutes after the infliction of tin- 
 blow, and it is only during these few minutes that we can lujpi to 
 prevent the escape of blood. 
 
 After the injury has been done, and the eye is sw(jllen and 
 puffed with blood, it becomes a matter of importance to remove, as 
 quickly as possible, the unsightly appearance. Yet this is practi- 
 cally impossible. We must wait until the blood is absorbed, a pro- 
 cess which will require several days. The most that can be done 
 is the application of cloths saturated with hot water. These should 
 be frequently changed, so that the part can be constantly kej)! warm 
 and moist. 
 
 There are various popular devices for the treatment of a bh' k 
 eye. The most common one, a piece of raw beefsteak, has the iidvaii- 
 tage of being moist and cool, but possesses no special merit other- 
 wise. Pugilists are said to be in the habit of puncturing tlie swollen 
 skin so as to squeeze out some of the blood, and thus hasten tiic 
 reduction of the swelling. This is, however, a somewhat dangerous 
 practice, since it renders the skin liable to an attack of erysipelas as 
 well as to the formation of matter, accidents which would not other- 
 wise occur. 
 
 Among the popular remedies for the relief of a black eye is a 
 poultice made of black bryony root. A poultice is made by scraping 
 some of the root and mixing it with bread crumbs. This is boiled 
 in a muslin bag and placed over the eye. It is said to ha\e an 
 excellent effect in promoting the absorption of blood from the skin. 
 
 Another popular remedy is the tincture of arnica. This is 
 used for injuries of all sorts, such as sprains and bruises. There 
 seems to be as yet no evidence that it has ever done any good, 
 
■^ 
 
 INILAMMATION AROUND Illi; KYIi LASHES. 
 
 617 
 
 though it is very certain that it frequently produces a rash on the 
 skill wliich may amount even to a serious eczema. It cannot be 
 rcconimended for the treatment of a black eye. 
 
 Inflammation Around the Eyelashes. 
 
 In discussing diseases of the skin, we had occasion to refer to 
 the fact that the little sacs or follicles from which the hairs in 
 various parts of the body grow, are liable to inflammation. Thus 
 one of the forms of that familiar and obstinate affection known as 
 " Harbcrs' Itch," consists simply in an inflammation of the hair 
 follicles of the beard. 
 
 The hair follicles of the eyelashes are also subject to a slow 
 and obstinate sort of inflammation, constituting an afi"ection which 
 is technically termed tinea tarsi. This affection is more common 
 among children than among adults. It begins with a redness and 
 irritability of the edges of the lids ; there occurs an increased 
 secrttion from the follicles of the eyelashes, which accumulates 
 during the night especially, and gums the lids togf;ther so that they 
 are separated with difficulty in the morning. The effort to pull the 
 lids apart usually results in pulling out several lashes. 
 
 After the disease has lasted a few weeks the discharge contains 
 matter, and dries into scabs which stick to the edges of the lids and 
 surround the lashes. Pimples form around the lashes, and when 
 they break there remain slight ulcers which are soon covered with 
 yellow crusts. 
 
 In a short time the lashes fall out, and the edges of the lids 
 become thick, rounded, and turned away from the eye — everted. 
 
 The result of this change in the shape and position of the 
 edges of the eyelids is, that the minute canals through which the 
 tears escape into the nose, are turned away from the globe. Hence 
 the natural moisture of the eyes no longer escapes through the 
 usual channel into the nostrils, but flows over the edge of the lower 
 lids onto the cheeks. This occasions the patient great annoyance, 
 since the skin below the eyes is constantly moist, and the indi- 
 vidual seems to be continually crying ; moreover, the irritation of 
 the skin caused by the constant moisture results oftentimes in the 
 production of soreness ana rawness. 
 
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 DISEASES OF THE EYE AND EAR. 
 
 This disease may occur in all classes of society, but is espe- 
 cially frequent among the poor and ill-fed. It is also common as a 
 sequel of several of the infectious diseases, especially scarlet fever, 
 measles, and whooping cough. 
 
 One of the worst features of this complaint is the tendency to 
 recur. After it has been once cured the patient is apt to suffer 
 from it again at intervals. 
 
 Treatment, — The first consideration of treatment is to put 
 the patient in the best possible condition for health. He frequently 
 needs tonics, exercise and recreation as much as if he were suffer- 
 ing from some severe constitutional disturbance. For this purpose 
 we may order one of the following prescriptions : 
 
 Extract of cinchona, - - - - Twenty grains. 
 
 Extract of nux vomica. . _ . Four grains. 
 
 Reduced iron, ----- Ten grains. 
 Mix and make twenty pills ; take one before meals. Or the fol- 
 lowing may be given : 
 
 Dilute nitro-muriatic acid, - - Six drachms. 
 
 Compound tincture of cinchona, - Two ounces. 
 
 Water to make four ounces. 
 Take a teaspoonful before meals. 
 
 In the local treatment of the eyelashes, one of the most 
 important elements is cleanliness. The edges of the lids should be 
 bathed with warm water three or four times a day, or oftener if 
 nece.^sary, to keep them perfectly clean ; at night after washing the 
 lids, the edges should be smeared with the following ointment; 
 
 Ointment of the nitrate of mer-'ury, - Fifty grains. 
 
 Vaseline, _____ Half an ounce. 
 
 This may be allowed to remain during the night, and washed 
 ofif in the morning ; after washing, the following lotion may be 
 applied: 
 
 Alum, _---_- Four grains. 
 
 Sulphate of zinc, _ . - - Two grains. 
 
 Water. --_.__ Two ounces. 
 If there be much discharge, this lotion may be applied several 
 times during the day also. 
 
 If the lashes be long, they should be trimmed closely with 
 scissors, in order that th^y may be kept clean more readily, and 
 that the ointment m.y penetrate well into the hair follicles. 
 
STYE. 
 
 619 
 
 In mild cases, this plan of treatment will be sufficient to effect 
 a cure in about two weeks. But if there be ulcerations and pim- 
 ples containing matter around the lashes, it will be well to apply 
 every morn'ng after washing the lids the following solution: 
 
 Nitrace of silver, _ _ . Xen grains. 
 
 Water, - - _ - _ One ounce. 
 
 A soft camel's hair brush should be dipped into this solution 
 and then applied to the little ulcers at the roots of the hairs. If 
 this does not suffice to prevent further ulceration, the sore places 
 may be touched with a pointed stick of the nitrate of silver. 
 
 In using this nitrate of silver, care should be taken that the 
 point touches only the raw spots and is not smeared over the 
 healthy skin. This should not be done more than two or three 
 times a week. 
 
 When the edge of the lid is raw and ulcerated between the 
 hairs as well as around them, we may apply a lotion containing 
 boracic acid: 
 
 Borax, 
 Lead water, 
 Glycerine, 
 Water, 
 
 One drachm. 
 Four drachms. 
 Two ounces. 
 Two ounces. 
 
 Stye. 
 
 A stye is merely a small boil located on the edge of the lid. 
 It seems to begin, in most cases, in a hair follicle. The affection is 
 so familiar that no description is necessary. 
 
 Trentment. — At the first indication that a stye is forming, it 
 is sometimes possible to prevent, or at least mitigate it by touching 
 the point gently with a siick of the nitrate of silver. It is, at any 
 rate, well to try this, since no injury is done, even though it may 
 fail to accomplish the desired object. 
 
 As soon as it becomes evident that the stye is too far advanced 
 to be arrested, the object should be to hasten the formation of 
 matter. The best means for accomplishing this is the application 
 of warmth and moisture. This may be done by applying a soft 
 cloth saturated with hot water, or by making a small linseed 
 
 
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 620 
 
 DISEASES OF THE EYE AND EAR. 
 
 
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 poultice. So soon as matter appears at the surface it will be well, 
 in Older to shorten the patient's discomfort, to open the boil and 
 squeeze out the contents. 
 
 Some persons are troubled with a succession of styes, which 
 follow one another at short intervals. Such individuals will In: 
 benefited by a tonic, and by regular evacuation of the bowels. 
 The following prescription may be administered : 
 
 Half a drachm. 
 
 Four drachms. 
 
 Six drachms. 
 
 One ounce. 
 
 To make four ounces. 
 
 Sulphate of quinine, 
 Dilute nitro-muriatic acid. 
 Tincture of the chloride of iron. 
 Syrup of tolu, . . - 
 Water, . . . . 
 
 A teaspoonful of this ma^ jc taken in a tablespoonful of water 
 before meals. 
 
 For children the following prescription will be beneficial : 
 
 Powdered cinchona, - - - Half a drachm. 
 Bicarbonate of soda, - - - Half a drachm. 
 White sugar, - - - . Forty grains. 
 
 Mix and make twelve powders ; one of these may be taken morn- 
 ing and night. 
 
 Smaller children will find the following mixture more pal- 
 atable: 
 
 Tincture of gentian, 
 Dilute muriatic acid, 
 Syrup of orange peel, 
 Peppermint water, - 
 
 Four drachms. 
 Four drachms. 
 One ounce. 
 To make four ounces. 
 
 A teaspoonful may be given in water before meals. 
 
 If the child be pallid and bloodless, the following prescription 
 may be ordered instead of the last : 
 
 Citrate of iron and quinine, - - Forty grains. 
 Syrup of tolu, . _ . . One ounce. 
 
 Water, - - - ... Three ounces. 
 
 A teaspoonful of this may be taken at meal-time. 
 
 When the skin of the cheeks is raw and sore, and the edt;cs of 
 the lids are extensively ulcerated, benefit will be derived from tbe 
 use of Fowler's solution, three or four drops of which in.i) be 
 taken in water twice a day. 
 
INFLAMMATION OF THE TEAR-DUCT. 
 
 621 
 
 After the formation of pus at the edj^es of the lids has ceased, 
 they should be bathed with the lotion and smeared at night with 
 the mercury ointment, as directed above. 
 
 Tumors of the Eyelids. 
 
 There are frequently formed, near the edge of the upper lid, 
 minute lumps, varying in size from a pin's head to that of a pea. 
 These little tumors occasion no pain, but are the source of consider- 
 able annoyance to the person's vanity. They often occur in 
 "roups — two or three of them being found near together on the 
 same lid. They may sometimes attain such a size as to interfere 
 with the movement of the lid, and to prevent the eye from opening 
 to its full extent. 
 
 These feel to the finger Hke small shot under the skin. 
 Sometimes they are soft, and at other times quite hard, so that the 
 patient is inclined to be anxious in regard to them. 
 
 These tumors grow very slowly, and may last for several years. 
 
 These masses are merely collections of matter in the follicles 
 which surround the eyelashes. They are, therefore, essentially of 
 the same nature as luetts on the head. 
 
 Treatment. — There is but one way to get rid of these little 
 tumors, and that is to open them and remove their contents. This 
 will scarcely be undertaken by any one but a surgeon, since it is 
 unsafe for an unskilled hand to bring a knife into the vicinity of the 
 eye. The operation is a trivial one, and the cut can be made from 
 the under surface of the lid, so that no scar will be visible. It will 
 be therefore advisable for any one to whom the personal appearance 
 is a matter of importance to have these little bodies removed. 
 
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 Inflammation of the Tear-Duct. 
 
 This is a frequent and an annoying affection. The tear-duct, 
 it will he remembered, is a small channel which runs from the inner 
 corn'jr of the eye, next to the bridge of the nose, down the inside 
 of the nt)se, and terminates in the nostril. Under ordinary circum- 
 stances, the moisture which is constantly secreted in the eye to keep 
 
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 1- vi 
 
 
 622 
 
 DISEASES OF THE EYE AND EAR. 
 
 it moist and its movements free, escapes into this little channel and 
 runs down into the nostril. It is a familiar observation that a cry- 
 ing fit often begins with a necessity for the repeated use of the 
 handkerchief, since the increased flow of tears can for a time escape 
 through the natural channel into the nose; it is only when the tears 
 flow so profusely that they cannot find immediate exit through the 
 natural channel that they overflow the lids. 
 
 Several causes may operate to close this channel into the nose. 
 A disease of the bone of the nose, such as often results from con- 
 stitutional syphilis, may obstruct the tear-duct. A more common 
 cause, perhaps, is an inflammation resulting from exposure to cold. 
 
 Symptoms. — One of the first symptoms perceived by the pa- 
 tient is the flowing of the tears over the lid. Indeed, in many cases, 
 this is the only symptom complained of, and this may have lasted for 
 years before the patient seeks medical advice. But, sooner or later, 
 there usually occurs a feeling of tenderness and pain in one side of 
 the nose, near the angle of the eye; the escape of the tears over the 
 lid is much increased. In a few days a decided swelling becomes 
 apparent at the tender spot on the nose; the skin over the spot is red 
 and sore. The swelling, redness and soreness may be so great that 
 the patient and his friends believe that he has erysipelas. After a 
 time there usually occurs a formation of matter at the swollen 
 point; and unless properly and promptly treated, this matter breaks 
 out through the skin, making a ragged and ugly opening, and one 
 which it is extremely difficult to heal. This accident may be antici- 
 pated if the patient experiences a sudden sense of relief from the 
 intense pain which he has experienced during the previous days. 
 
 In some cases the swelling extends from the side of the nose to 
 the eyelids, which become so swollen and puff"ed that the eye can- 
 not be opened. 
 
 If the disease be allowed to run its course without treatment, 
 the matter which has formed finally discharges spontaneously, tlic 
 inflammation subsides and the parts regain their natural appear- 
 ance ; but in most cases a small opening remains at the side of the 
 wound. Tliis communicates with the tear-duct and through it the 
 tears constantly escape onto the cheek. The result of this constant 
 irritation is a soreness and rawness of the skin — eczema 
 
 Treatment. — During the early days of the attack, the treat- 
 ment must consist in measures which shall prcmiotc the formation 
 
 l-l ii 
 
ARTIFICIAL EY?:s. 
 
 621 
 
 of matter, since it is usually impossible to prevent matter from form- 
 in^r. The patient will experience most relief from the applications 
 of hot fomentations, either as cloths wrung out of hot water or 
 as linseed poultices. These should be changed frequently, say 
 every two or three hours, in order to keep the inflamed skin moist 
 and warm. 
 
 As soon as it becomes evident that matter has formed, an open- 
 ing must be made to permit the pus to escape. This is far better 
 than to wait until the matter breaks through the skin spontaneously, 
 since the scar left by the knife will be smaller and less ragged than 
 the one which will otherwise be produced. The surgeon who 
 makes the opening will probably find it necessary to pass silver 
 probes through the tear-duct in order to open the channel and keep 
 it enlarged so that no further obstruction shall occur. In most cases 
 considerable difficulty will be experienced in persuading this open- 
 ing to heal, since the tears will escape constantly from the duct and 
 keep the wound from healing. 
 
 Artificial Eyes. 
 
 Many causes make it necessary to remove the entire eyeball. 
 It is unnecessary to specify these in detail, since the diseases are 
 almost invariably of such serious nature as to require the services of 
 a surgeon even before the operation becomes imperative. People 
 should understand that it is often absolutely essential to the life as 
 well as to the health of the patient that an eye be removed ; and 
 this, too, although the eye may look from the outside quite natural. 
 It has been already stated that the presence of a foreign body, such 
 as a particle of steel or stone in the eye, often endangers the sight of 
 the other eye as well as of the one which has been injured. In 
 such cases it is often advisable to remove the eye. There are also 
 cases in which a cancer grows in the back part of the eye, without 
 causing for a long time any unnatural appearanct^ which can be 
 seen from the outside. Under such circumstances, it is difficult for 
 the friends as well as for the patient to understand the necessity for 
 the removal of the eye ; but in every case the advice and opiiiion oi 
 the eje surgeon should be adopted. A neglect to have such an e\ v' 
 removed will usually result not only in a painful disease of the eye, 
 
 
Si 
 
 I ; 
 
 T ■, 
 
 624 
 
 DISEASES OF THE EVE AND EAK. 
 
 but also in an extension of this disease to the brain, whereby death 
 will be induced. 
 
 After an eye has been removed, it is advisable to substitute 
 foi- it an artificial eye, both for the cosmetic effect and for the pro- 
 tcction of the parts beneath. Artificial eyes consist of a thin layer 
 of enamel, colored so as to imitate the natural eye. These are 
 made so as to be very light, smooth and unirritating ; they consist 
 merely of a shell, which can be retained in position between the 
 lids. In many cases the resemblance to the natural eye is so per- 
 fect that the artificial nature is not detected. The writer once 
 heard a noted eye surgeon relate how he had dined at the same 
 table for six months with a gentleman who wore an artificial eye, 
 although the surgeon had never noticed the fact, nor even enter- 
 tained any suspicion that such was the case. When informed that 
 one of the gentleman's eyes was false, the surgeon was puzzled for 
 a few moments to decide which wars the artificial eye, so close was 
 the resemblance. These are, however, exceptionally successful 
 imitations. In many cases the artificial eye will not be recognized 
 unless attention is directed to it ; but in other instances, attention 
 is attracted by the fact that the artificial eye does not move as the 
 other one does. The amount of motion depends upon how much 
 of the eye has been removed. In those cases in which only the 
 front of the eye is taken away by the operation, the part which 
 remains — the stump — is freely movable, because the muscles 
 which move the eyeball are retained and grow fast in the stump. 
 The artificial eye lies upon the stump, and is moved with it. 
 If, however, so much of the eye must be removed that the part 
 remaining is too small to carry the glass eye, the latter is held 
 in position by the lids, and remains motionless. This is also the 
 case, of course, when the entire eye is removed. 
 
 The advantages of an artificial eye are as follows: It conceals 
 to a greater or less extent a deformity which is otherwise annoying 
 to the patient and often distressing to the beholder ; it is of great 
 service in maintaining the natural position and form of the lids ; it 
 prevents the lashes from irritating the shrunken eye ; it serves as a 
 defense against foreign bodies which are apt otherwise to get into 
 the eye and produce irritation ; it is also of great benefit in keeping 
 the openings of the tear-ducts in proper position, so that the tears 
 can be conducted away into the nostril. 
 
 The disadvantage of artificial eyes consislH in the irritation 
 
 Siii , ( 
 
ids ; it 
 :s as a 
 
 itation 
 
 ARrillCIAL KYLS. 
 
 625 
 
 *vhich may be caused by the glass. This is sometimes sufficient to 
 induce a chronic state of inflammation, which renders the eye 
 somewhat tender and causes a slight discharge of mucus. This 
 can usually be avoided if eyes of the best manufacture be obtained, 
 since the irritation is dependent usually upon the roughness of the 
 cd"cs of the eye, which is induced by the corrosive action of the 
 secretions. When properly made of the best materials, the eye 
 resists this corrosive action and remains smooth and unirritatingfor 
 a very long time. 
 
 Six or eight weeks should be permitted to elapse after the 
 removal of the eye before an artificial eye is introduced. This 
 interval is necessary in order to permit the wound to heal perfectly 
 and all swelling and irritation to subside. If the eye be introduced 
 too soon, there is apt to remain an irritation and discharge which 
 proceeds from some part where the wound had not entirely healed, 
 which is kept open by the eye. 
 
 The following directions are given at the Royal London Eye 
 Hospital to those who have had the misfortune to lose an eye : 
 
 INSTRUCTIONS FOR PERSONS WEARING AN ARTIFICIAL EYE. 
 
 To Take the Eye Out. — The lower eyelid must be drawn 
 downward with the middle finger of the left hand, and then with 
 the li^dit hand the end of a small bodkin must be put beneath the 
 Idwcr edge of the artificial eye, which must be raised gently for- 
 ward over the lower eyelid, when it will readily drop out. At this 
 time care must be taken that the eye does not fall on the ground 
 or other hard place, as it is very brittle and may be easily broken 
 by a fall. 
 
 To Put the Eye In. — Place the left hand flat upon the fore- 
 head with the fingers downward, and with the two middli rtngi is 
 raise the upper eyelid toward the eyehr iw ; then with ''he right 
 haml push the upper edge of the artificial e> <_ oeneath liC upper 
 eyelid, which may now be allowed to drop upon the i-»,e. The 
 eye must then be supported with the middle finge'^ of the left 
 iiand, while the lower eyelid is raised :>ver the lovvf dge with the 
 rii,dit hand. 
 
 The eye should be carefully washed ev«>r^ ^l^^ht upiMl fvmoval, 
 and may be allowed to lie during the nigtii m watei ctxitaming .1 
 
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 626 
 
 DISEASES OF THE EYE AND EAR. 
 
 little baking soda ; in this way the mucus and secretions wliicli 
 have adhered to the eye will be loosened, and may be readily 
 detached in the morning. 
 
 DISEASES OF THE EAR. 
 
 The essential parts of the ear are three in number : the extcnial, 
 the middle and the internal ear. The external ear comprises tlie 
 fleshy part of the organ situated outside of the skull and a channel 
 hollowed out of the bone and running into the head, called the 
 auditory meatus. The fleshy part of the ear seems to have no 
 especial value in man except as a means of disi)layiiig ornaments. 
 It represents in rudimentary form the somewhat elaborate and 
 movable structures which are so useful to many of the lower ani- 
 mals. The human ear is also provided with muscles, which, how- 
 ever, are mere reminiscences of the muscles which were probably 
 useful to man before he attained his present state of development ; 
 at any rate they are of no service in the human animal, though \vc 
 meet, now and then, with a man who possesses a slight ability to 
 move the ears. 
 
 The auditory meatus, the bony channel which leads from the 
 exterior to the middle ear, is of considerable importance to the 
 surgeon, since it becomes the seat of many difficulties which may 
 impair the patient's comfort and health quite materially. 
 
 Foreign Bodies in the Ear. 
 
 Foreign substances of various kinds are frequently found in the 
 external ear. These are especially often met with in children, who 
 seem to have an irresistible desire to insert small articles into the 
 orifice, presumably in order to find out what will become of them. 
 The substances which in this way find entrance in the ear present 
 a most remarkable variety ; the favorite articles are beads, peas, 
 beans and small nuts, but the monotony is varied by using pieces of 
 wood, slate pencils, and indeed anything which comes first to hand 
 when the desire for exploration seizes the child. 
 
fiiil -A vifw of lliu Labyrinth ill nil inverted position, 
 lai(l-"Iii'" *u a** '*' *'l"i^^' the ilistrlbutlou of the nerves. 
 
 5S4.— A view of the Left Ear in its 
 natural state. 
 
 602— A view of the I.abyrinth of the loft side laid open io 
 W-.-A luglilyniagnitie,! view of the e.xternal "* "^^"'^ ^^'^"'' ''^ **" ^ ^""^^' *'« structure-magnitied. 
 faceoftlu' lioiiy l.iiliyi'iiitJiofthelel'tside.oiHJiied 
 soubloexposethe Vestibuleaiid itn contents, etc. 
 
 . , 612.— A vertical section of the Cochlea, highly niiigni 
 
 -AH imaginary figure or plan of the Cochlea. fled, to show the arrangeineiit and connection of its pacta 
 
 41 
 
 E^R 
 
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 ! il 
 
 J! 
 
 !,' Ji fIWi 
 
FOREIGN HODIES IN THE EAR. 
 
 627 
 
 In many cases the presence of this body in the ear is not dis- 
 covered for some time ; not, indeed, until the child's deafness calls 
 attention to the existence of something wrong in the car. In other 
 cases the foreign body excites an irritation, which causes the child 
 to complain of pain, and often induces an inflammation, accom- 
 panied by a " running " from the ear. At other times this foreign 
 boilv excites no immediate difficulty, becomes incrusted with wax, 
 and remains in the ear for years. 
 
 On the other hand, parents and friends are ofien mistaken in 
 supposing that some foreign substance has lorlj.ed in the car. If 
 the child complain of a " buzzing " in the ear, the friends arc often 
 disposed to believe that some foreign substance has found its way 
 into tiie channel, and refuse to be convinced to the contrary. If 
 this buzzing be very loud, they usually think at once of some insect 
 as the probable cause of it. Now the fact is that a buzzing or roar- 
 in" sound in the ear is a frequent symptom of many affections, some 
 of which involve the ear only, while others have nothing to do with 
 this organ. There are various conditions of the system in which the 
 patient fancies he hears a roaring sound continually — a fact which 
 should be borne in mind by those who are incapable of imagining 
 any other cause for a buzzing in the ear than the presence of a fly. 
 
 Much injury has been done by rough and ignorant efforts to 
 extract supposed foreign bodies from the ear when none actually 
 existed ; for at the extremity of the bony channel there are situated 
 some of the delicate organs which are necessary for perfect hearing, 
 and the attempt to remove foreign bodies from the bony channel 
 may easily injure some of these parts, and even destroy the hearing 
 entirely. 
 
 Treatment, — If the foreign body can be distinctly seen from 
 the outside, a gentle attempt to extract it may be made by using a 
 pair of fine pincers (forceps). Great care should be used not to 
 injure the skin of the part by clumsy use of the instrument. 
 
 If no foreign substance can be seen in the ear, no attempt to 
 extract it with instruments should be made except by a surgeon. 
 In most cases the body can be removed by syringing the ear with 
 warm water. In order to accomplish this, a large syringe, holding 
 say six or eight ounces, should be filled with lukewarm water ; this 
 is held in one hand, the nozzle of the instrument being placed 
 against the upper part of the opening of the ear, so that the stream 
 
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 23 WEST MAIN STREET 
 
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 (716) 872-4503 
 
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 628 
 
 DISEASES OF THE EYE AND EAR. 
 
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 of v/ater shall flow along the roof of the channel and be permitted 
 to return along the lower part. The operation will be facilitated 
 by raising the fleshy part of the external ear. To accomplish this, 
 three fingers of the left hand may be steadied against the patient's 
 head, while the upper part of the rim of the car is grasped between 
 the thumb and finger of the same hand. The ear is then gently 
 raised and pulled slightly backward, whereby the channel of tlic 
 ear is rendered somewhat straighter, and the escape of a foreit,'n 
 body is facilitated. The water should be forced into the ear with 
 only a gentle pressure on the piston; if too much force be used 
 the delicate structures of the internal ear may be injured. 
 
 The syringing may be continued five or ten minutes ; if at the 
 end of that time no foreign substance has been removed, the effort 
 may be discontinued and repeated again several hours later. More 
 than this it is not advisable for a non-professional hand to attempt, 
 since the removal of foreign bodies from the ear sometimes taxes 
 the skill of the surgeon. After syringing, the ear should be dried 
 with a towel and a little plug of cotton placed in the opening for a 
 few hours. 
 
 The syringe selected should work easily and accurately, so 
 that no air bubbles need be forced into the ear; if the piston be 
 loose, so that air enters with the water, the operation is apt to be 
 extremely unpleasant to the patient. 
 
 The patient's clothing should be protected by towels placed on 
 the shoulder and tucked in behind the collar ; a basin should be 
 held close to the ear and touching the head so that the water may 
 run back into the vessel and not escape down the patient's neck. 
 T' e basin which is used for this purpose should be a separate one 
 from that which contains the water to be injected, so that this 
 water may remain clean and not become soiled with the matters 
 which are washed out of the ear. 
 
 Wax in the Ear. 
 
 One of the commonest causes of deafness is an accumulation 
 of wax in the bony channel of the ear. The wax which is naturally 
 formed in the ear, is ordinarily removed suflSciently by the ordinary 
 attention of the patient to his toilet. It is quite unnecessary for 
 people to use " ear spoons," hairpins and the like in order to remove 
 
FOREIGN HODIES IN THE EAR. 
 
 629 
 
 the wax from the ear ; for so long as the parts remain healthy, the 
 wax will be properly removed in the ordinary course of nature 
 without any care on the part of the patient. These ear spoons, in 
 fact, frequently favor the accumulation of wax in the ear by irritat- 
 ing the surface so that the wax formed is no longer soft and natural, 
 bvit becomes thick and hard — a condition which favors its retention 
 and accumulation in the ear. 
 
 The conditions which cause the wax to change its quality so 
 as to remain and accumulate in the ear, are not all known. Any- 
 thing which causes a prolonged irritation of the skin of these parts, 
 seems to cause the wax to harden and thus to prevent its escape. 
 
 Syniptomft, — The presence of wax in the ear usually induces 
 a gradual impairment of hearing. In most cases there occurs after 
 some time a persistent buzzing or roaring noise in the ear, which 
 may be so severe as to disturb the patient's sleep. Yet, if there be 
 no other unnatural condition present than the mere accumulation of 
 wax, there will probably be no pain. In this way we may distin- 
 guish this affection from several others which are accompanied by 
 deafness and roaring in the ears, in which pain is a constant and 
 prominent symptom. 
 
 The extent to which wax may accumulate in the ear in some 
 cases, is quite remarkable ; a hard black mass is found filling up 
 the entire ear quite to the surface. Cases are known in which a 
 patient has supposed himself permanently deaf, having suffered a 
 gradual loss of hearing years previously, yet the difficulty has been 
 found to be merely an accumulation of wax in the ear, the removal 
 of which restored the person's hearing perfectly. 
 
 Treatment. — The treatment for an accumulation of wax in 
 the ear is essentially the same as that already directed for the 
 removal of a foreign body. The ear must be gently syringed with 
 hot water, the details previously mentioned being most scrupu- 
 lously observed. It wiU be advisable to add to the water a little 
 borax or baking soda, in order to soften the wax and thus render 
 its escape easier. We may employ the following mixture : 
 
 Borax, ----- Half an ounce. 
 
 Water, ----- One pint. 
 
 This should be heated so that it feels sotnewhat unpleasantly warm 
 to the patient at first, and should be injected into the ear in such a 
 
 1! 
 
 i 
 
 
630 
 
 DISEASES OF THE EYE AND EAR. 
 
 r 
 
 way as to permit the escape of the water and the wax. If the first 
 syringing be unsuccessful, the process may be repeated once or 
 twice at intervals of several hours. 
 
 If the accumulated wax be in the shape of a plug, as it often 
 is, it will probably be loosened by the syringing and be forced to 
 the orifice of the ear. As this opening is somewhat smaller than 
 the interior of the channel, it may be necessary to extract the plug 
 by means of a forceps. This should be done carefully, without 
 forgetting the possibility of injuring the parts by the instrument. 
 In other cases the wax accumulates at the inner end of the channel, 
 on the surface of the delicate membrane which separates the exter- 
 nal from the internal ear. In this case the removal of the wax will 
 be a somewhat more difficult and tedious matter, which can scarcely 
 be accomplished without the assistance of a surgeon. 
 
 After the wax has been 'removed the surface of the skin in the 
 auditory meatus will be for some days quite sensitive and tender; 
 it is advisable, therefore, to insert into the canal a small plug of 
 cotton which has been well smeared with vaseline. This nay be 
 worn for several days, being changed for fresh cotton each day. A 
 patient who puts cotton into the ear should not forget to remove it ; 
 sometimes these accumulations of wax are found to have been 
 started by a plug of cotton which had been inserted and allowed to 
 remain in the ear by a careless person. 
 
 Running from the Ear. 
 
 \i,i 
 
 At the. end of the bony channel which constitutes the outer 
 part of the ear, there is placed a delicate curtain or membrane, which 
 hangs across this bony channel and closes it completely. This is 
 the membrane of the drum of the ear. On the inner side of this 
 curtain is a cavity hollowed out in one of the bones of the skull, in 
 which some of the most delicate structures concerned in the act of 
 hearing are located. This bony cavity is called the " middle ear, " 
 or the drum of the ear. This cavity is lined with mucous mem- 
 brane and communicates by a bony channel with the throat. This 
 bony channel, called the eustachian tube, serves as a means for 
 establishing a communication of air between the throat and the 
 middle ear. It is extremely important that this channel remain 
 
RUNNING FROM THE EAR. 
 
 631 
 
 Open and pervious to air, since if it become closed, the hearing is 
 apt to be impaired. The opening of the eustachian tube into the 
 throat remains closed most of the time, but is opened by the act of 
 swallowing. If air be forced into the throat, therefore, at the same 
 time that the patient swallows, it will find its way into the eusta- 
 chian tube, then through this into the middle ear. Advantage is 
 taken of this fact in treating diseases of the middle ear ; by forcing 
 the vapors of medicines into the nose while the patient is in the act 
 of swallowing, we may cause these vapors to pass directly into the 
 drum of the ear. 
 
 The channel which extends between the throat and the middle 
 ear — the eustachian tube — is important not only because of its 
 value in maintaining the hearing, but also in enabling us to under- 
 stand some of the diseased conditions which are found in the 
 middle ear, for an inflammation which affects the throat frequently 
 extends through this tube into the middle ear. If the inflammation 
 in the throat be a severe and violent one, such as occurs in scarlet 
 fever and diphtheria, the inflammation in the ear will probably be 
 also a severe one, resulting in the production of considerable matter. 
 If the inflammation in the throat be merely a slow and mild 
 afitection — a "catarrh" of the throat — the process which is 
 originated by it in the ear will probably also be a mild affection, 
 which is known by physicians as " catarrh of the middle ear. " 
 
 A " running from the ear " is almost always caused by an 
 inflammation in the drum of the ear which has resulted in the pro- 
 duction of matter. Now, the drum of the ear is a very small cavity, 
 scarcely large enough to hold a bean ; hence it takes but a very 
 small amount of matter to fill this cavity completely. So soon as 
 the drum of the ear is full of matter, considerable pressure is 
 exerted upon the nervous structures situated in the membrane 
 which lines the drum ; for since the matter is confined within the 
 cavity of the drum, it can find room only by pressure upon the 
 walls of that cavity. The result of this pressure is intense pain. 
 This pain becomes agonizing so that the patient cannot sleep nor 
 divert his thoughts for a moment from the torture which he experi- 
 ences in his ear. After several hours or days of agony, the per- 
 son experiences sudden relief; the pain ceases almost or quite 
 entirely, and at the same moment there is a gush of matter from 
 the ear. This sudden relief is occasioned by the bursting of the 
 delicate membrane — the membrane of the drum — which has 
 
 \\ 
 
 11 Ji ' ,.?> 1 
 
632 
 
 DISEASES OF THE EYE AND EAR. 
 
 hitherto been sufficiently strong to keep the matter confined within 
 the drum. The opening in the membrane may vary in size and 
 shape, but suffices to permit a free discharge of the matter which 
 would otherwise accumulate in the cavity of the ear. This matter 
 is formed continuously in the drum of the ear and escapes con- 
 stantly through the opening in the membrane of the drum into the 
 external ear, and finally onto the neck. A running from the car, 
 therefore, is usually a sign that there has been an inflammation in 
 the drum of the ear which has resulted in the escape of matter 
 through the bursting of the head of the drum. 
 
 Inflammation of the Drum of the Ear. 
 
 This affection is especially frequent in children, particularly 
 among scrofulous persons ; it is also a frequent sequel of scarlet 
 fever, measles and diphtheria. 
 
 Sifitiptoins, — The symptoms indicating the beginning of the 
 affection vary somewhat with the cause of the inflammation. In 
 those cases in which the affection follows scarlet fever and measles, 
 the symptoms which mark the beginning of it may be less severe 
 and pronounced than is otherwise the case. 
 
 In many cases inflammation of the drum of the ear begins 
 without apparent cause. In some it results apparently from expos- 
 ure to cold. It is especially frequent after a cold wind has been 
 allowed to blow directly upon the ear, or after the individual has 
 been sitting in a draught. 
 
 The first manifestation is a slight sense of deafness and uneasi- 
 ness in the ear. This is often followed by a decided chill, after 
 which the patient becomes quite feverish. Headache, a thick coat- 
 ing on the tongue, etc., the usual accompaniments of fever, may 
 be present. Meanwhile the pain in the ear becomes more and more 
 severe, until it is finally excruciating. If the patient be a child, he 
 cries constantly, complains of the ear, cannot eat or sleep. If it 
 occur in an adult, the individual is compelled to give up his occu- 
 pation entirely, and soon shows by his pallor and by the pinched 
 expression of his face that his suffering is extreme. The affected 
 ear is for the time being perfectly deaf. 
 
 This condition lasts until the head of the drum gives way from 
 the pressure of the matter confined behind it. This is a moment 
 
INFLAMMATION OF THE DRUM OF THE EAR. 
 
 633 
 
 of siipt'cme relief to the patient. The pain which has rendered his 
 life a torment for several days suddenly subsides. In most cases 
 the patient drops into a refreshing slumber within a short time after 
 the pain has been thus relieved. 
 
 The matter which gushes from the ear at the time of the burst- 
 ifijr of the membrane is extremely thick and yellowish. After a 
 (lay or two it may become somewhat thinner and less profuse, but 
 it is apt to persist for weeks. Indeed, if neglected and allowed to 
 (TO without treatment, this running from the ear may annoy the 
 patient for years. In fact, many individuals become so accustomed 
 to it that they cease to think about it at all. It is not uncommon 
 to find persons who have had a running from the ear since child- 
 hood, and who have never sought advice or treatment. 
 
 It is one of the curious popular fancies that a discharge from the 
 ear, which has already lasted for some time, is supposed to be quite 
 necessary to the person's health. Any suggestion by the physician 
 to the effect that measures should be taken to stop a discharge from 
 the ear in a child is often met by the alarmed remonstrance of the 
 parents, who fear all sorts of imaginary evil from what they term 
 " driving in " the discharge. 
 
 It must be stated most emphatically that such a notion is quite 
 erroneous and without foundation of any sort. It is indeed highly 
 desirable that a discharge from the ear should be stopped as early 
 as possible ; for, if no measures are taken to relieve the condition 
 which causes this discharge, loss of hearing in the affected ear is 
 certain to occur. If, therefore, there be any chance of saving the 
 hearing, it will be necessary to adopt the most energetic measures 
 at the earliest possible moment for stopping the discharge. It 
 might be mentioned as an additional inducement to cure this diffi- 
 culty, that a long-continued discharge is sure to cause rawness and 
 soreness of the skin in the auditory meatus, as well as on the adja- 
 cent parts of the face and neck. 
 
 Ti'eatnient, — Whenever the symptoms above described occur 
 in an adult, an inflammation of the drum of the ear is probably 
 present. In children it is sometimes difficult for a non- professional 
 person to detect the existence of this affection until the matter 
 breaks out of the ear, for there are no signs on the outside of the 
 head or ear by which the formation of matter in the drum of the 
 ear can be detected. Moreover, the symptoms are sometimes so 
 severe as to direct attention to the brain rather than to the ear, for 
 
 
 i 
 
 iiii 
 
«34 
 
 DISEASES OF THE EYE AND EAR. 
 
 ft i tl 1 
 
 convulsions and delirium may occur. In general it may be said 
 that if the pain be of a throbbing character, the affection is 
 probably in the middle ear. 
 
 At times, this inflammation causes the death of the patient by 
 spreading to the membranes which cover the brain, for there is 
 only a very thin shell of bone between the cavity of the middle car 
 and the cavity in which the brain rests. 
 
 Treatment, — An inflammation in the drum of the ear should 
 be treated promptly and energetically. In former days it was the 
 custom to apply three or four leeches around the external ear, 
 especially over the bony prominence just behind the ear. In these 
 latter days leeches are not so fashionable ; but surgeons frequeiitlv 
 scarify ih\?> part of the skin — that is, make a number of fine cuts 
 so as to permit a flow of blood. This should not, however, be 
 undertaken by any one except the surgeon. 
 
 The remedies which may be adopted in the household are, first, 
 hot fomentations to the ear and its immediate vicinity. Cloths 
 should be saturated with water as hot as the patient can bear and 
 applied to the ear ; these should be covered with oiled silk or rub- 
 ber sheeting, so as to keep the cloth warm, and the fomentation 
 should be changed frequently — even every half hour if necessary 
 — in order to keep the parts constantly moist and warm. 
 
 The comfort of the patient will be further promoted by fre- 
 quent injections of hot water into the ear. These will be best 
 made by the use of a fountain syringe. Numerous forms of foun- 
 tain syringes — most of them made of rubber — are to be found in 
 the market. If none of these can be procured, a fountain syringe 
 can be extemporized by hanging a small vessel containing the hot 
 water two or three feet above the patient's head ; a rubber tube is 
 then arranged as a syphon so as to conduct the water to the orifice 
 of the ear. A stream of hot water may be allowi-'d to flow t^cMitly 
 into the ear for fifteen minutes at a time. This injection may be 
 repeated every hour, or even less. After the injection the follow- 
 ing mi.xture may be employed : 
 
 Laudanum, . - . . _ One ounce. 
 
 Glycerine, ----- One ounce. 
 
 Water, ------ Two ounces. 
 
 A teaspoonful or two of this may be poured into the ear, after 
 which a small plug of cotton is applied so as to retain the liquid. 
 
INFLAMMATION OF THE DRUM OF THE EAR. 
 
 635 
 
 If the patient be feverish, a hot bath will be beneficial. In any 
 case, care should be taken to secure free evacuation of the bowels, 
 for which purpose a teaspoonful of the citrate of magnesia may 
 be taken. 
 
 It frequently becomes necessary to administer opium in order 
 to quiet the pain. If the patient be a child over five years of age, a 
 teaspoonful of paregoric may be given. This should be repeated in 
 one or two hours if the pain is still severe. In this case, as in every 
 other, it must not be forgotten that children are especially sus- 
 ceptible to the action of opium in any form, and that great care 
 must be observed in administering it to them. If these measures 
 do not give relief, the following ointment may be "»pplied to the 
 skin over the bony prominence just behind the ear : 
 
 Veratria, ----- Fifteen grains. 
 Vaseline, ----- One ounce. 
 
 It is sometimes possible to check the inflammation by these 
 means, so that the affection subsides without causing the membrane 
 of the drum of the ear to give way; but in the majority of cases the 
 inflammation results in the production of so much matter that this 
 membrane becomes softened and gives way. 
 
 After this has happened, injections of warm water into the ear 
 should be made five or six times a day, or even oftener if necessary 
 to keep the parts clean. After the first two or three days, we may 
 employ to advantage the following injection, which will tend to 
 diminish the production of matter, as well as to increase the comfort 
 of the patient : 
 
 Listerine, - - - - - 
 Glycerine, ----- 
 Water, 
 
 After the ear has been washed out with hot water, a tablespoon- 
 fu! of this may be injected slowly into the cavity. This injection 
 may be repeated three or four times a day. 
 
 Treatment of *^ Running from the Ear.** — After the 
 ear has discharged for many months or years, it is often a trouble- 
 some and difficult undertaking to arrest the formation of matter 
 completely. In many cases there is a growth of " proud flesh " in 
 the ear, which keeps up a constant discharge. If this be the case, 
 the matter must be referred to a competent surgeon, since the 
 
 - One ounce. 
 
 - Two ounces. 
 
 - Three ounces. 
 
 ^n.-, 
 
 
 
 m\ 
 
 ■ail 
 
 fir I '11 IKK 
 
 ^- 
 
 
 
636 
 
 DISEASES OF THE EYE AND EAR. 
 
 { •! 
 
 4^ 
 
 removal of this proud flesh is an iindcrtakinji requiring skill and 
 care. In many other cases, however, it is possible to stop the 
 discharge by simple injections into the ear. It will be, thcrcfnii-, 
 advisable to try the effect of these simple measures first. 
 
 The first item of treatment is perfect ciiuinliniss. The ear 
 must be syringed out as often as is necessary to keep the parts 
 clean. This may be done with simple warm water. 
 
 Four or five times a day there may be used the following 
 injection : 
 
 Listerine, ..... One ounce. 
 
 Tannic acid, - - - . . Three drachms. 
 Water, . . . . . Five ounces. 
 
 An ounce of this may be user! for an injection ; the sdution 
 should be thrown into the car very gently and as much litpiid as 
 possible allowed to remain in the cavity of the ear. After this has 
 been done, a piece of cotton smeared with vaseline may be inserted 
 into the cavity of the external meatus. 
 
 In many cases the skin around the opening of the ear becomes 
 raw and sore ; if the car be kept perfectly clean, this soreness will 
 probably disappear spontaneously. In any case the healinj,' of 
 the skin may be hastened by applying the following ointment : 
 
 Diachylon ointment, - - - - One ounce. 
 Vaseline, ---.-- One ounce. 
 Mix. 
 
 This treatment should be faithfully pursued for a month or si.\ 
 weeks, even though the discharge may cease somewhat earlier than 
 this. If these measures fail, it will probably be necessary to call in 
 the services of a surgeon. 
 
 The effects of an inflammation of the ear resulting in the dis- 
 charge of matter vary in different cases. Sometimes the discharge 
 ceases, under appropriate treatment, in a few weeks, and the indi- 
 vidual retains a very fair degree of hearing. Yet in these cases, as 
 well as in others less favorable, the opening in the membrane of 
 the drum of the ear persists ; it is, indeed, rare that this opening 
 heals spontaneously, or can even be made to heal under treatment. 
 This fact is mentioned because the idea prevails that if the " drum 
 of the ear " — that is the membrane of the drum of the ear — be 
 broken, the hearing is irreparably lost. This is an erroneous idea, 
 since many patients who have suffered in this way hear quite 
 
INJl'KIliS TO TIIK DRUM OF TMK EAR. 
 
 637 
 
 acutely TIk' loss of hcarinjj seems to depend rather upon the 
 il,im,ii;c that has l)ccn done witliin the cavity of the middle ear 
 th.m iii)im the size of the opening; in the membrane. 
 
 N'.irious operations have been devised for closinfj tlie opening 
 in the membrane of the drum ; these liave been in some instances 
 successful. In other cases attempts have been made to substitute 
 artificial membranes to replace the natural one where this has been 
 di'trovcil. In some instances a fair decree of success has been 
 (ibtaiiied, and the hearin^j of patients has been decidedly improved, 
 but such cases form a small minority. 
 
 In the majority of instances in which the hearing; has been lost 
 in coiisi'ciuence of an inflammation resultin^j in a running from 
 the ear, there is no hope of improvement. The running can 
 be stopped, but the damage to the hearing apparatus is beyond 
 repair. 
 
 Injuries to the Drum of the Ear. 
 
 * 4 
 
 Jl. :i !,: 
 
 'rli 
 
 m 
 
 The drum of the car lies so deep in the skull, and is conse- 
 quently so well protected by the bones of the head, that it is rarely 
 affected directly by injuries received to the head. In many cases 
 the external ear and the auditory meatus are damaged by a blow, 
 withmit afifecting the parts essential to the perception of sound, and 
 theiefoie without affecting the hearing. 
 
 Vet there are various accidents and injuries whereby the middle 
 t;;i,- — tlu' " drum of the ear" — is damaged. In some cases a sharp 
 iii>truinent liappens to enter the bony channel leading into the middle 
 car ; it may penetrate the membrane of the drum and destroy 
 some of the structures which lie behind this delicate curtain. 
 
 It sometimes happens that pins or needles are introduced into 
 the car b\- children and work their way into the drum of the ear. 
 Iii'^tanccs are known also in which a " box on the ear" has ruptured 
 the membrane of the drum — an efifect due, of course, to the violent 
 comi)ression of the air in the external ear. It is reported that a 
 similar sad accident has several times occurred in consequence of 
 a rapturous kiss on the ear. The possibility of such disastrous 
 results should be borne in mind by parents, school teachers and 
 lovers. 
 
 '■{ 
 
 i>n 
 
638 
 
 DISEASES OF THE EYE AND EAR. 
 
 Catarrh of the Middle Ear. 
 
 This is one of the commonest affections of the ear, especially 
 in the United States, where catarrh of the throat and nose is so 
 prevalent. It will be remembered that there is a direct coninuini- 
 cation between the throat and the middle ear through the eustachian 
 tube. It therefore can be readily understood that if the throat and 
 nose have been long subject to catarrh, this affection may spread 
 along the eustachian tube, and finally reach the middle ear. Such 
 is, in fact, the case; a person who suffers much from catarrh nf 
 the throat need not be surprised at noticing, sooner or later, some 
 impairment of the hearing. 
 
 SifmptomH. — The two most prominent symptoms of this 
 affection are deafness and ringing in the ears. Sometimes a dull 
 pain is felt occasionally, but this is by no means a constant symp- 
 tom. 
 
 Ringing in the ears and deafness are also symptoms accompa- 
 nying the accumulation of wax in the external ear; hence their 
 presence may indicate merely this harmless affection, and not the 
 more serious one consisting of a catarrh in the middle ear. 
 
 Treatment, — This is one of the affections in which the skill 
 of the surgeon is absolutely indispensable in effecting improvement; 
 no benefit can be expected from remedies which can be applied by 
 an unskilled hand. 
 
 Nervous Deafiiess. 
 
 This term was formerly very loosely applied ; under it were 
 included the affection just described, catarrh of the middle ear, as 
 well as several others affecting the inner portion of the apparatus of 
 hearing. There are, however, certain conditions which may be 
 properly described as " nervous deafness" — that is, deafness due to 
 a disease of the nervous structures essential to hearing. 
 
 The perception of a sound involves a somewhat complicated 
 process. As it ordinarily occurs, this process is as follows: The 
 vibrations of the air cause a tremor of the curtain which is placed 
 
it were 
 ear, as 
 iratus of 
 may be 
 s due to 
 
 plicated 
 : The 
 placed 
 
 NERVOUS DEAFNKSS. 
 
 639 
 
 across the inner end of the bony channel of the external ear ; there 
 lies in contact with the inner surface of this membrane a small bone 
 shaped like a hammer ; this is the first of a chain consisting of 
 thrc-e small bones lying in such close contact that a slight move- 
 ment of one is communicated to the other. The third bone of this 
 ch.iin lies in contact with another membrane, which closes a bony 
 channel filled with fluid. In this fluid — arranged in a somewhat 
 peculiar way — rest the ends of the nerves of hearing. A vibration 
 therefore which sets the membrane of the drum of the ear in a 
 tremor, is transmitted along these bones to the membrane closing 
 the inner bony canal, and through this membrane it is communi- 
 cated to the liquid in which the nerve-ends lie. The effect pro- 
 duced upon these nerve ends by the little wave into which this 
 liquid is thrown, causes in the individual the percLption kno ; d as 
 hearing. In order that this effect shall cause an impression I'pon 
 the consciousness, it must be transmitted along the nerve'^ of hear- 
 ing to the brain. 
 
 It is evident, thcefore, that there are many opportunitic- 'or 
 derangements of an apparatus so complicr.ted as this. Some of 
 these have ! •'•n already mentioned. A catarrh of the middle car, 
 for instance, causes such a thickening of the membrane of the 
 drum that it does not vibrate so readily, and hence does not trans- 
 mit sound to the nervous apparatus. An accumulation of wax in 
 the external ear causes deafness by preventing the air from reaching 
 the membrane of the drum. There are also diseases which affect 
 the nervous part of the apparatus and cause deafness, although the 
 drum of the ear and all its belongings may be perfectly healthy 
 and in natural condition. Such cases are, therefore, termed nerv- 
 ous deafness. 
 
 Such instances usually occur as the result of diseases affecting 
 the brain and the membranes which cover it. Thus deafness is 
 frequently the result of " inflammation of the brain " and of cfrebro- 
 spiiial incniiigitis. It occurs, too, as a sequel to scarlet fever, and 
 to other infectious diseases, 
 
 Stfinittonift. — Nervous deafness can be recognized as such 
 only by the absence of all symptoms which would indicate a disease 
 of the other parts of the ear. When it is found, upon close exami- 
 nation, that th6 membrane of the drum of the ear, as well as this 
 cavity itself, and the various channels leading to it are all in a per- 
 
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 640 
 
 DISEASES OF THE EYE AND EAR. 
 
 fectly natural condition, it may be inferred that whatever deafness 
 exists is due to disease of the nerves concerned in hearing. This 
 suspicion is in most cases confirmed by the history of the patient, 
 since he has usually suffered from brain fever or other severe dis- 
 ease which is known to occasion destruction of the sense of hear- 
 ing. 
 
 Such an opinion can, of course, be established only by a 
 surgeon ; yet the non-professional observer can usually form a pretty 
 accurate idea of the nature of the deafness in the following simple 
 way. The individual is, we will suppose, quite deaf in one or both 
 ears — usually in both, if the deafness be of nf"-vous origin. Now, 
 let a tuning fork be struck against the table, and its handle held to 
 the teeth of the individual, or placed against the head just behind 
 the ear. If the cause of the deafness be located elsewhere than in 
 the nervous part of the apparatus, the individual will now hear far 
 more distinctly than when the tuning fork is merely held ficar the 
 ear without touching it. If, on the contrary, the difficulty be located 
 in the nervous apparatus, the patient will not observe any marked 
 difference when the tuning fork is held in contact with the head. 
 
 The reason for this is, of course, evident. The nerves are the 
 organs absolutely essential to hearing ; the bony part of the ear 
 and the membrane of the drum are valuable merely to conduct tlic 
 waves of air so that they shall affect these nerves. Now, vibrations 
 are also well conducted by the bones of the head, and therefore by 
 the teeth ; hence, if the individual hears decidedly better when the 
 tuning fork is plared against the bones of the head than he did 
 before, it is evident that the fault is in that part of the hearing 
 apparatus whe/eby the vibrations are transmitted to the nerves, 
 and not in these structures themselves ; if, on the other hand, the 
 patient can not hear distinctly when the tuning fork is held to the 
 teeth, it is evident that the fault must lie, not in the conducting 
 apparatus, but in the nerves themselves. 
 
 • 
 
 Treatment. — When it is definitely decided that the deafness 
 results from disease of the nerve structures of long standing, all 
 treatment may be abandoned ; no means are known whereby these 
 diseased nerves can be restored to their natural condition. Almost 
 all the drugs known to the profession, and all other means, including 
 electricity, have been employed in vain to remedy this unfortunate 
 condition. 
 
EARACHE. 
 
 641 
 
 Yet it should never be assumed that this is actually the cause 
 of the deafness until no further possibility of doubt remains ; if 
 the disease be located in any other part of the ear, there is always 
 hope that faithful and persistent employment of proper remedies 
 may at least improve, if not entirely relieve the deafness. 
 
 Earache. 
 
 Pain in the ear may be caused by any one of several aflfections. 
 It is important that the differences in the cause be recognized, since 
 the treatment must vary according!}-. 
 
 The most frequent cause of earache in children is an inflamma- 
 tion of the nti'idle car. The symptoms of this affection have 
 been already described and the treatment mentioned. It is import- 
 ant that such a case be not passed over as " earache," and be treated 
 simply by pouring laudanum into the ear, and by similar measures 
 which arc intended simply to relieve pain ; for the pain is a symp- 
 tom of a serious affection which must be relieved, so far as possible, 
 by energetic treatment. Let it be remembered, therefore, that 
 every case of earache in children should be most carefully exam- 
 ined to ascertain the cause, and in most cases requires the services 
 of a surgeon. 
 
 A second frequent cause of earache, especially in adults, pro- 
 ceeds from decayed teeth. If this be the case, there will usually 
 bo evidence of the probable nature of the pain in the condition of 
 the teeth. If there be any doubt about it, a few light blows upon 
 the teeth will usually serve to reveal the existence of tenderness, 
 and probably of decay. 
 
 In such cases the pain in the ear will probably never be entirely 
 relieved until the teeth are properly attended to. Yet it should be 
 said by way of warning that a slight tenderness of the teeth is apt 
 to accompany earache, when the latter is of simply neuralgic char- 
 acter, even though there be no decay of the teeth. In such cases 
 pressure upon the teeth causes slight pain, but not the acute and 
 intense pain which occurs if the teeth be decayed. 
 
 A third variety of earache is a neuralgia affecting the nerves 
 of the side of the face. This is felt chiefly in the ear, but usually 
 spreads <vcr the side of the head and over the cheek and neck. 
 
 4» 
 
 m 
 
642 
 
 DISEASES OF THE EYE AND EAR. 
 
 Treatment. — In undertaking to treat an earache, the first 
 item is, of course, to ascertain the cause of the pain. If the pain 
 be caused by an inflammation in the middle ear, it will usuall)- Ijc 
 of a throbbing character and accompanied by deafness, and per- 
 haps by delirium and convulsions. The treatment for this affection 
 has been already outlined. 
 
 If the pain proceed from decayed teeth, pressure upon the teeth 
 will usually indicate its origin ; in this case the measures to be used 
 consist in attention to the teeth. 
 
 If the pain be of purely neuralgic character, the patient's gen- 
 eral condition will usually indicate a depraved state of health. In 
 these cases it is desirj ble to use tonics, and to apply sedative oint- 
 ments to the ear. For this purpose we may give the following : 
 Quinine, _ . - _ - Thirty grains. 
 
 Extract of nux vomica, - - Five grains. 
 
 Mix, and make twenty pills. Take one before meals. 
 
 An ointment may be made after the following prescription : 
 Veratria, ----- Fifteen grains. 
 Vaseline, ----- One ounce. 
 This may be applied to the skin around the ear. In some cases 
 relief can be obtained by penciHng the surface with the ti)ictiiic of 
 aconite. 
 
 If this condition be obstinate, and if the pain recur at short 
 intervals, a cure can be effected only by the strictest attention to 
 all the details which can improve the patient's general condition. 
 
 m 
 
 Polyp of the Ear. 
 
 A polyp is a little fleshy tumor which grows in the bony chan- 
 nel of the external ear, usually as the result of a long-continued 
 discharge from the ear. It generally projects from the bottom uf 
 the channel, where it may be seen as a bright red mass, partially 
 obstructing the passage to the membrane of the drum. This may 
 become so large as to fill the entire channel of the meatus, and 
 even to project from the orifice of the ear. 
 
 When there is an opening in the membrane of the drum, proud 
 flesh sometimes forms behind this membrane and projects through 
 
ECZEMA OF THE EAR. 
 
 643 
 
 it into the auditory meatus, causing an appearance similar to that 
 of a polyp. 
 
 Sf/mptoms. — The polyp may exist in the ear a long time 
 without causing any symptoms which attract the attention of the 
 patient. If it becomes so large as to obstruct the entrance into the 
 ear, it is apt to occasion a certain amount of deafness. If it grow 
 from the middle ear tnrough an opening in the membrane of the 
 drum, there is frequently a purulent discharge from the ear. 
 
 Trenttnent. — A polyp must be removed entirely by a sur- 
 gical operation ; no medicines taken internally nor applied directly 
 to the growth will afifect it. It is, therefore, necessary to employ 
 the services of a surgeon. 
 
 Granulations in the Ear. 
 
 Whenever a wounded surface heals, little red bodies are formed 
 called granulations. After there has been for some time an irritat- 
 ing discharge from the ear, the channel of the ear is apt to become 
 more or less filled with such granulations. These occasion a con- 
 stant discharge of matter, and may become so large as to block up 
 the passage of the ear and thus impair the hearing. In the latter 
 case they are called polyps. So long as they merely rest upon the 
 floor of the meatus they may escape notice unless a special exami- 
 nation of the ear is made. By pulling the external ear gently 
 upward and backward and looking into the channel, we can observe 
 small red bodies, more or less obscured by matter, usually at the 
 L^ck part of the opening. 
 
 Tt'eatmetit. — The ear should be syringed out with warm 
 water in the manner already described; after this a camel's hair 
 brush should be dipped in a solution of lunar caustic (forty grains) 
 in water (one ounce). With this the granulations should be brushed 
 every day, the syringing being regularly performed. 
 
 :?;.. 
 
 
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 Eczema of the Ear. 
 
 The external oar sometimes becomes the seat of an inflamma- 
 tion which is quite similar in all respects to inflammation of th,. 
 skin in other parts of the body, and is hence called ecsctna. If 
 
644 
 
 DISEASES OF THE EYE AND EAR. 
 
 m. 
 
 this be allowed to continue, the lobe of the ear frequently becomes 
 thickened ; indeed, the skin lining the meatus may become so thick 
 as to interfere seriously with hearing. 
 
 Treatment, — The affection is frequently consequent upon a 
 running from the ear ; in this case the latter difficulty must bi; 
 relieved before we can hope to permanently cure the inflammation 
 of the skin on the outside of the ear. After this has been accom- 
 plished, we may apply the remedies which have been recommended 
 in discussing " eczema. " 
 
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SURGICAL DISEASES. 
 
 Boil.— (Furuncle.) 
 
 The appearance and symptoms of this common affection are so 
 familiar as to require no description. A boil consists of an inflam- 
 mation of the true skin, resulting in a swelling from the deposit of 
 material in the skin. In most cases the central part of the boil loses 
 its vitality and turns gray. This dead tissue constitutes the so- 
 called " core " of the boil. When this core is detached and re- 
 moved the inflammation ordinarily subsides spontaneously. 
 
 The causes which produce boils are not very definitely ascer- 
 tained. In many cases the patient is in poor health and suffers 
 from a succession of boils until his general health is improved. In 
 other cases there seems to be no discoverable cause for the trouble, 
 since boils occur in individuals who enjoy apparently perfect health. 
 
 The boil is usually developed with a considerable degree of 
 constitutional disturbance. In most cases the patient feels ill, is 
 somewhat leverish and may even have chilly sensations. In other 
 instances the boil develops slowly and without much pain. 
 
 Treatment, — At the first indication of the development of 
 the boil, its formation should be hastened by the application of hot 
 flaxseed poultices, which are to be frequently renewed. These 
 poultices will diminish the pain and thus increase the comfort of 
 the patient. So soon as matter is formed, a free incision should be 
 made so as to open the boil thoroughly and permit the escape of 
 the core and whatever matter may have been produced. This will 
 Ljive the patient extreme relief, and should not be postponed by the 
 timid fears which are so often manifested. After it has been opened, 
 the boil should be poulticed for two or three days until the dis- 
 charge becomes less profuse. After this it may be dressed with 
 
 645 
 
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 646 
 
 SURGICAL DISEASES. 
 
 vaseline or carbolic acid ointment spread upon soft cloth. It is 
 far better to open the boil than to permit it ':o burst and dischar^^c 
 spontaneously; first, because the patient secures relief nuicli 
 sooner; and second, because the scar which remains will be far less 
 unsightly. 
 
 Carbuncle. 
 
 A carbuncle is generally merely an aggravated boil or a col- 
 lection of boils around the same spot. It is, therefore, much larger, 
 and usually contains two or more " cores. " It may attain the si/o 
 of a hen's egg or even larger, and may cause a diffuse swelling of 
 the skin around it for several inches. After increasing in size for 
 some days it softens at several points, which become of a dull red 
 or bluish color. If not interfered with, the skin breaks at these 
 points, permitting a thin reddish or yellowish discharge to escape. 
 If pressure be made, thick unhealthy-looking matter escapes. 
 These openings enlarge and spread toward each other, and finally 
 meet, making a large raw surface. 
 
 Carbuncles seem to proceed from essentially the same causes 
 as boils. The patient is usually in a debilitated condition, and 
 requires tonics and careful attention to the general health. 
 
 The carbuncle seems to exert a very depressing effect upon 
 the patient's strength ; if it be large, and especially if situated upon 
 the head or neck, it is liable to be attended with severe fever and 
 perhaps delirium. Such cases often result fatally. 
 
 Treatment, — The first object of treatment in every case is 
 to support the patient's strength. For this purpose he should take 
 tonics, alcoholic stimulants and a good diet. The following pre- 
 scription may be given : 
 
 Quinine, ----- One drachm. 
 
 Tincture of the chloride of iron, - One ounce. 
 
 Tincture of nux vomica, - - One ounce. 
 
 Water, ------ Two ounces. 
 
 Mix, and let a teaspoonful be taken in a wineglassful of water four 
 times a day. 
 
 The patient should be liberally supplied with whisky or brandy, 
 which can best be administered as egg-nog. This can be taken as 
 the patient is inclined. 
 
CARBUNCLE. 
 
 647 
 
 Care must be taken that the patient cats sufficient food. The 
 appetite is usually much impaired, and unless especial attention be 
 (jivcn to this point, he will suffer further '•^r-casc of his weakness 
 by nc;,'lcct to take a sufficient quantity of nourishment. It is well 
 to prepare bland and unirritating food, such as e|,'gs, milk, soups, 
 and the like. 
 
 I'l some cases the pain is so intense as to require the adminis- 
 tration of opium ; fifteen drops of laudanum may be t;<ken in water 
 three or four times a day, if necessary to relieve the pain. 
 
 Locally, the treatment consists in the application of hot poul- 
 tices to promote the formation of matter and the separation of the 
 cores. So soon as this production of matter has taken place, free 
 incisions must be made, after which gentle pressure may be applied 
 to the tumor to promote the escape of the matter. Poultices 
 should then be again applied for several days until the dead skin 
 and the matter '.v ich surrounds it have been thrown off. In some 
 instances it bccoi. 's necessary to repeat the incisions. 
 
 After the discharge has ceased to a great extent, the wound 
 may be dressed with vaseline. 
 
 Aside from the affection which is ordinarily meant by the term 
 carbuncle, there is an infectious disease which has also been desig- 
 nated by that name. This disease affects cattle primarily, causing 
 the destruction of immense numbers of cows, sheep and horses in 
 many European districts. It may also be so communicated to man, 
 to whom it is frequently a fatal affection. This disease is variously 
 known as anthrax, malignant pustule, wool-sorters' disease, and 
 cliarbou. 
 
 The disease is contracted by men whose occupation compels 
 them to come into intimate contact with living or dead cattle ; for 
 the germs of the disease retain their vitality after the death of the 
 animal, and may be transported around the world in the hides, or 
 the hair, or the flesh of animals which have died of the disease. So 
 frequent is the disease among the workmen engaged in handling 
 wool that it is commonly designated in England as " wool-sorters' 
 disease." It has also been communicated to workmen who were 
 engat;ed in repairing furniture stuffed with horse-hair, even after 
 that furniture had been in use for many years. It can, of course, and 
 has been communicated to those who partake of the flesh of animals 
 which have died of this affection. 
 
 This disease is very common in certain districts of Europe, 
 
Hi 
 
 w<»\ 
 
 648 
 
 SURGICAL DISEASES. 
 
 especially in France, Germany and Russia. It is known to exist in 
 the United States, though to what extent is as yet unknown, since 
 veterinary surgeons here have not scrutinized cattle with especial 
 reference to this disease. 
 
 The a.icction begins usually with the formation of a small dark- 
 red blister, which develops in a few hours to a lump of considerable 
 size, containing a little matter or bloody fluid. In a short time the 
 animal gives evidence of severe constitutional disturbance. It be- 
 comes weak and feverish. The appetite is lost, and within three or 
 four days death occurs. In most cases the pustule, through which 
 the matter was introduced into the animal, enlarges extremely, so 
 as to produce an enormous swelling of the skin and tissues beneath 
 it. 
 
 The carcasses of such animals contain the contagious principle ; 
 those who handle the bodies or the hides run the risk of contractility 
 the affection, if they happen to have any cuts or abrasions on the 
 skin. The soil over which such animals have grazed or on which 
 their bodies have lain, becomes saturated with the virus, so that 
 cattle which graze upon it subsequently are frequently affected in 
 the same way. 
 
 Treatment. — If the nature of the disease be recognized 
 early, the primary sore through which the virus enters the system 
 should be at once cut out. If several days have elapsed, however, 
 this treatment will probably prove unavailing ; in such cases hot 
 fomentations should be applied to the sore, and the individual 
 should take quinine and whisky. Three grains of quinine may be 
 taken in a tablespoonful of whisky mixed with as much milk, every 
 three or four hours. 
 
 Fortunately the disease is less dangerous to man than to cat- 
 tle ; the majority of cases in the human subject recover. 
 
 Felon. 
 
 A felon is an inflammation of the delicate memb.anc which 
 covers the bone — the periosteum. Such an inflammation may 
 occur around any of the bones, but the term felon is reserved for 
 an mflammation of this membrane covering the bones of the fingers. 
 
 In most cases the felon is developed on the last joint of a 
 
than to cat- 
 
 FELON. 
 
 649 
 
 flutter or of the thumb, though it may also appear on the other 
 joints. 
 
 The affection bepins with a sense of burning pain usually 
 imdcr the pulp of the finger or near the nail. The skin over the 
 part becomes red and swollen ; meanwhile the pain has become 
 intense and of a throbbing chiracter ; the patient is frequently 
 unable to sleep because of the st.'verity of the pain. 
 
 If the affection be allowed to proceed without interference, there 
 finally occurs an opening of the skin and a discharge of matter, 
 after which the pain subsides considerably. Yet the wound does 
 not usually heal well ; an obstinate sore remains from which a little 
 matter is discharged, and the edges of which are apt to be covered 
 with " proud flesh. " It will usually be found that the stubbornness 
 of this sore is caused by the presence of diseased bone at the bot- 
 tom of it. This bone dies and is finally cast off as small pieces, 
 wiiich become loosened and make their escape through the wound, 
 or are removed by the patient. In this way the joint, or even the 
 entire finger may be rendered useless ; in the most favorable cases 
 tiiere remains a deformity which may seriously impair the usefulness 
 of the finger. 
 
 Trrntmenf. — A felon is a most serious as well as painful 
 affection. The danger lies in the fact that if this membrane which 
 surrounds the bone be separated from the bone itself by the forma- 
 tion of matter beneath it, the bone dies and the usefulness of the 
 fint^er is impaired. The only way for preventing this accident is 
 by o|)ening the membrane which surrounds the bone so as to per- 
 mit the matter to escape, and thus to prevent it from burrowing 
 along between the bone and its covering. 
 
 In order to palliate the pain we may poultice the finger with 
 flaxseed meal ; by this means, moreover, we hasten the formation 
 of matter, which is one of the objects desired. So soon as it 
 becomes evident that matter is present — or even sooner in some 
 cases — a knife must be thrust through the flesh e/o7Ufi to the bone. 
 The cut should be freely made, so that the matter may escape 
 readily. This is of course extremely painful, but only for a few 
 moments, antl the relief which the patient obtains immediately far 
 more than compensates for the pain of the incision. 
 
 The importance of submitting the finger early to the surgeon 
 cannot be overestimated ; for the patient obtains thereby not only 
 
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650 
 
 SURGICAL DISEASES. 
 
 relief from the most intense suffering, but also the best chances for 
 preserving the usefulness of his finger. 
 
 After the felon has been opened, it may be poulticed again for 
 a day or two, until the discharge ceases. 
 
 Sometimes the inflammation occurs under the root of the nail, 
 and the incision must be made through the nail. The general prin- 
 ciple remains, however, that the matter must be permitted to 
 escape, in order to prevent a disease of the bone, which may result 
 in a loss of a part of the finger. 
 
 Ulcers of the Leg. 
 
 i i 
 
 4 
 
 One of the most common and troublesome affections, amonsr 
 poor people especially, is ulcer of the leg, particulary on the part 
 of the leg just above the ankle. 
 
 These ulcers are of various kinds, and originate in various 
 ways. They may proceed from a constitutional taint, such as 
 syphi1"'5 ; but they are more frequently caused by enlargement of 
 the veins of the leg. 
 
 In most cases the ulceration begins as a blister or pimple, 
 which after a time breaks and discharges a little watery fluid. This 
 sore may scab over, but usually breaks out again, and keeps con- 
 stantly increasing in size. In course of time the skin becomes 
 ulcerated and matter is freely discharged from it. These ulcers 
 may attain enormous size, so as to include, in fact, a considerable 
 portion of the skin between the knee and the ankle. 
 
 In most cases of severe ulceration of the leg in which the indi- 
 vidual has not had syphilis, the veins of the leg and thigh will be 
 found to be enlarged, constituting the condition known as " varicose 
 veins. " These ulcers occur almost always in middle 01 alvanced 
 life, though they may be found in children who are poorly noui- 
 ished. 
 
 Ti'entnient, — The healing of the ulcers will be promoted by 
 improvement of the general health. In most cases, however, the 
 sufferers are unable to enjoy the recreation, air and exercise 
 which form such important elements in improving the health. Yet 
 what can be done in the way of food and personal care should not 
 
 "•I 
 
 "'P}. 
 
ULCERS OF THE LEG. 
 
 651 
 
 be neglected, since such measures will have a marked effect in hasten- 
 ing the healing of the ulcers. 
 
 The treatment consists chiefly of local applications. Some- 
 times the ulcers can be healed by the constant application of 
 astringent ointments, of which the following is a good example: 
 
 Diachylon ointment, 
 Vaseline, 
 
 One ounce. 
 One ounce. 
 
 Mix. Apply the ointment spread upon soft cloths, which should 
 be bound over the ulcer by means of a bandage. 
 
 The healing of the ulcer will be promoted by measures which 
 tend to keep the blood out of the leg. For this purpose the leg 
 may be enclosed in a bandage of soft flannel which is applied 
 from the foot to the knee. Musli 1 bandages should be avoided, 
 since it requires considerable practice and skill to apply these 
 evenly and firmly. As they are ordinarily put upon the leg, they 
 do injury rather than good ; for they arc generally arranged so as 
 to leave deep impressions in the skin, and even to cut or abrade the 
 surface. 
 
 The healing of the ulcers will be hastened by keeping the foot 
 elevated as many hours in the day as possible. This can be best 
 accomplished by having the patient lie down, or at least by support- 
 ing the foot upon a chair. Yet, as a matter of fact, it is practi- 
 cally impossible to persuade a person to remain in bed or on a chair 
 all day and night, even though he have the opportunity ; and for 
 most individuals the opportunity is lacking. 
 
 It was, therefore, a godsend for persons afflicted with ulcers 
 of the leg, when Dr. Martin introduced to the profession the rubber 
 bandages, which he had himself employed in his private practice for 
 twenty-five years. These bandages are simply made of pure rub- 
 ber, of varying widths and lengths, according to the needs of the 
 patient. The bandage is applied directly to the skin without inter- 
 posing any dressings or ointments over the ulcer. It should be put 
 on in the morning before the patient leaves the bed, or even puts 
 his foot out of the bed. It is applied to the foot first, and then 
 wound snugly around the ankle and leg some distance above the 
 site of the ulcer. The patient can then rise and attend to his usual 
 duties. The bandage is quite warm, and causes profuse perspira- 
 tion of the limb ; there is apt to be also an increased discharge 
 from the surface of the ulcer. Yet these elements do not interfere 
 
 
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 ."#?ts 
 
652 
 
 SURGICAL DISEASES. 
 
 "I 
 
 ■ s 1 \ 
 
 11 h' 
 
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 at all with the beneficial effect of the bandage ; in fact, the benefit 
 seems to depend largely upon the moisture and warmth secured 
 by the bandage as well as by the support to the veins of the skin 
 
 At night the bandage is removed and carefully cleansed with 
 warm water, after which it may be hung up to dry until mornin^r 
 The limb should be also bathed and cleansed, and the ointment 
 above mentioned may be applied during the night. 
 
 The success obtained in the treatment of ulcers of the Ic^ by 
 the use of this bandage astonished every physician who employed 
 it. The most obstinate ulcers, even those which had resisted 
 ordinary measures for years, were healed in a few months or e\eii 
 a few weeks by the constant use of this bandage ; and the patient 
 had moreover the pleasure and profit of pursuing his usual avoca- 
 tion instead of being compelled to sit or recline during the day. 
 
 For all those, therefore, who suffer from obstinate ulcers of the 
 leg, a Martin's bandage should be obtained. If, after the ulcer 
 has been thoroughly hoaled, the bandage be no longer worn, the 
 trouble may return ; yet it can be again healed in the same way. 
 To afford the greatest security against a fresh outbreak of the ulcer, 
 the bandage should be worn for some weeks after the ulcer has 
 entirely closed. 
 
 There are a few cases in which ulcers of the leg heal very slowly 
 even under the use of a rubber bandage. In these cases there is 
 usually either some constitutional taint in the patient, such as gout, 
 rheumatism or syphilis, or the veins of the leg are extremely large. 
 In such cases the appropriate treatment must, of course, be directed 
 to the condition which seems to retard the healing of the ulcer. 
 
 There are cases of ulcers of the leg which can be healed only 
 after the varicose veins are operated upon ; so long as these veins 
 remain in their enlarged condition, either the ulcer will not heal, or 
 if it heals it soon breaks out again and becomes as bad as before. 
 By operating upon the veins so as to prevent the blood from dis- 
 tending them constantly, the ulcers may be healed almost without 
 treatment, since they are merely the results of enlarged condition 
 of the veins. 
 
 Hare-lip. 
 
 This familiar and unfortunate deformity, so called from its 
 fancied resemblance to the lip of a hare, is a congenital defect- 
 that is, one which results from improper formation of the child in 
 
 e^i 
 
HARE-LIP. 
 
 653 
 
 the mother's womb. This departure from the usual formation con- 
 sists simply in an arrest of the natural development. For in every 
 case the upper jaw consists at first of two distinct halves which are 
 separated from each other by a considerable space. If the develop- 
 ment of the foetus proceed naturally, these two parts grow toward 
 each otlier so that some time before birth the two halves of the 
 bciiie meet. There is, furthermore, in the early period of develop- 
 ment a separate piece of bone at the front of the jaw which should 
 become united to the rest before birth. Hare-lip results simply 
 from an arrest of the growth of the fcetus, as a result of which the 
 different pieces composing the upper jaw fail to grow together. 
 
 There are various degrees of hare-lip ; in its most complete 
 form there remains a space between the two sides of the roof of 
 the mouth as well as a deformity of the lip. In these cases there 
 remains, of course, communication between the mouth and the 
 nose along the upper part of the mouth — a portion which is, in the 
 perfect child, composed of bone, whereby the cavity of the mouth 
 is kept separate from that of the nostrils. 
 
 In other cases the bony roof of the mouth is perfectly formed, 
 but there remains a cleft in the soft palate as well as in the lip. In 
 still other cases the mouth is perfectly formed but the lip is cleft. 
 
 The most aggravated cases of this deformity constitute a serious 
 impediment to the usefulness of the individual ; in infancy the child 
 ma\- suffer somewhat from lack of nourishment, since fluids taken 
 into the mouth cannot be kept there, but escape through the roof of 
 the mouth into the nose and run out through the nostrils. Further- 
 more, the soft palate is an important agent in the process of swal- 
 lowing, and if it be cleft, even though the roof of the mouth be 
 whule, fluids are apt to pass into the nose and emerge from the 
 nostrils instead of going down the throat. 
 
 In more advanced years, too, this deformity constitutes a 
 serious impediment to distinct articulation ; an individual thus 
 afflicted is therefore debarred from those pursuits which require 
 public speaking. Indeed, it is difficult for some of these unfortu- 
 nate individuals to make themselves understood at all ; and they 
 always suffer mortification in the presence of strangers. 
 
 It IS highly important, therefore, that hare -lip should be reme- 
 died before the child has attained an age when the operation 
 becomes more difficult and uncertain. If the child be in good 
 health the operation should be performed during the first year of 
 
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654 
 
 SURGICAL DISEASES. 
 
 life, unless there be some circumstance which, in the opinion of the 
 surgeon, renders operation unadvisable. 
 
 If there be a cleft merely ii the lip, the operation is a com- 
 paratively trivial one ; parents should not postpone the matter 
 under the impression that the child will " stand it " better when he 
 becomes older. The sooner the deformity is remedied the better it 
 will be for the child. 
 
 h 
 
 Cancer of the Lip. 
 
 k \i9 
 
 This is a very frequent affection, especially among the lower 
 classes. The growth begins as a crack or raw surface on the lip, 
 which heals over apparently without any unusual symptoms ; but 
 in a short time it will be found that the healing process is not com- 
 plete, that there is merely a dry scab on the lip which falls offer is 
 scraped off by the movements of the mouth, and under which the 
 original crack or raw surface is visible. After a time the sore 
 becomes larger and the scab upon it becomes a thick crust. Some- 
 times the cancer begins in a little projection which looks like a 
 wart, situated usually near the edge where the red surface of the 
 lip joins the skin. 
 
 The growth may remain in this condition for months, and 
 scarcely attract the attention of the patient, who rarely suspects the 
 existence of any serious disease or seeks medical advice about it. 
 At last, however, perhaps in consequence of some irritating oint- 
 ment or application, the growth increases rapidly in size and 
 becomes ulcerated. In a few months or even weeks the lip has 
 become very thick, its surface is raw and covered with foul matter, 
 and the edges of the ulcer are sharply cut and turned outward. 
 In many cases the surface is covered with scabs of dried matter. 
 
 If the disease proceed without treatment, a considerable part 
 of the lip is destroyed ; the saliva dribbles from the corners of the 
 mouth ; the glands at the angle of the jaw and under the tongue 
 become enlarged ; the disease spreads so as to attack the inside of 
 ^'■± mouth, as well as the skin around the lip; the teeth fall out and 
 I t Uvidual dies of exhaustion. 
 
 . s> to the cause of cancer upon the lip we have no definite iiifoi 
 .-..'r . There are many reasons for supposing that a sore, which 
 
CANCER OF THE LIP. 
 
 655 
 
 'Hi 
 
 is at first simple and not cancerous, can be by constant irritation 
 inverted into a cancer. It is also true that cancers of the lip occur 
 with especial frequency in men who smoke clay pipes, or whose 
 avocation compels them to hold irritating articles between the lips. 
 The most frequent subject of cancer of the lip is the Irish laborer, 
 who smokes a clay pipe all day and evening. In such patients, it is 
 often observed that the cancer of the lip corresponds exactly in 
 position to the teeth between which the patient holds his pipe, since 
 these are usually worn away by this article of luxury. Yet it must 
 be admitted that cancer occurs on the lips of individuals who do not 
 use pipes, and that in many cases no source of irritation can be dis- 
 covered. Yet cancers occur also in other parts of the body which 
 are exposed to irritation, and we cannot doubt that, however they 
 may originate, cancers are at least aggravated and developed by 
 irritating agents. 
 
 Ml 
 
 •>', 
 
 Ti'edtinent. — The only cure for a cancer consists in early 
 removal. This fact has been so well established that it seems 
 astonishing that so many individuals can be persuaded, even by the 
 dread of the knife, to waste precious time in applying pastes, and 
 in other fruitless efforts, out of which unscrupulous men make hand- 
 some incomes. No instance is recorded in which a genuine cancer — 
 one which had been so pronounced by competent surgeons — has 
 been healed by any means whatsoever. This seems a sad fact 
 for the many sufferers from the disease; but it is a fact, and it 
 must be accepted as the inevitable. By deferring an operation 
 until pastes, plasters and the like have been applied to the sore, the 
 patient is simply losing valuable time, and perhaps throwing away 
 his sole chance for life. For the danger to life lies not in the origi- 
 nal cancer itself, but in the other cancers which subsequently grow 
 in the internal organs of the body. A certain time elapses before 
 these secondary cancers are formed ; just how long a time it takes 
 we cannot say. Under such circumstances, the wise course is evi- 
 dently to remove the original growth as early as possible, for if 
 once thoroughly removed, there is but little danger of the forma- 
 tion of cancers subsequently. 
 
 The lip is the most favorable, or rather the least dangerous, of 
 all the localities of the body for the occurrence of a cancer; for the 
 sore is so prominent as to attract the attention of the patient and 
 of his friends at an early period of its growth ; and the lip is so 
 
 43 
 
 S\^V, 
 
 Vf 
 
 I ' ) 
 
 
6S6 
 
 SURGICAL DISEASES. 
 
 formed that it affords the most favorable opportunity for the 
 thorough removal of the tumor. 
 
 The operation must, of course, be entrusted to the surgeon ; 
 our object is merely to impress upon the patient the necessity for 
 an operation, and the folly of wasting time by useless efforts to 
 evade the unavoidable. 
 
 ri 't-m'''i' 
 
 Polyp of the Nose. 
 
 The nose is the seat of tumors called polyps. These occasion 
 a feeling as if the nose were " stuffed up," so that the patient seems 
 to have a continuous cold in the head. This feeling and the 
 accompanying discomfort are usually aggravated in wet weather. 
 After a time there may occur an occasional discharge of blood in 
 small quantity when the patient blows the nose violently; and there 
 is apt to be an increased discharge from the affected nostril. 
 Sometimes the patient can bring the polyp into view in the nostril 
 by closing the opposite side of the nose with the finger and then 
 expelling the breath forcibly through the remaining nostril. If 
 the polyp be allowed to remain it keeps increasing in size, blocks 
 up the nostril completely, forces the partition between the nostrils 
 toward the opposite side, and may occasion serious deformity of 
 the face. 
 
 Treatment . — The polyp must be seized with a pair of for- 
 ceps and gently twisted off. This is usually a simple operation, if 
 the tumor be small ; when it has attained a large size considerable 
 difficulty may be experienced. 
 
 Mortification of the Jaw. 
 
 Considerable portions of the lower jaw, or even the entire bone, 
 may mortify as the result of mechanical violence, of decayed 
 teeth, or of the abuse of mercury, A more frequent and more 
 disastrous cause, however, is poisoning hy phosphorus. This occurs 
 with especial frequency in persons who have been long employed 
 in match factories. The health is gradually impaired and the lower 
 jaw becomes inflamed, swelled and finally mortifies, " with loss of 
 appetite, sallow countenance and feeble circulation. The first 
 indication of the disease is usually toothache, followed by the 
 
TONGUE-TIE. 
 
 657 
 
 dropping out of the teeth, more especiaHyof the grinders, and then 
 by the death o( a portion of the jaw. " If a portion of the jaw be 
 lost it is not reproduced, as so often happens when pieces of bone 
 mortify. 
 
 Tumors of the Mouth. 
 
 Tumors of various kinds are found in the mouth. The most 
 common is a little swelling which may appear hard to the finger, 
 but nevertheless contains a watery fluid. Such tumors may be 
 found anywhere on the inner surface of the lips or under the tongue. 
 They occasion no pain, and in most cases no annoyance, unless 
 they happen to be so situated as to obstruct the movements of the 
 to'iguc or of the jaws. 
 
 Ti'eatmeut, — If these tumors are not sufficiently large to 
 cause the patient much annoyance, they may be permitted to 
 remain, since they do no harm. If it become desirable to 
 remove them, this may be done by snipping out a piece of the sac 
 whirh contains them and permitting the contained fluid to escape. 
 Sometimes the tumor is permanently cured by this simple means ; 
 at other times it becomes necessary to repeat this operation a few 
 weeks subsequently, since the tumor fills up again as before. In 
 such a case, after permitting the contents of the tumor to escape 
 the second time, the inside of the cavity should be lightly touched 
 .with a stick of lunar caustic. It is always better to refer the matter 
 to a surgeon than to permit an inexperienced hand to meddle 
 with it. 
 
 If the tumor increase greatly in size, it may attain such dimen- 
 sions as to push the tongue to one side or to the roof of the mouth, 
 and thus interfere seriously with speech, with swallowing, and even 
 with breathing. In such cases, it is of course absolutely necessary 
 that the tumor be removed. 
 
 Tongue-tie. 
 
 This affection consists in an unnatural shortness of the " bridle 
 of the tongue " — the little band which binds the point of the 
 tongue to the floor of the mouth. It is usually detected in the 
 
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658 
 
 SURGICAL DISEASES. 
 
 infant by the diflficulty which the child experiences in nursing. The 
 affection is, however, not so common as is generally supposed; 
 many infants are believed to be troubled in this way whose subse- 
 quent history shows that such is not the case. If it be definitely 
 ascertained that the bridle of the tongue is really too short, the 
 defect can be easily remedied by snipping this fold of mucou-, 
 membrane with the scissors. This is a trivial operation, and yet 
 must be done with great care, in order to avoid wounding an im- 
 portant artery which runs along the lower part of the tongue. 
 
 Cancer of the Tongue. 
 
 liiiV^UP 
 
 r: I 
 
 V I 
 
 This is a frequent and serious affection. It begins as a sore 
 usually on the side of the tongue, which remains open for a Cdii- 
 siderable time and does not yield to the treatment that ordinarily 
 suffices to heal such ulcers. After a time the sore becomes dee|)er 
 and its edges sharp and everted. The ulcer gives rise to consider- 
 able pain and may be the source of hemorrhages. Before it has 
 attained large size it emits a peculiarly fetid odor which, with its 
 appearance, may suffice to arouse a suspicion of the nature of the 
 disease. In a few months the glands at the angle of the jaw 
 become enlarged and hard. 
 
 If allowed to progress, the cancer finally destroys a large part 
 of the tongue, and, if the patient live long enough, may spread 
 into the throat. 
 
 The only hope of relief lies in the early extirpation of the 
 ulcer and of the adjacent part of the tongue. If this be dmie 
 sufficiently early, the patient may escape with his life ; but if the 
 cancer return, as it usually does when the operation is too long 
 deferred, the most that can be hoped for is a relief from suftering 
 for a few months. 
 
 i i 
 
 Enlargement of the Tonsils. 
 
 The tonsils become enlarged as the result of frequent attacks 
 of inflammation of the throat ; and a permanent increase in size 
 may remain after an attack of quinsy. This enlargement usually 
 occurs in childhood, especially in scrofulous children, or in those 
 whose health is from any other cause impaired. 
 
',!:'■:» M 
 
 ENLARGEMENT OF THE TONSILS. 
 
 659 
 
 This enlargement gives rise to many inconveniences ; the ton- 
 sils arc liable to repeated attacks of acute inflammation, after each 
 one of which the swelling becomes greater and the irritation in the 
 threat is augmented. When the tonsils have attained a certain 
 size, the voice is rendered hoarse ; breathing is labored and noisy, 
 especially during sleep. Indeed, a child's slumbers are frequently 
 much disturbed by fits of choking, from which he awakens in ter- 
 ror. Swallowing may also be impeded and laborious ; sometimes 
 the food and drink escape into the nose. 
 
 If this condition be allowed to proceed, there is apt to occur 
 aa impairment of hearing in consequence of the spread of the 
 inflammation through the eustachian tubes into the car. In rare 
 cases suffocation has been caused by the collection of mucus in 
 the throat. 
 
 Trefttnient. — In most cases the child's general health needs 
 attention. He should be provided with the best of food and 
 allowed plenty of recreation ; in short, all those measures which 
 evidently conduce to the improvement of the health should be 
 employed. In addition, it may be well to administer tonic medi- 
 cines. The following formula may be given: 
 
 Syrup of the iodide of iron. 
 Glycerine, - - . 
 
 Water, - - . - 
 
 - One ounce. 
 
 - One ounce. 
 
 - Two ounces. 
 
 A teaspoonful of this may be taken after meals. 
 
 If the child be evidently scrofulous, as indicated by the pallor, 
 enlargement of the glands in the neck, and the other usual symp- 
 toms, cod-liver oil should be administered. 
 
 Local treatment in the throat can sometimes be made effectual 
 in reducing the size of the tonsils, or at least in preventing the 
 occurrence of unpleasant symptoms. This treatment may consist 
 in the use of astringent gargles, and in the application of remedies 
 directly to the enlarged tonsils by means of a camel's-hair brush. 
 The following gargle may be employed : 
 
 Alum, 
 Glycerine, 
 Tincture of myrrh, 
 Water, 
 
 One drachm. 
 One ounce. 
 Three drachms. 
 Four ounces. 
 
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66o 
 
 SURGICAL DISEASES. 
 
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 The local applications should be made by brushing the tonsils 
 once or twice a day with the following solution : 
 
 Tannin, Twenty grains. 
 
 Brandy, ..... One ounce. 
 
 Camphor water, .... Five ounces. 
 This may be used to szvab the throat For this purpose a piece 
 of sponge as large as a hickory nut may be tied firmly onto the ciui 
 of a piece of wood oi" whalebone. The sponge is moistened w ith 
 the solution, and then rubbed thoroughly over the surface of the 
 tonsils and the neighboring part of the throat. It will genciMlI\- bo 
 necessary to hold the tongue down with the handle of a spoon dur- 
 ing this process. Care must be always taken to fasten the spon<;e 
 firmly upon the handle, in order to prevent the possibility of its 
 slipping off into the throat. 
 
 Benefit can also be derived from the inhalation of liquids by 
 means of an atomizer. For this purpose the following solution 
 may be employed three times a day : 
 
 Listerine, . - . . . One ounce. 
 
 Tannic acid, ----- Half a drachm. 
 
 Glycerine, ----- Two ounces. 
 
 Water, _ - _ - - Three ounces. 
 
 This may be used warm, with an ordinary hand atomizer. 
 
 It is rarely possible to reduce the swelling of the tonsils materi- 
 ally in this way. The most that can be hoped for is to prevent an 
 aggravation of the difficulty, to keep the throat clear of mucus and 
 to toughen the membrane somewhat, so that there will be less pos- 
 sibility of frequent acute attacks. 
 
 In most cases it will be desirable to remove the tonsils when 
 these have attained a size such as to cause the more serious symp- 
 toms above related. The operation for removing the tonsils is a 
 very simple one, and it occasions the patient but little pain. 
 
 Enlargement of the 0vula. 
 
 The uvula is the name applied to the projection from the soft 
 palate which hangs into the throat, and can readily be seen when 
 the mouth is open. It sometimes happens that this organ becomes 
 enlarged to such an extent as to touch the top of the larynx. In 
 this case it causes a constant irritation and tendency to cough. 
 
FOREKJN BODIES IN TIIK THROAT. 
 
 061 
 
 If it be ascertained that the enlargement of the uvula is such 
 as to cause the patient serious annoyance, it should be cut off at 
 about the middle, so that it shall no longer cause a tickling of the 
 larynx. 
 
 Foreign Bodies in the Throat. 
 
 Foreign substances frequently lodge in the throat during the 
 act of swallowing. Although fish-bones arc the most common, 
 yet almost any solid body which is taken into the mouth, however 
 small, may cause trouble by lodging in some of the nooks and 
 ccirnors which arc found in the passage from the mouth to the stom- 
 ach or to the lungs. 
 
 In most cases such bodies are soon expelled by the patient's 
 own efforts in coughing ; in other cases they arc lodged high up in 
 the throat, and can readily be seen and removed by a bystander. 
 There arc instances, however, in which the body becomes firmly 
 lodged at a point beyond the reach of any one who is not provided 
 with proper instruments and the skill necessary to use them. The 
 consequences vary in different cases ; sometimes the body is so 
 situated as to prevent the entrance of the air to the lungs, and thus 
 causes speedy suffocation; in other cases, the substance produces no 
 immediately serious effects, but induces in time an ulceration in 
 either the oesophagus or the windpipe, which may result fatally. 
 The final result cannot be predicted in any case ; instances are 
 known in which a foreign body has ulcerated through the oesoph- 
 agus and has found its way into a distant part of the body, without 
 causing the patient serious illness. 
 
 In every case it should be borne in mind that the patient is 
 sometimes deceived by his own sensations, and that no foreign 
 body has remained in the oesophagus or the windpipe, although the 
 individual may be firmly convinced to that effect. Instances are 
 known in which surgeons have been induced to perform serious 
 operations for the removal of supposed bodies which actually had 
 no existence ; one of the most famous of the world's surgeons, 
 Nelaton, of Paris, made numerous unsuccessful efforts to remove a 
 body which he was led to suppose was a foreign substance in the 
 throat, but which he afterwards ascertained was merely the tongue- 
 bone (hyoid-bone). 
 
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 662 
 
 SURGICAL DISEASES. 
 
 It may be well in every case for the friends to examine the 
 throat so far as they can, since it is sometimes possible lo remove 
 very easily bodies which occasion the patient great annoj-anco, and 
 even endanger his life. The mouth should be opened and carefully 
 inspected, attention being particularly directed to the space just 
 behind the tonsils and behind the root of the tongue. If nothing is 
 detected, the forefinger may be passed into the mouth and swept 
 around the throat regardless of the patient's gagging and efforts to 
 vomit. It is sometimes possible to dislodge foreign substances, 
 such as lumps of meat and the like, by this simple maneuver. 
 
 If relief is not obtained in this way, an emetic may be adminis- 
 tered, provided the patient can swallow ; a teaspoonful of mustard 
 or of common salt dissolved in a glass of warm water should be 
 swallowed. The act of vomiting sometimes serves to dislodge par- 
 ticles and to eject them from the throat, thus securing to the patient 
 immediate relief. 
 
 If these means fail, the matter must be left in the hands of a 
 surgeon, since the extraction of foreign bodies from the throat is 
 one of the most difficult and delicate operations which the surgeon 
 is called upon to perform. In many cases, however, the case ter- 
 minates before it is possible to procure the serv'ces of a medical 
 man. The foreign body is ejected or the patient dies of suffoca- 
 tion in a few minutes. 
 
 It seems scarcely necessary to remark that in order to avoid 
 such accidents, care should be taken not to take a deep breath nor 
 laugh while the mouth is full of food. 
 
 Stricture of the Gullet. 
 
 By a stricture of the gr'llet, or oesophagus, we understand a 
 narrowing of the channel. The results of this decrease in the size 
 of the tube vary according to its degree. In slight cases it may 
 occasion the patient no particular annoyance, and he may not be 
 aware of its existence. When the caliber of the tube becomes nar- 
 rower, however, there occur symptoms which attract attention and 
 may even interfere seriously with the individual's health 
 
 The symptoms first noticed are difficulty of swallowing, which 
 has usually lasted for years and has gradually grown worse. In ad- 
 dition to this there occur spasms during the act of swallowing; which 
 
GOITRE. 
 
 663 
 
 sometimes compel the patient to reject the food taken into the 
 mouth. Swallowing frequently produces pain in the chest which 
 shoots upward toward the head and backward between the shoul- 
 ders. 
 
 The causes of this difficulty are various ; in many cases it 
 results from the accidental or intentional swallowing of corrosive 
 liquids, such as nitric acid or carbolic acid ; in other instances it 
 results from a constitutional taint, such as syphilis; in a great many 
 cases there is no apparent cause for the difficulty. 
 
 Tt'cntnient, — The treatment of the affection consists almost 
 entirely in the introduction of flexible instruments, made for the 
 purpose and called bougies, into the oesophagus. If the surgeon 
 can introduce an instrument through the narrow part of the cesopha- 
 gus, he can usually succeed by gradually increasing the size of 
 the bougie, in rendering the opening sufficiently large to relieve 
 the patient from the most distressing symptoms. 
 
 Sometimes a stricture of the oesophagus is caused by the 
 growth of a cancer at some point in the tube. In this case the 
 patient is apt to vomit frequently, the matter ejected being streaked 
 with blood Sometimes severe hemorrhage occurs from the cancer, 
 the blood escaping into the stomach or rising into the mouth. 
 
 When the stricture is dependent upon such a growth, there 
 usually remains but one mode of relieving the patient — an opera- 
 tion must be performed whereby a tube can be introduced into the 
 stomach, and food administered in this way. If the growth be a 
 cancer, such an operation can, at most, prolong the patient's life 
 some time, and relicv.: his suffering; he will, of course, ultimately 
 die of the disease. 
 
 Goitre. 
 
 A goitre is an enlargement of a gland which is situated at the 
 front of the neck, and is naturally so small as to occasion no .. r'.^- 
 able prominence. Under certain conditions this gland undergoes 
 enlar^'enient, causing a swelling of the neck. This swelling may 
 attain an enormous size, so that the circumference of the neck is 
 much greater than that of the head. In some rases this enlarge- 
 ment of the gland occasions no further annoyance than results from 
 the mechanical impediment to the movements of the head and neck ; 
 
 4 I "' :i 
 
 
 I'*' .'1^ hi 
 
664 
 
 SURGICAL DISEASES. 
 
 li ! 
 
 I' h 
 
 in most instances, however, the enlarged gland presses upon the 
 windpipe and gullet, as a result of which the patient experiences 
 great difficulty in breathing and in swallowing; there is also a con- 
 stant and obstinate cough, which greatly exhausts the patient and 
 resists all treatment. 
 
 In young persons it can usually be cured ; but if it have 
 become hard, and the patient be advanced in years, a cure can 
 scarcely be hoped for. 
 
 Goitre is what is termed an endemic disease ; that is, one which 
 seems to prevail only in certain localities, and to be, therefore, 
 associated with some peculiarity of soil or climate. It occurs 
 chiefly in the mountainous districts of Switzerland and Austria, 
 especially in the Tyrol and along the valley of the Rhone ; it is 
 also prevalent in the chalky districts of England. 
 
 Various attempts have been made to trace this disease to some 
 particular influence of the climate or soil in these localities, yet it 
 is not yet ascertained exactly what the origin of the affection is. 
 
 The disease occurs chiefly among people in debilitated health, 
 and is more often seen in females than in males. 
 
 In this country goitre is a rare affection as compared with its 
 prevalence in many parts of Europe. 
 
 TreattneHt. — An important item of treatment is the removal 
 of the patient from those influences, whatever they may be, which 
 induce the disease ; hence, a change of residence is almost essen- 
 tial. No medicines can be relied upon to check the growth of the 
 tumor, though much good seems to have resulted in many cases 
 from the use of iodine. This should be applied to the skin in the 
 following form : 
 
 Tincture of iodine, - - - - One oun.e. 
 
 Glycerine, ----- Two ounces. 
 
 This may be painted over the enlarged gland every day or two; if 
 the skin show much evidence of irritation, the oainting process 
 may be performed less frequently. 
 
 At the same time the patient may take iodine internally in '.e 
 form of iodide of potassium. The following prescription may be 
 administered : 
 
 Iodine, ------ Four grains. 
 
 Iodide of potassium, - - - Four drachms. 
 
 Syrup of sarsaparilla, - - - Four ounces. 
 A teaspoonful of this may be taken three times a day after meals. 
 
«»• 
 
 TUMORS OF THE NECK. 
 
 665 
 
 
 If the faithful and persevering use of these remedies fail in 
 diminishing or in arresting the growth of the tumor, electricity may 
 be employed. Cases are known in which the use of this agent has 
 scorned to arrest the growth and even to cause its disappear- 
 ance. 
 
 There are cases, however, in which the embarrassment of 
 breathing and swallowing is so great as to call for immediate relief 
 in order to save the life of the patient. In such cases the tumor 
 has been frequently removed. This is a most serious and dangerous 
 operation, which often results in the immediate death of the patient. 
 It is t,renerally undertaken only in those cases in which speedy death 
 is inevitable if the growth be not removed. In the most favorable 
 cases the patient recovers promptly from the operation, and is per- 
 manently cured. 
 
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 Tumors of the Neck. 
 
 Tumors of many different kinds grow in the side of the neck 
 and under the chin. Among the most frequent of these are enlarge- 
 ments of the lymphatic glands. These glands are present inconsid- 
 erable numbers in every individual, in that part of the neck 
 especially which lies between the side of the jaw and the 
 collar-bone. Under ordinary conditions these glands are so small 
 that they do not occasion any prominence of the skin, nor can 
 they even be felt with the finger. In certain diseased condi- 
 tions, however, the glands undergo a gradual enlargement, and 
 attain a size sufficient to cause marked prominence of the skin. 
 Such enlargement of the glands occurs in the course of acute dis- 
 eases which are accompanied with an inflammation of the throat. 
 Thus they are very common in scarlet fever and diphtheria. After 
 recovery from these diseases, the glands subside spontaneously, so 
 that in a few weeks no trace of their former dimensions can be 
 detected. In certain constitutional taints, however, the enlarge- 
 ment of the glands persists for a long while. The commonest of 
 these constitutional conditions is scrofula. By scrofula we under- 
 stand a depraved condition of the system, which occurs with 
 especial frequency in the children of consumptive parents. In fact, 
 scrofula and tuberculosis (consumption) seem to be manifestations 
 of the same unnatural condition. 
 
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6(>6 
 
 SURGICAL DISEASES. 
 
 The enlarged glands of a scrofulous child are apt to occasion a 
 great deal of trouble. For a long time they remain hard and pain- 
 less ; but, sooner or later, they become, one at a time perhaps, 
 somewhat tender. It will then be noticed that the lump is no 
 longer hard and firm as before, but has become softened and feels 
 as if it were a little sac containing a thick liquid. Such is in fact 
 the case. The gland has become softened by the formation of mat- 
 ter within it. In the most favorable cases, this matter ma\- be 
 taken back into the system without breaking the skin ; but, in the 
 majority of instances, the matter will find its way to the surface. If 
 it be allowed to break through the skin spontaneously, it usually 
 burrows for a considerable distance before escaping through the 
 skin. The result is that the neck becomes honey-combed with a 
 series of channels — techii. ally called yf.y/«/^ — which are sometimes 
 of considerable length. Thj i;»:itter oozes through these openings, 
 but little escaping during the vcn':y-four hours. Yet the aftection 
 is an extremely obstinate one, ana resists many efforts at cure. 
 
 It is therefore desirable, in the interest of the patient, that the 
 matter should be let out with the surgeon's knife rather than 
 allowed to escape spontaneously There will remain, of course, a 
 scar for every incision; but this scar is very neat, and even positively 
 handsome, when compared with the long, uneven and ragged scars 
 which remain after the matter has been allowed to burrow under the 
 skin before escaping. 
 
 Treattnent, — The treatment of these scrofulous glands must 
 begin, and in fact consists chiefly in the administration of remedies 
 which shall improve the child's general health. For this purpose we 
 rely largely upon sanitary measures. The child must be well fed 
 and permitted plenty of sunshine, air and recreation. In addition. 
 we may prescribe cod-liver oil, a teaspoonful of which may be given 
 after meals. The patient may also take fifteen drops of the s)rup 
 of the iodide of iron in water three or four times a day. 
 
 The local treatment of the glands consists first in an eftort to 
 prevent the formation of matter. This will be impossible if the 
 child be not placed in the best sanitary condition. For the purpose 
 of preventing suppuration (the formation of matter) the tincture of 
 iodine may be painted over the lump two or three times a week. If 
 this be found to irritate the skin too much, the iodine tincture may 
 
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 WRY-NECK. 
 
 667 
 
 casion a 
 nd pain- 
 perhaps, 
 ip is no 
 md feels 
 is in fact 
 1 of mat- 
 ma)- be 
 it, in tlie 
 rfaco. If 
 t usually 
 ough the 
 ed with a 
 Dmetimes 
 openings, 
 affection 
 cure. 
 ;, that the 
 :her than 
 course, a 
 positively 
 gcd scars 
 ndcr the 
 
 ids must 
 
 remedies 
 
 rpose we 
 
 well fed 
 
 addition, 
 
 be given 
 
 le syrup 
 
 The following solution will be found 
 
 effort to 
 e if the 
 purpose 
 
 nctureof 
 week. If 
 
 ture may 
 
 Four grains. 
 One drachm. 
 One ounce. 
 One ounce. 
 
 be diluted with glycerine, 
 less irritating : 
 
 Iodine, . - - 
 
 Iodide of potassium, 
 
 Glycerine, 
 
 Water, 
 
 After it has become evident that matter is already formed in 
 the 'i-land, it is advisable to have the swelling opened at once, in 
 order to avoid the burrowing of the matter and the formation of 
 troublesome fistulae, such as will otherwise occur. 
 
 If these fistuliB have once been formed, it is usually nec- 
 essary to lay them open freely with the knife in order to heal 
 them. 
 
 Wry-neck. 
 
 This peculiar distortion, in which the head is bent toward 
 one shoulder or the other (usually the right), is due to any one of 
 several causes. The most frequent cause consists in a contraction 
 of a muscle which runs from the breast-bone to the bony promi- 
 nence of the skull behind the ear. This unnatural state of contrac- 
 tion of the muscles may be the result of an inflammation, whereby 
 the muscle is bound by adhesions to the surrounding tissues, or 
 it may be merely a spasmodic affection. It occurs chiefly in feeble 
 and sickly children. 
 
 The same result — wry-neck — may occur as the effect of a 
 disease of the spine, or of some growth in the side of the neck. 
 A similar deformity results also from extensive burns of the neck, 
 since the scar which remains contracts and pulls the head down- 
 ward. 
 
 Treat iiient. — The treatment must be adapted to the cause of 
 the affection. If the difficulty results from a spasmodic or inflam- 
 matory condition of the muscle, it may be relieved by treatment 
 addressed to the general health ; tonics and medicines which regu- 
 late the stomach and bowels will be found most serviceable. If the 
 side of the neck be very tender and painful, hot fomentations should 
 be applied around the neck, and a dose of Rochelle salts or the 
 citrate of magnesia should be given. If there be no especial ten- 
 
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668 
 
 SURGICAL DISEASES. 
 
 derness upon pressure, relief from the deformity can often be 
 obtained by ironing the neck with a warm flat-iron, a piece of 
 flannel being laid over the skin. 
 
 In some cases these and all other measures fail ; in these 
 instances the condition wun be remedied by a surgical operation 
 which consists in dividing the muscle where it is attached to the 
 breast-bone and the collar-bone. 
 
 Weeping Sinew. 
 
 This term is applied to a swelling formed upon the sinews — that 
 is, the continuation of the muscles. These tumors occur most 
 frequently about the wrist and on the fingers. At first the swell- 
 ing consists of a turner, which is usually transparent enough to per- 
 mit the flame oi' a r i le to be seen through it. After it has lasted 
 for some time, and has been the seat of inflammation, the swelling 
 loses its softness and transDa'"ency. 
 
 At first such a ti.mor causes no other annoyance than results 
 from mechanical interference with the use of the fingers and of the 
 hand ; but sooner or later it usually causes a dull, heavy pain, and 
 renders the hand much less useful than it formerly was. In some 
 instances these tumors attain an extraordinary size, projecting down 
 into the palm of the hand, or upward onto the forearm. 
 
 Ti'entment, — These swellings should not be tampered with 
 unnecessarily, since if improperly treated they may occasion the 
 patient much suffering, and even imperil his life. So long as they 
 occasion no especial annoyance or pain, they may be let alone. 
 Afterward it may become necessary to take some measures for 
 relief. 
 
 It will be well to begin by rubbing the skin over the tumor 
 with pure alcohol several times a day. This has been known to 
 cause their disappearance. If there be no sign of improvement 
 under this treatment, the sac may be ruptured by a blow. This 
 will be best accomplished by laying the patient's hand upon a pillow 
 and then striking the tumor sharply with the side of a heavy book. 
 The result is a disappearance of the tumor for the time beint^, since 
 the liquid is forced out of it into the surrounding tissue. A band- 
 
housemaid's knee. 
 
 669 
 
 atre may be now applied around the arm over a piece of folded 
 lint, which is placed upon the location of the tumor. 
 
 In most cases it will be found that the swelling returns again 
 after some weeks or months. In this case it will be well to refer 
 the matter to a surgeon, since a delicate operation will probably 
 be necessary. 
 
 Housemaid's Knee. 
 
 This affection consists of a swelling on the front of the knee, or 
 rather on the upper part of the leg just below the knee. It consists 
 of an enlargement of a little sac which naturally exists over the 
 knee-pan. This sac becomes filled and dilated with watery fluid, 
 constituting a soft fluctuating tumor. The swelling may vary in 
 size from that of a hazel-nut to the dimensions of a walnut The 
 swelling is at first painless, and remains so until irritated by 
 mechanical violence ; it may then become acutely inflamed and 
 occasion much pain. 
 
 This affection is termed housemaid's knee, because it occurs 
 with especial frequency in servant girls, presumably in consequence 
 of kneelinp" upon hard, damp floors. So long as it remains painless 
 it need not be interfered with, unless it attains such a size as to in- 
 convenience the patient. In this case it may be punctured with a 
 fine needle, and the fluid allowed to escape. If it become inflamed, 
 tlio patient suffers great pain and high fever ; the knee swells so that 
 walking is impossible. 
 
 Ti'catnicnt, — During an inflammation of such a tumor the 
 patient should lie quietly in bed. Hot cloths must be wound 
 around the knee and frequently changed, in order in keep up a 
 constant warmth and moisture. In two or three days the pain and 
 swelling usually subside, and the patient's condition remains as 
 before. In other cases matter forms, ipd it becomes necessary to 
 open the swelling with the knife. 
 
 The tumor can usually be made to disappear by passing a 
 si'^o/i through it ; this consists in inserting a needle armed with 
 clean silk into and through the sac, the silk being permitted to 
 remain. This causes some inflammation, as a result of which the 
 sac gradually dries up. Several other plans of treatment are in 
 use, but can be practiced only by the surgeon. 
 
670 
 
 SURGICAL DISEASES. 
 
 Wounds. 
 
 
 There are certain general principles involved in the treatment 
 of wounds, which should be understood by all persons, cspccialh- 
 by those who are liable to be injured in the country, where the 
 services of a surgeon cannot be quickly procured. Many a life is 
 lost by ignorance of the most elementary principles of the treat- 
 ment of wounds ; principles which it is extremely easy to compre- 
 hend and by no means difficult to carry into execution. 
 
 It is a fact that the natural tendency of healthy flesh is to heal 
 a wound without the formation of matter or the occurrence of any 
 untoward accident. There is no difference in this respect between 
 the slight cuts which everyone receives occasionally, and the more 
 severe and dangerous wounds. If the individual be in good health, 
 and be free from constitutional taint, the natural course of a wound 
 is toward immediate and perfect recovery. We are all famih'ar 
 with the fact that a simple cut with a penknife usually heals with- 
 out any difficulty or danger to the patient ; yet it sometimes 
 happens that death results from an apparently trifling injury of this 
 kind. So, too, severe and extensive wounds are usually supposed 
 to heal less readily and safely ; yet the fact is that patients have 
 recovered from the most severe and dangerous injuries as nicely 
 and easily as from the cut of a penknife. Many instances are on 
 record in the annals of surgery in which recoveries have occurred 
 from the most frightful injuries. One of the most famous of these 
 is the well-known case which occurred some years ago in New- 
 England, in which a heavy iron bar — a so-called " tamping iron " 
 — was driven by a premature explosion of blasting powder, clear 
 through the head of one of the workmen ; yet the man recovered 
 perfectly without serious trouble. So, too, instances are known in 
 which persons have been literally disembowled, the abdomen being 
 ripped up by sabres, bayonets razors, the horns of enraged cattle. 
 etc., so that the intestines protruded ; yet such wounds too may 
 heal as quietly and nicely as the more trivial ones. 
 
 The difference between the rapid and uninterrupted healing of 
 a wound on the one hand, and the interruption of the proci:ss by 
 the formation of matter, the occurrence of erysipelas and other 
 accidents on the other, is usually the result of the manner in which 
 the wound is cared for and treated. There are, of course, instances 
 
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 BAISTDAGKS.-FIG. l. 
 
WOUNDS. 
 
 071 
 
 III which organs of vital importance arc injured, or in which 
 the location of the wound prevent the execution of proper princi- 
 ples of treatment ; in such instances it is often impossible for the 
 surgeon to carry out those measures which he knows to be neces- 
 sary for the rapid healing of the wound; since, in order to do so, 
 lu' would run the risk of injuring important organs, the damage to 
 which might destroy the patient's life. 
 
 A most important revolution in the treatment of wounds has 
 marked the progress of surgery in the last twenty years. It was 
 formerly expected that the wound left by the amputation of a leg, 
 for instance, would heal only after several weeks, and after a good 
 deal of matter had been formed. At the present time, on the other 
 hand, surgeons expect such wounds to heal far more rapidly, and 
 without the formation of matter to any considerable extent ; if the 
 case does not progress so favorably as this, the blame usually rests 
 with the surgeon, providing, of course, the patient is in good con- 
 dition, and the limb was healthy at the point of amputation. 
 
 It is not necessary to enter into any detailed discussion of the 
 methods employed by surgeons in the treatment of wounds. Cer- 
 tain 'funeral principles, however, must be mentioned, which can be 
 understood and applied by any one without the experience, prac- 
 tice and skill which belong to the surgeon. 
 
 We may formulate these principles, which apply to the treat- 
 ment of all wounds, in the following way : 
 
 First. — Stop the bleeding. 
 
 Second. — Cleanse the wound thoroughly from all foreign mat- 
 ter as well as from blood clots, unless these are necessary to pre- 
 vent bleeding. 
 
 Third. — Restore the parts to their natural position so far as 
 possible. 
 
 Fourth. — Keep the wounded member perfectly quiet. 
 
 In order to stop the bleeding it becomes necessary, of course, 
 to prevent the blood from flowing to the surface of the wound. 
 The exact method for accomplishing this may vary somewhat i-^ 
 ditilercnt cases ; but in general it may be said that we can temp^i 
 arily check the bleeding at once by compressing the edges of the 
 wovmd. Thus if the scalp be wounded by a knife, there will occur 
 a profuse flow of blood which may in a short time obscure the 
 woiuul and be sufficiently profuse to render the patient faint. In 
 these cases we can at once stop the bleeding partially or completely 
 
 
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 67: 
 
 SURdlCAI- DISKASES. 
 
 by simply compressing^ the edges of the wound. So in j^eneial we 
 may control the bleeding, to a certain extent, by simple jiressiiio ; 
 if the wound be in a soft part the pressure should be exertid In- 
 taking hold of the bleeding edge with the fingers and compressini^ 
 the severed bhiod vessels in this way. 
 
 Cuts about the head are especially troublesome for the non- 
 professional to manage, for several reasons: first, because the >c,iln 
 is richly supplied with blood vessels and the bleeding is conse- 
 quently apt to be very profuse. The appearance of an individual, 
 who has received even a slight scalp wound, is apt to be unpleasant 
 and terrifying in the extreme ; for the blood streams down ny^r- 
 the face, giving the pers(jn an unnatural and alarming apijcarancc, 
 and the clotting of the blood in the hair conveys the imj)n.-siuii 
 that the injury is really quite extensive. Another difficulty is the 
 trouble in finding the actual extent of the wound, since it in ron- 
 cealed by the hair. It will usually be found, after the blond is 
 washed off and the hair has been clipped away, that the iiiiurv is 
 really far less extensive than was supposed ; for a conipaiati\Llv 
 slight wound in the scalp is usually followed by considerable hem- 
 orrhage. 
 
 The next measure to be taken in arresting the flow of blodd is 
 fo tic llic bleeding vessels. This operation should be left tu tjic 
 surgeon, unless the bleeding is very profuse and cannot be arrested 
 by pressure. If it become absolutely necessary to take some addi- 
 tional measures other than compression, for the stoppage of the 
 bleeding, it will be best to bathe the cut surface with ice-cold water 
 or with very hot water. The latter is sometimes remarkabU- ciTi- 
 cient in stopping the bleeding. If the blood still flow, a ijiccc nf 
 soft cloth should be folded into a pretty firm mass, wet witli w.iier 
 and inserted into the wound in such a way as to cover the surface 
 where the bleeding is most profuse ; pressure may then be made 
 upon this for a few minutes, at the end of which time the I)keding 
 has usually ceased. This folded cloth will be still more efticicnt in 
 controlling the escape of blood if it be sprinkled over with puw- 
 dered tannin or alum ; these agents act as astr':ngeuts — that i-, they 
 have a tendency to close the cut ends of the vessels. 
 
 If the wound be located on the arm or leg, the bleeding can 
 often be stopped without applying any astringents directly to the 
 injured surface. It is always better to keep everything out of the 
 wound (except water) until the surgeon's arrival ; for the Iiealiiii^ of 
 
 i» ii 
 
WOLNUS. 
 
 673 
 
 M 
 
 the wound is apt to be dclaycil by the presence of substances 
 which are introduced after the wouiul itself has been made. If 
 tlir injitry be located in the arm or lej,', it will be well to compress, 
 iidt tlu' cd^es of the wound itself, but the limb at some point 
 bttwecii the wound and the body, l"'or the blood j^oes into the arms 
 iiiid li'i,'s through lari;e blood vessels — artifiis — the location of 
 which can be easily ascertained ; and by compressing these arteries 
 we shut off the flow of blood to the entire limb, and, of course, 
 stop the bleeding from the wound. 
 
 The large artery which supplies most of the blood to the lower 
 cNtroniity passes from the trunk to the limb cjuite near the front 
 siufacf (if the body. If we place a finger upon the skin of the 
 rriiin about halfway between the bony prominence of the hip-bone 
 and the inner surface of the thigh where it joins the body, we can 
 usually feel, upon slight pressure, the beating of the artery. In 
 fact, unless the individual be somewhat fleshy, the regular rise and 
 fall of the skin can be distinctly seen when the person is bared. 
 In case of a wound in the lower extremity we can, therefore, arrest 
 the flow of blood by firm pressure upon the artery just at the fold 
 of the groin. 
 
 If for any reason it be impracticable to employ this means of 
 compressing the vessel, the same result can be attained, though less 
 neatly and ccmipletely, by .tying a cloth around the thigh. Some 
 soft material, such as a large folded handkerchief or towel, should 
 be employed for this purpose, since it w ill be necessary to tie the 
 limb tit^htly, an operation which will injure the skin if such hard 
 materials as rope be used. The best place for compressing the 
 limb in this way is about four inches above the knee-pan, where the 
 artery lies close to the thigh-bone. 
 
 In case of bleeding from a limb, benefit will be derived by 
 keeping the limb elevated, since the flow of blood will naturally be 
 diminished by such position. 
 
 Tiic artery which supplies the blood to the arm passes from the 
 body across the armpit just below the head of the bone of the arm. 
 Tills artery may be compressed most advantageously at a point 
 about one-third of the way from the shoulder to the elbow. By 
 pressing the fingers firmly against the side of the arm next to the 
 body at this point, we may feel the beating of the artery. Firm 
 pressure against the bone of the arm will arrest the flow of blood 
 through the vessel and stop the bleeding at any point below. 
 
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 674 
 
 SURGICAL DISEASES. 
 
 It will usually be advisable, however, to tie a towel tightly 
 around the arm, since this limb is not so fleshy as the thigh, and 
 pressure exerted in this imperfect way is usually quite sufficient to 
 stop the bleeding. 
 
 If for any reason the arm cannot be compressed at this poiiV. ; 
 if, for example, the wound extend almost or quite to the shoulder, 
 there is still another way for arresting the bleeding by pressure, for 
 the artery which goes to the arm passes across the front of the 
 chest just behind the collar-bone; in this position it lies above the 
 first rib. We can, therefore, compress the vessel by exerting pres- 
 sure against the first rib just behind the collar-bone, near the point 
 of the shoulder. This can be done with the thumb or by means of 
 a large door-key, which should be first wrapped with a handker- 
 chief in order not to injure the skin. 
 
 Additional advantage in checking the flow of blood is obtained, 
 if the wound be situated below the elbow or below the knee, by 
 bending the arm firmly at the elbow or the leg firmly at the knee. 
 In this way the artery is compressed, since it runs across the joint 
 in such a way as to be pressed by this position of the limb. A 
 bandage may then be put around the arm or leg so as to hold it 
 firmly in this bent position. 
 
 It should be remembered that the flow of blood is necessary 
 to the life and welfare of the tissues composing a limb ; hence it is 
 not advisable that a bandage which cuts oft' the flow of blood to 
 the entire arm or the entire leg should be allowed to remain more 
 than an hour; it will be much better to remove it before the 
 expiration of this time, and to observe whether the blood still flows 
 from the wound. 
 
 By the means thus described, bleeding may be checked from 
 all wounds of the extremities ; but wounds in the palm of the hand 
 or sole of the foot are especially dangerous, and should never be 
 permitted to go without the advice of a surgeon. For the arrange- 
 me-' of the blood vessels in these parts of the body is pecidiar; 
 and an injury to the arteries at these points may result in the loss 
 of the hand or foot, even though the bleeding apparently ceases 
 for a short time after the use of the measures already indicated. 
 It is often necessary in the treatment of such wounds to perform 
 an operation whereby the leading artery can be tied higher up in 
 the arm or leg. 
 
BLEEDING FROM THE MOUTH. 
 
 Bleeding from the Nose. 
 
 675 
 
 This accident is rarely attended with danger; even when the 
 bridge of the nose is crushed by a blow, the bleeding is usually 
 checked without the use of any other measures than those which 
 have been already described. In most cases it will suffice for the 
 patient to sit erect while the back of the head and neck are bathed 
 with ice-water. If this be not sufficient to arrest the bleeding, a 
 solution of alum in cold water may be injected up the nostrils with 
 a syringe. In other cases it has been found that bleeding from the 
 nose can be checked by inhaling the vapor of warm turpentine. 
 
 In some cases it becomes necessary to resort to mechanical 
 means in order to arrest the bleeding. This is, to a certain extent, 
 working in the dark, since it is not always possible to ascertain from 
 what point the blood issues. It is always better to summon a 
 medical man in cases of bleeding from the nose which resist the 
 measures already described ; but in the meantime a piece of soft 
 cloth, such as an old handkerchief, may be rolled into the shape of 
 a cone of such size that it can enter the nostrils easily. This may 
 be wound with thread so as to make it firm and yet leave the sur- 
 face smooth. After being dipped in alum water or spirits of 
 turpentine, this plug can then be gently introduced into the nose 
 and allowed to remain there. 
 
 At times it becomes necessary to plug the nostrils where they 
 open into the throat as well as in front. This operation can scarcely 
 be performed by any one except a surgeon. Some individuals 
 have a bleeding from the nose periodically, and seem to feel better 
 after it. J^ich persons usually feel dull and stupid and suffer from 
 headache for a day or two before the bleeding occurs. 
 
 Bleeding from the Mouth. 
 
 Blood which escapes from the mouth may come from any one 
 of several sources ; the most frequent of these arc the throat, the 
 stomach and the lungs. The mouth itself rarely bleeds, except as 
 the result of mechanical violence. Another source for the blood 
 which may issue from the mouth is the nose, for bleeding from the 
 
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 SURGICAL DISEASES. 
 
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 nose sometimes occurs at a point so far back in the nostrils that 
 the blood escapes backward into the throat instead of running from 
 the nose onto the face. Blood which thus falls into the throut is 
 usually swallowed, and may not be noticed until the patient vomits, 
 when it will be supposed that the blood is escaping from the 
 stomach. This is a somewhat rare occurrence — that is, it seldom 
 happens that the blood escaping from some point in the nostrils 
 gets into the stomach without also issuing from the nose ; the 
 possibility of it must, however, be borne in mind. 
 
 We can usually discover from the appearance of the blood as 
 well as from the manner of its ejection, whether it proceeds from 
 the stomach or from the lungs. It is, of course, an important 
 point to decide, both as to the treatment required and as ' .e 
 significance for the patient. 
 
 When blood escapes from the stomach, it is distinguished by 
 the following features : 
 
 First. — It is almost invariably of a darker color than that 
 which we designate " red " blood, and also darker than blood 
 which escapes from the lungs. It often resembles coffee-grounds 
 in appearance. This remark may not apply if the blood escapes 
 suddenly and in large quantity into the stomach, for in this case it 
 may have the usual bright red hue. 
 
 Second. — The blood issues from the stomach chiefly during the 
 act of vomiting, while it is ejected from the lungs mostly by congli- 
 ing. A feeling of sickness at the stomach is frequently present 
 when the blood proceeds from this organ. 
 
 Third. — The blood which comes from the stomach is often 
 mixed with particles of food. 
 
 Bleeding from the lungs is apt to occur suddenly and without 
 any warning in the shape of nausea or vomiting. It frequently 
 happens that the patient is suddenly seized with a violent fit of 
 coughing, during or after which a gush of bright red blood csca[)es 
 from the mouth and nose. 
 
 We can, therefore, recognize the source of the blood when it 
 proceeds from the lungs : first, by its bright red color ; scconil, by 
 its appearance during the act of coughing ; and third, by tlie 
 absence of premonitory symptoms. 
 
 Whenever blood escapes into the throat, whether it have pro- 
 ceeded from the lungs or the nose, some of it will be swallowed. 
 In this case the patient frequently vomits, and hence blood may be 
 
BLKEDINi; FROM THE BOWELS. 
 
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 ejected which has the characteristic dark color and appearance of 
 cdiVoe-grounds ; yet in these cases there need be no affection of the 
 stomach whatsoever. 
 
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 Bleeding from the Bowels. 
 
 When blood escapes from the bowels the patient is usually 
 r.fflicted with hemorrhoids, or " piles. " Bleeding from this source 
 need occasion no alarm ; indeed the patient's sufferings are usually 
 alleviated by it. 
 
 In other cases an escape of blood from the bowels is a 
 svmptom of disease higher up in the intestine. The affection 
 which is most frequently accompanied by hemorrhage from the 
 bowels is typhoid fever. In this disease severe bleeding some- 
 times occurs ; and in some cases but little blood escapes from 
 the body, so that the patient may even die from unsuspected loss of 
 blood into the bowel. 
 
 We can usually distinguish blood which escapes from some 
 point high up in the bowel from that which comes from piles by the 
 color ; blood which issues from piles is usually of a bright red color, 
 while that which proceeds from the upper part of the intestine is 
 {Generally very dark, or even black ; its true nature may in fact 
 escape detection, since it looks very much like pitch. 
 
 Trcfitinenf, — In every case in which blood escapes from the 
 internal organs — the lung, the stomach or the bowels — medical 
 advice is required immediately. Until such assistance can arrive, 
 ^ome of the following measures maybe employed with the hope of 
 arresting the bleeding. 
 
 Bleeding from the stomach should be treated by giving the 
 patient pounded ice freely and telling him to swallow it at once. 
 This may be followed by a teaspoonful of milk or water containing 
 fifteen drops of the spirits of turpentine ; this dose may be repeated 
 ill a quarter of an hour if necessary. It will be well not to burden 
 the patient's stomach with many remedies, since to do so will simply 
 provoke vomiting, whereby the bleeding may be increased. If the 
 ice and the turpentine have been administered, nothing further or 
 better can be done. If these agents be not obtainable, a teaspoon- 
 
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 SURGICAL DISEASES. 
 
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 IS 
 
 ful of alum or of tannin may be dissolved in a glass of water, a 
 tablespoonful of which should be given to the patient every twenty 
 or thirty minutes. 
 
 If drugs can be readily obtained, the patient should have 
 instead of the alum or tannin, a half teaspoonfnl of the tincture of 
 ergot ; this dose may be repeated at the end of fifteen or twenty 
 minutes. 
 
 Bleeding from the lungs should be treated by permitting the 
 patient to inhale the vapor of warm turpentine. A convenient way 
 for accomplishing this is to pour an ounce or two of turpentine into 
 a teapot filled with boiling watet", the patient applying the mouth 
 near to the spout of the ves' i. Or turpentine may be poured 
 upon a napkin which is folded into the shape of a cone and applied 
 over the mouth and nose ; the patient should take deep breaths, 
 and the turpentine must be renewed as soon as it evaporates. The 
 chest may be meanwhile rubbed with brandy and water ; the 
 patient should be held in the sitting posture, the shoulders sup- 
 ported by a pillow ; he should be enjoined not to struggle nor 
 talk. 
 
 A popular remedy for bleeding from the lungs, as well as from 
 the stomach, is common salt. A teaspoonful of this may be mi.xed 
 with pounded ice, if nothing better can be obtained. 
 
 Bleeding from the bowels should be treated by giving half a 
 teaspoonful of the spirits of turpentine in a tablespoonful of milk, 
 and by the application of cold cloths over the abdomen. If tlicsc 
 measures do not suffice, ice-water maybe injected into the rectum, 
 or pieces of ice wrapped in soft cloth may be inserted into the 
 bowel. In these cases the tincture of ergot is a valuable remedy; 
 half a teaspoonful of this may be given, and a similar amount taken 
 at the expiration of fifteen or twenty minutes. The patient should 
 of course lie perfectly quiet, and resist, so far as possible, the 
 inclination to evacuate the bowel. 
 
 Bleeding from the Urinary Organs. 
 
 Blood frequently escapes from the body mixed with the urine, 
 and it becomes important to know the source from which, it pro 
 ceeds. It may escape from any part of the urinary tract from the 
 kidneys down. If it proceed from the kidneys, the patient rarely 
 
FAINTING. 
 
 679 
 
 detects the nature of the substance, because the urine does not 
 present the usual red color of blood, but appears of a smoky hue. 
 
 If the blood appears in the urine, with its usual bright red 
 color, it has probably escaped from some point in the bladder, or in 
 the urethra. In women, it may, of course, have entered the urine 
 from the vagina. 
 
 Bleeding from the bladder is a symptom of several affections. 
 The most common of these is a severe inflammation of the bladder ; 
 this will be recognized by the other symptoms present, such as the 
 (Treat pain and frequent desire to pass water. Another source of 
 blood in the urine is a tumor of the bladder. Such tumors are apt 
 to occur in young or middle-aged men, and may cause no otiier 
 symptoms than the bleeding. A microscopical examination of the 
 urine will detect the nature of the difficulty. 
 
 Bleeding occurs from the bladder also in cases of stone in the 
 bladder. In such cases there is usually considerable pain and 
 frequent desire to void urine. The pain is greater when the patient 
 exercises violently, and is usually less severe when he rests quietly 
 i-n bed. 
 
 Bleeding may also occur from the neck of the bladder in 
 patients who have had gonorrhoea. In such cases the blood appears 
 at the end of the act of urination, and is therefore not mixed with 
 the urine. If the bleeding proceed from the bladder, on the other 
 hand, the blood is mixed with the urine and escapes during the 
 entire act of urination. 
 
 Bleeding may also occur from tumors in the urethra. These 
 can be recognized only by a surgeon well versed in the diseases of 
 the L;enital organs. 
 
 Fainting. 
 
 This subject may be noticed appropriately in connection with 
 loss of blood, since it frequently results from this cause. 
 
 Fainting, swooning, or, as it is technically called, syncope, is 
 the result of a sudden weakness in the beating of the heart. At 
 times, indeed, the heart actually ceases to beat for a moment. As a 
 result, the blood is no longer propelled throughout the body, and 
 the arrest of its flow to the brain results in a cessation of the func- 
 tions of this organ. Prominent among these functions is, of course. 
 
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 680 
 
 SURGICAL DISEASES. 
 
 consciousness ; hence fainting consists, primarily, in a loss of con- 
 sciousness from weakness of the heart. 
 
 The brain has, however, several duties to perform in rcguhitiii" 
 the different functions of the body, in addition to its work in carryin^r 
 on mental operations. One of these functions, which depends directly 
 upon a stimulus derived from the brain, is breathing. Ilcncc 
 whenever the brain ceases to act for a moment, the breathing stops. 
 This constitutes another prominent feature of fainting. 
 
 Fainting is, therefore, essentially the beginning of death, since 
 both the circulation of the blood and the breathing are arrested, 
 In some cases, indeed, death ensues, since these functions arc not 
 resumed. In the majority of cases, however, the beating of the 
 heart commences after a few seconds or a few minutes. The rush 
 of blood through the brain revives this organ, and sets in motion 
 again the apparatus which is regulated by the brain ; the breathing 
 begins ; the consciousness returns ; the individual " comes to. " 
 
 Fainting may occur from any cause which interferes with the 
 action of the heart. Thus a violent emotion may arrest the con- 
 traction of the heart ; over-exertion of the body may accomplish 
 the same result. Loss of blood is also a frequent cause ; blows in 
 the region of the heart, on " the pit of the stomach," are efficient 
 causes ; general debility, such as results from lack of food, may 
 cause fainting. 
 
 SfiniptomH. — Fainting is so familiar to all that detailed 
 description is unnecessary. The face becomes suddenly pale and 
 assumes even a ghastly hue ; the breathing becomes rapid and 
 shallow; the pupils of the eyes increase in size ; the individual 
 becomes dizzy and weak, so that he is no longer able to stand 
 erect, and falls to the ground unless supported. The sufferer 
 describes his sensations as a feeling as if everything were " swimming 
 around. " This is usually the last thing that he remembers. 
 
 The important point with reference to fainting consists in the 
 recognition of this condition as distinguished from others in which 
 the individual loses consciousness. For there are several other 
 bodily states which are accompanied by sudden loss of conscious- 
 ness during whicb the patient falls. The most frequent and im- 
 portant of these are epilepsy, hysteria and apoplexy. A detailed 
 description for distinguishing between these affections has been 
 already given in the chapters devoted to these diseases ; it will suf- 
 
FAIN riNC 
 
 68 1 
 
 ficc to mention here a few prominent points which characterize 
 tliese various aftections. 
 
 Ill c/^ili'psy the patient usually screams at the moment of fall- 
 ing, •iii'l li's body becomes rigid, and a few moments afterward 
 distorted by violent convulsions. He foams at the mouth, and liis 
 face assumes a livid hue. 
 
 In lirstcria there is never a complete lack of consciousness ; 
 the patient does not exhibit the same ghastly pallor and muscular 
 weakness characteristic of fainting. Furthermore, she usually 
 nianaf'^es to have a few convulsio-is before recovering. 
 
 In apoplexy the individual breathes loudly and deeply, the lips 
 arc puffed out during respiration, the pupils are usually contracted 
 to a \cry small size, and the pulse is full and strong. 
 
 In most cases the circumstances surrounding the individual 
 point with sufficient clearness to the nature of the difficulty. 
 
 Tfcattnent, — The most important point in the treatment of 
 a fainting person is to place the patient flat upon his back, without 
 a pillow. Indeed we may sometimes to advantage lower the 
 head, and even hold the individual in such a posture that the body 
 and legs shall be on a higher level than the head. The object of 
 this position is, of course, to get as much blood to the brain as 
 possible; it is, indeed, merely an attempt to secure by the force 
 of gravity the effijct which is ordinarily accomplished by the con- 
 tracliiui of the heart. In most cases the patient revives in a few 
 moments if allowed to lie quietly upon the floor or upon a bed, 
 and be permitted to breathe plenty of fresh air. Care should be 
 taken to prevent bystanders from crowding around the fainting 
 person ; windows or doors should be opened, so that air may be 
 atlniitlcd. 
 
 The clothing should be loosened around the neck and chest. 
 Cold water may be dashed upon the face, or upon the breast if this 
 be bare. A bottle of hartshorn may be held about three or four 
 inches from the nostrils, so that its vapor is taken into the lungs. 
 
 These measures almost invariably restore the individual if the 
 conditiini be merely that of fainting from ordinary causes; if they 
 be inefficient, an ounce of whisky or brandy may be mixed with 
 the same quantity of warm water and injected into the rectum. 
 
 After the patient shows signs of returning consciousness, he 
 should not be permitted to rise nor even to raise the head f'"om the 
 bed ; a low pillow may be put under the head for comfort. 
 
 
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682 
 
 SURGICAL DISEASES. 
 
 Treatment of Wounds. 
 
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 In the discussion of wounds, it was stated that the first object 
 of treatment was to arrest the bleeding, the various means fi)r 
 accomplishing which have been already narrated. 
 
 The next object is to cleanse the ivonnd. The importance (if 
 this measure cannot be over-estimated ; the execution of it makes 
 all the difference between a rapid and painless healing of the injiiiy 
 on the one hand, and the formation of matter and other accidents 
 on the other. 
 
 The exact details for cleansing the wound vary according to 
 the nature and location of the injury. In general, the best plan 
 consists in filling a syringe with clean, cold water, which should 
 then be gently squirted into the cut in all directions. It is often 
 necessary to raise the cut edge of the skin in order to direct the 
 water into the cavities of the wound. This is especially true of 
 wounds of the scalp ; for in such injuries it frequently happens that 
 the scalp is detached from the skull for a considerable distance 
 away from the edge of the cut. If foreign bodies (particles of dirt, 
 pieces of clothing, etc.,) be allowed to remain, the wound will not 
 heal nicely ; it will remain open at some point for a long time and 
 discharge considerable matter ; furthermore, there is., under such 
 circumstances, danger of the occurrence of erysipelas. 
 
 While we are thus careful to remove all foreign substances 
 from the wound, we must be equally cautious in preventing the 
 introduction of any matters which can injure the tissues. Care 
 should be taken to employ only clean instruments and clean water 
 in handling the injured part ; and the hands themselves should be 
 scrupulously cleansed before being allowed to come into contact 
 with the wound. If time can be obtained, it will be well to procure 
 some disinfectant in order to wash the wound, and to employ as a 
 dressing. For this purpose, carbolic acid may be used ; care must 
 be taken, however, not to bring the strong acid in contact with the 
 wound, since it will burn the parts severely. A solution of the 
 acid in water can be employed, one part of the acid to twenty-five 
 or thirty parts of water being about the best proportion. After 
 mixing the acid with the water, the solution should be thoroughly 
 shaken or stirred in order to secure thorough mixture ; otherwise 
 drops of the pure acid may remain in the water and cause a severe 
 burning when applied to the wound. 
 
TREATMENT OF WOUNDS. 
 
 6S3 
 
 Carbolic acid is objectionable in many respects as a disinfect- 
 ant for popular use ; many accidents have happened through care- 
 lessness or ignorance in substituting the strong acid for the proper 
 solution in water ; moreover, it takes time to prepare and 
 tlioroii^dily mix the acid. For these reasons, it is desirable to 
 have some other substance which can be prepared for use more 
 niiickly, and which cannot, even in the hurry and excitement con- 
 sequent upon an accident, be carelessly or ignorantly employed to 
 the patient's disadvantage. The best agent which can be kept on 
 hand for use in the household treatment of wounds, is a solution 
 of several of our best disinfectants which is sold under the name of 
 " Lambert's listerine. " This preparation has come into general use 
 among physicians as a most pleasant, reliable and convenient 
 dressing for wounds. It will keep indefinitely, and hence, may be 
 constantly kept in the house for use in emergencies. This liquid 
 should be diluted with water in washing out fresh wounds, one 
 part of the listerine being mixed with four parts of water. 
 
 After the wound has been washed out, care should be taken 
 to restore the injured parts, so far as possible, to their natural posi- 
 tion and to keep them there. If the edges of a wound are allowed 
 to "■ap'^ widely, the process of healing will be a slow and tedious 
 one. and will probably be complicated by a profuse production of 
 
 matter. 
 
 In order to accomplish this object the edges of the wound should 
 be "-ently dried with a soft towel. Any blood clots which may lie 
 in the cut or around its edges should be gently and carefully re- 
 moved. If these seem to be firmly attached, or if they are formed 
 at a point which has recently bled profusely, it will be well not to 
 touch such clots of blood ; for their removal might be followed by 
 a recurrence of the bleeding. 
 
 The edges of the wound should then be drawn together so far 
 as the nature of the injury permits. To hold them in position sur- 
 geons resort to three dififerent measures, which may all be employed 
 in the treatment of the same wound. 
 
 The first of these measures is the application of stitches. This 
 is a delicate operation, which can moreover be made to inflict con- 
 siderable injury rather than benefit, if performed by unskillful hands. 
 It is, therefore, advisable for the non-professional bystanders to re- 
 frain from any attempt to stitch up the wound, leaving this to the 
 discretion of the surgeon upon his arrival. 
 
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684 
 
 SURGICAL DISEASES. 
 
 The second means for closing a wound is the application uf 
 sticking-plaster. The best variety of plaster is that which ih made 
 for surgical use. This can be applied, however, only by a snmc- 
 what practiced hand. The best form for popular use is, pcrliaps, 
 that which is known as the " Mitchell Novelty " plaster, i)r ,i kind 
 which is called Martin's adhesive plaster. One or both of tliL^c 
 may be kept in the house for emergencies. If there be notliiiio at 
 hand except the common " court plaster," or some of the nuuurdus 
 " moisture plasters," these maybe employed until something better 
 can be obtained. 
 
 This plaster should be cut into strips from one-quarter ti> one- 
 half of an inch in width, and long enough to secure a firm lioUl on 
 the skin on either side of the cut. The exact length will of course 
 vary, according to the location of the wound. The vicinity of the 
 injured part is then again cleansed and dried. If the wound be upon 
 the head, or other part of the body covered with hair, the liair 
 should be clipped as closely as possible on both sides of tlie wonnd 
 in order to give the plaster an opportunity to adhere to the skin. 
 
 The strips of plaster should be applied one at a time, usually 
 at right angles to the length of the wound. In order to accomplish 
 this nicely, the edges of the wound should be carefully drawn to- 
 gether and held in position by one person while another applies the 
 plaster. A strip should be applied to the skin on one side of the 
 cut and at one or the other end of the wound, the middle of the 
 strip being held over the injured skin. This is made to adhere upon 
 one side of the cut, and while it is pressed firmly against the skin 
 with one hand, it is gently drawn to the opposite side of the wound. 
 The plaster is then pressed firmly to the skin on the other side of 
 the cut, beginning close up to the opening. After it is attached at 
 this point the remainder of the strip may be spread out and firmly 
 pressed to the skin. A second strip of plaster is then ai)[)lied in 
 the same way, and so that its edge shall touch that of the first strip. 
 If there be much tendency to gaping of the wound, it will be better 
 to apply the second strip, so that its edge slightly overlaps that of 
 the one already applied. A third strip is then placed in position in 
 a similar manner, and so on until the wound has been closed along 
 its entire length. 
 
 If the wound be a deep one, or if the edges be n-^t clean cut, 
 it will be well not to close the entire wound, but to leave the lower 
 end of it uncovered ; the object of this is to permit the escape of 
 
TREATMENT OF WOUNDS. 
 
 685 
 
 matter and blood which may be formed and ooze into the wound. 
 If the cut be closed along its entire length, and matter should be 
 subsequently formed, the healing process will be retarded, the 
 cdL'es of the cut will swell and fail to unite ; by leaving an opening 
 throu'^h which the matter can escape, we can at least secure li^aj- 
 intr for the wound through the greater part of its extent. In such 
 a case it will be advisable not to place the strips of plaster in con- 
 tact, but to leave spaces between adjacent strips, so that the matter 
 can escape at several points, if necessary. 
 
 If the wound be not a deep one, no further dressing is required 
 than a simple wet cloth. This may be kept in position by a band- 
 age pinned somewhat tightly around the injured part. 
 
 If, however, the wound be a deep one, so that it penetrates 
 throu'^i the skin and fat into the red flesh beneath, it is necessary 
 to employ the remaining means for keeping the parts in their nat- 
 ural position. This third measure consists in the application of a 
 bandage and compress. 
 
 By a compress we mean simply a piece of lint or soft cloth, 
 folded so as to make three or four thicknesses, and wet with cold 
 water. This is laid upon the wound so as to cover the edges and 
 the skin in the immediate vicinity. A stout muslin bandage may 
 then be snugly applied to the limb, so as to exert considerable 
 pressure upon the edges of the wound, though not so tightly as to 
 cause the patient much pain. 
 
 The fourth object in the treatment of wounds is an effort to 
 secure perfect rest for the injured member. The location of the 
 injury must of course determine just what is necessary in order to 
 keep the part in perfect repose. If the injury has been inflicted 
 upon the lower extremity, the individual should keep the recum- 
 bent posture ; if the arm be the seat of the injury, a bandage or 
 sling should be arranged so that the patient cannot thoughtlessly 
 use the arm, or even the fingers. This is an important item of 
 treatment, the neglect of which will retard the process of healing, 
 or even cause the half-healed wound to break out afresh. 
 
 If the injured member feels perfectly comfortable except for a 
 slight smarting, the dressing need not be changed for a day or two; 
 in fact, if the cut be not deep, a single dressing often suffices, and 
 may be allowed to remain for a week or ten days. If, however, 
 the wound be the source of pain, the bandage and the compress 
 should be removed and fresh ones substituted, the bandage being 
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 686 
 
 SURGICAI DISEASES. 
 
 this time applied somewhat more loosely than before. If the stick- 
 ing plaster become loosened and the edges of the wound show a 
 tendency to separate, fresh strips should be applied. This is a mat- 
 ter requiring considerable tact and delicacy ; two or three iioints 
 shouiJ never be forgotten. First, each strip should be lot)sciutl at 
 both ends, which are then lifted at the same time, so as to separate 
 the plaster from both sides toward the cut, thus detaching tlir ])las. 
 ter last from the very edges of the wound. The object of this is, 
 of course, to prevent these edges from separating, as will iisiiallv 
 occur if we simply loosen the strip at one end and then pull it from 
 the skin. A second point in applying the new strips is, care to put 
 on each fresh strip before the old one lying next to it has hixMi 
 removed ; the strips are, therefore, replaced one by one succes- 
 sively. If we take off all the plaster before applying the ficsh 
 strips, the edges of the wound are left without any support and may 
 fall apart. 
 
 If there is no discharge of matter from the wound, no finthcr 
 dressing will be required than those mentioned. If, on the other 
 hand, matter be formed, it will be necessary to arrange the bandage 
 so that pieces of lint or soft cloths wet with cold water can be 
 kept constantly applied. If the solution of listerine above men- 
 tioned be at hand, these cloths may be wet with this liquid instead 
 of simple water. 
 
 Care must be taken to secure the free discharge of matter from 
 the wound, and to prevent its accumulation in the dressings. For 
 this purpose the dressings (all except the plaster) may be removed 
 two or three times a day — or oftener, if necessary, to keep the 
 wound clean — and the surface should be washed with the listerine 
 solution. A sponge should be wet with this solution and squeezed 
 so that the liquid falls upon and washes the surface. 
 
 If the edges of the wound be reddened and elevated, there is 
 probably some collection of matter underneath. In this case the 
 wound should be syringed out very gently with the listerine and 
 water. The syringe used for this purpose should be of hard rubber 
 and should be carefully washed and cleansed every time it isuset 
 
 With this treatment the wound can usually be h' ' ; )Ut 
 
 the occurrence of any untoward accident. 
 
 It should be remembered that a wound is someti, the scpt 
 of severe inflammation, especially that form which is known as t -3'- 
 sipelas. The occurrence of this accident is indicated by a diffuse 
 
PUNCTURKD WOUNDS. 
 
 687 
 
 redness and swelling of the edges of the wound; at the same time the 
 patient usually has a severe chill, or series of chills, followed by a 
 hif^h fever. For a complete description of the disease, the reader is 
 nforred to the chapter on erysipelas. 
 
 Another complication which sometimes follows upon wounds is 
 the occurrence of blood-poisoning — technically called pywinia. 
 This accident is, however, seldom met with after simple wounds of 
 the flesh, being commonly observed in cases of injury in which a 
 bone has been damaged. 
 
 Punctured Wounds. 
 
 Hitherto we have referred chiefly to wounds made with sharp 
 instruments, whereby the flesh is cut cleanly Such wounds are 
 called incised wounds. There arc, however, injuries which claim 
 especial attention, from the character of the wounds inflicted. The 
 treatment varies somewhat, according to the nature of the wound 
 ami the way in which it was received. 
 
 Surgeons divide wounds, for convenience of description and 
 discussion, into four classes: incised, punctured, lacerated and con- 
 fined wounds. The special features of these are indicated by the 
 iMines. A punctured wound is made by a pointed instrument, such 
 as a needle or a bayonet. 
 
 A lacerated wound is an injury to the flesh, by which the skin 
 and siift parts are torn. 
 
 A contused wound is one in which the flesh is extensively 
 bruised. 
 
 Punctured wounds are made by many different instruments. 
 The cc-mmonest ones result from the entrance of pins, tacks, nails, 
 splinters of wood and the like, into the flesh. These wounds are 
 often more serious than their extent would seem to indicate. This 
 fact seems to result from the nature of the opening into the flesh, 
 ind from the tendency of the skin «ad muscles to close after the 
 nstrunient is withdrawn. The injurious effects are often due to the 
 accunnilation of matter or blood in the bottom of the wound. The 
 outer part heals over, but matter forms within, causing heat, red- 
 ness and swelling of the skin. After a time the wound may break 
 open attain or a serious inflammation may proceed from this point 
 and invdve the surrounding skin. 
 
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 688 
 
 SURGICAL DISEASES. 
 
 Another accident which often accompanies punctured wounds, 
 is the entrance of some foreign matter with the instrument. This 
 matter may be scraped off by the flesh and remain in th j wound, 
 where it will excite inflammation. 
 
 The danger of a punctured wound depends upon the organs 
 injured, upon the size of the wound, but especially upon the condi- 
 tion of the instrument with which it was made. A wound made 
 with a clean instrument, or in such a way that it can be readily 
 washed out, is not especially dangerous; but when the injury is 
 inflicted by rough and dirty instruments, such as a rusty nail, heal- 
 ing does not occur rapidly nor kindly. In these cases the tissue is 
 usually bruised and lacerated along the track of the wound, so that 
 much of it mortifies and excites irritation, just like the presence of 
 a foreign body. In such cases there is apt to be also some dirt or 
 sand or the rust of the nail left in the bottom of the wound. 
 
 There is still another feature which renders a punctured wound 
 especially dangerous ; this is the liability to the occurrence of 
 lock-jaw. This disease seems to ioUow injuries inflicted with dull, 
 rather than sharp instruments, and seems to result from *^hc bruis- 
 ing of a nerve somewhere in the course of the wound. 
 
 Punctured wounds are, of course, especially dangeroas wherever 
 the flesh is fir.n r d bound together by strong sinews and sheaths ; 
 this condition prevails especially in the palm of the hand and the sole 
 of the foot. It has been already mentioned that even ci uui-cut 
 wounds are to be watched with especial care when they are made 
 in the hand or foot ; and this caution is doubly necessary if the 
 wound be not clean cut or incised, hut putictitred. 
 
 The smaller punctured wounds are often more dangerous than 
 those inflicted with larger instruments, simply because they afford 
 less opportunity for the escape of matter and foreign particles. 
 
 Treatment. — In treating a punctured wound, we should first 
 of all extract the instrument which has inflicted the injury, if it 
 still remains in the wound ; auu we should be careful to ascertain 
 that no fragment has broken off and remained in the flesh. Thus, 
 when a splinter of wood has entered the skin, a piece of it is 
 almost certain to remain imbedded in the flesh. If this be allowed 
 to stay, matter will form around it and a sore will be formed pro- 
 portionate to the size of the foreign body which causes the trouble. 
 It is, therefore, advisable in every case in which a particle of for- 
 
PUNCTURED WOUNDS. 
 
 689 
 
 eirjn matter remains in the flesh, to enlarge the opening with a sharp 
 knife, or other suitable instrument, and to remove the foreign body 
 witii pincers or forceps. This is far better and more satisfaciory than 
 to attempt to pry it out with a needle or pin ; for such an attempt 
 merely irritates the wound and rarely accomplishes the desired 
 
 object. 
 
 If the point of a needle be broken off in the flesh, the part 
 should be kept perfectly quiet until the opening can be enlarged ; 
 for such sharp objects soon disappear deeper in the tissues, if the 
 limb be moved. It is surprising to see what journeys through the 
 body needles sometimes perform ; they may appear months or years 
 subsequently at some distant portion of the surface. Fortunately, 
 ihcy irrcly do any harm in these wanderings through the body. 
 
 If tbe needle can be felt in the skin, the flesh may De squeezed 
 up so that one end or the other of the needle can be brought near 
 to the surface ; the skin should then be cut at this point, the needle 
 pushed until '.he end appears in the cut, and then withdrawn with 
 the pincers. 
 
 In every case in which a punctured wound of considerable size 
 is made, the opening should be thoroughly cleansed with carbolic 
 acid solution, or with the mixture of listerine and water above 
 mentioned. After this a compress of lint saturated with the same 
 solution should be applied over the opening and kept in position by 
 a snug bandage. The limb should be kept perfectly quiet, and the 
 compress may be moistened every vwo or thre: hours and reap- 
 plied. 
 
 This dres'-Ing may be continued for three or four days if the 
 vvound seems to progress favorably. At the end of this time it will 
 be evident whether the patient is going to experience serious trou- 
 ble from the injury. If such be the case, the flesh in the vicinity 
 of ihe wound will be swollen, red and painful ; the patient is apt to 
 feel a burning and throbbing pain in the limb, al. nrst confined to the 
 immediate vi'^inity of the wound, bu^ subsequently spreading up 
 the arm or leg. 
 
 So soon as sw-^-lling, redness and a burning pain occur, the 
 part may be covered v/ith a soft, warm linseed poultice, and this 
 should be renewed every two or three hours. Ihis treatment will 
 sometimes enable matter which may be forming to escape to the 
 surface ; if it does not, that is, if the pain and swelling continue 
 unabated or even increase, it is pretty certain that matter has 
 
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 SURGICAL DISEASES. 
 
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 accumulated in the bottom of the wound. There is but one course 
 open when this accumulation of matter occurs ; this consists in upcn- 
 ing the wound down to the matter and permitting this to escape, 
 A sharp penknife, carefully cleansed, should be introduced into the 
 original wound and carefully passed into the flesh until, upon its 
 withdrawal, matter appears upon the knife blade and in the wound. 
 This is an extremely important item ; for it does no good to enlarge 
 the superficial part of the opening without permitting the pent-up 
 matter to escape. 
 
 If this little operation be successfully performed, the patient 
 will experience considerable relief in the course of a few hours; 
 the poultices should be continued for another day, or until the 
 swelling and the throbbing pain have subsided. 
 
 It is important that provision should be made for a free dis- 
 charge of the pus ; otherwise the skin may heal over again before 
 the bottom part of the wound has healed. If the synipto'ms just 
 related — the swelling and throbbing pain — occur a second time, 
 the knife should be introduced as before, and, in order to keep the 
 passage open until the bottom of the wound has healed, a little 
 pUig of white wax should be made and inserted almost to the bot- 
 tom of the wound. This wax may be cut into the general shape 
 required, and then moulded and its surface smoothed by immersion 
 in hot water. As the wound heals from the bottom, the outer end 
 of the plug may be gradually cut off. 
 
 By carefully providing for the escape of matter, we diminish 
 very considerably the danger of lock-jaw. 
 
 Lacerated ivounds usually give the patient considerable trouble 
 from the slowness with which they heal. This tardiness does not 
 result from any inherent difficulty in the healing process, but sim- 
 ply because the edges of such wounds cannot be accurately kept in 
 position. When a wound is torn or lacerated, the edges of the 
 skin and flesh are more or less ragged, and the ends or rags of 
 flesh usually mortify. 
 
 Whenever it becomes impossible to bring these edges accu- 
 rately together ; whenever, therefore, raw spaces remain between 
 the edges, the wound heals by the formation of new flesh and skin. 
 The bottom of the wound becomes filled with numerous small 
 elevations as large as pin's heads. These are of a deep red color, 
 and are covered with a yellowish creamy liquid, which is called 
 
\vc diminish 
 
 PUNCTURED WOUNDS. 
 
 691 
 
 healthy pus. These little red bodies, called £-rauu/attofts, are filled 
 with blood, and bleed readily upon slight pressure. 
 
 These granulations are gradually converted into flesh, which 
 fills up the bottom of the wound. As fast as the lower part of the 
 wovnul is thus closed by new flesh, the granulations rise to the sur- 
 face ■ in other words, the wound becomes shallower. When they 
 have attained the level of the skin, it will be observed that the edge 
 of the wound is lined with a very delicate white margin, which is 
 continuous with the surrounding skin. This delicate margin is the 
 new skin which is growing over the surface of the granulations. 
 
 If the parts remain healthy and free from complications no 
 further treatment is required for a lacerated wound than simple 
 cleanliness and protection from mechanical injury. The red sur- 
 face of the granulations should be washed with water two or three 
 times a day, care being taken that no pus remains collected in some 
 nook or corner of the wound. After this washing, a little vaseline 
 should be spread upon lint, and this maj- be laid over the wound, 
 so as to cover the edges of the surrounding skin. A bandage 
 loosely applied, or a few adhesive straps, complete the dressing. 
 
 It sometimes happens that these granulations are not perfectly 
 healtliv. In this case they become much larger than natural and 
 usuallv have a pale red color. Such granulations are called by 
 sur<'^cons " flabby, " and in popular parlance " proud flesh. " This 
 condition is especially apt to occur when the wound has been filled 
 u]) to the level of the skin, the flabby granulations, or " proud 
 flesh," rising above the general surface. 
 
 The conditions of the granulations can be readily improved, 
 that is the proud flesh can be removed, by simply applying to the 
 surface some burnt alum. This should be thickly dusted on those 
 parts where the granulations arc most prominent. Two or three 
 3uch applications usually suffice to ', . 'ce the surface to the level 
 of the skin. If the proud flesh resist this treatment, it may readily 
 be removed by lightly touching it once a day for two or three days 
 with a stick of lunar caustic. 
 
 The formation of the scar completes the process of healing. 
 With reference to scars, it should be said that they always decrease 
 in size w ithin a few months or years after the infliction of the wound. 
 It is sometimes surprising to see how small a scar has become in 
 comparison with the size of the wound on which it was formed. 
 
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 SURGICAL DISEASES. 
 
 This tendency of scars to contract and grow smaller has, however, 
 a disadvantageous as well as a beneficial side, for if the scar be ex- 
 tensive it may have a tendency to deform the surface by drawing it 
 out of shape. Thus, burns of the neck frequently result in a form 
 of " wry-neck," whereby the chin is drawn downward toward the 
 shoulder. 
 
 Scars are at first quite red, but become in the course of time 
 as white as the surrounding skin. 
 
 There is one feature in connection with lacerated wounds 
 which may be borne in mind, namely, that they rarely bleed pro- 
 fusely. Hence the immediate danger from such a wound is far less 
 than from a clean-cut incised wound of the same or even less ex- 
 tent. 
 
 In dressing all wounds, care should be taken to preserve the 
 tissues so far as possible. In many cases especially of lacerated 
 wounds it becomes necessary to trim ofif shreds of flesh and skin, 
 but this should be done sparingly with regard to the skin. Every 
 piece of skin, however small, is of value in hastening the process 
 of repair and in diminishing the size of the scar. 
 
 When lacerated wounds are very extensive there often occurs 
 considerable difficulty in s^^curing skin enough to cover the wound- 
 ed surface. It is not necessary that all the surface be covered with 
 skin at the time the wound is dressed, but the skin should be so ar- 
 ranged as to divide up the raw surface into small patches instead of 
 leaving it all in one large piece. The importance of this lies in the 
 fact that when the wound is filled up with granulations, it often re- 
 fuses to heal entirely. New skin will be formed at the edges to a 
 certain extent, but it will not spread over the entire surface. Such 
 cases require the care of a surgeon, and often tax his ingenuity and 
 skill. Several ingenious devices have been introduced into surgery 
 within comparatively few years and arc now extensively practiced. 
 One of these consists in what is called "skin grafting." Small 
 pieces of skin are cut from other parts of the body, anil are 
 " planted " on the surface of the granulations. A dozen 01 two 
 of these may be thus scatterei. around on the open surface o{ a 
 large wound which refuses to heal under ordinary treatment. These 
 little pieces may be either laid upon the surface or inserted into lit- 
 tle openings made with the point of a knife. The wound is then 
 covered with oiled silk, which is retained in position by strips of 
 Sticking-plaster. In the course of a few days small bluish white 
 
PUNCTURED WOUNDS. 
 
 693 
 
 specks maybe seen upon the surface, which gradually enlarge until 
 it becomes finally evident that each one of them is a little island of 
 
 new skin. 
 
 Another device which has rendered excellent service, is what is 
 called " sponge grafting. " This consists in planting small pieces of 
 fine, soft sponge at different parts of the surface of a wound cov- 
 ered with granulations. The granulations grow up into the meshes 
 of the sponge, and thus new flesh is built up in and around the 
 scaffolding of sponge. This measure has been found especially 
 useful in cases in which pieces of flesh have been cut out and lost. 
 In such cases the surgeon can sometimes build up the end of a 
 fino'er or thumb, instead of having a deformed and unsightly flat- 
 tened member. 
 
 Another point with reference to lacerated wounds should be 
 mentioned here, namely, that no tissue should ever be thrown 
 away if completely separated from the body, unless it be torn and 
 mangled. A piece of skin which has been entirely removed from 
 the surface will often grow again if it be carefully cleaned and 
 re-applicd to the raw surface. In fact the writer has cut out pieces of 
 skin from legs which had been amputated three hours before, and 
 has seen them grow when planted on wounds of other individuals. 
 So, too, the end of the finger, or of the nose even, if completely 
 severed from the body, may often be made to grow again in its 
 proper position. To accomplish this it must be carefully washed 
 with warm water, accurately fitted to its former position and firmly 
 strapped there by means of adhesive plaster and bandages. The 
 member should be wrapped in cloth wrung out in hot water, since 
 the circulation will be promoted by warmth and moisture. 
 
 Contused luoiinds are those in which the skin has been not only 
 severed, but also bruised. A bruise implies the rupture of some 
 of the blood vessels in the skin and an escape of blood from these 
 vessels into the meshes of the skin. So long as the skin is not 
 wounded, that is, while the injury remains simply a bruise, no great 
 danger is to be apprehended. But if the bruise be complicated by 
 a wound, the injury is an important and serious one. The gravity 
 of these wounds seems to depend upon the danger that the blood 
 which escapes into the skin may undergo putrefaction. If it does, 
 there will result mortification and formation of matter around the 
 wound, with perhaps extensive death or " gangrene " of the sur- 
 rounding skin; and there may occur a poisoning of the blood. 
 
 
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 694 
 
 SURGICAL DISEASES. 
 
 Contused wounds rarely bleed profusely, since the blood vessels are 
 torn rather than cut, and the blood clots in the meshes of the 
 skin. 
 
 Treatment. — The general principles required in the treat- 
 ment of contused wounds are the same as those already discussed 
 in describinj^ incised and lacerated wounds. 
 
 The first object of treatment is to stop further bleeding. The 
 necessity for this will be indicated by a constant swelling of the 
 part rather than by an escape of blood from the wound ; for it is to 
 be remembered that the blood escapes into the meshes of the skin, 
 and that considerable hemorrhage may occur without the appear- 
 ance of blood externally. It is therefore advisable to ripply cold 
 water or ice to the part, and to raise the limb. 
 
 The difficult part of the treatment of contused wounds is the 
 prevention of inflammation and perhaps gangrene of the part. 
 For this purpose, that is tc preserve the vitality of the tissues, 
 there is nothing better than simple warmth and moisture. Hence 
 so soon as the bleeding has ceased, the limb should be wrapped 
 in cloths saturated with hot water, and these should be renewed 
 every two or three hours or oftencr if required to keep the limb 
 very warm and moist. These cloths may be covered with oiled 
 silk or rubber cloth to retard evaporation. 
 
 It is rarely necessary, or even advisable, to attempt to secure 
 rapid healing of the skin by the use of sticking plasters; for if there 
 be much bruising of the flesh around the wound, its edges will not 
 unite promptly under any treatment. 
 
 In many cases it will be observed after a few days that some 
 of the skin in the vicinity of the wound has become black and 
 emits a fetid odor ; this skin is dead or " gangrenous," and must be 
 removed with the scissors. 
 
 Gunshot Wounds. 
 
 Under this term are included all wounds made by substances 
 discharged from firearms. 
 
 The efiect of a gunshot wound varies, of course, extremely 
 with the nature of L.e missile as well as the part of the body injured. 
 One of the usual effects is a condition which much resembles faint- 
 
"cs will not 
 
 GUNSHOT WOUNDS. 
 
 695 
 
 ing and which is called shock or collapse. This condition may fol- 
 low any severe injury, and will be discussed in a separate chapter. 
 
 Cannon shot grinds to powder any human tissues which it meets 
 within five or six hundred yards of the gun. If it strike a limb, 
 the ball carries it away or grinds it into pulp. 
 
 The bleeding from a cannon shot is not usually severe, since 
 the vessels are torn across and the blood clots at once ; moreover, 
 the condition of shock supervenes, during which the heurt's action 
 is very feeble, and the blood is not propelled with iiuch force. 
 
 After a cannon shot has traveled a greater distance and has 
 thus lost much of its impetus, it is still capable of inflicting severe 
 and even fatal injury. A curious feature about the course of such 
 a spent cannon ball is, that its course may often be changed by 
 objects which it meets, without affecting its power to inflict injury. 
 
 " A private in the First Royals was working in the trenches 
 before Sevastopol. He was in the act of shoveling up some earth, 
 with his body bent and his right hand in which he held the handle 
 of a shovel low down in front of the space between his legs. In 
 this position he was struck by a round shot. It shattered his arm, 
 leaving it hanging only by the skin, and passing between the thighs 
 at their upper parts, it tore away from each of them a large mass 
 of the integuments and muscles, and laid bare the femoral artery 
 on one side. It carried in front of it the genital organs, and guided 
 by the curve of the buttocks, it swept away a large portion of the 
 hip on one side." — Dniitt. 
 
 Cannon shot, when nearly spent, may inflict severe injuries 
 without breaking the skin. Even when rolling along the ground 
 it retains power enough to take ofl" a man's foot — a fact which has 
 surprised many a soldier who attempted to stop one of them by 
 putting out his foot. 
 
 A popular notion prevails that the " wind" of a ball, that is, 
 the current of air set in motion by its flight, is capable of inflicting 
 serious injuries without actual contact with the ball itself. Experi- 
 ence on the battle field has shown that this idea is erroneous ; 
 many instances are known in which a person's clothes have been 
 torn away without causing him any serious injury. "A shot 
 ricochetted with great force over one of the parapets, carrying 
 away the cap from a seaman's head. The man was a little stunned, 
 but no further mischief ensued. When the cap was picked up it 
 contained a handful of hair which had been shaved from the scalp 
 
 
 
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 696 
 
 SURGICAL DISEASES. 
 
 by the shot. This would have been a 'poser' for the old wind con- 
 tusionists. " — Diiygan. 
 
 Musket and rifle balls produce the greater number of injuries 
 inflicted during a battle. Although they rarely cause such frij^ht- 
 ful lacerations as those produced by cannon balls, yet they arc 
 capable of destroying bones and flesh quite as effectually. 
 
 Small shot fired from a shotgun produce different effects, 
 according to the distance which they may have traveled before 
 striking. The shot always scatter after leaving the gun, and after 
 they have become separated they rarely penetrate the flesh to an\- 
 great distance. So long as they remain together, however, they 
 inflict very serious injury, which may be indeed more severe than 
 that caused by a musket ball. 
 
 Firearms which contain no ball may, nevertheless, cause 
 serious damage by the impact of the wadding. Gunshot woiinds 
 of all kinds are furthermore complicated by the effects of the gun- 
 powder, if the weapon be discharged at short distance from the 
 individual who receives the charge. 
 
 Bullets frequently pursue a roundabout course in their passage 
 through the body. They arc apt to be deviated from their original 
 direction by striking the bones or hard articles contained in the 
 clothing. Even a suspender button may be sufificient to divert a 
 ball from its course. In consequence of this fact, it is often impos- 
 sible to tell what course the ball has pursued after penetrating the 
 skin, or where it should be looked for. Instances are known in 
 which a ball has entered the chest, struck one of the ribs and trav- 
 eled clear around the body under the skin, without penetrating the 
 heart or lungs ; sometimes such a ball emerges at the side of the 
 back-bone at a point opposite the wound made by its entrance at 
 the front ; in such a case the natural supposition is that tlie bullet 
 has passed directly through the body, though it may rcall)- have 
 inflicted no serious injury. The position of the limbs tnidently 
 modifies the course of the ball which may strike them ; if the bullet 
 strikes the arm obliquely for instance, it is very apt to glance oti' 
 and emerge from the skin at a point a few inches from that at which 
 it entered. Many curious instances arc related, showing the 
 remarkable effects upon the course of a ball which may be exerted 
 by the simplest accident. Druitt relates the case of an officer w ho 
 was struck in the abdomen by a musket ball. The bullet came 
 into contact with a button of his trousers, which it bent double. 
 
tfl 
 
 GUNSHOT WOUNDS. 
 
 697 
 
 Its direction was changed by this obstacle, so that instead of entcr- 
 iiv' the abdomen it turned down and lodged in the thigh. Another 
 man was struck in the neck by a bullet ; it entered the skin at the 
 side of the larynx, " Adam's apple," passed completely around the 
 neck, and was found lying in the hole where it had entered. When 
 a bullet passes thus superficially under the skin, it often leaves a 
 track which is marked by a dark red or blue line. This may, how- 
 ever, be so small as to escape attention. 
 
 It is often, for many reasons, important to know which of two 
 orifices made by a bullet is the one at which the ball entered. This 
 can usually be decided without difficulty. The opening made by 
 tJie ball during its entrance into the body is usually smaller than the 
 bullet itself, and its edges are turned inward. The orifice left by 
 the bullet in leaving the body, on the other hand, is usually larger 
 than the ball itself, and its edges are turned outward. 
 
 Tveatment of Gunshot Woimtls. — The plan of treatment 
 adopted for the treatment of gunshot wounds has, like other 
 departments of surgery, undergone essential modification in the past 
 few years. It was formerly the custom of surgeons to probe the 
 wound at once and to make every effort to extract the ball. Expe- 
 rience has shown, however, that the operation of probing may 
 cause far more serious damage than the presence of the ball itself; 
 in fact, if no other body than the bullet have been carried into the 
 wound, no particular danger is to be. apprehended from it subse- 
 quently ; the damage done is inflicted by the movement of the 
 bullet ; after this has come to rest, it ceases to exert an injurious 
 effect. 
 
 The popular impression still is that the bullet must be extracted 
 at any cost, and that the patient has but little chance of recovery 
 until the ball be removed. Many a surgeon has sacrificed his 
 judi^mcnt to this popular prejudice and has attempted to find and 
 extract a bullet when he really believed that it would be better for 
 the patient to omit all efforts in searching for the ball. 
 
 There is one feature in many cases which warrants an attempt 
 to find and remove a bullet ; this is, the p(^-sibility that particles of 
 clothing have been carried into and have lodged within the wound. 
 If this have occurred, the wound often refuses to heal ; considerable 
 mattir is produced and discharged, and the patient may suffer from 
 sc\crc fever and even blood-poisoning (pyaemia). 
 
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698 
 
 SURGICAL DISEASES. 
 
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 If the ball be lodged near the surface, it can usually be detected 
 at once by a simple probe or by the finger ; in this case it may be 
 extracted with the pincers or forceps. It is, however, not desirable 
 to search very vigorously for the missile. Sometimes the bulkt 
 can be found lying just under the skin ; in such a case a cut may 
 be made through the skin and the bullet extracted. 
 
 Generally speaking, we may lay down the following rules fur 
 the treatment of gunshot wounds : 
 
 First — Be sure that every instrument and finger which ap- 
 proaches the wound \'i> perfectly clean. By this we mean not simply 
 that the fingers and instruments shall be clean in the ordinary sense 
 of the word, but also that they shall be thoroughly disinfected. 
 
 Second — Insert a simple probe or, if the wound be lar^o, a 
 finger into the wound and search for the ball ; if it be not found at 
 once, without attempting to enlarge the wound, desist from 
 further probing. 
 
 Third — Syringe out the wound with one of the following 
 solutions : 
 
 Carbolic acid. 
 Water, 
 
 Or, if more convenient : 
 
 Listerine, . _ . 
 
 Water, 
 
 (The ingredients and fingers which are allowed to touch the 
 wound should be thoroughly cleansed with one of these solutions 
 before being introduced.) 
 
 Fourth — Place a compress, that is a piece of folded lint wet 
 with one of these liquids, over the wound and hold it firmly in 
 place with a bandage. 
 
 Fifth — Keep the wounded member perfectly quiet ; if the 
 wound be severe, the patient should be kept in bed for a day or 
 two. 
 
 The bleeding from gunshot wounds is not often profuse or dan- 
 gerous. The most severe cases are those in which the blood 
 escapes into the interior of the body. In such instances the patient 
 may bleed to death before the bystanders have any suspicion that 
 such an event is possible, since little or no blood escapes from the 
 wound. 
 
 The termination is preceded by rapid failure of the patient's 
 
 Two drachms. 
 Eight ounces. 
 
 One ounce. 
 Y'w'c ounces. 
 
SHOCK. 
 
 699 
 
 strength ; he becomes blanched, his pulse is weak and rapid, and 
 consciousness is <;radually lost. 
 
 The treatniLMit of hemorrhage into the interior of the body is in 
 many cases ineffectual, though sometimes it becomes possible for a 
 sur"ei)n, acquainted with the anatomy of the parts, to reach and close 
 the bleeding vessels. The only household remedies that can be 
 employed are tincture of ergot, a teaspoonful of which may be 
 fTJvcn at once and repeated in half or three-quarters of an hour. 
 TIk' patient should be kept perfectly quiet, and his strength should 
 be rallied by the administration of alcoholic stimulants, such as 
 egg-nog. 
 
 Shock. 
 
 This term is applied by surgeons to the state of depression 
 whicii occurs after a severe injury. This depression manifests itself 
 by an impaired action of the nervous system, including weakness 
 of the heart-beat and interference with breathing. 
 
 Sf/tHptoms, — After receiving a severe injury, the patient 
 becomes cold, faint, perhaps semi-unconscious ; the limbs tremble, 
 and are unable to support the weight of the body. The pulse is 
 very weak and rapid, and can sometimes be scarcely felt at all. The 
 skin is cool, and often covered with clammy perspiration ; nausea 
 aiul vomiting occur. The patient's mind may remain quite clear, 
 thinii;li more frequently he is bewildered and unable to answer ques- 
 tions coherently. 
 
 This condition of shock is more frequently observed after 
 severe budil)- injury, but may also be induced by excessive mental 
 emotion, especially fright. The general symptoms are essentially 
 the same in both cases, showing that the condition results from a 
 depression of the nervous system. 
 
 Man\' interesting experiments upon animals illustrate the 
 mechanism of shock in the human subject. Thus we may expose 
 the heart of a frog and observe that it continues to beat regularly 
 and quietly. If, however, a leg of the frog be crushed with a ham- 
 mer, the motion of the heart is arrested at once. 
 
 Shock may follow an injury of trifling extent, if the wound be 
 inflicted upon a vital part of the body. In nervous and timid indi- 
 
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700 
 
 SURGICAL DISEASES. 
 
 viduals a comparatively slight injury, which does not affect any 
 organs of vital importance, may also be followed by the (irdiiiaiy 
 symptoms of shock. Thus, an officer was observed to fall from lii, 
 horse during a battle in the late civil war. Examination showed 
 that a bullet had pierced his breast, and he showed all the symp- 
 toms of severe shock. Up<in opening his clothes to dress the 
 wound, the surgeon was surprised to find that the bullet ha.. Ijclii 
 stopped by a memorandum book in the breast pocket of the c.ut, 
 and had not reached the skin. 
 
 The result of shock depends largely upon its severity, as wdl 
 as upon the condition of the patient at the time of the injury. The 
 danger lies in the weakened action of the heart. If this dcprcssiiin 
 effect exceed a certain point, the heart's action ceases entirely. In 
 some cases the patient dies within a few minutes after the receipt nf 
 the injury. In other instances he rallies for a time, but sinks ai^ain 
 in the course of a few hours. In the latter case he may have 
 regained temporarily full possession of his mental faculties, ami the 
 heart may have resumed its contraction with a fair degree of force. 
 If the patient sink a second time the face becomes pale, the skin 
 cold and clammy, as before ; the mental functions are more dis- 
 turbed than they were immediately after receiving the injury. In 
 most instances the patient dies during this second collapse. 
 
 ,!( 5« 
 
 Ti'eatinent. — The prime object of treatment is to strengthen 
 the beating of the heart. 
 
 If the shock be caused by a bodily injury, the strength of the 
 heart's action can be increased by the use of two remedies — 
 ammonia and alcohol. 
 
 The ammonia may be given by permitting the patient to inhale 
 it; the hartshorn should be held near to the nostrils, and the 
 patient should be told to take long breaths. If the hartshorn be 
 fresh and strong, it should not be approached closer than four or 
 five inches to the nose ; or it may be diluted and held still closer. 
 
 Alcohol should be given in the shape of whisky, brandy or 
 wine ; a tablespoonful of one of these liquors maybe administered 
 in water or milk every twenty minutes until the pulse becomes 
 stronger and the patient shows some sign of reviving. If vomiting 
 occur, the whisky or brandy should be mixed with an equal bulk 
 of milk and injected into the rectum. In severe cases the stimu- 
 lating effect of these remedies can be most rapidly obtained by 
 
!lf 
 
 SHOCK. 
 
 701 
 
 inicctiriR whisky or ether under the skin with a hypodermic syr- 
 
 iiiLif. 
 
 The heart can also be strengthened by the application of 
 
 w.unUh to the body. The patient shoidil, therefore, be warmly 
 
 covcrcil, and hot bottles or flat-irons wr.ippcd in flannel, so as not 
 
 tn 1)11111 the skin, should be applied to the feet, between the thighs, 
 
 to tin: sides, and in the armpits. The hands and arms may be 
 
 rubbed briskly for the same purpose. 
 
 In desperate cases extraordinary measures are sometimes 
 reciuircd to tide the patient over the first half hour or hour of 
 depression. Some of these measures arc easily understood and 
 ;ini)lie(l. It is a general principle that the heart is stimulated to 
 contraction by the presence of blood within it ; this can be readily 
 shown bv removing the heart from a dog. for instance, and laying 
 it upon the table, where it will continue to beat for a number of 
 minutes, but finally become quiet. If we now inject some warm 
 blood into the cavity of the heart, the organ begins to beat again 
 with renewed vigor. 
 
 This principle can be applied in various ways to stimulate the 
 tailini;' part of a patient sufi'ering from a shock. One of these ways 
 is the injection of warm blood into the vessels of the patient — an 
 operation known as transfiisioii. This operation has been exten- 
 sively practiced, but because of its delicacy and of the dangers 
 incident to it, it can be undertaken only by a medical man. To 
 perform it, fresh blood is drawn from a bystander or from an ani- 
 mal, and briskly whipped with a bunch of clean straws until all the 
 stringy part — the fibrinc — has been separated from the rest of the 
 blood and adheres to the straw. The part of the blood which 
 remains liquid is then introduced into the arm of the patient. 
 
 The effect is often most remarkable ; the pulse, which may 
 have been so weak that it could not be felt at the wrist, becomes 
 quite strong and full ; consciousness returns, the face acquires a 
 little color, and the patient rallies markedly from his former condi- 
 tion. 
 
 The goc J effects of the transfusion are apt to be transient, 
 however; within three or four hours the individual may relapse 
 into his former condition and require further stimulation. 
 
 The d.mgers which accompany the introduction of blood into 
 an individual have led to the employment of various other liquids 
 as substitutes. Prominent among these are milk and a solution of 
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 702 
 
 SURGICAL DISEASES. 
 
 salt in warm water. A detailed discussion of these measures j, 
 unnecessary in a work of this sort, since the operation is one of ilic 
 most Jifficult and dehcate in surgery, and should, of course, i\e\cr 
 be undertaken by a non-professional person. 
 
 There are, however, several ways for securing a stimulatidii of 
 the heart through an increase in the quantity of blood. While the 
 introduction of blood from another person into the heart of tlu' 
 patient is both difficult and dangerous, it is a very simple prcjccdmc 
 to introduce the patient's own blood from other parts of his bmlv 
 into his heart. In other words, we can transfuse the patient :citii 
 his own blood. To accomplish this we have simply to force the 
 blood from other parts of the body to the heart, and to prevent ii 
 from returning again. 
 
 This plan can be carried into execution by elevating the leL;s 
 of the patient, or by wrapping them firmly in an elastic bandage. 
 In many cases the heart's action is much strengthened by simply 
 raising the p.itient's legs from the bed, and by supporting them in 
 this position for fifteen or twenty minutes. This should alw.i)-^ be 
 done whenever the patient's condition is such as to threaten immi- 
 nent death. 
 
 The quantity of blood sent to the heart can be increased by 
 enveloping the legs in elastic bandages. The bandage should be 
 applied while the leg is elevated, being wrapped first around the 
 toes and then extended up the leg to the middle of the thigh. rhi> 
 may be allowed to remain for half an hour, at the expiratiun of 
 which time the other limb may be bandaged in the same wa\-. the 
 bandage being removed from the first. It is not desirable that the 
 bandage be allowed to remain upon one limb more than thirty or 
 forty minutes at a time, since the nutritio of the part ma\- stili'cr 
 if the blood be kept out of the limb for so long a time, and por- 
 tions of the skin or muscles in the leg may mortify after the band- 
 age is removed. 
 
 This measure, taken in connection with the use of stinuilaiits 
 and the frictions of the surface which have been already described, 
 may often succeed in keeping the patient alive during the few hours 
 which succeed the infliction of the injury. 
 
 It should be remembered that the use of stimulants during 
 shock can be carried to excess. In this case the patient will be aDt 
 to suffer from fever and delirium ' fter he rallies from the injury. It 
 is therefore necessary t' discojitinue the alcohol when the signs ol 
 returning strength become apparent. 
 
POISOiXLD WOUNDS. 
 
 Poisoned Wounds. 
 
 703 
 
 It has been already stated, in the discussion of wounds in gen- 
 eral, that the natural tendency of a wound is to heal, and that any 
 failure to heal is evidence either of some constitutional taint in the 
 individual or of the entrance of foreign particles or substances into 
 the- wound. In many cases these foreign substances are of unknown 
 naturr ; they seem to be constantly present in the atmosphere and 
 to adhere to all articles which are exposed to the air ; hence, unless 
 especial care is taken to prevent their access to the wound, their 
 cfi'ccts become visible in the delays and accidents which retard 
 
 healint;. 
 
 '1 here are other ^ascs in which the course of a wound is dis- 
 turbed by the introduction of foreign substances of known origin. 
 The chemical poisons of various kinds are frequently introduced 
 carelessly or ignorantly into wounds which would otherwise heal 
 without difficulty; and as a result of such introduction, the healing 
 of the wound is retarded, and perhaps the life of the patient is 
 imperiled. Then there are numerous animals and insects whose 
 bite is i'ccompanied by the introduction of poison secreted in their 
 bodies. A familiar example of this is the musquito ; the wound 
 made by this pest is trifling in iiself, less extensive, indeed, than 
 the prick of a needle ; yet this wound is followed by far more irri- 
 tation than can be originated by the point of a needle. The ex- 
 planation lies in the fact that the musquito deposits in the wound 
 which he makes an irritating poison. The most common variety 
 of poisoned wounds is that which results from the introduction of 
 putnd ixniinal matter. The process of decomposition or putrefac- 
 tion includes the formation of numerous substances which possess 
 poisonous properties. The exact time at which these substances 
 arc formed varies under different circumstances, occurring earliest 
 of course in warm weather. Within a few hours or days after death 
 the carcass of an animal putrefu^s to such an extent that some of 
 these poisonous substances are contained in the ^.vA\ and juices. 
 Tin; iiUinduction of this flesh under the skin of a man is followed 
 by the most serious inflammation, and jjcrhaps b)- that grave con 
 ilition know n as " blood-poisoning. " It is not necessary that any 
 wouml of considerable size be inflicted in order to cause this result; 
 in tact the most dangerous cases occur in individuals who were not 
 aware, at the time that they came in contact with the putrid matter, 
 
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 704 
 
 SURGICAL DISEASES. 
 
 that thc}' had any wound at all. The entrance of the poison — tlic 
 i)i feet ion as it is teclinically termed — t)ccurs most frequently through 
 slisj^ht scratches or " !iani;-nails," of whose existenci; the indi\'i(lu,il 
 may not be aware. 
 
 The cases most frequently broufjht to the notice of the surm-wii 
 occur in tlu- metlical students or physicians who are infected w hilc 
 dissecting or making post-mortem examinations, and in farnuis up 
 others who are poisoned while skinning or cutting up live stdck. 
 One cannot be too careful, when engaged in such emplojnient^, to 
 protect the hands in every possible way. Thr skin of the hamU 
 and arms, especially in the vicinity of the nails, ^liduld be carLtiillv 
 inspected to detect the existence of any slight scratches; in fact, 
 it is advisable to place the hands in some slightl\' irritating sohi- 
 tion, such as weak vinegar, in < ier to be sure that "o tender points 
 have been overlooked. In this way we may sometimes detect 
 wounds and scratches so slight that they have escaped observation 
 by the e\-e. 
 
 If any such scratch or abrasion be discovered, the safest plan 
 is to avoid all contact with animal matter which shows the least 
 signs of putrefacti mi. If it be absolutely necessary to perform Mich 
 work, all scraiches and abrasions should be sealed up b\- paintinL,^ 
 them with collodion. If the individual possess a pair of rubber 
 gloves, these ma\- be worn with advantage. 
 
 The danger from infection is especially great if the anini.il have 
 died of some poisonous disease. One of the commonest sources 
 of infection through handling dead animals is the disease known as 
 "malignant pustule" or "wool-sorter's disease," a description of 
 which has been given on a previous page. The carcass of an ani- 
 mal which has died of this affection is dangerous even before putre- 
 faction has begun, since there exists in it a poisonous principle 
 which is quite independent of the substances formed during putre- 
 facti(Ui. 
 
 Another common source of infection is the disease known as 
 i^idiithrs or farcy. It is generally known to those who come into 
 contact with horses or cattle, that the discharge from the nose of 
 an a.nim.d sufTering from this disease can communicate the aflcction 
 to man ; and that this matter can be transferred by means of towels 
 or cloths, with an etpiall)' deadl)' eftect. 
 
 There is anotlier source of danger for those who are coinpelleii 
 to be much in the vicinity of the Ciircasscs of anirials, even tliouj^h 
 they may not come into actual contact with the dead bodies; the 
 
 
 It 
 
 \MrJX 
 
POISONED WOUNDS. 
 
 70s 
 
 disease may bo communicated t(j them through the bite of flies 
 whicli have previously alighted upon the carcass. 
 
 If poison has been introducetl into the skin through some 
 sli'dit scratch or abrasion, such us a hang-nail, there first appears a 
 painful pimple or small boil at the spot. Considerable pain is felt 
 at and around the spot, and it may extend over the whole hand and 
 up the arm. In a day or two the hand becomes much swollen, and 
 red lines can often be traced up the arm. These lead to tender 
 lumps in the armpit — the enlarged lymphatic gland. l?y this 
 time the patient has had one or more severe chills which are fol- 
 lowed by fever and great mental disturbance, perhaps even 
 di:lii'iuni. 
 
 Treatnietlt, — So soon as suspicion is aroused that the sore 
 results from the introduction of poisonous matter into the skin, no 
 time should be lost in laying the inflamed surface open. A free cut 
 should be made with a sharp knife, so as to let out any matter 
 whici. may be present. Many surgeons advise that two cuts cross- 
 ing each other at right angles should be made. 
 
 After the bleeding has ceased, the wound should be thoroughly 
 -.vashed with a solution of carbolic acid, or of listerine, such as has 
 ''■.en described in the discussion of wounds. If the sore has been 
 obtained from an animal suffering with an infectious disease, such 
 as malignant pustule or glanders, it is advisable to cauterize the 
 spot thoroughly. 
 
 The best agent for this purpose, in the hands of a non-profes- 
 siiinal person, is the strong carbolic acid, since this cauterizes the 
 tissues thoroughly, without causing such extensive destruction of 
 the flesh as most of the other agents employed for this purpose. A 
 piece of soft rag should be wound around the end of a stick, and 
 dipped in the strong carbolic acid, after which it is pressed firmly 
 upon the raw surface. 
 
 Instead of carbolic acid, we may employ the strong nitric acid 
 or creosote. 
 
 The objection to the use of these liquids is the fact that they 
 arc apt to run from the diseased to the health}' flesh, ;uul cause a 
 much larger sore than is necessary. It will be most convenient 
 pcriiaps, on this account, to employ a stick of lunar caustic, or the 
 white-hot iron. The latter agent seems formidable, but is, really, 
 tme (if the least painful of all caustics. To use it, the sharp end of a 
 pnker.or a large nail, may be heated ri'/z/Vr-hot and applied immedi- 
 
 
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 !?ii|'if ill 1 
 
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7o6 
 
 SlkCK Al, DISl'.ASKS. 
 
 iitcly to the woundctl surfaci-. If it l)i> allowed to cool so that liio 
 niftal becomes red insteail of white, it will occasion imich more 
 pain. 
 
 After the wound has l)i>eii thus opened and eautt'iizi-d, soft Hax- 
 seed [joultices should he applied for two or three days, or until the 
 swellini; and rednt^ss subside. Care should I)i- taken that no niaitir 
 cedleets in the wound. To prevent this the sore should he ijior- 
 ou^hly syrint;ed three or four times a da>', and incisions should he 
 made with a knife to afford free outlet to any matter which ina\ he 
 formed. 
 
 The constitutional treatment is also a matter of jjjreat iini)or- 
 tance. Wlu-n inllammation has spread up tin- arm, and has caused 
 tenderness of tlie {.glands in the armpit, there is usu.dly decided eon- 
 stitiitional disturbance. 'I'his c*.)nilition is in fact a form of blood- 
 
 The patient will require a nutritious diet in an easily di;.;eslihlc 
 form. lie should have ei;^fs, milk and broths in abundance. rhc 
 medicines reipiired consist chiefly in (/uiuiftc and aUoliol. These 
 should be administered freely. The alcohol may be ^iven in tlio 
 sha|)e of whisky or brand)', an ounce of which (two tablespoonhils) 
 should be administered in milk as often as every two hours. There 
 "ttle daiiL'^er of 
 
 is very w 
 
 e dan_L;er of intoxicatin}.; the p.itient who is sulteriiii; I 
 
 niii) 
 
 bl 
 
 oocl-noisoniiu 
 
 II 
 
 e can endure an amoun 
 
 t of 1 
 
 icpior which « tnil 
 
 rcndi-r a healthy person " dead drunk. 
 
 The (piinine .should bi- ^iven in the form of powder, which 
 
 niav 
 
 be wrapi)ed in gelatine wafers so as to conceal the taste. Three 
 grains of the dru^' should be administered four times a da)'. 
 
 In adilition to these measures it will be necessary to ^ive the 
 patient a warm bath every da)\ in order to reduce the fever. 
 
 The most serious complications are apt to arise in tlu' 
 
 inimc- 
 
 ili.ite vicinity of the wound, especially if this be located on tin- hand. 
 Matter forms and Inirrows uiuler the skin and between the inuscles. 
 Incisions must be frcquenti)' mach- in tlilfercnt ])arts of the liaiul ami 
 arm. Sometimes the entire member below the ellxnv see 
 honeyci>mbed with burrows made by the pus, and is riddl 
 openinL;s, natural or artificial, through which this pus cscaj 
 
 ins to he 
 
 en wi 
 
 ih 
 
 )es. 
 
 Since sucli serious consequences result irom poisoned wmiiuis, 
 it liecomes .i matter of much importance to ])revent, so far as jxissi- 
 ble. the occurrence of siich a wound ; that is, 
 
 th 
 
 e mtrocuictioii u 
 
 poisonous materials into any accidental scratches, l-'or this purpose 
 
 i»»| 
 
r.iri;s and siiNds oi' ixskcis. 
 
 707 
 
 it tii.n- be well to carry a stick of lunar caustic in the pocket, and 
 to c.uitcii/.c iinnu'diatcly any cut or scratch wliich may be (Uscov- 
 ,n(l after the iiand lias been exposed to the introduction of poison- 
 mis material. It is also advisable to oil llu' hands tiiorouf^dily before 
 introdiicini; them into tlu; carcass of a dead animal or handling' any 
 parts of the animal. 
 
 Bites and Stings of Insects. 
 
 The most frecpient wounds of this kind are tiiose made by bees 
 or \vas])s. These are not of course danf^erous, unless many be in- 
 flicti'd at the same time, or unless the sufferer be a yoim^^ child. 
 Single stin.qs are, however, quite ])ainful, and occasion much swell- 
 in" if inflicted around the i-yes or in the nuuith. 
 
 VVlu'ii a lar^e nundicr of bees attack an animal, they inflict 
 injnriis which are usually fatal. Men, as well as horst;s, have been 
 repeatedly stun^ to death by an infuriated swarm of bees. 
 
 In some parts of the country there are found certain other 
 small animals which inflict |)ainful and severe wounds. In tlie 
 southern anti western parts of our country individuals frequently 
 suffer from the bill' of a lar^^e spider called tlie tarantula. In the 
 iKirlhern part of the country there is a small black spider which is 
 often found in the nei^diborhood of (jld lo^s and trunks of trees, 
 ami whieh inflicts a ])ainful wound. 
 
 In the Southern States, and more especially in trr)pical cf)un- 
 tries, the iidiabitants are troubled with t'.i'o pests, which inflict seri- 
 ous and even fatal injury. These are the centipede and the scor- 
 pion. These are fortunately found only in a small portion of the 
 Uniletl States, where they attain but comparatively small size. In 
 ollur p.uls of the world these animals are much lai^er and inflict 
 mi re serious wounds. The bite inflicted by the centipede may be 
 serious, and even fatal. 
 
 Twnimrnt. — The bites of spiders and tlie stints of bees and 
 wasps usually recpiirt- no other treatment than measures to allay the 
 pain. 'Jhere are various popular remedies employed for this pur- 
 pose, .Sometimes hartshorn is applied to the skin in the vicinity of 
 the wound ; some people consider a cabbage leaf the best possible 
 application. The fact is, that anything which seives to cool the sur- 
 
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 708 
 
 SURGICAL DISEASES. 
 
 lii. 
 
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 face diminishes the irritation and pain. Cloths wet with cold water, 
 or a mixture of equal parts of water and hartshorn, are usually \cry 
 grateful to the sufferer; or a solution of ordinary bakin^^ soda, a 
 teaspoonful of which is stirred up in a glass of water, will make a 
 cooling and pleasant application. 
 
 If a person be stung in the mouth or throat, the swellinij 
 which results is apt to be so great as to embar /ass the breathiin;. 
 In such a case the patient should even before the parts are much 
 swollen, employ faithfully gargles of hot "iter containing a liitlc 
 borax. A popular remedy is a mixture of v'inegar and water, 
 which is heated and used as a gargle. The swel;ing is sonictinics 
 so great as to render surgical interference necessary in order to pre- 
 vent suffocation. The tongue may be punctured with a sharp pen- 
 knife in several places, and the use of the gargles should be cun- 
 tinued. 
 
 In many of these cases the pain is so great that opium must be 
 given to alleviate it. For this purpose twenty drops of laudaraim 
 may be taken every two hours until three or four doses have been 
 administered. 
 
 Snake Bites. 
 
 The most widely distributed and most dreaded serpent of the 
 United States is the rattlesnake. The injury inflicted by a ratt'-i- 
 snake is not really a bite, but a blow. The animal is provided with 
 two teeth or fangs, which lie horizontally in the mouth under ordi- 
 nary circumstances, but are raised to the erect position when the 
 snake becomes aggressive. These fangs are grooved with small 
 canals which communicate with the gland that secretes the poison. 
 The fangs are struck into the flesh, and at the same instant the 
 poison is ejected through the canals along these teeth. 
 
 The eftects vary with the condition and age of the individual, 
 as well as with the part which is wounded. Children are more sus- 
 ceptible than adults. Wounds upon the extremities are usually less 
 dangerous than those upon the trunk. 
 
 Many persons who are apparently bitten by rattlesnake^ ■-uffer 
 no injury beyond the mere mechanical damage. The reason t^r thi^ 
 is usually that the fangs penetrate the clothing before reaching the 
 skin, and that the poison is arrested in this way and does not enter 
 
s not enter 
 
 SNAKE BITES. 
 
 709 
 
 the flesh. It is furthermore true that the first stroke is the most 
 dangerous, while the subsequent ones may be comparatively harm- 
 less. This fact is probably due to the ejection of most of the 
 piiisoii with the first blow, the subsequent strokes being accom- 
 panied with but little flow of the poij.onous material. 
 
 Dr. Weir Mitchell, of Philadelphia, published in 1868 the re- 
 sults of a series of observations upon the poison of the rattlesnake. 
 He found that this reptile cannot destroy itself by means of its own 
 poison, as has been supposed. In fact it is generally true 
 that poisonous reptiles are harmless toward others of the same 
 species. 
 
 Dr. Mitchell further found that the poison of the rattlesnake 
 may be taken into the mouth or stomach of a man without doing 
 him any injury, provided there be no cut or abrasion in the lining 
 membrane of these organs through which the virus could enter the 
 system. 
 
 T!ie first effects of the introduction of rattlesnake poison into 
 the human body are very similar to the symptoms of sJiock as it 
 occurs after the infliction of a severe wound. The patient becomes 
 extremely pale and cold ; sometimes the skin exhibits a yellowish 
 hue ; the surface is covered with clammy perspiration ; the pulse is 
 very rapid and feeble ; nausea and vomiting frequently occur ; loss 
 of consciousness, delirium and convulsions are sometimes observed. 
 In the meantime the skin in the vicinity of the wound swells to an 
 enormous size and becomes mottled with blood which has escaped 
 from the vessels. 
 
 In many cases the patient dies during this stage. Th.e time 
 which elapses between the infliction of the wound and the fatal 
 result may vary from half an hour to five or six weeks. 
 
 If the individual survive the first effects, he is apt to suffer for 
 days and weeks from a condition similar to that ot blood-yioisoning, 
 which it undoubtedly is. Abscesses form in the neighboihood iW 
 the bite, and sometimes at distant parts of the body as wvli. 
 
 It is generally known among farmers that ho>^ possess aa 
 immunity against the bite of the rattlesnake. This curious fact «i 
 often utilizeil for the purpose of destroying these reptiles. If hogs 
 be turnetl loose in a locality which is frequ, nted by rat: < nake>. 
 they usually manage to destroy a considerable num^>^ 1 of the 
 reptiles in a few days. In fact, if thv hogs be d. I of 
 
 food, they usually devour the rattlesnake. 
 
 
710 
 
 SURGICAL DISEASES. 
 
 ' » 
 
 These snakes arc considered most dangerous during the month 
 of August. The fact is, that they inflict more bites about this lime 
 of year than at any otlier season ; the reason for this seems to be 
 that the rattlesnake sheds liis skin early in September, and that 
 while the old skin is coming off, the reptile is blind, and strikes 
 promiscuously in the direction of any object which approaches it. 
 
 The one favorable feature of the rattlesnake, is the fact that 
 the rattle is almost invariably sounded before the blow is indicted 
 — a circumstance which has saved many lives. There are several 
 other venomous snakes whose bite is quite as deadly as that of the 
 rattlesnake, and which are more dangerous because they give no 
 
 M 
 
 i* ' \ 
 
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 Li' Is 
 
 ! f: .'■>■■-, 
 
 1% 
 
 Tt'efttment. — The treatment of rattlesnake bites has been 
 the subject of much discussion in the scientific as well as the public 
 press. Any number of remedies has been vaunted as " specihcs " 
 against the poison of the rattlesnake. Then there have been 
 
 numerous " snake-stones," which have been asserted to posses^, the 
 qualities ascribed to ;he familiar " mad-stones " — that is, they are 
 said to possess the power of drawing the poison out of the wdmui. 
 Minute and apparency truthful accounts of the wonderful pr()])er- 
 ties of these stones appear now and then in some of the daily 
 papers, usually at a season when there is a dearth of news. Most 
 careful inquirj' has failed to reveal the existence of any such stone 
 which could demonstrate its supposed powers when put to the 
 test. 
 
 At different times various remedies have been presented by 
 members of the medical profession as cures for the rattlesnake 
 poisi-n. Among these is ammonia, which is largely used by the 
 Australian physicians, iodine, and the South American drug known 
 as curara. None of these, howe\er, have fulfilled the antici- 
 pations of those who introduced them to the notice of tlic pro- 
 fession. There is, in fact, no known remedy which can be relied 
 upon to counteract the effects of rattlesnake poison. 
 
 In every case in which a person has been bitten by a rattle- 
 snake, there are two things which should be done as quickly as 
 possible. The first is to tic a baiidagc tiglitlv aroiDid titc limh, 
 above the wound. Anything which ccmies i\and)- can be ii-ed for 
 this purpose, such as a strap or a handkerchief; and it should be 
 drawn very tightly in the hope of stopping the circulation of blood 
 in the limb completely. The object of this is, of course, to pre- 
 
e mcinth 
 :his lime 
 nis Id 1)c 
 and that 
 d strikes 
 ;hcs it. 
 fact that 
 ; inflicted 
 re several 
 Kit of the 
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 has been 
 the public 
 spccihcs" 
 liave been 
 )OSses> the 
 5, they are 
 ho wound, 
 fill proper- 
 
 thc daily 
 ws. Most 
 
 such stone 
 
 put to the 
 
 L'scntcd by 
 
 rattlesnake 
 
 iscd by the 
 
 ul;- known 
 
 le antici- 
 
 the pro- 
 
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 n- a rattie- 
 tpiickly as 
 / the limb. 
 be u-ed lor 
 ■htiuld be 
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 rse, to pre- 
 
 S.NAKE lillHS. 
 
 711 
 
 vent the introduction of the poison into the system, an object which 
 can be attained only by arrcstinjj the circulation. 
 
 TJie next th'.ig to do is to suck the ivouiid thorouf:jhly. There 
 >;hoviki be no hesitation whatsoever on the part of any bystander to 
 perform this office for the sufferer, for if the lips and tonj^ue be free 
 from scratches and cracks, there is no danj^er whatsoever in taking 
 the poison into the mouth, or even in swallowing it. Although the 
 act may be an unpleasant one, yet it may save the life of the 
 patient. 
 
 After this has been done, it will be well to cut out the skin and 
 tissues around the wound. This should be done heroically and 
 thorouc;hly. There need be no hesitation in making a free incision, 
 since it will be at most a trifling loss of flesh which will soon be 
 replacetl if the individual live, while economy in the amount of 
 flesh removed may lead to the retention of some of the poison and 
 the death of the individual. 
 
 If no one can be found with sufficient nerve to perform this 
 operation, the wound should be thoroughly cauterized in the fol- 
 iowmg way : A piece of iron wire or a small nail is heated white 
 hot and then inserted firmly into the opening made by the fangs of 
 the reptile ; or a piece of soft rag may be wound firmly about the 
 end of a stick, dipped in nitric acid, and then used to cauterize the 
 wounds. 
 
 Dr. Mitchell advises that after these measures have been used, 
 the bandage around the limb should be relaxed for a- moment and 
 then lightened again. After a quarter or half an hour this loosen- 
 \\v^ of the bandage for a few seconds may be repeated. In this 
 way the poison — if any remain in the wound — is introduced into 
 the system in small installments, and it will probably produce less 
 serious effects than would result if the entire quantity reached the 
 system at once. 
 
 Aside frcmi this local treatment, the patient requires stimula- 
 tion. Kor this purpose two remedies arc especially recommended 
 — alcohol and ammonia 
 
 In the Western States the great remedy for the bite of the 
 rattlesnake is ivhisky. This is administered in such quantities as 
 would appall an inhabitant of any other region. It seems to be a 
 fact, however, that the sufferer from rattlesnake poison can swallow 
 without becoming intoxicated a much larger ciuantity of whisky 
 than he cculd otherwise bear. Any other alcoholic stimulant, such 
 
 
 
 
I 
 i 
 
 m:\ 
 
 I 
 
 I 
 
 713 
 
 SURGICAL DISEASES. 
 
 as rum, brandy or gin, may be used instead of whisky. The liquor 
 may be j^iven until the patient shows sij^ns of into.xication. 
 
 If there be signs of shock — a pale and cold skin, feeble pulse 
 and semi-unconsciousness — a half teaspoonful of hartshorn shuuld 
 be given in the whisky every half hour. 
 
 If the patient vomit, and therefore cannot retain the'uliiskv, 
 it should be given as an injection into the rectum ; for this purpnsc 
 it is mixed with an equal quantity of milk. 
 
 After the patient has recovered from the immediate effects of 
 the bites, the wounded limb should be enveloped in cloths satur- 
 ated with hot water, which are renewed sufficiently often to kcLU 
 them warm and moist. The patient should be supplied with nour- 
 ishing food in abundance, and his strength supported with cjui- 
 nine. 
 
 In India people are troubled with a most venomous and dan- 
 gerous snake, the cobra. An English physician. Sir Joseph I'ayrcr, 
 who has had long experience in medical practice in India, gives the 
 following directions for the treatment of persons who have been 
 bitten by this serpent: 
 
 " Apply at once a ligature, or ligatures, at intervals of a few 
 inches, as tight as you can possibly tie them, and tighten the one 
 nearest to the wound by twisting it with a stick, or other such aL,ant. 
 Scarify the wound and let it bleed freely. Apply either a hut iron 
 or live coal, or explode some gunpowder on the part ; or apply 
 either carbolic or some mineral acid or caustic. Let the ])atient 
 suck the wound while you are getting the cautery ready, or if any- 
 one else will run the risk, let him do it. If the bite be on the toe 
 or finger, especially if the snake has been recognized as a deadly 
 one, either completely excise, or immediately amputate at the next 
 joint. If the bite be on another part where the ligature cannot be 
 applied, or, indeed, if it be on the limbs above the toes or fingers, 
 cut the part out at once completely. 
 
 " Let the patient be quiet. Do not fatigue him by exertion. 
 Wlien, or even before symptoms of poisoning make their appear- 
 ance, give eau-de-luce, or ammonia, or carbonate of anmionia, or, 
 even better than these, hot spirits and water. There is nooccasion 
 to intoxicate the person, but give it freely and at frequent intervals. 
 
 " If he becomes low, apply mustard plasters and hot bottles, 
 galvanism or electro-magnetism over the heart and diaphragm. 
 Cold douches may also be useful. 
 
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BROKEN BONES — FRACTURES. 
 
 7^1 
 
 " The antidotes in addition may be used by those who have faith 
 in them ; but, as I have said, I fear there is no reason to believe 
 that they are of any use. Encourage and cheer the patient as much 
 as possible. As to local effects, if there be great pain, anodynes 
 may be applied or administered, and antiseptic poultices to remove 
 sloughs ; collections of matter must be opened. 
 
 " Other symptoms are to be treated on general surgical princi- 
 ples. 
 
 " This, I believe, is the sum and substance of what we can do in 
 snake bite. If the person be not thoroughly poisoned, we may 
 help him to recover. If he be badly bitten by one of the more 
 deadly snakes, we can do no more." 
 
 To sum up, then, we may outline the treatment of bites by 
 poisonous snakes as follows: 
 
 Tie a bandage or cord very tightly around the limb. 
 Suck the wound thoroughly. 
 
 Cut out the skin and flesh for a distance of half or three quar- 
 ters of an inch around the marks of the fangs ; or, instead of this, 
 cauterize the wound thoroughly with a hot iron or with nitric acid 
 or with carbolic acid. 
 
 Give the patient plenty of whisky and hartshorn. After cauter- 
 izing the wound, wash it thoroughly with water or with a solution 
 of carbolic acid in water. 
 
 After this has been done, the bandage or cord may be loosened 
 for a few seconds and then reapplied. 
 
 Repeat this loosening of the bandage every twenty minutes 
 for two hours, at the end of which time it may be permanently 
 removed. 
 
 Encourage the patient and give him plenty of good food. 
 
 Broken Bones — (Fractures.) 
 
 The composition of the bones varies at different times of life, 
 and there is found a corresponding variation in the liability to 
 breaking c\x fracture. 
 
 In childhood the bones are quite soft and flexible. In fact, 
 several of the bones of the body are composed more or less of 
 gristle until near the age of 1 8 or 20 years. As the person 
 advances in life, the bones become harder, because the proportion 
 
 
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714 
 
 SURGICAL DISEASES, 
 
 of mineral matter in them — lime and its compounds, especially — 
 increases. Then, again, the weight of the body becomes greater, 
 and, consequently, the force of a fall is increased. 
 
 As a result of these different factors, fractures of bones arc far 
 more frequent in adults than among children, and are most com- 
 monly met with among people in middle or advanced life. In con- 
 sequence of the difference in occupation, fractures are more frequent 
 among males than among females. 
 
 There are several causes which predispose to fracture, that is, 
 which render the bones of some persons far more liable to fracture 
 than those of others. Among these causes are certain diseases of 
 the bone, especially rickets, long disuse of the limb, such as lui])- 
 pens after accidents which compel the patient to keep his bed. 
 There are, moreover, cases in which the bones are extremely brit- 
 tle, as a result, apparently, of some error in the nutrition of the 
 body, without any manifest disease. 
 
 Bones may be broken, first, by direct violence. A blow upon 
 the head or the falling of a heavy bo''y upon the arm illustrates this 
 form. 
 
 Second, by indirect violence; that is, the force is applied to 
 some other part of the body than that in which the bone i- frac- 
 tured. Thus a fall upon the shoulder frequently occasions a frac- 
 ture of the collar-bone, and a fall, in which the individual throws 
 out the hand to \ reak the force of the blow, often results in a frac- 
 ture of a bone of the forearm just above the wrist. 
 
 Third, fracture may result from muscular action. Thus the 
 knee-pan is sometimes broken across by violent muscular elTorts in 
 jumping. 
 
 A fracture may be complete or incomplete. That is, the bone 
 may be broken right across, or the break may extend only part way 
 across — the remainder of the bone bending. This is illustrated by 
 .ne attempt to break a green stick; and the fracture is accordingly 
 ':alled a " green stick fracture. " This variety is especially apt to 
 occur in children, whose bones are soft and flexible. 
 
 Another important distinction is the division of fractures into 
 simple and compound. 
 
 A simple fracture is one in which the skin is not wounded. 
 
 In a compound fracture, on the other hand, the skin is hiokcn 
 either by the violence which caused the fracture or by the protrusion 
 of one of the broken ends of the bone through the skin. 
 
fracUircs into 
 
 BROKEN BONES — FRACTURES. 
 
 715 
 
 The Repair of Fractures. — It is important to understand tiie 
 general principles concerned in the repair of the fractures of bones, 
 since the treatment is regulated by these principles. 
 
 For the first few days after the infliction of the injury, but 
 little change occurs around the broken ends. The violence which 
 caused the fracture has, of course, crushed a great many blood 
 vessels, large or small, and considerable blood escapes from these 
 into the tissues around the broken ends. There occurs, therefore, 
 a swelling of the part, which becomes in a few days " black and 
 blue." This blood is gradually absorbed just as it is when a bruise 
 is inflicted without fracture. 
 
 After a period which varies from three to seven days, the pro- 
 cess of repair begins. This consists in the formation of material 
 between and around the broken ends of the bone. This material 
 mav be likened at first to glue, which it resembles indeed some- 
 what in its chemical composition. This material is called lymph, 
 and serves to unite the ends of the bones temporarily. 
 
 In the course of several weeks this lymph becomes converted 
 into gristle, and finally into true bone. Meanwhile ';he seat of the 
 fracture is marked by a lump, which consists of this lymph as it is 
 changing into bone. 
 
 When we consider that this lymph is apt to be thrown out 
 around the bone within a few days, and that it becomes gradually 
 cnanLjed into bone, we can appreciate the importance of placing 
 the broken ends in their proper positioi. immediately after the 
 fracture ; for the position which they assume at this time will 
 become permanent by the formation of bone around the broken 
 ends. 
 
 This lymph can readily be disturbed and broken during the 
 early weeks of the healing process ; hence it is very important that 
 measures should be taken for keeping the ends of the bones perfectly 
 quiet. 
 
 The entire process of healing, that is, the transformation of all 
 the new material into bone, requires a period of several months ; 
 but usually within six to ten weeks the process is so far advanced 
 that the ends of the bone are kept firmly in position without arti- 
 ficial assistance. 
 
 Fractures heal far more rapidly in children than in adults ; the 
 power ^A repair diminishes in advanced life, so that in many aged 
 individuals the ends of a broken bone never unite completely — 
 47 
 
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 Jf-i, 
 
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7i6 
 
 SURGICAL DISEASES. 
 
 that is, there is no true bone formed between the broken ends, 
 which are bound together by a membranous attachment. 
 
 There are some bones, fractures of which do not readily unite. 
 In some of these the formation of true bone — bony union, as it is 
 called — rarely occurs. Fractures in the hip-joint, that is the head 
 of the thigh-bone ; fractures of the point of the elbow and of the 
 knee-pan are unusually troublesome in this respect. Moreover, if 
 pieces of the skull are completely removed, the gap is filled up, 
 not with true bone, but with a membranous material. 
 
 'A- 
 
 Sjftnptoms. — There are certain general symptoms which are 
 present in most cases of fracture. These are : 
 
 Firsi — Pain usually immediately over the point of injury. In 
 some cases, in which the other symtoms are obscure, the e.\ist- 
 ence of a fracture is determined chiefly by the presence of a sharp 
 pain when the finger is pressed upon a certain point. 
 
 Second — Swelling. 
 
 Third — Deformity. This often consists simply in a shortening 
 of a limb. In fractures of the thigh or of the arm, for instance, we 
 can readily see, even without measuring, that the injured limb is 
 considerably shorter than the other one. 
 
 At other times the deformity consists in a lump or a depression. 
 Thus the fracture which so frequently occurs just above the wrist 
 is usually marked by a projection of one of the broken ends, so as 
 to cause a painful lump under the skin. 
 
 Fourth — Unnatural mobility. This is a very important symp- 
 tom, by which alone we can often detect the presence of a fracture 
 positively. If the thigh be broken, for instance, there appears to 
 be a new joint in the limb. 
 
 Fifth — Loss of power in the limb. If a bone be broken, the 
 patient carefully refrains from every muscular effort to move the 
 part, since every movement causes extreme pain. 
 
 Sixth — A grating sound and feeling. When the limb is moved 
 so that the ends of the broken bone come in contact, the patient 
 feels a rasping sensation, which is also communicated to the fingers 
 of the surgeon. Sometimes a corresponding sound can be heard 
 at the same time. 
 
 All of these six symptoms may be present in case of fracture, 
 yet we must not assume the absence of a fracture because one or 
 more of them cannot be detected. In fact, the only absolutely 
 
BROKEN BONES — 1 kACTURES. 
 
 717 
 
 ns which are 
 
 positive proofs of the existence of a fracture are the unnatural mobil- 
 ity of the part and the grating sound, technically called crepitus. 
 
 In many cases it is a simple matter, even for the uninitiated, 
 to detect the existence of a fracture. In other instances the symp- 
 toms are so obscure that the skill of the most experienced surgeon 
 is taxed to decide the question. In every such case -c will be well 
 to proceed for some days upon the supposition that fracture has 
 actually occurred; for if the bone be not broken, no damage will 
 be inflicted by the treatment ; while on the other hand, if there be 
 a fracture, incalculable injury may result from neglect. 
 
 In every case in which the least doubt exists as to whether a 
 bone be actually broken, the injured member should be closely 
 compared with that of the opposite side. The sound limb should 
 be completely bared, and the injured one compared with it as to 
 outline, movement, etc. Then we should take a tape-measure and 
 compare as accurately as possible the length of the corresponding 
 parts of the two limbs. After this we may grasp the injured mem- 
 ber with both hands, placing one above and the other below the 
 seat of the injury. The hands should then be moved in opposite 
 directions from the axis of the limb ; thus one hand should be pressed 
 backward and the other forward at the same time. In this way we 
 detect any unnatural mobility and feel the grating sensation, if a 
 fracture exist. 
 
 It is important to know how the fracture was made. For we 
 can form a better estimate of the extent of the injury, as well as of 
 the direction of the break, if we know in what way the force was 
 applied. 
 
 Fractures which are produced by direct violence are usually 
 more serious than others, because they are commonly accompanied 
 by bruising or laceration of the tissues. 
 
 As to the direction of the fracture — that is whether the bone is 
 broken squarely across or obliquely — we are thrown for information 
 upon the position and appearance of the part. It is sometimes 
 possible to feel distinctly the broken ends ; this is especially often 
 the case in those bones which lie close to the skin, such as the 
 collar-bone, the shin-bone, and portions of the bone constituting 
 the forearm. Fractures of long bones — that is, those of the thigh, 
 leg, arm, and forearm — are usually oblique. 
 
 It is extremely important to ascertain as definitely as possible 
 the line of direction of the fracture ; since the " setting " of the bone 
 
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 718 
 
 SURGICAL DISEASES. 
 
 will require different manipulaf ions according to the relative posi- 
 tion of the ends of the fragment. 
 
 A fracture is sometimes mii/;aken for a severe bruise, for a 
 sprain and for a dislocation. 
 
 Such a mistake may be made by even the most experienced 
 surgeon, especially if the parts around the seat of the injury are 
 much swollen and very tender. For unless the surgeon's finj^arcan 
 be brought into pretty close contact with the injured bone, there 
 may remain a doubt in many cases ai\ to what the exacL condition 
 of things is. 
 
 If there be much swelling, so that an accurate examination of 
 the part is impossible, the limb should be enveloped in cloths satu- 
 rated with hot water, which are changed every two hours. These 
 cloths may be covered with oiled silk or a piece of rubber clulh, in 
 order to retain the warmth and moisture as long as possible. 
 
 After a few days the swelling usually subsides, and the i)ain is 
 so much decreased that the parts can be handled to much better 
 advantage. 
 
 A bruise may be accompanied with -as much pain, swelling and 
 loss of power in the limb as a fracture. But these fymptoms sub- 
 side in a few hours or days, after which it becomes apparent that 
 the loss of power was but temporary. 
 
 A sprain may resemble a fracture in many respects ; iliere is 
 apt to be a point of extreme tenderness just as is the case when 
 the bone is broken. But the sprain, as well as the bruise, is dis- 
 tinguished from a fracture by the absence of unnatural niobiHty and 
 of crepitus. 
 
 A dislocation is usually characterized by a lack of mobility of the 
 limb. There is also in most cases a deformity which shows at once 
 that the bone is out of place. 
 
 The distinction between a fracture and a dislocation is, how- 
 ever, in some instances extremely difficult even for the suri^een. 
 In fact the two accidents are often combined. The.se injuries in 
 the neighborhood of join*.s are the most puzzling of all which the 
 surgeon is called upon to treat. 
 
 General Treatment of Fractures,— After it is apparent 
 
 that a bone has been broken, a temporary dressing should be 
 arranged until the patient can be transported to his home or to a 
 hospital where he is to remain during the healing of the fracture. 
 
SETTING OK A UKOKEX BONE. 
 
 719 
 
 iruise, fi^r a 
 
 The object of this temporary dressing should be simply to 
 keep the limb quiet so that the broken ends shall not move and 
 tear the flesh during transportation. If the wounded limb be a 
 leg, a piece of wood long enough to stretch from the hip to the 
 ankle should be obtained and applied to the back of the leg. This 
 is to be kept in position by bandages placed around the thigh and 
 the leg. A few laths will answer the purpose very well. 
 
 If the wounded member be the forearm, it may be slung tem- 
 porarily in a large handkerchief knotted around the neck. If the 
 arm be injured it will be well to apply a short piece of wood, fast- 
 ened to the arm by bandages so as to render the part immovable. 
 
 The patient should be laid upon a hard bed which stands firmly. 
 The fracture may then be more carefully examined, and the nature 
 of the required dressing determined. 
 
 If there be much swelling at the seat of injury, it is in most 
 cases advisable to delay the the application of splints for a day or 
 two, until the swelling has been reduced. To accomplish this the 
 limb should be wrapped in cloths saturated with hot water, which 
 should be changed sufficiently often to keep the part moist and 
 warm. Meanwhile the limb may be steadied and prevented from 
 moving by rolling up two blankets and placing the rolls one on 
 cither side of the limb. If the operator have a little skill, a single 
 blanket may be made to accomplish the purpose by making two 
 rolls of it, one from either end, between which the limb can be laid ; 
 or sticks of wood may be wrapped in soft cloth and placed on either 
 side of the injured member. If there be a wound at the seat of injury, 
 a piece of rubber cloth should be laid under the limb. In any case 
 the injured part may rest upon a pillow. 
 
 Setting of a Broken Bone. 
 
 The treatment of a fracture consists of two essentials : 
 
 First. — To restore the broken ends to their natural position. 
 
 Second. — To keep them in this position. 
 
 The first of these — the restoration of the bone to its proper 
 position — is what is popularly known as "setting" the bone. 
 
 The chief difficulty, both in replacing the ends of the bones and 
 in holding them in position, lies in the resistance of the muscles of 
 the limb. These muscles are irritated either by the original injury 
 
 Hi 
 
 
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 \svnu 
 
 « 
 
 
720 
 
 SURGICAL DISEASES. 
 
 m.i 
 
 or by the sharp ends of the bones which project into them. As a 
 result of this, as well as of the natural tendency of the muscles to 
 contract, the limb is shortened. The amount of shortening varies 
 extremely, both with the strength of the muscles involved and with 
 the obliquity of the fracture. Thus a fracture of the thigh is always 
 followed by a considerable degree of shortening, which it is indeed 
 very hard to overcome. A fracture of the leg is also accompanied 
 by shortening, though this is somewhat more readily remedied. 
 
 In setting the bone we must first of all remember that wc have 
 to overcome the muscular force by which the limb is rendered 
 shorter than the other ; for if we neglect to do this, and apply the 
 dressing without returning the limb to its proper length, the broken 
 ends of the bone will unite in this unnatural pcsition, and the limb 
 will remain \ "rmanently shorter than its fellow. 
 
 To overcome ihis muscular contraction, we place the limb in a 
 position in which the muscles are relaxed as much as possible. Thus 
 if we have to treat a fracture of the forearm we bend the arm at the 
 elbow, and usually at the wrist, so that the fingers are turned upward 
 toward the front of the arm. 
 
 The simple position of the injured member sometimes suffices 
 to overcome the contraction of the muscles and to restore the 
 broken bone to something like its natural position. Yet, in most 
 cases, it becomes necessary to employ additional means to accom- 
 plish this object by pulling the lower fragment away from the 
 upper. This must be done with care and yet with considerable 
 force. One person should grasp the limb firmly below the point of 
 injury, while another seizes it above this point. Care should be 
 taken that the upper fragment is grasped below the next joint above 
 the wound. Thus if the leg be broken five or six inches from the 
 ankle, one person should grasp the calf, not the thigh; for if a joint 
 be allowed to intervene between the points which are grasped in 
 the hands of the operators, the force which should be expended in 
 pulling the lower fragment away from the upper, will probably do 
 little more than stretch the ligaments of the joints and separate the 
 surfaces of the bones. Thus if the leg be broken above the ankle, 
 and the attempt be made to restore the position of the limb by pull- 
 ing on the foot while another person holds the thigh, it is probable 
 that although the ankle and the knee-joint may be severally 
 stretched, the broken end of the bone will not be forced into posi- 
 tion. 
 
Y'.'. 
 
 SETTING OF A BROKEN BONE. 
 
 721 
 
 In every case, therefore, care should be taken that the force is 
 applied directly to the two fragments of the broken bone itself and 
 not to distant parts of the same limb. Thu'^ in the example which 
 we have taken for illustration (a fracture of the leg five or six inches 
 above the ankle), one person should grasp the limb just above the 
 ankle as well as the foot, while ant)ther should take hold of the leg 
 just below the most prominent part of the calf 
 
 As to the degree of force which should be employed in restor- 
 ing the bone to its proper position, we can only say that this resto- 
 ratioii must be accomplished, and that so much force must be used 
 as is necessary to efiect it. The degree of force required varies of 
 course with the size and strength of the muscles whose contraction 
 is to be overcome. Thus a fracture of the forearm can usually be 
 set without the exercise of much strength, while a fracture of the 
 thigh can be placed in position only by the most strenuous efforts. 
 
 In consequence of the difficulty which is thus experienced in 
 overcoming the muscles of the injured limb, and of the pain which 
 is inflicted upon the patient by this effort, surgeons usually admin- 
 ister ether when they have occasion to set a broken thigh, or even 
 a broken leg. The administration of ether accomplishes two 
 objects. 
 
 First, the patient suffers no pain during the setting of the 
 bone. 
 
 Second and chiefly, the muscles are relaxed by the effects of 
 the ether, so that they offer no further resistance to the surgeon's 
 efforts in replacing the broken ends of the bone in their natural 
 position. This measure is absolutely necessary in order to accom- 
 plish the perfect setting of a broken bone which is surrounded by 
 large and powerful muscles. 
 
 Cases occur in which the bone retains its natural length even 
 after a complete fracture, so that no effort is required on the part 
 of the surgeon to lengthen the injured limb. In these cases the 
 bone is broken square across. These instances occur most fre- 
 quently in the forearm and in the leg, where the member contains 
 two bones. If only one of these bones be broken, and the frac- 
 ture be made transversely — that is, square across — the limb often 
 remains in position, because its shape and length are preserved by 
 the second and uninjured bone. 
 
 We may know that we have succeeded in " setting the bone " 
 if the limb resumes its natural length and outline. In many cases 
 
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 722 
 
 SURGICAL DISEASES. 
 
 we can feci, moreover, that the fragments are now in position 
 instead of projecting one over the other as before. In order to be 
 perfectly sure, we must measure the length of the limb and cnni- 
 pare this with that of its sound fellow. 
 
 If the thigh be broken, a strip of stout inelastic cord or tape 
 may be used, one end of it being placed at the navel, while tlie 
 other end is carried to the outside edge of the kneepan at its mid- 
 dle. After this has been done on one side, the length between the 
 navel and the corresponding point of the kneepan on the other Ic 
 should be measured. The two should coincide either exactly or 
 within a small fraction of an inch. A certain difference — aniniiiu- 
 ing in cases of fractured thigh to half an inch — may be disre- 
 garded ; first, because there is often a difference betv cen the leiij^tli 
 of the two limbs in persons who have never suffei' ( any fracture; 
 and second, because a certain amount of shortening ••>lly inev- 
 
 itable in fractures of the thigh. 
 
 In making comparative measurements of the two limbs in this 
 way, care must be taken to avoid sundry errors into which we in;iv 
 readily fall. Thus it must be carefully noted that the patients 
 limbs lie parallel with the axis of the trunk — that is, that they form 
 no angle with the body at the hips — for if the legs are not straiijht, 
 if they happen to be inclined a little to the right or the left, the 
 distance from the navel to the knee will, of course, be greater in 
 one than in the other. 
 
 Dressing of Fractures. 
 
 After having placed the fragments in position, our next care is 
 to take such measures as will keep them in place ; otherwise the 
 movements of the patient and the contraction of the muscles in the 
 injured limb would soon cause a displacement of the broken ends. 
 Indeed, in many cases it is necessary to apply the bandages while 
 the limb is held in position by the assistants ; for if the parts be 
 relaxed long enough to put on the necessary dressings, the limb 
 shortens and takes the same position as before. 
 
 In order to attain this object and keep the parts in position, 
 we employ supports, splints, bandages and apparatus of several 
 kinds. 
 
DRKSSING OF FRACTURKS. 
 
 723 
 
 Jiffinlftffeti, — For the application of dressings to fractured 
 limbs, the best material for bandages is muslin or cotton cloth. 
 'I'liis can be procured at the various depots for surgical appliances; 
 yit bandages can be readily prepared in the household by tearing 
 up sheets. The width of the strips into which the sheet is torn 
 shmild vary according to the locality requiring the bandage ; in 
 general, we may say that from two to four inches is the breadth 
 required. 
 
 The length of the bandage also varies ; of course several 
 shorter ones can be made to answer the same purpose as one long 
 one. For bandaging a leg from the foot to the knee, we require 
 ordinarily about five yards. The strips may be sewed together end 
 to end. so as to make the length requires 
 
 In order to apply a bandage properly, ihis must be first rolled 
 firmly and evenly around a stick. It should then be carefully 
 applied, the roll being held close to ♦ . leg as it is carried up the 
 limb. If much loose bandage is allowed to 'ntcrvene between the 
 1 and th? leg, it will b'' impossible to <'ti>ply the bandage nicely. 
 Care shoula be taken that the bandage is put on evenly ; that is, it 
 should not be applied tightly in one place so as to cut off the circu- 
 lation, and loosely in another so that it will slip. 
 
 In order to apply a bandage nicely and smoothly on any part 
 of the body which tapers — such as the arm or leg — it is neces- 
 sary to turn the bandage over at every circle around the limb. 
 This process is called reversing, and can be learned only by personal 
 instruction. 
 
 In bandaging the hands and feet, we should leave the ends of 
 the fingers and toes uncovered, in order that we may see their color 
 and feel how warm they are. This is an important item, especially 
 when the bandage is applied by an unskilled hand ; for if it be too 
 tightly applied so that the circulation is impaired, it is necessary to 
 loosen the bandage at once, and reapply it less tightly. We can 
 observe the existence of this condition by a blue or livid color of 
 the fingers or toes, which are at the same time unnaturally cool. 
 This coolness and lividity are caused by the interruption to the cir- 
 culation through the limb. 
 
 In order to hold the bones in place we need in some cases only 
 a bandage. Thus fractures of the skull, and many of those of the 
 trunk, can be kept in position by adhesive plaster and simple band- 
 ages. 
 
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 724 
 
 SURGICAL DISEASES. 
 
 Fractures of the long bones, however — indeed of any bone in 
 one ci the extremities — are to be treated by th*.- use of splinls. 
 
 Splints may be made of various materials ; the commoncsl arc 
 those of wood, leather, pasteboard and plaster of Paris. The selec- 
 tion of the splint depends upon the requirements of the case. In 
 every instance the two requisites which are to be chiefly sought, 
 are strength and lightness. 
 
 For ordinary purposes, splints can be made out of thin wood, 
 such as shingles or siding, which can be cut to the length and sh.ipc 
 required. Another convenient material is sole-leather. The 
 advantage of this is its ready adaptability to the shape required. 
 It can be moulded to the limb by first soaking it in hot water. 
 Stiff pasteboard is useful in many cases where no great strength 
 is required. 
 
 In order to fit a splint of pasteboard or sole-leather to a limb, 
 a pattern should be first cut in paper ; the leather or pasteboard 
 can then be cut after this pattern, soaked in hot water until it is 
 quite flexible, and applied to the limb. A bandage should then be 
 applied so as to hold it in position. After it has become dr\- tin 
 the limb, it will retain its form. It should then be removeil, the 
 edges trimmed and padded with cotton. In fact, every splint, of 
 whatever material it be made, should be covered with cotton sheet- 
 ing, which is to be made especially thick at the prominent points of 
 the limb, where pressure on the part may be ^ pected. Thus, in 
 applying a splint to the leg, especial care should be taken to pad 
 thickly the projections at the ankle and at the knee. The cotton 
 should also be made to overlap the edges of the splint, so that there 
 can be no chafing of the skin. 
 
 These are important points in the preparation of the splint; 
 by observing them, we can avoid many of the unplt asant incidents 
 and accidents which are apt to occur during the treatment of a 
 fracture. 
 
 In many cases, a lighter and weaker bandage than one of these 
 will answer every purpose ; such bandages can be readily made of 
 glue or of starch, or of a mixture of the two. 
 
 To make a starch bandage, a quantity of thick starch is pre- 
 pared and kept warm, while a bandage is smoothly and evenly 
 applied over the limb which is previously well padded with cotton 
 to avoid chafing. The starch is then applied to the bandage which 
 covers the limb, and allowed to cool. A second layer of starch is 
 
DRESSING OF FRACTURES. 
 
 725 
 
 then rubbed into the bandage, and still a third, if necessary to give 
 it the proper degree of stiffness. In applying the starch, it is best 
 to use the hands rather than a brush, since it is important to rub 
 the starch thoroughly into the bandage and into all the crevices. 
 
 A bandage of glue and starch can be made in a similar way, 
 and has the advantage of being somewhat stiffer than one made of 
 starch aUme. To do this, take equal parts of boiled starch and 
 melted glue, heat them together and mix thoroughly while still 
 warm. The limb is enveloped in cotton so as to protect the skin ; 
 a bandage is evenly applied, and is then smeared with the warm 
 mixture of glue and starch. 
 
 If such a dressing be found too yielding, it may be strength- 
 ened by applying a second bandage outside of the first and satu- 
 rating this with the starch or with the mixture of glue and starch. 
 In fact, three, four, or five layers of bandage may be thus applied, 
 if necessary, each layer being smeared with starch in turn. The 
 last layer should be covered with a simple bandage unstarched. 
 
 If it become necessary to employ a very stiff and firm dress- 
 in" which shall surround the limb, it will be well to use the p/asUr 
 of Paris. These are prepared in the following way: 
 
 A muslin or soft cotton bandage, two and a half or three inches 
 wide, is dusted over with the dry plaster of Paris. To do this well, 
 the bandage is unrolled and the plaster thoroughly rubbed into the 
 meshes of the cloth, beginning at one end. There is usually dan- 
 ger of getting too little plaster into the bandage, in which case the 
 dressing will be weak and flexible. Every care should be taken, 
 therefore, to get as much as possible into the cloth. After this, 
 they should be loosely folded up, ready for application. 
 
 The limb, meanwhile, is enveloped with a double layer of 
 sheet cotton, with extra thickness at the bony prominences of the 
 ankle, the knee, the elbow, or any other parts of the body which 
 must be covered. When the limb is ready the bandages, whose 
 meshes are already full of plaster of Paris, are placed in lukewarm 
 water, where they are allowed to remain until wet through, a pro- 
 cess which usually requires three or four minutes. These bandages 
 should not be allowed to remain in the water too long, because the 
 plaster of Paris becomes hard and brittle and will crumble when 
 the dressing is applied. Hence it is advisable to put only two or 
 three of these rolls in the water at a time, a fresh one being added 
 so soon as one is removed for application to the limb. 
 
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 I I 
 
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 um'*^' 
 
726 
 
 SURGICAL DISEASES. 
 
 The bandages are then applied closely and evenly to the limb. 
 One or two thicknesses are usually sufficient, and we should never 
 put on more than three or four, since the bandage will thereby 
 acquire an unnecessary weight and rigidity. After the dressing is 
 thus applied, a mixture of plaster of Paris and water, having the 
 consistency of cream, should be plastered over the entire dressing 
 with the hands. 
 
 It is important that the plaster of Paris employed for this pur- 
 pose shall not have been long exposed to the air and moisture ; for 
 plaster which has been subjected to this exposure will not harden 
 ■well, and a dressing made of it will not possess the necessary stiff- 
 ness and firmness. 
 
 An important feature in the application of rigid dressing is 
 that the limb shall not be completely enveloped. Hence it is nec- 
 essary to cut open the starch or glue or plaster of Paris dressing. 
 The reason for this lies in the fact that the limb almost invariably 
 swells somewhat after the application of the dressing ; and unless 
 this can be loosened the patient will suffer much pain and perhaps 
 injury in consequence. 
 
 Hence whenever a dressing of starch or glue or plaster of Paris 
 has been applied, it should be cut open so soon as it has dried. Tlie 
 plaster of Paris dressing is usually dry in twelve hours; the starch 
 or glue dressing may require twenty-four hours. In any case we 
 can determine when they are dry by feeling of them and noting 
 their rigidity. After they have dried, a pair of scissors may be 
 inserted under one end of the bandage and made to cut the entire 
 dressing open. It will be necessary in every case to select for this 
 purpose that part of the dressing which is least important in sup- 
 porting the brDken bone. Thus if the part enveloped in the dress- 
 ing be the leg, the bandage may be cut open along the fiont just 
 over the shin-bone. In cutting open the plaster of Paris bandage 
 it will be necessary to employ a very heavy, strong pair of scis- 
 sors. 
 
 After the dressing has been thus opened, a bandage maybe 
 applied around it lightly so as to hold it firmly in position. This 
 may be removed every second or third day iji order to see h-^w 
 closely the dressing is fitted to the limb. In many instances the 
 part swells considerably for the first day or two and then becomes 
 smaller ; it will be necessary therefore to gradually tighten the 
 bandage which is employed to hold the dressing in position. 
 
RESULTS OF FRACTURES. 
 
 727 
 
 If there be an open wound anywhere — and there often is at 
 the seat of the fracture — this should be exposed to view and 
 relieved from pressure by cutting an opening in the dressing over 
 the wound. The edges of this opening should be covered with lint 
 spread with vaseline, in order to prevent the discharges from the 
 wound from escaping upon and under the dressing. 
 
 If the fracture be located near a joint, the splint should be 
 made to include this joint so as to secure perfect repose for the limb 
 in the vicinity of the injury. 
 
 Special devices are employed in the treatment of certain frac- 
 tures. A favorite one for the treatment of fractures of the leg is what 
 is known as a fracture-box. This will be described in treating of 
 this particular affection. 
 
 Besults of Fractures. 
 
 It is highly important that people should understand certain 
 facts regarding the probable results of fractures. That there is a 
 vast amount of misunderstanding on the subject is shown by the 
 frequent suits for malpractice brought against physicians, and even 
 against the most skillful surgeons. As these suits almost invariably 
 result in favor of the surgeon, and, in fact, merely serve to adver- 
 tise him and increase his practice, it would be well for those who 
 suffer from fractures to understand that in the majority of cases the 
 limb will not recover its former value and beauty even in the hands 
 of the most skillful surgeon. 
 
 The first danger to be apprehended is, of course, loss of life. 
 This danger is much greater in people of feeble constitutions and 
 impaired health, though the fatal result may occur even in robust 
 individuals The danger to life is much greater when there is a 
 wound communicating with the break in the bone — that is, in com- 
 pound fractures. Fractures are more dangerous in the lower extremi- 
 ties than in the upper, and most dangerous when located between 
 the hip and the knee. 
 
 There is, furthermore, some chance that the bones will not 
 unite. This is a rare incident, more frequent in old persons than in 
 others. There ar^ certain parts of the body, fractures of which 
 are more apt to be followed by trouble of this kind than others. 
 
 
 
 i \ 
 
 "":I^OT1 
 
 
 |Vp 
 
 ■■r-t^i^l 
 
 
 •"■iM 
 
 
 ■ ^■'^'^ 
 
 ^Ifi^aBii 
 
 -•, « 
 
 iif 
 
 ^■fe' 
 
728 
 
 SURGICAL DISEASES. 
 
 Thus, fractures of the kneepan and of the upper end of the thigli- 
 bone occasionally fail to unite. 
 
 In these cases the ends of the broken bone are bound together 
 by a membranous material, forming a so-called false joint. This 
 may in time become quite manageable, and give the patient but 
 little annoyance. In other instances the limb remains practically 
 useless in consequence. There are certain operations known to 
 surgeons whereby the healing of the broken ends can be furthered 
 if they show signs of refusing to unite. 
 
 A most common result of fracture is permanent shortening of 
 the limb. This is especially apt to occur in fractures of the leg and 
 of the thigh. In fact, fractures of the thigh are, for practical pur- 
 poses, sure to result in shortening of the leg. 
 
 In many cases this shortening is inconsiderable, and docs not 
 materially impede the patient's movements nor detract from his 
 comfort. If the limb be only half an inch to an inch shorter than 
 its fellow, the patient will rarely experience any difficulty. This 
 fact can be better comprehended when we remember that there is 
 a difference of nearly half an inch between the length of the two 
 legs in the average healthy person who has never suffered a fracture. 
 If, however, the fracture result in the shortening of the linjb, 
 amounting to one and a half or two inches, the patient may be 
 compelled to wear a shoe with an extra high heel. The important 
 point for the public to remember is, that such a shortening may 
 result in the very best surgical hands, and that it is not, therefore, 
 necessarily evidence of any lack of skill. Such a shortening is 
 especially apt to occur in a robust and muscular individual. 
 
 Another feature to be borne in mind is that a limb which is 
 just as long as the other one when removed from its splint, may 
 become shorter in the course of a month or two. This seems to 
 result from the fact that the new bone formed at the seat of the 
 fracture is so soft that it gives way when the weight of the body is 
 brought upon it in the patient's efforts to walk. 
 
 In many cases a deformity results inevitably from fracture, 
 Such deformity may, of course, be the result of improper treat- 
 ment ; the bone may not have been properly set, or even if origin- 
 ally set in the proper way, the dressing may have become loose, so 
 that the broken ends of the bone have been pulled out of their 
 proper position by the action of the muscles, and the bone has 
 healed in this unnatural position. Yet there are instances in which it 
 
RESULTS OF FRACTURES. 
 
 ;29 
 
 m 
 
 is an utter impossibility to keep the broken ends in proper position 
 during the healing of the fracture. One of the most common places 
 for these intractable fractures is the collar-bone. It is well known 
 to surgeons that more or less deformity is the rule after the fracture 
 of the collar-bone, notwithstanding all the efforts of the most skill- 
 ful surgeon to prevent it. Another fracture which is apt to be fol- 
 lowed by deformity is the one which so frequently happens when 
 people in falling put out the hand to break the fiill. This often 
 results in a fracture of one of the bones of the forearm just above 
 the uiist, technically known as Colics^ fracture. The deformity 
 which so often results from this fracture has led to innumerable suits 
 for malpractice against surgeons. Patients might save many law- 
 yer's fees by remembering the fact that it can be proven in court, 
 by the testimony of the entire medical profession if necessary, that 
 this fracture is in many cases inevitably followed by deformity, and 
 that a deformity is not, therefore, sufficient evidence of lack of 
 skill on the part of the surgeon. 
 
 Another accident which sometimes results in fracture is stiff- 
 ness of the limb. It is a fact that simple disuse of a join<- for sev- 
 eral weeks is, in most cases, sufficient to cause stiffness of the joint. 
 This stiffness may gradually disappear if persistent and system- 
 atic etibrts are made to bend the limb ; in some instances, on the 
 other hand, the stiffness is permanent. 
 
 Such a loss of motion is especially apt to occur if the fracture 
 has been located near a joint, so that the dressing has necessarily 
 prevented movement of the joint during the healing of a fracture. 
 Yet it may happen when the injury is located somewhat remotely 
 from a joint. 
 
 In fractures of the thigh there remains almost invariably some 
 stiffness of the knee as well as of the hip. When the patient first 
 rises from his bed he may be quite unable to bend the knee. 
 This stiffness, however, usually passes off in the course of a few 
 weeks or months. 
 
 All these accidents may occur as a result of simple fracture — 
 that is, fractures in wnich the bone is broken without any wound of 
 the skin communicating with the break. If the latter feature be 
 also present — that is. if the fracture be compound — the probabili- 
 ties of disastrous results are much increased. This fact results 
 from several causes : first, because an injury which results in a com- 
 pound fracture is often more extensive and severe ; and, second, 
 
 t , 
 
 'MM 
 
730 
 
 SURGICAL DISEASES. 
 
 f ■ 
 
 ,i : 
 
 because the presence of the wound interferes in many cases with 
 the application of dressings, so that it is impossible to employ the 
 appliances necessary to keep the broken ends in their proper posi- 
 tion. 
 
 There are certain complications which may follow any fracture, 
 but are almost invariably met with in connection with compound 
 fractures, that is those in which the skin is wounded over the break- 
 in the bone. It is especially important, therefore, that compound 
 fractures be carefully watched. 
 
 In treating such a fracture it is important that we do every- 
 thing possible to promote the discharge of matter which may form 
 in the wound. The retention of this matter may result in an infec- 
 tion of the body, which often terminates fatally, and is known 
 under the name of pyceinia, or blood-poisoning. 
 
 We should, therefore, in every case of compound fracture sec 
 that a free opening is made for the discharges. It has been already 
 stated that, in treating such a fracture, a hole should be cut in the 
 dressing over the wound ; and it is also necessary that the wound 
 be syringed out two or three times a day w'xi.i an antiseptic solu- 
 tion. For this purpose we may keep on hand one of the following 
 liquids : 
 
 Carbolic acid, . .. - . Half an ounce. 
 Water, ..... One pint. 
 
 Instead of this, it will be better to employ the following solution : 
 Listerine, ..... Two ounces. 
 
 Water, .-.-.- Eight ounces. 
 
 After syringing the wound thoroughly with one of these liquids, it 
 may be dressed by laying upon it a piece of lint or soft cloth 
 spread with vaseline. 
 
 If the wound be extensive and the bone be badly crushed, it is 
 often necessary to amputate the member. The services of the sur- 
 geon are, of course, in this case indispensable. In some such cases 
 surgeons are enabled to save the limb by immersing it in warm 
 water, into which a little carbolic acid (about 2 per cent.) has been 
 poured. For this purpose a trough of tin or zinc is made so as to 
 contain the water and to hold the limb comfortably. The injured 
 member is permitted to remain in this trough for a week or two, 
 or until the severity of the inflauunation has disappeared. In such 
 cases it is, of course, impossible to keep any dressings applied for 
 
BLOOD-I'OlSttNINi; — I'V.I^MIA. 
 
 731 
 
 the purpose of retaining the limb in position. In fact, in such 
 instances the question is not whether the patient shall have a per- 
 fect limb without deformity or shortening, but simply whether he 
 siuill have any limb at all. 
 
 The treatment of compound fracture usually includes also the 
 use of opiates to quiet pain. For the first two or three days it 
 mav be necessary to give an eighth of a grain of morphine every 
 five or six hours. 
 
 The patient will also usually have considerable fever during the 
 first week after the injury. This should be treated by the use of 
 Rochcllc salts in sufficient quantity to secure free movement of the 
 bowels at least once a day. It may be advisable also, in case the 
 fever is high, to sponge the patient twice a day with warm water 
 and to give him the following prescription : 
 
 Quinine, - - - Twenty-four grains. 
 
 White sugar. 
 
 One drachm. 
 
 Mix and make twelve powders. Take one every four hours. 
 
 His fever will be allayed to a certain extent by the following 
 mi.xture : 
 
 .Acetate of potash, . . . Five drachms. 
 
 Sweet spirits of niter, - - - Two ounces. 
 
 Water, ------ Two ounces. 
 
 Mix and take a teaspoonful four times a day. 
 
 If there be unusual redness around the wound, and especially 
 if the skin show signs of a black discoloration, the injured member 
 should be immersed for a few hours every day in hot water to whicli 
 a little carbolic acid has been added, and the portion of the skin 
 which has become dark should be cut off; for this discoloration is 
 due to death or gangrene of the tissue, and if it be not cut off it 
 will finally be separated by the formation of matter, after the 
 patient has experienced much annoyance and some danger from it. 
 
 The chief danger to be apprehended in these cases of com- 
 poiuul fracture is 
 
 1 » f. 
 
 ^1 
 
 li'*>^" 
 
 *:'■ 
 
 -4^ 
 
 Blood Poisoning— (Pyflemia). 
 
 This disease occurs usually in patients who are suffering from 
 wounds which produce considerable matter. It is especially fre- 
 quent in cases in which the bone has been injured, such as com- 
 pound fractures and amputations. It results from the collection of 
 
 48 
 
733 
 
 SURGICAL DISEASES. 
 
 matter in the wound, and can usually be avoided if the matter W 
 promptly and freely removed from the wound. In other words, 
 perfect cleanliness gives security, and the only security, a^'aiiist 
 blood-poisoning in cases of fracture in which the skin is broken and 
 a wound connects the fracture with the external air. 
 
 SymptOfns. — Pyaemia may occur at almost any period after 
 the infliction of the injury except the first few days. The first 
 indications are usually seen in a change in the appearance of the 
 wound. So long as everything proceeds favorably, the ed<;is <]f 
 the wound remain smooth and white, and the matter discliarj^rd is 
 of a creamy appearance. If blood-poisoning is to be expected, 
 the edge of the wound usually becomes swollen and red, quickly 
 changing to a purple or livid hue ; this change of color soon extends 
 to the skin surrounding the wound, which becomes dark. 
 
 The wound gapes, and the process of healing ceases quite 
 abruptly. In some cases portions of the wound, which seem to 
 be already closed, re-open. The matter discharged diminishes in 
 quantity and exchanges its creamy appearance for that of a bluod\ 
 fluid. 
 
 While these changes are going on the patient experiences one 
 or more severe chills, followed by high fever. He usually com- 
 plains also of pain in the vicinity of the wound, though this may 
 have been for days or weeks quite painless and comfortable. 
 
 The subsequent history of the case may present either one of 
 two distinct types. If the symptoms referred to have appeared 
 within the first week after the receipt of the injury, the patient 
 usually exhibits the symptoms which indicate an overwhelming^ 
 blood-poisoning — technically called septicceniia. In this case he 
 has one or more severe chills, followed by a very high fever, which 
 continues without intermission. The mental functions are derant^cd ; 
 the patient is completely prostrated, frequently has convulsions or 
 delirium, and lies in a state of semi-unconsciousness, from which 
 he is aroused with difficulty. This condition almost invariably ter- 
 minates fatally within eight or ten days ; death may occur in two 
 or three days. 
 
 If the symptoms of blood-poisoning do not occur until after 
 the first week from the infliction of the injury, the symptoms pre- 
 sented usually follow a different type. The patient has not only 
 one or two chills at the beginning of the difficulty, but sutlers from 
 
HLOOD-POISONINO — PY.EMIA. 
 
 733 
 
 repeated chills so long as the state of blood-poisoning exists, 
 riitse chills may occur every two or three days, or several of 
 thcni may be observed in the course of the same day. 
 
 The chills are followed by high fever, which, however, is not 
 constant but intermittent ; that is, for some hours or days the heat 
 of the patient's body may be about natural. 
 
 The sufferer is prostrated also by profuse sweats, which may 
 appear just after the fever, or may occur without any such prelim- 
 inary. In most cases he suffers also from diarrhea. 
 
 The mind is usually clear and the patient perfectly rational ; 
 in this respect his condition is easily distinguished from that just 
 tlcscribcd, called septicemia. 
 
 He is usually troubled with an obstinate dry cough, which 
 resists the treatment ordinarily employed to relieve such an affec- 
 tion. 
 
 In the course of a few days the patient complains of severe 
 pain in one of the joints, usually the elbow or knee. The joint 
 swells, though it may not exhibit any heat or redness, such as gen- 
 erally accompanies inflammatory swelling. After a time it becomes 
 evident that the joint contains some liquid substance, and if a 
 needle be inserted into this liquid it will be found that the contents 
 of the joint consist of matter or pus. In a few days one or more 
 of the remaining joints will become similarly affected, and before 
 the patient recovers or dies — usually the latter — a series of abscesses 
 involving the different joints are developed. 
 
 Meanwhile the patient rapidly loses strength and flesh ; the 
 emaciation is often extreme. 
 
 
 
 >tf 
 
 i'l' 
 
 ix,**- 
 
 Tiwatment, — The treatment of the severe form of blood- 
 poisoning — septicaemia — is usually unavailing; the patient suc- 
 cumbs in a few days or a week. He should be liberally plied with 
 alcoholic stimulants. An ounce of whisky and an equal quantity 
 of milk may be mixed and given every three or four hours. In 
 case the patient vomits, or is so stupid that he cannot be made to 
 swallow, the whisky and milk may be given as an injection into the 
 rectum. The diet should consist of milk, eggs, broth and similar 
 nutritious food. 
 
 As medicine, we may administer three grains of quinine four 
 or five times a day. 
 
 The second form of blood-poisoning, that in which the patient 
 
 A.r 
 
 V ']• 
 
 \ 
 
 U) 
 
734 
 
 SURGICAL UISKASES. 
 
 has repeated chills and an intermittent fever, offers somewhat bcttn 
 prospects for recovery, thouj^h even here the chances are thai lie 
 will die. 
 
 The first thing to be done is to secure perfect cleanliness of 
 the wound. For this purpose the dressing should be entirely 
 removed, and the wound and its vicinity carefully scrutinized to 
 ascertain the e.xistence of black patches of skin or tissue. Am- of 
 these which may be found should be at once removed. All the 
 corners and nooks in the wound should be thoroughly syringed out, 
 and incisions must be freely made in order to lay open an)thiiig 
 which seems to be a collection of matter. The limb should be 
 immersed in a trough containing hot water, with which carbolic 
 acid or listerine had been mixed. If carbolic acid be used, about 
 an ounce of it should be put in every quart of water. If listerine 
 be employed, about two ounces to the pint of water will be 
 required. 
 
 If the patient be suffering from a compound fracture no dress- 
 ing should be applied. The first object now is to save the life of 
 the patient, and not to secure the perfect healing of the limb. 
 
 All instruments, dressing, bandages, etc., which come in con- 
 tact with the wound should be thoroughly cleansed with a solution 
 of carbolic acid or listerine, and should be carefully kept from con- 
 tact with other wounds, for the matter which is formed in the 
 wound, as well as the blood of the patient, is highly infectious — 
 that is, if introduced into the body of another person they will 
 produce the disease in him. 
 
 It will be better that all such dressings be burned as soon a:; 
 used. 
 
 The room should be carefully and freely ventilated, and kept 
 at a temperature of 65 or 70 degrees F. 
 
 The medicines which have sometimes seemed beneficial in 
 improving the condition of the patient are quinine, the salicylate 
 of sodium, and the tincture of the chloride of iron. The following 
 prescription may be administered : 
 
 Quinine, - - - - - 
 Tincture of the chloride of iron, 
 Syrup of orange peel, 
 Water, 
 
 One drachm. 
 One ounce. 
 One ounce. 
 Two ounces. 
 
 Mix and give a teaspoonful in water five times a day. 
 
 The salicylate of sodium seems to accomplish some, though not 
 
ijL()<)i)-i'oisi)NiN(; — i'V.i;mia. 
 
 735 
 
 at better 
 c that he 
 
 nliness of 
 : entirely 
 ;inize(l Id 
 All)' of 
 All the 
 ingcd out, 
 anything; 
 should be 
 h carbolic 
 scd, about 
 If listerine 
 er will be 
 
 e no dress- 
 : the life of 
 limb, 
 me in con- 
 
 li a solution 
 roni con- 
 Tied in the 
 ectious — 
 they will 
 
 as soon a-.^ 
 
 1, and kept 
 
 leneficial in 
 salicylate 
 following 
 
 though not 
 
 all. of the good which may be expected from the quinine ; and 
 because of its comparative cheapness it has been much employed 
 as a substitute. This should be given in doses of ten grains each 
 four or five times a chiy. 
 
 The patient will need alcoholic stimulants, which should be 
 administered early in the disease ; it is a mistake to wait until the 
 sufl'crer is so weak and emaciated that he can scarcely swallow or 
 retain any remedies. Whisky should be given in the shape of 
 egg-nog or mixed with an equal quantity of milk. There is but 
 little danger of intoxicating the patient, who can endure an extraor- 
 dinary quantity of alcoholic beverages without exhibiting the usual 
 cfiects of alcohol. 
 
 The food plays a very important part in sustaining the strength 
 of the patient. He should have an abundance of milk and eggs 
 and strong broths. In many cases the patient will prosper upon 
 raw meat, which should be cut up very fine. 
 
 Food should be administered at short intervals, say three or 
 four hours, and in small quantities. 
 
 In many cases it will become necessary to nourish the patient 
 by the injection of liquid food into the rectum. 
 
 No time nor effort should be wasted in attempts to control the 
 diarrhea or the sweats of the patient, for these are probably efforts 
 of nature to eliminate the poison from the system. At any rate, 
 they resist the action of medicines so long as the general condition 
 of blood-poisoning persists. 
 
 Py.-emia often lasts for weeks, and even months ; and for a 
 long time it may be doubtful what the ultimate result will be. The 
 case of the late President Garfield is an instance known to all, in 
 which the patient wavered between life and death for nearly three 
 months. 
 
 In some cases the disease has been cut short by the amputa- 
 tion of a wounded limb. This is readily comprehensible when we 
 remember that the poison in the blood which causes the symptoms 
 proceeds from the wound. In fact, it seems as if each chill was an 
 evidence of the entrance of a fresh installment of the poison from 
 the wound into the blood. At any rate it has been frequently 
 observed that after the patient manifested unmistakable signs of 
 pvfEmia, indeed, after the disease had lasted for weeks, recovery 
 has occurred immediately after the amputation of the limb which 
 had received the injury. A question so serious must, of course, be 
 left to the decision of a surgeon. 
 
 X 
 
 ir 
 
 r k 
 
 ii'i 
 
 !; \^\\ 
 
736 
 
 SUKOICAL DISEASES. 
 
 Erysipelas. 
 
 This is another of the diseases which frequently ensue, espe- 
 cially upon compound fractures; while not so commonly fatal as 
 pyiemia, it is nevertheless a serious complication, and one which 
 may terminate the patient's existence. 
 
 The occurrence of erysipelas in a wound is usually preceded 
 by a severe chill, followed by high fever. The edges of the wound 
 become swollen and red, and the patient experiences pain in and 
 around the site of the injury. The surface of the skin is often 
 studded with little blisters filled with a clear liquid ; these b(.ct)nic 
 somewhat darker in color and increase in size. After a time 
 the blisters dry up into scabs, or open and reveal raw surfaces 
 beneath. 
 
 If the attack be not very severe, the patient's general condi- 
 tion remains good ; he suffers from fever, his tongue is furred, 
 appetite diminished, and bowels constipated. The redness and 
 swelling extend a short distance over the surrounding skin, but 
 fade out at the end of a week or so. 
 
 If the attack be severe, on the other hand, the swelling' and 
 redness spread continually; the skin becomes soft and has a peculiar 
 boggy or doughy feeling. The wound becomes at first dry, and 
 there is secreted from it a thin watery fluid, instead of matter; 
 after a time, however, matter forms in large quantities in tlie 
 inflamed skin. 
 
 Meanwhile, the patient's condition becomes serious; he is 
 completely prostrated, often delirious. The temperature is very 
 high, and chills occur repeatedly. In fact the condition resembles 
 very much that of blood-poisoning ; this latter affection indeed 
 often results from, or at least follows upon, erysipelas in a wound. 
 
 Treatment, — If the attack be not severe, but little tieat- 
 ment is required aside from the measures which are commonly 
 employed in all feverish conditions. 
 
 The patient's bowels should be evacuated by the use of some 
 saline cathartic, such as Rochelle salts, a teaspoonful of which 
 may be taken at night. 
 
 Locally we may apply to the inflamed skin cloths saturated 
 with a solution of carbolic acid in water (an ounce of the acid to a 
 
ERVSU'ELAS. 
 
 737 
 
 quart of water); or wc may employ for the same purpose the follow- 
 ing solution : 
 
 Suf^ar of lead, .... Two drachms. 
 
 Tincture of opium, ... One ounce. 
 
 Water, Eight ounces. 
 
 The patient should also take the tincture of t he chloride of iron 
 internally. The following prescription may be given : 
 
 Quinine, . . - . - Half a drachm. 
 Tincture of the chloride of iron, - One ounce. 
 Water, ----- Three ounces. 
 
 Mix, and take a teaspoonful in water every four hours. 
 
 In severe cases it becomes necessary to support the patient's 
 strength and to give exit to the matter which is formed in the 
 ir'^amcd skin. The latter object can be accomplished only by in- 
 c ons with the knife, which should be freely made wherever it is 
 evident that matter has formed in the skin. In this affection also, 
 the dressing of a fractured limb should be removed, and the atten- 
 tion devoted simply to the removal of the erysipelatous condition. 
 
 After these incisions are made, the wounds should be frequently 
 syringed with a solution of carbolic acid or listcrine, which have 
 been described in the discussion of pyzemia. The inflamed skin 
 may be rubbed with vaseline or pieces of lint upon which this salve 
 has been spread. 
 
 Internally, the patient should take the prescription given 
 above, containing the tincture of iron and quinine. The dose may 
 be given every two or three hours. In addition, we should admin- 
 ister alcohol in some form, preferably as whisky or brandy. 
 
 In many cases the patient can secure ease only by immersing 
 the limb in a bath of hot water. Carbolic acid should be added to 
 this in the strength already mentioned. 
 
 It rarely becomes necessary to administer opiates for the relief 
 of pain. 
 
 The diet should be carefully attended to. The directions given 
 under the head of pyaemia will apply also to erysipelas. 
 
 Ventilation should be attended to. It is to be remembered, 
 also, that erysipelas is infectious ; if there be any other person 
 afflicted with wounds, or if a woman have been recently confined in 
 the house, it is very important that the sufferer from erysipelas 
 should be removed to another dwelling; otherwise we may expect. 
 
 
 ! I' 
 
 
 f\ 
 
 k 
 
 i^i 
 
 ^^ m,T 
 
 fi if i" si; 
 
ii 1: !'■ 
 
 ■■ ■ rt 
 
 i? 
 
 
 73« 
 
 SURGICAL 1)ISI':ASES. 
 
 in spite of the most careful attention to ventilation and disinfection, 
 that erysipelas will appear in the one individual or child-bed fever 
 in the other. 
 
 Fracture of the Skull. 
 
 The sl:ull can be fractured only by considerable violence, such 
 as blows or falls upon the head. 
 
 The e.xtent and shape of the fracture, as well as its location in 
 the skull, vary with the amount and direction of the force. ,'\ 
 blow with a large blunt weapon, such as a hammer, or a fall upon 
 the head, usually results in a long, irregular fracture ; a blow with 
 a sharp instrument is apt to cause a star-shaped fracture or scries 
 of fractures. 
 
 In many cases the skull is broken at a part somewhat disUmt 
 from the point at which the force was applied. Thus, if an indi- 
 vidual be precipitated from a height, and strike upon the top of the 
 head, there may be only a severe bruise and laceration of the scalp 
 at the point where the head strikes the pavement, without any 
 fracture of the bones ; yet there is apt to be an extensive fracture 
 at the base of the skull, which may entirely escape notice. 
 
 Sjfnij>foms. — The symptoms and the effects accompanying a 
 fracture of the skull depend largely upon the damage done to the 
 brain. In some cases fracture of the skull causes but little more 
 injury than a severe scalp wound ; while in other instances a frac- 
 ture which is insignificant in appearance may cause speedy death. 
 
 The effects vary also with the age and condition of the patient. 
 A child endures .such a fracture far better than an adult. 
 
 The features which render fracture of the skull dangerous to 
 life are these : 
 
 Concussion of the brain. 
 
 Bleeding inside of the skull. 
 
 The splintering of fragments from the skull bones, which pene- 
 trate the substance of the lirain or cause pressure upon it. 
 
 Inflammation of the brain and its membranes consequent ii|)"ii 
 the injury to them by the fragments of bone. 
 
 Fractures of the skull are usually compound — that is, the scalp 
 is wounded at the place where the bone is fractured. 
 
/iolcncc, such 
 
 :s, which peiie- 
 pon it. 
 [nscqucnt up"" 
 
 IKA< TLKI-: OV rilK SKULL 
 
 739 
 
 In any case it will be possible to feel the edge of the bone at 
 tlvj i)oint of fracture. If the scalp be uninjured, this edge cannot, 
 ,,f course, be felt with the same distinctness, t)Ut is, nevertheless, 
 perceptible ir. the great majority of cases. 
 
 There are certain other conditions which may sometimes be 
 mistaken by the inexperienced for a fracture of the skull bone. 
 riuis a blow upon the head sometimes causes the formation of a 
 blood clot under the scalp which may cause a ridge similar to that 
 produced by the edge of a broken bone. 
 
 If there be a wound of the scalp at the point of injury to the 
 bone, liic finger inserted into the wound will readily feel a rough, 
 iacjgcd edge, projecting above a bony surface. 
 
 It sometimes happens that fracture of the inner layer of the 
 skull l)ones occurs without any break in the outer layer. To under- 
 stand this we must remember that the bones of the skull are some- 
 wliat peculiarly constituted. There are, in fact, three distinct lay- 
 ers, the outer one somewhat flexible, the middle spongy, like a 
 Iioiiey-comb, and the inner one extremely hard and brittle. In 
 consequence of these qualities, it sometimes happens that a severe 
 blow will cause merely a slight depression of the outer layer, which 
 by virtue of its elasticity, rebounds again without breaking ; while 
 the inner layer, because of its extreme brittleness, is broken. 
 
 These fractures of the " inner table " of the skull are extremely 
 difficult of detection. Since there is no break in the outer part of 
 the skull, we arc unable to feel the roughness which may actually 
 exist ill the inner part of ihe bone at the surface of the brain. In 
 r.ici, this fracture can be recognized only by the symptoms which 
 indicate the presence of bone splinters in the brain substance. 
 
 In many cases a blow upon the head causes symptoms similar 
 to tl;c).;c of fracture, wiiich may be due to an escape of blood onto 
 the surface of the brain or to simple concussion without any frac 
 turc. In such cases the exact cause of the symptoms may remaio 
 in (loul)t f(jr some days. If there be no fracture, the symptoms 
 usually subside in the course of a week or two, while if there be a 
 tracture, the difficulty is apt to persist much longer. 
 
 In children the bones of the skull are much softer and thinner 
 than in adults ; hence depressions of the skull may be produced 
 without any actual breaking of the bones. Such depressions usu- 
 ally result in complete recovery. 
 
 Fractures at the base of the skull are especially dangerous. 
 
 fit 
 
 >rl 
 
 'I " 
 
 1 
 
 .f|,^. lb 
 
 I I 
 
 :^.. 
 
740 
 
 SURGICAL DISEASES. 
 
 1/ . 
 
 "I ; 
 
 111' 
 
 hi 
 
 h: ? 
 
 because of the important nature of the parts of the brain adjacent 
 to the base of the skull. Such fractures usually result fatall\-. 
 
 They may be suspected if there be some of the following symp. 
 toms : 
 
 Profuse bleeding from one of the ears. The blood is usuallv 
 of a dark rather than of a bright red color. 
 
 The escape of a clear watery fluid through the ear. 
 
 The absence of fracture on the top of the head, if the patient 
 have fallen directly upon this part. 
 
 Stupor or semi-unconsciousness ; paralysis of muscles of the 
 face ; loss of feeling in one part of the face or tongue. 
 
 The ultimate result in cases of fracture of the skull varies much 
 with the location and extent of the injury, as well as with the a;^c 
 and condition of the patient. In every case such an injury is, of 
 course, serious. 
 
 In some instances the danger seems to proceed r ' ost cntirclv 
 from pressure of the fragments upon the brain. Wht is pressure 
 is removed by raising the fragments to their former position, so 
 that they no longer press upon the brain, the serious symptoms 
 subside. 
 
 In other cases it becomes necessary to remove splinters of bone 
 which have penetrated the substance of the brain. So long as these 
 remain in the brain the individual fails to recover his usual func- 
 tions. 
 
 In many cases the patient ultimately recovers entire!}-, even 
 though the original injury was an extensive and serious one. In 
 other cases the patient suffers for many years from occasional de- 
 rangements of the mental functions. Epilepsy has been known to 
 result from the pressure of the fragments upon the brain. The 
 disease has been repeatedly cured by removing pieces of bone at 
 the seat of the injury. 
 
 Other affections manifested in various parts of the nervous sys- 
 tem, as well as in the operations of the mind, sometimes result from 
 injury to the brain caused by a fracture of the skull. 
 
 Trentnient, — A fracture of the skull is always a most serious 
 and dangerous accident. A little mismanagement may cause the 
 death of the patient, while the exercise of proper care and skill may 
 restore him to a perfectly natural condition. It is, therefore, very 
 important that the services of a surgeon be immediately secured; 
 
FRACTURE OF THE SKULL. 
 
 741 
 
 d is usually 
 
 vet, since it sometimes happens that many hours, or even several 
 days must elapse before the arrival of the suryjcon, simple directions 
 will be given for the management of these cases, aside from the part 
 which consists in operations. 
 
 The fracture will usually be accompanied by a wound of the 
 scalp, which often bleeds profusely. The first requirement is, there- 
 fore, an effort to check the bleeding, directions for which have been 
 given on a previous page. 
 
 After the bleeding has ceased, the wound may be carefully 
 washed with water containing carbolic acid (one ounce of the acid 
 to a quart of water), or with a solution of listerine (one ounce of 
 listcrine to five of water). Extreme care must be taken that no 
 foreifTn material of any sort be introduced into the wound by means 
 of instruments, fingers, sponges, etc. It is also necessary to keep 
 the hair out of the wound ; for this purpose the scalp should be 
 closely clipped, or even shaven, for a distance of two inches around 
 the edges of the wound. 
 
 It will not be advisable for a non-professional person to med- 
 dle with the fragments themselves. For it is to be remembered 
 that the most delicate and one of the most essential organs of the 
 body, the br^^in, lies immediately under and in contact with the 
 broken bones ; hence any awkwardness in manipulating instru- 
 ments might result in serious and even fatal damage to the 
 brain. 
 
 After the wound has been cleansed and the bleeding stopped, 
 a compress — that is, a piece of lint or soft cloth folded so, as to 
 make three or four thicknesses — should be wet with coid water 
 and applied over the wound, covering its edges completely. This 
 compress should be moistened every half hour or hour ; it may 
 be retained in position by a bandage lightly applied. 
 
 The attention is then directed to the general condition of the 
 patient. So far as the wound in the head itself is concerned, noth- 
 ing more can be done except by means of an operation ; the 
 danger to be apprehended is that inflammation of the brain may 
 occur, and this can be best averted by the application of cold 
 water to the head, and by the measures to be presently described. 
 
 The patient should be kept perfectly quiet in a darkened room ; 
 the head should be laid rather low. Noise and all other influences 
 which could disturb the sufferer must bo carefully avoided. The 
 inquiries of curious friends should not be permitted to disturb the 
 
 '5 !r:f ;L 
 
 ',v- 
 
 \.y: 
 
 n 
 
 
 
 »- ■ 
 
 i 
 
 I' !. 
 
 , f 
 
 J 
 
 J* 
 
 f r ' 
 
 M. 
 
742 
 
 SURGICAL DISEASES. 
 
 ; 
 
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 i , 
 
 patient ; hence it would be better to admit no one to the room 
 except those whose attention is necessary. 
 
 Free evacuation of the bowels must be secured ; a teaspoon- 
 ful of Rochelle salts given once a day will usually accomplis;' the 
 desired object. 
 
 In addition the patient should take one drop of the ' uie 
 of aconite every half hour or hour. This is a very powerful 
 remedy and its effect must be carefully observed ; so som as the 
 pulse at the wrist shows a decided decrease of strength, the remedy 
 should be discontinued or administered in smaller quantities. 
 
 This treatment is adapted to those cases in which the pntient 
 is perfectly conscious and shows no impairment of the mental 
 functions. There are, of course, instances which require especial 
 treatment. Thus sometimes the patient suffers from shock, a con- 
 dition which has been already described. In this case wo must 
 employ the treatment which has been recommended in discussiiv^r the 
 subject ; hot bottles should be applied around the patient's body, 
 ammonia (hartshorn) held near his nostrils, and a teaspoonful ol 
 whisky mixed with the same quantity of milk or water, should be 
 given by the mouth or by the rectum, as occasion requires. 
 
 Sometimes the patient's condition resembles apoplexy. In 
 fact, fracture of the skull often induces precisely the same condition 
 as that which we call apoplexy, when it occurs without a wound — 
 that is, an escape of blood into the brain. In this case wc should 
 employ essentially the same treatment as that which lias been 
 recommended in treating of this disease. 
 
 The danger is augmented somewhat if the brain itself be 
 wounded. Yet, we cannot predict in every case just what the 
 effect of this complication will be, for many instances are known, 
 in which a portion of the brain has been entirely removed without 
 preventing or even retarding recovery. The well-known case in 
 which a tamping-iron was driven clear through a man's skull, 
 creating an immense wound, from which he recovered perfectly, is 
 a familiar example. 
 
 If foreign bodies are lodged in the brain, the danger of inflam- 
 mation, and hence of a fatal result, is somewhat increased, .Such 
 bodies should be removed as soon as possible. 
 
 There sometimes results from a fracture of the skull, a protru- 
 sion of the brain through the wound, a condition called licnna of 
 the brain. This can sometimes be cured by pressure upon the pro- 
 
INFLAMMATION OV THE 15UAIN. 
 
 743 
 
 tiiiding part, made by applying a bandage tightly over it ; but the 
 treatment of such a complication should always be left to the 
 surgeon. 
 
 It is impossible to give in detail the measures which may be 
 required in various injuries of the brain ; each case must be seen 
 ;uui treated by itself. It may be said in general, that surgeons 
 have in later years acquired more confidence and success in 
 operating upon the skull and the brain. In former times the sur- 
 geon was inclined to avoid most scrupulously any interference with 
 this delicate portion of the body ; within the last ten or twenty 
 years, however, the brain has been frequently and successful!)- 
 operated on in case of injury. One of the authors of this book- 
 once found it necessary to open a passage with the knife almost 
 into the middle of the brain, and to introduce a rubber tube to this 
 point, where it was allowed to remain for several weeks. The 
 patient recovered completely. 
 
 One of the most serious complications arising in connection 
 with fractures of the skull, is 
 
 
 ffSi 
 
 
 Inflammation of the Brain. 
 
 This inflammation, affecting the brain and the membranes that 
 cover it, is the cause of much of the mortality which follows injuries 
 to the skull. 
 
 It begins one, two or three weeks after the infliction of the 
 iniur\ . Its course is, in some cases, abrupt and severe, terminating 
 in a short time in the death of the patient ; in other cases, the disease 
 begins insidiously, and may not be suspected for some time, until 
 the i)atient suddenly becomes unconscious or paralyzed. 
 
 
 iff ;' it. 
 
 Ml 
 
 ill' 
 
 SiiiHpt<HH-s. — The patient complains of sharp and severe 
 pain in tlie head, aggravated by motion, by exposure to the light, 
 and by noise. At the same time there is apt to be some nausea 
 and vomiting ; the pulse becomes rapid and the mind somewhat 
 confuseil. 
 
 After these symptoms have lasted a day or two, the patient 
 has a severe chill, followed by high fever; the pulse becomes very 
 I'apid and full. The pain in the head is by this time excruciating, 
 
 ' I 
 
 I. i5n 
 
 u 
 
I 
 
 '«# 
 
 744 
 
 SURGICAL DISEASES. 
 
 the pupils of the eyes become very small ; light and noise cause 
 the patient extreme pain and annoyance. There is obstinate 
 vomiting, and the bowels are constipated. In many cases delirium 
 and convulsions follow, terminating in unconsciousness. 
 
 After these symptoms have lasted for a few days or a week, 
 there is an entire change in the appearance of the patient. lie no 
 longer complains of pain or of annoyance from light or sound ; he 
 is apt to lie unconscious or in a state of low delirium. In many 
 cases the muscles of the face are paralyzed, so that the patient 
 squints and exhibits various distortions of the countenance ; the 
 pulse is slow and dull, the breathing deep and labored. 
 
 If there be much discharge of matter from the wound, the 
 patient usually has several chills at irregular intervals. The edges 
 of the wound become dry and swollen ; the matter usually disap- 
 pears and a thin watery liquid escapes in its stead. If any bone be 
 exposed, it becomes dry and white. 
 
 If there be no wound, the vicinity of the injury becomes swol- 
 len and doughy. 
 
 The condition arises from inflammation of the brain. This in- 
 flammation usually proceeds to the formation of matter. When 
 examined after death, the surface of the brain is found to be covered 
 with matter. There may also be formed collections of matter- 
 abscesses — in different parts of the brain, though these arc more 
 frequently found some months or years after the injury. 
 
 Ti'eattnent. — The treatment of inflammation of the brain 
 consists of local applications and of remedies to be taken inter- 
 nally. 
 
 The head should be closely shaven and surrounded with ice 
 contained in rubber bags or wrapped in soft cloths. In some cases 
 benefit is derived from the application of fly-blisters to the nape of 
 the neck. Mustard plasters may be applied to the feet and to the 
 calves of the leg. 
 
 Internally medicines are administered to cause free evacuation 
 of the bowels. For this purpose we may give the following pre- 
 scription: 
 
 Calomel, Twenty grains. 
 
 Bicarbonate of soda, - - - Two drachms. 
 
 Mix, and make eight powders ; take one four times a day. If 
 this does not suffice to secure copious evacuation of the bowels, we 
 
!-'i. 
 
 i mmm 
 
 FRACTUPiES OF THE LOWER JAW. 
 
 74: 
 
 icomcs swol- 
 
 may administer one or two drops of croton oil, placing it upon the 
 
 It will be necessary also to support the patient's strength, since 
 the disease rapidly causes exhaustion. For this purpose we should see 
 that tlie diet is nutritious and easily digestible. If there be so much 
 vomiting that the stomach is unable to retain food, milk and broths 
 shmild be administered as injections into the rectum. An ounce of 
 milk mi.xed with the same quantity of whisky may be injected every 
 four hours if the patient seems feeble. 
 
 Two grains of quinine should also be given four times a 
 
 day. 
 
 In many cases all these measures are unavailing ; the patient 
 sinks rapidly and dies within ten days after the first signs of 
 inflammation were manifested. In some of these cases it becomes 
 evident that the brain is being compressed by the accumulation of 
 matter on its surface ; in such cases surgeons have frequently relieved 
 the patient and have sometimes effected a cure by an operation 
 called trepanning. This consists in boring through the skull and 
 removing a piece of the bone. In this way the matter can be 
 evacuiited and the pressure upon the brain removed. This oper- 
 ation is, however, extremely dangerous, and is not always success- 
 ful in saving the life ofthe patient. 
 
 Fractures of the Lower Jaw. 
 
 .41 
 
 This is a frequent and troublesome fracture. The bone is 
 broken by violence applied directly to it, such as the kick of a horse 
 
 or the blow of a fist. 
 
 Sjimptoni!*, — This condition is easily recognized by the unnat- 
 ural movement of the fragments. By placing the fingers over the 
 painful spot, we can easily detect a grating upon slight movement; 
 and upon looking into the mouth we can usually see the fissure in 
 the bone. The teeth, also, are displaced, and some of them are 
 often loosened. The jaw is usually turned toward the injured 
 side. 
 
 Tt'catmenf. — The treatment of a fracture of the lower jaw is 
 extremely troublesome, especially if the bone be broken at the side, 
 as is usually the case. The difficulty lies in keeping the fragments 
 
 at rest. 
 
 •• i it' 
 
 M 
 
 ill 
 
 ) I 
 
 M 
 
 'i I 
 
 
 :rif, 
 
746 
 
 SURGICAL DISEASES. 
 
 
 M 
 
 Many dressings have been employed in the treatment of fi :ici- 
 ures of the jaw. The two measures which arc of most value nw. 
 a splint on the outside of the jaw and a wire to pass between thi' 
 teeth. 
 
 The splint should be made of felt, pasteboard, gutta-pnch.i, 
 or glue. These should be fitted to the jaw in the way descrilK-d in 
 discussing dressings in general. The splints should pass around the 
 entire jaw from ear to ear, and should extend under the chin from 
 side to side. After it has been fitted, it is held in place by a band- 
 age which passes around the head and under the jaw. 
 
 Dr. Hamilton, of New York, uses for the dressing of a fract- 
 ured jaw a strong leather strap. This passes under the chin and 
 buckles over the top of the head. It is held in place by aiiotlier 
 strap which passes around the head above the ears and across the 
 forehead. A third strap is attached to the last-named at the back 
 of the head and passes over the crown to be attached to the strap 
 which runs under the jaw. In using this apparatus care sliould be 
 taken not to buckle the straps too tightly. This contrixancc 
 answers exceedingly well in many cases. 
 
 It is generally advantageous to hold the two fragments close to 
 each other by twisting a wire around the two teeth which are near- 
 est to the break in the bone. For this purpose, a silver wire is 
 used. If the teeth be sound and firm, considerable torce can be 
 employed in this way in holding the fragments in position. 
 
 If none of these methods be employed, a reasonably good dress- 
 ing can be made by applying two bandages. A strip of muslin or 
 sheeting, three feet long and six inches wide, is prepared for this 
 purpose. At the middle of it, and about three-quarters of an inch 
 from one edge, a slit is cut, long enough to permit the chin to pass 
 throuf;h it. The ends of this slit should be stitched so that it will 
 not tear when applied. This is then arranged so that the ciiin pro- 
 jects through the opening, while the ends of the bandage are made 
 to meet behind the head. Another strip is then passed at ris,'ht 
 angles to this, running under the jaw and over the top of the head. 
 The two may be then tied together by another bandage, which 
 passes from the knot at the back of the neck to the one at the top 
 of the head. 
 
 Whatever dressing be employed, it is important that the patient 
 should himself use every effort to prevent movement of the frag- 
 ments ; for none of these dressings are so perfect as to permit free 
 
nt of fi;ict- 
 it viiluu arc 
 ictwccn the 
 
 iitt;i-iHich,i, 
 dcscribLil in 
 i arouiul the 
 lie chin tVoin 
 c by a baiid- 
 
 g of a fract- 
 [he chin anJ 
 
 e by another 
 id across the 
 1 at the back 
 to the >trap 
 ire shoukl be 
 ^ contrivance 
 
 mcnts chi>eto 
 iiich are near- 
 silver wire is 
 orce cm be 
 iun. 
 
 ' <^ood dress- 
 ()f muslin nr 
 ired for thi^ 
 rs of an inch 
 chin to pass 
 so that it will 
 the chin pro- 
 at;e are made 
 assed at ri;4ht 
 of the head. 
 ndage, which 
 no at the top 
 
 lat the patient 
 
 of the frag- 
 
 Ito permit free 
 
 FRACTURE OK THE NOSE. 
 
 747 
 
 movement. To further this object, the patient should have liquid 
 food only — milk', broth, etc. Difficulty is sometimes experienced 
 in introducing food without opening the mouth. Most persons have 
 some defect in the teeth through which a straw can be readily intro- 
 duced, and the liquid thus sucked into the mouth. In other cases, 
 ;i sound tooth has been extracted to afford an opportunity for intro- 
 duciii" the straw. In order to avoid such a sacrifice of a sound 
 tooth, surgeons sometimes place a thin piece of cork, shaped like a 
 wedge, between the upper and lower jaw, at the seat of fracture. 
 This should have a groove above and below, so that it will be held 
 funily by the teeth. In this way the jaws are held apart so that food 
 can be readily introduced. 
 
 Fracture of the Upper Jaw. 
 
 This is a rare accident which occurs only when the face is 
 severely injured. The bones should be replaced with the fingers, 
 and can usually be held in position with adhesive straps — sticking- 
 jilastcr and bandages. 
 
 Fracture of the Nose. 
 
 The upper part (the " bridge ") of the nose is composed of two 
 small bones, one on either side. These are frequently broken by a 
 blow. The lower part of the nose consists of cartilage or " gristle," 
 which cannot be fractured, though it may be detached from its 
 junction with the bones above. 
 
 A tVacture of the bones of the nose is not always easy to 
 detect, because the parts are so much swollen that it is impossible 
 to feel the outline. It is generally necessary to examine the inside 
 of the nose — a matter which can be successfully done only by an 
 experienced hand. 
 
 TtTdthirnt, — So long as the parts arc much swollen, no> 
 attempt should be made to set the broken bones. Cloths saturated 
 with cold water should be applied until the swelling subsides 
 
 The bone should then be raised into position by inserting a 
 small pencil into the nostril and prying the depressed fragment out- 
 ward ; we may assist this effort by the judicious use of the fingers 
 49 
 
 AutW 
 
 ! Jl 
 
 
 
!:i 
 
 H Z 
 
 748 
 
 SURGICAL niSKASKS. 
 
 on the outside. We should not discontinue the attempi, (\,ii 
 though there be j)retty free bleeding from the nose, for if the boiiL 
 heals in its unnatural position there will, of course, reni.iin an 
 unsightly deformity. 
 
 If the bones do not stay in place, a plug of tiglitlv'-nillc i| 
 cotton should be inserted into the nostrils to keep them in po^j. 
 tion. This cotton should be covered with rubber or willi oiKil 
 silk, and be smeared with sweet oil or vaseline. It should be taken 
 out for half an hour every day in order not to cause rawness ami 
 ulceration of the nose ; it will be better to make a fresh pluy each 
 day. 
 
 Fracture of the Collar-bone. 
 
 This is one of the most frci[aent fractures with which the sur- 
 geon has to deal. It usually results from the application of violence 
 to the shoulder. It often occurs in children. 
 
 The bone is usually broken near the middle, and the iVacliiic 
 is in most cases oblitjue, so that one end rides over the other. 
 
 This fracture will be detected by simply feeling aloiin tin. 
 course of the collar-bone and comparing it with the correspoiuliii;,' 
 bone of the other side. There will be felt a roughness and usualh- 
 a projection at one point, pressure upon which causes the i)aticiit 
 acute pain. By manipulating the bone at this point we can usually 
 detect a grating sensation. 
 
 The patient is unable to use the arm ; the shoulder dreops 
 toward the chest. This drooping is due to the removal of the 
 natural support of the shoulder, the collar-bone. 
 
 In children, a fracture of the collar-bone presents soiuewlial 
 different signs. It will be remembered that fractures of hones in 
 children are frequently incomplete, a portion only of the hone 
 being broken, while the remainder \'ields to the pressure anil bcnd.^ 
 As a result, the shoulder often retains its natural position in children 
 who have suffered this " green stick " fracture of the collar-bone. 
 The chief signs in these cases are extreme tenderness at sonic point 
 in the bone and swelling in the vicinity of this painful spot. 
 
 Tt'eattnent. — Fractures of the collar-bone are very easily set, 
 but are kept in position with great difficulty. In fact more or less 
 deformity is the usual result ; cases in which the bone heals with- 
 
FKACTL'HK OK TIIK (Ol.l.AK-noNl':. 
 
 749 
 
 :cnipl, ivin 
 
 if tlu' bone 
 
 , ri-inain an 
 
 i<^hUy-rnlKil 
 cm in pdNi- 
 r witli oiKil 
 iviUl ))(.■ lakcn 
 r;i\vne>s and 
 sh pliiy each 
 
 •hich llu- sur- 
 on of violence 
 
 d the flMCtlllT 
 
 he olluT. 
 inij aloii^ the 
 corrcspondini; 
 :ss and usually 
 ,cs tin- patient 
 |\VL' can usually 
 
 Kuddcr dfoopv 
 cnioval iif the 
 
 i-nts sinucwliat 
 cs of bones ill 
 b of the bone 
 lure and beiuls. 
 jon in chiklr^'" 
 Ik- collar-bone, 
 at some point 
 [id spot. 
 
 'cry easily set, 
 
 let more or less 
 
 ,nc heals with- 
 
 out any deformity are to he rt'j;ardcil as exceptions, and indicate 
 ,r,,(id fortune rather than exceptional skill on the part <>f the sur- 
 ^eon. 
 
 Ihe difficulty lies simply in the impossibility of keepin^^ the 
 fra,L;mcnts at rest. lOvery movement of the- arm and shoulder has a 
 tendency to disturb the broken ends of tlu- collar-bone. 
 
 It would be out of place in this work to describe the various 
 kinds of apparatus which have been devised and employed in the 
 treatment of broken collar-l)ones. (lood results have been obtained 
 with nearly all, thouyh none can be relied upon to prevent deform- 
 ity. 
 
 riu; chief object of the apparatus is to keep the shoulder pressed 
 firmly backwanl, for in this way the broken ends of the b(jne are 
 brought into their proper position. To accom])Iish this object, straps 
 are applieil around the arm just below the shoulder, and arouiul the 
 shoulder itself. These arc then drawn backward and attacheil to 
 straps proceeding; from the other siu)ulder. By insertin^f buckles 
 at the back between the shoulders, these straps can be tij^hlened sc 
 as to liold the shoulder of the injured side firndy in positicni. 
 
 Another way is to attach broad bands of adhesive plaster 
 around the arm and shoulder of the injured side, and to make tliese 
 adhere firmly across the back and under the arm of the opposite 
 
 side. 
 
 The writer once secured a perfect result — that is, union of the 
 fras^incnts with absolutely no deformity — by fitting a plaster of Paris 
 jacket over the shoulder and arm of the injured side. The jacket 
 e.Kteiuled down onto the chest and back, and was re-enforced by 
 muslin bandag'S extending around the body and over the opposite 
 shoulder. When the dressing was removed it was almost impossible 
 to detect any difference between the collar-bones of the two sides. 
 This result, however, has been obtained by other dressings, and 
 does not necessarily pro\'e the superiority of the plaster of Paris. 
 
 When the patient lies flat upon the back, the shoulder falls 
 backward, and the fragments drop into their natural position. If, 
 therefore, the patient can be passive enough to keep this position 
 most all the time for a month, the best possible chance for recovery 
 without deformity is thereby afforded. Most individuals would 
 prefer to suffer a slight deformity rather than to endure the monot- 
 ony of such a measure. It may be, however, worth the trouble if 
 the patient is a girl. 
 
 ;i I 
 
 '•!. 
 
 }■ 
 
 i . -m^ 
 
 i;1 
 
 ' 
 
 i 
 
7SO 
 
 SURGICAL DISKASliS, 
 
 Fracture of the Shoulder-blade. 
 
 This is ail imiisual acciclcnt, which results from a severe: l)l<iw 
 upon the back of tlu; shoulder. 
 
 The sij^ns of this affection arc pain in moving; the sliouhUr .md 
 tenderness upon pressure ()\cr tlu- siiouldir-blacle. My carcfui 
 manipulation we ca.i soinetimes tletect a {^aating sensation between 
 tl;e two frat^nients. 
 
 Ti'vatniviit. — riie muscles attached to the back part of the 
 shoulder-blade must be relaxed, in order that the two fras.;nu'iiN 
 shall be kept in their proper position. This is done by passing ,i 
 slin{^ made of a larjre handkerchief uiuler the elbow and arouiul tlic 
 neck. This is drawn somewhat tight, so that the shoulder is a little 
 higher than the opposite one. The elln)W is then to be IjoiuuI Id 
 the side of the body by a broad bantlage passetl around the arm 
 and chest. The healing process usually recpiires four or five weeks, 
 and care must be taken in avoiding muscular effort with this arm fyr 
 some weeks more. 
 
 Fractures of the Arm-Bone— (Humerus). 
 
 The arm — that portion of the upper extremity between the 
 shoulder and the elbow — is frequently broken by direct \ inlcncc, 
 For convenjence of description and discussion such fractures arc 
 divided into three classes: 
 
 First — I'ractures of the upper cwd of the bone, near the 
 shoulder. 
 
 Second — Fractures of the middle part of the bone, tecliiiically 
 called the sJiaft. 
 
 Third — Fraciuics of the lower end of the buiie, near the 
 elbow. 
 
 Fractures of the Upper End of the Humerus. — These fractures 
 are usually caused by a blow upon the arm, or by a fall of the 
 individual. In some cases the end of the bone is at the same time 
 driven tightly against and into the shoulder-blade at the joint, or 
 the lower fragment is wedged firmly into the upper portion. Such 
 fractures are called impacted. 
 

 IkACTl'KKS OK TIIK AKM-HONK — IIUMKUUS. 
 
 751 
 
 '1'ir 
 
 severe hluw 
 
 In most cases tlie two fra>^Miieiils remain sc[)aratc and distinct; 
 llic>i\ the usual (Mies, are called n()n-imj)actc-d. 
 
 A non-impacted fracture of the arm near the shoulder can 
 usually be recognized without much di(Ticult>-. The si};ns by which 
 Mich recoj^nition is effi'eted are: 
 
 First — Swelliiij^' and pain at a certain point. 
 
 Sfti'i/i/— I nnatnral movement of the arm. 
 
 I'liini — A t;ratin}^' sensation when the arm is moved by fjrasp- 
 in^ till' elbow, the shoidder, meanwhile, beiuj^^ helil fast. 
 
 I'oiirlh — Loss of power in the arm. 
 
 if the fracture be impacted, there will be no <,'rating sensation 
 pciceplible, and the movements of which the arm is capable will 
 iKil vary essentially from those of a healthy arm except that they 
 arc accompanied by ^jreat i)aiii. 
 
 jwactures of the arm near the shoulder-joint are sometimes 
 confounded with dislocations of the shoulder. It is not a difficult 
 ni. liter to distinguish a dislocation from a fracture which is not 
 complicated in any way; but in many cases a fracture at the upper 
 pari of the arm is accompanied by a dislocation of the u[)per frag- 
 ment, so that both conditions are present at the same time. These 
 arc ihe cases in which errors are often made, and which, even when 
 rccof^nizcd, offer serious olistacles to successful treatment. 
 
 A few points are given whereby an uncomplicated fracture of 
 the r.iin can be, in most cases, distinguished from a simple disloca- 
 tion of the shoulder : 
 
 First , in case of fracture, the hand of the injured arm can be 
 placed by the patient or by another person upon the shoulder of the 
 opposite side, while the elbow is at the same time kept in contact 
 with the chest. 
 
 Incase of dislocation, the hand of the injured arm cannot be 
 placed upon the opposite shoulder, cither by the patient or by 
 another person, unless the clboiv is alloivcd to recede froin the 
 chest. 
 
 Second, in case of fracture, the elbow of the injured arm 
 usiiallylics against the body. If there be a dislocation on the other 
 hand, the elbow almost invariably stands out from the body. 
 
 Third, in case of fracture, the end or liead of the arm-bone can 
 be felt in its proper position under the prominence of the shoulder. 
 If there be a dislocation, the shoulder of the affected side looks 
 unnaturally flat and square. A sharp prominence can often be felt, 
 
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752 
 
 SURGICAL DISEASES. 
 
 constitutingthepoint of the shoulder. By comparing it with the other 
 side, the difierence in shape strikes even the inexperienced eye. 
 
 Fourth, in case of fracture, the grating sensation can usually 
 be felt. In dislocations no such .sensation can be detected. 
 
 Fifth, in fractures the arm can be moved with unusual free- 
 dom. In dislocation the arm is fixed and almost immovable. 
 
 I ' ' "^ 
 
 iliiJ^' 
 
 Treatment, — The treatment of fracture of the arm in the 
 vicinity of the shoulder-joint is a somewhat difficult procedure. It 
 is important that we distinguish whether or not the fracture is 
 impacted; that is, whether the two fragments are forced togetlier, 
 or remain loose and separate from each other. 
 
 If the fracture be impacted, it is very important that we clumld 
 not separate the fragments by rough manipulation or pulling upon 
 the arm ; for the upper fragment is usually very short, and if we 
 detach it from the lower, we are unable to grasp and place it in 
 position again. Even if there should be a slight bend in the bone 
 at the point of fracture, the result will certainly be much better 
 than we can hope to attain if we separate the fragments and then 
 attempt to set the bone again. 
 
 If we find that the fracture is impacted, therefore, we should aim 
 to keep the arm quiet in the position most favorable to healing. A 
 sling suspended from the neck should be passed around the fore- 
 arm and elbow, so that the arm is drawn well up toward the shoulder. 
 We may then put a pad, consisting of a folded towel or a piece of 
 lint, in the arm-pit, between the arm and the chest. A bandaf,re is 
 then applied several times around the body and the arm, so as to 
 prevent any motion of the injured limb. 
 
 If the fracture be not impacted, it is necessary to apply a 
 splint. For this purpose various plans are employed. The best 
 for domestic use consists in making a splint out of leather or stiff 
 pasteboard. This should be cut of such size and shape as to extend 
 from the elbow up on the shoulder, and to come about half way 
 around the arm from front to back. In order to fit this nicely to 
 the shoulder, it should be split up about three inches from the 
 shoulder end, and the edges of this slit should be cut away so that 
 the opening has the shape of a V. When this is applied to the out- 
 side of the arm, the sides of this V-shaped cut can be brought 
 together and the splint thereby nicely fitted to the curve of the 
 shoulder. 
 
FRACTURES OK THE ARM-UONE — HUMERUS. 
 
 753 
 
 A second splint, made of the same material, should extend 
 along the inside of the arm from the elbow to the arm-pit. In this 
 way the two fragments are brought between the two splints and can 
 be held firmly in that position by a bandage. 
 
 These splints should be carefully padded with cotton ; the 
 edi,'cs, especially at the end of the inner splint which lies in the 
 armpit, should bo covered with several layers of cotton in order to 
 prevent chafing of the skin. 
 
 After these splints have been prepared, and several rolls of 
 bandages two and a half inches wide are ready for use, the injured 
 arai sliould be drawn forward from the body a little ; an assistant 
 then grasps the arm at the elbow and flrawc it firmly downv.-ard, 
 while another assistant holds the shoulder and prevents it from being 
 drawn with the arm. While the member is thus held in position 
 the padded splints are applied, one on the outside and the other on 
 the inside of the arm. They are then bound firmly in position by 
 means of the bandages. The arm is then slung in a handkerchief, 
 which is then knotted around the neck and covers the fore-arm 
 and elbow. 
 
 If the patient be stout and muscular, it will be necessary to 
 employ in addition to this bandage a pad made of a folded towel or 
 napkin whicli is placed in the armpit. 
 
 This dressing must be kept on the arm four or five weeks, at 
 the end of which time we may expect that the broken ends have 
 united. It will be well, however, not to permit the original dress- 
 ing to rei.Kiin the entire time ; for in many cases the arm is consid- 
 erably swollen at the time of the injury, and hence a splint which 
 fits it well at that time becomes loose a few days subsequently. If, 
 therefore, there be much swelling when the first dressing isappli(;d, 
 this should be removed after four or five days and altered so as to 
 fit the arm more closely. Five or si.x days later the dressing may 
 be loo-^encd so that the skin can be inspected at the points where 
 the ends of the splints come in contact with it. It will often be 
 fiiuml that the splints have chafed the sk... somewhat, and if the 
 dressing be not removed, severe ulcerati n may follow. If any 
 chafing of the skin be discovered, pieces of lint spread with vase- 
 hnc may be applied over the sore spot, and in re-applying the dress- 
 ing, care should be taken to prevent pressure upon these chafed 
 spots. In any case it wi\J be well to renew the padding of the 
 splints, especially at their edges and ends. 
 
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754 
 
 SURGICAL DISEASES. 
 
 If the patient do not complain of soreness after this first 
 removal of the dressing, this may be allowed to remain till the end 
 of the four or five weeks. 
 
 If the patient's skin be especially delicate it will bcnecessar\to 
 remove the splint every five or six days, and to bathe the skin wiiii 
 a mixture of alcohol and water in equal parts. Every time that Uie 
 dressing is removed, and the broken bone is thus left without sup- 
 port, extreme care should be taken that the arm is not nio\ cd 
 either by an effort of the patient himself or by the careless handling 
 of others. 
 
 After the dressing is removed, the arm should still be carried 
 in a sling for a week or ten days. It may be removed from the 
 sling every day, and should be gently bent and extended by an 
 assistant. This exercise may be performed for ten or fifteen min- 
 utes the first day the time being gradually extended as the arm 
 becomes accustomed to it. 
 
 At first the arm will be very stiff as well as weak ; but both 
 motion and strength will be regained in the course of time. 
 
 In unfavorable cases there occurs some impairment in the 
 movements of the shoulder-joint, as a result of an extension of the 
 fracture up to the end of the arm-bone. If this have occurred, 
 some loss of motion is inevitable ; such a loss of power cannot 
 therefore be attributed to lack of skill on the part of the surgeon. 
 
 Fractures in the Middle of the Ann-bone. — These arc the most 
 favorable of all the fractures in the arm-bone, since they do not 
 interfere with the movements of the joints, and they are readily 
 accessible for treatment. 
 
 Such fractures are recognized by the usual signs : the arm is 
 swollen, and very painful at some particular point ; there is a loss 
 of power in the arm and hand, unnatural movement — such as 
 might occur from the formation of a new joint. By gently movin;j[ 
 the upper and lower parts of the arm we can distinguish a giiUin^; 
 sensation. 
 
 Trentnient, — There are certain fractures near the middle of 
 the humerus which require special dressings ; these we cannot 
 describe in detail. For our purpose it will suffice to mention the 
 dressing which is applicable to most cases of fracture in this .^^itua- 
 Mon. 
 
 A splint should be prepared which consists of two pieces 
 united at their ends at a right angle. This splint is to be applied 
 
FRACTURES OF THE ARM-BONE — HUMERUS. 
 
 755 
 
 Hi 
 
 \rc the most 
 
 to the front of the arm and fore-arm, the right angle fitting into the 
 front of the elbow joint when the arm is bent. The upper piece should 
 be long enough to extend almost to the armpit, while the lower one 
 reaches nearly to the wrist. 
 
 A second splint is prepared long enough to reach from the 
 elbow to the shoulder along the back of the arm. 
 
 These splints are carefully padded with cotton in the manner 
 already described. 
 
 The arm should then be drawn downward by an assistant who 
 grasps the limb at the elbow. While it is held in this position the 
 splint- are applied and bandages are wound firmly around the arm 
 from the wrist to the shoulder. The arm is then rested in a 
 
 sling. 
 
 The object in including the forearm in the splints is simply to 
 prevent movement at the elbow. This is an important part of the 
 treatment, since such movement often results in delay, or even fail- 
 ure, of the fragments to unite. 
 
 This dressing may be allowed to remain (if the patient do not 
 complain of pain from the splints) about two weeks. At the end 
 of this time the splints should be removed and others applied which 
 extend only as far as the elbow. The object of this change is to 
 permit movement of the elbow, which otherwise often becomes 
 quite stiff. 
 
 At the end of four or five weeks the splints may be removed 
 entirely, if union have taken place between the fragments. The 
 arm should be carried in a sling for another week or two until the . 
 new bone has become firm enough to endure ordinary movements 
 without breaking. 
 
 Fractures of the Arvi-boiic near the Elbow. — No fractures in the 
 body tax the knowledge and the skill of the surgeon more severely 
 than those involving the elbow-joint. The arrangement of the 
 bones and ligaments is so delicate and intricate that an injury to 
 this joint is usually followed by some loss in the movements natura 
 to it. Fractures of the humerus in its lower portion frequently 
 extend into the joint and cause serious impairment of the power 
 and motion of the arm. They are often complicated with some dis- 
 location of the bones forming the joint. 
 
 There are, however, some fractures which break the bone of 
 the arm almost transversely across just above the joint. It is of 
 such fractures, uncomplicated with dislocation of the bones, that 
 we shall speak in this chapter. 
 
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756 
 
 SURGICAL DISEASES. 
 
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 A fracture of the lower part of the humerus is indicated by the 
 usual signs. 
 
 Firsi — There is pain at some point in the arm, increased 
 upon pressure with the fingers. 
 
 Secotid — By moving the forearm backward and forward while 
 the arm is firmly held, we can often distinguish a grating sensa- 
 tion. 
 
 Third — The low^r end of the upper fragment of the bone 
 can often be felt by placing the fingers over the front of llie arm 
 just above the elbow. 
 
 Fourth — The movement of the arm at the elbow is not im- 
 paired. 
 
 1 [fth — There is often some shortening of the arm, which can 
 be del,'. t.J. by measuring on the inside of the arm from the elbow 
 to the A iii'der, and by comparing this measurement with the 
 corresponding distance on the sound side. 
 
 Sixth — If the arm be bent and allowed to rest naturally, there 
 will be an unusual prominence of the elbow. 
 
 This fracture is sometimes confounded with a dislocation of the 
 bones of the fore-arm. The latter can, however, usually be recog- 
 nized by the following signs : 
 
 1. The arm cannot be bent at the elbow. 
 
 2. There is no grating sensation to be felt when the injured 
 member is moved. 
 
 3. There is an unusual prominence at the back of the 
 elbow. 
 
 4. There is no sharp edge to be felt at the front of the arm ; 
 the lower end of the arm-bone can be felt as a smooth, rounded and 
 thick body, situated just in the bend of the elbow. 
 
 5. There is no shortening of the distance between the shoul- 
 der and the elbow. 
 
 Ti'eatnieut. — The chief danger to be apprehended from a 
 fracture of the arm near the elbow is that stiffness of this joint will 
 remain permanently. This is a point which is to be borne in mind 
 in the application of a dressing ; for if the elbow be permanently 
 stiff, it is highly important that the arm should be dressed in such 
 a position as will give it the greatest possible usefulness when the 
 elbow becomes stiff. 
 
is not im- 
 
 ju the shoul- 
 
 FRACTURES OF THE ARM-HONE — HUMERUS. 
 
 757 
 
 It is therefore customary to apply splints to a fracture of this 
 tlcscription in such a way that the arm is bent at the elbow almost 
 at a rii(ht angle across the body, the thumb beintr turned 
 upward. 
 
 During the first few days there is so much swelling around the 
 elbow that it is impossible to apply a splint with advantage or even 
 to ascertain exactly what the injury is. This swelling should be 
 treated by wrapping the arm in cloths saturated in hot water, antl 
 surrounding these with oiled silk or rubber sheeting. After the 
 swelling has been reduced the splints may be applied. 
 
 These should consist of two pieces. The outer splint should 
 extend from the shoulder to the wrist on the outside of the arm, 
 being bent at a right angle at the position of the elbow. The inner 
 splint should also consist of two pieces with a similar angle at the 
 elbow. Some surgeons use only the outer splint, and seem to 
 secure good results. 
 
 These splints must be very carefully padded, extra thicknesses 
 of cotton being arranged to cover the bony prominences of the 
 elbow. They are then applied in the way indicated, and are 
 fj'.stcned in position with a firm bandage. The arm thus dressed 
 should be supported in a sling. 
 
 The splint should be worn from three to five weeks ; the older 
 tiic patient the longer it becomes necessary to support the arm, 
 •liiice union occurs less promptly in advanced life than in childhood. 
 At the end of this time the splint shoukl be removed, and the elbow 
 should be gently bent. 
 
 In most cases it will be found that there is decided stiffness of 
 the elbow-joint ; in fact at first it may be impossible for the [)atient 
 to bend the arm at all. By gently exercising it for a few minutes 
 everyday, however, there will be a gradual decrease in the stiffness 
 of the joint. Sometimes motion is completely regained, while in 
 other cases a certain amount of stiffness remains permanently. 
 
 In order to obviate this stiffness of the elbow, surgeons have 
 .sonutmies employed a single splint provided with a hinge at the 
 elbow. This is applied to the back of the arm, and after the first 
 ten days, the arm is gmitly bent at the elbow for a few minutes a 
 day. This can often be done without disturbing the ends of the 
 fiactured bone. 
 
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758 
 
 SURGICAL DISEASES. 
 
 Fractures of the Fore-arm. 
 
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 The fore-arm consists of two bones called the ulna and the 
 radiiis. The relative position of these two bones with reference to 
 each other and to the bone of the arm, must be understood in (uder 
 to appreciate the recognition and treatment of fractures of the fore- 
 arm. 
 
 When the arm is held so that the palm of the hand is turned 
 upward and the thumb outward, the radius lies on the outer side, 
 the ulna on the inner side of the fore-arm. When the hand is 
 turned over so that the palm is downward, the radius makes a 
 revolution about the ulna, the latter remaining in its former position. 
 The rotation of the hantl, therefore, about the axis of the foro-arm 
 is ,-. mpanied by a rotation of the radius around the ulna. In 
 order to accomplish this it is evident that the radius shall not be 
 very firmly fitted into the bone of the arm at the elbow-joint. In 
 
 fa 
 
 Mie 
 
 • ius merely lies in contact with the humerus at the 
 
 elbow. 
 
 The ulna, on the other hand — the bone which lies on the side 
 of the fore-arm corresponding to the little finger — is firnil)- fitted 
 to the arm-bone at the elbow ; this joint consists chiefly, therefore, 
 of the adjacent surfaces of the humerus and of the ulna. The 
 projection at the back of the elbow, popularly known as tlic "crazy 
 bone," is the upper end of the ulna. 
 
 The movements executed by the bones of the fore-arm are 
 most delicate and complicated, hence, even a slight interference 
 with them by fracture or dislocation, is apt to be followed by a 
 decrease in the freedom and extent of motion of the forc-arni. 
 
 Fractures of the Fore-arm near the Elhoiv. — The most frequent 
 fracture affecting this portion of the fore-arm consists in the break- 
 ing off of the upper end of the ulna — the portion called the craz}- 
 bone. This occurs as the result of a fall or blow upon the elbow, 
 and sometimes in consequence of violent muscular contraction of 
 the arm. 
 
 This fracture is easily detected, since the bone is covered in 
 this position only by the skin. By feeling along the edge of the 
 ulna we find that the point of this bone is separated from the shaft. 
 We can often distinguish a little block of bone which is pulled a 
 short distance from the elbow up the arm. By straightening the 
 
FRACTURES OF THE FORE-ARM. 
 
 759 
 
 arm the ulna approaches somewhat this fragment, which has been 
 broken off and separated from it, In other cases the fragment is 
 not separated much from the rest of tlie bone, and we can feel dis- 
 tiiictlv a groove between it and the body of the bone. When the 
 arm is straightened we can detect a grating sensation at the point 
 of injur}'. 
 
 A perfectly characteristic feature of this fracture is, that while 
 the movement in the elbow-joint is perfectly free, so that another 
 individual can bend the fore-arm backward and forward without 
 difficulty, the patient himself is unable to straighten the arm. This 
 results from the fact that the arm is straightened by the contraction 
 of a muscle which is attached to the point of the ulna, that is to the 
 " crazy-bone. " In this injury the point of the bone where the mus- 
 cle is attached is broken off, and hence the patient cannot exert any 
 force upon the fore-arm so as to straighten the arm. 
 
 Tt'entment, — While it is usually an easy matter to replace 
 the broken fragment, it is often impossible to secure a bony union. 
 The fragment becomes united to the rest of the bone by means 
 of a membrane or ligament. If this occur — and it may happen 
 in the hands of the most skillful surgeon — the patient will never be 
 able to straighten the arm completely. When he attempts to do 
 so the fragment to which the muscle is attached is pulled away from 
 the rest of the bone. 
 
 The first object of treatment is to keep the arm perfectly 
 straiL;ht. Probably the best splint for the purpose is that of Dr. 
 Hamilton. This consists of a piece of wood as wide as the broad- 
 est part of the arm, and long enough to reach from the wrist to a 
 point three or four inches from the shoulder. At a distance of 
 about three inches below the bend of the elbow, this piece of wood 
 should be notched deeply on either side. This splint, thickly 
 padded with cotton, is placed on the front of the arm so thai the 
 notches lie in position about three inches below the elbow. A 
 b.uidage is then carried around the hand and up the fore-arm, over 
 the splint. When it reaches the notches, the bandage is passed up- 
 ward above the elbow, so as to secure a hold behind the broken 
 fragment. When the bandage is carried around to the notch at 
 the other side of the arm and tightly drawn, this fragment is drawn 
 downward so as to come into contact with the bone from which it 
 was broken off. The bandage is carried twice through the notches 
 
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76o 
 
 SURGICAL DISEASES. 
 
 in this way so as to secure a firm hold on the fraj^mcnt After this 
 the bandage is continued up to the end of the splint. 
 
 In order to prevent any soreness or rawness of the skin, i; is 
 well to cover the broken fragment with cotton before the bandam' 
 is applied. 
 
 This splint is to be kept in position three or four weeks. At \hv 
 end of this time the bantlage may be removed and the ln.n, 
 examined to see whether the fragment is firmly united to the bmu'. 
 If it still seems loose, the splint should remain in position for a ucrk 
 or two longer. 
 
 This fracture is apt to be followed by some stiffness of tlic 
 joint, which, however, disappears if the arm be gently beiil 
 regularly. 
 
 Fracture at the Middle of the Fore-arm. 
 
 . 
 
 This fracture is usually caused by direct violence such as a 
 blow, though it sometimes results from a fall upon the hand. 
 
 If both bones be broken, the usual signs of fracture will lie 
 apparent. There will be an unnatural mobility of the arm — a gral 
 ing sensation and loss of power. 
 
 If, however only one bone be broken, these signs arc less ap- 
 parent, for the other bone maintains the form and length of the aim. 
 Sometimes, too, it is impossible to detect the grating seusalinn. 
 
 In every case we should find the point at which pressure causes 
 the patient acute pain, and observe whether this is on the outn or 
 outer or inner side of the arm; that is, whether it is located over the 
 radius or the ulna. We then pass the fingers along the course of 
 the bone, feeling carefully for any point at which a little pressunis 
 followed by a yielding of the bone. If we find such a point, we 
 can sometimes, by placing the thumb of one hand over it, ami the 
 thumb of the other hand two or three inches higher up, distinguish 
 a faint grating sensation. 
 
 The peculia'* impairment of motion may also enlighten us as 
 to the location of the fracture. The radius, as has been said, is 
 especially concerned in the rotation of the hand ; any injury to the 
 radius is apt to be followed by an impairment in the power to turn 
 the hand over. 
 
I'-RACTUKK OK Till'; FORE-ARM NKAR TIIK WRIST. 
 
 761 
 
 Ti'cntHieilt. — It has been already stated that injuries to the 
 boius of the fore-arm are frequently followed b)- some impairment 
 in the movements of the hand. It is extremely im])ortanl that the 
 fact be recognized in the treatment of the fracture. The first 
 obiect of treatment must, therefore, be an effort to separate the 
 l),)iu's at the point of fracture. In consequence of the arrangement 
 of the nuiscles in the fore-arm, the broken ends of either bone are 
 apt to be drawn toward the other bone ; unless this position is 
 relieved, the two bones may grow together at the point of fracture, 
 a condition which will residt in serious loss of motion, since the 
 hand cannot be rotated or turnetl over. 
 
 In order to avoid this two splints of wood should be prepared, 
 long enough to reach from the elbow to the wrist. 'I'he splint 
 which is applied to the T. ont of the arm should extend down to the 
 palm of the hand, so that the fingers can be bent iq) over it. These 
 splints should be well padded and applied to the arm ; the padding 
 (of cotton) should be made somewhat thicker in the middle so that 
 it shall sink in between the bones and keep them separate. 
 
 In applying the splints care should be taken that the arm lies 
 SI) that the palm is turned upward ; this is necessary in order that 
 the bones shall be kept apart. In this position of the hand, the 
 two bones of the forearm lie parallel and widely separated, while 
 when tlie hand is in any other position the radius lies across the 
 ulna and close to it. 
 
 After the splints have been applied and fastened by means of 
 a bandage, the arm should be supended in a sling, the palm of the 
 hand being turned inward with the thumb uppermost. 
 
 The dressing should be worn for about a month, and the arm 
 .should be carried in a sling for a week or two afterwards. 
 
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 Fracture of the Fore-arm Near the Wrist. 
 
 The most usual fracture in this location is what is variously 
 designated as Colics' fracture, or " silver-fork " or " back-door " 
 fracture. The first name is derived from an Irish physician Dr 
 Colics, who first called attention to this fracture. It is called silver- 
 fork fracture from the peculiar appearance of the wrist and hand ; 
 for the back of the arm and hand is no longer straight, as in the 
 
 . 
 
 
762 
 
 SURGICAL DISEASES. 
 
 natural condition, but presents a series of curves much rcscniblin</ 
 the shape of a silver fork. It is called " back-door " fracture 
 because it so frequently occurs in women when they step out of 
 the back door of their kitchens onto an icy pavement. 
 
 It is one of the most troublesome of all fractures. No matter 
 what plan of treatment be adopted, there almost invariably remains 
 either some deformity of the wrist, or some impairment of motion, 
 or both. This fracture is, therefore, the subject of innumerable 
 suits against surgeons for malpractice ; it would be well for people 
 to understand that the wrist can rarely be restored perfectly in both 
 form and movement, and that the result will almost inevitably be 
 unsatisfactory. 
 
 This fracture is easily recognized by the outline of the wrist, 
 to which reference has been already macl_. The patient will be 
 unable to bend the hand or to turn it toward the thumb side of 
 the arm. 
 
 Treatment, — It is important to observe whether the frag- 
 ments are loose and movable, for in many cases the ends of the 
 bone are firmly driven into each other, that is, impacted. If this 
 be the case, and if the patient be old, the fragments should not be 
 separated unless the deformity is very great. For, by permitting 
 them to remain, we are sure of having them held in place more 
 securely than can always be done by a dressing. 
 
 If the fragments are impacted with great deformity, it becomes 
 necessary to separate them ; this is to be done by pulling firmly 
 upon the wrist. 
 
 When the fragments are movable, it is very easy to " set" the 
 bone, but not always easy to keep it in place. By simply clasping 
 the hand of the patient and pulling it away from the arm as well as 
 toward the little finger side, the bone falls readily into place ; in 
 fact, it can often be put into position by simply pressing upon the 
 broken ends with the thumbs. In order to keep it in position vari- 
 ous methods have been devised. Several objects are to be accom- 
 plished by the dressing. 
 
 The lower fragment is to be drawn down into its position and 
 kept there. 
 
 The hand must be prevented from falling toward the thumb 
 side, as it naturally does when the bone is thus fractured. The 
 arm must be kept at rest. 
 
 The usual method for dressing this fracture consists in the 
 
lonsists in the 
 
 FRACTURE OF THE FORE-ARM NEAR THE WRIST. 
 
 763 
 
 application of a splint which, because shaped very much like a 
 pistol, is ordinarily termed the " pistol-splint. " This consists of 
 (iiie j)icce, the lousier limb of which is applied to thu fore-arm, while 
 the shorter limb, which is bent at an an<;le of about 135 de^^rees, 
 covers the palm of the hand. This is carefully padded and applied 
 to the front of the fore-arm and hand, where it is held in position 
 b\- ;' firm bandasre. By thus turning the fingers toward the opposite 
 side of the arm, we prevent the lower fragment frona riding over 
 the upper one and hold it in position. Some surgeons are in the 
 habit of placing a pad, made by rolling up a piece of bandage, 
 between the splint and the edge of the lower fragment; this is 
 rarely necessary. By having the padding of the splint thicker in 
 the middle than at the sides, we keep the fragment of the radius 
 frfini touching the ulna, and thus prevent the two bones from grow- 
 ing together. 
 
 Some surgeons use two splints in dressing a CoUes* fracture: 
 one similar to that just described, and the other, a straight splint, 
 which is applied to the back of the fore-arm and covers the wrist. 
 Professor Gunn, of Chicago, often dresses this fracture by simply ap- 
 plying a broad strip of adhesive plaster around the wrist at this point. 
 Whatever dressing be applied, the arm should be supported in 
 a sling which is suspended from the neck. 
 
 The dressing should be carefully inspected every day, to see 
 that the arm suffers no damage. Somtimes the bandage is applied 
 so tightly as to cut off the circulation in the hand ; this will be indi- 
 cated by coldness and blueness of the fingers, and must be remedied 
 at once by loosening the bandages. If the patient complain of 
 Ljrcat pain, the bandage should be loosened and the seat of the 
 fracture examined to see that the parts are in the proper position. 
 
 After the hand has been thus treated for two weeks, the dress- 
 ing may be removed and replaced either by a simple strip of adhe- 
 sive plaster around the wrist, or by a single short splint on the 
 front of the arm, which extends only to the wrist. In this way the 
 hand is permitted to move freely, and the stiff.'' s of the wrist, 
 which often results if the first dressing remain too long, is in great 
 measure avoided. So soon as this second dressing is applied, the 
 hand should be gently bent backward and forward by a second per- 
 son. In the second week the hand may be slightly rotated, that is, 
 turned over and back. By thus exercising the joints we may suc- 
 ceed in avoiding the stiffness which otherwise results. 
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 764 
 
 SURGICAL DISEASES. 
 
 Fractures of the Hand. 
 
 The bones constituting the hand are sometimes broken h\- :\ 
 blow upon the hand or by striking the fist against some haul 
 object. 
 
 It is sometimes difficult to recognize a fracture of one of these 
 bones, because the swelling is so great that accurate ' 'nation is 
 
 impossible. In most cases, however, we can detect ^ .unful spdt 
 at which a grating sensation is felt ; this feeling is much ])laiiK'r 
 when the patient bends the fingers. There is some deformit), p ut 
 of which may remain after the bones unite ; but the usefulness of 
 the hand is not thereby impaired. 
 
 Ti'i'dtincnt, — A piece of wood long enough to reach from 
 the knuckle to the middle of the fore-arm and as wide as the palm, 
 is padded with cotton as already directed. This is applied to the 
 front of the arm, a pad being interposed between the enil f)f it and 
 the palm of the hand. A bandage is then applied so as to keep the 
 palm pressed against the splint. If only one of the buncN Ix 
 broken, the splint need not be so wide. 
 
 These fractures are sometimes dressed by simpl ispint;- the 
 fingers around a large ball of yarn or cotton, and ' .anda"in<' 
 
 the hand over this. 
 
 Fractures of the Fingers. 
 
 These are usually by direct violence, and are commonh- asso- 
 ciated with wounds of the flesh. In the latter case the treatment 
 must often be directed to the wound rather than to the fracture. 
 
 If we have a simple fracture to deal with, it will be an easy 
 matter to recognize the condition. The outline of the fiiiLjer is 
 changed, and we can usually see and feel the broken ends without 
 difficulty. 
 
 Treatment. — Fractures of the fingers should be treated very 
 carefully, since a deformity in this location is very annoyin<^. In 
 setting the bone, which can easily be done by simply pulling upon 
 the end of the finger, care should be t iken that the fragments arc 
 accurately replaced. 
 
:.c treated very 
 
 1-KACTURliS OF THE KlliS. |t| 
 
 A splint of wood or pasteboard should be cut sufficiently lonjj 
 to extend from the end of the fnij^'er onto the forearm. After this 
 has been padded it should be bound to the finj^'er with a narrow 
 bandai^e. The ends of tlu' lin^^ers should be left uncovered, that wc 
 call see whether the circulation is interrupted , if this end beconvj 
 blue and cold, the bandaj^e should be loosened and re-applied. 
 
 If two fintjers be broken, each should have its own splint ; for 
 if wc apply but one splint and a bandage around both finj^ers, there 
 is apt to result a deformity, since the broken fragments often heal 
 at an angle. 
 
 Many surgeons employ a plaster of Paris dressing for broken 
 fingers. This holds the parts firmly, but has the disadvantage that 
 the fingers cannot be so easily and readily inspected. 
 
 In any case the hand should be suspended in a sling ; it is 
 important to avoid movements of the hand and fore-arm, since these 
 are accompanied by muscular action which often disturbs the posi- 
 tion of the frcigmeiits. 
 
 If the fracture be accompanied by severe wounds of the flesh, 
 the treatment is more complicated and must be devised for each 
 particular case. In every instance an effort should be made to 
 save the fingers, even though they be badly mangled, since even 
 deformed fingers are often very useful. 
 
 Fractures of the Ribs. 
 
 The ribs arc usually broken only by direct violence, because in 
 consequence of their elasticity they readily yield to a force applied 
 from without. In elderly persons the ribs break more easily than 
 in the young, and it is chiefly among persons in advanced life that 
 these cases are observed. 
 
 Fracture of the ribs can usually be detected by the following 
 signs : 
 
 The patient suffers extreme pain upon breathing, which he 
 refers to one particular spot. He is unable to lie down upon the 
 injured side without pain ; the difficulty in breathing is usually 
 increased in the recumbent posture. If one of the fragments have 
 penetrated the lung, the patient coughs up bloody mucus mixed 
 with air ; sometimes air escapes from the lung into the cavity of the 
 
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766 
 
 SUKGICAI, DISEASES. 
 
 1 
 
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 :lu;st, 
 
 and cvon in 
 
 to Ih 
 
 c connective tissiu; tiiulcr tlu: skni. 
 
 ]i\ \h 
 
 latter case the skin is piiffcMl tip and crackles when pressed with 
 tlie rinj.jers. 
 
 By leelini' alonir the coiirsi: of tlu; ril)s we detect 
 
 painliil 
 
 spot 
 
 pressure wi 
 
 til {\ 
 
 (t rinj;ers placed an inci) or two apart revcil 
 
 a };ratin^ si-nsation at this point. I?y [)lacin;r the ear over tile skin 
 at the seat of the suspected IVactiirc: we cm hear a j^raliiifr sniiiul 
 (hirin!:j th(; niovenients of tlu" clicst in hrealiiiiij.;. If tiierc lie ,iiiy 
 (liniciilty in detectin}^ the seat of fracture we can usually lind lln 
 spot by placiiif^f one hand upon the back aiul the other upon ih, 
 brcast-btinc and pres-iin^^ with considerable force ; the i)atient will 
 cxperiiMice a sharp pain at the seat of tlu; fracture. 
 
 ]' 
 
 •'racture nf the ribs is sonu^linies simula 
 
 ted 1 
 
 )y a severe bruise 
 
 of the side ; in this case there is no ^ratiuff sensation, but there is 
 so iiuicli pain upon pressure that the patiiiit cannot cMiduri- a circ 
 fill examination. If the injury be only a l)ruise without fracture, 
 the pain and teiuK-riU'ss will subside in a few days ; if there he a 
 fracture, on the other hand, the pain during bre.ithin^ persist ;. 
 
 A simple fracture of the ribs unites readily evc-i\ willioiit 
 dressinf^. If, however, there be si>me injury to tlu; luni;, inMaiiuua 
 lion of the lun^, or of the membiane coveriii<^f it — the />/(///ir—- 
 may involve the patient in a serious ilhu^ss. 
 
 f no such iiill.inuiia 
 lion follow, a rapid recovery ma)' bt' expected vvrn tlwHudi the ■ l.in 
 be piilVed up with air which has escaped under it. It is siir|ii i iii!; 
 to see the effi-cts soimtimes produced by this accident ; tin enliie 
 side of the chest, indicd the whole body, may be enornien l\ 
 swollen ; tin- skin is simply full of air, and crackles wheiu \( r the 
 finders are pressed upon it. No danger is t<> be appreluiuled rmin 
 this condition, however, unh;ss the air has also i;si:a|)ed inlnand 
 filled up the cavity of the chest between tlu; lim[;s ami the rili . ; in 
 this case the lun^ may be compressed so that the [lalieiil t aiinni 
 breathe, and dies of suKocation. 
 
 Ti'i'OttnvHt. — in most casi-s then: is no perceptible detmniily, 
 unless several adjacent ribs havt- lieeii broken. If there lie an 
 cvi'ieiit disi)laceme!it of the fra^^mciils these are to be redu( ed I'y 
 pressure with the tinkers. 
 
 The object of treatment consists in measures which k strain 
 the movements of the chest on the affected side, as ,i result nl 
 which the frat;me«ts are kept at rest and have an (^pportuiiit)' tn 
 
I'KA( TURKS <)l' 11 IK SPKN'K. 
 
 1^1 
 
 heal, 'litis ol)jcct can he accomplished hy api^'yiiifj broad bands 
 of adhesive plast(;r around llu- injured side from the spine to the 
 l)reasl-bonc-, 'Ihese strips of plaster shonl<l bt about two inclics 
 wide, each one overlappin}.j the one beneath ; a sufllcieiit number 
 shuuld be applied to cover five or six in( lies f)f the side of the 
 ( lust. If adhesive straps cannot lie obt. lined, the movements of 
 llie chest may be arrested by a banda^'e [)laced arour.d the body 
 drawn as tij.;htly as the patient: can bear it. 
 
 In some cases the application of such a bandaj.;e may at first 
 increase the patient's (lisc<imfort. This, however, lasts but a short 
 lime, and in a few hours f;reat relief is afforded. 
 
 Thi: dressing; must be worn four or five weeks. 
 
 Fractures of the Spino. 
 
 This injury occurs only as the result of severer mcclirmical vio- 
 lence. 
 
 The consecpiences depend upon the d.imatn' inflicted to the 
 spinal cord. i'Or it must be r(mu;nd)ered that the spine is a bony 
 c.uial, colli, lininj.r the nerves which run from the brain to the limbs 
 ,inil trniiU. An\' injur)- to the s|)ine which causes pressure upon 
 llicse nerves must of course oecasioii inlerfer(;iice with tlu' functions 
 III the body and limbs. 
 
 it sometimes happens that portions of the spine are broken off 
 uillioni aHectini; the contents of this bony canal, fur tin- l>.u:k -bom.; 
 is (innposed of different joints, each of wlii( h is provided with a 
 linns' projection or .v/v/zT, wlii( h extends baikw.inl bum the spinal 
 iiihnun. It is these bony s|)iiu:s which (Diiititute the ridi;e of the 
 li.ick bone. Tin; ap|ilicatioii of violence is siMiietimes folluwed by 
 ,i!ra(tureof one or more of these spines, without injury to the 
 |i,nl (if the b.ick-bone which contains the iierve,. In this case 
 llnre is no further damaj.;e than the p.iin at the ixiintcif injury. 
 We can !iO!netimes ditect a movable pieci: of boiu , and possibly 
 lerl the I'.i.itiii^' sensation customai)' in fractures. Tin re may also 
 lie a marked deformity diu' to the displacement of tlii' broken bony 
 |ii(ijection. II" this be- replaced, and the |)atient kept <piiet, union 
 Dccms witlnuit difficulty and no |)eiiii.iiieiit injury results. 
 
 In most cases, however, a baituii' of th<' spine invoK'es those 
 parts i)f the bones which constitute the bony canal surrounding llie 
 
;-68 
 
 SURGICAL DISEASES. 
 
 . 
 
 J ' 
 
 spinal cord. In this case the cord itself, including the bundle of 
 nerves which proceed from the brain ;o the limbs, is injured. It is 
 not necessary, in order to interrupt the nervous current, that the 
 spinal cord should be actually wounded or cut, for simple pressure 
 upon it suffices to interfere with the passage of the nervous influence 
 along the cord. 
 
 It sometimes happens, therefore, that a very slight fracture — 
 one which cannot be detected by the usual signs — is quite sufficient 
 to compress the spinal cord and to arrest the passage of nervous 
 force from the brain to the limbs. Indeed, it has been observed 
 in many cases that if there be no displacem-^ *• of the broken bono, 
 but simply an escape of blood into the mal canal, the same 
 symptoms follow as if a piece of the bone were driven into the 
 spinal cord. 
 
 Symptoms which follow an injury to the spine resulting in 
 wounding or compression of the spinal cord, vary according to the 
 location of the injury. If the fracture occur in the lower part of 
 the back, there results paralysis of the legs and of the bladder and 
 rectum. The patient is unable to move the lower extremities or to 
 evacuate the bladder or bowels voluntarily ; there is usually a loss 
 of feeling in the lower half of the body, though during the first few 
 hours or days there may be an extreme sensitiveness of the extrem- 
 ities so that the slightest touch, even the contact of the bedclothes, 
 causes extreme pain. 
 
 If the injury be situated at some point higher up in the spine, 
 there will be paralysis of the trunk as well as of the limbs, and if 
 the spine be injured in the neck the entire body except the hand 
 will be paralyzed. In the latter case death sometimes occurs 
 instantaneously. 
 
 Treatment. — The treatment of fracture of the spine consists 
 usually in the treatment of the symptoms of the various oiL^ans 
 caused by injuries of the spinal cord The bowels and bladder 
 give the patient a good deal of trouble, since he has no control 
 over either ; the bladder usually becomes severely inflamed 
 
 In some rare cases it has been possible to set fractures of the 
 spine with the effect of relieving somewhat the symptoms of the 
 patient. In the majority of cases, however, no treatment applied 
 to the seat of the injury itself is of any avail in overcoming the 
 injury; for the damage is done at the time of the fracture, and a 
 
inc consists 
 
 FRACTURES OF THE HIP. 
 
 769 
 
 replacement of the bone cannot undo the injury done to the spinal 
 cord. 
 
 The subsequent history of these cases varies in details, but 
 always includes permanent paralysis to a greater 01 less extent. In 
 the most favorable instances, the power of movement in the limbs 
 is recovered to a certain degree ; in most cases the spinal cord 
 undergoes degeneration at the seat of injury ; the flesh mortifies, 
 forming large bed-sores, and the patient finally dies of exhaustion. 
 
 The injured person should be kept in the recumbent position, 
 and regular evacuations of the bladder and of the bowels should 
 be secured by the use of the catherer in the one case, and of warm- 
 water injections in the other. Medicines will rarely accomplish any 
 cTood. Sometimes benefit is derived from the application of croton 
 oil to the skin at the seat of the injury. 
 
 Fractures of the Hip. 
 
 The hip is formed by the edge of a bone which constitutes 
 a large part of the pelvis — the bony basin which contains the 
 bladder, rectum, and some of the organs of generation. The hip- 
 bone itself is very strong and well protected ; hence it is seldom 
 broken except in case of severe injury, such as crushing between 
 cars or wagons. 
 
 The fracture of the bone is not an especially serious injury, 
 and recovery may occur without deformity or subsequent difficulty. 
 In most cases there occurs not simply a fracture of the bone, but 
 also injury to the organs contained in the pelvis ; as these organs 
 are extremely important, injury to them is a most serious accident, 
 and one which frequently terminates in death. 
 
 A fracture of the hip-bone is not always recognized even by 
 the experienced surgeon ; for the bones arc so completely surrounded 
 by flesh and so immovable that the. ordinary signs of fracture are 
 not presented. In some cases it is possible to detect crepitus (a 
 grating sensation) when the bones are firmly pressed together ; a 
 hand should be placed upon cither hip and pressure exerted by 
 pushing the edge of the hip-bone inward. If this occasion great 
 pain at some other point than that pressed upon by the hand, 
 there is a probability that the bone is fractured. In most cases, 
 
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770 
 
 SURGICAL DISEASES. 
 
 however, the diagnosis must rest upon the symptoms rather than 
 upon any signs which can be detected by the eye or the hand. 
 
 Treatment, — If there be any marked deformity, this should 
 be rectified by replacing the fragments, so far as possible. The 
 patient should then be placed upon a hard bed with the knees 
 drawn up ; a broad bandage is firmly applied around the hips and 
 the upper part of the thighs. In special cases it may be neccssaiv 
 to place the patient in some other position, in order to correct some 
 particular deformity. 
 
 In e' .y case care should be taken to see that the patient 
 evacuates the bladder regularly, because this organ is often iniuied 
 by the accident, so that the urine is retained. If this be the case a 
 catheter should be regularly introduced. 
 
 Fractures of the Thigh-bone. 
 
 The thigh may be broken at any part of its length ; fractures 
 most frequently occur, however, at two points — first, at the part of 
 the bone which fits into the socket of the hip-joint ; and second, at 
 a point somewhat below the middle of the bone. 
 
 Fractures at the first-named part of the bone — which is called 
 the nec/c of the thigh-bone — most frequently occur in old people, 
 as a result of a fall upon the hip, though they may also result fr(5in 
 a fall upon the feet. Fractures at the lower part of the bone aie 
 usually tho consequence of direct violence, such as the passage of a 
 wagon-wheel over the thigh or the fall of a heavy weight upon it. 
 Fractures of the thigh-bone are usually oblique, so that one end o{ 
 the broken bone rides over the other. The muscles attached to 
 this bone are very powerful, and as a result of these two faetuis, 
 the fracture is almost invariably accompanied with a great deal uf 
 shortening of the thigh. 
 
 Siifits, — The signs of a fracture of the thigh anywhere below 
 the neck of the bone, are usually so clear that the conditon is rec- 
 ognized without difficulty. There is great pain and swelling in the 
 thigh ; the limb is often bent at some point, and it may even he 
 possible to execute such movements with the lower part of the 
 thigh as would indicate the presence of a joint between the knee 
 

 FRACTURES OF THE THIGH-BONE. 
 
 77^ 
 
 ,1. 
 
 .iiid the hip. We can also distinguish a grating between the ends 
 of the bone ; the thigh is shortened sometimes one or two inches. 
 A characteristic sign of a fracture of the Miigh, is the position of the 
 foot, the toes being turned outward away from the other leg. 
 
 l-'racturc of the thigh is usually accompanied by severe and 
 extensive injury to the flesh; this may have resulted from the 
 violence which caused the fracture, or may be the result of lacera- 
 tion by the broken ends of the bone, which are usually sharp. 
 Sometimes dangerous hemorrhage results from injury to large 
 blood vessels ; in other cases the laceration of ':he flesh is so great 
 as to require amputation. 
 
 If a fracture be simple, that is, if there be no wound of the flesh 
 communicating through the skin, the parts usually heal without 
 difficulty ; the fracture involves no danger to life. In many cases 
 the thigh never recovers its former strength, and sometimes breaks 
 UL^ain at the same spot upon the infliction of much less violence 
 than before. It is necessary to keep the dressing applied for two 
 months after the injury, and the weight of the body should not be 
 home upon the limb for another month. 
 
 A complication of fracture of the thigh is stiffness of the 
 knee ; this results simply from the enforced inactivity of the knee 
 during the time when the dressing was applied. This stiffness can 
 usually be relieved to a great extent, though in some cases motion 
 is never fully recovered in the joint. 
 
 Tt'cattUi'lit. — A fracture of the thigh is one of the most diffi- 
 cuh to treat satisfactorily. There arc several difficulties which are 
 met with nowhere else in tne body. First, the muscles of the 
 thigh are so powerful that it is a matter of great difficulty to over- 
 come their contraction sufficiently to keep the broken ends in 
 position ; second, the limb is so large and heavy that especial 
 iliessings are required in order to hold it in place. The ends of the 
 fragment are oblique, so that the broken surfaces are large and 
 slow to heal. 
 
 The dressing must therefore fulfill several conditions: First, 
 it must be applied to the limb in such a position that the muscles 
 are relaxed and do not pull the fragments out of place ; second, it 
 must overcome the tendency of the fragments to override each 
 other, a tendency occasioned by muscular contraction, as well as 
 by the weight of the limb. 
 
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772 
 
 SURGICAL DISEASES. 
 
 In the treatment of fracture of the thigh a most important item 
 is the effort to avoid shortening of the limb. This effort is r ...y 
 entirely successful, since the difficulties in the treatment are so great 
 that they cannot be always overcome by any dressing at present 
 employed. By careful treatment, however, wc can diminish tlic 
 amount of shortening to a minimum. 
 
 In order to avoid shortening of the limb, it is necessary that 
 the length of the leg be measured every few days after the dressing 
 is applied. This is a delicate process, which must be done with 
 much care and accuracy in order to avoid erroneous results. 
 
 The length of the limb is to be ascertained in the following 
 way: 
 
 The person should be bared as far as the waist, or at least the 
 outside of the thighs and legs is to be uncovered. The patient 
 lies upon a hard bed, care being taken that the legs lie parallel and 
 exactly in a line with the body. 
 
 A tape measure, which must be inelastic, is employed for the 
 measurement ; one end of this is to be pressed firmly against the 
 sharp corner of the hip-bone at the front of the body. The tape 
 is then unrolled down the leg and pressed firmly against the bony 
 prominence of the anklo either on the outside or on the inside. 
 Extreme care must be taken, in securing the comparative length of 
 the two limbs, that the tape is pressed upon exactly corresponding 
 points on the two sides of the body. 
 
 After measuring in this way, it will be well to repeat the meas- 
 urement, starting from the navel as the upper point. The inaccuracy 
 of these measurements will readily be shown if we repeat them a 
 few times between the same points on the same individual ; it will 
 be found that no two measurements of the same distance will 
 exactly coincide. 
 
 The fractured limb should be so dressed that its length as it lies 
 in the splint eqijals at least that of the sound limb. When healin;,^ 
 occurs, there will usually be some shortening; this will not matter 
 if it do not exceed half or three-quarters of an inch, since the dif- 
 ference will not necessarily cause any limping. In fact the two 
 legs of the same individual arc rarely of the same length. 
 
 The choice of a splint for dressing a fractured thigh depends 
 upon circumstances as well as upon the individual preference of the 
 surgeon. It would be out of place in this work even to enumerate 
 all the different varieties of splints which have been recommended 
 
FRACTURES OF THE THIGH-BONE. 
 
 773 
 
 fjth as it lies 
 
 and arc used for the treatment of this fracture. It will be sufficient 
 to mention briefly three varieties, which will be found to answer 
 the requirements of all cases and to afford the best results. 
 
 The first of these consists essentially of a double inclined plane. 
 This is made by joining two pieces of board at their ends at an 
 anisic of about 90 degrees. The pieces must be sufficiently broad 
 to support the thigh and the leg. This is carefully padded with 
 cotton, and the leg is placed upon it so that the angle formed by 
 the two pieces rests under the knee. The patient's bed is raised at 
 the foot so that tlie weight of the body tends to draw the upper 
 fragment away from the rest of the limb. The leg is bound to this 
 splint with bandages, and the splint itself should be fastened to 
 the foot of the bed so that it will not follow the movement of the 
 
 trunk. 
 
 Another method consists essentially of the following appa- 
 ratus : 
 
 Long adhesive straps are placed one on either side of the limb, 
 from the point of the fracture down to the ankle ; they project then 
 several inches beyond the sole of the foot. These adhesive straps 
 are held in position by a bandage firmly applied about the limb 
 from the ankle up to the seat of the fracture; a piece of wood the 
 center of which is perforated by a single opening is then fastened 
 to the ends of the straps projecting beyond the foot, so that the 
 wood lies parallel with the sole of the foot. A piece of clothes- 
 line or stout cord is then knotted at one end and passed through 
 the hole in the center of this block. This rope is then passed 
 over a " standard," that is a block of wood fastened to the foot of 
 the bed and supporting a small pulley which should be at the level 
 of the ankle. To the end of the rope which is passed over the 
 pulley and hangs at the foot of the bed a weight is attached suffi- 
 ciently heavy to pull the lower fragment of the thigh-bone from 
 the upper. If the patient be a robust adult, two bricks will usually 
 be necessary to accomplish this ; if the patient be a child a year 
 old, a weight of one pound will usually answer ; a half-pound 
 should be added for each additional year of the child's age. In 
 every case it will be better to regulate the weight by the effect pro- 
 duced upon the thigh than by any rule. 
 
 In applying the strips of adhesive plaster along the side of the 
 leg care should be taken to pad with cotton the bony prominences 
 at the ankle ; otherwise the skin will become raw and sore. 
 
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 774 
 
 SURGICAL DISEASES. 
 
 The bed upon which the patient lies should be inclined, tlic 
 foot of the bed being raised ; in this way the weight of the hodv 
 tends to keep the upper fragment of the thigh-bone pulleil awnv 
 from the lower fragment, which is meanwhile drawn in the ojipositr 
 direction by the weights attached to the rope. 
 
 A modification of the same principle consists in a so-calkd 
 " side splint." This consists of a piece of board, siding or similar 
 light stuff, long enough to reach from a point above the hip-hdiu.- tn 
 another point several inches below the sole of the foot. It sliuuld 
 be about three inches wide, or may be made to taper so as to 
 be broader above where it is to lie in contact with the thigh and 
 trunk. 
 
 This splint is well padded with cotton, especially at the edj^'Ls. 
 It is then to be applied to the outer side of the limb, the upper end 
 extending above the hip-bone. It may be fastened to tiie limb 
 either by a roller bandage which is applied from the toes u|) to the 
 body or by strips of adhesive plaster, which are placed around tlio 
 leg and the splint at intervals of five or six inches. It is advisable 
 to employ both of these measures, the strips of plaster being 
 applied first and the bandage put on afterward. 
 
 Some surgeons modify the procedure by using a wcii,dit in 
 connection with this side splint. Two strips of adhesive i)laster 
 arc applied one on the inside the other on the outside of the lei;, 
 as high as the knee. These strips are fastened to the leg by means 
 of a bandage. A block is placed between the strips, below tlie 
 sole of the foot, in the way already described. To this a ueii;ht is 
 attached and carried over a pulley in a standard. The side splint is 
 then applied in the way just described. 
 
 In using this side splint care must be taken to " set" the hone 
 before the bandages are applied, for the fragments arc kipt apart 
 by the pressure of the bandage which holds the liinl) against the 
 splint. The bone is set by two persons, one of whom grasps the 
 thigh at the groin, so as to pull the body toward the head of the 
 bed ; the other, meanwhile, seizes the ankle or the knee and draws 
 the lower fragment downward toward the foot of the bed. The 
 splint should be bandaged ':o the leg while the limb is thus held. 
 
 This dressing is not so satisfactory as the preceding, if the 
 patient be robust and muscular, for it will be impossible to main- 
 tain the broken ends of the bone in their proper position, and con- 
 siderable shortening will result. 
 
FRACTURES OF THE TIlKill-IiONE. 
 
 775 
 
 In dressing fractures of the thigh in children, a special splint is 
 used. 'I'liis consists of two pieces extending up the leg with a 
 (,,-(,ss-picce between the ends below the foot. Strips of plaster arc 
 apjjlied to the sides of the leg as before, and the rope which runs 
 throuL;li the block under the sole of the foot is fastened to the 
 cross-piece of the splint. This in turn is supplitd with a piece of 
 clothes-line and a weight, the latter being suspended over a pulley 
 and standard. 
 
 The object of this dressing is to keep the linil:) perfcctl}- quiet, 
 ail object which cannot be otherwise attained in treating restless 
 children. Indeed, surgeons sometimes employ a splint of this kind 
 ill which the cross-piece is so long that both legs of the child lie 
 between the side-splints, and can be attached to the dressing so 
 that movement in the bed is impossible. 
 
 The disadvantage in all these methods is, that the patient is 
 compelled to keep his bed for five or six weeks, and is not per- 
 mitted any freedom of movement even in the bed. The condition 
 becomes extremely monotonous and even painful ; the result is 
 that the dressing must be loosened and changed so often that the 
 frat^ments of the broken bone are not retained in position and the 
 limb heals with considerable shortening. 
 
 Several splints have been devised which obviate, to a greater 
 or ksscr extent, the necessity for perfect quiet on the part of the 
 patient. One of these, which is now in general use in our large 
 hospitals, is the invention of Dr. Smith, of New York. It consists 
 of an iron frame, which can be made cither of small gas-pipe or of 
 solid iron rod half an inch in diameter. This is bent so that one 
 piece lies on either side of the limb, being joined to its feUow by 
 a cross-piece just below the foot. The inner rod extends uj) to the 
 body on the inside of the thigh, while the outer one is made long 
 enough to reach the top of the hip-bone. The two side-pieces are 
 bent at an angle of about 1 50 degrees at the point where the knee 
 is to rest. Such a splint can readily be made by a blacksmith. 
 
 Strips of bandage are then pinned across from side to side of 
 this splint, in such a way as to allow the limb to rest easily upon 
 them. Two broad strips of adhesive plaster are then applied to 
 the sides of the leg, which is then bandaged in the usual way. The 
 block of wood attached to the lower end of these strips is fastened 
 tightly to the cross-piece of the iron splint. 
 
 The splint is then to be suspended by a rope, which passes 
 
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77^ 
 
 SURGICAL DISEASES. 
 
 iNI 
 
 through a pulley in the ceiling, so that this rope shall pull the 
 splint toward the foot of the bed. This part of the bed is elevated 
 by placing bricks under the feet, and the rope, which passes over 
 the pulley, is tightened so as to draw the limb toward the foot of 
 the bed. In this way the broken ends of the bone are drawn apart 
 and kept separate, since the weight of the body keeps a constant 
 traction on the upper fragment. 
 
 The advantages of this splint are several : the patient is per- 
 mitted considerable movement in the bed and can thus avoid the 
 monotony and annoyance inseparable from the other splints already 
 described. The limb, moreover, is kept above the bed and can be 
 more readily inspected and adjusted as occasion requires. 
 
 It would be advantageous to make ? splint which would permit 
 the patient to be up instead of lying flat upon his back. An 
 attempt has been made to secure such a dressing by the application 
 of plaster of Paris bandages. Experience has shown, however, 
 that such a bandage is inefficient in holding the fragments apart if 
 the limbs be large and muscular ; since in this case the baiulaife 
 does not secure sufficient hold upon the flesh to overcome the con- 
 traction of the powerful muscles of the thigh. Furthermore, the 
 limb always decreases somewhat in size from disuse ; hence a 
 bandage which fits perfectly when first applied soon becomes so 
 large that it fails to grip the leg as tightly as the requirements of 
 the case demand. 
 
 A plaster of Paris bandage, therefore, cannot be recommended 
 for the first dressing, but it is often useful after two weeks have 
 elapsed, by which time the fragments have united firmly enough to 
 retain their proper position if the limb be kept quiet. A plaster of 
 Paris banrbige answers the requirements, since when it is applied 
 the patient is unable to exert the muscles of the thigh, and hence 
 cannot displace the fragments ; yet he can rise from his bed and 
 remain up the entire day, thus avoiding in part at least the drear! 
 ness of his enforced confinement. 
 
 We ca'n, therefore, in many cases remove the splint which has 
 been originally applied, between two and three weeks after the 
 accident, and replace it by a plaster of Paris dressing. The mode 
 of application of this dressing is thu- described by the late Dr. 
 Hodgen, the eminent surgeon, of St. Louis : 
 
 " The first point is to secure a thorough extension of the limb 
 while the plaster is being put on and is hardening. If the lower 
 
FRACTURES OF THE THIGH-BONE. 
 
 ni 
 
 fragment can in some way be drawn down and held there while the 
 plaster sets, the limb will then be incased firmly, and the patient 
 may sit up and move about upon crutches without disturbing it. 
 
 To secure this extension, prepare an ordinary table by boring 
 through its end a hole two inches in diameter, through which a bar 
 may pass, extending two feet above the surface of the table, 
 reaching the floor below and made fast to a cross-piece between the 
 lc"^s. From the top of this bar another one passes to the other end 
 of the table and rests on a bar like the first, or upon a box or other 
 support. One or two hours before the main dressing is applied, a 
 plaster of Paris bandage should be put on the foot and leg up to the 
 calf, the surface of the foot and leg being first covered with cotton 
 batting or soft cotton cloth, making it thicker over the ankle than 
 above or below. When this dressing is hard a bandage can be tied 
 around it and attached below the sole of the foot to a rope which 
 passes through pulleys. A very strong force can thus be applied to 
 draw the limb down without cutting or improperly compressing it. 
 
 Having now the table prepared, a hard plaster splint on the 
 foot and lower part of the leg, and bandages filled with plaster in 
 readiness, you are prepared to apply the dressing. Place the 
 patient upon his back on the table under the horizontal bar, with 
 the upright bar or stanchion between his thighs pressing up by the 
 side of the injured limb. This upright should be well covered with 
 soft cloth, and its object is to hold back the body and upper part of 
 the thigh against the force drawing the limb downward. Raise the 
 hips from the table by means of a broad bandage passing beneath 
 them and tied to the bar above. Cover the whole limb with soft 
 flannel or a piece of woolen blanket, and fit it as neatly as possible. 
 Then give the patient ether to relax the muscles and apply the force 
 to the rope attached to the lower part of the leg until the leg is as 
 long as the sound one. 
 
 Having soaked the bandages (already filled with dry plaster 
 before rolling them) two or three minutes in water, wind them on 
 the limb smoothly but not tightly, in small successive thicknesses, 
 sprinkling dry plaster on the surface frequently and smoothing it 
 with the hand. 
 
 " When the limb is well encased, allow the patient to remain in 
 the same position for twenty or thirty minutes, until the plaster 
 sets, then put him in bed and keep him there three or four days. 
 After that he can move about on crutches. 
 
 
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778 
 
 SURGICAL disi;asi:s. 
 
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 " This (dressing must be carefully xvatc/icd, lest it be too tii:;ht. 
 If there is much pain, and if the toes become dark and lose tlicir 
 feeling, it must be cut off. If it becomes too loose a fresh diii.' 
 must be put on. " 
 
 The fact that there is such a variety of dressings employed for 
 the treatment of fractures of the thigh, indicates the difficulty which 
 surgeons experience in securing a healing of the bone without 
 shortening of the limb. Indeed, it must be repeated here that 
 some sJiorteniiig of the limb must be expeeted. No apparatus has 
 been devised which can be relied upon to secure a perfect result, 
 and no experienced surgeon will ever promise to treat the fracture 
 so as to make the broken limb as long as it was before. 
 
 Fractures of the Neck of the Thigh-bone. 
 
 i fi.-yg 
 
 
 Fractures occur at this part of the thigh-bone chiefly in chlerly 
 people. There are several reasons for this. In the first place the 
 bones generally are more brittle in advanced life than in youth and 
 middle age. The mineral matter in the bone is present in lari^'er 
 proportion, while the animal matter — the part which gives tiulxn': 
 its elasticity — is decreased in quantity. For these reasons all the 
 bones become more brittle and are more readily broken in advanced 
 life. 
 
 There is another reason why fractures occur at the neck of the 
 thigh-bone more frequently in elderly people than in younger jiei- 
 sons. This reason is that the neck of the bone changes its position 
 with regard to the shaft. In young persons the neck forms an 
 oblique angle with the shaft, while in old age the nock is low- 
 ered so that it makes almost a right angle with the body o{ the 
 bone. 
 
 Fracture of the neck of the thigh-bone occurs all ' always 
 as the result of a fall upon the hip or upon ■ 1 jes. Yet in some 
 cases the bone is fractured by force appl iie feet; thu 't may 
 
 result from simply stepping somewhat Ilea ^lown a stair, .iideed 
 it is surprising to observe what slight causes nave bei n known to pro- 
 duce this fracture in elderly people. Tripping u, '\\ the carpet or 
 getting the foot entangled in the bed-clothes have been observed to 
 occasion such a fracture. 
 
FRACTURES OK TllK NLCK OF TlIK TllKill-liONE. 
 
 779 
 
 Whenever an elderly person experiences a sharp pain, accom- 
 panied witli himeness or inability to walk, after such a trifling' acci- 
 dent , we should suspect the existence of this fracture and examine 
 the hip. 
 
 This fracture is very often impacted; that is the lower fragment 
 is driven firmly into the upper. It is important to distinguish 
 whether or not impaction has occurred, since the treatment will 
 vary somcwliat in different cases. 
 
 Several signs are present in both impacted and non-impacted 
 fractures. These are pain and swelling around the hip joint; turn- 
 ing out of the foot, the toes being directed away from the opposite 
 leg; shortening of the limb, flattening of the hip, the bony promi- 
 nence being less distinct than on the opposite side ; loss of power 
 tu use the leg. 
 
 In addition, we may remember that the fracture usually orcu's 
 from a blow upon the hip, or from some sudden wrenching of the 
 limb. 
 
 There are two signs whereby we can distinguish anon-impacted 
 from an impacted fracture of the neck of the thigh-bone. These are: 
 
 mrst — An unnatural mobility of the thigh. This, of course, 
 results from the fact that the two fragments are entirely separate, 
 so that the movements of the limb are not restricted by the barriers 
 natural to the hip-joint. 
 
 Second — A grating sensation can often be felt when the thigh 
 is moved around somewhat forcibly. 
 
 If the fracture be impacted, on the other hand, the movements 
 of the limb will be less and not more than natural, and no grating 
 sensation can be felt. 
 
 iMactures of the neck of the thigh-bone arc sometimes con- 
 founded with dislocation of the hip. It is important that we 
 recognize the difference at once, since a dislocation of the hip can be 
 reduced and the patient be about again in a few days, while a frac- 
 ture at the neck of the bone rarely heals completely in an elderly 
 person. 
 
 The following points of distinction will enable any one to 
 recognize the difference between a dislocation of the hip and a 
 non-impacted fracture of the neck of the bone. 
 
 First — In dislocation of the hip there is no grating sensation ; 
 in fracture there is. 
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 SURGICAL DISEASES. 
 
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 Second — In dislocation the bone cannot be replaced except 
 with difficuhy ; in fractu"c the limb can be readily straif^htencd, hut 
 docs not retain its natural position. 
 
 Third — In dislocations the foot is usually turned inward, tlic 
 toes toward the opposite leg ; in fractures the toes arc usually tunicd 
 outward. 
 
 Fourth — In dislocations the limb remains fixed in one position, 
 no motion being obfainable at the h o-joint ; in fractures, on the 
 other hand, the thigh can be moved by a second person. 
 
 Treatment. — The treatment of fractures of the neck of the 
 thigh-bone in elderly persons is usually unsatisfactory, and sonic- 
 times quite useless. The result depends rather upon the condition 
 of the individual than upon the particular dressing used. 
 
 Perfect recovery never takes place ; in some cases, union 
 occurs by means of a membrane or ligament, and not of true bone. 
 In a considerable number of cases the fragments do not unite at 
 all. 
 
 The limb is always perceptibly shortened, and the individual 
 is often permanently lame. Sometimes the shock rauscd bv tlie 
 ■'injury results in prostration of the patient, and causes death in a 
 r^w months. 
 
 The treatment varies accoiding as the fracture is or is not 
 impacted. This point sho dd, therefore, be decided before the leg 
 has been roughly moved or examined. 
 
 If the fracture be impacted, nothing further is necessary than 
 perfect repose for the limb ; the patient should be kept upon his 
 back in bed. 
 
 If the fracture be not impacted, the treatment should aim at 
 the accomplishment of three objects : 
 
 First, the ends of the bone should be replaced ; the lower frag- 
 ment should be drawn downward, to prevent shortening ; the limb 
 must be kept perfectly quiet. 
 
 The bone can usually be set without much difficulty. One 
 person grasps the hip and pulls strongly toward the htuid, while an 
 assistant seizes the leg and draws it forcibly toward the foot of the 
 bed. It will sometimes happen that the part, rcii'ain almost in 
 position even after the force is rela.xed ; in most case however, 
 the displacement of the broken ends takes place again so soon as 
 thf pulling is discontinued. It is therefore necessary to apply the 
 dressing while the extension of the limb is still maintained. 
 
 -ll 
 
laced except 
 i^htened, hut 
 
 .1 inward, tlie 
 isually turned 
 
 one position, 
 ctures, on the 
 on. 
 
 c neck of the 
 ry. and sonic- 
 thc condition 
 ;cd. 
 
 cases, union 
 t of true bone. 
 3 not unite at 
 
 the individual 
 
 caused by the 
 
 ises death in a 
 
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 •c is or is not 
 
 before the leg 
 
 necessary th;ui 
 kept upon his 
 
 should aim at 
 
 the lower frag- 
 ung ; the limb 
 
 ifficulty. One 
 head, while an 
 the uM>t of the 
 nain almost in 
 asL: , however, 
 lain so soon ;'^ 
 ry to apply the 
 tained. 
 
 FRACTURES JUST AHOVE THE KNEE. 
 
 78 I 
 
 The simplest dressing consist? in a strip of board, three or 
 four inclies wide, a;,d long enough 'o extend from the lower ribs to 
 ;i point several inches beyond the sole of the foot. A cross piece 
 should be fastened to the lower end, in order to keep the splint 
 ui)riglit. 
 
 This splint is to be well padded and applied to the limb while 
 the patient lies upon his back in bed and the assistants hold the 
 limb HI position. The splint is firmly bound to the limb by a 
 bandage which passes around the waist and hips, and by a second 
 bandage, narrower than the first, which extends from the foot to 
 the thigh. 
 
 If the limb be very muscular, it will be necessary to use one 
 of the splints described in the previous chapter for fractures of the 
 shaft of the thigh-bone. In most cases, however, it will not be 
 advisable to torture the patient with dressings which compel him 
 to remain upon his back in one position for a month, for the most 
 that we can hope for is a serviceable and not a perfect union of the 
 fragments; there will probably be shortening and permanent lame- 
 ness; moreover, the patient is usually old and feeble, and his 
 health will be seriously impaired by the confinement and the rigor- 
 ous dressing necessary to the most perfect result. It will therefore 
 be better, in treating fractures of the neck of the thigh-bone in 
 aged and inf'rm persons, to apply the splint already indicated for a 
 couple of weeks, ai\d then to remove it and trust to simple repose 
 to effect the healing. Indeed in many instances it becomes abso- 
 lutely necessary to relieve the patient from the burden of a dress- 
 ing, and to give him some air and recreation, in order to save his 
 life. The exact dressing, the time during which it is to be applied, 
 must be in every case determined by the circumstances and by the 
 L'eneral condition of the individual. 
 
 Fractnres Just Above the Knee. 
 
 The shpft of the thigh-bone may be broken across just above 
 the knee ; in this case the treatment and the dressings required arc 
 the same as those needed for the treatment of fractures in the 
 middle portion of the bone. 
 
 The bone may, however, be broken lengthwise just above the 
 knee ; that is, one of the bony prominences which enter into the 
 
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782 
 
 SURGICAL DISEASES. 
 
 formation of the knee-joint may be split off. Sometimes, indeed, 
 the end of the bone is fractured into several pieces. 
 
 Siffns. — Fractures of the thigh-bone near the knee can usually 
 be recognized without difficulty, since the bone is in this j)ait 
 covered Avith but little flesh. It is usually easy to feci the ridges 
 made by the edges of the fragments, and by moving these pieces 
 we can readily detect a grating sensation. If the fracture be trans- 
 verse and just above the joint, there may be great similarity to a 
 dislocation of the knee ; but in the latter case motion is very much 
 impaired, while if the injury be a fracture there is even more than 
 the natural amount of movement. 
 
 The severity of the injury depends largely upon wnether the 
 fracture extends into the knee-joint. If this occur, there will prob- 
 ably be permanent stiffness of the joint ; in fact the bone may be 
 so extensively damaged that amputation of the leg may be neces- 
 sary. If the knee-joint escape injury, the fracture usually heals in 
 two months, with possibly a slight degree of shortening. We can 
 usually recognize an extension of the fracture into the joint by the 
 fact that the knee becomes enormously swollen and that movement 
 of it causes great pain in the joint. 
 
 Treatment, — If one of the bony prominences on the side of 
 the knee be broken off, the bone can be set by simply straight- 
 ening the limb. The dressing should consist of two splints, one on 
 either side, made of siding, and long enough to extend from the 
 ankle to the hip. These should be carefully padded and applied 
 by means of a firm bandage. This bandage should not cover the 
 knee-joint, for this joint will probably become much swollen and 
 very painful, and will require the application of hot, moist cloths to 
 allay the inflammation which will arise. 
 
 If there be any laceration of the limb, it will be advisable not 
 to employ the splints mentioned, but to place the leg in a box 
 made for the purpose long enough to reach from tlie foot to the 
 thigh and well padded. In tliis way tJie wounded surface and the 
 inflamed knee-joint are readily accessible to the eye and hand of 
 the attendant. 
 
 So soon as the bones seem to have united, the knee should be 
 gently bent a little every day, so as to avoid the stiffness of the joint 
 which is very apt to ensue in these cases. Care must, however, be 
 
FRACTURES OF THE KNEE-PAN. 
 
 783 
 
 taken not to break the bone again during the efforts at bending the 
 knee. 
 
 If the part of the bone which enters into the joint be seriously 
 damaged, permanent stiffness of the joint is inevitable. In this 
 case the leg should be dressed at a slight angle, since the limb will 
 be more useful if the stiffened knee be slightly bent than if it be 
 perfectly straight. The dressing should consist of a " double 
 inclined plane " already described, the angle situated under the 
 knee being raised two or three inches above the ends of the 
 splint. 
 
 In nearly all cases of injury to the bones in the vicinity of the 
 knee joint, there occurs considerable swelling and inflammation in 
 the joint itself. This must be treated by the application of hot, 
 moist cloths. 
 
 i'l-l 
 
 jn the side of 
 
 Fractures of the Enee-pan. 
 
 The knee-pan h a somewhat elliptical-shaped bone which lies 
 on the front of the knee. It is not bound directly to any other 
 bone ; indeed it is really a part of the large muscle constituting the 
 front of the thigh. This muscle runs over the front of the knee 
 and is attached to a point of the leg-bone just beneath the knee. 
 When the muscle contracts the leg is straightened. The knee-pan 
 is located at just that part of the muscle which is stretched over the 
 end of the thigh-bone, when the leg is bent ; the object of this little 
 bone is, therefore, to endure the friction which is inevitable when the 
 log is bent. The muscle is attached to the upper edge of this bone, 
 the lower edge being firmly bound by a ligament to the front of the 
 leg-bone. 
 
 It is necessary to understand the anatomy of this part in order 
 to ap[)rcciate the ways in which it can be fractured as well as the 
 difficulty in securing a union of the fragments. 
 
 The bone is most frequently broken by direct violence such as 
 occurs when a person falls forcibly upon the knee. In some cases, 
 however, muscular contraction alone is sufficient to break the bone ; 
 such instances occur usually during violent efforts, such as are 
 made in jumping or in kicking. 
 
 The usual fracture is a transverse one, running from side to 
 side of the knee-pan. Sometimes the bone is broken vertically, 
 
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784 
 
 SURGICAL DISEASES. 
 
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 and in some cases a blow upon it shatters the knee-pan into sev- 
 eral pieces. 
 
 Siffus. — This fracture is usually recognized without difficultN- ; 
 one can almost always feci the fragments, unless the limb be inucli 
 swollen. If the fracture be transverse, there can be felt a distinct 
 crack or fissure, which may be half an inch wide, running across 
 the front of the knee. In this case there will probably be no 
 grating sensation. If the fracture be vertically, or if the bone be 
 broken into several pieces, we can often detect a grating sensation 
 when the leg is straightened and bent. 
 
 A characteristic symptom of this fracture is the inabilitv of 
 the patient to straighten the leg ; if the leg be straightened for 
 him by another person, he can easily bend it, but when it is bent 
 he is unable to straighten it. The reason for this is evident wiien 
 we remember what has been said about the anatomy of the parts. 
 The leg is straightened by the contraction o( the muscle which is 
 attached to the upper edge of the knee-pan. If this bone be broken, 
 the upper fragment is drawn away by the muscle of the thigli, witii- 
 out moving the lower fragment or the leg to which it is attached. 
 
 Treatment. — The treatment of a fractured knee-pan is ex- 
 tremely troublesome, and the results are usually unsatisfactory, 
 The difficulty lies in the fact that the two fragments are rarely 
 united by bone, but are simply joined together by a band or hi,;a- 
 ment; the result is that the length of the limb is increased, and 
 hence the leg can not be managed with the same accuracy and 
 facility. 
 
 The most favorable of these fractures for treatment is the ver- 
 tical one. To treat this fracture, it is only necessary to keep the 
 leg t][uiet and straight. During the first (cw days there will prob- 
 ably be some swelling of the knee-joint, which should be treated 
 by the application of hot cloths. After this swelling has subsided, 
 the limb should be placed upon a straight splint of wood which runs 
 from the ankle to the middle of the thigh. After this is well pad- 
 ded it is attached to the under surface of the leg by means of band- 
 ages placed above and below the knee. The healing process re- 
 quires six to eight weeks. 
 
 If it be necessary that the patient be on his feet, the lei; may 
 be enveloped in a plaster of Paris dressing, which shall extend from 
 the ankle to the middle of the thigh. This will serve to keep the 
 
accuracy aiicl 
 
 FRACTURES OF THE KNEE-PAN. 
 
 785 
 
 kiice at rest. The patient should not place the foot to the ground, 
 but should use crutches. 
 
 Transverse fracture of the knee-pan is an extremely trouble- 
 some one, because the frajijments are separated and can be main- 
 tained in contact only with difficulty. Many drcssiuL^s have been 
 ileviscd for the treatment of this fracture ; the simplest and one of 
 the most effective is that of Dr. Hamilton. 
 
 The difficulty in keeping the fragments together arises, as has 
 been said, from the contraction of the large muscles at the front of 
 the thigh Now, if we can relax these muscles, we can prevent, in 
 a great measure, their effect in drawing the upper fragment of the 
 knee-pan away from the lower. When the thigh is bent at an angle 
 witli the trunk, these muscles are relaxed. Dr Hamilton, there- 
 fore, advises that the patient's body be supported in bed by pillows 
 pkiccd beiiind the back, while the limb is rested upon an inclined 
 plane, so that the foot is raised ten or twelve inches above the bed. 
 He makes a splint composed of three pieces of board. The first 
 of these pieces supports the leg, and is long enough to reach from 
 the hip to the sole of the foot. This piece is ten inches wide at the 
 knee. 
 
 The upper end of this piece is connected by a hinge to a second 
 piece of board, which rests upon the bed; this piece is as broad as 
 the first and several inches longer. A third piece is joined by 
 hinges with the second, and folds upward, so as to meet the first piece 
 and extend above the toes of the foot. This third piece is provi- 
 ded with pegs, which project from the edges ; by means of these 
 pcLjs and of hooks attached to the first piece, just under the foot, 
 the limb can be rested at any desired height. 
 
 The splint, therefore, when complete, makes a triangle, the base 
 of which is prolonged so as to form a support for the foot. 
 
 A tlee[) notch is cut in either side of the first sj)lint at a point 
 four or Cwc inches below the knee. This splint is then thickly 
 p;ulded with cotton, especially under the knee. The limb is then 
 phiced upon the inclined plane, and the foot is fastened to the splint 
 by means of a bantlage carried around the ankle. Another bandage 
 i-< then applied in the notch, and is carried from this point above 
 the up[)er fragment of the knee-pan ; it is then brought through the 
 notch (in the opposite side, under the splint, and through the first 
 notch on the other side. The bandage is carried around the leg 
 and through the notches five or six times, being brought lower upon 
 
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786 
 
 SURGICAL DISEASES. 
 
 the knee at each successive turn. After the entire knee is covered 
 this bandajTo is pinned, and a second one is applied around the 
 entire limb from the ankle up to the hip. 
 
 Another dressing is made on essentially the same principle ; 
 instead of the bandage, which encircles the limb through ihc 
 notches, strong clastic bands are used. These arc attached to pc;:;s 
 driven in the side of the splint. One of these bands is brought 
 above the upper fragment, and the other below the lower fragment, 
 the tv/o bands crossing each other at the knee like a pair of sus- 
 penders on a man's back. The advantage of this dressing is that 
 the friigmcnts are constantly pressed together by the elasticity of 
 the rubber, while the knee is exposed so that we may readily 
 examine the injured knee-pan without removing the dressing or 
 disturbing the limb. In Hamilton's dressing, on the other hand, 
 the band;).jc which is passed through the notches does not bring 
 the fragments together with the same certainty, and is apt to 
 become loose in a few days ; moreover the condition of the knee- 
 pan cannot be examined without removing the bandage. The dis- 
 advantage of the rubber consists in the liability to chafing of the 
 skin under the bands ; this can be avoided by placing cotton 
 between the skin and the rubber. 
 
 The fragments usually unite by the formation of a ligament 
 between them. The result may be considered very good if the 
 fragments are not separated more than a quarter or even half an 
 inch. If this be the case, the patient will be able to walk without 
 limping, though he will experience at first some awkwardness in 
 advancing the foot in walking. 
 
 After a fracture of the knee-pan the patient cannot be too 
 careful in avoiding any strain upon the knee for months. It will 
 be well for him to wear a firm elastic band, which shall encircle the 
 leg for three inches above and below the knee, leaving a slit large 
 enough for the knee-pan to project through it. 
 
 There will be, of course, some stiffness of the knee, resulting 
 from the enforced inactivity of the joint for six or eight weeks. 
 This may be overcome by gently bending tbe leg, beginning with 
 a little exercise for fifteen minutes every day and gradually increas- 
 ing both the extent and duration of the motion. 
 
 A star-shaped fracture of the knee-pan — usually the jcsult of 
 a blow or a fall upon the knee — requires special treatment in dit- 
 ferent cases. In general, it becomes necessary to place the leg 
 
dually iiicrcas- 
 
 FRACTURES OF THE FIBULA. 
 
 787 
 
 upon a splint in the shape of the inclined plane already described. 
 Ill fact, Dr. Hamilton's dressing for a transverse fracture of the 
 knee-pan, which has been already described, answers very well for 
 many cases of star-shaped fracture. 
 
 Fracture of the Leg. 
 
 In anatomy the word leg designates that part of the lower ex- 
 tremity which is situated between the knee and the ankle, in dis- 
 tinction from the thigh, which extends from the hip to the knee. 
 
 The leg contains two bones ; the larger is situated on the inner 
 side, and forms the prominent edge which we call the "shin." 
 This bone is called the tibia, and constitutes the more important 
 part of the support of the body. It constitutes the greater part 
 of the ankle-joint, the other bone of the leg forming only a small 
 projection at the joint ; the tibia is the only one of the two bones 
 which enters into the formation of the knee-joint. 
 
 The other bone of the leg, called i\\c fibula, is a slender bone 
 lying on the outer side of the limb ; it is covered with flesh except 
 at its lower end, where it constitutes the bony prominence on the 
 outer side of the ankle. 
 
 Either of these bones may be broken while the other remains 
 uninjured, or both are fractured at the same time. 
 
 Fractures of the Fibula. 
 
 These are the least serious fractures of the leg ; they arc often 
 caused by comparatively slight violence, which does no injury to 
 the flesh ; and inasmuch as the other bone of the leg, the tibia, 
 constitutes the greater part of its strength, a fracture of the fibula 
 gives but little trouble in treatment, and heals without deformity 
 or loss of power. 
 
 One of the most common fractures of the fibula, is that which 
 surgeons call " Pott's fracture ; " this consists of a break in the 
 bone about two or three inches above the ankle-joint. In some 
 cases the ligament which binds this bone to the heel is torn 
 away. 
 
 Pott's fracture is accompanied, in most cases, by a character- 
 istic deformity ; the foot is turned outward. At first sight the 
 
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788 
 
 SURGICAL DISEASES. 
 
 patient seems to have suffered a serious injury which may cripple 
 him for life ; but it really constitutes one of the simplest and must 
 easily managed fractures. By running the fingers along the bonv 
 prominence at the other side of the ankle, we can readily detect 
 the rough edges of the broken bone, and can usually feel a gratiiiij 
 sensation when we press the thumbs upon the two fragments. 
 
 In some cases the inner bony prominence of the ankle — the 
 tip of the tibia — is also broken off; in this case the foot is usuallv 
 turned inward. This constitutes a more serious injury than a 
 simple fracture of the fibula alone. 
 
 Treatment. — When the fibula only is fractured, the treat- 
 ment is quite simple and easily carried out. The tibia supports the 
 leg and maintains its length, so that the only object of treatment is 
 to straighten the limb by pulling the foot inward to its natural 
 position, and to keep the leg quiet in this position. 
 
 The setting of the bone is accomplished by simply drawing the 
 foot downward to its proper position, when the fragments fall into 
 place. To hold the leg in this position, several dressings arc em- 
 ployed. The simplest is made by rolling up a blanket from cither 
 end, so that two rolls joined in the middle are formed. The lct( is 
 then placed in the space between these two rolls, a bunch of cotton 
 being put under the ankle so as to keep the foot raised to the 
 proper level. Two strips of cloth or pieces of clothes-line arc then 
 tied around the blanket so as to press firmly upon the limb. The 
 injured member, encased in a blanket, is then rested upon a pihow, 
 Care should be taken that the leg preserves its proper position, 
 that is that the foot is not allowed to fall outward ; other than this, 
 no precautions are required. 
 
 The bone is healed in about four weeks, though the patient 
 should be very careful in using the limb for two or three weeks 
 longer. 
 
 The fibula is sometimes broken at its upper part near the knee, 
 but as this rarely happens except in connection with a fracture of 
 the tibia also, directions for treatment will be given in discussing 
 this fracture. 
 
 Fractures of the Tibia. 
 
 In most cases the violence which fractures the tibia is sufficient 
 also to cause a break of the fibula as well. There are instances, 
 however, in which the tibia is broken by direct violence, such as a 
 
drawing the 
 ents fall into 
 
 FRACTURES OF THE TIBIA. 
 
 789 
 
 blow on the shin-bone. If the fibula remains unbroken, it acts as 
 a splint in preserving the form and length of the leg. If the fracture 
 of the tibia be oblique, the fragments usually rise one over the 
 other and the foot is frequently turned inward. In such a case 
 tJK object of treatment must include the restoration of the foot to 
 its proper position. If the fracture be transverse, that is, square 
 across the bone, there is frequently no shortening and no deformity. 
 
 Treatiiient. — For the first few days it is usually necessary 
 to apply hot fomentations, such as cloths saturated with hot water. 
 These may be continued until the swelling has subsided. Mean- 
 while the limb may be placed in a fracture-box. This box consists 
 of four pieces; one piece, which should be about an inch broader 
 than the thickest part of the calf, lies under the leg. To the lower 
 extremity of this there is fastened an upright piece long enough to 
 project above the toes of the injured foot ; on either side of the first 
 piece there is fastened by means of hinges a side piece which ex- 
 tends above the top of the leg. 
 
 This box may be thoroughly cushioned with cotton batting, or 
 filled with bran, while the side pieces which are fastened with 
 hinges are laid flat upon the bed. The limb is then placed upon 
 the cotton or upon the bran, and bound to the upright foot piece 
 by means of a bandage. The box and the foot attached to it 
 are then drawn toward the foot of the bed with sufficient force 
 to straighten the limb and to reduce any deformity which may 
 be present. The side pieces are then raised so as to enclose 
 the limb, the bran or cotton being thickly packed above the 
 bony prominences of the ankle so as to prevent the leg from 
 shortening. Two or three bandages are then tied around the 
 entire box so as to exert pressure upon the cotton padding sur- 
 rounding the limb. The box containing the injured limb is then 
 placed upon a pillow in a position most comfortable to the 
 patient. 
 
 If the fracture be oblique and there be consequently a decided 
 tendency to shortening of the broken leg, it will be advisable to 
 attach a weight to the b 'X so as to keep the limb constantly 
 extended. This weight should be fastened to the foot piece by 
 means of a rope running over a pulley. In this case the foot 
 should be fastened to the upright piece at the foot of the box by 
 means of strips of adhesive plaster. 
 
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790 
 
 SURGICAI, DISEASES. 
 
 In every case ,in which a fracture-box is employed, extreme 
 care must be taken to see that the broken ends are kept accurately 
 in position. The movements of the patient's body frequently 
 result in displacement of the broken ends, so that unless the limb 
 is carefully watched, the bone may heal with some deformity. In 
 fact the fracture-box is not the most satisfactory dressing for iiie.x- 
 pericnced hands to use. It will be better for such to empKiy a 
 starch or plaster of Paris bandage in the way which has i)eeii 
 already described, for if this bandage is once properly applietl, it 
 remains in position and prevents subsequent displacements of the 
 fragments such as usually occur under the use of a fracturc-bo.x. 
 
 If there be merely a transverse fracture of the tibia witliout 
 displacement of the broken ends or shortening of the leg, the 
 dressing which has already been described in connection with 
 simple fractures of the fibula will be sufficient. A blanket folded 
 from either end so as to make two rolls between which the limb 
 rests is placed under the leg ; two bandages arc then tied around 
 the blanket near either end so as to hold the limb firmly between 
 the rolls. 
 
 Fractures of both Bones of the Leg. 
 
 « 'i 
 
 These are the most serious and troublesome of ali tractures of 
 the leg, especially when accompanied with wounds of the skin, as 
 is so often the case. Because when both bones are broken there 
 remains nothing to preserve the form and the length of the limb; 
 hence the dressing must be made to supply these requisites. 
 
 Fractures of both bones of the leg may be divided for conven- 
 ience into two classes : simple and compound ; that is, tliose 
 which are not, and those which arc accompanied with wounds of 
 the flesh communicating with the break in the bone. This distinc- 
 tion is an item of much consequence in the treatment. 
 
 The most frequent variety of fractures involving both bones of 
 the leg, is that in which the tibia is broken in its lower part and 
 the fibula at the upper part near the knee. In every case in which 
 the tibia is found to be fractured near the ankle, a careful examina- 
 tion of the fibula at its upper part should be made ; for in many 
 cases the fracture of the fibula in this part is overlooked by inex- 
 perienced persons. 
 
■h I- 
 
 M<ACTUKLS OF HUTU HONES OF TlIK LEG. 
 
 791 
 
 Trcatnient, — The treatment of simple fractures — that is, 
 those in which there is no wound of the skin — consists in rcstor- 
 iii<r the limb to its natural len^'th and contour, and in holding the 
 bones in position by means of a dressing. There is rarely any 
 difficulty in setting the bones ; the patient is iilaced upon his back, 
 and by gently pulling upon the foot, we can usually restore the 
 broken fragments to their natural position. 
 
 It is, however, by no means so simple a matter to keep the 
 fragments in position ; for the powerful muscles attached to the 
 bones of the leg are constantly tending to displace the broken ends, 
 as well as to shorten the leg. The dressing must, therefore, be 
 applied not only with great care, but also with an accurate knowl- 
 cd<'e (jf the requirements of the case. 
 
 There are numerous dressings employed in the treatment of 
 fractures of the leg ; each of these has certain advantages in cer- 
 tain cases. One frequently applied is the plaster of Paris bandage ; 
 leather, starch bandage, and the fracture-box are frequently used. 
 
 Probably the most generally useful of all dressings for fractures 
 of the leg is that made of plaster of Paris. This can often be 
 applied immediately after the injury, though it is better to wait 
 until the swelling, which almost invariably occurs, has been reduced 
 by hot-water dressings. If the bandage be applied before the 
 swelling has begun — that is, immediately after the receipt of the 
 injury — the pressure of the dressing will probably cause serious 
 injury and perhaps mortification of the tissues. Indeed, in every 
 case in which a plaster of Paris dressing is applied to the leg, the 
 circulation of the limb should be carefully watched ; this can be 
 observed by inspecting the condition of the toes and of the foot ; 
 wlicncvcr this part of the limb becomes cold, blue and numb, we 
 may know that the circulation is impeded and that tlie dressing is 
 too tight. In such a case the bandage should be at once removed 
 and re-applied more loosely ; the failure to do this may result in 
 mortification (gangrene) of the flesh. 
 
 The plaster of Paris dressing may be applied to the leg in the 
 following way : 
 
 Some loose cloth, such as an old sheet, should be cut so as to 
 make seven or eight bandages, each about nine feet long and three 
 inches wide. These bandages, unrolled, are thickly dusted over 
 with plaster of Paris, which is rubbed into the meshes of the cloth. 
 The bandages are then rolled up and laid aside for subsequent use. 
 
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793 
 
 SURGICAL DISKASKS. 
 
 The limb is then enveloped with cotton batting, from tin; toes 
 to the lower part of the thigh. This may be held in place by a lew 
 coarse stitches. 
 
 The bandages containing the dry plaster of Paris arc then placed 
 for about three minutes in lukewarm water. One of these is then 
 applied to the limb, beginning with the foot, just above the toes. 
 It is wound smoothly over the cotton batting as far as the knee. A 
 second bandage is then applied over the first, a fresh roll bcinj.; 
 placed in the water to soak during the application of the second to 
 the limb. This is done so that the bandages shall not lie in the 
 water more than three or four minutes ; for if they do remain in ,i 
 longer time the plaster becomes brittle and " crumbly," so that it 
 will not set firmly enough to make a stiff dressing. 
 
 Three or four thicknesses should be applied to the limb. After 
 the last bandage is applied, a little plaster mi.xed with water, so as to 
 have the consistency of cream, should be laid on with the hand and 
 plastered smoothly over the limb. 
 
 Such a dressing becomes hard in half or three-quarters of an 
 hour, though it may not dry entirely for several hours. Durini; the 
 first half-hour or hour — that is, until the plaster becomes sufficiently 
 hard to retain the limb in position — the leg should be heiil by an 
 assistant. This is a very important part of the process, since if it 
 be carelessly done, the fragments may become displaced before the 
 plaster becomes hard, as a result of which the limb may heal with 
 some deformity. The assistant who holds the limb during the hard- 
 ening of the plaster should, therefore, be carefully instructed to pull 
 gently upon the foot, so as to preserve the natural length of the 
 limb, while, at the same time, the calf is supported so that the 
 broken ends shall remain on the same level. This is a somewhat 
 tedious task, which should be entrusted only to a conscientious 
 assistant. 
 
 After the plaster has become thoroughly hardened — say after 
 ten or twelve hours — the bandage maybe cut open by passini; a 
 pair of strong shears along the front of the leg. The edges of the 
 plaster may then be turned upward a little, so that they shall not 
 scratch the skin ; and some cotton should be tucked under these 
 edges to protect the limb. 
 
 After a few days it will usually be found that the limb has 
 shrunken somewhat, so that the bandage seems a little large ; in 
 this case it may be tightened by applying an ordinary muslin band- 
 
KKACTUKKS OK BOTH HONKS OK TIIK \.KC,. 
 
 79i 
 
 age around it from the foot upward, or by simply tying two strips, 
 uiic at the ankle and the other just below the knee. 
 
 In every case in which plaster of Paris dressin^^s are applied, it 
 should not be forjjjotlen that damage can be inflictetl by inij)airment 
 of the circulation ; the caution already given rcg.irtling ihe condition 
 of the toes must be observed. 
 
 Another form of plaster splint is the so-called " Bavarian " 
 dressing, which was used extensively in the I'ranco-I'russian war. 
 This is made out of some soft thick cloth, such as flannel or cheese 
 cloth ; two pieces are cut from this cloth long enough to cover the 
 injured lind), and wide enough to surround the leg entirely ; the 
 outer piece being one or two inches broader than the inner one. 
 These two pieces are sewed together along their entire length with 
 two seams about half an inch apart. 
 
 The injured leg is then laid upon the cloth, so that the scams 
 lie under the middle of the lindj ; the inner piece is then brought 
 over the limb so that its edges meet in front, where they are 
 fastened by means of a few cftarsc stitches. The limb is thus envel- 
 oped in a garment which should fit it closely like a stocking. The 
 edges along the seam in front are trimmed off even with the sur- 
 face. 
 
 The plaster of Paris is mixed witli water so as to have the 
 consistency of cream ; it is then spread upon the outer piece of the 
 bandage, which has not yet been applied to tlie lind). The plaster 
 should be about half an inch thick, and after it has been evenly 
 spread, the outer piece containing it is brought over the limb and 
 applied firmly and smoothly. 
 
 The dressing thus consists of a layer of plaster between two 
 thicknesses of cloth ; the plaster docs not extend entirely around 
 the limb, since the double seam at the back leaves a space half an 
 inch broad containing no plaster. When the plaster of Paris has 
 become hardened, the stitches along the front of the inner layer arc 
 cut and the dressing can be opened, since the space at the back 
 between the two seams permits a hinge-like motion. Tlu; dressing, 
 when applied, should be kept in position by an ordinary bandage. 
 
 The advantages of this dressing are several ; it is easy of 
 application, especially advantageous for an inexperienced person ; 
 the hinge at the back not only permits the ready removal of the 
 dressing, but also allows the splint to be loosened or tightened 
 according as the swelling or shrinking of the limb requires. 
 
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 794 
 
 SUKtilCAl, DISKASKS. 
 
 A plasl'.r of Paris (licssini; made in (Ik- usual way, l)y i; 
 
 ic use 
 
 of !).uulat;(.'s saturated with tlic piaster, sonictiincs rrciuins tiim- 
 luiu!; .IS llu- limb slniulvs. \\y simply tiillini; oK IklII' an incli 
 
 or 
 
 an iiuli iVntn i itlu r vAi'c aloiu- the front of tin- \r 
 
 \\v can icdiii 
 
 its si/a> sullicicnti)' to priiuit it to hi' tii^litly .ipplicd, even aftci 
 limb 1 
 
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 »as slniink 
 
 ken 
 
 consiiieraltU- 
 
 Ti'4'afnirnt of Compoumf Fi'ovlm'cs, — A (onipoiuK 
 fiaotiMf — thai is, one eoinplieated with a wound ■ f the lU 
 oftt'n presents eertain diflieuhies in tri-atinent, for tin- (bcssini; 
 aK\ ays be so iua<K' as to permit Iri'e access to tiu' wound, 
 
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 nui-4 
 
 as we 
 
 to allow tlu 
 
 I'scape 
 
 il matter which ma 
 
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 lormed 
 
 In III, my 
 
 lie lll.ulc 
 
 c.ises llu- wouiul is of such a nature that no attempt can 
 to prevent deformit)- in the healini; of the limb, tlu- object of lieu 
 meiit in such c.ises beiiij4 simply to savi- tlu- \v[\, 1 n man\' in,! 
 the tre.ilment of a compound fracture of the le<; consists for ,i 
 
 aiUTs 
 week 
 
 or ten d.iys 'Meiidy in immersiui; the K-t; in warm water ; ii 
 d 
 
 II ni'iil 
 
 conipdii 
 
 11(1 
 
 dres^iiiL' )e applied. It must be boriu; in mind th.it 
 
 fractu'- .', e let; fretpiently ^i\c rise to the f.ital disease knnwii 
 as b,I,>od poisoiiini; {^f^ynniiii), anil that this condition is f.udicil hv 
 the application of stiff dressini;s, which retard tiie bee e i ,ipc nl 
 ■ every case the attempt to avoid deformity miisl !)(■ 
 o the cll'ort to s;>,ve llie limb a 
 
 ma 
 
 SI 
 
 p.it I 
 
 s well .IS the life (if ih, 
 
 li 
 
 n cases iii which the injur)' is not very e.vtensivt , we ni.n 
 
 often apply, from the very first, a ri^iil ilrcssin^, which si 
 
 Kill 111,1111- 
 
 t.iin the limb in t.iii nosition. 
 
 Tl 
 
 le dressintr which is most 
 
 i.ciu'r.illy 
 K'liiil be 
 
 usebil for such b-.u:tures i,. the pl.ister of I'. iris splint ; it ,1 
 api)lieil accoi'lin;;- to tl' ~ directions .ilre.uh' !;iven, but sli 
 modified by havini; .m opeiiini; cut in it which shall expose the udiuuI 
 
 Olllll |)f 
 
 itself and the flesh around it for a distance of at 
 
 ast one 
 
 This openini; or window m.i\- be cut within .ui hour after the haiul- 
 
 .iijc Has 
 
 )ceii 
 
 .ipplied — th.it is before the pl.ister li.is 1 
 
 iccomc 
 
 tl 
 
 lorouL'hlN' iuiril 
 
 n 
 
 le W( 
 
 )und should be treated 
 
 accordiii" lu 
 
 the princi]iles already l.iid ilown for the treatment of such injuries; 
 extreme cmc must be taken to prevent the accumulation of matter 
 
 in the wound, which cm be done bv thorouph 
 
 ly sy 
 
 rininii'' wi 
 
 111 tht 
 
 solution o{ Lambert's listcrinc previously mentioned (one part of 
 listcriiic to five of water). 
 
I'KACi'ui^i'.s <)!• iiii': iioM'S oi'' nil'; I'ooi 
 
 795 
 
 Fractures of the Bonos of the Foot. 
 
 Tlusc fV.icturcs ;irc iiiit iccDiMiizcfl uilli jMcat facility, for t lie 
 l)i)ii( s ( niii|)(>siii;4 tlir loot an; so small, in<};iilar and li;;litly hoimd 
 l,i.M lliir that it is cxticmclv diniciilt for an cxixriciucd stirt;coii to 
 (Iclcit ,111 injur)' to tlicm. I lie proiiiinciK '■ of tlic heel is formed 
 li\' the lariM'st l)oiic o( the loot ; a fra( Inn- of this hone often 
 nrcsi'iils many of the ordinary sijMis of fracture, such as (hformity, 
 lo^s (if power in the member, and a vjatin;; stMisation l)(;tvveen the 
 fragments. 
 
 I'l.ictures o( the toes aie, o( course, readily detected; the 
 ociuial |)riiici|)Ies of (Uaj^nosis and treatment are (;ssentially the 
 s.uiir as already staled in discussim; fractures i,\ the (inj;ers. 
 
 iMMctures of th<' i)oiies which connect the toes with the rest of 
 the fool — correspondiiij^f, therefore, with the bones lyin^j between 
 the knuckles and the wrist in tlur upper extremity — are also recoj^- 
 iii/cd in most cases witiiout much difficulty, since tin.' clianj^e of 
 fniiii and the o;ratinj4 sensation between the fragments arc usually 
 pciceptible. 
 
 I'Vatlui'es of the foot are usually the result of dir(H:t violence, 
 such as the passage of a wa5.;<)n whecd over the number. 'Ihey 
 are, therefore, accompanied with seven; injury to the flesh ; now 
 the llcsliy part of the foot consists L'ir^(;ly of litjanu.-nts and teiulons 
 (sinews) which are extremely important in mainlainin;; the form of 
 the fool as well as in execiitinj^f the movenu'iits of tin same. 'Ilierc; 
 results, tlu'refore, in p.iany cases serious injury to the form of the- 
 foot, as well as considerable impairnient of its movements ; |)';rma- 
 nciil stiffness of the joints may also result. 
 
 Tvcdtinvnt, — rile trcratment of fractures of the foot varies in 
 details aci-ordani; to the location and extent of the fracture. (Certain 
 j,'LMKMal principles ;ipply to all such, and may be staletl here. 
 
 The foot must be restored, as far as possible, to its natural 
 form. This is often a difficult matter for one who is not ;ic(piainted 
 with the anatomy of the part, because the small Ijonc's composing; 
 the foot proper, fit into one anotluM' in sucii a complicated way that 
 the)- can bi; restored to their natural position only by delicate and 
 skillful manipulation. 
 
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 796 
 
 SURGICAL DISEASES. 
 
 In all cases the injury will be accompanied by considLiablc 
 swellins^, which increases the difficulty in the recognition and treat- 
 ment of the fracture. It will be necessary, therefore, after restor- 
 ing the form of the foot so far as possible, to apply hot fomentations 
 — cloths saturated with hot water and covered with oiled silk or 
 oilcloth — for four or five days, or until the swelling subsides. If 
 the injury be situated below the ankle joint and above the toes, no 
 further dressing is required in most cases ; if the injury be situated 
 in the front part of the foot, advantage is often derived from the 
 use of a splint. This splint may consist either of one of the usual 
 bandages — glue, starch or plaster of Paris — or it may be made out 
 of a shingle ; the selection of the dressing depends largely upon 
 the circuni ' uices of the case as well as upon the individual prefer- 
 ences of the surgeon. Sometimes especial contrivances are recjuircd 
 to hold the bones in position. 
 
 A fracture of the toe rec^uires merely a small splint of wood, 
 pasteboard or leather, whereby the toe can be kept perfectly quiet 
 in its natural position. 
 
 It sometimes happens that the extremity of the heel bnnc is 
 broken off from the foot, either by direct violence or b\' 'ini.scuhi,- 
 effort. This broken fragment is drawn out of place by tin; ^ r- 
 ful muscles composing the calf of the leg, which are attached to it. 
 We can readily detect the deformity by simply loolcing at the heel, 
 and by gentle manipulation can discover that the point of the heel 
 is displaced, and that there is a grating sensation between this and 
 the rest of the foot. 
 
 In treating this fracture, the first object is to relax the mus- 
 cles composing the calf; for, until this is done, it will be absolutely 
 impossible to restore and retain the broken fragment in its natural 
 position. 
 
 To reia.x these muscles, the knee is bent and the toes of the 
 foot are brought as far backward as possible, so as to brine;' the 
 foot in a line with the leg ; this raises the heel and relaxes the 
 muscles conqjosing the calf 
 
 In order to keep the limb in this position the leg should be 
 enveloped in cotton batting and th.en covered uith an ordinary 
 bandage, which is made to extend from the thigh .iroiind the lei; 
 so as to keep the knee bent ; it is extremely important that this 
 bandage be continued down the foot as far as the toes, in order to 
 hold t'v: heel well up toward the calf. 
 
hit of llic heel 
 twccn this and 
 
 NON-UNION OF HONES AFTER FRACrURES. 
 
 797 
 
 This position of the limb can sometimes be maintained by- 
 careful attention to a simple bandage ; but in most cases it is abso- 
 lutely nece ^uy to employ some more permanent and more rigid 
 dressing. Numerous mechanical devices have been employed for 
 this purpose ; any one can easily invent such a dressing, bearing in 
 mind the fact that the prime object is to keep the foot as nearly as 
 possible in a line with the leg, so that the heel is brought high up 
 on the limb. 
 
 A very useful dressing for this purpose is that of plaster of 
 Paris or of starch. This dressing secures perfect repose for the 
 limb. Such a dressing has, however, the disadvantage of unneces- 
 sary weight and compression of a large amount of surface. 
 
 One of the most convenient and simple forms — one which can 
 be readily employed by even inexperienced hands — consists of a 
 l(;ather strap or band, which is fastened around the thigh just 
 above the knee, and from which a tape, or another strap, extends 
 to a hook in the heel of a shoe or slipper; the leathern band 
 around the thigh should be well-cushioned or padded with cotton. 
 The advantage of this dressing consists in its simplicity and ease of 
 a})plication ; the disadvantage is the degree of motion afforded to 
 the fragments. 
 
 Non-union of Bones After Fractures. 
 
 In some cases the broken ends of the bone do not unite. The 
 causes for this failure are several : 
 
 First — A constituticMial taint of the individual. 
 
 Second — The co-existence of some wasting disease, such as 
 consumption. 
 
 Tliird — Improper dressing, as a result of which the fragments 
 are permitted to move during the healing process instead of being 
 held firmly in contact with <.'ach other. This is one of the most 
 frequent causes of failure t)f the broken fragments to unite. 
 
 Fourth — Interference with the circulation of the injured limb, 
 in consequence of the tightness of the bandages. 
 
 Fifth — The presence of some substance between the broken 
 ends. 
 
 There are certain bones after fractures of which we expect 
 non-union ; that is, the fragments become united by ligaments, or 
 
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798 
 
 SURGICAL DISEASES. 
 
 membranes, and not by true bone. The knee-pan and the upper 
 end of the thigh-bone are examples of this sort. In some cases of 
 fractures of other bones also a simiUir union takes place by means 
 of ligaments instead of bone; but by non-union, in general, we 
 understand an entire failure of the fragments to unite either by liga- 
 ment or by bone. 
 
 This condition is indicated by the persistence of the original 
 signs of fracture, at least b}- the mobility of the fragments and by 
 the grating sensation. Thus it sometimes happens that after a 
 dressing has been applied five or six weeks, the fracture is unind 
 to be just as distinct and complete as at the time of the injury. 
 
 n< 
 
 Treatment. — The treatment of non-united fractures is often 
 troublesome, and sometimes ineffectual. It requires a cireful 
 study of the patient's general condition, as well as close attention 
 to the dressing and to the anatomy of the injured part. 
 
 In some cases the fracture can still be healed if the patient be 
 allowed to enjoy air and exercise instead of lying in bed. Thus 
 it has often happened that the fracture of the leg, for example, 
 which has been treated by placing it in a fracture-box, has failed 
 to unite for four or five weeks, while the patient was lying on Iiis 
 back; but when the box was replaced hy a plaster of Parij splint, 
 which permitted the patient to walk around wirh the use of 
 crutches, union has promptly occurred. 
 
 At other times the fracture fails to unite apparently from sim- 
 ple lack of vitality on the part of the patient. In such cases, the 
 desired object can be sometimes obtained by the use of an 
 unusually nutritious diet, and of tonic medicines. In such cases, 
 we may prescribe with advantage quinine, iron and the hypo- 
 phosphites. 
 
 In a large number of cases the failure of the fragments to 
 unite is caused by the imperfection of the dressing, as a result of 
 which the fragments are permitted to move during the movenic.its 
 of the limb. It is therefore always important to secure such a 
 dressing as will retain the fragments in perfect repose, and to see 
 that this object is accomplished. 
 
 In most cases in which a fracture has failed to unite, it is advis- 
 able to adopt some means for improving the circulatitju of the 
 blood through the part. The simplest measure, one that can be 
 easily employed, consists in removing the dressing, or at least so 
 
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 by means 
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 : patient be 
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 such cases, 
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 NON-UNION OF BONES AFTER FRACTURES. 
 
 799 
 
 much of it as will expose the vicinity of the fracture, and of 
 applying friction to the skin for half an hour every day. The surface 
 should be briskly rubbed with the hands, and afterward some 
 stimulating liniment, such as the compound soap liniment, should 
 be applied and rubbed gently into the skin. 
 
 If these measures fail, that is, if at the end of ten days there 
 be no evidence of union between the fragments, more active means 
 must be employed. These should be left to the hands of the sur- 
 geon, whenever professional services can be secured, for it is 
 important that no time be lost, since the chances for the healing 
 of the fragments are diminished by the lapse of time. Until the 
 services of a surgeon can be secured, the following plan may be 
 adopted : the dressing should be removed and the broken ends of 
 the bone should be rubbed briskly against each other for two or 
 three minutes, by placing the hands one above and the other below 
 the point of fracture. The splint is then applied, and the limb 
 kept at perfect rest. In some cases this may be sufficient to cause 
 the fragments to unite. In most instances, however, it will be 
 necessary to employ some operative procedure whereby an inflam- 
 mation may be excited at the point of fracture, sufficient to induce 
 the repair of the bone. Various plans are adopted for this pur- 
 pose. One consists in driving ivory pegs into the ends of the 
 bone. Another plan consists in joining the broken ends by silver 
 wires. Sometimes the ends are sawed off so as to expose fresh 
 surfaces. These operations can, of course, be performed only by a 
 surgeon. If it be impossible to secure surgical skill, the patient 
 must be content to wear some apparatus which shall serve as a 
 substitute for the bone, and shall give the required stiffness to the 
 limb. 
 
 Another accident which sometimes complicates the healing of 
 a fracture is " bad union. " By this we mean that although union 
 has occurred between the fragments, yet the limb heals in such a 
 way as to impair materially its usefulness. 
 
 Bad union occurs if the bone is not [)roperly set at the begin- 
 ning;, or if tiie dressing be so loose and ill applied as to permit the 
 fragments to acquire a new and improper position. As a result the 
 limb may be so crooked or deformed that it is of but little service.- 
 to the patient. 
 
 If this be discovered before the bones have firmly united — say 
 in the first two or three weeks after the injury — the position can be 
 
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 800 
 
 SURGICAL DISEASES. 
 
 remedied by simply setting the bones over again and apjilyiii" a 
 dressing which sliall hold them firmly in position. If the mistake 
 be not discovered until the fragments are firmly united, thcic is 
 still a way to correct the deformity. This consists in putting ihc 
 patient to sleej) with ether and then in breaking the bone again In- 
 main force. After this the limb is placed in a proper position and 
 dressings firmly applied in such a way as to prevent a repetition of 
 the former misfortune. 
 
 It sometimes happens that a limb which is perfectly strai'dit 
 and apparently healed when the splints are removed, bends and be- 
 comes deformed within a few days afterward. It is sometimes 
 possible to remedy this by placing the limb in the splints again for 
 another week or two ; but in many cases the form of the limb can 
 be restored only by breaking the bone again and treatin^i '^ -i^ a 
 new fracture. To avoid such an accident the patient shoidd be 
 careful not to subject the newly-united bone to any severe strain for 
 several weeks after the dressing is removed. If the broken member 
 be the thigh or the leg, he should be careful to emplo)- criitclics 
 and canes, so as to relieve the bone from the weight of the body. 
 If the injured limb be an arm or a forearm, it should be carried in a 
 sling for a week or two after the union appears to be complete. 
 
 Dislocations. 
 
 Dislocations of joints are usually recognized without difficulty, 
 but require extreme care and skill in treatment. In order to un- 
 derstand the genera] principles involved in treating a dislocation, 
 it is necessary to appreciate the structure of a joint. 
 
 The bones whose ends come together to form a joint are 
 usually thicker at the ends than in the middle or shaft. This en- 
 largement of the end of the bone serves to increase facility of move- 
 ment by offering a larger surface, and also to afford attachment for 
 the structures which bind the bones together. If we select for ex- 
 ample the shoulder-joint, we find that the end of the arm bone i-^ 
 larger than the shaft, and that it has a large rounded surface which 
 rests against a concave surface in the shoulder-blade. The ends ol 
 the bones do not lie in actual contact. Each is covered with a thin 
 layer of cartilage, or " gristle," which is more elastic than the bone 
 
DlSI.UCATIoNS. 
 
 80 1 
 
 itself. Tlic adjoining ends of the bones are furtlicrmorc bound to- 
 [Tctlicr by strong, firm bands, called lij^aiiuiits. These permit a 
 certain amount of movement between the adjoining surfaces, 
 thouL^h they do not allow the ends of the bones to be drawn 
 apart. In order to diminish the friction between the ends of the 
 bones which move over each other, a little bag or sac is inserted 
 between these ends, and its inner surface kept moist by a watery 
 
 fluid. 
 
 In addition to these structures, which belong to the joint itself, 
 there are certain accessory structures which are often of great 
 importance in maintaining the form and strength of the joint. 
 These are the tendons or " sinews," which pass over from one bone 
 to another and serve to keep these bones in their proper position. 
 
 Whenever the adjoining surfaces of the bones constituting a 
 ioint become separated, the condition is termed a dislocation. 
 Dislocation may be partial or complete, according to the amount of 
 the displacement which has occurred between the adjacent ends of 
 the bones. 
 
 Dislocations are in most cases caused by violence ; and hence 
 they may be complicated with v/ounds of the flesh and with frac- 
 tures of the bone. 
 
 In some instances dislocations occur without any external vio- 
 lence, but simply from the contraction of muscles. 
 
 The injury inflicted by a dislocation depends upon the violence 
 which has been employed to accomplish it. In severe cases there 
 occurs not simply a displacement of the bones, but also a lacera- 
 tion and destruction of the other tissues which enter into the 
 ormation of the joint ; the ligaments which bind together the 
 ends of the bones arc torn ; the sac which lies between the adja- 
 cent bones is ruptured, and sometime.^ the tendons and muscles 
 which surround the joint are lacerated. 
 
 If the ends of the bones themsehes escape injur} (he useful- 
 ness of the joint can usually be perfectly restore*', by proper treat- 
 ment ; the ligaments, tendons .n\d mriuscles he;' perfectly. If the 
 ends (if the bones be crushed or inju; -d, the v mines'- of the joint 
 is rarely restored complete ly 
 
 If the dislocated bone - not replaced nut e;. in the \ leinity 
 of its forniei- position, a Dew false jo.11, is (>ften formed, very 
 similar to the true mk , anil pern ' a c<insidcrable amount o£ 
 motion. 
 
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 SURGICAL DISEASES. 
 
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 Symptoms of Dislocations. 
 
 There are certain symptoms which are present in most disli). 
 cations, whereby tliey are recognized and distinguished from frac- 
 tures. These are : 
 
 First, Deformity. — The unnatural outline in a dislocation is 
 observed especially in the vicinity of the joint. In case (if fracUiic 
 of the long bones, the deformity is usually apparent at some point 
 between the joints. 
 
 In every case it is advisable to compare the injured joint with 
 the corresponding one of the opposite side. To do this the l)ody 
 should be stripped of all clothing at and around the two joints. 
 
 Second, Loss of Motion of the Joint. — This serves to distin- 
 guish a dislocation from a fracture, which is usually characttii/.cd 
 by an unnatural freedom of movement. The loss of motion which 
 accompanies a dislocation is observed not simply when tin: iialii nt 
 himse'f attempts to move the injured member, but also wluii sucl\ 
 an attempt is made by another person. In case of fracture thcro 
 is frequently a loss of power on the part of the patient to mnvc 
 the limb, while a second individual can readily elicit all the natural 
 and some unnatural movements. 
 
 Dislocations like other injuries are accompanied by swcllini,^ 
 pain and tenderness at the point of injury. These are usually more 
 pronounced in case of dislocations than in fractures. 
 
 There are some cases in which it becomes impossible even for 
 a surgeon to determine precisely whether or not a dislocation 
 has occurred ; this is especially apt to be the case so soon as the 
 swelling has occurred. Dislocations may be mistaken for bruises 
 and sprains. In such instances the application of hot fomentations 
 for a few days reduces the swelling and tenderness, after which the 
 nature of the injury can be ascertained with greater accuracy. 
 
 ill 
 
 lit] 
 
 Treatment of Dislocations. 
 
 There are certain general principles which must be borne in 
 mind in treating dislocations. The object of treatment is, of 
 course, to restore the displaced bone to its former position. The 
 obstacles to be overcome in this effort are chiefly the contraction of 
 muscles and the presence of ligaments. 
 
II '?'!■! ri 
 
 TREATMKNr Ol- DISLOCATIONS. 
 
 803 
 
 It luis been said in speaking; of fractures, that the muscles are 
 in a state of constant contraction, and liiat this contraction is 
 increased by injury. Mence wlienever a bone is fractured obh'cjuely 
 so that the broken ends can slide over each other, the Uiub is at 
 once shortened by the action of the muscles which pull one fra^'- 
 incnt past the other. This same effect is manifested in case of dis- 
 location ; the displaced bone is drawn upward toward the bone 
 a'niinst which it naturally rests. To reduce the dislocation — that 
 is, to restore the displaced bone to its natural position — wc must 
 overcome or avoid the muscular action whereby the bone is held in 
 its natural position. In some cases this becomes an extremely 
 (lifficult item of treatment ; indeed in former years com[)licated 
 mechanical means were used for overcoming this contraction of the 
 muscles ; at present we accomplish the same result in simpler 
 ways. 
 
 The means for iiccomplishintj this in the different dislocations 
 will be discussed under the special heads ; there is, however, <mic 
 means for overcoming muscular contraction, which is generally 
 ai)plicable, and to which surgeons often resort in order to restore 
 displaced bones to their proper position ; this is the administration 
 of ctlicf. Under the influence of this sidjstancc all the muscles of 
 the body become relaxed. In this condition dislocated bones can 
 be replaced with much greater ease. 
 
 A second feature to be considered in the reduction of a dis- 
 location, is the position of the ligaments and tendons around the 
 joint. When a bone is displaced, it often assumes such a position 
 that it is separated from the cavity in which it should rest by 
 several ligaments. If an attempt be made to restore the bone 
 directly to its former position, its progress is opposed by these 
 li-^faments ; this opposition cannot be overcome by any reasonable 
 decrree of force, and it is furthermore not desirable that it should 
 be (wercome, since to do so, would tear and lacerate the ligaments. 
 It is therefore necessary to avoid, so far as possible, any collision 
 between the !r)nes and the ligaments which surround the joint. 
 This is accomplished by placing the bone in the position which it 
 uccupied at the moment when it was dislocated ; by so doing, the 
 end of the displaced bone is brought opposite to the opening 
 between the ligaments which was made at the time of its escape 
 from its socket. 
 
 A clear comprehension of the measures required by this latter 
 
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 SURGICAL DISEASES. 
 
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 principle, can be attained only by a somewhat intimate knouk'dji^'c 
 of the anatomy of the parts. While it is impossilde in a work of 
 this sort to exjjlain details, the j^encral facts will be mentioned in 
 connection with the individual fractures. 
 
 A dislocated bone should be restored to its former positidii as 
 soon as possible after the dislocation. In the fjrcat m.ijorit}- of 
 cases the restoration of the bone can be effected without difficult)-. 
 
 It will not be safe for an inexperienced person to administer 
 ether ; that is although deaths from ether are quite rare in the 
 hands of physicians, yet in ignorant or careless hands the drug is a 
 most dangerous one. Wc can sometimes accomplish in a some- 
 what imperfect way the result aimed at in administering ether — 
 that is the relaxation of the muscles — in the following way: At 
 the instant when wc are ready to exert whatever force may be 
 necessary to reduce the dislocation, wc divert the attention of the 
 patient from the operation by a sudden exclamation or by asking 
 him a question. The muscles are relaxed for a few moments while 
 his mind is thus fixed on the subject of the remark ; if the effort 
 be made to reduce the limb during these few moments, it will often 
 be possible to accomplish a reduction which would otherwise baflle 
 all attempts without ether. 
 
 It is desirable to know the position of the limb at the time 
 when the bone was displaced ; for we can generally best succeed in 
 restoring the bone to its former position by placing it as nearly as 
 possible in the position which it occupied at the moment of its es- 
 cape from the socket. Thus if the shoulder-joint have been dislo- 
 cated by violence which raised the arm forcibly upward above the 
 head, we can usually succeed in restoring the bone by placing the 
 patient upon his back antl drawing the elbow up above the shoulder, 
 and by exerting a gentle force in pulling the arm in this direction. 
 It is always necessary to have an assi'^tant, who shall steady the joint 
 while the operator manipulates the dislocated limb. 
 
 After the dislocation has been reduced, the limb should be kept 
 perfectly quiet for several days at least. This is necessary, not only 
 to avoid the pain which movement would occasion, but also to afford 
 an opportunity for the healing of the lacerated tissues around the 
 joint. If the limb be not kept quiet, a second dislocation with 
 additional injury to the tissues may occur. In most cases rest can 
 be secured sufficiently by the application of bandages. Sometimes 
 it is advisable, also, to apply a splint of leather or wood to accom- 
 plish the same purpose. 
 
DISLOCATION' OF lill'. I.oWilk jAW. 
 
 S05 
 
 If there be much pain aiul swelling' in the joint, it is desirable 
 to envelop the part in cloths saliirated with hot water. 
 
 A joint which has l)een once dislocated must always be treated 
 with extreme care subsequently. No free use of the part, such as 
 is natural to it, should be allowed in less than a month aflir the ilis- 
 location, and even after that, care should be taken to avoitl any 
 violent effort. 
 
 Dislocation of the Lower Jaw. 
 
 The jaw-bone is attached to the skull by li<;amcnts and mus- 
 cles, and rests against the bones of the skidl at one point on either 
 side, where there is a shallow socket made to receive the rounded 
 head of the bone. In consequence of the extensive rant^e of nu)ve- 
 mcnt required of this bone, the socket is made cpiite shallow, and 
 therefore offers but little resistance to the escape of the bone from 
 its position. The jaw is held in place, not by the bony socket, but 
 bv the liLTaments and powerful muscles which are attached to it. 
 
 The lower jaw may be dislocated on one side only or on both 
 sides at the same time ; the latter accident is the more common. 
 The dislocation may be caused by direct violence, such as a blow 
 or the extiaction of a tooth ; indeed, there arc numerous ways in 
 which the accident has been brought about. The most common of 
 these is the muscular action which accompanies the act of gaping 
 or yawning. It is a little singular that this accident occurs more 
 frequently in women than in men ; it has been known to happen as 
 an incident in a curtain lecture. 
 
 SjfHli»tont,s. — This condition is easily recognized even by the 
 inexperienced ; the chin is more prominent than natural and pro- 
 jects downward, the patient being unable to close the mouth , there 
 is an unnatural depression in front of the ear, and sometimes a 
 prominence at the back part of the check, which is not observed in 
 the natural condition. If but one side be dislocated, the chin and 
 jaw project toward the opposite side, while if both sides of the 
 bone be displaced, there is simply a forward and downward pro- 
 jection of the jaw. 
 
 Treatment. — The simplest and best way for reducing a dis- 
 location of the jaw is as follows: 
 
 The operator stands in front of the patient and introduces the 
 
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 SURGICAL DISEASES. 
 
 thumbs, wrapped in a soft napkin or protected by a thick {jlow, 
 into the patient's mouth, until they rest upon .he teeth of the lowir 
 jaw, as far back as they can be placed. The fingers meanwhile 
 grasp the chin. Pressure is then made upon the teeth by means uf 
 the thumbs, so as to force the jaw downward and at the same time 
 press it backward. Meanwhile the chin is pressed toward the upper 
 jaw by means of the fingers which grasp it. The thumbs thus act, 
 to a certain extent, as fulcra, while the jaw becomes a lever. Con- 
 siderable force must be used to overcome the contraction of tlie 
 powerful muscles which are attached to the back part of the j.iw- 
 bone ; but if pressure be steadily made, it is usually possible to 
 effect the reduction in this way. An unpleasant feature of this 
 method is the bruising which the thumbs of the operator are almost 
 certain to receive, either during the operation or at the moment 
 when the jaw glides backward into its place ; for at this moment 
 the mouth is firmly closed even without the will of the patient. 
 
 In order to avoid this injury to the thumbs of the operator, 
 another method is often employed, which differs from the one just 
 described merely in the substitution of two pieces of cork for the 
 thumbs. The patient sits upon the floor, his head being placed 
 between the knees of the surgeon. Two pieces of cork a quarter 
 of an inch or more thick are placed between the teeth of the two 
 jaws, as far back as possible. The operator then presses the chin 
 upward toward the upper jaw and forces it gently backward at the 
 same time. This method may be tried first, and if it fails, the i>ne 
 first described should be employed. 
 
 Extreme care should be taken in the use of the jaw after it 
 has been once dislocated, for it is extremely prone to displace- 
 ments subsequently, even after slight violence. 
 
 Cases have occurred in which the dislocation was not reduced ; 
 in such instances a new joint is formed, which answers the pur- 
 pose reasonably well. 
 
 Dislocation of the CoUar-Bone. 
 
 Either extremity of the collar-bone may become displaced as 
 the result of violence. 
 
 Dislocations of the inner end of the bone, where it joi,.s the 
 breast-bone, usually cause a displacement of the collar-bone 
 
DISLOCATIONS OF THL SHOULDER. 
 
 807 
 
 upward, so that it makes a prominence under the skin. This con- 
 dition is, therefore, readily recognized. 
 
 Dislocation of this end of the bone backward is said to have 
 occurred from curvature of the spine ; it is an uncommon acci- 
 dent. 
 
 Dislocations of the outer end of the collar-bone, where it 
 joins the shoulder blade, son.ctimes occur from violence applied to 
 the shoulder. In this case the end of the collar-bone usually pro- 
 jects above the shoulder-blade, where it makes a decided promi- 
 nence. 
 
 Tt'catment. — Dislocations of the collar-bone are usually 
 reduced without difficulty, though it is not so easy a matter to keep 
 them in place. The shoulder should be pressed backward, while 
 the fingers at the same time force the dislocated end of the bone 
 downward toward its natural position. 
 
 After the bone has been thus restored to its proper place, a 
 dressing should be applied after the manner described in discuss- 
 ing fractures of the collar-bone. The treatment of the two is 
 practically the same. A collar-bone which has been once dislo- 
 cated is, however, apt to get out of place subsequently upon slight 
 provocation. 
 
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 Dislocation of the Shoulder-Blade. 
 
 The shoulder-blade forms joints with the collar-bone and with 
 the bone of the arm. Either of these joints may suffer displace- 
 ment ; it is customary to describe them as " dislocations of the 
 collar-bone" and " dislocations of the shoulder," respectively. 
 
 , '■' ' 
 
 Dislocations of the Shoulder. 
 
 These are the most common of all dislocations ; their fre- 
 quency results from the peculiar anatomical relations of the joint 
 as well as from the exposure of the shoulder itself to mechanical 
 violeMice. 
 
 The shoulder joint is arranged so as to afford a very exten- 
 sive range of motion ; hence, it is impossible that the socket 
 
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8o8 
 
 SURGICAL DISEASES. 
 
 should be very deep. As a matter of fact, the bony socket of tlu: 
 sh ildcr joint is quite shallow, and affords but little purchase to 
 hold the head of the arm-bone. The socket is, however, deepened 
 by a rim of cartilage placed around the bony edge. Yet, notwith- 
 standing this arrangement, the head of the arm-bone is easily dis- 
 placed from its attachment to the shoulder-blade. 
 
 This accident may result from direct as well as indirect violence. 
 It is most frequently caused perhaps by blows or falls upon the 
 shoulder; it often results from falls in which the weight of the body 
 strikes upon the hand or forearm. The accident happens though more 
 rarely as the result of violent muscular efforts, such as are made 
 in lifting heavy weights. 
 
 Siffiis. — The head of the arm-bone may be displaced in any 
 one of four ways : that is, it may take any one of four posi- 
 tions, outside of the shoulder joint. In order to understand 
 these, the reader must have a slight knowledge of the anatomy uf 
 the joint. 
 
 Just above the shallow socket of the shoulder-blade, in wliich 
 the head of the arm-bone rests, there is a bony projection, which 
 constitutes the point of the shoulder. This is called the acroiiiipii 
 process of the shoulder-blade. Just in front of this, at the outer 
 end of the collar-bone, is another projection from the shoulder- 
 blade, wliich is called the coracoid process. The acromion process 
 prevents the head of the bone from being forced upward, but it 
 sometimes escapes into the cavity just under the coracoid process. 
 This is not always a complete dislocation ; that is, the head of the 
 bone usually rests upon the edge of its proper socket. 
 
 This variety of dislocation — in which the head of the bone is 
 located under the coracoid process of the shoulder-blade — is easily 
 recognized by the existence of a lump just under the outer e.xtreniity 
 of the collar-bone. By comparing the shoulder with the sound one 
 of the opposite side, it will also be noticed that the injured shoulder 
 is flatter and more pointed than the other. 
 
 A second dislocation of the head of the arm-bone is that in 
 which the arm is displaced into the armpit. The head of the bone 
 lies, therefcjre, just under the socket where it belongs. 
 
 In a third form, the head of the arm bone is thrown forward 
 onto the ribs, usually lying between the second and third rib. 
 This is a very rare dislocation. 
 
DISLOCATIONS OF THE SIIOULDLR. 
 
 809 
 
 ,ockct of the- 
 purchase to 
 -r, deepened 
 fet, notwith- 
 is easily dis- 
 
 rcct violence, 
 ills upon the 
 it of the body 
 5 though more 
 I as are made 
 
 placed in any 
 
 of four posi- 
 
 to understand 
 
 le anatomy of 
 
 )kidc, in which 
 ojcction, \y\\\c\\ 
 ;d the acroiiiion 
 is, at the outer 
 the shoulder- 
 roniion process 
 upward, but it 
 racoid process, 
 he head of ihu 
 
 Lt. 
 
 of the bone is 
 lade — is easily 
 outer extremity 
 h the soiuid one 
 injured shoulder 
 
 bone is that in 
 ad of the bone 
 
 [thrown forward 
 and third rib. 
 
 In the fourth variety of dislocation, the head of the arm-bone 
 is displaced backward onto the shoulder-blade. 
 
 There are also other varieties which occasionally happen, and 
 are recorded in the literature of surgery. Their occurrence is, 
 however, so rare that no discussion of them is necessary. 
 
 All dislocations of the arm-bone are accompanied by extreme 
 pain in the arm and shoulder, and almost always by a numbness of 
 the fingers and arm of the injured side. This numbness results 
 from the pressure of the dislocated bone upon the large nerves 
 which pass to the arm directly under the shoulder joint. The ex- 
 tent of these symptoms varies with the amount of damage done to 
 the tissues during the escape of the bone from its socket. 
 
 The most frequent dislocation is that in which the head of the 
 one is displaced downward and lies in the armpit. The signs of 
 this dislocation are : 
 
 Fii'st — The position of the arm. The elbow stands out from 
 the side, while the upper end of the bone is plainly felt in the arm- 
 pit. 
 
 Second — Flattening of the shoulder. This is readily under- 
 stood when wc remember that the natural prominence of the 
 shoulder is due largely to the head of the arm-bone, and to the 
 powerful muscle which covers it. When the bone is dislocated 
 into the armpit, there remains a cavity in the position formerly 
 occupied by the rounded head of the bone. Moreover, the acro- 
 mion process, that sharp projection from the shoulder-blade, 
 i;ives to the shoulder a pointed and square appearance which 
 strikes the eye at once, especially if it be compared with the unin- 
 jured shoulder of the opposite side. 
 
 Third — The ininiobility of the arm. All attempts to move 
 the arm, either by the patient himself or by another person, are 
 ineffectual in causing any extended movement. Such efforts in- 
 duce extreme pain. 
 
 A characteristic feature can be brought out by the attempt to 
 place the hand of the injured arm upon the opposite shoulder. It 
 is often impossible to accomplish this at all ; if it can be done it will 
 be noticed that the elbow of the injured arm is widely separated 
 from the chest when the hand rests upon the opposite shoulder; if 
 the elbow be kept in contact with the body, it will be quite impos- 
 sible to place the hand on tli,c shoulder. 
 
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 SURGICAL DISEASES. 
 
 Fourth — The Iciif^thcning of the arm. If a tape measure be 
 stretched from the point of the injured shoulder to the point of the 
 elbow, the forearm meanwhile being bent, it will be found that this 
 distance is perceptibly greater than the corresponding measurement 
 on the sound side. 
 
 Dislocation of the head of the arm-bone under the cura- 
 coid process of the shoulder-blade, can readily be made out by feel- 
 ing the head of the bone in this unusual position. 13y taking hold 
 of the elbow and rotating the arm, we can feel that the head of the 
 bone, which constitutes the lump, moves with every movement of 
 the arm. 
 
 In this dislocation the elbow is usually turned away from tlie 
 body, though not to the same extent as in the dislocation into tlic 
 armpit. 
 
 The dislocation of the head of the bone backward onto the 
 shoulder-blade is readily detected by the presence of a lump in this 
 new position as well as by the unnatural flatness of the shoulder. 
 The loss of motion and unnatural position of the arm are evident as 
 in the former cases. In this dislocation the elbow is usually situated 
 near the side, instead of away from the chest. 
 
 Dislocations of the head of the arm-bone are usually recognized 
 without difficulty, provided there be no complications of any sort. 
 There are, however, many cases in which dislocations are accom- 
 panied by fractures, and others in which the fractures alone pre,sent 
 in many respects the symptoms usually found in dislocations. 
 
 The most frequent accidents which are apt to be mistaken for 
 dislocations are : 
 
 Fracture of the acromion process of the shoulder-blade ; frac- 
 ture of the outer end of the shoulder-blade ; and fracture of the 
 arm-bone just below the socket. The two first-mentioned fractures 
 can easily be distinguished from dislocations by the fact that the 
 deformity of the shoulder is easily remedied by simply lifting the 
 elbow upward ; so soon as the arm is unsupported, the shoulder 
 drops again. In case of dislocation this restoration of the form of 
 the shoulder is impossible. Furthermore, if one of the fractures 
 named be present, the movements of the arm are not especially 
 impaired ; while if the injury be a dislocation, the arm remains 
 fixed. 
 
 In these fractures as well as other?, a grating sensation can be 
 
DISI.OCATIONS OK TIIF SIIOL'I.DKR. 
 
 SlI 
 
 '\ 't 
 
 leasurc be 
 oint of the 
 d that this 
 lusurciv.ent 
 
 the cora- 
 Hit by fet.l- 
 takiii'^; hold 
 head of the 
 lovcment of 
 
 ay from the 
 ion into the 
 
 ird onto the 
 lump in this 
 he shouUkr. 
 re evident as 
 ually situated 
 
 \y recognized 
 
 of any sort. 
 
 s are accom- 
 
 alone present 
 
 Ications. 
 
 mistaken for 
 
 felt when the fragments are rubbed against each other ; in cases of 
 dislocation there is no grating sensation to be perceived. 
 
 I'ractures of the arm-bone near the socket of the shoulder 
 joint are easily detected by the usual mobility of the arm and by 
 the grating sensation which can be detected when the arm is 
 moved. 
 
 ihere are, however, cases in which the ilislocation of the bone 
 is complicated with one of the fractures already mentioned. In 
 these cases it often puzzles even an experienced surgeon to detect 
 the exact nature of the difficulty. For the symptoms of both frac- 
 ture and dislocation are present and counteract to a certain extent 
 one another's significance. 
 
 Ti'cnfinent. — There are several methods for reducing dislo- 
 cations, any one of which can usually be made to succeed in 
 skillful hands. 
 
 To reduce a dislocation of the arm-bone into the armpit — 
 comnu)nly called a doxonivani dislocation — it is necessary to draw 
 the arm downward in order to enable the head of the bone to ride 
 over the edge of the cavity in which it should rest ; at the same 
 lime the upper part of the arm must be pressed outward, so as to 
 <j;ive the head of the bone a chance to regain its socket. 
 
 It will be remembered that the chief obstacle in the reduction 
 (if dislocation is the muscular contraction whereby the bone is 
 tirmlv fixed in its unnatural position. It is therefore necessary to 
 use considerable force in restoring the bone to its place. 
 
 The most common method was until recently the plan com- 
 monly known as " placing the heel in the armpit. " To perform this 
 operation the patient, stripped to the waist, is laid upon a hard bed 
 or upon blankets placed upon the floor. 
 
 Ihe operator removes the boot from the left foot if the 
 patient's left shoulder be dislocated, and from the right foot in 
 dislocation of the right shoulder. He then seats himself upon the 
 bed, opposite the patient's hips, and places the foot in the armpit. 
 He then grasps the arm at the elbow, preferably by means t)f a 
 towel or soft cloth wound tightly around the limb. The operator 
 then pulls firmly upon the arm, so that it shall move downward and 
 outward, bracing himself meanwhile with the foot against the 
 shoulder. After the pulling has been continued foi; half a minute, 
 the arm should be gently carried inward toward the patient's body, 
 53 
 
 %-y 
 
 
 u 
 
 '%\ 
 
I 
 
 ! I 
 
 IP 
 
 :;l'| 
 
 8l3 
 
 SURGICAL DISKASES. 
 
 SO that the upper end of the bone shall be forced outward and shall 
 reach the socket. 
 
 Another method consists in placing the patient upon achaii, in 
 a sitting posture ; the operator puts his foot upon the scat of llu 
 chair, so that the knee shall rest in the patient's armpit ; the arm is 
 then pulled outward and downward, while the shoulder is forced 
 against the supporting knee. After this effort has been continued 
 for twenty or thirty seconds, the elbow is pressed inward under tlic 
 operator's thigh, so that the head of the bone is brought outward 
 to its socket. 
 
 This method, it will be seen, involves just the same princijjlcs 
 as .he one in which the operator's heel is placed in the paliciil's 
 armpit. 
 
 These methods are usually successful, though they are not by 
 any means scientific ; the success is attained by main force and not 
 by skill. At the present time surgeons employ a method wliicli 
 secures a reduction of the dislocated bone without the exercise of 
 force. The principle upon which this method is based consists 
 simply in placing the arm in the position which it occupied at the 
 moment of dislocation. The method is known as that of "niaiiipu- 
 lation. 
 
 It is practically impossible to describe in detail the nKini])ula- 
 tions by which dislocations of the shoulder can be readily reduced, 
 but it may be said that an approximation to this method can be 
 performed in essentially the following way : 
 
 The patient is laid upon a hard bed, or upon the floor ; the 
 operator grasps the arm at the elbow, while an assistant holds the 
 shoulders firmly. The arm is then drawn downward and is made 
 to describe a semicircle, the elbow being carried from the side and 
 brought upward above the head ; after it has reached this position, 
 the srm is drawn upward away from the body. In most cases the 
 bone slips back into place during this movement. 
 
 In the dislocation forward onto the chest or backward onto the 
 shoulder-blade, the bone can usually be replaced by placint,' the 
 heel in the armpit, or by the method last described, in which the 
 arm is swept around from the body to a position in which the elbow 
 lies above the head. Some difl!iculty may however be experienced, 
 difficulty which can be overcome only by a knowledge of tiic 
 anatomy of the structures concerned. 
 
 In almost every case the successful reduction of the bone is 
 
Dislocations of the uluow. 
 
 813 
 
 ward and shall 
 
 indicated by a " click " at the moment when tlie head of the arm 
 bone falls into the socket. Even if this do not occur, the restora- 
 tion of the displaced bone is indicated at once by the freedom <»f 
 movement exhibited by the arm as well as by the restoration of the 
 natural form to the shoulder. 
 
 If these methods fail to secure the replacement of the bone, 
 and if the services of a surgeon cannot be procured, ether should 
 be administered to the patient. The object of this is to relax the 
 muscles of the body ; after this has been accomplished, the bone 
 can often be reduced with case, even though it has resisted violent 
 efforts while the patient was conscious. It is important that every 
 dislocation be reduced within a few days at the Litest ; for if it be 
 permitted to remain, the reduction becomes a matter of great diffi- 
 culty and even danger. After a bone has remained out of place 
 for several weeks, it becomes bound in its new position by bands or 
 li<:;aments, while its former socket is often fdled up by similar tissue. 
 Under these circumstances the effort to reduce the dislocation is 
 opposed not only by the muscular contraction, but also by these 
 new tissues. It is, indeed, often possible for an experienced 
 siuL^eon to reduce a dislocation which has existed for some months, 
 but such an attempt should never be made by an inexperienced 
 person. 
 
 After the dislocation has been reduced, the arm should be 
 suspended in a sling and firmly bound to the side of the chest by 
 means of a broad bandage which passes around the body. Two or 
 tliree turns of a bandage should also be passed under the elbow and 
 over the shoulder, so as to support the arm and prevent it from 
 slipping out of place. This bandage should be worn for a week or 
 ten days at least, after which the arm should be supported in a 
 sling. For several months, great care should be observed not to 
 subject the shoulder to any severe strain, since the bone can be 
 very easily dislocated a second time. 
 
 t- ■ 1 
 
 m 
 
 i! J 
 
 5i»i 
 
 Dislocations of the Elbow. 
 
 ^ mi 
 
 In of the bone is 
 
 The structure of the elbow joint is far more complicated than 
 that of the shoulder joint, and dislocations in this place are corre- 
 spondingly difficult of recognition and of treatment. While it is 
 often possible for an inexperienced person to reduce a dislocation 
 
 i 
 
 ^i 
 
8i4 
 
 SURGICAL DISKASES. 
 
 of the shoulder, injuries to the elbow should always be submitted 
 to the surgeon. 
 
 The elbow joint is formed by three bones ; above, the li)\vt:r 
 end of the arm-bone, and below, the two bones of the forearm. 
 The bone which lies on the same side of the forearm as the little 
 finjjer — called the ulua — is chiefly concerned in the formation (jf 
 the hinge which constitutes the elbow. The other bone of the fori. - 
 arm, l)'ing on the same side as the thumb and called the radius, 
 enters chiefly into the formation of the wrist joint and forms but a 
 comparatively small part of the elbow joint. At the elbow, the 
 radius merely rests against the lower end of the arm-bone, while tlir 
 ulna is hollowed out so as to make a deep socket which receiver 
 the lower end of the arm-bone. 
 
 Either one of these bones of the forearm may be dislocated ; 
 or both bones may be displaced at the same time. The ulna alone 
 is sometimes forced out of place by being driven backward; at 
 other times it is displaced sideways. The most common form i^, 
 however, the dislocation of both bones backward. 
 
 Dislocations at the elbow joint are frequently accompanied 
 with fracture. The socket in the ulna, which receives the lower end 
 of the arm-bone, is so deep that the edge of it is often chipped oft" 
 when the displacement occurs ; in some cases the end of tlic 
 humerus fitting into this socket also suffers fracture at the same 
 time. In other cases the arm-bone is broken transversel)' at ,i 
 point jiist above the joint, the lower fragment being pulled back- 
 ward with the bones of the forearm. 
 
 The sinews and ligaments which bind together the bones at 
 the elbow are so firm thi; displacement of the bones can be accom- 
 plished only by the exercise of consich.Table violence. It is ii'^ualiy 
 occasioned by a blow upon the elbow or by a fall in wiiich tlic 
 weight of the body is transmitted through the elbow. 
 
 Signs, — The signs of dislocation vary somewhat accordiiii; 
 to the e.xact nature of the injury. In most cases the swellint; is so 
 great by the time the surgeon arrives, that some doubt as to the 
 exact condition may exist for several days, until the swelliiij,' can 
 be reduced by the application of hot cloths. In every case it is 
 important to compare the injured with the sound side ; hence the 
 other arm should be bared for comparison. 
 
 There are three points — three bony prominences — which serve 
 
DISI.orA'llONS <)1' TIIK Kl.llOW. 
 
 Sis 
 
 as landmarks or ^niitlcs in dclcrniining Ihc niiturc of the injury, 
 riicsc arc tlic two projections from the lower end of the arm-bone, 
 one on either side, and the prominence known as the crazy-I'ine. 
 
 When tile forearm is bent so that the elbow makes a right 
 anj^le, the upper end of the ulna constituting the point of the 
 rljiow should be situated about half way between the outer and 
 inner projections of the arm-bone. Jn most dislocations of the 
 ilhow. the relation and distance between these three points is 
 markedly different fr,)m the natural arrangement. 
 
 When both bones are displaced backward, the forearm is bent 
 and the palm of the hand turned somewhat downward, the point 
 vi the elbow projecting behind the arm. 
 
 It will be found that the arm can be straightened to a consid- 
 erable extent without causing extreme pain, but any attempt to bend 
 it beyond a right angle causes acute pain. We can generally feci 
 an unnatural prominence behind the arn), unless the swelling is 
 already very great. 
 
 Sometimes both bones are displaced outward. In this case the 
 point of the elbow is no K)nger situated midway between the two 
 bony prominences of the arm ; the inner one of these projects 
 extremely, and the skin is drawn over it \ery tightly. 
 
 If the ulna alone be dislocated backward, the palm of the 
 hand is turned downward ; the point of the elbow projects very 
 pcrcc])tibly behind the arm. 
 
 If the radius alone be dislocated, the accident is recognized 
 usually by an impairment in the rotation of the hand. It is somc- 
 tinus possible to see and feel the extremity of the bone at the front 
 of the elbow-joint. 
 
 m 
 
 'I. f! 
 
 l__ which serve 
 
 TiTdfinenf. — The reduction of dislocation of the elbow is 
 often a difficult task, especially if much swelling has occurred. 
 
 The arm should be bent over the knee, while the foot of the 
 operator is placed upon the chair in which the patient sits. J5y 
 bending the forearm around the knee and pulHng it at the same 
 lime away from the arm, it is sometimes possible to reduce the dis- 
 location. 
 
 Another way consists in grasping the elbow-joint with the 
 right hand so that the palm shall cover the point of the elbow 
 which projects backward ; the forearm meanwhile is held with the 
 left hand of the operator. By exerting pressure so that the point 
 
 m.:- •)' 
 
8i6 
 
 SURGICAL DISEASES. 
 
 of the elbow is forced forward and the arm backward with the ri^Iit 
 hand, the disphiccmcnt is sometimes reheved. 
 
 If these efforts be unsuccessful, an assistant slioidd iiold tliu 
 arm and exert pressure downward and outward for a few seconds, 
 while the operator disposes of his hands about tlie joint in a way 
 so as to exert pressure upon the point of the elbow and upon tlii 
 lower part of the arm. Tiic forearm should then be bent by the 
 assistant while the operator forces the point of the elbow fm- 
 ward. 
 
 In many cases it is impossible to reduce a dislocation of the 
 elbow-joint without the use of ether ; under the influence of ihi^ 
 drug, the muscles become so relaxed that the manipulations of the 
 displaced bones are much facilitated. 
 
 Some stiffness of the joint often follows a dislocation; this can 
 be best avoided by passive motion of the forearm, exertetl by a 
 s.'cond individual. It will usually be necessary to keep the joint 
 enveloped in hot fomentations for a week or two after the disloca- 
 tion is reduced. The arm should be carried in a slint;. 
 
 Dislocations of the Wrist. 
 
 Ill' 
 
 This is an unusual accident; violence applied to the hand and 
 wrist frequently occasions a fracture of the radius, but rarely a sepa- 
 ration of this bone from the wrist. 
 
 Sfffus, — The deformity is so characteristic that no dflaikil 
 description is necessary ; the ends of the bones of the forearm can 
 be felt and seen above the back of the hand or below the palm. 
 The motion of the jtiint is lost. 
 
 Treat men t. — This dislocation can usually be reduced without 
 difficulty in the followin<j; way : 
 
 An assistant holds the forearm of the patient and pulls gently 
 toward the body, the operator meanwhile grasps the hand and 
 pulls away from the arm, manipulating the dislocated bones at the 
 same time so as to force them into place. 
 
 A splint should be applied to the hand and forearm for a week 
 or two after the accident, in order to afford time for the healini,^ of 
 the ruptured ligaments. It is sometimes necessary to apply hot 
 fomentations for some days after the injury. 
 
DISMJCATIONS OK TIIK TIHMII. 
 
 817 
 
 Dislocations of the Thumb. 
 
 ; 
 
 lucctl without 
 
 This is a frequent accident. Thi- thumb may be clisphiced 
 citiicr forward or backward, usually in the latter direction. The 
 tlisplacement often results from a fall upon the hand while the 
 liii^fcrs are spread apart ; amon^f the youth of the country it is also 
 often caused by the blow of a base ball. 
 
 Shjiis. — The deformity is easily recojfnizcd ; the end o( the 
 hone to which the thumb is joined projects either in front or 
 bthiiu!, while the ujjperend of the thumb proper makes a corre- 
 spDiuling prominence in the opposite direction. 
 
 Trentnu'Uf, — The dislocation can be reduced h\r simply 
 pulling upon the thumb while an assistant holds the hau'! It is 
 Usually necessary to apply a bandage around the thumb in order 
 to secure sufficient purchase. This can be best seem d by m in- 
 strument devised by Dr. Levis. It consists sim[)ly .1" a thin stiip 
 (if wood ten or t-\> vjIvc inches long and aI)out a!i inch wiu- . Si.K 
 .,r eight holes are cut throttgh one end of this near the cd. cs ; tiie 
 other «.!ul is shaped so that a shoulder projects on either side. 
 'Iwo pieces of tape about three feet long are then passed through 
 two pairs of holes in the strip of wood, leaving loops through 
 'vhich the finger or thumb can be passed. The displaceil thumb 
 i-. then inserted under these loops, and then laiil upon the piece of 
 wiHid, where it is firmly held by drawing the tapes tightly over it. 
 and wiiuling their ciu^ around the projecting shoulder. Hy this 
 cnnirivance the operator secures a much firmer hold upon the 
 tluiinh than he could otherwise obtain. 
 
 Another method consists in manipulating the joints so as to 
 put the ilisplaced thumb in the position it occupiei.1 at the moment 
 (if dislocation. " Trial should be made of the excellent method of 
 I'rnf. Crosby, of New Hampshire, originated bj- him in l(S26, and 
 since recommended by Gerdy, of Paris. It simply consists in 
 pu-hing the phalanx back until it stands perpendicularly on the 
 iiictacari)al bone, when by strong pressure against its base from 
 hohinil forward, and by flexion it is reailily carried now into its 
 natural position." — Gross. This method consists, therefore, simply 
 in raising the thumb to a right angle with the hand, and pushing 
 its base — that is, the part which joins onto the hand — forward so 
 that it shall slip into position. 
 
 ' I 
 
 !:^- 
 
 m 
 
 •I 
 
 M 
 
 fi"; 
 
 r 'i^ii 
 
 *, 
 
 r 
 
 i'' I 
 
 i >i ■ 
 
if 
 
 11! ■ 
 
 lir 
 
 8l8 SURGICAL DISEASES. 
 
 Dislocation of the Fingers. 
 
 The fingers; may be displaced either forward or backward 
 The dislocation is easily recognized by the unnatural projection of 
 the bones. 
 
 The treatment consists essentially in the methods already de- 
 scribed in discussing dislocations of the thumb. 
 
 Dislocation of the VertebrsB. 
 
 The spinal column is composed of rings of bone which lie one 
 upon another, gradually decreasing in size from the lower to the 
 upper portion. These rings of bone are provided with several 
 projections and prominences by means of which they fit tightly 
 into one another ; they are furthermore bound together very firmly 
 by numerous ligaments and sinews. 
 
 The object of this security in the constrtiction of the spinal 
 column is to afi"ord the greatest possible protection to the delicate 
 nervous tissue which passes through the spinal column — the 
 spinal cord. So perfect is this structure that dislocations of the 
 vertebrae occur with comparative rarity ; indeed it often happens 
 that a man executed by hanging suffers no displacement of tL: 
 vertebra; of the neck, notwithstanding the sudden and violent 
 :strain upon the spinal column occasioned by his sudden fall from 
 the trap. 
 
 It does sometimes happen, however, that one or more of the 
 rings — the vertebra; — suffer displacement; this can only occur 
 from the application of great force. 
 
 The results vary according to the location of the displacement. 
 If some of the lower vertebra; are displaced, there results usually 
 paralysis of the lower extremities. If the vertebrae in the middle 
 of the back are dislocated, the paralysis affects the lower part of the 
 trunk also. If one of these rings in the neck is dislocated, the result 
 is often immediate death from suffocation. 
 
 Signs, — In some cases it i= possible to feel, by careful exami- 
 nation of the bony prominences in the back, that one or more of 
 the rings are displaced. The question is, usually, whether the vcr- 
 
DISLOCATION OK THE VliRTEBR^. 
 
 819 
 
 or backward. 
 1 projection of 
 
 >ds already do- 
 
 le which He one 
 le lower to the 
 sd with several 
 they fit tightly 
 ether very firmly 
 
 Dn of the spinal 
 
 I to the delicate 
 
 il column — the 
 
 ilocations of the 
 
 t often happens 
 
 lacemcnt of th: 
 
 en and violent 
 
 udden fall from 
 
 or more of the 
 can only occur 
 
 Jie displacement, 
 results usually 
 rae in the middle 
 [lower part of the 
 Icated, the result 
 
 ly careful cxami- 
 one or more of 
 kvhether the ver- 
 
 tebrae are dislocated or fractured. The question is not usually of 
 much importance from a practical point of view, since the effect 
 upon the patient is about the same in both cases. 
 
 Treflttneut. — A few cases arc on record in which dislocations 
 of the vertebra; have been reduced, and the patient has recovered 
 completely. Dr. Hodgen says that he " was once successful, by 
 pulling the head gently upward, in the case of a man whose head 
 was drawn backward and turned to one side. The accident in this 
 case was caused by falling from the top of a load of furniture, and 
 the patient had been totally unconscious for four hours, breathing 
 irregularly and noisily. The bones came into place with an audible 
 snaj) and the man was restored at once, swearing at the horse he 
 supposed he was still driving. " 
 
 The attempt may be made to reduce such a dislocation by 
 pulling the head and shoulders upward, while an assistant pulls the 
 legs and hips downward. Sometimes the effort can be assisted by 
 gentle manipulation of the dislocated vertebrs by a third individ- 
 ual. These movements should be made very carefully and gently, 
 since instances are recorded in which fatal injury has been done by 
 the attempt to reduce the dislocation. 
 
 In most cases all efforts to relieve the displacement will be un- 
 successful ; and even if the bones are replaced, the injury done to 
 the spinal cord cannot be repaired. It becomes necessary to pro- 
 vide means for securing regular evacuations from the bowels and 
 bladder, since the patient loses all ctMitrol over these organs. 
 
 The urine should be drawn three or four times a day with a soft 
 catheter. The bowels must be kept open, either with injections of 
 warm water or with the daily use of cascara cordial. This remedy 
 answers admirably in securing evacuations under such circum- 
 stances; yet, in some instances, it becomes necessary to supplement 
 its use with injections. 
 
 One of the most troublesome complications of this condition 
 is. the formation of bed sores. These form earliest over the bony 
 prominences of the hips and pelvis. To prevent their occurrence, 
 extreme care must be taken to wash the skin thoroughly, and to 
 harden it by means of frequent bathing with alcohol or brandy and 
 water in equal parts. 
 
 The skin can be protected also by the use of cushions. These 
 are best made in the shape of rings, upon which the patient's hips 
 
 'a\ 
 
 rtt 
 
 1] 
 
 Hi 
 
 li 
 
 m 
 
 i.;r 
 
 :i\l 
 
 ■J I 
 
 'i\ 
 
 •!n 
 
 'l"fli 
 If! 
 
 I 
 
 r H 
 
820 
 
 SURGICAL DISEASES. 
 
 rest whila the bony prominences fall within the ring. The 
 best form is made of rubber and filled with air, and known as " air 
 cushions. " 
 
 These can be imitated by making a tube of cloth or muslin, 
 stuffing it with cotton, wool or horsehair, and then sewing the ends 
 of the tube together, so that it takes the form of a ring. 
 
 The ultimate result is usually death ; the utmost care and 
 attention succeed only in prolonging the patient's life a few months 
 and rendering him more comfortable during this time. In a few 
 rare instances recovery has occurred. 
 
 Dislocation of the Hip. 
 
 This accident occurs only from the application of great xid- 
 lence, for the hip-bone is so snugly fitted into its socket, and is so 
 firmly bound in place by strong ligaments and powerful muscles 
 that a great deal of force is necessary in order to dislodge it fioni 
 its socket. 
 
 There is, therefore, in most cases, considerable injury to the 
 tissues of the leg and hip, as well as a dislocation of the bone. The 
 latter is by itself a comparatively slight accident, but occurrinL,^as it 
 usually does, in connection with serious injury to other tissues, a dis- 
 location of the hip must be regarded as a dangerous accident. 
 
 These misplacements usually occur in males, and most com- 
 monly during adult life — a fact which is doubtless due to the 
 exposure of such individuals to mechanical violence of all kindN. 
 In some few cases it has been known to result from the applicatieii 
 of slight force, such as the tvisting of the limb when the foot is 
 caught in the carpet ; in such iistances, there is usually some disease 
 of the bones, or of the tissues s'lrrounding them. 
 
 The head of the thigh-bone may be displaced in any one of 
 four ways : 
 
 First — It may be displaced upward and backward from its 
 socket, so that the head of the bone rests upon the pelvic bone. 
 This is the more common variety of dislocation of the hip. 
 
 Second — The head of the bone may be displaced downward 
 and inward, so that it rests on the front surface of the pelvic bone, 
 just below and outside of the groin. This dislocation occurs second 
 in frequency to the one just described. 
 
• DISPLACEMENT UPON THE BACK OF THE HIP-BONE. 821 
 
 Third — The head of the bone is sometimes displaced backward 
 and slightly downward. 
 
 Fourth — The dislocation results in the displacement of the 
 held of the bone upward and forward, so that it rests in the groin. 
 This is the rarest of all forms of dislocation of the hip. 
 
 1 
 
 'Ji 
 
 in any one ot 
 
 Displacement upon the Back of the Hip-bone. 
 
 This dislocation, the most frequent of all, is usually caused by 
 falling while the leg is drawn inward toward the other one. It may 
 also result from a severe blow upon the thigh. 
 
 SiifHS. — If the patient stand upon the sound limb, it will be 
 noticed : 
 
 F/rsi — The limb is rotated inward, so that the great toe rests 
 upon the instep of the other foot. 
 
 Second — The knee is bent and is held in front of that of the 
 other leg. 
 
 Third — The bony prominence at the upper end of the thigh- 
 bone, outside of the joint, projects more than that on the uninjured 
 side. The distance between this prominence and the front of the 
 hip-bone is less on the injured than on the uninjured side. 
 
 Fourth — The limb is fixed and rigid ; the hip-joint cannot be 
 moved by the patient nor by a second person. 
 
 Fifth — The injured member is shorter than the other limb. 
 
 If the patient be very fleshy, some of these signs may be 
 scarcely perceptible. If, on the other hand, the subject of the injury 
 be thin, it will often be possible to see and feel the dis{)Iaced bone, 
 or at least to perceive distinctly the unnatural swelling on the 
 back of the hip of the uninjured side. 
 
 Tins dislocation is recognized at once by an experienced 
 .surgeon. To non-professional persons it may at first seem that the 
 patient has suffered a fracture of the neck of the thigh-bone, rather 
 than a dislocation. In order to enable one to detect at once the dif- 
 ference between these two conditions. Dr. Hamilton arranges the 
 points of distinction in the following tables : 
 
 DISLOCATION UPON THE HACK OF THE HIP-BONE. 
 
 1. Very rare in aged perse ns. 
 
 2. Never caused by a fall upon the prominence on the outer side 
 of the upper end of the thigh-bone, called the" great trochanter. " 
 
 II 
 
 if- 
 
 :! t 
 
 r-A 
 
822 
 
 SURGICAL DISEASES 
 
 ■I 
 
 3. Absence of gratinfr. 
 
 4. Unnatural stiffness, or loss of motion. 
 
 5. Limb always shortened. 
 
 6. Limb almost always turned inward, drawn toward sound 
 limb, and bent. 
 
 FRACTURKS OF THE NECK OF THE THIGH-BONE. 
 
 1. Very frequent in old age. 
 
 2. Often caused by a fall upon the " great trochanter." 
 
 3. Grating sensation present. 
 
 4. Limb can be moved freely, except when motion causes 
 pain. 
 
 5. Limb not always shortened. 
 
 6. Limb never turned inward, but is almost always slightly 
 turned outward, and generally lies in the same direction with the 
 other limb. 
 
 Dislocation of the head of the thigh-bone forward toward tlic 
 groin is often caused by some force which draws the knee or foot 
 outward and downward. 
 
 Siffiis, — If the patient stand on the sound limb it will be 
 noticed : 
 
 1. The foot of the injured limb is advanced and the toes 
 turned somewhat outward. 
 
 2. The body is bent forward and toward the injured side. 
 
 3. There is an unusual flattening at the point where the other 
 side of the body exhibits the prominence of the upper part of the 
 bone. 
 
 4. There is an unusual prominence in the groin. 
 
 5. The limb is shorter than the sound one. 
 
 In many cases it is possible to feel a movement at the promi- 
 nent point in the groin when the thigh is rotated. 
 
 In the other varieties of dislocation of the hip, the symptoms 
 are very similar to those presented by the two forms just described. 
 The symptoms vary somewhat under different circumstances, but in 
 every case the deformity, the loss of motion and the shorteninj; 
 of the limb are sufficient to indicate the nature of the com- 
 plaint. 
 
 The non-professional observer can in almost every case, by the 
 exercise of care and attention, recognize a dislocation of the hip; 
 
DISPLACEMENT UPON THE BACK OK THE HIP-BONE. 
 
 823 
 
 )ward soiiiK 
 
 mb it will be 
 
 and the toes 
 
 in most cases this knowledge must suffice, since the detection of 
 the individual and separate dislocations requires an intimate knowl- 
 cdi;*-' of the anatomy of the parts concerned, and a practical 
 acquaintance with the signs of these riffcctions. A simple means 
 for recognizing a dislocation — a means applicable to all varieties 
 of displacement — is said to be the following: 
 
 A line is drawn with ink or lead pencil along the skin of the 
 limb from the bony prominence at the front of the hip to the bony 
 projection at the back of the haunch. If the limb be uninjured, 
 that is, if no dislocation has occurred, the upper end of the thigh- 
 bone should touch the lower border of this line ; if, on the other 
 hand, the hip has been dislocated, the upper end of the thigh-bone 
 lies above this line. 
 
 Dislocations of the hip are often complicated with fractures of 
 the neck of the thigh-bone ; and some of these fractures — those 
 in which the fragments are driven into each other or impacted — 
 frequently simulate a dislocation of the hip to a considerable degree. 
 The latter can, however, usually be distinguished from dislocations 
 by the fact that the limb can be moved, while in displacements of 
 the bone the limb is fixed and immovable. 
 
 Dislocations of the hip-bone in children are sometimes accom- 
 panied by a separation of the head of the bone from the neck. 
 This occurs in children only, because during early life the head of 
 the bone is not firmly attached to the narrow part which connects it 
 with the shaft. 
 
 Ti'ratiucHt, — The treatment of dislocations of the hip has 
 undergone a radical modification in the last few years. In former 
 times it was supposed that the chief obstacle to the restoration of 
 the bone to its proper place consisted in the contraction of the 
 powerful muscles constituting the hip and the thigh. Hence 
 mechanical appliances were emploj'cd whereby the limb could be 
 l)ullcd away from the body with extreme force. Systems of pulleys 
 were attached to rings in the wall or to the bed, and several men 
 exerted their utmost strength in pulling the thigh away from the 
 body. In one unfortunate instan :c, this feat was literally accom- 
 plished, the thigh being torn from the body. 
 
 A more careful study of the anatomy of the parts showed how- 
 ever that the chief obstruction in the reduction of these dislocations 
 was not muscular contraction, but a certain ligament which formed 
 part of the capsule or sac surrounding the joint. This fact was 
 
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 824 
 
 SURGICAL DISEASES. 
 
 brought to the notice of the profession largely by two distinguished 
 surgeons, Dr. Gunn, of Chicago, and Dr. Bigelow, of Boston. It 
 was demonstrated that there is a ligament which extends from the 
 hip-bone to the head of the thigh-bone, having a shape nmcli 
 resembling that of the letter Y. It is hence called the " Y " li^a. 
 ment. It was found that the head of the bone often escaped fiijui 
 the sac of the joint through this ligament, and that the presence 
 of the ligament constituted the obstacle to the restoration of the 
 head of the thigh-bone to its socket. 
 
 The recognition of this fact is followed by a change in tlie 
 methods of treatment, for it became evident that the object was no 
 longer to overcome the contraction of the muscles, but merely to 
 manipulate the bone so that the head should be slipped through tlie 
 opening, and should at the same time avoid the obstacle caused 
 by the twisting of the Y ligament. The present methods consist, 
 therefore, merely in such movements of the thigh as shall sccurctlie 
 passage of the head of the bone through the the capsule of the 
 joint. 
 
 These methods will be described, although their successful < .e- 
 cution requires a certain amount of experience and acquaintance 
 with anatomy. There is, however, a method which can be readily 
 employed, even by non-professional persons, and which often suc- 
 ceeds in reducing dislocations. 
 
 This method, which was first described by Dr. Allen, of Ver- 
 mont, is essentially as follows : 
 
 The patient is placed upon his back upon the floor; the oper- 
 ator stands over him, holding the injured limb between his legs. 
 The patient's leg is bent at the knee, so that the ankle conies 
 between the thighs of the operator ; the latter then clasps his hands 
 below the knee of the patient and lifts gently until the hitter's body 
 is raised from the floor. In this way the weight of the body is 
 made to pull away from the thigh. 
 
 After the patient has been held in this position for a few 
 seconds there often occurs a movement of the head of the thigh- 
 bone into its socket, accompanied by an audible click. 
 
 If this method fail, another attempt may be made by lifting 
 both legs of the patient instead of one ; after the limbs arc thus 
 held for a few seconds, the head of the bone often slides back into 
 its socket. 
 
 If both of these measures fail, it will be necessary to resort 
 
Allen, of Vor- 
 
 ;essary to resort 
 
 DISPLACEMENT UPON THE BACK OF THE HIP-BONE. 
 
 825 
 
 to the methods by manipulation. These vary according to the 
 particular dislocation which it is desired to reduce. 
 
 In most of these cases it becomes necessary to administer 
 ether ; first, in order to prevent the unconscious resistance of the 
 patient ; and, second, to relax the muscles. If no ether be admin- 
 istered, an extra amount of force must be eniplnyed, which may 
 occasion injury to the tissues or to the bone itself 
 
 The patient is placed upon some blankets spread upon the floor 
 or upon a hard bed. If the dislocated limb be the rit^ht one, the 
 operator grasps the ankle with his right hand and places the left 
 under the knee. 
 
 The leg is bent to a right angle at the knee, and the thigh to 
 something more than a right angle with the body. Care should be 
 taken not to bend the limb at the hip so much as to bring the thigh 
 in contact with the body, since the tissues about the joint may be 
 lacerated by manipulations of the limb in this position. 
 
 The thigh is then turned outward away from the body, while 
 at the same time it is rotated upon itself by pulling the ankle away 
 from the other limb. 
 
 At this point of the manipulation the direction of the leg is 
 therefore obliquely outward, while the thigh itself is inclined in- 
 ward. 
 
 The limb is then slowly extended, that is straightened at both 
 tlie knee and the hip-joint. It will often be found even at the first 
 attempt that the head of the bone drops into its socket during the 
 manipulation. Sometimes, indeed the reduction occurs quite 
 unexpectedly before the maneuver has been completctl. 
 
 Backward dislocation of the hip — the variety in which the 
 lioad of the bone lies behind its socket — is recognized by the 
 symptoms and signs already mentioned. 
 
 The treatment consists essentially in the measures already 
 described, though the attempt to reduce a dislocation by a manipu- 
 lation requires some modification. 
 
 The leg is bent at the knee at a right angle, and at the thigh 
 bo that this forms about a right angle with the body. 
 
 The thigh is then turned outward from the body, while at the 
 same time the entire limb is rotated outward by means of the hand, 
 which is applied to the ankle of the patient. 
 
 The limb is then slowly straightened at the knee and at the 
 hip. 
 
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826 
 
 SURGICAL DISEASES. 
 
 J 
 
 During this movement the head of the bone usually slips into 
 place. 
 
 Dislocation of the thigh-bone forward and inward under the 
 groin often results from violence applied to the foot while the limb 
 is placed obliquely to the body. It has repeatedly happentni to 
 individuals walking upon icy pavements, and is an occasional un- 
 pleasant incident in skating. 
 
 The body is bent forward; the foot of the injured limb is turned 
 somewhat outward, the heel being raised and placed against the ankle 
 of the other limb ; the knee is slightly bent, and cannot be straight- 
 ened without extreme pain ; the leg is shortened to a greater degree 
 than usually happens in the other dislocations. 
 
 If the individual be not supplied with much fat, the head of the 
 thigh-bone can usually be felt in its new position. 
 
 Treatrneiit, — One of the best methods for reducing this dis- 
 location is that practiced by Dr. Hamilton. 
 
 The patient lies upon the floor or on a hard bed. A folded 
 sheet is passed under the hips, the ends being crossed in front of the 
 body and held by two assistants on cither side of the bed, A third 
 assistant stands by the uninjured side of the patient, passes his hand 
 under the sound leg and seizes the ankle of the other limb. 
 
 The operator standi by the injured side of the patient, a folded 
 sheet is passed over his shoulders and carried between the patient's 
 thigh as high as possible under the injured limb. 
 
 The assistants who hold the ends of the sheet draw upon these 
 and thus hold the hips firm. The third assistant, standing by the 
 uninjured side of the patient, pulls the injured thigh toward him. 
 The operator raises his shoulders, and thus lifts the head of the 
 thigh-bone toward the head of the patient. 
 
 The method by manipulation is somewhat simpler, in that fewer 
 assistants are required. It is performed as follows : 
 
 The patient lies upon his back on the floor. The operator, 
 standing upon the side of the dislocation, grasps the ankle with one 
 hand and places the other under the knee. The limb is bent so that 
 the thigh stands perpendicularly to the body. 
 
 The leg is then turned outward by carrying the foot away from 
 the opposite limb. The leg is then rotated toward the other leg, 
 while at the same time the limb is carried across the front of the 
 body so that the knee is brought to the floor. 
 
DISPLACEMENT UPON THE HACK OF THE HIP-BONE. 827 
 
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 \e head of the 
 
 ^r, intliat fewer 
 
 In this way the head of the bone is hftcd upward and forced 
 somewhat outward. 
 
 In the hands of an experienced and skillful surfjcon, disloca- 
 tions of the thif^h-bone, when not complicated with fractures or 
 extensive injuries to the flesh, arc reduced without much difficulty. 
 Any other individual will probably find much trouble in effecting 
 the reduction. 
 
 In every case a non-professional person should first try the 
 method introduced by Dr. Allen, described above. If this fail, 
 he may attempt to use the appropriate method by manipulation ; 
 in all his efforts, however, he should be careful not to employ 
 much force, for the proper manipulation can be executed with but 
 a gentle amount of muscular effort on the part of the operator ; 
 anv Ljreater force usually causes harm and not <f()od. 
 
 If these efforts be unsuccessful, it will be better to await the 
 arrival of a surgeon, even though a day or two must elapse, than 
 to experiment with the injured limb. If a much longer delay be 
 unavoidable — and this may sometimes happen in a thinly-settled 
 country — another attempt may be made while the patient is under 
 the influence of ether. 
 
 After the reduction has been accomplished, the thighs should 
 be tied together for a week, and the patient should not rest the 
 weight of the body upon the limb for two weeks at least, for after 
 the hip has been once dislocated, a repetition of the accident may 
 occur even after slight violence. 
 
 In most cases it will be necessary to envelop the hip in hot 
 fomentations for several days, in order to reduce the swelling and 
 palliate the pain. 
 
 It occasionally happens that dislocation of the hip is followed 
 by more or less complete paralysis of the limb. This results from 
 pressure upon a large nerve which passes out from the body just 
 behind the hip-joint; the displaced head of the bone is pressed 
 against this nerve and drawn firmly upon it by the contraction of 
 the powerful muscles composing the hip. 
 
 The ultimate result is doubtful, dependent upon the amount of 
 injury which has been sustained by the nerve. The treatment of 
 this complication must consist in frictions of the limb with the hands 
 and with stimulating liniments (such as the soap or ammonia 
 liniments), and in the use of electricity. 
 
 After the hip has been dislocated for several weeks, it can be 
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 828 
 
 SURGICAL DISEASES. 
 
 reduced only with great difficulty and with some danger, for the 
 violence necessary to break up the bands and adhesions which have 
 been formed since the displacement of the bone, often causes a 
 severe and dangerous inflammation. These old dislocations shcnikl, 
 therefore, never be meddled with by non-professional persons. 
 
 Dislocation of the Knee-pan. 
 
 In discussing fractures of the knee-pan, it was remarked that 
 this bone is not attached directly to any of the bones of the lc{j, 
 but is simply located in the sinew or tendon of the large muscle 
 which forms the front part of the thigh. Its object is simply to 
 diminish friction where the muscle passes over the end of the thigh- 
 bone. 
 
 Yet, notwithstanding this fact — that the knee-pan is not bound 
 directly to the thigh-bone — it is not very frequently dislocated. 
 
 It may, however, be displaced by direct violence, such as a 
 fall upon the knee ; it sometimes is dislocated also by the sud- 
 den contraction of the muscles which are attached to its upper 
 border. 
 
 The knee-pan may be dislocated either outward or inward or 
 upward ; or it may be turned upon its edge, so that one border of 
 it rests upon the end of the thigh-bone, while the other projects 
 under the skin. The most common displacement is toward the 
 outer side of the leg. 
 
 Siffns. — This outward dislocation can be recognized by the 
 change in the form of the knee ; the front of the knee seems flat- 
 tened, while the knee-pan itself can usually be seen on the outer 
 side of the limb. 
 
 This dislocation is accompanied by a loss of motion in the leg, 
 the patient being unable to bend the knee. 
 
 The outward dislocation of the knee-pan is met with more fre- 
 quently in women than in men. This results from the peculiar 
 obliquity of the thighs in females ; for, in consequence of the 
 greater breadth of the hips in women, the thighs are directed 
 somewhat obliquely inward, and a violent contraction of the mus- 
 cles has a natural tendency, therefore, to displace the knee-pan 
 toward the outer side of the limb. 
 
DISLOCATION OF THE KNLE-l'AN. 
 
 829 
 
 tion in the leg, 
 
 A dislocation of the kncc-p;in toward the inner side of the 
 limb is accompanied by essentially the same symptoms ; the form 
 of the knee is somewhat different, since the prominence of the 
 knee-pan is now observed on the inner side of the limb. 
 
 That form of dislocation of the knee-pan in which the bone 
 rests edgewise, is extremely rare. It can be readily recognized by 
 the peculiar shape of the knee, which now presents a sharp edge 
 instead of its usual flat surface. In a few exceptional cases the 
 knee-pan has been turned completely over, so that the surface 
 which ordinarily rests upon the thigh-bone lies directly under the 
 skin. 
 
 Treatment, — In treating an outward dislocation of the knee- 
 pan, the patient rests upon his back upon the floor ; the leg is 
 straightened and the foot raised. 
 
 The operator stands facing the patient and places the heel of 
 the injured limb upon his shoulder; he then pushes strongly upon 
 the displaced bone, so as to force it back into its former posi- 
 tion. An inward dislocation is treated in essentially the same 
 manner. 
 
 A dislocation of the knee-pan upward results from a rupture 
 of the ligament or sinew which binds the little bone to the large 
 bone of the leg, called the tibia. The knee-pan can be readily 
 pulled back into its place, but slips up ag:'in as soon as the pres- 
 sure is removed, because the muscle which is attached to its upper 
 border pulls it upward onto the thigh. 
 
 The treatment of this dislocation consists, therefore, in meas- 
 ures which shall overcome the contraction of this muscle and hold 
 the knee-pan in place until the tendon which unites it to the leg 
 has healed again. This requires the application of a dressing simi- 
 lar to that which is employed in fractures of the knee-pan. For a 
 discussion of these the reader is referred to the chapter on this 
 latter subject. 
 
 The ligament heals after the lapse of seven or eight weeks, 
 and the patient regains the use of the limb. He should, however, 
 be careful not to subject the leg to any strain for several months 
 subsequently ; it is advisable for him to wear a strong elastic band 
 over the knee which shall assist in holding the knee-pan in position. 
 In many cases the ligament which joins the knee-pan to the tibia is 
 longer than natural and the movement of the limb is consequently 
 somewhat though not seriously impaired. 
 
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830 
 
 SURGICAL DISEASKS. 
 
 In treating a dislocation of the knco-pan in which the bone 
 lies edgewise on the front of the leg, the patient should be placid 
 upon his back, as before, the heel of his injured limb resting upon 
 the shouklcr of the operator. 
 
 The surgeon then presses in one direction with one hand upon 
 the upper border of the bone, while pressure is made in the oppo- 
 site direction against the lower border by means of a la'rge door- 
 key or some similar instrument. 
 
 In most cases several efforts must be made before the bone is 
 restored to its proper position ; the reduction may be assisted by 
 bending and straightening the leg several times while the pressure 
 upon the edges of the knee-pan is continued. 
 
 The difficulty lies, of course, in the contraction of the lar^'c 
 muscle to which the knee-pan is attached. In order to overcome 
 this an assistant may make firm pressure downward — that is, 
 toward the knee — by spreading both hands over the front of the 
 thigh a few inches above the knee-joint. 
 
 In all dislocations of the knee-pan, the joint becomes much 
 swollen. In the more favorable cases this swelling subsides in ;i 
 few days under the use of hot fomentations ; but in some instances 
 a serious inflammation, which may materially injure the structures 
 composing the knee-joint, occurs. In every case the manipulations 
 should be conducted as gently as possible, and hot fomentations 
 should be assiduously applied to the knee. The limb should be 
 laid upon a splint of wood extending from the hip to the ankle, 
 and fastened by means of a bandage applied to the leg and to the 
 thigh. 
 
 Dislocations of the knee-pan are apt to recur upon slight 
 provocation. It is therefore advisable for the patient to wear a 
 rubber or leather bandage around the knee for some months subse- 
 quent to the injury, and to take every precaution in avoiding severe 
 strains upon the limb. 
 
 Dislocation of the Cartilages of the Knee-joint. 
 
 It has been said, in describing the structure of joints in general, 
 that the surfaces of the bone which lie in contact are usually covered 
 by a thin layer of " cartilage " or " gristle. " In most cases these 
 pieces of cartilage are so firmly connected to the bone upon which 
 
DISLOCATION OF TIIK CARTILAGES OK Tllli KNliE-JOINT. 83 1 
 
 m 
 
 they rest that they arc not separated from it even by the violence 
 whicli may cause a dislocation. 
 
 The cartilajjes in the knee-joint, however, arc sometimes torn 
 .iway from the bone. This is particularly true of the two disks of 
 cartilage which rest upon the upper end of the large hone in the 
 \^.vr — the it/'ia. It sometimes happens that violence applied to the 
 knee or to the foot causes a tearing off of one or both of these 
 pieces of cartilage from the tibia, The piece escapes into the cavity 
 of the knee-joint, and not only interferes seriously with the move- 
 ments of the joint, but occasions such pain as to render the limb 
 practically useless. 
 
 SiffHS. — This is an accident which is rarely recognized by 
 non-professional persons, because it may not be accompanied by 
 ;iny change in the form of the limb. 
 
 It is indi . ted by the occurrence of a sudden agonizing pain in 
 the joint, aggravated by any attempt at motion. The leg cannot 
 be straightened, but remains in a slightly bent position. After the 
 acute symptoms have subsided, there remain pain and tenderness 
 in the knee ; by feeling the joint we can usually detect an especially 
 painful spot. 
 
 In many cases this condition is not regarded as very serious by 
 the patient, and the limb is not submitted to the inspection of a 
 sun'eon. In such cases there usually remains a permanent disa- 
 l)ility of the limb. It is important that the case be treated at once, 
 since by reducing the dislocation of the cartilage the usefulness of 
 the leg can be entirely rcstoied. 
 
 Treatment, — The patient is placed upon his back, the thigh 
 being bent at the hip and the leg at the knee. The operator places 
 one hand upon the ankle and supports the knee with the other 
 hand. He then bends the knee suddenly and forcibly, and imme- 
 diately straightens the leg, making at the same time a twisting 
 movement of the joint. 
 
 It sometimes happens that the first attempt at reduction is 
 successful, as is indicated by the perfect restoration of the move- 
 ments of the limb. In most cases several efiforts are required before 
 the reduction is accomplished. Indeed it often happens that all 
 attempts to reduce the dislocation arc unsuccessful until ether is 
 administered, when the cartilage is replaced with ease. 
 
 It has also happened that after several attempts have been 
 
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 83^ 
 
 SURGICAL DISEASES. 
 
 made unsuccessfully, and the undertaking is abandoned, the patient 
 has unconsciously succeeded in restoring the cartilage to its posi- 
 tion by movements of the limb. 
 
 After the dislocation has been reduced, it becomes necessary 
 to envelop the knee in hot fomentations, and to place it on a Ioiilj 
 splint, which shall secure perfect rest for the joint, for two weeks. 
 After the splint is removed, a knee-cap made of leather or strong 
 elastic should be worn, since the dislocation is very apt to 
 recur. 
 
 Dislocation of the Knee-joint. 
 
 The knee-joint is formed by the thigh-bone above, and the 
 large bone on the inner side of the leg called the tibia, below ; 
 there is, in addition, at the front of the joint, the small bone called 
 the patella or knee-pan. 
 
 By dislocation of the knee-joint we understand a displacement 
 of the tibia, which is dragged away from its natural position against 
 the lower end of the thigh-bone. Although this joint is a very 
 shallow one — that is, the sockets at the upper end of the tibia 
 are very shallow, in order to permit the extensive motion of the 
 limb — yet dislocations are quite rare. This freedom from dis- 
 placement is due to the firm ligaments by which the bones arc 
 bound together, as well as to the protection afforded by the tendons 
 or sinews of the large muscles. The displacement can, therefore, be 
 caused only by extreme violence; hence, a dislocation of the knee 
 is usually accompanied by extensive injury to the tissues of the 
 leg. 
 
 Dislocations of the knee are occasioned by direct or indirect 
 violence ; among the common causes are blows upon the leg and 
 twisting of the limb by false steps during rapid walking. It is 
 sometimes occasioned also by falling down stairs. 
 
 Signs. — A simple dislocation of the tibia can be easily recog- 
 nized by the evident deformity of the limb. I*" the tibia be dis- 
 placed forward, there is a swelling at the back of the knee and i 
 disappearance of the knee-pan, which falls into the depression at 
 the upper end of the tibia. 
 
 The large blood vessels and nerves which run to the leg and 
 foot lie just behind the end of the thigh-bone, at the knee-joint. By 
 
led, the patient 
 ige to its posi- 
 
 omes necessary 
 ace it on a loni,^ 
 , for two weeks. 
 ;athcr or stronc; 
 is very apt to 
 
 e above, and the 
 the tibia, below ; 
 small bone called 
 
 nd a displacement 
 il position against 
 1 joint is a very 
 - end of the tibia 
 e motion of the 
 reedom from dis- 
 ch the bones arc 
 d by the tendons 
 can, therefore, be 
 ation of the knee 
 the tissues of the 
 
 direct or indirect 
 upon the leg and 
 d walking. It is 
 
 :an be easily recog- 
 the tibia be dis- 
 of the knee and i 
 the depression at 
 
 run to the leg and 
 he knee-joint. By 
 
 DISLOCATION OF THE ANKLE. 
 
 833 
 
 a displacement of the bones, these vessels and nerves are sometimes 
 injured, as a result of which there may be numbness and paralysis 
 of the foot. 
 
 If the upper end of die tibia be dislocated backward, it forms 
 a prominence at the back of the knee, which is readily recognized 
 as the end of the bone. The front of the knee, meanwhile, con- 
 sists of the two large projections which belong to the thigh-bone. 
 The knee-pan is very prominent, and is bounded by a deep depres- 
 sion on either side. In a complete dislocation of the knee the limb 
 is shortened. 
 
 Treatnienf. — If there be no laceration of the flesh, a dislo- 
 cation of the knee can usually be reduced without much difn- 
 
 culty. 
 
 If the upper end of the tibia be dislocated forward, the leg 
 should be straightened as far as possible; an assistant then pulls the 
 leg away from the thigh, while the operator presses the displaced 
 end of the bone back into its proper position. 
 
 If the head of the bone be displaced backward, the knee is 
 bent forcibly over the thigh of the operator, while an assistant 
 pulls as before. 
 
 In some cases the dislocation can be reduced after previous 
 failures by using a rocking motion from side to side while the limb 
 is being pulled upon. 
 
 The injury is followed by great pain and swelling of the knee. 
 It is necessary to place the leg upon a splint, to which it is fastened 
 by means of bandages so as to secure perfect repose. The knee is 
 then covered with hot fomentations and surrounded with oiled silk 
 or rubber cloth. 
 
 After the swelling has subsided and the injury seems to have 
 been repaired, ey.reme care must be taken to protect the knee from 
 violent straining of all kinds. The patient should not stand or 
 walk upon the limb until he has been provided with a strong knee- 
 cap of leather or with a bandage. 
 
 Dislocation of the Ankle. 
 
 This is a frequent accident, often caused by alighting from cars 
 or carriages in motion and from falling down stairs. It is always a 
 serious injury and often results in the loss of the foot, since ampu- 
 tation is frequently necessary. 
 
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 834 
 
 SURGICAL DISEASES. 
 
 The ankle-joint is formed by the two bones of the leg above 
 and by the uppermost bone of the foot — called the astragalus — 
 below. The astragalus fits into a groove or mortise which is 
 formed by the bones of the leg. The weight of the body is trans- 
 mitted from the thigh to the foot by means of the large bone of 
 the leg called the tibia ; the lower end of this rests directly upon 
 the broad, curved surface of the astragalus. In order to prevent a 
 displacement sideways, the joint is provided with a bony shoulder 
 on either side of the astragalus : the inner shoulder is a projection 
 of the tibia, while the outer shoulder is the end of the fibula. The 
 astragalus is therefore covered above and on either side by the 
 bones of the leg. The result of this arrangement is, first, that the 
 ankle is protected from dislocations to a great extent ; and second, 
 that when a dislocation is effected, there occurs almost invariably a 
 fracture of one or both of the bones of the leg. 
 
 There are, however, dislocations in which the foot slips directly 
 forward or directly backward without breaking either of the bones 
 of the leg. 
 
 Signs, — Dislocation of the foot forward is an infrequent occur- 
 rence. It can be readily recognized by the deformity of the foot 
 and ankle. The heel disappears, since the heel-bone is pushed 
 forward under the ends of the bone of the leg ; an unusual protu- 
 berance is felt at the upper surface of the foot just in front of the 
 leg. 
 
 Dislocation of the foot backward can be recognized by 
 extreme length of the heel, the leg seeming to be planted at about 
 the middle of the foot ; the toes are pointed downward, the heel 
 upward. 
 
 Dislocation of the foot outward is accompanied by a fracture 
 of the lower end of the fibula, which is generally broken two or 
 three inches above the joint. This accident is therefore classed 
 among the fractures rather than the dislocations, and has been 
 already described under the head of " Pott's fracture. " It is 
 usually caused by a " turning over" of the ankle. The sole of the 
 foot is turned outward or even upward, while the inner side rests 
 upon the ground. 
 
 In some cases there is a fracture not only of the outer bone of 
 the leg — the fibula — but also of the projection from the tibia which 
 protects the inner side of the joint. 
 
 Dislocation of the foot inward is accompanied by a fracture of 
 
DISLOCATION OF THE ANKLE. 
 
 835 
 
 the lower end of the tibia, and sometimes with a fracture of the 
 fibula as well. In this case the sole of the foot is turned inward, 
 so that the outer edge rests upon the ground. 
 
 There sometimes occurs also an injury which is not necessarily 
 a dislocation, though the astragalus may be actually forced out of 
 place. This consists in a separation of the tibia from the fibula. 
 In the natural condition these bones arc bound tightly together by 
 moans of ligaments ; but in consequence of violence, such as a fall 
 upon the feet, the bones are sometimes sprung apart. If they be 
 widely separated the astragalus is forced up between them, causing 
 a stiffness of the ankle and a shortening of the limb ; there may 
 also be a fracture of one or both bones. This accident usually 
 results in permanent loss of movement in the ankle. 
 
 Treatment. — Dislocations of the ankle which are not accom- 
 panied by laceration of the flesh are usually reduced without diffi- 
 culty, and do not cause permanent impairment of Llie movements 
 of the joint. 
 
 The general plan is to make extension, that is, pull the foot 
 forcibly away from the leg, while at the same time the ends of the 
 displaced bones are forced backward into position. 
 
 In the backward dislocation of the foot, the leg should be bent 
 upon the thigh so as to relax the muscles which arc attached to the 
 heel ; in fact this measure is to be recommended in most of the 
 dislocations at the ankle. 
 
 Those displacements which are accompanied by fracture of the 
 bones must be treated according to the principles already laid 
 down in discussing fractures. 
 
 If there be extensive injury to the flesh, the condition is 
 always a serious one ; for in many instances amputation of the foot 
 becomes necessary In every case, it is true, in which there is a 
 chance of saving the member, the surgeon should postpone an 
 operation, but it frequently happens that after weeks have elapsed 
 it becomes evident that the bones are so injured as to be incapaule- 
 of supporting the weight of the body ; and it is better to relieve 
 the patient from the annoyance of the diseased bone. 
 
 All such injuries to the ankle as are complicated with wounds 
 of the flesh should be submitted to the care of the surgeon at ()nce ; 
 a neglect to do so may cost the patient a limb or even his life. 
 
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 836 
 
 SURGICAL DISEASES. 
 
 Dislocation of the Bones of the Foot. 
 
 The foot contains twenty-six bones ; seven of these constitute 
 the back part of the foot and lie under the bones of the leg. Only 
 two of these bones are of such size and prominence as to warrant 
 any especial reference to their dislocation. The others are, it is 
 true, occasionally dislocated, but only by violence which lacerates 
 and mangles the foot badly, so that the injury comes under the 
 head of wounds rather than of dislocations. 
 
 The upper bone of the foot, the astragalus, lies in contact 
 with the two bones of the leg, from which it receives the weight of 
 the body. This bone is sometimes separated from the other bones 
 of the foot, as from the tibia and fibula, by violence, usually ap- 
 phed in jumping or falling. 
 
 If the astragalus be displaced forward, it can be felt at the 
 front and upper part of the foot, while the rest of the foot is twisted 
 toward the opposite side. 
 
 If the astragalus be displaced backward, the foot is bent and 
 the heel projects to an unusual extent. 
 
 Treatment, — The bone can sometimes be brought into its 
 proper position by bending the leg upon the thigh and by pulling 
 the foot back into position, while at the same time pressure is made 
 directly upon the displaced bone. These efforts often fail, and it 
 becomes necessary to cut the large sinew which extends from the 
 calf to the heel. This operation should be performed only by a 
 surgeon. 
 
 If it becomes impossible to reduce the dislocation, the patient 
 may nevertheless have a very useful foot. To secure the best result 
 he must apply hot fomentations ev . y two or three hours until the 
 swelling and inflammation have subsided ; for months, conse- 
 quently, he should be careful not to place the weight of the body 
 upon the foot. 
 
 The five bones which connect the back part of the foot with 
 the toes — the metatarsal bones — are sometimes displaced by great 
 violence. This is a rare accident, and one which can rarely be 
 successfully treated except by an experienced surgeon. 
 
RUPTURE — HERNIA. 
 
 837 
 
 m 
 
 S'fe 
 
 rl I 
 
 Dislocation of the Toes. 
 
 This is a rare accident, and one usually associated with fracture. 
 
 TIk; great toe is the one displaced in almost all cases. The 
 treatment is essentially the same as that which has been described 
 in discussing dislocation of the thumb. 
 
 \4 
 
 Rupture — (Hernia). 
 
 3t is bent and 
 
 This term signifies a protrusion of any organ of the body from 
 the cavity where it naturally belongs ; thus we may have a hernia 
 of the brain or lung as well as of the bowels. Under the term 
 " rupture," however, people generally understand a protrusion of 
 the bowel from the cavity of the abdomen into one of the channels 
 found in the groin or around the genitals, and in this sense the 
 word is used in this chapter. 
 
 The chief forms of rupture are those in which the bowel 
 escapes into the upper part of the thigh, or through an opening 
 called the inguinal canal, or at the navel. We may, therefore, 
 speak of rupture as follows : 
 
 1. Inguinal hernia. 
 
 2. Femoral hernia. 
 
 3. Umbilical hernia. 
 
 The inguinal canal is an opening or channel which passes 
 obliquely through the abdominal walljustabove the bone at the lower 
 part of the front of the body. Before birth, this canal remains open 
 in order to permit the passage of certain organs from the abdomen 
 through the abdominal wall — a process quite natural to the devel- 
 opment of the child. After this has been accomplished the canal 
 diminishes in size, and is so firmly closed that in most individuals 
 the contents of the abdomen never escape. The opening of this 
 canal is, however, a weak point in the abdominal wall, and when 
 a person violently compresses the contents of the abdomen, as is 
 done during the evacuation of the bowels and during childbirth, the 
 intestines are sometimes forced into and through this canal, and 
 appear under the skin outside of the abdominal cavity. 
 
 In other cases the inguinal canal is not closed as usually 
 happens ; it remains open to such an extent that a fold of intes- 
 
 •I ^Ik 
 
 I 
 
 
 ^'U 
 
 
 ^■^ 
 
 
lu 
 
 838 
 
 SURGICAL DISEASES. 
 
 tine is found in it, even at the birth of the child. This condition 
 is called congenital hernia. 
 
 There is also another canal which leads from the abdomen a 
 short distance downward into the thigh, alongside of the lar<^e 
 artery and vein which passes from the body into the lower limb. 
 This canal is sometimes forced open by pressure of the abdominal 
 contents, a loop of intestine escaping into it and forming a slight 
 prominence under the skin at the upper part of the thigh. In cnn- 
 sequence of the greater breadth of the hips and pelvis in women, 
 this variety — the femoral hernia — is more common in women 
 than in men. 
 
 Umbilical hernia occurs usually soon after birth, though it mav 
 also begin in more advanced life. It results from weakness of the 
 abdominal wall at the point where the umbilical cord is attached in 
 the foetus. 
 
 Surgeons divide all ruptures according to the condition of their 
 contents into three classes : 
 
 1. Reducible hernias, those whose contents can be pushed 
 back into the abdomen. 
 
 2. Irreducible hernias, whose contents cannot be returned into 
 the abdominal cavity. 
 
 3. Strangulated hernias, that is, those which are constricted 
 at some point so that the passage of their contents and the circula- 
 tion of blood in them are obstructed. 
 
 The most frequent form of rupture is the inguinal hernia, 
 which occurs in males much oftener than females. It usually begins 
 immediately after some violent strain or exercise. This strain may 
 consist in lifting, jumping, etc. 
 
 In some cases the patient feels a sharp pain and soon after- 
 ward notices a lump in the groin ; at other times there will be no 
 especial symptoms to call attention to this part of the body ; the 
 patient observes simply a gradual swelling in the groin or (jf the 
 scrotum. 
 
 When the rupture is fully developed there is a swelling in this 
 part which may vary in size, being sometimes a« large as a man's 
 head ; it is usually somewhat tender and elastic, though easily com- 
 pressible. There is no redness of the skin nor other sign of inflam- 
 mation, the patient suffering no pain. 
 
 If the hernia consists of one or more loops of intestine which 
 have escaped through the inguinal canal, there may be some 
 
This condition 
 
 condition of their 
 s can be pushed 
 
 it be returned into 
 
 RUPTURE — HERNIA. 
 
 839 
 
 interference with the functions of the bowels ; the patient is often 
 troubled with constipation and sometimes with attacks of colic and 
 vomiting. In other cases the hernia d(jcs not contain the intestine 
 itself, but consists merely of some of the layers of fat — techni- 
 cally called omentum — which cover the intestines. In this case 
 the tumor is not so tense or clastic, and the rupture may cause the 
 patient no other trouble than the mechanical annoyance caused by 
 the swelling. 
 
 There are certain signs whereby we can distinguish a rupture 
 from other tumors which are present in the same part of the body. 
 Thus a hernia varies in size with the position of the individual ; it 
 is smaller when he lies down and larger when he stands erect. 
 In many individuals the swelling disappears entirely during the 
 
 night. 
 
 By directing the patient tc cough, and holding the hands upon 
 the base of the tumor where it joins the body, we can feel a decided 
 impulse transmitted to the fingers during the act of coughing. 
 Many persons can reduce the hernia, that is push it back into the 
 abdomen at will, though it usually reappears so .soon as the fingers 
 are removed. Irreducible hernia occasions several inconveniences. 
 After taking a full meal the patient is often troubled with dragging 
 pains in the abdomen and attacks of vomiting. It is in these cases, 
 too, that colic and constipation so frequently occur. 
 
 'Pi 
 
 111: 
 
 Treatinent. — In treating a reducible hernia the nsual plan 
 and one which should be always tried, is the use of a iruss. It is 
 very important that the hernia should be attended to, since it is 
 liable to cause serious trouble at any moment. In ordering a truss 
 it is customary to take the circumference of the body at the hips, 
 about midway between the bony prominence at the front of the hip 
 and the large bony projection at the upper end of the thigh-bone. 
 It is much better, however, to have the truss adjusted to the person 
 by one accustomed to the work ; for a badly-fitting truss not only 
 gives a great deal of annoyance, but is also somewhat dangerous, 
 since it deludes the patient with a sense of security, and may induce 
 him to make efforts and execute movements which will result in 
 injury to the rupture. 
 
 Several operations are practiced by surgeons for the radical 
 cure of rupture. These are more or less successful, but cannot be 
 relied upon always ; nor are they entirely devoid of danger. 
 
 ■ I ! 
 
 ' ; ' 
 
 d 
 
 n 
 
 \\i 
 
 ftiif^ 
 
IM» 
 
 iJ 
 
 i!i 
 
 
 840 
 
 SURGICAL DISEASES. 
 
 If a truss be applied while the patient is still a child or youth, 
 a permanent cure is often efifected, since the canal becomes gradu- 
 ally closed and strong enough to prevent the escape of the bowel 
 from the abdominal cavity. 
 
 It is highly important that the truss should be worn constantly 
 it would be much better if the patient would wear it even in bed. 
 By removing it for a few moments he frequently undoes the good 
 that it has taken weeks to accomplish, since the intestine may be 
 forced into the canal while the abdominal wall is unsupported by 
 the truss. 
 
 If some time must elapse before the patient can provide him- 
 self with a truss, a bandage should be applied which shall support 
 the abdominal wall until the truss can be obtained, A small pad, 
 made by folding soft flannel or cotton cloth, is placed over the 
 opening through which the rupture appears. A bandage is then 
 applied around the waist, and a second one is pinned to this in 
 front, and is passed between the thighs and fastened to the bandage 
 again behind. This second strip covers the pad, and holds it firmly 
 in position. Several layers of bandage may be applied until suffi- 
 cient protection is afforded. 
 
 The truss must usually be worn for several years, and perhaps 
 even during the entire life. The patient cannot be too careful in 
 the matter, since he is constantly liable to an accident which may 
 cost him his life. 
 
 When the truss is obtained, the rupture should be returned to 
 the abdominal cavity. To do this, the patient is placed upon his 
 back on the bed, the foot of the bed being slightly elevated. The 
 operator then exerts a gentle pressure upon the swelling from 
 below upward, kneading the tumor meanwhile so as to facilitate the 
 passage of the intestine into the abdominal cavity. No violence 
 should ever be used in this manipulation. 
 
 Strangulated Hernia. — A hernia is said to be strangulated 
 when the intestine is grasped or constricted so tightly at some point 
 as to prevent the passage of its contents along the bowel. 
 
 Strangulation may occur in an old as well as in a recent hernia. 
 Sometimes the patient is not aware that he has ever had a rupture 
 until the symptoms to be presently described occur ; in other 
 instances the individual has suffered for a long while from hernia, 
 and has perhaps become so accustomed to it that he neglects to 
 take proper precautions in the use of a truss and in the avoidance 
 of violent effort. 
 
hild or youth. 
 
 ecomes gradu- 
 
 of the bowel 
 
 jrn constantly ; 
 it even in bed. 
 ndoes the good 
 \testine may be 
 insupported by 
 
 an provide him- 
 ch shall support 
 . A small pad, 
 placed over the 
 bandage is then 
 inned to this in 
 d to the bandage 
 id holds it firmly 
 pplied until suffi- 
 
 ;ars, and perhaps 
 
 be too careful in 
 
 tident which may 
 
 RUPTURE — HERNIA. 
 
 841 
 
 Sffrnptoms, — The first symptoms of which the patient com- 
 plains are due to the obstruction of the bowels. This will be un- 
 derstood when it is remembered that a loop of the intestine is 
 forced into the canal and doubled upon itself so as to make a 
 knuckle-like protrusion. The result of this is that the contents of 
 the intestine cannot pass through the constricted part. 
 
 The first symptoms are, therefore, colicky pains, often accom- 
 panied by an accumulation of gas which distends the abdomen. 
 The patient experiences a sense of tightness in the abdomen; he 
 has a constant desire to evacuate the bowel, but his efibrts are 
 unavailing. After a few hours, vomiting occurs; the vomited mat- 
 ters are at first merely the contents of the stomach, but subse- 
 quently contain bile and even matters which can be recognized by 
 their odor as the contents of the bowels. The patient becomes 
 much prostrated ; the pulse is rapid and feeble, the skin pale, the 
 countenance exhibits anxiety and distress. There soon ensues an 
 inflammation at the seat of the constriction. The abdomen 
 becomes very tender and swollen. If no relief be obtained, the 
 parts begin to mortify and the patient sinks into a condition of 
 collapse which soon terminates fatally. 
 
 Treatment. — If these symptoms occur, no time should be 
 lost in securing the services of a surgeon ; for the patient's life de- 
 pends upon speedy and skillful relief. Until his arrival, the follow- 
 ing measures may be tried for the relief of the patient. The object 
 of treatment is, of course, to restore the intestine to its proper 
 position in the abdominal cavity. This can sometimes be accom- 
 plished by manipulation alone. 
 
 The patient should lie upon a bed the foot of which is elevated. 
 The knees are to be drawn up so as to relax the muscles. The 
 bladder and rectum should be emptied by the patient himself if 
 he is in a condition to accomplish it, otherwise by the use of a 
 catheter and by injections of warm water into the rectum. 
 
 If there be anybody present who is competent to administer 
 ether, the patient should be put under the influence of this drug; 
 otherwise he should be engaged in conversation, so as to divert his 
 attention from the manipulations which are to be performed. The 
 operator then grasps the tumor with both hands and very gently 
 compresses it. He should then attempt to pass the intestine up 
 through the ring, which can be plainly felt with the finger, at the 
 
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 .»!':« -hi 
 
 % 
 
 Z ■ n I; • 
 
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 m 
 
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 f L' r I. : 
 
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 6 ^ 
 
 
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 842 
 
 SURGICAL DISEASES. 
 
 base of the tumor. Great care and gentleness must be exercised 
 in this effort since unnecessary violence may cause serious injur}-. 
 
 The manipulation should be continued for twenty or thirty 
 minutes, unless the patient complain of extreme pain before the 
 expiration of that time. The return of the bowel to the abdom- 
 inal cavity will be indicated by a gurgling sound and sensation, 
 the tumor at the same time disappearing. 
 
 If this effort does not succeed, the patient should be placed in 
 a hot bath (100 degrees F). By this means the tissues are often 
 relaxed so that the loop of intestine can be returned to the abdo- 
 men with considerable ease. 
 
 If all these measures fail, the patient should take twenty or 
 thirty drops of laudanum, and cold applications should be made to 
 the swelling, A piece of ice, wrapped in flannel, may be bound 
 over the skin. It is important to inspect the skin every twenty or 
 thirty minutes, to see that it does not become too cold, a condi- 
 tion indicated by a ghastly whiteness ; for if the temperature be 
 lowered too much, mortification of the part will ensue. 
 
 It sometimes happens that, after the patient awakens from the 
 sleep which is induced by the laudanum, another effort may be 
 successful in reducing the hernia. 
 
 Care should be taken to avoid the use of purgatives or cathar- 
 tics ; these merely aggravate the patient's sufferings and render his 
 condition more precarious. 
 
 If all these measures fail, an operation must be performed. 
 The friends should reconcile themselves to this idea at once, and not 
 insist upon delay in the hope that the difficulty may be remedied 
 spontaneously. For this is one of the conditions in which delay is 
 not only dangerous but fatal ; in fact, an operation should be per- 
 formed just so soon as a faithful effort at reduction has proved 
 unsuccessful. 
 
 Strangulated hernia may occur either in the inguinal canal 
 or at the upper part of the thigh in the femoral canal. In the 
 latter case the symptoms are essentially the same as tho.sc just 
 described, and the remedies needed are identical. A femora! 
 hernia rarely attains a large size, and the chances for reducing it 
 without operation are not so good as in the case of inguinal 
 hernia. 
 
 The symptoms of strangulated hernia should be borne in mind, 
 and the possibility of this condition remembered whenever obstinate 
 
SPRAINS. 
 
 843 
 
 )C exercised 
 us injury, 
 ty or thirty 
 1 bcfurc the 
 the iibchim- 
 l\ sensation, 
 
 be placed in 
 
 les are often 
 
 to the abdo- 
 
 kc twenty or 
 Id be made to 
 jay be bound 
 rery twenty or 
 cold, a condi- 
 jmperature be 
 
 ue. 
 
 akens from the 
 effort maybe 
 
 tives or cathar- 
 and render his 
 
 be performed, 
 Ltonce, and not 
 lay be remedied 
 which delay is 
 should be per- 
 son has proved 
 
 inguinal canal 
 
 canal. In the 
 
 le as those just 
 
 lal. A femoral 
 
 for reducing it 
 
 tase of inguinal 
 
 borne in mind, 
 lenever obstinate 
 
 vomiting without any apparent cause occurs. For it sometimes 
 iiappcns that the loop of intestine which becomes strangulated is 
 ^o small that it does not produce any appreciable tumor ; it is only 
 by close inspection that even the experienced eye and finger can 
 detect a minute tumor. Cases have occurred in which patients have 
 died of strangulated hernia without any suspicion existing in the 
 minds of the friends or the physician as to the real nature of the 
 difficulty, which was discovered only by a post-mortem examination. 
 
 Sprains. 
 
 A sprain is a wrenching of a joint, whereby some of the liga- 
 ments — the bands which unite the bones — arc torn or severely 
 stretched. In many cases there occurs also an injury to the bones. 
 
 The severity of the injury varies extremely. A severe sprain, 
 while containing no element of danger to the life of the patient, is 
 nevertheless a serious injury, which may result in the permanent 
 impairment of the functions of the joint. 
 
 Ti'Cfftinent, — The first item in the treatment of a sprain is fcr- 
 fcct rest of the limb. In many cases it is advisable to apply a splint 
 in order to prevent any unconscious movement of the part. The 
 splints arc essentially the same as those which have been described 
 in treating of fractures. 
 
 A most valuable feature for reducing the swelling and pain con- 
 sists in wrapping the joints with cloths saturated witli water as hot 
 as can be comfortably endured. These fomentations should be con- 
 tinued for three or four hours. So soon as the pain and swelling 
 have somewhat subsided an elastic bandage or cap should be placed 
 around the joint. 
 
 Care should be taken in avoiding any violent movements of the 
 affected joint for some weeks after the injury. Some stiffness may 
 occur, which can be overcome by having the joint moved regularly 
 every day by an assistant. The restoration of the motions can also 
 be furthered by the use of some stimulating liniment, such as the 
 ammonia liniment. 
 
 In some cases serious disease of the bone follows a sprain. This 
 is the result of the original accident and cannot be averted by treat- 
 ment. 
 
 55 
 
844 
 
 SURGICAL DISEASES. 
 
 Bruises. 
 
 A bruise consists in the rupture of blood vessels by application 
 of violence, and the escape of the blood into the surrounding tis- 
 sues. 
 
 If no further injury be inflicted than the simple damage to tlie 
 flesh, perfect recovery may be expected with no other detriment 
 than the annoyance and pain occiisioned by the violence. 
 
 Trentment, — The object of treatment is to prevent, so far as 
 possible, the escape of blood into the tissues, and to promote the 
 absorption of the blood which has already escaped. 
 
 To check the flow of blood some cold application should be 
 made to the part. Ice or ice-water is the most convenient, and can 
 readily be obtained. It is not wise to apply leeches or to use other 
 measures for removing the blood which has accumulated in the tis- 
 sues ; for this blood is already clotted, and can best be removed by 
 the natural process of absorption. 
 
 The only danger to be apprehended occurs in case of exten- 
 sive lacerations of the tissues, by which a large blood vessel has 
 been injured. In such cases there is some danger of mortification 
 of the skin, and even of the flesh underneath. 
 
 In such instances it is absolutely necessary to keep the part 
 constantly moist and warm. This can be done by applying hot 
 fomentations over the entire surface, and renewing them as often 
 as the temperature is decreased. 
 
 In rare instances the blood accumulated in the tissues putrefies, 
 giving rise to the formation of matter. In this case the skin 
 should be freely opened and the blood removed, after which the 
 wound should be thoroughly an;! repeatedly cleansed with the fol- 
 lowing solution: 
 
 Listerine, . _ _ - - Two ounces. 
 
 Water, ------ Ten ounces. 
 
 Burns and Scalds. 
 
 The effects of burns or scalds vary with the degree of the 
 injury. If the damage to the tissues be not severe, nothing but 
 local treatment is required ; if, on the other hand, the surface be 
 
by applic:i^i'>n 
 rrounding tis- 
 
 damage to the 
 ther detriment 
 :ncc. 
 
 event, so far as 
 to promote the 
 
 ation shouUlbc 
 /cnient, and can 
 i or to use nthcr 
 ilated in the tis- 
 tbe removed by 
 
 m case of cxten- 
 
 jlood vcfiscl has 
 
 of mortification 
 
 o keep the part 
 by applying hot 
 tg them as often 
 
 tissues putrefies, 
 
 lis case the skin 
 
 after which the 
 
 ised with the fol- 
 
 kvo ounces, 
 jen ounces. 
 
 Ithe degree of the 
 
 ].verc, nothing but 
 
 id, the surface be 
 
 BURNS AND SCALDS. 
 
 845 
 
 extensively burned, the patient exhibits the signs of shock or col- 
 lapse. 
 
 The pain consequent upon a burn or scald can be most quickly 
 relieved by immersing the patient in a bath with a temperature of 
 about 70 or 75 degrees F. If this be not obtainable, cloths sat- 
 uated with warm water may be laid upon the part. 
 
 After the burn has he^^n thus treated for an hour, the limb should 
 be enveloped in cotton which has been saturated in carbolic acid 
 solution, two ounces of the acid being thoroughly mi.xed with two 
 qui'rts of water. If this be not at hand, the burned surface should 
 be thickly sprinkled with flour. 
 
 If the burn be superficial it will be necessary only to cover 
 the part with a piece of thin cloth smeared with vaseline, which 
 may be allowed to remain for a day and then removed. If, how- 
 ever, the burn be a deep one, there will be mortification of the 
 surface and pieces of skin and flesh will be separated by the forma- 
 tion of matter. It is very important that the dressing which is 
 applied be not allowed to adhere to the surface, since it will stick 
 to the skin, and its removal will occasion the patient much pain. 
 
 In cases of deep burns, the most satisfactory dressing con- 
 sists in placing the limb, or the entire patient, as the case requires, 
 in a permanent warm bath. The pain is thereby relieved, and the 
 separation of the mortified flesh proceeds most rapidly and satis- 
 factorily. This method is employed almost exclusively in the 
 renowned hospital in Vienna, Austria. 
 
 If this cannot be accomplished the limb should be enveloped 
 in soft cloths spread with vaseline ; this dressing should be 
 changed every day. So soon as matter begins to form the parts 
 shoiikl be thoroughly washed with warm water containing a little 
 carbolic acid or listerine (two ounces of listerine to eight ounces of 
 water) at every dressing. 
 
 If there be much pain in the burned surface, it can be relieved 
 by dissolving a tablespoonful of baking soda in a pint of water 
 and applying this by means of soft cloths to the surface. These 
 cloths must be wet every hour, in order to prevent them from dry- 
 ing and sticking to the surface beneath. 
 
 When the pieces of mortified flesh become of a dark color 
 there will usually be a fetid discharge. These pieces of flesh must be 
 removed with the scissors ; before doing this the limb should be 
 bathed for half an hour in warm water. 
 
 »l^»i[iHl ifv"' 
 
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 s ' y ' 
 
 
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 tsl 
 
 \\: 
 
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 1 I. 
 
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 846 
 
 SURGICAL DISEASES. 
 
 If the burn be extensive the patient is collapsed ; the skin is 
 pale and cold, the pulse rapid and feeble, the patient sometimes 
 unconscious. Stimulants must be applied at once ; hot bottles or 
 flat-irons wrapped in flannel should be applied to the feet and to 
 the sides of the body ; ammonia should be held i;ear the nostrils, 
 and a tablespoonful of whisky or brandy may be given in milk. 
 If there be much pain ten drops of laudanum may be added to 
 the whisky. 
 
 After the patient rallies from the shock, care should be taken 
 to supply him with liquid diet only for several days. Indeed, no 
 indigestible articles should be allowed for a week or two after the 
 injury, since such cases are frequently complicated with ulceration 
 of the small iutestine, a complication which would be aggravated 
 by the use of solid or indigestible food. 
 
 Diseases of the Teeth. 
 
 Nowhere else in the world are the teeth so poor and so liable 
 to decay as in America ; and as a result American dentists have 
 acquired that perfection which comes from extensive practice, and 
 are world-renowned. 
 
 It would be out of place to discuss in this work the particular 
 influences which seem to hasten the decay and irregularities in 
 development of the teeth which are so familiar in this country. 
 It may be said in general, that the artificial habits consequent upon 
 civilization are responsible for the deterioration of the teeth. It 
 seems reasonable to suppose, that in the natural condition of man- 
 kind the teeth would be as well preserved as thty are in wild ani- 
 mals ; in fact, observation of some of the lower races shows that 
 this supposition is well founded. 
 
 The consumption of artificially prepared food, which is the 
 universal custom among civilized peoples, seems to favor the decay 
 of the teeth by introducing several substances, especially acids, 
 which destroy the enamel of the teeth. Furthermore, the reten- 
 tion of particles of matter between the teeth results in the decom- 
 position of such matter and the formation of ?.cid substances. 
 
 Mechanical violence also favors the decay of the teeth. For 
 so long as the enamel is perfect the teeth are safe from decay, while 
 
 i. 
 

 d ; the skin is 
 ient sometimes 
 
 hot bottles or 
 he feet and to 
 ;ar the nostrils, 
 
 given in milk. 
 ay be added to 
 
 should be taken 
 ys. Indeed, no 
 or two after the 
 with ulceration 
 d be aggravated 
 
 DOor and so liable 
 jican dentists have 
 isive practice, and 
 
 work the particular 
 id irregularities in 
 xr in this country, 
 its consequent upon 
 
 n of the teeth. It 
 
 condition of man- 
 
 ,ty are in wild ani- 
 
 ;r races shows that 
 
 food, which is the 
 IS to favor the decay 
 ■es, especially acids, 
 Ihermore, the reten- 
 jesults in the dccom- 
 Icid substances. 
 of the teeth. For 
 
 ife from decay, while 
 
 DISEASES OF THE TEETH. 
 
 84X 
 
 the removal of a portion of this shell exposes the softer and more 
 destructible parts of the tooth to the action of corrosive sub- 
 stances which may be contained in the mouth. 
 
 If the teeth could be kept perfectly clean there would proba- 
 bly be no decay ; though it must be admitted there is a great dif- 
 ference in the natural preservative power of the teeth. Some 
 individuals, even though employing all possible means for keeping 
 the teeth clean, are unable to prevent decay. 
 
 The care of the teeth should be begun with their appearance 
 in the mouth. It is a mistake to suppose that the first set of teeth 
 require no attention since they will subsequently be removed. The 
 fact is that the foundation for many irregularities and difhculties 
 with the permanent teeth arises in a neglect to properly care for the 
 milk teeth. 
 
 The child should be taught habits of cleanliness with regard 
 to the teeth as well as elsewhere ; a small soft brush should be 
 used for the first set. 
 
 It is further advisable that the child's teeth should be inspected 
 occasionally by a dentist ; this is especially necessary if there be any 
 irregularities manifested in the growth of the teeth. For if care- 
 fully attended to the teeth can be straightened and arranged so as 
 to be almost perfect no matter how irregular they may seem to be 
 at the beginning. 
 
 Irregularities of the teeth have been the subject of much study 
 and attention on the part of educated dentists. A valuable paper 
 called " An inquiry ir.to the causes of irregularities in the develop- 
 ment of the teeth " has been recently published by Dr. Kingsley, 
 of New York, I'rom which the following extracts are taken : 
 
 " The peculiarities of the permanent teeth it is unnecessary to 
 describe in detail. In the departure from symmetry they assume 
 almost every variety of position, so that it would be almost impos- 
 sible for the human mind ta conceive of an irregular arrangement 
 which would not find its counterpart in nature. 
 
 " These variations are recognizable by every one ot extended 
 observation, and are deformities, because they are a grf.ater or less 
 departure from a normal standard. Such a standard cannot in the 
 very nature of things be one shape to which all must conform or be 
 classed as deformed. 
 
 " Symmetry and harmony do not imply uniformity ; and the 
 dental art may developed up to the highest type of perfection, and 
 
 ■F, 
 
 ri'^^ 
 
 ■iif 
 
 if;i 
 
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 i;:tS 
 
 I ^ 
 
 in 
 
 5f! 
 
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 848 
 
 SURGICAL DISEASES. 
 
 yet there exist as great a variety of forms as there would be in the 
 faces of the aggregated beauties of the world. 
 
 " In 1864 Messrs. Cartright and Coleman, of London, made 
 an examination of some 200 ancient skulls in the crypt of Hythc 
 Church, Kent. These skulls, of which there is no authentic history 
 further than that they have been there for centuries, were appar- 
 ently of both sexes and all ages. 
 
 " The jaws presented in all instances unusually well developed 
 dental arches. The teeth were remarkable for regularity of position, 
 only two deviations being noticed ; one upper canine shut within 
 the lower jaw, and one bicuspid was turned upon its axis and there 
 might have been other slight irregularities which were unnoticed, 
 but in no single instance was there anything seen approaching to 
 that which under the term ' contracted arch ' so commonly exists 
 in the present day. 
 
 " The average width of the dental arch in these skulls, from the 
 outside of the first molar to the corresponding point, was two and 
 a half inches. 
 
 " In 1869 Mr. John R. Mummery, of London, contributed to 
 the Odontological Society of Great Britain the most valuable paper 
 on this subject which I have ever read. I accord more importance 
 to his personal examinations than I do to the observations of any 
 man not a practical dentist. The statements of all others, even 
 those of ethnologists, being less precise and more general in their 
 character, must be accepted with some allowance. 
 
 " He examined all the available skulls of ancient races and of 
 modern uncivilized races to the number of about three thousand, 
 and tabulated more than one-half of them, which were classified as 
 follows: Ancient British, 203 ; Roman British, 143; Anglo-Saxon, 
 "j^ \ and Ancient Egyptian, 36. Of modern uncivilized races; 
 North American, 145; Polynesiai., 204; East Indian, 223; 
 African, 438 ; and Australian, 165. 
 
 " From a careful analysis of the measurements given in histables 
 I find that the average width of the dental arch, from first molar 
 across to first molar, in the skulls of ancient races, wa: a trifle less 
 than two and three-eighths inches ; the same measurement of the 
 uncivilized moderns showed an c verage width of a trifle above two 
 and a half inches. 
 
 " The narrowest measurement given by him of any skull of any 
 race is two and one-eighth inches. 
 
DISEASES OF THE TEETH. 
 
 849 
 
 Id be in the 
 
 " The highest average of any race is nearly two and three- 
 quarter inches, and these belong to the New Zealander, the Fiji 
 Islander and the Ashantees. 
 
 " The narrowest average was found among the Hottentots and 
 Bushmen of South Africa. 
 
 " In these tables there is abundant evidence that the full measure 
 and type of both dental and maxillary arches has been sustained 
 among all races of simple habits, of all ages. 
 
 " Dr. Nichols, a dentist who spent twelve years in the Rocky 
 Mountains on the Pacific coast, during which period he examined 
 the mouths of thousands of Indians and Chinese, informed me that 
 he never saw an instance of irregularity of the teeth in either of 
 these races, with but one exception, and that a displaced canine in 
 the mouth of a Chinese woman. The jaws of both races are uni- 
 versally well formed and amply developed ; and this is also true 
 of all semi-barbarous and savage races of good physical organ- 
 ization. 
 
 " The standard of normality of the dental arch is a curved line 
 expanding as it approaches the ends, and the teeth all standing on 
 that line. 
 
 " Abnormality will include such a shape of the arch as is not in 
 harmony with the surrounding features — all crowding and twisting 
 and all departures from a regular line in the positions of the 
 teeth. 
 
 " Almost the only answer received by the dental student as to 
 the cause of these irregularities has been ' premature extraction 
 of the milk teeth,' and consequent contraction of the jaw; and this 
 answer has been almost universally accepted without a question as 
 to its philosophy. 
 
 " It is only within a few years that any one has been bold enough 
 to doubt the universally accepted theory which so glibly accounted 
 for every presentation of abnormality. 
 
 " No one of extended observation will hesitate in believing that 
 there is a faculty or power at work, modifying materially the phy- 
 sique of the present generation, altogether inexplicable by the 
 too commonly asserted influencing power of climate, hygiene or 
 diet. 
 
 " One of the most alarming characteristics of the present age 
 and the present civilization is found in the rapidity of its move- 
 ments and the activity of its mind, in the larger aggregate of highly 
 
 % ■ ; if 
 
 ■rf : 
 
 l\'l'f 
 
 \i 
 
 !ir' 
 
 ll 
 
 rm 
 
 'Hi 
 
 'U ' 
 
 \% 
 
 1 1 
 
 ii 
 
 n 
 
 It 
 
 f r- 
 
I) 
 
 
 
 850 
 
 SURGICAL DISEASES. 
 
 organized and excessively developed nervous systems and in the 
 increasing tendency to nervous and brain diseases. 
 
 " As the peculiarities of progenitors in mind, temperament and 
 physique are by nature stamped upon their offspring, we see a gen- 
 eration of children inheriting a tendency to a nervous exaltation 
 which every slight favoring circumstance encourages and stimulates. 
 This is unquestionably more noticeable in the centers of luxury in 
 this country than in any other portio.i of the civilized globe. 
 
 " Fathers who are under a mental strain to the verge of insanity 
 transmit that exr.lLation to their offspring. Children are no longer 
 children except in their immature physical development ; their 
 emotions are under constant stimulus and excitement, and if there 
 is not in all insta ■ es an absolute intellectual pi«ecocity, wc h;ive 
 relatively a mental aii' ?rvous development far in advance of the 
 physical. Hence if tli mental is only up to the average of its 
 years, we find it associattj .vith anything but a robust physique; 
 and the contrast remains the same. One of the manifestations of 
 this precocious emotional and exquisitely developed nervous sys- 
 tem is its influence upon the development of the teeth, while the 
 physical system is following in tardy but vain efforts to keep pace 
 with it. 
 
 " My argument from this universally recognized condition i^ 
 this : During the formative and eruptive periods of the permanent 
 teeth, they are under the influence of an independent and peculiar 
 vital force ; this innervation pushes on their development and erup- 
 tion regardless of the more tardy growth of the bony system ; 
 being implanted in a crowded position, in undeveloped jaws, they 
 never have an opportunity to recover from it, and emerge in the 
 same disordered arrangements in which the crowns were formed. 
 
 " The grounds for such an opinion are not merely, theoretical but 
 are the results of observations in private practice for nice tlian a 
 quarter of a century. 
 
 " In a personal investigation of the mouths of congenital idiots 
 found in the asylums of this country, in Great Britain and iM'ancc, 
 together with the Cretins of Switzerland, are found with hardly an 
 exception broad jaws and well-developed teeth, showing that when 
 the mind was inactive and the brain sluggish the teeth grew nor- 
 mally and in regular order. 
 
 " A perfect dental development is the result of well-balanced 
 physical and nervous systems, without hereditary taint. 
 
DISEASES OF THE TEETH. 
 
 851 
 
 i.r 
 
 , and in the 
 
 eramcnt and 
 ve see a gen- 
 us exaltation 
 id stimulates. 
 
 of luxury in 
 
 globe. 
 
 •ge of insanity 
 
 are no longer 
 )pment ; their 
 :, and if there 
 ocity, wc have 
 idvancc of the 
 
 average of its 
 3ust physique; 
 anifestations of 
 d nervous sys- 
 ;ceth, while the 
 ;s to keep pace 
 
 :cd condition i:^ 
 f the permanent 
 ;nt and pecuhar 
 
 ment and cnip- 
 bony system; 
 
 ped jaws, they 
 ,d emerge in the 
 
 were formed. 
 ly theoretical but 
 
 "or more than a 
 
 Ico 
 
 ngenital idiots 
 
 tain and iMancc, 
 
 with hardly an 
 
 nving that when 
 
 I teeth gvew nor- 
 
 lof well-balanced 
 taint. 
 
 " There can be no question that the Creator intended there 
 should be perfect harmony in the development of physical and 
 nervous systems, and that where such harmony exists we come 
 nearest to the standard of a perfect organization. This harmony 
 of organization, or true balance of the two systems, demands that 
 in the earlier years of life the brain and the nervous system be held 
 in abeyance to the physical. 
 
 " The healthier mental organization is of slower growth. If, 
 therefore, we find that a certain mode of life destroys this harmony 
 — breaks up this balance — there will follow necessarily deteriora- 
 tion and destruction of the race ; and this is based on well-recog- 
 nized physiological law. If the brain and the nervous system are 
 in an undue state of activity, the drain upon the sources of nutri- 
 tion will be at the expense of the physical system. 
 
 " No force operating on the brain can interrupt or alter the 
 type or inherited model of the dental arch, after the first ten 
 years of life. 
 
 " I do not hesitate to place it upon record that the next genera- 
 tion will see more of abnormality in dental development, and an 
 increase of nervous and cerebral diseases, and that the two are 
 related and spring from the same cause. 
 
 " It is too late to stop it in those who have passed infancy, 
 but it is not too late to modify and partially remedy the evil in 
 those now being born, and those who may be begotten hereafter. 
 
 " To fathers and mothers surrounded by luxury and flattered 
 with the precocity of their infants, which they are stimulating to 
 the last degree, I say you are the enemies of your race ; you are 
 sowing the seed of nervous, mental and physical disorders from 
 which the harvest will be fearful, and the end death to your family 
 and to your name. Do not, under peril, encourage this brilliancy 
 of your child, which is now so charming rather let the mind 
 
 stagnate. 
 
 " For the first seven years of life give concern o/i/jf o his morals 
 and to his physique ; nourish him as you would nourisli na animal 
 from which you desired the finest development, stimulating only 
 his moral nature, and his intellect will take care of itself. Thus, 
 if he have no hereditary taint, you will have laid the foundation of 
 a splendid specimen of his race. " 
 
 K 
 
 i. 
 
 
 J 
 
 » 1 
 
 .;i 
 
 I W>i 
 
8S2 
 
 SURGICAL DISEASES. 
 
 Toothache. 
 
 The most frequent causes of toothache are : 
 
 First — Decay of the tooth extending to the nerve contained in 
 the pulp of the tooth. 
 
 Second — Inflammation of the membrane surrounding the root 
 of the tooth. This usually causes a swelling of the gum, and the 
 formation of an abscess or a " gum boil." 
 
 Third — The general condition of the body, which predisposes 
 to neuralgia. 
 
 Treat^nent. — ^The treatment depends upon the source of tlie 
 pain. There is no one remedy which can be relied upon to cure 
 toothache in general. 
 
 If the tooth be decayed, a dentist should be consulted and his 
 opinion so ight ; co the advisability of removing the tooth. 
 
 In many cases it is possible for him to devitalize the pulp of 
 the tooth, all the cavitv and retain a useful member. 
 
 Until the hv.. vicca of a dentist can be procured the pain can be 
 alleviated by the application of oil of cloves, creosote, chloroform, 
 laudanum, or Jamaica ginger. The cavity of the tooth should be 
 cleaned with a little cotton ; a few drops of one of the substances 
 named is then placed upon a small wad of cotton, which is then 
 gently inserted into the cavity of the tooth. 
 
 If the toothache be caused by inflammation at the root of the 
 tooth, it can sometimes be quieted by painting the gum with a 
 mixture of tincture of aconite and tincture of iodine in equal parts. 
 Sooner or later, however, matter will form at the root of the tooth ; 
 the abscess should be opened at once. Such teeth are usually of 
 no service, and may be extracted. 
 
 Toothache which originates not in any local difficulty around 
 the tooth, but in a constitutional condition, must be treated by 
 internal remedies. In many cases advantage will be derived from 
 the internal use of quinine, two grains of which may be taken 
 three times a day. 
 
 Toothache is sometimes of malarial origin ; it may come on 
 every second day, just like the chills and fever of ague. In such 
 cases it must be treated by quinine. 
 
:rve contained in 
 
 funding the root 
 le gum, and the 
 
 ?hich predisposes 
 
 the source of the 
 ied upon to cure 
 
 consulted and his 
 
 the tooth. 
 
 talize the pulp of 
 
 aer. 
 
 ;d the pain can be 
 
 psote, chloroform, 
 
 tooth should be 
 the substances 
 
 )n, which is then 
 
 it the root of the 
 the gum with a 
 e in equal parts. 
 oot of the tooth ; 
 h are usually of 
 
 difficulty around 
 t be treated by 
 be derived from 
 may be taken 
 
 ~~|it may come en 
 ague. In such 
 
Mad Dog. 
 
 Scorpion. 
 
 Rattlesnake, 
 
 Tarantula, 
 
 %iV-.U'^^ 
 
 
 
 Centipede 
 
 XoppiertWid. 
 

 ?i?? 
 
 pion. 
 
 ik T 
 
 li^jm 
 
 ara 
 
 ntula. 
 
 :^ 
 
 
 I *t'>My».»j<' j) 
 
 ''', i'l'J'^^^V 
 
 . .r-,#<t; 
 
 jpper 
 
 ^n-„ 
 
 \'S AND TilEIR ... 
 
 .ire certair subsvanc' 
 wliiclr arc always p- 
 -•"ly ot.h>. r nmtcriiii-:. ,■ ,,. 
 
 '''.i'^ i)r in rfTtai-! --".i.-.r'' 
 
 ■ tage <if t!: 
 
 \C\t their inJ! 
 .'-ucl. .lb pruss- 
 tll"erK f.iii-c 
 
 i . '- :• - 
 
 ;h and 
 Cht- a^■<:■nues 
 ' ing nibbed u^ 
 ■ i ibrasion. 
 into tlu^ stomat. 
 / ir- hlnriil in an iiici' 
 
 '■i^h thk^ memi' 
 The r.i.. .. .. ,. 
 
 -n\3 v.'Vijeh Occur ^f^ Food. 
 
 lis of li; ' 
 
 ige. 
 
 853 
 
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 \y 
 
 \'R 
 
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 f:t • -.1 
 
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 hi' 
 
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 S; ■■ .5 
 
 
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 C^ntipade. 
 
POISONS AND THEIR ANTIDOTES. 
 
 There are certain substances which all recognize as poisons — 
 substances which are always poisonous to all persons. There are, 
 however, many other materials which are poisonous only under 
 certain conditions or in certain quantities ; such substances furnish 
 a large percentage of the cases which come under the care of the 
 physician. 
 
 Poisons exert their injurious effect upon the body in various 
 ways. Some, such as prussic acid, arrest the action of the heart 
 at once, while others cause a gradual change in the functions of 
 other organs. Poisons are often introduced into the system by 
 being taken into the mouth and swallowed ; yet they can be intro- 
 duced by any of the avenues of approach — by being breathed 
 into the lungs, by being rubbed upon the skin, or by simple con- 
 tact with a scratch or abrasion. 
 
 Poisons taken into the stomach when this organ is empty are 
 absorbed into the blood in an incredibly short time. It has been 
 repeatedly demonstrated that poisonous liquids appear in the blood 
 within a few seconds after they have been taken into the stomach. 
 If the stomach be full of food, absorption is less rapid and the 
 probabilities for the removal of the poison are much greater. 
 
 When taken into the body by being inhaled, poisons usually 
 manifest their effect at once, since no appreciable time is required 
 for their passage through the membrane of the lungs. 
 
 Numerous cases of poisoning from the use of injurious sub- 
 stances in food and in articles of clothing arc brought to the 
 notice of the physician. The most common of these will be men- 
 tioned in the following pages. 
 
 Poisons which Occur in Food. 
 
 Probably the most common form of poisoning by food is Icad- 
 poisoning. The symptoms of this affection have been already 
 described on a previous page. 
 
 853 
 
 
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 li •. 
 
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 i 
 
 u;! :t 
 
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 m 
 
 n 
 
 i 
 
 1! 
 
 m-m ^ 
 
i' 
 
 854 
 
 POISONS AND THEIR ANTIDOTES. 
 
 The most frequent source of lead which is taken into tlic 
 stomach is drinking; water. Some springs and wells contain lc;ul 
 in such quantity as to render them unfit for use ; but the lead is 
 not usually obtained from the ground, but from the service pipes. 
 Dr. Chandler, of New York, found one-tenth of a grain of lead in 
 a gallon of Croton water, after it had stood for six hours in a Ic.ul 
 pipe. 
 
 Many drinking vessels also contain lead ; even those wliicli 
 are made of Britannia metal or other material that is itself fico 
 from lead, contain a good deal of this metal in the solder with 
 which the parts are cemented together. It was found in one 
 experiment that water which had stood twenty-four hours in such a 
 vessel contained lead in the proportion of over eleven grains to 
 the gallon. The occasional use of such water probably causes no 
 injury, but the long-continued employment of it may result in the 
 symptoms of lead-poisoning, even if there be no more than one- 
 tenth of a grain of the metal in a gallon of water. 
 
 Cans and other vessels used to preserve fruits, lobsters, etc., 
 are frequently soldered in such a way that the lead contained in the 
 solder becomes mixed with the contents of the can ; if these con- 
 tents contain free acids there may result also chemical combina- 
 tion with the solder, so that the lead is dissolved in the liquid 
 contained in the vessel. 
 
 Some years ago, an extensive series of cases of lead-poisoning 
 in New Orleans was traced to the drinking of soda water from a 
 particular and popular fountain. It was discovered that the reser- 
 voirs were so constructed as to permit the solution of lead com- 
 binations in the soda water. A S<:otch chemist rece-ntly found half 
 a grain of lead in a gallon of soda water. 
 
 Vinegar often contains lead as an impurity, resulting from the 
 manufacture. 
 
 All vessels, pipes, spigots, and the like, which contain lead, 
 and are exposed to the action of acid liquids, are liable to furnish 
 a poisonous element in the liquids which pass through them. 
 
 Many cooking vessels are lined with materials containing lead; 
 this is said to be true of some of the so-called porcelain-lined ves- 
 sels. 
 
 Instances are known in which lead-poisoning has followed the 
 use of flour from a certain mill. Investigation shovi^ed that tiie 
 mill-stones, having been worn so as to become uneven, had been 
 
^r^r^^i 
 
 POISONS IN SUGARS. 
 
 «5S 
 
 iTpaircd by fillinpj up the cavities with molted lead ; particles of 
 tliis iiad been worn away and mixed with the flour. 
 
 Copper Poisoning from Food. 
 
 lead-poisoning 
 
 ;elain-lined ves- 
 
 Thcre are various compounds of copper, which are occasion- 
 ally found in different articles of food, and which cause injurious 
 effects when taken into the body. The most commonly met with 
 of these is the sulphate of copper or " blue vitriol." 
 
 Compounds of copper are frequently used in coloring; pickles, 
 and for prescrvin<f the color of vc^ijetables, such as ^rccn {)eas, 
 wliich have been canned and preserved. Prof. Redwood found 
 that cans containing from eight to ten ounces of peas, furnished 
 one or two grains of blue vitriol. 
 
 Copper is sometimes mi.xed with the food from cooking uten- 
 sils made of copper or brass. The copper is separated from these 
 vessels by acid liquors, by oils and fats, and by salt water. Several 
 ca'^es arc on record in which serious, and evtn fatal, poisoning has 
 occurred from the use of food cooked in copper and brass 
 vessels. 
 
 Poisons in Sugars. 
 
 There has been a great deal of popular discussion upon the 
 possibility of poisoning from sugar. The fact is, that while sugar 
 is largely adulterated, yet but little matter of a poisonous sort 
 finds its way into the ordinary varieties of sugar. 
 
 It has been asserted that sulphuric acid may be present in suf- 
 ficient quantity to cause injury. The fact is, that although sul- 
 phuric acid is used in the manufacture of the cheaper sugars, yet 
 it is so effectually removed that it causes no perceptible effects. 
 
 Numerous analyses have been made by chemists in different 
 parts of the world, as a result of which it seems to be well estab- 
 lished that there need be no fear of using sugar because of the 
 presence of sulphuric acid. Prof. Chandler, of New York, exam- 
 ined for the Board of Health of that city, a large number of speci- 
 mens of sugar obtained from the stores, without finding any 
 injurious articles. 
 
 Hi 
 
 \\\ 
 
 \v 
 
 ^M 
 
 : h, i 
 
I 
 
 856 
 
 POISONS AND THEIR ANTIDOTES. 
 
 Some time ago it was asserted that a serious illness was caused 
 by a specimen of syrup obtained in a town in Michigan. Prof. 
 Kedzie, President of the State Board of Health of Michigan, made 
 an analysis of seventeen specimens of syrup, one of which was the 
 article in question. He found that sulphuric acid was present in 
 three of\the samples, though not in quantity sufificient to cause 
 injury. 
 
 It has been asserted that white sugars sometimes contained 
 compound of lead, since sugar of lead is known to be used in 
 decolorizing sugars. A number of examinations of sugar have 
 failed to reveal the presence of lead in quantity sufficient to arouse 
 suspicion of an injurious influence. 
 
 Many syrups contain compounds of iron, which are introduced 
 from the vessels in which the sugar is melted or the cane is 
 crushed. No injurious effects are, however, to be apprehended 
 from this source. 
 
 Poisoning from Colored Fabrics. 
 
 A large number of cloths and papers used in the arts are 
 colored with compounds of arsenic ; and many articles for personal 
 wear are colored with aniline dyes which, in most cases, contain 
 arsenic as an impurity. 
 
 Wall papers, window shades and carpets are frequently colored 
 green with what is popularly known as Paris green, a compound of 
 arsenic and copper. In course of time the wear on the carpets, 
 wall papers, etc., liberates a number of particles of arsenic which 
 float in the air and are inhaled by the occupants of the room, 
 Chemical examination of the dust in rooms containing these aiticle.s 
 has repeatedly shown tlie presence of a perceptible quantity of 
 arsenic. That this quantity may sometimes become a dan^^erous 
 element can be comprehended when it is known that a square foot 
 of wall paper has been found by analysis to contain thirty-five 
 grains of arsenious acid (white arsenic). Dr. Kedzie, of i\Iichii,Mn, 
 examined the paper in five cases in which poisoning had occurred; 
 he found from one to five grains of arsenic in every square foot of 
 the paper. 
 
 Aside from these articles — wall paper, etc. — there are numer- 
 ous articles in every-day use which are colored with arsenic and are 
 
Iness was caused 
 Michigan. Prof. 
 Michigan, made 
 jf which was the 
 I was present in 
 afficient to cause 
 
 etimes contained 
 n to be used in 
 IS of sugar have 
 ifficient to arouse 
 
 ich are introduced 
 ed or the cane is 
 ) be apprehended 
 
 LCS. 
 
 pd in the arts arc 
 
 irticles for personal 
 
 ost cases, contain 
 
 frequently colored 
 ten, a compound of 
 on the carpets, 
 ^s of arsenic which 
 )ants of the room. 
 lining these articles 
 ^ptible quantity of 
 :come a dangerous 
 that a square foot 
 contain thirty-6.vo 
 Icdzie, of Michigan, 
 liing had occurred; 
 /cry square toot of 
 
 • there arc numcr- 
 /ith arsenic and arc 
 
 POISONING FROM COSMETICS. 
 
 857 
 
 often the cause of injurious effects. Children's toys, for instance, 
 arc very frequently the source of injury from the arsenic which 
 they contain ; wafers, table mats, confectionery papers, artificial 
 flowers, etc., have all been known to cause poisonous effects. 
 
 The aniline colors themselves are quite incapable of causing 
 injury; but since arsenic is used in the preparation of the dyes, 
 these latter often contain a sufficient quantity of the poison to exert 
 an injurious effect when long applied to the skin. The most com- 
 mon ways in which the aniline colors cause poisoning is by the use 
 of stockings and under garments. 
 
 The first effect is simply an irritation of the skin manifested by 
 the formation of pimples ; if the cause be not recognized and 
 avoided, a serious skin disease and even constitutional effects may 
 follow. 
 
 Poisoning from Cosmetics. 
 
 The most common sources of poisoning of this kind are pow- 
 ders for the face and dyes for the hair. 
 
 The most frequent poison in these articles is lead. Hair-dyes 
 sometimes contain other poisonous substances as well. 
 
 While articles can be obtained from the market free from 
 these injurious substances, yet there is some difficulty in assuring 
 one's self of their purity, since all claim to be free from injurious 
 effects. Those who insist upon being certain of the harmlessness 
 of their toilet articles can use the following mixtures, which can be 
 put up at any drug store. 
 
 A white powder for the face can be made as follows : 
 
 Wheat starch, - - - - 220 parts. 
 
 Oxide of zinc, - - - - 30 parts. 
 
 Oil of rose, _ _ - . Four drops. 
 
 A red powder can be made as follows : 
 
 Carmine, _ _ _ _ One part. 
 
 Carbonate of magnesium, - - Four parts. 
 
 It has been stated in discussing hair-dyes that an imitation 
 of the Persian method can be employed without danger of injury. 
 Instead of this the following hair-dye, proposed by Hagar, will be 
 found useful and harmless : 
 
 
 j , J. , l4 
 
 • I 
 
 \' 
 
 1 V ' 
 
 , i 
 
 i u 
 
 ^ ■ 
 
 H 
 
858 
 
 POISONS AND THEIR ANTIDOTES. 
 
 Ten parts of the subnitrate of bismuth are heated in a glv^s 
 vessel with 150 parts of glycerine ; caustic potash solution is then 
 gradually added while the mixture is stirred ; af^er a time the 
 liquid becomes perfectly clear. A solution of citric acid is then 
 added so as to make the liquid about neutral in reaction — that is, 
 so that it will not change the color of either red or blue litmus 
 paper. Add orange flower water until the liquid measures 300 
 parts. 
 
 Poisoning from Insect Powders. 
 
 The powders used to destroy insects and vermin of ot . kinds 
 usually contain either phosphorus, arsenic, strychnine or corrosive 
 sublimate. The effects and the proper treatment for these various 
 poisons will be hereafter described. 
 
 Poisoning from Meats, Fish and Cheese. 
 
 In most cases meats, such as sausage and ham, derive wluit- 
 ever poisonous properties they may possess from certain decompo- 
 sitions which take place in the flesh. These changes result from 
 defects in the mode of preparation of the meat, such as imperfect 
 smoking and curing. In such cases the inner portion of the mass 
 of flesh is not acted upon by the preservative agent ; it becomes 
 softened and putrid. 
 
 In other cases the flesh contains some of the living parasites 
 which infest cattle and hogs, and the sickness caused in the con- 
 sumer is due to the activity of these parasites in his body. The 
 most frequent of these are the trichina splialis, and the minute plant 
 which causes the disease known as " malignant pustule." 
 
 Cow's milk sometimes conveys a poisonous principle ; a case 
 was recently reported in Philadelphia in which a family sickened 
 from the use of the milk of a cow which died on the following 
 morning. It was found that the animal was suff"ering from malig- 
 nant pustle, and that the human victims had been infected with this 
 disease. 
 
 Cases occur now and then in which several members of a 
 family suffer from symptoms of poisoning which can be traced 
 
i in a glv-<s 
 :ion is then 
 a time the 
 add is then 
 on — that is, 
 r blue Utmus 
 neasures 300 
 
 af ot . kinds 
 
 ; or corrosive 
 
 these various 
 
 ese. 
 
 n, derive what- 
 
 rtain deconipo- 
 
 ges result from 
 
 1 as imperfect 
 
 n of the mass 
 
 t ; it becomes 
 
 lliving parasites 
 
 ;d in the cnu- 
 
 is body. Hi^' 
 
 he minute plant 
 
 lule." 
 
 •inciple ; a case 
 [family sickened 
 the following 
 ig from malig- 
 ifected with this 
 
 members of a 
 can be traced 
 
 POISONING BY MEDICINES AND CHEMICALS. 
 
 859 
 
 pretty conclusively to the use of cheese. The most careful 
 chemical and microscopical examinations of such specimens have 
 repeatedly failed to reveal the injurious substance. It seems prob- 
 able that the injurious properties of the cheese are due to aonie 
 unusual form of fermentation. 
 
 Treatment is usually not called for until after the patient has 
 been sick for some hours. The difficulty begins with a feeling of 
 nausea and general indisposition, soon followed by vomiting and 
 diarrhea. The general effects and ultimate result vary in different 
 cases, since they are due to different substances contained in the 
 meat or cheese. 
 
 So soon as a suspicion of the actual nature of the complaint is 
 entertained, an emetic should be given; for this purpose a tcaspoon- 
 fiil of mustard should be stirred in a glass of warm water and given 
 at once. This may be followed after half an hour by a brisk purg- 
 ative. In many cases nothing further will be required ; if the 
 patient manifest signs of weakness and prostration, it will be neces- 
 sary to support his strength by alcoholic stimulants. A table- 
 spoonful of whisky may be given in a little milk every hour or 
 two. 
 
 Poisoning by Medicines and Chemicals. 
 
 H {I Acids, — The mineral acids — nitric, sulphuric and muri- 
 atic — are sometimes used for suicidal purposes, and are sometimes 
 taken by mistake. 
 
 Symptoms. — If one of the strong acids be taken into the 
 mouth, the patient becomes instantly aware of the mistake by the 
 intense pain. If the liquid be swallowed, the pain is felt along the 
 throat and gullet into the stomach. 
 
 Upon examining such a patient, we find the lining membrane of 
 the mouth dry and hard, and sometimes presenting a yellowish or 
 blackish appearance as if charred. The patient vomits violently, 
 the matter ejected being sometimes red from admixture with blood, 
 and sometimes of a black and tarry appearance ; this latter sub- 
 stance is really blood, which has been acted upon by the acid. 
 
 If much of the liquid have been swallowed, the patient 
 becomes prostrate ; the hands and feet are cold and clammy, the 
 S6 
 
 m 1 ." ' 
 
 i 1' 
 
 f ! 
 
 imi^ 
 
I 
 
 
 860 
 
 POISONS AND THEIR ANTIDOTES. 
 
 pulse small and feeble and very rapid. In the course of a few 
 hours there sometimes occur bloody or tarry evacuations from the 
 bowels. 
 
 Treatmoit. — The first object of treatment is to neutralize the 
 acid ; that is, to cause it to combine chemically with other sub- 
 stances, so as to deprive it of its corrosive power. For this 
 purpose, we may give any alkaline substance, such as soda or pot- 
 ash. It is, of course, improper to give the strong alkalies, since 
 these are themselves corrosive. 
 
 A teaspoonful of washing soda stirred up in water or if this 
 cannot be promptly procured, as much soap in water should be 
 given at once; or a 1 . .le plaster may be knocked off the wall, 
 broken into small pieces and administered in water. 
 
 After a sufficient quantity of this has been given to ncutrah/c 
 the acid — the exact amount must, of course, depend upon the 
 quantity of acid which has been taken — the patient should take 
 three or four eggs beaten up together, or, if these be not at hand, 
 a glass or two of milk. After a short time he may have some 
 bland tea or barley water. 
 
 It is not advisable to give emetics or to use the stomach pump; 
 the acid will be neutralized at once by the alkaline substances, and 
 will exert no further corrosive action. It is necessary to keep the 
 stomach as quiet as possible, since it is already damaged by the 
 acid, and if it be made to contract violently by the act of vomiting 
 further injury may occur. 
 
 The patient's mouth and throat are extremely sore ; the surface 
 usually mortifies in patches, and pieces of the flesh come away, lea\'- 
 ing raw surfaces. Nothing can be done to prevent this ; we can sim- 
 ply take care that the parts are kept as quiet as possible, and are not 
 irritated by food. If the injury be not extensive, the patient miy 
 take liquid food — milk, broths, and the like, — in small quantities 
 at short intervals. If, on the other hand, a large quantit\- of acid 
 has been taken, or much time has elapsed before the administra- 
 tion of the antidote, the nourishment should be administered by 
 injections into the rectum. 
 
 Poison bj/ AJImUch, — The alkalies which arc most frequently 
 taken into the mouth are potash, soda and hartshorn. 
 
 Symptoms. — The symptoms are very similar to those caused by 
 the mineral acids. They are manifested more especially in the 
 
POISONING BY MEDICINES AND CHEMICALS. 
 
 86l 
 
 )urse of a few 
 tions from the 
 
 , neutralize the 
 vith other sub- 
 er. For this 
 as soda or pot- 
 r alkalies, since 
 
 kvater.. or if this 
 vater should be 
 ed off the wall, 
 
 ^en to ncutrali;.c 
 icpend upon the 
 lent should take 
 e be not at hand, 
 may have some 
 
 le stomach pump; 
 - substances, and 
 isary to keep the 
 damaged by tlie 
 e act of vomiting 
 
 sore ; the surface 
 
 come away, lea\'- 
 
 this ; we can siia- 
 
 jsiblc,and arc not 
 
 ;, the patient may 
 
 In small quantities 
 
 ]c quantity of acid 
 
 Ire the adniinistra- 
 
 administei-cd by 
 
 Ire most frequently 
 lorn. 
 
 Ito those cause 
 
 d by 
 
 especially in the 
 
 throat, however, causing the patient to choke and gag. Hartshorn 
 has not only a local influence upon the lining membrane of the mouth 
 and throat, but also afifects the system generally, frequently giving 
 rise to convulsions. 
 
 Treatment. — The alkalies are neutralized by acid substances, 
 and are converted into soap by oils. Hence, the treatment consists 
 in the administration of acids and fat. 
 
 The patient should take a glassful of weak vinegar, or vinegar 
 and water in equal parts. This should be followed in ten minutes 
 by a tablespoonful of sweet oil. 
 
 If neither of these remedies is at hand, an abundance of warm 
 water should be administered, followed in a short time by a glass of 
 milk. 
 
 Poisonitiff hy Oxalic Acid. — Oxalic acid is a solid sub- 
 stance, and is usually taken by mistake for some of the other white 
 crystalline substances (such as Epsom salts). 
 
 This acid does not cause any serious injury to the lining mem- 
 brane of the mouth or throat. Its injurious effects result from its 
 absorption into the system, since when in the blood it acts as a 
 deadly poison. 
 
 Treatment. — Any alkaline substance, chalk, magnesia, washing 
 soda or lime, should be given at once in quantities dependent upon 
 the amount of oxalic acid which has been swallowed. Immediately 
 after this the patient should take two or three eggs or a glass of 
 milk. 
 
 After five minutes, vomiting should be provoked, either by 
 giving a teaspoonful of mustard in a glass of warm water or by 
 tickling the throat with the finger or with a feather. 
 
 Poisoning hy Carbolic Acid. — Carbolic acid is sometimes 
 taken by mistake, and occasionally used for purposes of suicide. 
 
 Symptoms. — The symptoms are in many respects those caused 
 by mineral acids. The surface of the mouth and throat is turned 
 white by the acid. The patient soon becomes prostrated, a condi- 
 tion which is due to the constitutional effects rather than to the 
 local injury. 
 
 The urine contains blood, and in a few hours acquires a dense 
 black color so that it resembles ink. 
 
 \im 
 
 i.[^ 
 
 :i!: 
 
 : 
 
 In 
 
 ■i ;, 
 
 Hi 
 
 I'f. 
 
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 ^■^■■' 
 
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862 
 
 POISONS AND THEIR ANTIDOTES. 
 
 Treatment . — The whites of eggs should be beaten up and ad- 
 ministered in abundance. After this, vomiting should be caused 
 by administering mustard and warm water. After the stomach is 
 emptied of its contents, sweet oil, with or without magnesia, must 
 be administered. 
 
 Poisoning by Priissic Acid and its Compounds, — Pi ns- 
 
 sic acid is often taken with suicidal intent. The cyanide of potas- 
 sium is one of its compounds, which is almost as deadly as the acid 
 itself. Bitter almonds also contain a considerable quantity of prus- 
 sic acid. The oil of bitter almonds, as well as cherry-laurel water, 
 are sometimes taken by mistake. 
 
 If the prussic acid be strong, or if much of the cyanide of 
 potassium be taken, no measures offer much promise of recovery; 
 for these drugs cause a rapid arrest of the heart's beating, as well as 
 a cessation of the breathing. 
 
 Treatment. — Vomiting should be promoted as soon as possible 
 by tickling the throat or by a teaspoonful of mustard in warm water. 
 Meanwhile ammonia should be held near the nostrils, and cold water 
 should be dashed upon the face and chest. 
 
 So soon as the patient seems capable of breathing, he should 
 be stimulated by strong coffee conta'ning a little whisky or brandy. 
 In many cases there is a numbness and a loss of feeling in the 
 limbs ; the skin should be vigorously rubbed with a flesh brush or 
 a coarse towel, and the patient frequently spoken to in order to 
 prevent him from lapsing into unconsciousness. 
 
 While these measures are being executed the following solu- 
 tion may be prepared : Ten or fifteen grains of green vitriol 
 should be dissolved in two ounces of water ; to this half a tea- 
 spoonful of subsulphate of iron solution is added, and enough 
 caustic soda to make the liquid somewhat alkaline in reaction. 
 Half of this may be given at once. 
 
 Poisoning by Arsenic, — This is indicated by an acrid taste 
 in the mouth and a sense of tightness in the throat ; in a short 
 time a buiiiing pain is felt in the pit of the stomach, soon extend- 
 ing into the abdomen ; nausea and vomiting occur ; there is 
 extreme thirst. 
 
 If the quantity taken be large, convulsions may occur, and the 
 patient soon becomes prostrated. 
 
;n up and ad- 
 ild be caused 
 \e stomach is 
 lagnesia, must 
 
 >unds, — Pvus- 
 Ltiide of potas- 
 dly as the acid 
 lantity of prus- 
 •y-laurel water, 
 
 the cyanide of 
 se of recovery ; 
 lating, as well as 
 
 1 soon as possible 
 d in warm water, 
 s, and cold water 
 
 ithing, he should 
 rhisky or brandy, 
 feeling in the 
 flesh brush or 
 to in order to 
 
 L a 
 
 following solu- 
 of green vitriol 
 
 this half a tca- 
 ded, and enough 
 line in reaction. 
 
 by an acrid taste 
 hroat -, in a short 
 ach, soon cxtend- 
 occur ; there is 
 
 nay occur, 
 
 and the 
 
 POISONING BY MEDICINE AND CHEMICALS. 
 
 863 
 
 Treatment. — Vomiting should be excited at once ; give a tea- 
 spoonful of mustard in warm water or tickle the throat with the 
 finger. 
 
 Then administer dialyscd iron in teaspoonful doses, and follow 
 this with milk, whites of eggs and barley water. 
 
 Poisoning by Copper and its Compounds,— The most 
 common sources of this poison are blue vitriol and verdigris. The 
 symptoms are very similar to those of poisoning by arsenic. 
 
 Treatment. — Whites of eggs are to be administered freely, 
 after which vomiting should be excited with warm water and mus- 
 tard or by irritating the throat with the finger. 
 
 After the contents of the stomach have been evacuated eccs 
 and milk should be given. 
 
 -fefc.- 
 
 Poisonimf h\f Quicksilver Coinponnds. — The most fre- 
 quently met with of these is corrosive sublimate ; the red precipi- 
 tate and white precipitate and vermilion are other compounds 
 which are sometimes taken into the stomach. 
 
 Treatment. — Whites of eggs and milk are to be freely given, 
 afterwards vomiting should be excited. After the stomach has 
 been emptied, milk or linseed tea should be given. 
 
 Poisoning by Zinc Compounds, — The only one of these 
 which is apt to be used as a poison is white vitriol. 
 
 The treatment is the same as that for poisoning by compounds 
 of copper or. mercury. 
 
 Poisoning by Compounds of Lead, — These are sugar of 
 lead, white lead, goulard water and red lead. 
 
 Treatment. — Epsom salts should be given freely, one or two 
 ounces being dissolved in water. 
 
 After this vomiting should be excited by a teaspoonful of 
 mustard stirred in a glass of warm water, and by tickling the 
 throat. 
 
 Poisoning by Lunar Caustic. — A teaspoonful of com- 
 mon salt dissolved in a cupful of water should be swallowed at 
 once, and followed by the whites of a dozen eggs. 
 
 If vomiting do not occur at once it should be excited by tick- 
 ling the throat, or by the usual emetics. 
 
 itiul'fti •!' 
 
 ri 
 
 H 
 
 *;■;!• 
 
 p^i rj "■ 
 
 i f I 
 
 ■ " 
 
 ' i 
 
 \'\ 
 
 r:f 
 
p \ 
 
 15 
 
 1 1' 
 
 864 
 
 POISONS AND THEIR ANTIDOTES. 
 
 Poisoning hy Opium. — A large percentage of the cases of 
 poisoning which the physician is called upon to treat result from 
 the use of opium, laudanum or morphine. It is important that 
 this condition be recognized, since certain principles of treatment; 
 must be carried out in order to overcome the effects of the dru" 
 upon the system. 
 
 Symptoms. — The symptoms caused by the use of opium vary 
 extremely according to the quantity of the drug which has been 
 taken. If a comparatively small quantity has been swallowed 
 the patient becomes gradually drowsy, the pupils of the eyes are 
 contracted, the breathing becomes slower, the pulse is less rapid 
 and full. 
 
 If a large quantity be taken these symptoms ensue in a very 
 short time, and are rapidly followed by complete unconsciousness ; 
 stupor has been known to ensue within three minutes after a hypo- 
 dermic injection of morphine. 
 
 The patient does not die, however, during this stage. So long 
 as he can be roused by shouting or shaking there is still a possibil- 
 ity of complete recovery. 
 
 If the individual be so comatose that he cannot be roused in 
 any way, a condition of extreme prostration ensues. The pupils 
 of the eyes are contracted to the size of pins' points ; the breathing 
 becomes so slow that every respiration seems to be the last. The 
 acts of breathing may be diminished from sixteen or eighteen in a 
 minute, which is the usual number, to eight, six, or even four per 
 minute. The pulse is very slow and very full; the face is pale and 
 livid ; the skin is cool and clammy. 
 
 Even when these symptoms have ensued it is possible for the 
 patient to recover, though death is usually the result. 
 
 In some persons who are especially susceptible to the action of 
 opium, many of these symptoms may be brought on by a dose of 
 the drug which is perfectly safe for most persons. 
 
 Treatment. — The objects of treatment are: First, to empty 
 the stomach ; second, to keep up the breathing ; third, to stimulate 
 the heart. 
 
 To empty the stomach an emetic should be given at once. A 
 teaspoonful of mustard in a glass of warm water should be admin- 
 isteied, and the throat should be irritated by the finger. Those means 
 are, however, often insufficient. In the first place it may be ini- 
 
"a 
 
 ' ill 
 
 POISONING BY MEDICINE AND CHEMICALS. 
 
 865 
 
 ;';' 
 
 stage. So long 
 still a possibil- 
 
 possiblc to induce the patient to swallow, and the lining membrane 
 of the throat and stomach are so benumbed by the drug that they 
 may not respond to these irritants. 
 
 If vomiting do not promptly occur after two or three draughts 
 of mustard and water have been given, a stomach pump should be 
 brought into requisition. This can be extemporized by any one 
 \vh(i has a piece of rubber tubing four feet in length and half an 
 inch in diameter. One end of this should be passed into the 
 stomach. To do this it is only necessary to push the tube into 
 the back part of the mouth, well up against the back part of the 
 throat, and then to direct it downward. It is important to keep 
 the tube pressed well against the back part of the throat in order to 
 avoid passing it into the wind-pipe, which lies a little further in 
 front. After the tube has been passed into the throat for eighteen 
 or twenty inches, the outer end should be elevated ; water is then 
 poured into it from a pitcher, one or two quarts being employed for 
 the purpose. The end of the tube is then lowered so as to make a 
 siphon; the liquid returns from the stomach through the tube into 
 a basin held for the purpose. This process should be repeated 
 once or twice. 
 
 To keep up respiration, the patient's skin should be briskly 
 whipped with a wet towel ; at intervals of five or ten minutes, his 
 head and chest may be dashed with cold water ; the effect will be 
 greater if ice-cold water and warm water (i 10 degrees Fahr.) be 
 employed in quick succession. In the intervals between the 
 douches, the patient may be made to walk the floor, supported on 
 cither side by an assistant. This measure is, of course, impossible 
 if the patient be so profoundly unconscious as to be unable to use 
 his limbs. Yet much more can be done in this direction than 
 would be supposed by one who has had no experience. 
 
 As a last resort, artificial respiration may be performed, a pro- 
 cess which is described under the head of drowning. It has some- 
 times been possible to save a life by keeping up artificial respira- 
 tion for half or three-quarters of an hour after the patient has ceased 
 to breathe. 
 
 Strong coffee should be prepared, and may be administered at 
 short intervals by the mouth if the patient can swallow, otherwise 
 by the rectum. 
 
 If an electric battery can be procured and managed by some 
 
 i ix^i 
 
 u 
 
 n 
 
 n 
 
 , f 
 
 t i 
 
 '^ 
 
 ' • 
 
 .., '.t ' 
 
866 
 
 POISONS AND THEIR ANTIDOTES. 
 
 one acquainted with it, one pole should be applied to the nape of 
 the neck and the other to the pit of the stomach. 
 
 The effects of opium can be counteracted in great measure liy 
 atropine. This is a powerful drug and should be used by a physi- 
 cian if the services of a medical man can be procured. One-forticlli 
 of a grain of atropine may be injected under the skin if the symp- 
 toms of opium poisoning be profound ; this dose may be repeated 
 in fifteen or twenty minutes if the breathing be very slow and show- 
 no signs of improvement. 
 
 Ammonia should be held near the nostrils; if the pulse become 
 weak, a tablespoonful of whisky may be administered by the 
 rectum every half hour until four or five doses have been given. 
 
 Poisonimf hy Belladonna, Henhane, Stramonium 
 and Diffitalis. — These drugs cause different symptoms, but tlic 
 differences between them will be recognized only by a medical man. 
 In general there occurs a state of excitement and agitation often 
 culminating in delirium ; there is frequently vomiting, diarrhea 
 and extreme pain in the bowels. 
 
 Treatment. — If vomiting have not occurred, it should bo pro- 
 voked at once by tickling the throat and giving a teaspoonfu! of 
 mustard in a glass of warm water. The patient should then take a 
 teaspoonful of powdered charcoal. After this, milk and strong tea 
 may be given. 
 
 If the pulse be very weak and feeble and the patient appear 
 much prostrated, ammonia (hartshorn) should be held near tlie 
 nostrils and a teaspoonful of whisky should be given every twenty 
 or thirty minutes until six or eight doses have been taken. 
 
 PoiHoning hy Strychnine^ Nit.r. Vomica , White Ilrl- 
 lehore. Oleander and Spiyeliu, — Finely powdered charcoal, 
 which can be made by pounding in a handkerchief the coal from 
 a wood fire, should be given at once in large quantities. 
 
 Vomiting is to be excited by tickling the throat and by the 
 administration of mustard in warm water. After this strong coftee 
 should be given. 
 
SMOTHERING. 
 
 867 
 
 SMOTHERING. 
 
 Under this term may be included several conditions, caused in 
 various ways, but presenting essentially the one feature — a lack of 
 breath. This result follows drowning, strangling, choking, hang- 
 ing, etc. 
 
 The essential feature in all these conditions is the cessation of 
 breathing. In hanging, it is true, when properly done, the verte- 
 bra; in the neck are dislocated. This injury is beyond all relief. 
 
 So long, however, as no other feature is present in the case 
 than the stopping of respiration, there is always a chance for 
 recovery within a certain time after the breathing has ceased. 
 
 If the respiration has been arrested by constriction of the 
 throat, such as occurs in hanging and strangling, the first thing to 
 be done is, of course, to cut the uLject which causes the constric- 
 tion. Even though consciousness be completely lost, an effort 
 should be made to revive'the patient. 
 
 Treatment. — In case of choking from the presence of food 
 or other matters in the throat, the body should be inverted so that 
 the head is lower than the shoulders. The body may then be 
 violently shaken ; if relief be not at once obtained, the finger 
 phould be introduced into the throat and an effort be made to 
 extract the foreign body. In case of drowning, the body should 
 be so placed that the head is lower than the chest ; this can be 
 arranged by placing the body over the knee of another person, or 
 any object of sufficient height. In this way some of the water will 
 probably escape from the lungs and air passages. 
 
 Artificial respiration is then to be performed in one of the 
 following ways : 
 
 The patient is placed upon his back, the head hanging over 
 some projection, such as the end of a bench, upon which he may 
 lie. The operator stands above the patient's head, grasps the arms 
 below the elbows and draws them upward above the head, inclining 
 them away from the body at the same time. After holding them 
 in this position for a second, the arms are returned again to the 
 sides of the body so that the elbows rest against the chest and the 
 
 rv"i 
 
 it. 
 
 
 hXy't 
 
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 868 
 
 SMOTHERING. 
 
 forearms on the abdomen. The operator should press the patient's 
 arms firmly against the chest and abdomen so as to force all the air 
 out of the lungs. 
 
 By raising the arms in this position the chest is expanded and 
 the air enters the lungs ; by pressing the arms upon the body, the 
 air is forced out of the chest again. In this way the respiration is 
 artificially induced. 
 
 This scries of movements should be executed at first about ten 
 times in the minute ; in ten or fifteen minutes the rapidity of the 
 movement may be increased to fifteen or eighteen respirations per 
 minute. 
 
 If an assistant be present, he should see that the tongue docs 
 not fall back into the throat ; the end may be grasped by means of 
 a soft cloth or towel, and should be pulled forward out of ihc 
 mouth. 
 
 This process should be continued ten or fifteen minutes, 
 whether the patient show signs of life or not. At the end 
 of this time, the car may be applied to the patient's chest to 
 observe whether or not the heart beats. Any movement of tlie 
 heart, however slight, is an indication that life can be saved by 
 further respiration ; even though no movement be felt, the respira- 
 tions should be continued for at least half an hour. 
 
 Howard's Method of Reviving the Drowned. 
 
 The following method of Dr. Howard is used in the New York- 
 harbor : 
 
 Rule i. — Upon the nearest dry spot expose the patient to a 
 free current of air ; rip the clothing away from the waist and give a 
 stinging slap upon the pit of the stomach. If this fails to arouse the 
 patient, proceed to force and drain away the water which has 
 entered the stomach, according to rule 2. 
 
 Rule 2. — Turn the patient upon his face, the pi' •" 
 stomach being raised, upon a folded garment, above t a ol 
 
 the mouth. For a moment or two make steady pressui .)on the 
 back of the stomach and chest, and repeat it once or tu u iint' 
 fluid ceases to flow from the mouth. 
 
 Rule 3. — Quickly turn the patient upon his back, with a 
 
REVIVING THE DROWN'ED. 
 
 869 
 
 h - 
 
 Is back, with a 
 
 bundle of clothing between it so as to raise the lower part of the 
 brcast-bonc higher than the rest of the liody. Kneel beside or 
 astride of the patient, and so place your hands upon either side of 
 the pit of the stomach, upon the front part of the lower ribs, that 
 the fingers fall naturally in the spaces between them and point 
 toward the ground. Now grasping the waist, antl using your 
 knees as a pivot, throw your whole weight forward as if you 
 wished to force the contents of the chest and stomach out of 
 the mouth. Steadily increase the pressure while you count i , 
 _', 3, then suddenly let go, with a final push which spring.-; you 
 into an erect kneeling position. Remain erect upon your knees 
 while you count i, 2, then throw your weight forward, and pro- 
 ceed again as before. Repeat the process at first about five times 
 a minute, increasing the rate gradually to about fifteen times ^ 
 minute, and continue it with the regularity of the natural breath- 
 ing which you are imitating. If another person be present, 
 let him with the left hand hold the tip of the tongue out of the 
 left side of the mouth with the corner of a pocket handkerchief, 
 while with the right hand he grasps both wrists and pins them 
 to the ground above the patient's head. 
 
 After-treatment. — When breathing first returns, dash vio- 
 lently a little cold water in the face. As soon as breathing has been 
 perfectly restored, strip and dry the patient rapidly and completely, 
 and wrap him in blankets only. Give hot brandy and water — a 
 teaspoonful every five minutes the first half hour, and a table- 
 spoonful every fifteen minutes for an hour after that. If the 
 limbs are cold, apply friction. Allow abundance of fresh air, and 
 let the patient have perfect rest. 
 
 ' PRACTICAL SUGGESTIONS. 
 
 Avoid delay. Promptness is of the first importance. A mo- 
 ment lost may be a life lost. Waste no time in gaining shelter. 
 When gained, it oftener harms than helps the patient. 
 
 Prevent erozvding around the patient. However difficult this 
 may be, it must be enforced. Friends must not be allowed to 
 obstruct the circulation of air, nor to engage the patient in con- 
 versation when rallying. 
 
 Avoid attempts, to give sti.nula;:is before the patient is ivcll 
 a'''>' to szvallow. It helps to obstruct respiration, and may choke 
 tiie patient. 
 
 {' '! it ^ 
 
 ' ;< 
 
 II J' 
 
 i': 
 
 hi: 
 
 "sill 
 
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 [I 
 
il 
 
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 870 
 
 REVIVING THE DROWNED. 
 
 Avoid hurried, irregular motions. The excitemert of the 
 moment is almost sure to cause this in inexperienced hands. 
 Just as a flickering candle moved caislssly, goes out, so the 
 heart when its beatings arc imperceptible, needs but little cross 
 motion, or interruption, to stop it. The movements of rule \ 
 should therefore be performed with deliberation and regularity. 
 
 Avoid an over-heated room. The animal heat which is needed 
 cannot be supplied from without, but must be generated in the 
 system. This is best promoted by a free supply of cool air, and 
 internal stimulants. The vital heat resulting is best retained about 
 the patient's body by blankets alone. 
 
 Avoid giving tip the patient too soon to death. At any time 
 within one or two hours you may be on the very threshold kA 
 success, though no sign of it be visible. Several times success 
 has been known to follow half an hour's apparently useless effort. 
 Rest and watchful nursing should be continued for a few days after 
 resuscitation, or various chest troubles may en^ue. 
 
imert of the 
 need hands, 
 out, so the 
 lit little cross 
 nts of rule , 
 id regularity. 
 tiich is needed 
 lerated in the 
 ' cool air, and 
 retained about 
 
 At any time 
 
 ry threshold of 
 
 times success 
 
 r useless effort. 
 
 L few days after 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 Self-preservation is the first law of nature — in point of time 
 only ; for a second law, not les? imperious, is race-preservation. 
 Life, it has been said, is a struggle to gratify two instincts — hunger 
 and love. In the preceding pages we have :onsidercd tlie diseases 
 affecting man as an individual; affecting those organs which are con- 
 cerned in the maintenance of the individual. We shall now proceed 
 to the discussion of the diseases which affect man as a sexual being, 
 a? an instrument in the preservation of his race — in other words, 
 to the diseases of tiie sexual or reproductive organs. 
 
 Among the lowest beings, animals and plants, the maintenance 
 of the individual and of the race is provided for by one and the 
 same organism. Ti^c minute plant, the fungus familiar to us under 
 the name of yeast, is a microscopic ball, which, placed under favor- 
 able conditions, not onl/ maintains its own proper life, but also pro- 
 duces similar independ'Mi"" bein^.;. On the surface of the original 
 ball, minute buds appear, grow, and finally are detached, with the 
 size, shape and powers of the parent organism. As we ascend the 
 sen' J of life, however, we find special organs set aside in each ani- 
 mal and plant, intended solely for the production of new and similar 
 beings. In the highest animals, this office of reproduction — the 
 most important of all the animal duties — becomes so complicated 
 that tlic labor is divided between two classes of beings — male and 
 female — which, while similar in all the essentials of individual life, 
 present marked differences in t'lf > sexual powers and organs. 
 
 in all the higher animals, man included, the development of the 
 sexual organs, and therefore of the sexual instincts, occurs only after 
 the previous development of those orgins and instincts essential to 
 the preservation of the individual. The interval which elapses be- 
 tv een the birth of the animal and the advent of its sexual life varies 
 according to the term of the animal's natural life. The rabbit 
 
 871 
 
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 I'M 
 
 
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 ; 11 
 
 
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i 
 
 !■■ 
 
 872 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 becomes sexually mature within a year after its birth; the elephant 
 only after a score of years ; the human animal after ten to fifteen 
 years. The child is a sexless being, possessing only the rudiments 
 of sexual organs, the germs of sexual instincts. There are, there- 
 fore, no essential differences — mental or moral — between the boy 
 and the girl. After a certain period — in our climate usually between 
 twelve and eighteen years — the sexless becomes a sexual being, 
 assuming those traits, physical, mental and moral, which change it 
 into him or her. The distinction between brother and sister, here- 
 tofore maintained with difficulty by peculiarities of dress and artifi- 
 ficial customs, becomes natural and unmistakable. The angular 
 awkwardness and innocent freedom of the girl are replaced by tlie 
 rounded grace and conscious modesty of the woman ; the boy is 
 no longer a companion to be romped with, but an admirer to be 
 enslaved. Both man and woman differ physically from the child, — 
 he more than she — and differ still more markedly from each other. 
 His skin is rough and hairy ; hers smooth and hairless. His out- 
 line is angular, his shoulders broad, his hips narrow, his muscles 
 strong, his bones large, his skull thick, his voice deep and harsh; 
 her contour is rounded, her shoulders narrow, her hips broad, her 
 skin thickly padded with fat, her voice smooth and child-like. Man's 
 physical development fits him especially to maintain the struggle for 
 existence; woman's whole physique is designed for the preservation 
 of her race. Man is essentially strong and selfish ; woman, weak 
 and generous. In man is embodied the individual; in woman, the 
 race. , 
 
 " Love is of man's life a thing apart, 
 'Tis woman's wliole existence," 
 
 a fact admirably illustrated by two familiar peculiarities of 
 women : In breathing, the child and the man employ largely the 
 muscles of the abdomen ; woman, on the contrary, breathes almost 
 entirely with the chest, because the mutual performance of her 
 sexual duties compels the use of her abdomen muscles for other 
 purposes than those of breathing. Although man's shoulders are 
 broader, yet his collar-bone is shorter than woman's. The latter, 
 therefore, though lacking somewhat the strength and freedom of 
 movement in the shoulder-joint, can support a but den, as of a 
 child, on her breast with less fatigue than he. The transition of 
 the girl into the woman implies mental and moral as well as physical 
 growth — a fact not always appreciated by parents. The physical 
 
le elephant 
 n to fifteen 
 2 rudiments 
 ; are, therc- 
 een the boy 
 illy between 
 ;xual being, 
 ch change it 
 sister, here- 
 ss and artifi- 
 Thc angular 
 placed by the 
 11 ; the boy is 
 idmirer to be 
 n the child,— 
 na each other. 
 :ss. His out- 
 V, his muscles 
 ep and harsh ; 
 lips broad, her 
 Id-like. Man's 
 he struggle for 
 le preservation 
 woman, weak 
 in woman, the 
 
 GENERAL REMARKS. 
 
 873 
 
 changes — certainly the most tangible — consist in the development 
 of the sexual organs, lying on cither side of the womb ; connected 
 with it by tubes about four inches long, are two bodies resembling 
 almonds in size and shape. These bodies are called the ovaries (or 
 egg-producers) ; each contains even at the birth of the infant thousands 
 of very minute bodies, the eggs. During the earlier years of the 
 child's life these bodies and their contents remain undisturbed ; but 
 at an age which varies with climate, race and surrounding, between 
 8 and 16 years, the ovaries enlarge; several of these microscopic eggs 
 swell, until finally one of them bursts its covering as well as the wall 
 of the ovary. Meanwhile the other organs concerned in reproduc- 
 tion are likewise awakening to new life ; the womb, in sympathy 
 with the ovaries, is swollen with blood during the ripening of the 
 egg in tlie ovary. The climax of the process is two-fold : First, 
 in the ovary the escape of the ripened egg by rupture of its cover- 
 ings ; second, in the womb the escape of blood by rupture of the 
 blood vessels. The egg is carried from the ovary along the con- 
 necting tube to the womb, and is usually carried with the blood 
 escaping into this organ out of the body ; the girl menstruates. 
 This, the local jDrocess, is accompanied usually by evidences of gen- 
 eral disturbance — lassitude, peevishness, pains in the back and 
 loins. Sometimes even convulsions or fainting fits are experi- 
 enced. 
 
 This condition — lasting usually one or more days — recurs at 
 intervals often of great irregularity. One month, two, three, six 
 months may elapse before a repetition of the process. The breasts 
 also, accessory organs of reproduction, exhibit an increase in size, 
 and frequently become the seat of painful or other unusual sensa- 
 tions. During the period of two years, more or less, this transi- 
 tion stage endures, — the birth of the woman — during which the 
 infant woman demands not 'ess careful and assiduous supervision 
 than the infant child ; for JuiUig this period the girl is peculiarly 
 susceptible to diseases of the flesh and perversions of the mind. 
 She must be protected not only from the ailments which inevitably 
 arise from neglect to recognize the importance of the change at 
 hand, but also from diseases which affect other parts of the body 
 with es]:)ecial frequency at just this time of life. For it is a fact 
 as the infant is suscet 
 
 J' 
 
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 range 
 
 from causes which do not affect adults, so the girl, during the 
 infancy of her womanhood, is likewise peculiarly susceptible to 
 
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 874 
 
 DISEASES OF WOMEN AND CHILDREN, 
 
 influences which do not affect her younger or her older sisters. 
 The importance of this fact cannot be over-estimated, and is 
 scarcely as yet fully appreciated ; though one of the greatest boons 
 which has in recent years been granted to women by the commu- 
 nity is the more general recognition of the necessity for special care 
 at this, the dawn of her sexual existence. As we recognize for 
 convenience a physical, mental and moral nature, so we may con- 
 sider the changes and the perils at this period as physical, mental 
 and moral. 
 
 Among the possible physical ills is the manifestation of consti- 
 tutional tendencies and of hereditary taints which have lain dor- 
 mant since the birth of the individual. It happens but too often 
 that the delicate child of consumptive parents, which has main- 
 tained fair health during its previous years, yields when tliis 
 increased demand is made upon it and manifests the first pronounced 
 symptoms of the parents' fatal malady ; so, too, insanity, cpilepsv 
 and a score of other affections, the tendency to which was imparted 
 with the parents' blood or acquired through their ignorance, attack 
 the girl at this her critical period, perhaps to overwhelm her at once, 
 or at least to secure a foot-hold from which they can never be dis- 
 lodged. Then again there are certain ailments which seem to aft'ect 
 the children of robust and of delicate parents alike. Such is 
 chlorosis, popularly known as the green sickness, [^because of the 
 greenish tinge sometimes exhibited by the otherwise pale counte- 
 nance. In this disease the blood is impoverished, whence the 
 extreme pallor ; yet the root of the evil lies not in the blood, but in 
 the nervous system. The beginning is insidious: lassitude, even pros- 
 tration ; disinclination for exertion and society ; a capricious appe- 
 tite, often exist for a considerable time without other symptoms, to 
 the perplexity of parents, perhaps even of the physician ; then 
 occur impairment of digestion, constipation, palpitation of the 
 heart, pallor, irregularity, perhaps suppression, of the menstrual 
 function. Sometimes most curious and perverted tastes are dis- 
 played, such as a passion for nibbling slate pencils, for devouring 
 pickles, drinking vinegar, etc.; mental perversities no less re- 
 markable may be exhibited, so that in a few months the pre- 
 viously healthy, rosy child has become an irritable and irritatiiij.^ 
 invalid ; the alarmed friends consider that the girl is in a decline, 
 talk of consumption and heart disease, or having an indistinct idea 
 that a pale individual should always take iron, dose the unfortunate 
 
)lder sisters. 
 ated, and is 
 reatest boons 
 r the commu- 
 ir special cart- 
 recognize for 
 we may con- 
 ysical, mental 
 
 tion of consti- 
 liave lain dor- 
 
 but too often 
 lich has main- 
 Ids when this 
 irst pronounced 
 ianity, epilepsy 
 ;h was imparted 
 norancc, attack 
 elm her at once, 
 in never be dis- 
 ch seem to affect 
 alike. Such is 
 
 because of the 
 
 I ^ 
 
 ise pale countc- 
 |ed, whence the 
 :he blood, but ill 
 ktudc, even pros- 
 jcapricious appc- 
 er symptoms, lo 
 physician ; then 
 pitation of the 
 the menstrual 
 tastes are dis- 
 is, for devouring 
 itics no less re- 
 months the prc- 
 ble and irritating 
 Irl is in a decline, 
 Ian indistinct idea 
 the unfortunate 
 
 GENERAL REMARKS. 
 
 875 
 
 giri with that article. It should be, however, realized that the 
 green sickness is too serious and complicated to be entrusted to 
 home remedies ; that the patient should be at once placed under the 
 care of a competent physician. The disease is caused by a lack of 
 air, sunshine, exercise and amusement ; by anxiety, fear, or other 
 emotions; by overwork, physical or mental. To avoid it, there- 
 fore, one needs to know only the cause. Its first symptoms can be 
 almost invariably cut short by a change of scene, of occupation 
 and of company. 
 
 Yet the most serious physical ills originating at this period are 
 those affecting primarily the organs undergoing development. At 
 this time are laid but too often the foundations of those ailments 
 peculiar to women, and especially to American women, causing 
 painful and irregular menstruation in the girl, sterility in the wife 
 and invalidism in the mother. These ills may be traced usually not 
 to any willful interference with or abuse of these organs, but to an 
 over-zealous use and cultivation of other organs. It is too often 
 forgotten that the chief aim of the girl is to become a woman, and 
 that the time preceding and following the first menstruation should 
 be devoted primarily to this change, to this development of the 
 sexual functions, even to the neglect of other functions. The girl 
 therefore demands and must receive other treatment than her 
 brother ; for him, sexual development is a more gradual and less 
 integral process ; one which does not materially change the bent of 
 his inclinations, the direction of his pursuits, nor his physical habits, 
 which intrudes itself upon his attention by no imperious calls ; a 
 change, indeed, of which he is often long unconscious. For her, it 
 is an introduction into a new world, or rather into the world, on 
 the outskirts of which she has passed the previous years of childish 
 probation ; it is the transformation of the caterpillar into the butter- 
 fly. For her there is no possibility of ignoring the change at hand; 
 body, mind and soul unite in calling her attention to the duty of 
 the hour ; the strange, uneasy, perhaps painful bodily sensations, 
 the mental languor and indisposition for accustomed pursuits, the 
 indefinable longings and emotions, indicate as plainly to others also 
 the dawn of the new existence. The successful initiation of the 
 child into this new life, is evidently the first and most important 
 object of those interested in her welfare ; for whatever may be her 
 material and social advantages, she must be nevertheless a woman ; 
 and for a woman, the successful pursuit of happiness is impossi- 
 ble without sexual perfection. 
 57 
 
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876 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 The care demanded by the child during the period of puberty 
 includes no active interference with the sexual functions themselves, 
 but simply the regulatioii of the other functions of body and mind, 
 so that the child's strength, or at least a sufficient portion thereof 
 may be diverted from other into the new channels ; a diversion of 
 strength which would, we may assume, occur in the natural state 
 of the animal without artificial regulation or interference. Indeed, 
 it should be understood that the object of supervision, whether by 
 parents or by the physician, is not to surround the girl with arti- 
 ficial barriers, nor to stimulate in any way her sexual development, 
 but merely to remove those artificial barriers and unnatual stimu- 
 lants to proper sexual growth which are the necessary and insepar- 
 able outgrowths of our social customs ; for it is a fact often observed 
 and repeated, that the stimulants to excessive mental effort, insepar- 
 able from a high state of civilization, result in a neglect of the 
 bodily functions. It is not asserted that extreme mental and phys- 
 ical culture are incompatible ; but to secure their co-existence in 
 the same individual, each — body and mind — must be carefully and 
 conscientiously trained. The tendency of modern life, particularly 
 in the United States, is to high-pressure mental effort, without 
 regard to the physical foundation therefor. Nowhere in the world 
 is the stimulus to mental effort so great and so widely dissemin- 
 ated ; nowhere are the rewards for successful effort so sure and so 
 readily attained ; nowhere are the opportunities and inducements for 
 individual effort, the natural resources and advantages for collective 
 enterprises, so enticing. As a result, therefore, the burdens of life 
 are most eagerly assumed at an age which was formerly regarded 
 as scarcely that of discretion. As a further result, the preliminary 
 training of our youth of both sexes is crowded into a period utterly 
 insufficient even for the modest attainments of our grandfathers, 
 and doubly so for the acquisition of that knowledge which our 
 modern schools profess to teach. The formal pleasures of society 
 also are no longer monopolized by adults, but arc eagerly sought 
 by and granted to children. The demands of society can be met 
 only by a certain devotion to fashion, whose behests must, there- 
 fore, be obeyed by the children also. The theater and the novel 
 are amusements as legitimate for the girl as for the mother. In 
 short, precocity is the order of the day. The girl of fifteen is bat 
 the copy of her elder sisters indulging in the same pleasures and 
 employments, which oftentimes tax severely their more mature 
 
GENERAL REMARKS. 
 
 ;n. 
 
 eriod of puberty 
 tions themselves, 
 body and mind, 
 ; portion thereof 
 s ; a diversion i)f 
 the natural state 
 ference. Indeed, 
 ision, whether by 
 ;he girl with arti- 
 cual development, 
 i unnatual stimu- 
 ssary and insepar- 
 "act often observed 
 ital effort, insepar- 
 1 a neglect of the 
 ; mental and pliys- 
 cir co-existence in 
 list be carefully and 
 :rn life, particularly 
 iital effort, without 
 where in the world 
 .o widely disseniin- 
 brt so sure and so 
 nd inducements far 
 tages for collective 
 the burdens of life 
 formerly regarded 
 It, the preliminary 
 to a period utterly 
 our grandfathers, 
 wledge which our 
 ilcasurcs of society 
 are eagerly sought 
 ociety can be met 
 bests must, there- 
 ate r and the novel 
 r the mother. In 
 lirl of fifteen is bat 
 |ame pleasures and 
 :hcir more mature 
 
 877 
 
 strength and endurance. The result is plain and inevitable : at 
 thirteen, the woman is born and for four years should have nothing 
 to do which can interfere with her growth into womanhood. To put 
 her upon the same diet of amusement and employments as are suited 
 to a woman of twenty, who has completed her sexual growth, must 
 evidently be disastrous ; to subject her immature and tender mus- 
 cles and bones to the same pressure and strain that may be borne 
 with safety later in life, is irrational in the extreme. An infant fed 
 upon beefsteak and potatoes could hardly escape dyspepsia and 
 other disorders of digestion ; the child compelled to carry heavy 
 weights would naturally have a deformed back-bone and legs ; the 
 infant woman, placed upon a diet adapted only to vigorous adults, 
 and assuming a share of the physical burdens inseparable from the 
 pleasures of society, can scarcely hope to escape the penalties 
 as surely inflicted by the sexual as by other organs when abused. 
 The average girl of thirteen has, perhaps, vitality enough to develop 
 into a robust woman ; but she has not vitality enough to accom- 
 plish both this task and the duties which are but too often thrust 
 upon her. One or the other — either the physical development or 
 the social accomplishments, or both — will be but imperfectly 
 attained; and since the imperfect performance of the s'^-ial duties is 
 the rnore readily and earlier observed and avoided, tue deficit is 
 left but too often on the physical side of the account. 
 
 Yet we cannot charge upon social pleasures the whole, nor 
 indeed the greater part, of the abuse to which the budding woman 
 is subjected; for the greatest enemy to the sexual health of our 
 young women has been the popular system of education. The 
 theater and the ball are but occasional and by no means inexorable 
 demands ; the school is an unavoidable requirement. Our popular 
 systems of education assume that boys and girls can be properly 
 treated alike, and maybe expected to accomplish the same work in 
 the same time and at all times. However true this assumption 
 may be in childhood and in adult life, it is certainly opposed to all 
 observation and experience during the period of sexual develop- 
 ment. We need not concern ourselves with the questions which 
 agitate and are agitated by our friends, the advocates of women's 
 rights, so-called. The question of the relative superiority of man and 
 woman is quite foreign to the present subject ; the comparison of 
 mental and moral powers of the two sexes is also quite irrelevant. 
 The fact is, that the girl has a much greater physical and a more 
 
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8/8 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 IH 
 
 intense mental development to acompHsh than the boy; and must 
 moreover complete that development in a shorter time than is allowed 
 him ; whence it follows that she cannot and should not be expected 
 to devote to other functions, whether of mind or of body, as much 
 energy as may be properly required of him during the same period 
 This fact, so apparent upon the slightest consideration, has been 
 strangely enough ignored by both parents and educators. Girls 
 and boys, whether sitting side by side in the same school-room or 
 pursuing parallel courses of study in different institutions, have been 
 expected to work not only five days in the week, but also four 
 weeks in the month. The boy can do it; the girl can — sometimes; 
 yet it is expected that she will always ; she is spurred to perform 
 her school work at any cost by comparison with her male competi- 
 tors. Too often the success of her school life is purchased by the 
 sacrifice of her sexual perfection. It has been said thac the thou- 
 sand ills which torment American women may be ascribed largely 
 to the educational methods of our schools and colleges ; not that 
 such methods are the only cause of female diseases, but that they 
 are an important factor. Strange as it may seem, this neglect of 
 the peculiarity of the female organization has been nowhere more 
 apparent and more rigidly insisted upon than in institutions founded 
 and devoted to the education of women. The platform of woman's 
 rights has not as yet been made to include as a plank the right to 
 complete the natural sexual development — a right which implies a 
 sufficient opportunity for the growth of the ovaries and the accessory 
 reproductive organs, and for the establishment of their periodical 
 functions. " It is not enough," says Dr. West, " to take precautions 
 till menstruation has for the first time occurred ; the period for its 
 return should, even in the healthiest girl, be watched for, and all 
 previous precautions should be once more repeated ; and this 
 should be done again and again, until at length the habit of regular, 
 healthy menstruation is established. If this be not accomplished 
 during the first few years of womanhood, it will in all probability 
 never be attained. " 
 
 There are instances in our large cities, by no means rare, in 
 which this special mechanism of menstruation remains undeveloped 
 or attains at best an incomplete, unsatisfactory, perhaps painful de- 
 velopment. It is the unanimous experience of physicians, that such 
 cases of imperfect sexual development are usually found in girls with 
 brilliant school records. The body can rarely discharge two 
 
GENERAL REMARKS. 
 
 879 
 
 yr ; and must 
 lan is allowed 
 be expected 
 jdy, as nuich 
 same period, 
 on, has been 
 caters. Girls 
 ;hool-room or 
 )ns, have been 
 but also four 
 — sometimes; 
 red to perform 
 male competi- 
 rchased by the 
 i thac the thou- 
 scribed largely 
 leges ; not that 
 i, but that they 
 ,, this neglect of 
 1 nowhere more 
 itutions founded 
 form of woman's 
 ank the right to 
 which implies a 
 |nd the accessory 
 their periodical 
 Itake precautions 
 ,e period for its 
 hed for, and all 
 ;ated; and this 
 habit of regular, 
 ,ot accomplished 
 all probability 
 
 ^o means rare, in 
 lins undeveloped 
 frhaps painful de- 
 Isicians, that such 
 lound in girls with 
 discharge two 
 
 important duties well at the same time. To secure the best work 
 from the brain, we rest the muscles and the stomach. The best 
 mental effort, the best literary and scientific work is not performed 
 in the first hour after dinner. It has been found by actual 
 observation, that a greyhound started immediately after a full meal, 
 in the pursuit of a fox, does not digest his food so long as he con- 
 tinues the violent muscular eftbrt of running; while the stomach of 
 a second animal, permitted to rest after his dinner, soon completes 
 its task of digestion. The hound has strength and vitality enough 
 either to digest the food or to pursue the fox, but not to perform 
 both duties at the same time. Muscle-work and stomach-work must 
 interfere with each other if attempted together. The digestion of 
 the dinner slows the muscles, the contraction of the muscles slows 
 the digestion. In order that the animal shall run swiftly, the bulk 
 of the blood must circulate in the muscles; in order that the stomach 
 shall digest properly, a large quantity of blood must circulate in the 
 stomach. The animal does not contain blood enough to support 
 (Treat activity of both stomach and muscles at the same time. So, 
 too, the development of the girl's reproductive organs requires the 
 circulation of large quantities of blood in these organs. The 
 mental activity necessary to prepare and recite her lessons demands 
 the circulation of large quantities of blood through the brain. The 
 girl has not blood enough to perform both lines of work at the same 
 time. Menstruation slows her brain ; study slows her menstruation. 
 During the menstrual week the first business is menstruation, in 
 favor of which study and other mental effort must be subordinated. 
 This, let it be remembered, should be the rule, not only at the first 
 and second monthly periods, but also at every period for three or 
 four years, until, in other words, sexual development is complete. 
 For if the brain be worked continuously, the ovaries must be 
 slighted; and if slighted, the insult and injury can never be 
 repaired. If the reproductive organs are not developed now, they 
 will not be at any later period. If imperfectly fashioned now, they 
 can be only patched, and not perfected, in after life. Blood must be 
 allowed to flow to these organs in ample quantity, even though the 
 brain have not enough left to study very luird, nor the feet enough 
 to dance very energetically ; even though the corset lace be 
 loosened, to permit the increase in size in the ovaries and womb 
 below, and in the breasts above. 
 
 " Every physician," says a recent writer, " can point to students 
 
 
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 880 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 whose splendid cerebral development has been paid for by ema- 
 ciated limbs, enfeebled digestion and disordered lungs. Every 
 biography of the intellectually great records the dangers they have 
 encountered, often those to which they have succumbed in over- 
 stepping the ordinary bounds of human capacity, and while beck- 
 oning onward to the glories of their almost preternatural achieve- 
 ments, register, by way of warning, the fearful penalty of disease, 
 suffering, and bodily infirmity, which nature exacts as the price for 
 this partial and inharmonious grandeur. It cannot be otherwise. 
 The brain cannot take more than its share, without injury to other 
 organs. It cannot do more than its share, without depriving other 
 organs of that exercise and nourishment which are essential to their 
 health and vigor. It is in the power of the individual to throw, as 
 it were, the whole vigor of the constitution into any one part, and 
 by giving to this part exclusive or excessive attention, to develop it 
 at the expense and to the neglect of the others. " In the training 
 of our girls the tendency has certainly been to defraud the sexual 
 organs of their just due, during the earlier years of their develop- 
 ment; to train the mind, without regard to the suffering which may 
 be inflicted upon the body ; to train the girl's mind, indeed, as the 
 boy's is trained. Already we are perceiving the result : the Amer- 
 ican woman is both physically and mentally a unique type of 
 humanity, remarkable alike for vivacity, mental attainments, intel- 
 lectual beauty of face and feature on the one hand, and for the 
 appalling absence of physique on the other. A young American, 
 landing in England, exclaimed : " Now for the first time I see 
 women." An English lady, visiting the Boston schools, said : " I 
 never saw before so many pretty girls together. " These remarks 
 indicate fairly well the impressions made upon natives of the one 
 hemisphere by women of the other. The transient, delicate beauty 
 of feature is accorded to the American girl ; the permanent, tan[ji- 
 ble beauty of health belongs to her European cousin. 
 
 It is a painfully significant fact, that the one department of 
 medicine in which the American physician confessedly excels his 
 European brethren, is the diseases of women ; in medicine, as in 
 other things, practice makes perfect ; the skill of the American 
 medical man is, then, an unenviable commentary on the physique of 
 the American woman. 
 
 The ailments which affect the organs immediately concerned in 
 reproduction are not, of course, thrust upon the attention of the 
 
GENERAL REMARKS. 
 
 88l 
 
 prcncral public ; yet the generally imperfect development of the 
 accessory sexual organs is a secret the knowledge of which is by no 
 means confined to milliners and dressmakers, who are said to be in the 
 habit of adapting not the dress to the figure, but the figure to the 
 dress. If the only evil resulting from this imperfection of develop- 
 ment were the loss of beauty, it would not call for attention on the 
 part of the medical adviser ; but it must be remembered that 
 imperfect development of the breast modifies not only the contour 
 of the woman, but also impairs the health of her offspring, and 
 usually implies, moreover, an unsatisfactory condition of the organs 
 directly instrumental in the production of the new being. A recent 
 writer calls attention to this fact in these words : " There is another 
 marked change going on in the female organization at the present 
 day, which is very significant of something wrong. In the normal 
 state nature has made ample provision in the structure of the 
 female for the nursing of her offspring. In order to furnish this 
 nourishment, pure in quality and abundant in quantity, she must 
 possess vigorous and healthy digestive organs and a well-developed 
 sexual system. Formerly such an organization was very generally 
 possessed by American women, and they found but little difificulty 
 ill nursing their infants. It was only occasionally, in case of some 
 defect of the organization, or where sickness of some kind had over- 
 taken the mother, that it became necessary to resort to the wet- 
 nurse or to feeding by hand ; and the English, the Scotch, the Ger- 
 man, the Canadian-French and the Irish women now living in this 
 country, generally nurse their children. The exceptions arc rare. 
 But how is it with our American women who become mothers? 
 To those who have never considered this subject, and even to med- 
 ical men who have never carefully looked into it, the facts, when 
 correctly and fully presented, will be surpris-ing. It has been sup- 
 posed by some that all, or nearly all, our American women could 
 nurse their offspring just as well as not ; that the disposition only 
 was wanting, and that they did not care about the trouble or con- 
 finement necessarily attending it. But this is a great mistake. This 
 very indifference or aversion shows something wrong in the organ- 
 ization as well as the disposition. If the physical system were all 
 right, the mind and natural instincts would generally be right also. 
 While there may be here and there cases of this kind, such an indis- 
 position is not always found. It is a fact, that a large number of 
 our women are anxious to nurse their offspring, and make the 
 
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882 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
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 attempt ; they persevere for a while, perhaps for weeks or months, 
 and then fail. There is still another class that cannot nurse at all, 
 having neither the organs nor nourishment requisite even to 
 make a beginning. Why should there be such a difference between 
 our American women and those of foreign origin residing in the 
 same locality and surrounded by the same external influences? The 
 explanation is simple: there is a want of proper physical develop- 
 ment. " The girl's energies have been devoted to study and mental 
 accomplishment. Her blood has been devoted to her brain ; the 
 development of other organs and of other powers has been sadly 
 neglected. 
 
 Dr. Weir Mitchell, of Philadelphia, says: " Worst of all, to 
 my mind, most destructive in every way, is the American view of 
 female education, the time taken for the more serious instructions 
 of girls extends to the age of 1 8, and rarely over this. During 
 these years they are undergoing such organic development as ren- 
 ders them remarkably sensitive. To-day the American woman is, 
 to speak plainly, physically unfit for her duties as woman, and is, 
 perhaps, of all civilized females, the least qualified to undertake 
 those weightier tasks which tax so heavily the nervous system of 
 man. She is not fairly up to what nature asks from her as wife and 
 mother. How will she sustain herself under the pressure of those 
 yet more exacting duties which nowadays she is eager to share with 
 the man?" Dr. Clarke, of Boston, remarks: " In our schools it is 
 the ambitious and conscientious girls, those who have in them the 
 stuff of which the noblest women are made, that suffer; not the 
 romping or lazy sort; and thus our modern ways of education pro- 
 vide for the non-survival of the fittest. Girls of bloodless skins 
 and intellectual faces may be seen any day by those who desire the 
 spectacle, among the scholars of our high and normal schools — faces 
 that crown and skins that cover curving spines which should be 
 straight, and neuralgic nerves that should know no pain. Later 
 on, when marriage and maternity overtake these girls, they bend 
 and break beneath the labor like loaded grain before a storm, and 
 bear little fruit again. A training that yields this result is neither 
 fair to the girls nor to the race." 
 
 It must be remembered, also, that the reproductive organs are 
 the key to a large part of the mental and moral nature — to all that 
 makes a woman womanly. At 45 years, or thereabouts, the sexual 
 organs of woman wither and cease to perform their accustomed 
 
HYGIENE OF PUBERTY. 
 
 883 
 
 i or months, 
 iiursc at all, 
 to even to 
 nee between 
 iiding in the 
 uences? The 
 ical dcvelop- 
 ly and mental 
 er brain ; the 
 IS been sadly 
 
 orst of all, to 
 :rican view of 
 ,us instructions 
 this. During 
 )pment as rcn- 
 ican woman is, 
 woman, and is, 
 d to undertake 
 •vous system of 
 her as wife and 
 essure of those 
 er to share with 
 our schools h is 
 .ve in them the 
 suffer; not the 
 education pro- 
 bloodless skins 
 who desire the 
 schools — faces 
 [hich should be 
 o pain. Later 
 ^irls, they bend 
 •e a storm, and 
 [result is neither 
 
 kive organs are 
 lure— to all that 
 ]outs, the sexual 
 
 [eir accustomed 
 
 duties; and it is a fact familiar to us all, that at that age a woman 
 loses the chief, indescribable charm which she has previously pos- 
 sessed. Her physical vigor and intellectual accomplishments are 
 retained undiminished, but she is no longer a woman. So, too, it 
 has been observed that those unfortunate females who arc con- 
 demned by disease to the loss of the ovaries, become, like the women 
 who have had the change in life, sexless creatures. Woman's entire 
 being, therefore, mental and moral, as well as physical, is fashioned 
 and dia'cted by her reproductive powers. It is easy to understand, 
 therefore, that if these powers be never completely developed, 
 there will and must be an arrest of development of her mental and 
 moral nature. It is, then, not alone for the welfare of her body 
 that the dawn of the girl's sexual life should be carefully super- 
 vised. In the changes accompanying the development of the sex- 
 ual system at puberty there is exhibited a most remarkable example 
 of the intimate and extreme sympathy between the brain and the 
 ovaries, between the mind and the reproductive powers. The 
 change in the disposition and character of the girl at this time is by 
 no means limited to the birth of the sexual feelings and the ideas 
 associated with these feelings ; for there arises at the same time a 
 new nature, comprising the highest sentiments of humanity, social, 
 moral, and even religious. 
 
 Hygiene of Puberty. 
 
 The care demanded by the girl relates directly, of course, to 
 her bodily functions, but just as certainly to her mental state. Cer- 
 tain rules should be observed throughout the entire period of puberty, 
 and certain additional precautions are necessary during the menstrual 
 flow. It may seem unnecessary to remark that the first requisite 
 is food ; yet it is nevertheless true that attention should be paid to 
 both quantity and quality of the food during this period of devel- 
 opment. For the girl's appetite is often very capricious ; she is 
 sometimes, though rarely, inclined to excessive indulgence at table, 
 A more common and more serious error is either positive disinclin- 
 ation for nourishing food, or the rejection of all except particular 
 articles of diet — and these frequently cakes, pastry and sweatmeats. 
 It is not necessary to prescribe nor insist upon any special regimen 
 nor line of diet, but simply to remember that the girl should have 
 
 ■ 
 
 i. , 
 
 T,. 
 
 :\ 
 
 f: 
 
I!' I 
 
 884 
 
 DISEASES OF WOMEN AND CHILDREN, 
 
 an abundance of nourishing food at regular hours ; that she should, 
 and probably will, display a marked increase of appetite, for which 
 she should not be teased ; to which, indeed, she should be encour- 
 aged ; for during these few years the demands on her system for 
 nourishment are unusually great. And it is a most unfortunate and 
 mistaken delicacy which would restrict the gratification of nature's 
 demands at this time. 
 
 Meat, especially fat meat, the usual garden vegetables, fruits, 
 and especially milk, may constitute the bulk of her diet. Tea, coffee, 
 wines and condiments — which are at no period of life especially 
 advantageous as a regular diet — maybe positively injurious during 
 this stage. 
 
 The next most important factor in the building of body and 
 brain alike is sleep. Early to bed and late to rise may be a judi- 
 cious modification of the old saw at this time. The hours that the 
 girl may apparently lose by lying in bed at this period of her life 
 will be r(. deemed a hundred-fold in her more mature and valuable 
 years. 
 
 Exercise, to is an indispensable aid in the development of the 
 girl during y Nor can any rules be laid down for the exe- 
 
 cution of t tton. That activity of body only may be 
 
 regarded as _rv-ise which gives the child pleasure. The line at 
 which exercise ends and work begins must be determined by the 
 individual tastes, strength and surroundings in each case. Yet this 
 is, of course, a matter which can be judiciously regulated by tli_ 
 parents in every instance. One fact only should be borne in 
 mind — that exercise, to be beneficial, must be taken in fresh air, 
 v.'hether indoors or out ; and that the human animal, like other 
 creatures, plants and animals, attains * best development when 
 bathed in the life-giving rays of the sun. The girl has no need of 
 a complexion as yet : she should have have her sun-bath daily 
 without a parasol, even though she become as brown as the tradi- 
 tional Indian. Not the least of the advantages of physical exer- 
 cise, undertaken, as it naturally is, with companions of the same 
 age, is that it diverts the girl's attention from the changes going on 
 in hor own nature, prevents her froni brooding upon mysteries of 
 which she has, and as yet can have, no comprehension — in short, 
 assists her in remaining a child until childhood has passed. In 
 this way, too, exercise constitutes one of the best safeguards against 
 the vicious habits to which gms, as well as boys, frequently become 
 
 
she should, 
 ,e, for which 
 [ be encour- 
 :r system for 
 brtunate and 
 n of nature's 
 
 tables, fruits, 
 Tea, coffee, 
 life especially 
 urious during 
 
 r of body and 
 nay be ajudi- 
 hours that the 
 ■iod of her life 
 e and valuable 
 
 ;lopment of the 
 vn for the exe- 
 only may be 
 The line at 
 irmined by the 
 lease. Yet this 
 ;ulated by tlv. 
 be borne in 
 en in fresh air, 
 mal, like other 
 lopment when 
 has no need of 
 sun-bath daily 
 n as the tradi- 
 phy&ical cxcr- 
 s of the same 
 anges going on 
 n mysteries of 
 ion — in short, 
 as passed. 1" 
 icguards against 
 uently become 
 
 HYGIENE OF PUBERTY. 
 
 885 
 
 addicted during these years of life. It is a matter of general obser- 
 vation that such habits acquire particularly strong hold upon those 
 who, from lack either of opportunity or inclination, have not 
 enjoyed the outdoor exercise so natural to children of both sexes 
 at this time of life. 
 
 Clothing, too, is a matter of extreme importance, and one 
 which cannot be passed over in silence, in discussing the hygiene of 
 puberty. So long as the girl remains but a child, so long will she 
 suffer only immediate and direct effects from the present curious 
 fashion of dressing girls. It has doubtless puzzled every one who 
 has stopped to consider the question, to conjecture by what law of 
 nature or art the clothing of a girl previous to 12 years of age 
 should be bunched around her waist, while her neck, arms and legs 
 are nearly oi quite unprotected. Her brother — certainly as vigor- 
 ous and able to withstand the weather as she — is clothed from the 
 neck to the wrists and to the ankles. The girl's costume is adopted, 
 with slight variations, by the ballet-dancer with a purpose — that of 
 exhibiting her physical charms ; yet that cannot be the object in 
 thus clothing the girl of ten years, since she has no charms to 
 exhibit, other than could be displayed to the same advantage by her 
 youthful brother. Yet we will not stop to remonstrate upon this 
 prevalent fashion of clothing children before puberty, since tlie ill 
 effects — the imperfect protection against the weather — are per- 
 fectly apparent. With the commencement of puberty the girl's 
 dress is changed ; yet oftentimes not to the same extent as the 
 interests of her body demand, for it cannot be too earnestly insisted 
 upon that her entire body should be at all times, but especially dur- 
 ing the menstrual week, thoroughly and warmly clothed. Thick 
 shoes and v/oolen stockings may not be so esthetic, but are cer- 
 tainly, in the long run, more profitable. Neck, shoulders, and the 
 figure generally, will be more attractive in after years if carefully 
 and completely and warmly clothed now. 
 
 At this time, too,, the girl is ordinarily inducted into that 
 peculiarly feminine garment, the corset. Now, it is not our pur- 
 pose to indulge in a tirade of abuse of this must useful article of 
 feminine apparel. Every medical man, as well as every woman, 
 can understand the advantages resulting from the use of the corset ; 
 indeed it is not the use but the abuse of the article which has been 
 the subject of so many attacks upon it. A corset suspended by 
 shoulder-straps so that the weight of the skirts attached to it should 
 
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 886 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 be borne by the shoulders and not by the h"p? and abdomen; a 
 corset which permitted a perfectly free expansion of the chest in 
 breathing would certainly be devoid of all objections as well as 
 eminently useful. Just so far, however, as the weight of clothin<T 
 suspended from the corset is borne at the waist, just so far as the 
 expansion of the chest is restricted by the corset, in just so far is 
 the garment objectionable and injurious. At present the corset 
 suspended from the shoulders is the rare exception, and within the 
 last few years it has had to sustain not only the weight of the mani- 
 fold skirts, but has been continuously dragged downward by two 
 elastic bands fastened to the stocking. Then again, though no 
 woman was ever known to admit that the corset impeded her 
 breathing in the least ; though every woman can prove most con- 
 clusively, by inserting her ' nd within the corset, that her person 
 has ample room in the garment, yet it is equally true that no dress 
 habitually worn over the corset can be made to meet if that gar- 
 ment be removed — except, indeed, by especial effort and adapta- 
 tion of form on the part of the werirer. It is not maintained that 
 no pressure can be borne without injury by the mature woman; 
 but it is certain that the position of the womb and ovaries in the 
 body may be modified by unnatural pressure of clothing during the 
 period of sexual development ; for these organs '-apidly acquire 
 additional size and weight at this time, and if in addition they be 
 forced downward by the intestines and other organs contained in 
 the abdomen — as they certainly will be by a tight corset and heavy 
 clothing — they will be found, at the end of puberty, not in the 
 postion and in the condition natural to them, but much lower in 
 the pelvis, and often unnaturally crowded with blood. 
 
 This is the condition commonly known as falling of the womb, 
 so often accompanied by derangement of the menstrual function 
 and by discharges — a condition which may be detected not infre 
 quently before marriage, but which is naturally more apt to be 
 observed in the wife and mother. 
 
 When properly used, therefore, the corset is perfectly unobjec- 
 tionable, and is indeed at times a most valuable article in support- 
 ing the person ; yet it must be admitted, that during at least the 
 first years of puberty, the girl has no need for such support, and 
 that her appearance is not improved by the article whose chief use 
 appears to be to hold in position certain artificial substitutes for 
 natural organs not yet developed. To the use of these pads there 
 
1 
 
 HYGIENE OF PUBERTY. 
 
 887 
 
 domen; a 
 e chest in 
 
 as well as 
 af clothing 
 3 far as the 
 ist so far is 
 
 the corset 
 1 within the 
 f the mani- 
 'ard by two 
 
 though no 
 npeded her 
 ^e most con- 
 ,t her person 
 that no dress 
 : if that gar- 
 
 and adapta- 
 intained that 
 ture woman; 
 ovaries in the 
 
 g during the 
 
 idly acquire 
 
 ition they be 
 contained in 
 
 let and heavy 
 not in the 
 uch lower in 
 
 |of the womb, 
 prual function 
 :ed not infre ■ 
 )re apt to be 
 
 jctly unobjcc- 
 
 |le in support- 
 
 at least the 
 
 support, and 
 hose chief use 
 Substitutes for 
 
 »sc pads there 
 
 is, from the physical standpoint, only one objection — that they but 
 too often defeat their own object ; that by pressure they prevent 
 the breast from acquiring the size, shape and firmness natural 
 to it. 
 
 It would be perfectly proper and yet entirely useless to insist 
 that the girl during the period of puberty has no need for a corset ; 
 that if she be allowed to wear one, custom and her own mistaken 
 idea as to what constitutes a beautiful figure will almost certainly 
 induce her to abuse the corset and still more fatally abuse her own 
 body For so long as women believe that physical beauty increases 
 as the size of the waist diminishes ; 01 so long as they labor under 
 the mistaken impression that men admire small waists ; just so 
 long will the corset be employed as a straight-jacket — health, 
 hygiene, advice, remonstrance and doctors to the contrary notwith- 
 standing. The doctor has, it is true, a certain though not very 
 noble satisfaction in this matter — he knows that the woman who 
 persistently, perhaps even contemptuously, disregards his advice in 
 the matter, will be in future years a valuable patient, needing long, 
 expensive, often futile treatment at his hands. If the feminine por- 
 tion of the community could be convinced not only that the com- 
 pression of the body by a tight corset is as barbaric as the com- 
 pression of the China woman's toes by a tight shoe ; not only that 
 the fashionable figure of the modern woman is a wide departure 
 from the ideal of nature and art alike — for these facts are known 
 to all ; but also that the figure of the average fashionable woman 
 is not the ideal form desired and admired by the average man, 
 there might be hopes that the corset would be loosened ; that the 
 growing girl would have an opportunity for unrestricted physical 
 expansion. 
 
 Another important consideration in the care of the girl during 
 puberty is the regular evacuation of the bowels and bladder. If 
 either the rectum or the bladder be habitually distended, there is 
 apt to occur a change either in the shape or position of the womb. 
 In treating diseases of the womb, the physician is called upon in 
 almost every case to secure proper action of the bowels ; and in the 
 majority of instances it is found that torpidity of the bowels has 
 endured since puberty — that the habit of constipation was formed 
 at that period of life. We have used the word habit intentionally ; 
 for it may be safely affirmed that, e.vcept in those exceptional cases 
 in which there is disease of the part, habitual constipation cannot 
 
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 'III 
 
 888 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 exist if proper care and attention be exercised. There should be 
 no false delicacy in the matter ; these functions may not be 
 regarded, as they sometimes are, as relics of the primitive and bar- 
 barous state of man, to be slighted and neglected, and performed 
 only when further neglect becomes impossible. In childhood and 
 youth, but especially in the girl at puberty, it should be impressed 
 upon the mind that the regular evacuation of the bowels and the 
 bladder is a part of the daily duties to one's self. Medicines arc 
 rarely necessary if this plan be followed ; if at a certain hour of 
 the day — usually best and most convenient in the morning — the 
 attention be fully and conscientiously devoted to that purpose. 
 
 Care During the Honthly4.Ghanges. 
 
 If it be borne in mind that puberty means the rapid develop. 
 ment of those most important functions whereby the girl is trans- 
 formed into the woman, and that the monthly changes are the 
 periodical crises of this epoch, marking the successive steps of her 
 pilgrimage from childhood to womanhood, it becomes evident that 
 during these monthly periods everything should be subordinated to 
 the performance of this function. Other organs, therefore — body 
 and mind, brain and muscle — should be rested. The first law of 
 the menstrual period is, therefore, rest. By this we do not mean 
 that absolute repose is demanded, but merely that nothing should 
 be required or permitted to which the girl's strength is inadequate 
 or her mind indisposed. It is best to say in general terms that she 
 should do less than the usual work, that she should take less than 
 the usual exercise, whether for pleasure or profit, whether in walking, 
 riding, dancing, or domestic employment. Not less important is 
 freedom from mental efibrt and anxiety. Hence it will be found, as a 
 rule, desirable to keep the girl out of school one or more days during 
 each period, particularly if she be ambitious and studious. In many 
 cases it becomes absolutely necessary, as already indicated in previ- 
 ous pages, to withdraw the child from school during the earlier 
 months or years of puberty. 
 
 The warmth of the body should be carefully and evenly main- 
 tained. At no period of life may so much damage follow the wet- 
 ting of the feet, sitting in a draught, etc. Yet, while a moderate 
 
 1:1: 
 
WHEN PUBERTY IS DELAYED. 
 
 889 
 
 e should be 
 Tiay not be 
 tive and bar- 
 id performed 
 \ildhood and 
 30 impressed 
 iwels and the 
 viedicines are 
 ;rtain hour of 
 lorning — the 
 purpose. 
 
 ). 
 
 rapid develop- 
 e girl is trans- 
 iianges are the 
 ive steps of her 
 ties evident that 
 subordinated to 
 lereforc — body 
 The first law of 
 e do not mean 
 nothing should 
 Ih is inadequate 
 d terms that she 
 take less than 
 lether in walking, 
 jess important is 
 illbefound.asa 
 [lore days during 
 adious. In many 
 dicated in previ- 
 uring the earlier 
 
 md evenly main- 
 |e follow the wet- 
 Ivhile a moderate 
 
 and uniform temperature is so eminently desirable, it must not be 
 assumed that the girl should be kept in a close, hot room. Fresh 
 air is always necessary at this as well as at other times. Nor is it 
 true that the customary baths should be omitted during this period. 
 If care be taken to avoid extremes of temperature, there is no occa- 
 sion for deviation from the usual custom. The bath should have a 
 temperature of 75" to 85° F. It is scarcely necessary to remark 
 that extreme emotional excitement of whatever kind should be 
 avoided at these times, whether those emotions be awakened by 
 actual occurrences or merely called into action by the pages of a 
 novel. For no part of the human nature is so intimately associated 
 with the sexual organs as the emotions The emotional existence 
 is indeed largely founded upon the sexual power and function, and 
 no part of the animal organism is so easily and seriously deranged 
 by the exercise of the emotions. It is a fact familiar to mostw'omen 
 that the menstrual flow, even in the mature woman, can be dimin- 
 ished, arrested or increased by various emotional excitements during 
 the monthly period. 
 
 Between the monthly changes no other precautions are neces- 
 sary than have been already indicated, and these are suggested and 
 directed by the one dominant fact that at this period of life the res*- 
 of the girl's body should be employed in buildinp- up proper sexual 
 
 organs. 
 
 When Puberty is Delayed. 
 
 The examination of several thousand cases has shown that in 
 the United States the first menstruation occurs on the average 
 between the ages of 14 and 15 years. This average represents, 
 of course, numerous exceptions ; menstruation not infrequently 
 occurs at 12 or 13, on the one hand, or is delayed until 16, 17 or 
 18, on the other. These and even greater variations from the aver- 
 age are perfectly consistent with health and with the proper devel- 
 opment of I'le sexual organs ; neither the early development nor 
 the long delay need cause anxiety nor medical interference. While 
 every girl is to a certain extent a law unto herself in this particular, 
 yet certain influences are known to modify the rapidity of sexual 
 development. Foremost among these is climate ; in animal as in 
 vegetable hfe rapidity of growth and decay is proportional, other 
 
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890 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 things being equal, to heat. Hence the tropics furnish not only 
 the most profuse and luxurious vegetation, the most brilliantly 
 decorated of the animal creation, but also the most pre- 
 cocious of human beings ; and we find it generally true that the 
 average age of sexual maturity in women increases from the equa- 
 tor toward the poles. Another point of considerable interest in 
 this connection is this : Even in a mixed population like that of 
 the United States, where individuals of the same family often 
 represent ancestors from different quarters of the globe, the women 
 of dark complexion, brunettes, retain not only the dark hue com- 
 mon to the people of tropical climates, but also the tendency to 
 mature sexually at an earlier period than their fairer sisters, whose 
 complexion suggests relationship with the less fiery-blooded and 
 more slowly developing races of the North. It is generally true 
 also that girls of large frame, whose general development therefore 
 takes place later in life, 'experience puberty also at a more advanced 
 age than their smaller sisters. 
 
 Race, too, accompanies certain differences in the period of 
 sexual maturity ; and while we may suppose that differences in race 
 were originally the results of differences in climate and natural sur- 
 roundings, yet it is true that even in our own country, exposed to 
 essentially identical conditions of climate and temperature, the dark- 
 eyed Jewess and the dark-skinned negress attain sexual maturity 
 one, two or three years earlier than other females. 
 
 While, therefore, inherited tendencies are largely influential in 
 determining the exact period of puberty, yet individual influences 
 may be made to hasten or retard to some extent this development. 
 Idleness, physical and mental ; stimulating, highly-seasoned food 
 and beverages ; constant stimulation of the emotions by works of 
 fiction, by the theatre, and by the society of the opposite sex ; by 
 observation of, and association with, older girls blessed with long 
 dresses and lovers — all these and similar influences, the atmos- 
 phere of more mature years, which the child is often injudiciously 
 permitted to breathe, naturally hasten her sexual development. 
 Could any doubt exist upon this question, it would be allayed by 
 the fact that girls born and bred in the country attain their sexual 
 development later than those in the city. Not only doe:-- the fii /l 
 menstruation occur six or seven months later in life in the country 
 than in the city girl, but the period of puberty, when onc( inaugu- 
 rated, proceeds less rapidly. The comparative freedom of the former 
 
EN. 
 
 furnish not only 
 : most brilliantly 
 the most prc- 
 illy true that the 
 :s from the cqua- 
 erable interest in 
 ition like that of 
 ame family often 
 globe, the women 
 le dark hue com- 
 ) the tendency to 
 irer sisters, whose 
 fiery-blooded and 
 t is generally true 
 dopment therefore 
 .t a more advanced 
 
 in the period of 
 differences in race 
 te and natural sur- 
 )untry, exposed to 
 perature, the dark- 
 in sexual maturity 
 s. 
 
 rgely influential in 
 
 dividual influences 
 
 this development. 
 
 hly-seasoned food 
 
 tions by works of 
 
 opposite sex ; by 
 
 Dlessed with long 
 
 ences, ihe atmos- 
 
 often injudiciously 
 
 ual development. 
 
 uld be allayed by 
 
 ittain their sexual 
 
 only does the fin/c 
 
 ife in the country 
 
 vhen onc( inaugu- 
 
 domof the former 
 
 WHEN PUBERTY IS DELAYED. 
 
 891 
 
 from those peculiarities of city life which stimulate the passions 
 while repressing the physique, explains both the rapidity and the 
 imperfection of the sexual development in the city girl as compared 
 with her country cousin. 
 
 Just as the age at which puberty begins varies with the individ- 
 ual, so, too, does the rapidity with which the process is completed 
 differ. In some the first menstruation is followed at the usual period 
 of twenty-six or twenty-eight days by the second and third, and 
 subsequent ones appear at the interval common in mature years. 
 Not so in all cases, however. A considerable interval, sometimes 
 c\xn six months, may elapse after the first before the appearance of 
 the second menstrual flow, and that, too, without the occurrence of 
 pains in the back, or other symptoms common to such occasions. 
 In such cases menstruation seldom becomes regular during the first 
 year or even two years of puberty. Yet it must be understood that 
 this condition demands no interference by either physician or parent. 
 It merely indicates that the process of ripening is proceeding more 
 slowly, though by no means less surely, than in other cases. So 
 long as the menstrual flow is accompanied with no more than the 
 usual symptoms of general disturbance, so long as the girl's gen- 
 eral health remains unimpaired, so long will her sexual development 
 progress satisfactorily without artificial means. 
 
 The same individual difi'erences arc manifested in the intervals 
 elapsing between the menstrual periods ; while, the average time 
 may be regarded as twenty-six to twenty-eight days, some healthy 
 women menstruate at intervals of twenty-four, twenty-one, eighteen, 
 or even sixteen days ; others thirty, thirty-five or even forty. This, 
 too, is a matter which need occasion no anxiety nor demand inter- 
 ference, provided the intcrvid be maintaineti with reasonable regu- 
 larity. It sometimes happens, also, that after child-birth, the 
 monthly periods become regularly longer or shorter than they were 
 previous to that occasion. 
 
 The length of time during which the flow continues SHiir also 
 vary in different individuals, and, indeed, in tH -ame woman to a 
 less extent, without overstepping the bounds of nealth. Vhile the 
 general average in our climate may be regarded as about four days, 
 some women flow si.x, others only two or even one d; - . So, too, 
 die quantity of blood lost at each menstrual epoch r^csents similar 
 variations within the bounds of health — four •■ h\e ouncr* repre- 
 senting a fair average. In these respects a^so, notwith.^aB^rmg the 
 58 
 
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892 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 individual peculiarities, the same general laws prevail as are illus- 
 trated in the development of the function in general. In tlic 
 warmer climate the average flow is greaier and the interval shorlor; 
 in the colder climates menstruation is generally less frequent and 
 less profuse. Social surroundings and personal habits exert marked 
 influence in this regard ; the same factors which induce early niLii- 
 struation are usually productive of more frequent and profuse dis- 
 charges. The youthful devotee to society, so-called, is not infre- 
 quently annoyed by menstrual irregularity, which her rustic sister 
 
 — a stranger perhaps to household and culinary luxuries — escapes. 
 It may be said in general that the more robust and vigorntis tlie 
 individual the less is the interference with the general health at the 
 menstrual period. It is usually the weak, nervous, delicate women 
 
 — those accustomed to personal luxury and emotional excitement 
 
 — who are most subject to profuse and frequent menstrual dis- 
 charges. There is one point of importance which may be ascer- 
 tained without difficulty — the menstrual blood never clots when 
 this function is nacurally performed ; a clotting of the blood indi- 
 cates something wrong in the organs concerned. 
 
 Such, then, are the circumstances usually attendant upon 
 healthy menstruation during the first year of the girl's sexual life, 
 Sometimes, however, cases are observed in which the process even 
 from the beginning presents unnatural features requiring the advice 
 and assistance of the physician. Among these is painful menstrua- 
 tion or 
 
 Dysmenorrhoea. 
 
 It is doubtless difficult to define the exact line separating pain- 
 less and painful menstruation, since few females subject to the vari- 
 ous unnatural influences of our artificial society escape entirely 
 more or less pain at the menstrual epoch. We may assume that in 
 the natural state of man menstruation, like all other body func- 
 tions, is a painless process — an assumption supported by our 
 knowledge of this process and its analogues among the lower ani- 
 mals and the lower races of mankind. We are, however, accus- 
 tomed to regard a certain amount of pain felt chiefly in the small 
 of the back accompanied with headache, languor, and perhaps pain- 
 ful sensation in the breasts, as natural ; and to refrain from all 
 
7 ipm 
 
 il as arc illus- 
 cral. In the 
 tcrval shorliT ; 
 , frequent ami 
 s exert marked 
 uce early men- 
 fid profuse dis- 
 ;d, is not infre- 
 icr rustic sister 
 iries — escapes. 
 d vigorous the 
 al health at the 
 deUcate women 
 jnal excitement 
 menstrual dis- 
 i may be ascer- 
 lever clots when 
 the blood indi- 
 
 attendant upon 
 girl's sexual life. 
 the process even 
 uiring the advice 
 ainful menstrua- 
 
 separating pain- 
 ibject to the vari- 
 escapc entirely 
 liy assume that in 
 Ither boily func- 
 kpported by our 
 |ng the lower ani- 
 howevcr, accus- 
 icfly in the small 
 and perhaps pain- 
 refrain from all 
 
 DYSMENORRIia:A. 
 
 893 
 
 interference unless the general health of the girl is at the same 
 time obviou '.ly impaired In these cases there is usually a certain 
 amount of languor, and even pain in the intervals between the 
 menstrual epochs — a symptom which demands immediate attention. 
 It may be stated in general that painful menstruation is caused by 
 one of three conditions: First, a depreciated condition of the 
 constitution originating either in the blood or in the nervous system, 
 and causing a tendency to neuralgia ; second, an unnatural state of 
 the womb; and third, an unnatural condition of the ovaries. In 
 girls dysmenorrhoea is usually due to the first of these causes, less 
 frequently to the second and third ; we should especially look out 
 for chlorosis, or the green sickness, for physical exhaustion, whether 
 due to over-work or over-indulgence in social pleasures, to mental 
 exhaustion from excessive study and emotional excitement. In 
 some cases, too, the pain appears to be due not to any diseased 
 condition, but rather to a tendency of the individual to rheuma- 
 tism or gout or to malarial influences. It is important to note for the 
 benefit of the physician who may, perhaps, be consulted, whether 
 the pain occurs chiefly before the beginning of the flow and ceases 
 with its appearance, or whether the pain keeps pace with the 
 amount of blood lost, increasing, therefore, during the first day or 
 two of menstruation. It is further desirable to note whether there 
 be any appearance of clotting, or whether particles of reddish 
 appearance, resembling somewhat pieces of flesh, be contained in 
 the discharge ; also whether the pain be felt chiefly in the back or 
 in front, whether it be continuous or be felt at intervals and accom- 
 panied with straining — resembling, therefore, the so-called bear- 
 ing-down pains ; also whether a whitish or yellowish discharge pre- 
 cedes by one or more days the appearance of the proper menstrual 
 flow. 
 
 Since the causes of painful menstruation are so various, it is 
 evident that the treatment must vary in different individuals. In- 
 deed here, as elsewhere, it must be borne in mind that medical 
 treatment is intended not to destroy a disease, but to assist an indi- 
 vithial subject to a disease; that it is, therefore, :iot the disease, 
 but the patient that is treated. To relieve painful menstruation, we 
 must, therefore, know what causes the pain before attempting to 
 remove it. And since the causes, so numerous and various, can be 
 generally definitely and accurately located only by the special 
 knowledge and skill of the medical adviser, it is impossible to lay 
 
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 894 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 down any set of rules for the treatment of painful menstruation, 
 There are certain measures, however, which are decidedly useful in 
 diminishing the pain, and therefore beneficial in nearly all such 
 cases, even though they do not remove the cause nor prevent the 
 recurrence of the pain at the next period. Such girls will be 
 benefited by wearing flannel next to the skin not only during but 
 also between the monthly periods; by taking special care to a\(jid 
 exposure to cold and wet for several days before the monthly is 
 expected ; by retaining the recumbent posture during at least the 
 first day or two of the flow; by the application of flannels winiii; 
 out of hot water to the small of the back and lower part of the 
 abdomen. Sometimes, indeed, a light mustard plaster may be 
 applied to the abdomen with even greater advantage; care bcin;^T 
 of course taken not to mix in the plaster enough mustard to blister 
 the skin. A bottle of hot water or a hot flat-iron wrapped in flan- 
 nel may be applied to the small of the back and to the feet if the 
 moisture of the plaster or hot cloth be disagreeable. If the pain 
 still be excessive, a teaspoonful of paregoric or ten drops of lauda- 
 num may be administered. Yet it must be remembered that, as a 
 rule, laudanum and other opiates, alcoholic stimulants, whisky 
 slings and other remedies, should be as far as possible avoided; 
 because, since more or less relief follows their employment, the girl 
 will acquire the habit of resorting to them every month, and thus 
 prolonging and rendering permanent the unnatural condition of 
 the sexual organs on which the pain depends. It is advisable to 
 consult a physician at once, if the employment of the hot flannels 
 and other local remedies mentioned be not followed by relief with- 
 out any resort to medicines. It is a popular impression that such cases 
 are benefited by marriage and maternity; and such is undoubtedly 
 the case in one class of patients suffering from painful menstruation. 
 But marriage, like other remedies, cannot be advantageously pre- 
 scribed for all. Indeed, many such cases suffer an aggravation of 
 the menstrual difficulty upon the assumption of the duties of the 
 wife and mothe 
 
 Another disorder of menstruation which may occur, though 
 less frequently, in the maiden as well as in the matron, is an 
 excessive loss of blood during the monthly sickness — a condition 
 termed in medicine menorrhagia. Another condition, often trace- 
 able to the same causes, is the appearance of blood in the interval 
 between the regular menstrual periods ; this latter condition is 
 
'{ 
 
 DYSMENOKKIICEA. 
 
 menstruation. 
 dccUy useful in 
 nearly all such 
 lor prevent the 
 h girls will be 
 only durintj: but 
 al care to a\ oid 
 the monthly is 
 •ing at least the 
 f flannels wruni; 
 )wer part of the 
 plaster may be 
 itage; care bcint:; 
 nustard to blister 
 I wrapped in flan- 
 Lo the feet if the 
 blc. If the pain 
 ;n drops of lauda- 
 imbercd that, as a 
 timulants, whisky 
 possible avoided; 
 ployment, the girl 
 month, and thus 
 ural condition of 
 It is advisable to 
 f the hot flannels 
 cd by relief with- 
 ;ion that such cases 
 Ich is undoubtedly 
 linful menstruation, 
 tvantageously pre- 
 an aggravation of 
 the duties of the 
 
 lay occur, 
 
 though 
 
 the matron, is an 
 kness— a condition 
 Idition, often trace- 
 lood in the interval 
 llattcr condition is 
 
 895 
 
 designated metyorrhagia. We may in general divide the causes of 
 profuse menstruation into two classes : first, those associated with 
 the womb itself, and, second, those dependent ujion constitutional 
 conditions. Among the former are displacements of the womb, or 
 changes in Its shape ; inflammation of the inside of this organ, the 
 formation of tumors upon and within it ; the retention in the womb 
 of fragments of the after-birth ; the increased size of this organ after 
 pregnancy, often resulting from getting up prematurely and indulg- 
 hig in work and exercise after delivery. The causes not referable 
 directly to the uterus, and especially frequent in girls as distin- 
 guished from married women, are general debility from improper 
 physical and mental training, emotional excitement, etc. As 
 already indicated in the previous pages, domestic remedies must 
 consist in the avoidance of such impropriety of diet, clothing, 
 exercise and habits, and during the menstrual week of maintaining 
 the recumbent posture. A change of air, society and surroundings 
 will frequently, while influencing the general physical and mental 
 health, restore the natural mode of menstruation. 
 
 Another condition — one which causes mothers much anxiety, 
 often needless during the earlier years of the girl's sexual life — is 
 what is popularly termed suppression of the menstrual flow — the 
 failure, partial or complete, of the monthly sickness to appear at 
 the expected periods. It should be remembered that during the 
 first years the menstrual flow rarely recurs with the same regularity 
 as to time, duration and quantity, which is often manifested in the 
 woman's more mature years ; a girl may skip a period or two with- 
 out thereby furnishing cause for alarm or interference, unless there 
 be other evidence of deranged functions. The fact that a girl's 
 monthly flow may last but a day or two, may be also quite consist- 
 ent with perfect health. If, however, the flow be much diminished 
 or entirely disappear in one who has previously menstruated regu- 
 larly and profusely, and if she at the same time manifest other 
 evidences of imperfect functions — such as headache, nausea, pain 
 in the back, loss of appetite, inability to sleep, and unusual sense 
 of exhaustion — measures may be taken to promote the menstrual 
 discharge. In these cases it will usually be found that the cause 
 is to be sought in the general condition and not in any diseased 
 state of the sexual organs. The treatment will, therefore, naturally 
 be directed to the constitution rather than to the womb. Partial 
 or complete suppression of the monthly flow, technically called 
 
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 WEBSTER, NY 14580 
 
 (716) 872-4503 
 

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 I 
 
896 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 amenorrhcea, is frequently found in patients suffering from con- 
 sumption, chlorosis, and heart disease ; but aside from these 
 unfortunates, this suppression is peculiarly frequent among women 
 who live indolently and luxuriously among the higher classes of 
 society. Therefore, in such cases the menstrual function is but one 
 of the many functions habitually performed but imperfectly; there 
 is no flow of blood from the womb, merely because the woman's 
 body does not produce nor contain blood enough for the purpose. 
 In such cases treatment is directed naturally to the restoration of 
 the general health and to the avoidance of those injurious influences 
 inseparable from persistent devotion to society. If it be possible 
 to restore the color to the cheek and flesh to the body, the mens .rual 
 flow will usually appear at once in proper quantity and at proper 
 times, without paying any attention to the sexual organs. At 
 times, however, it may be desirable to encourage the menstrual 
 discharge by promoting the flow of blood to the lower abdominal 
 organs — an object which may be accomplished by the application 
 of hot cloths, by a gentle laxative, and by careful friction and 
 gentle kneading of the abdomen and loins, followed by rest and 
 quiet ; or a hot hipTbath of fifteen minutes' duration may be used 
 to accomplish the same result. 
 
 Such are the more usual physical disorders associated with 
 the perf rmance of the menstrual function in the earlier years of 
 womanhood. In discussing them, we have assumed that the child 
 is naturally formed in all particulars, and that no other influences 
 than inherited tendencies and errors of training have been at work- 
 in interfering with the proper performance of the menstrual func- 
 tion It should be mentioned, however, that nature exhibits occa- 
 sionally certain freaks in this, as in other departments of the body 
 — freaks which, because undetected, even unsuspected, may occa- 
 sion considerable anxiety and difficulty. In some children, who 
 exhibit the other characteristics of fully developed womanhood, 
 menstruation is not observed; indeed, cases are on record in which 
 women have married and borne children without menstruating, the 
 monthly flow having appeared, perhaps, after the birth of one or 
 more children. In other cases there is a mechanical obstruction to 
 the escape of blood from the womb — a membrane which closes 
 completely instead of partially the natural orifice of the parts. In 
 such instances the usual symptoms of the monthly sickness, such 
 as headache, pain in the back and languor, recur at regular inter- 
 
 I 
 
 1 
 
DVSMENORRHCEA. 
 
 897 
 
 'I *! 
 
 jg from con- 
 ; from these 
 mong women 
 her classes of 
 ;ion is but one 
 :rfectly; there 
 e the woman's 
 r the purpose. 
 
 restoration of 
 ious influences 
 
 it be possible 
 , the meni.rual 
 
 and at proper 
 il organs. At 
 
 the menstrual 
 )wer abdominal 
 the application 
 ful friction and 
 /ed by rest and 
 on may be used 
 
 associated with 
 earlier years of 
 that the child 
 ther influences 
 e been at work 
 menstrual func- 
 cxhibits occa- 
 nts of the body 
 ctcd, may occa- 
 c children, who 
 cd womanhood, 
 record in which 
 enstruatin^', the 
 birth of one or 
 ,1 obstruction to 
 ine which closes 
 f the parts. In 
 y sickness, such 
 at regular inter- 
 
 vals, though no blood can of course escape; after a number of 
 months the accumulation of blood in the vagina and womb may be 
 so great as to render each menstrual period extremely painful and 
 even to cause an enlargement of the abdomen, which may give 
 rise to an unjust and cruel suspicion of incontinence. It is scarcely 
 necessary to state that a watchful mother could and would early 
 detect the unnatural formation by simple inspection of the genital 
 organs. This discovery should be made early, not only for the 
 satisfaction of the knowledge acquired, but also because the condi- 
 tion can be at once and very simply relieved without any danger to 
 the girl, if but few menstrual periods have transpired; while on 
 the other hand, after some years, when the accumulation of blood 
 has become excessive, the operation necessary to secure the nat- 
 ural performance of the function may have far more serious conse- 
 quences for her than could have ensued in the first or second year 
 of menstruation. 
 
 It sometimes happens, too, that while a girl is otherwise well 
 and perfectly developed, one or more of her sexual organs fail to 
 undergo the change natural at the period of puberty, and remain 
 in the undeveloped condition natural to the child; indeed it may 
 happen that some of these organs are entirely absent — have been 
 left out of the child's body in the making, just as an individual is 
 sometimes born without the usual number of fingers, or even without 
 arms. It is scarcely necessary to observe that such an individual 
 can never hope to perform the duties of the wife and mother. If 
 indeed the ovaries only be lacking she may become a wife, although 
 she will never exhibit the peculiarities of outline and figure, of 
 heart and mind characteristic of the complete woman ; she is, and 
 must remain a sexless being. If the sexual organs be all present 
 the girl may ultimately become a woman even at the advanced age 
 of 24 or 25 years — there being merely a delay, and not an arrest 
 of development. In such cases it may be possible to hasten the 
 change by exposure to those very influences, such as emotional 
 excitement, which are known to concentrate the bodily energies 
 upon sexual organs ; possibly something can be done also with 
 medicine and electricity. The most efficient agent is doubtless 
 marriage, which is, under the circumstances, of course scarcely a 
 legitimate and honorable means, and one usually impracticable. 
 
 On the other hand, sexual development occurs sometimes at a 
 remarkable early age. Thus instances are on record in which the 
 
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 m K 
 
 '.' , 
 
898 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 f 
 
 peculiar physical changes, including the monthly discharge of blood, 
 began at five, at three and at two years ; indeed two cases have 
 been recently reported in which menstruation began with the life of 
 the infant. That the sexual development actually occurs in such 
 precocious children is shown by the fact that girls have become 
 mothers at nine, even at seven, years of age. It might be inter- 
 esting, but is scarcely necessary to enumerate the various deviations 
 from the usual type of menstruation which have been observed in 
 individual cases ; such, for instance, as those in which the loss of 
 blood occurs from the nose instead of from the womb. Yet it is 
 necessary to call attention to the fact that tumors connected with 
 the ovaries or the womb are occasionally developed during puberty, 
 and that such tumors may give rise to excessive and irregular men- 
 struation, or may even cause a complete suppression of the courses. 
 Numerous instances have been observed in which a sudden cessation 
 of menstruation, followed in a few months by enlargement of the 
 abdomen, has been construed, notwithstanding the unfortunate giiTs 
 tearful denials, as evidence of pregnancy ; and although in the 
 majority of such cases — tearful denials included- -the suspicion is 
 well founded, yet the possibility should be borne in mind that sup- 
 pression of the courses, enlargement of the abdomen, and otiier 
 symptoms usually produced by pregnancy may be also caused by 
 a tumor of the abdomen ; that in any doubtful case the girl should 
 have the benefit of the doubt and be submitted to medical exami- 
 nation before an ineffaceable stain be allowed to deface her fair 
 name. 
 
 We have thus sketched the care and attention which may be 
 properly bestowed upon the girl's body during the trying period of 
 puberty. Yet it is understood that a not less important duty of a 
 mother during these same years is a training of the moral nature. 
 This department docs not belong, of course, essentially to the medical 
 adviser, nor will it be discussed in these pages. Yet one suggestion 
 should be made by the physician, since he is often called upon to treat 
 cases arising from defects of the moral training. At this time of 
 the girl's life there is an imperative necessity for the most intimate 
 and intelligent sympathy between mother and daughter. At no 
 other time in the life of the human female has she such pressinjj 
 need for guidance, support, encouragement and affectionate soli;i- 
 tude ; at no other time is she so completely dependent for sympathy 
 and tenderness upon members of her own sex. She is entering a 
 
DYSMENOKKHCEA. 
 
 899 
 
 re of blood. 
 I cases have 
 :h the life (if 
 ;urs in such 
 ave become 
 rht bo inter- 
 is deviations 
 observed in 
 h the loss of 
 ). Yet it is 
 nnected with 
 ring puberty, 
 regular men- 
 f the courses. 
 Iden cessation 
 ement of the 
 ortunatc ^nrl's 
 hough in the 
 le suspicion is 
 nind that sup- 
 en, and other 
 Iso caused by 
 ;he girl should 
 edical exami- 
 eface her fair 
 
 rhich may be 
 lying period of 
 cant duty of a 
 moral nature. 
 to the medical 
 me suggestion 
 |d upon to treat 
 ,t this time of 
 most intimate 
 Ighter. At no 
 Isuch pressing 
 :tionate solici- 
 for sympathy 
 is entering a 
 
 to her, unknown and unexplored realm. She is assuming duties 
 and powers which she would often gladly escape ; she is bewildered, 
 perhaps overwhelmed, by new emotions and desires which she is 
 unable, often unwilling, to direct and control. The various circum- 
 stances which thus increase her need for sympathy and affection 
 constitute at the same time a barrier between her and her male rela- 
 atives. In these, her new trials and troubles, she cannot make con- 
 fidants of father and brothers as has been her previous habit, for 
 however tender their regard, she feels instinctively that they can 
 have no intelligent appreciation of her situation ; she must seek 
 sohce and counsel from woman, and of all women, most naturally 
 of her mother. Yet the experience of physicians sometimes re- 
 veals the fact that the mother's advice and assistance have been 
 very tardily and even grudgingly bestowed ; that the entire matter 
 has been ignored so far as possible, perhaps even until the girl has 
 been terrified by the sudden appearance of her first menstrual 
 flow ; that she has been taught to regard her sexual functions as an 
 evidence of total depravity, a part of the original curse in the gar- 
 den ; something to be ashamed of, repressed, neglected, and not 
 infrequently in such cases the girl's knowledge of the powers and 
 possibilities of her future sexual life have been derived, in large 
 part at least, from her playmates and school companions. In very 
 brief conversation with the child the physician readily perceives 
 whether her information has been derived from her mother or from 
 other sources, for in the latter case there is apparent a false deli- 
 cacy, a furtive air, a tacit impression that the whole subject belongs 
 in the realm of forbidden fruit. The child plainly betrays by her 
 manner a consciousness of guilt in knowing anything about the 
 subject at all, indeed often afifects an ignorance of matters which 
 she evidently understands. It may be perhaps true in the abstract 
 that the girl should be kept in ignorance of the sexual relation ; of 
 the significance of those changes which she is now experiencing ; 
 yet it is quite sure, as a matter of fact, that she will not remain in 
 this state of ignorance. For it is practically certain that the in- 
 formation will be obtained through either legitimate or illegitimate 
 channels, and it is surely far better that she should hear the truth 
 from her mother; that she should be impressed with a solemn sense 
 of the dignity, responsibility and yet danger to body and soul in- 
 separable from her sexual powers that she should be taught the 
 conscientious discharge of her new duties • that she should be in- 
 
 
 n 
 
 
900 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 structed to regard these as the crown and glory of her womanhood. 
 This plan is certainly far better physically, mentally and morally 
 than that she should learn from girls as ill-instructed as herself that 
 the prime object and use of her sexual powers is sensual gratifica- 
 tion ; that marriage is on the same moral plane as licensed prosti- 
 tution ; that maternity is the unwelcome though inevitable result 
 of the sexual instinct; for if the girl entertain such ideas she will 
 certainly not confide in her mother that implicit trust so essential 
 to her own safety. She \\ ill brood and dream in private over the 
 great mystery thus revealed. This unfortunate and mistaken im- 
 pression is but too often strengthened by the mother's neglect to 
 introduce the subject — a neglect prompted either by false delicacy 
 or by the erroneous belief that the girl is as yet but a child and 
 can't comprehend such matters ; a silence which may be interpixt- 
 ed by the girl as a tacit confirmation of her suspicion. We would 
 not be understood as insisting that the girl of 14 or 15 should he 
 instructed in all that pertains to the sexual relations. We would 
 merely express our conviction that in order to secure the complete 
 confidence of her daughter, the mother must impart, and that, too, 
 early in puberty, at least some of the elementary truths as to the 
 meaning of sexual development. Let her not beguile herself into 
 the belief that the matter may be better postponed until the child 
 has acquired more e.vperience and discretion ; let her remember 
 that the question is merely whether the information shall bo con- 
 veyed in the delicate spirit and pure motive of the mother or 
 clothed with the degrading influences of doubtful jest and innuendo. 
 The details of the communication must be of course left to the 
 mother's tact and discretion. 
 
 Were mothers generally in the habit of early instructing their 
 daughters as to the significance of puberty, it would bo scarcely 
 necessary for us to allude to a topic which, under present circum- 
 stances, cannot be conscientiously ignored — indulgence in secret bad 
 habits. Probably every mother who reads this line recoils in dis- 
 gust at the idea of associating her own daughter's name with such 
 a possibility; for every mother believes, naturally, that //tv child is 
 too pure in soul and body ever to conceive or practice a habit so 
 loathsome ; but be not too sure. A part of this fond belief is 
 doubtless justified — probably very few children have ever con- 
 ceived the idea or the possibility of such practices ; and were the 
 habit limited to the few precocious enough to discover them inde- 
 
DYSMENORRHCEA. 
 
 901 
 
 amanhood. 
 [id morally 
 icrself that 
 \\ jrratifica- 
 iscd prosti- 
 itablc result 
 leas she will 
 so essential 
 ate over the 
 nistaken im- 
 's neglect to 
 alse delicacy 
 ; a child ami 
 be intcrpret- 
 
 We would 
 I 5 should be 
 
 We would 
 the complete 
 and that, too, 
 uths as to the 
 le herself into 
 intil the child 
 lier remember 
 shall be con- 
 Ihe mother or 
 land innuendo. 
 Isc left to the 
 
 Istructing their 
 lid be scarcely 
 ■esent circuni- 
 ;c in secret bad 
 recoils in dis- 
 lame with such 
 liat /u-r child is 
 :icc a habit so 
 fond belief is 
 lave ever con- 
 and were the 
 Iver them inde- 
 
 pendently, and to practice them voluntarily, it would scarcely be 
 necessary for us to mention this repulsive subject. But the fact is, 
 that the child rarely escapes a knowledge of this subject, communi- 
 cated by the precept and example of older playmates, servants and 
 even nurses. In many cases the girl or boy is instructed to per- 
 form such unnatural acts at a time when she or he is mentally in- 
 capable of comprehending their significance, and even physically 
 mcapable of experiencing any pleasurable emotion in connection 
 therewith ; the child is, therefore, not only ignorant of the physical 
 wrong, but is also quite innocent of any intention, or even con- 
 sciousness of moral impurity. Although Miss Catherine Bcecher 
 long ago sounded the note of warning to parents, and although this 
 warning has been often repeated, and confirmed in popular publica- 
 tions by medical men, yet parents are not yet fully awakened to the 
 wide-spread prevalence of this habit among the youth of both 
 sexes. It may be safely said that wherever children between twelve 
 and sixteen years of age habitually congregate, there the habit is 
 more or less rife; in every school, especially in the boarding-schools, 
 where the children are withdrawn to a large extent from the enno- 
 bling influences of personal contact with their parents; in every 
 crowd of boys or even girls, there will be found one or more indi- 
 viduals who arc not content to be themselves addicted to this habit, 
 but are sure to impart a knowledge of it to their companions, many 
 of whom., unconscious of any wrong, are easily induced to imitate. 
 Indeed, almost every physician could mention cases in which the 
 innocent child has been instructed in this vice by the servants in 
 her father's house, perhaps even by her own governess. 
 
 The effects, physical and moral, of indulgence in this habit, 
 though greatly exaggerated and distorted in the circulars and books 
 w'th which the country is flooded by patent medicine venders and 
 other quacks, are nevertheless dire enough. Among them we may 
 enumerate loss of appetite and of flesh, bodily and mental weak- 
 ness, nervousness, and disorders of the sexual and urinary organs. 
 Yet, perhaps, the most disastrous is the moral effect, for this un- 
 natural and premature excitement of the sexual desire must neces- 
 sarily direct the child's thoughts and inclinations into improper 
 channels, and may well dispose the girl to become an unreluctant 
 victim to profligate arts in subsequent years. In one of the sad- 
 dest cases in the writer's experience the possibilities just expressed 
 have been realized. A girl had, at the very beginning of puberty, 
 
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 I 
 
 I I 
 
 .^u 
 
 \U'\ 
 
9C2 
 
 DISEASES OF WOMFN AND CHILDREN. 
 
 been taught the habit by a companion, and became a slave to the 
 passions thus nurtured, and finally a victim to one who knew how- 
 to arouse these passions to which she was herself enslaved ; and 
 when, at nineteen, she became an outcast from society, she vainly 
 lamented that no one had ever warned her at that early age of 
 innocence and ignorance against the disastrous moral tendencies 
 of her secret habit. 
 
 Nowhere have we better illustration of the value of prevention 
 as compared with cure; for this habit, once acquired, it seems at 
 times impossible to break. In some cases it has been found neces- 
 sary to resort even to mechanical restraints, such as tying the hands. 
 Yet if it be discovered that the child is addicted to this unfortunate 
 habit, a cure would best be effected, in most cases, certainly not by 
 severe censure and harsh reproof, but by kind sympathy and affec- 
 tionate encouragement. Oftentimes, doubtless, these measures, 
 directed by a mother's tact, will suffice. It should also be observed 
 that there be no local physical causes which can keep up an irrita- 
 tion of the sexual organs ; for it is a fact that, in exceptional cases, 
 the habit is maintained, perhaps even generated by local disease of 
 the womb or of the skin of these parts ; by worms in the lower bowel, 
 and by imperfect attention to cleanliness. So, too, the inclination 
 thereto may be diminished by hard beds, light covering at niyht, 
 regular evacuation of the bowels and bladder, especially late in the 
 evening ; sometimes, also, ablutions with cold water, shortly before 
 retiring, may be beneficial. If these simple measures, combined with 
 the judicious advice and restraint of the parents, fail to abolish the 
 habit, a physician should be at once consulted ; for this a matter too 
 serious to be neglected or to be hidden. Far better than the attempt 
 to cure the habit, however, is the prevention thereof, which can be 
 accomplished very readily if the mother possess the entire confidence 
 of her daughter. If the girl be taught to converse with her mother 
 as freely upon her sexual functions as about the action of the bowels, 
 it is rarely possible the child could acquire or attempt to conceal such 
 habits. It is not, of course, necessary under such circumstances, 
 to warn the child particularly against these habits in such terms 
 as may excite an unnatural curiosity for further knowledge, but 
 merely to instruct her in a general way that any handling of these 
 parts is injurious and degrading. 
 
 In this connection it should be observed that while such habits 
 are usually acquired during or after puberty, yet cases have been 
 
DYSMENOKIUICEA. 
 
 903 
 
 observed — in boys more frequently, it is triic, than in girls — in 
 which children, at an age usually incapable of sexual excitement, 
 yes, even infants in arms, have habitually performed such acts, 
 accomplished by movements of the thighs and contortions of the 
 body ; and the acquisition of the habit is not infrequent among 
 children who present as yet nn sign of sexual development. 
 
 A condition often found in girls, though not by any means 
 confined to them, is a discharge commonly known as " the whites," 
 and technically called IcucorrJura. In married women, this dis- 
 charge is usually a symptom of disease of the womb, and it will be 
 referred to in considering the diseases of that organ. In girls, on 
 the other hand, leucorrhoea often occurs without any disease of 
 the womb, the discharge proceeding entirely from the vagina. 
 Although most common after puberty, yet it is not rare to find 
 this same condition in girls from eight to fifteen years of age. In- 
 asmuch as this same symptom accompanies also a certain con- 
 tagious disease, there sometimes arises a suspicion that the girl 
 has, whether voluntarily or not, been brought in contact with some 
 one suffering from this disease, and physicians are sometimes con- 
 sulted by anxious mothers as to the possibility that their children 
 have been tampered with by others. If such be really the case, 
 there will usually be other and unmistakable evidence ; the fact of 
 the discharge alone does not warrant any suspicion of contact with 
 others. In girls from eight to eighteen, the discharge, though 
 usually white, has sometimes a tinge of yellow, or even green ; is 
 sometimes so slight as merely to attract notice by stains upon the 
 linen, at other times so profuse as to occasion great annoyance. 
 There is usually no pain, though sometimes a slight burning sen- 
 sation is felt, particularly just before and aftei the menstrual period; 
 the monthly flow is itself often irregular, both as to quantity and 
 time; the general health is usually somewhat impaired; the indi- 
 vidual is pale and languid — suffers from constipation, irregular and 
 ill-defined pains in different parts of the body, especially the loins, 
 loss of appetite and sleep. 
 
 ;i, 
 
 
 w 
 
 \\ 
 
 • I 
 
 Causes. — LeucorrhcEa, as it occurs in girls, is usually not a 
 symptom of disease of the womb, but indicates merely a relaxed 
 condition of the vagina, dependent most always upon an impair- 
 ment of the general health. It is especially frequent in those 
 children whom we are accustomed to call scrofulous — those with 
 
 ..i 
 
 ■; f 
 
 i.ii 
 
904 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 pale, waxy skins, prone to enlargements in the neck, the children 
 of delicate parents. Such children often have more or less dis- 
 charge from various mucous membranes; they have red, watery 
 eyes, and oftentimes excessive secretion from the nose. In sucli 
 children the discharge from the vagina is to be regarded in the 
 same light and treated largely in the same way ; that is, by efforts 
 to improve the general health, by proper attention to diet, air, 
 exercise, etc. In other cases, Icucorrhoea is the direct result of im- 
 proper habits of life, and is especially frequent in the girls of lar;;o 
 cities who receive less than the proper quantity of fresh air and 
 sunshine, live in hot and ill-ventilated rooms, and wear clothing 
 which, whatever its design may be, does not protect the person 
 from cold and wet. The general use of woolen underclothing and 
 stockings, and of thick shoes, would go far toward cradicatin"- 
 leucorrhcEa from girls. Yet sometimes the cause is to be found, 
 not in the direct violation of ordinary rules of health, but in ex- 
 cessive mental strain, whether of the intellect or of the emotions. 
 Leucorrhcea is especially frequent among the so-called nervous 
 girls. It is not infrequently also a symptom of chlorosis. 
 
 Treatment, — The treatment *of leucorrhcea must usually 
 begins with an investigation of the girl's habits of body and mind 
 and of her general health ; for, in most instances, the discharge 
 ceases without any local treatment, if proper care be exercised to 
 secure nourishing food, warm clothing, appropriate physical and 
 mental exercise. Locally, it rarely becomes necessary in the leu- 
 corrhcea of girls — and of them we are now speaking — to do more 
 than secure simple cleanliness, though it must be borne in mind 
 that reliance must not be placed upon local treatment to the nci,^- 
 lect of those general rules of health and hygiene already indica'cd. 
 If the discharge be merely white or glairy, like the white of an 
 egg, it will be usually sufficient to employ, morning and night, a 
 simple injection of lukewarm water, a quart of which may be 
 slowly injected by means of a Davidson syringe ; if, after several 
 days, the discharge still continues, two tablespoonfuls of alum may 
 be mixed with the water before injecting. Regular movements of 
 the bowels should also be secured, though only a gentle laxative 
 may be employed. A warm hip bath, followed by vigorous fric- 
 tion of the skin with a coarse towel, will also be found beneficial. 
 After the discharge has ceased, the injection should be continued 
 for two or three weeks, to prevent a return of the difficulty. 
 
P'H tf 
 
 DYSMENORRIUKA. 
 
 905 
 
 \e children 
 ir less dis- 
 •cd, watery 
 ;, In such 
 -dcd in the 
 5, by efforts 
 to diet, air, 
 result of ini- 
 ;irls of larL;o 
 resh air and 
 ■ear clothm^f 
 t the person 
 rclothiny and 
 1 eradicating^ 
 to be found, 
 h, but in cx- 
 the emotions. 
 ailed nervous 
 lorosis. 
 
 must usually 
 ody and mind 
 the discharge 
 e exercised to 
 ; physical and 
 iry in the Icu- 
 r — to do more 
 orne in mind 
 nt to the nct,^- 
 ady indica'cd. 
 e white of an 
 and night, a 
 hich may bo 
 f, after several 
 ,s of alum may 
 movements of 
 cntle laxative 
 vigorous fric- 
 lund beneficial. 
 be continued 
 lifficulty. 
 
 Another complaint often manifested by pirls during puberty, 
 though by no means monopolized by them, is liystfria, popularly 
 known as hy.sterics. While in many cases there is undoubtedly a 
 physical basis for this disease in some derangement of tiic sexual 
 organs, yet in a very huge number of in lances hysteria is a 
 purely mental disorder, the result of a lack of balance between the 
 emotions and the will. The cases occurring during puberty usually 
 fall in this latter category ; there is ordinarily no disease of the 
 womb or ovaries, but merely a development of the emotional 
 nature in advance of the judgment and discretion ; it is a result of 
 the methods of education, mental and moral training, and peculiar 
 social influences to which the girl has been exposed. It is often 
 noticed that hysterical women have been irritable, capricious and 
 over-indulged children ; and a hysterical convulsion or " fit " is 
 oftentimes to be regarded as merely the woman's way of express- 
 ing the feelings conveyed by children and men in angry words, 
 boisterous behavior and sulkincss. This is so generally under- 
 stood that people arc not usually inclined to bestow upon hysterical 
 females the same amount of s> mpathy and solicitude which would 
 seem to be demanded by the violence and dangerous character of 
 the fits ; it is considered that the hysterical convulsion is merely an 
 evidence of bad temper, cunningly expressed iti a way to demand 
 an attention and sympathy which could not be 5,ccurcd by the tem- 
 per without the fit. While such is doubtless the true explanation 
 of many hysterical convulsions, yet we may not, in justice to many 
 unfortunate women, class all cases in this same category ; for often- 
 times it is absolutely certain that there is no intention to deceive or 
 to abuse our confidence by enlisting our sympathies against our 
 judgment. Indeed, instances have been known — though rare ones, 
 it is true — in which a woman has had a hysterical convulsion when 
 alone ; and nervous women have often been observed to exhibit 
 the same appearances under the influence of sudden and uncon- 
 trollable, but genuine emotions. 
 
 The conduct of a woman during a hysterical attack varies so 
 extremely that no comprehensive description can be given. At 
 times there is merely an immoderate indulgence in an emotion 
 which is, under the circumstances, perfectly natural and legitimate, 
 such as an excess of tears or of hilarity. At other times there 
 occurs the sequence of events popularly associated with the idea of 
 hysteria — a rapid and sudden change from laughter to tears, and 
 
 u 
 
 ill 
 
 /' 1 
 
 s| 
 
 :. r 
 
906 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 conversely. Then again there may be associated convulsive move- 
 ments of the body and limbs, accompanied with screams. In tlu 
 fully developed hysterical convulsion there are certain characteristic 
 features ; they usually occur during a certain depression of spirits 
 or bodily discomfort, especially at or near the menstrual cpncli. 
 The patient often experiences headache, perhaps cramps and numb- 
 ness in the limbs, sometimes a feeling described like that of a l)all 
 roiling around in the abdomen and chest, which often rises into tlu 
 throat accompanied by a feeling of choking. This latter symptom 
 a very frequent sensation in genuine epilepsy, may c.lso be sinuilatcd 
 in the disease under discussion. The breathing usually becomes 
 hurried and irregular, there is palpitation of the heart and pro- 
 nounced flushing, often alternating with pallor, of the face. About 
 this time the patient usually falls, screams, pulls her Iiair, and 
 undergoes a variety of bodily contortions ; the arms i c thrown 
 
 aimlessly about, the knees often drawn violently up to the ^ > 
 
 and as violently extended ; occasionally nausea and vomiting ensue 
 The general appearance of the patient, the disheveled hair, starini; 
 eyes, bodily writhings, interference with circulation and respiration, 
 constitute a startling picture, one well calculated to distress and 
 alarm the uninitiated, especially those who may have a personal 
 and affectionate interest in the patient's welfare ; yet it maj- be said 
 once for all that there is not the slightest element of danger, that 
 the complete recovery of the patient is merely a question of time — 
 a few minutes or perhaps several hours. 
 
 Causes, — The causes of hysteria have been already indicated. 
 In some cases, especially in married women, there will be found a 
 diseased condition either of the womb or of the ovaries, the rehef 
 of which will be followed by a disappearance of the hysteria. Yet 
 in the majority of cases, especially of those which occur during 
 puberty, the fault lies, not with the sexual organs, but in the 
 training of the moral and emotional nature ; sometimes indeed its 
 development can be traced to extreme emotional excitement- 
 fear, anger, disappointment of the affections, religious fervor; 
 and since maternity is the natural culmination of a woman's life, 
 it is not surprising that hysteria should be especially prevalent 
 among those females whose sexual and maternal feelings find no 
 natural gratification, and who at the same time have no other object 
 in life which may divert their attention. It is an interesting fact, 
 and one which has practical importance in the training of girls, that 
 
DYSMKNORKIIfKA. 
 
 907 
 
 hysteria is eminently " catchiny," that is to say, that the appearance 
 of one case of hysterics is almost inv.iriahly followed by the same 
 trouble in females who are intimately associated with the ori^'inal 
 victim ; and this is especially true of ^Mrls durinjj the accomplish- 
 ment of puberty. It is a familiar fact that boarding-schools and 
 colleges for girls are sometimes swept by hysteria as if by an 
 epidemic, so that comparatively few of the pupils between 13 and 
 iH years escape entirely this affliction. It is in such cases — which 
 are really merely examples of the innate tendency of the human 
 mind to mimicry — that the purely emotional nature of hysteria 
 is manifested ; for in these instances the disease can be usually 
 entirely eradicated by simply stimulating the girl's will to combat 
 her emotions. Sometimes a rather harsh stimulus is especially 
 eflicient. It is related of a French p1'-:ician who was called to . 
 one of the Parisian convents, where most . ' the young lady pupils 
 had recently become hysterical, that having assembled the inter- 
 esting patients he heated a number ■> iron; red-li' .. before their 
 eyes and with a bland smile informea them thaL the first girl who 
 !i 1,1 hysterics would be cauterized down the pine. He had no use 
 for his iron... 
 
 A case of hysteria, which does not yield readily to social and 
 moral influences which can be brought to bear in the home circle, 
 should be brought to the notice of the physician ; for there are no 
 rules to be laid down as to the administration of medicine. If 
 drugs are required — the exception rather than the rule — it will be 
 desirable to know the cause of the hysteria, since this is really a 
 symptom, and not a disease. 
 
 Among the numerous eminent medical writers who have pub- 
 licly urged the considerations set forth in the preceding pages, no 
 one, perhaps, is more worthy of attention than Dr. William 
 Goodcll, of Philadelphia, who closed a recent address on the sub- 
 ject in the following pertinent words: " I am old-fashioned enough 
 to believe that the chief end of woman is to be married, to have a 
 home of her own, and to give birth to healthy children ; and that 
 woman, as woman, has no moral right to (\o anything that will unfit 
 her for this end. Whatever does damage to her, does damage to 
 those born to her; and her disabilities arc their disabilities — disa- 
 bilities far-reaching and never-ending. A woman has undoubtedly 
 the right to remain single all her life ; but as a late writer forcibly 
 observes, if she considers herself a candidate for love and marriage 
 59 
 
 .'2t 
 
 1: 
 
 H'! 
 
 r i*i 
 
 i! V' 
 
I 
 
 908 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 she has no moral right to touch any employment that will in an\- 
 degree unfit her for domestic life and all the responsibilities that t;o 
 with marriage. Now, while in the abstract this is undoubtedly 
 true, yet I fear that it could be carried out only in the new Atlantis, 
 or in some other equally ideal community. But while a physician 
 cannot undertake to create a fancy republic where hygcia shall 
 reign supreme and where every rule of good health and of good 
 morals shall be observed, he can work efficiently toward the 
 redemption of woman. He can discourage women from takinj^ 
 those industrial employments which tend to impair their health and 
 to unfit them for the duties and functions of woman. Of this class 
 are all those occupations which oblige the worker to be on her feet, 
 and especially during her monthly periods. Should a dire neces- 
 sity drive them to such work, he can so influence public opinion as 
 to compel their employers to give them the daily or the monthh- 
 rest which they may need. 
 
 " Nor can women as a class sustain, without injury, the same 
 amount of brain work as men. Where can a robust school-mis- 
 tress be found ? Or how rare is it for a highly intellectual woman 
 to be a healthy one ? Then again, compare the health of the boys 
 with that of the girls at our public schools. Women, from their 
 own sensations and feelings, call themselves 'unwell' during tlie 
 monthly flow. They are, by their own showing, literally unwell, 
 and are, therefore, at that time, as unfit for severe brain-work as for 
 fatiguing body work. The curriculum of studies in our female 
 schools should, therefore, be lengthened out and graded to the phys- 
 ical needs of our girls — our nascent women. Out of school hours 
 there should be very little study; while 'unwell' their brains 
 should not be overtaxed and their bodies overworked. Mothers 
 should be taught how to preside over the physical education of their 
 daughters — how to pilot their frail bodies safely through the shoals 
 and quicksands of girlhood. The clothing should be thick and 
 warm and supported, not from the waist but by the shouKlers ; 
 their shoes stout and roomy ; their chests unronfined by corsets ; 
 their brains not overtaxed. Candies, doughnuts and hot biscuits 
 must be struck out from their path ; such trash has made our ilent- 
 ists world-renowned. Habits of regularity in sleep, as well as in 
 the evacuations, should be scrupulously enforced. Over-work in a 
 constrained position, especially that at the sewing machine, must he 
 forbidden. Let them daily take sunshine and exercise in the open 
 
MARRIAGE. 
 
 909 
 
 air. But on the other hand let them durnig their monthly sick- 
 ness, avoid picnics, sleighrides, dancing parties, and other like 
 imprudences. 
 
 " The risks from the suppression of the flow should be vividly 
 pointed out, else they could hardly be persuaded to forego pleasures 
 which at such times are fruitful sources of mischief. Mothers should 
 therefore diligently supervise the menstrual week of their daughters, 
 and at that time forbid all over-work of brain and of body. Would 
 that all women could be taught to look upon the law of periodicity 
 in their nature not as an affront to womanhood, not as the mark of 
 a curse, but as a dower of health and of beauty, if respected — as 
 the leaven of life-long invalidism, when abused." 
 
 . f i|M 
 
 
 Marriage. 
 
 Ul'j 
 
 rain-work as for 
 
 ;ided to the pliys- 
 
 |t of school hiiurs 
 
 ,•11 ' their brains 
 
 i-ked. Mothers 
 
 ild be thick and 
 the shoulders ; 
 
 and hot biscuits 
 
 Over-work in a 
 nachinc, must be 
 ise in the open 
 
 In selecting a partner for life many factors, religious, social, 
 mental and moral, perhaps I should say also pecuniary, enter into 
 consideration, which it is not the province of the medical adviser 
 ti) discuss ; yet there are certain facts bearing upon the physical 
 basis of marriage which it is the physician's duty to impart, and 
 which may therefore be properly presented here. 
 
 First — It should be remembered that marriage implies as its 
 natural result the production of offspring; and that a due regard fur 
 the welfare of such possible and probable offspring should be taken 
 into consideration as a by no means unimportant element. It is, 
 therefore, evident that marriage can be complete only when the par- 
 ties to the contract are physically competent to fulfill the sexual rela- 
 tion, and, more than that, when the woman is capable of maternity. 
 Now, while the girl is frequently capable, even in the earlier years of 
 puberty, of becoming a mother, yet it is a fact patent even to the 
 unprofessional mind, and well established by medical observation, 
 that the girl is physically unfit for maternity, and that the disastrous 
 results of premature motherhood are often visited, not alone on the 
 jouthful mother as physical injuries, but are also apparent in the 
 puny bodies and limited intellect of her offspring. The girl, in 
 other words, is not made a woman by her first menstruation, for in 
 the years to follow there must occur not only the development of 
 her sexual organs, but also the increase in size and change of form 
 
 11^ l! 
 
 irt 
 
9IO 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 of her whole frame, particularly the part included between her hips 
 — the pelvis — whereby the germ of a new life may be fitly and fully 
 developed within her body, and at the proper time permitted to pass 
 through the pelvis to the outer world. For the too youthful wife 
 marriage often proves a pain, not, a pleasure ; a grief, and not a joy. 
 The imperfectly developed womb and ovaries, which might well 
 have attained perfection if permitted to remain unmolested, unable 
 to meet the demands of matrimony, are goaded into a state of irri- 
 tation and disease. Her nervous system is often thereby enfeebled 
 and she is prone to general prostration, as well as to those diseases 
 peculiar to women. If she become a mother, she experiences more 
 risk of in'ury during and subsequent to her confinement ; and when 
 called upon to nourish her infant as well as her own still growing 
 body, it is not surprising that she often breaks down entirely. 
 
 It has been found that in our latitude and climate women 
 usually continue to grow and develop up to the age of 20 years; 
 though there are, of course, numerous exceptions in which maturity 
 occurs earlier as well as later than this period. On the other hand, 
 there are certain physical disadvantages accompanying over-maturity 
 in the bride ; for it is a well-established fact that women who expe- 
 rience the first confinement at an age exceeding 28 or 30 years 
 furnish a larger mortality from child-birth than those who become 
 mothers between 20 and 30 years of age. From the physical 
 standpoint alone, therefore, matrimony seems most advisable as a 
 rule between 20 and 25 years — an age. too, previous to which the 
 mental development is not usually such as to demand marriage. 
 
 In the choice of a husband no adviser can influence the dic- 
 tates of a woman's heart ; and it is not our purpose either to usurp 
 the duty of the parents in suggesting ordinary discretion and pre- 
 vious acquaintance with the mental and moral, as well as the 
 physical, characteristics of the suitor; nor to pad our pages with 
 romantic, sentimental, and utterly absurd advice, so interesting to 
 imaginative young ladies, as to just how tall and heavy and grace- 
 ful and mf.nly he should b^ ; as to what should bo the color of his 
 eyes, etc. It should be, however, remarked that certain physical 
 characteristics ought, in the interest of the girl herself, to constitute 
 insuperable obstacles to matrimony : It cannot be too emphatically 
 insisted upon, that a man and a woman presenting the same heredi- 
 tary taints, suffering from the same constitutional disease, or ten- 
 dency to disease, should not, as they value their own happiness and 
 
MARRIAGE. 
 
 911 
 
 '■t i«'^ 
 
 ween her hips 
 fitly and fully 
 tnitted to pass 
 
 youthful wife 
 and not a joy. 
 :h might well 
 )lestcd, unable 
 a state of ini- 
 reby enfeebled 
 
 those diseases 
 periences more 
 lent; and when 
 n still growing 
 1 entirely, 
 climate women 
 re of 20 years ; 
 I which maturity 
 
 the other hand, 
 ig over-maturity 
 omen who cxpe- 
 
 28 or 30 years 
 ose who become 
 
 ,m the physical 
 ;t advisable as a 
 (Ous to which the 
 
 .nd marriage. 
 Iifluence the dic- 
 le either to usurp 
 
 .cretion and pre- 
 as well as the 
 
 :l our pages with 
 
 so interesting to 
 
 heavy and grace- 
 
 [0 the color oi his 
 certain physical 
 
 •self, to constitute 
 too emphatically 
 the same hcredi- 
 
 [1 disease, or ten- 
 
 |wn happi»^'='^ '^'^^^ 
 
 that of their possible cnildren, marry. In our land this is particu- 
 ularly true in regard to consumption and insanity. Were our laws 
 made with the same rigid regard for physical health as prevailed in 
 ancient times, we would doubtless forbid marriage to all suffering 
 or likely to sufifcr from consumption ; and while we are in these 
 days more humane ; while we take into consideration, in the esti- 
 mation of conjugal happiness, the mental and moral as well as the 
 physical welfare of the participants, yet we must remember that con- 
 sumption is an eminently hereditary disease, and that the child's 
 chances of becoming a victim to it are greater if both parents be 
 born of tainted stock than if one at least be healthy. The same 
 remark may be applied to insanity, epilepsy and other diseases of 
 the nervous system ; for we may be sure that while children may 
 escape if the tainted be mixed with healthy blood, yet the most 
 accravated and numerous cases of obstinate nervous diseases arc" 
 found in families where both parents exhibit a tendency to the dis- 
 ease. In this general fact, too, we have a solution of that much- 
 discussed question, whether relatives, particularly cousins, should 
 be allowed to marry. With reference to this, wc may say that the 
 simple fact of relationship — when not nearer than that indicated — 
 constitutes no physical impediment to marriage, yet there usually 
 e.\ists in these cases a physical objection ; for the physical imper- 
 fection, if any exist — hereditary taints and tendencies to disease — 
 will probably be found in both members of the family, and these 
 defects and taints would in all probability be condensed and 
 aggravated in their children ; and while we may say that there is 
 no physical objection to the inter-marriage of cousins as such, pro- 
 vided both be healthy, yet there will usually be found upon closer 
 scrutiny a family tendency, the aggravation of which by inter- 
 marriage, would be disastrous to happiness. 
 
 It need scarcely be remarked that close and repeated inter- 
 marriage among relatives is, from the physical point of view, unde- 
 sirable. It is a law, true of man as of other animals, that the most 
 vigorous qualities of a given stock are best maintained by a certain 
 admixture of foreign blood ; and it is a fact of observation, that 
 marriages between Americans — those whose ancestors have lived 
 in this country for several generations — are less productive in at 
 least the number of the children than marriages between a native 
 American and a European ; though it must be admitted that since 
 the size of the family is influenced by many. other circumstances 
 
 
 t 
 
912 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 than the simple fertility of the parents, we are not justified in 
 drawing the same conclusion from the fact just stated as might fol- 
 low such observation upon animals. It is specially interesting in 
 this connection to note the peculiarity of the Jews : they, as is well 
 known, marry, as a rule, only members of the same race, and yet 
 are remarkable for both physical and mental vigor of their numer- 
 ous progeny. The peculiar traits, mental and physical, we niav 
 indeed say moral, are retained and perpetuated by inter-marriage, 
 and yet a sufficient latitude of choice is allowed to secure a projier 
 admixture of stock. It must, however, be remembered that the 
 religious tenets of Israel provide not only for the health of the soul, 
 but contain also admirable regulations for the health of the body ; 
 to which perhaps their fertility and general health are to be in part 
 attributed. 
 
 In selecting the time for marriage, certain physical facts should 
 not be lost sight of amid social considerations. The health of the 
 wife and of her possible offspring is furthered by consummation of 
 the marriage rite in the spring or in the fall ; for entrance upon this 
 new life is beset with physical and mental trials, which are certainly 
 all the more trying amid the heat of summer or the cool of winter. 
 One important consideration gives spring an advantage (jver 
 autumn: that if a child be born within a year its chances will be 
 far better for surviving the trying period of teething, since the most 
 critical part of this process will then occur in cool weather, and not 
 In the heat of summer. The wedding should occur about the mid- 
 dle of the interval between two menstrual periods. 
 
 Although custom ordains that the newly-married pair shall 
 start at once upon a wedding tour, yet it is generally understood 
 that this tour need not be extended a greater distance than suffices 
 to remove them from the immediate and critical observation of their 
 friends ; indeed, it is a hopeful sign to observe that the wedding 
 tour is no longer so imperatively required by society as formerly. 
 From the physical point of view, certainly nothing could be more 
 objectionable than a long journey immediately subsequent to the 
 marriage ceremony. When, in addition to the annoyances insepar- 
 able from traveling, the bride is subjected to the trials incident to 
 initiation into her new life, it becomes apparent that the girl is, 
 during the ordinary bridal trip, subjected to a severe and in large 
 part unnecessary physical strain, and that, too, at a time most 
 critical and important for the security of her future happiness, as 
 
PREGNANCY. 
 
 913 
 
 well as that of her husband. They are, it is true, withdrawn to a 
 certain extent from the rude realities of life into an atmosphere of 
 affection and sentiment ; yet it must be remembered that this 
 affection and sentiment, however sincere and hearty, has a physical 
 basis — a foundation which would be much better and more securely 
 laid if both, especially the bride, were relieved from all unnecessary 
 fatigue and annoyance, for at this time she has supreme need of 
 physical perfection and at the same time of the greatest tact and 
 discretion ; sometimes, too, she must be prepared for disappoint- 
 ment, for probably every man, however sensible and rational in 
 other matters, is positively silly during the courtship and engage- 
 ment ; invests his fiancee with perfections of body and mind which 
 arc actually never clothed in mortal shape ; in fact he marries an 
 ideal creature of his own imagination, and during the first week of 
 married life must learn to substitute the actual for the ideal. Hence 
 it often happens that a certain revulsion of feeling is felt by many 
 men, who nevertheless have sincere affection for their wives — a 
 revulsion of feeling for which the bride is not responsible, and yet 
 which she must anticipate and be prepared to meet. There can be 
 little doubt, though it is a matter of course which scarcely permits 
 of actual demonstration, that the seeds of much unnecessary discord 
 and unhappiness are sown during the honeymoon by ignorance and 
 lack of tact. It is therefore extremely desirable that all useless 
 troubles and fatigues, such as those attendant upon traveling, be 
 postponed until the wedded life be fairl_> begun. And it is hardly 
 necessary to add that it is desirable to avoid the inquisitive eyes of 
 friends and acquaintances, while on the other hand it is just as 
 undesirable to forget and forsake the world entirely during this 
 time ; the boy who eats jam without bread will surely have dys- 
 pepsia. 
 
 
 Pregnancy. 
 
 The minute bodies contained in the ovaries — the eggs — un- 
 dergo an enlargement, and one or more of them escape from the 
 ovaries, usually daring the monthly period, and are carried along the 
 tube connecting the ovaries with the womb. Arrived in this latter 
 organ they are as a rule cast off with the secretion and leave the 
 body. But if in the course of their progress from the ovary the 
 
 ■i< 
 
914 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 egg meet and become penetrated by the male element it is not cast 
 off as in the former case, but becomes lodged in the membrane 
 which lines the womb. Then follows a development of the germ 
 and with it of the containing womb — and this development consti- 
 tutes the process known as pregnancy. Associated with this pro- 
 cess and intimately dependent upon it, are various other conditions 
 manifested sometimes in parts of the body so remote that it is not 
 easy to discover the connection with the organs especially con- 
 cerned. Indeed almost every part of the body is liable to manifest 
 deviations from its usual state at this time ; yet some of them arc 
 of such constant and uniform occurrence as to be regarded as signs 
 of pregnancy. Yet it should never be forgotten that the absolute 
 signs of pregnancy — those which cannot be induced by other 
 causes — are very limited, especially in the early months. 
 
 While certain changes early occur in the generative organs 
 themselves which may lead the physician to suspect the existence 
 of pregnancy, yet the first symptom which attracts the attention of 
 the womap herself is usually the suppression of the monthly flow. 
 This, of course, is not an infallible sign of pregnai'cy, since sup- 
 pression may be caused also by several other condit! jns, and indeed 
 not infrequently occurs in early married life without any appreci- 
 able cause, unless, indeed, we may attribute it to the infl,ucncc on 
 the nervous system consequent upon sexual intercourse. And on 
 the other hand the monthly sickness may continue during a part or 
 even the whole of pregnancy. It occasionally happens that the young 
 wife continues to menstruate more or less profusely at the first two 
 or three periods after pregnancy has actually begun. Indeed, 
 cases are on record in which women have menstruated only diirin;:; 
 pregnancy. 
 
 A second symptom upon which women generally lay consider- 
 able stress is morning sickness. While this is a very common 
 symptom, and when present may have considerable value, yet its 
 absence is by no means- proof of the contrary condition. There is 
 no certainty nor uniformity as to the time at which this symptom 
 may make its appearance. At times it seems to begin almost ;it 
 the very day of conception, while at other times it may make its 
 appearance only after suspicion is already aroused by the suppres- 
 sion of the monthly sickness. There is also considerable variation 
 in the duration of this condition ; in some cases it may last for a 
 few weeks only, in others may persist until delivery. As a rule, 
 
PREGNANCY. 
 
 915 
 
 it is not cast 
 
 ; membrane 
 
 of the germ 
 
 ment consti- 
 
 /ith this pro- 
 
 ;;r conditions 
 
 :hat it is not 
 
 pecially con- 
 
 le to manifest 
 
 » of them are 
 
 irded as signs 
 
 t the absohite 
 
 cod by other 
 
 nths. 
 
 ;rative organs 
 
 : the existence 
 
 he attention o{ 
 monthly flow. 
 
 ,-cy, since sup- 
 
 jns, and indeed 
 
 jt any appreci- 
 
 le inftucncc on 
 
 urse. And on 
 uring a part or 
 that the young 
 at the first two 
 o-un. Indeed, 
 ted only durinj; 
 
 y lay consider- 
 very common 
 le value, yet its 
 ition. There is 
 1 this symptom 
 begin almost at 
 ,t may make its 
 by the suppres- 
 lerable variation 
 It may last for a 
 lery. As a rule, 
 
 we may say it begins during the first month and ends at the third 
 or fourth. Occasionally, too, the nausea and vomiting occur in 
 the evening and not in the morning. 
 
 Changes in the breast constitute also a usual sign of pregnancy 
 — as will be expected when we consider the duties which these 
 organs are to perform in nourishing the germ now undergoing 
 development. Among the earliest indications are certain va"-ue 
 feelings sometimes described merely as a sense of fullness, but 
 often amounting to uneasiness and even pain. The breast becomes 
 larger and firmer; the nipple is more prominent; the veins under 
 tl-,c skin become more conspicuous because larger ; the rose-colored 
 circle surrounding the nipple becomes larger, darker, and exhibits 
 numerous small projections. While these changes possess consider- 
 able value as signs of pregnancy, yet they usually occur so late — 
 often beginning only with the third month — that the question may 
 be decided without them ; this is particularly the case if the woman 
 be already a mother, since the changes in the breasts are usually 
 less marked in subsequent than in the first pregnancy. 
 
 Another symptom frequently, though not always present, is 
 irritability of the bladder. In the later months the necessity for 
 frequently voiding the urine is not uncommon ; yet this symptom 
 sometimes makes its appearance in the second or third week, and 
 is sometimes followed later by inability of the woman to retain the 
 urine, which frequently escapes by day as well as by night, in spite 
 ut all her efforts to control it. 
 
 Changes in the abdomen are, in the earlier months, very un- 
 certain signs of pregnancy — reliance upon which has occasioned 
 numerous, often ridiculous blunders. During the early weeks of 
 pregnancy the abdomen actually becomes smaller and it is not 
 until the the thirteenth or fourteenth week that enlargement begins ; 
 yet it often happens that there will be an accumulation of gas in the 
 intestines which may simulate quite closely the usual enlargement, 
 and if this happen during the first month or two of pregnancy the 
 great expectations of the young wife are often terribly blighted 
 when a few weeks later she finds her abdomen much smaller than 
 before. Many a childless woman, too, approaching the change of 
 life is led to hope from this deceitful enlargement of the abdomen 
 in connection with the suppression of the menstrual discharge that 
 she is finally pregnant. There are so many causes which may con- 
 tribute to abdominal enlargement that this symptom has but little 
 value in determining pregnancy, until the later months. 
 
 \\0. 
 
 . 1 
 
 11 
 

 9i6 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 The movements of the child, or rather of the foetus in tlio 
 womb, communicate to the mother the sensation known as quick- 
 ening. The exact time at which the movements are first perceived 
 varies with several conditions — the activity of the fcetus and the 
 condition of the mother. The average time is perhaps the eight- 
 eenth or nineteenth week, though it may occur as early as the 
 fifteenth or may be postponed until the eighth or ninth month. 
 Since quickening consists merely in the perception of the fcetal 
 movements by the mother, it is evident that there is considerable 
 room for mistake, especially in the first pregnancy, since similar 
 sensations may be induced by the movement of gas in the bow els, 
 by contractions of the abdominal muscles as well as by other causes. 
 Nor is the absence of this feeling a proof of the non-existence of 
 pregnancy. In the later months, sometimes even in the earlier, the 
 movements of the foetus become so violent as to occasion percepti- 
 ble movement of the womb and of the abdominal muscles — move- 
 ments which may even give the mother pain. Yet all these ap- 
 pearances may be simulated by other conditions than pregnancy; 
 sometimes even intentionally. In more numerous instances, how- 
 ever, the woman is herself deceived, and often persists in her self- 
 deception under circumstances which render the occasion highly 
 absurd. It has repeatedly happen^ed that the enlargement of the 
 abdomen and movements simulating perfectly those of quic'cenint^ 
 have entirely disappeared so soon as the woman has been allowed 
 to inhale chloroform, but have returned again so soon as she re- 
 covered consciousness. While such an occurrence usually suffices 
 to convince the friends of the non-existence of pregnancy, it just as 
 often fails to influence the conviction of the would-be mother. It 
 is related by Hume that Queen Mary of England, whose marriage 
 with Philip of Spain was not blessed with children, at one time de- 
 ceived herself into the belief that she felt the movement of the 
 fcetus. So confident was the joyful Queen that even her physicians 
 were, or professed to be convinced, notwithstanding the previous 
 years of barrenness. The approaching event became the subject 
 of public and private rejoicings, and of supplications for the con- 
 tinued health and safety of the Queen and of her son. The latter, 
 as is well known, failed to appear — the Queen had deceived her- 
 self. 
 
 Changes in the skin also often appear as one of the accompani- 
 ments of pregnancy ; these are usually manifested by a darkening 
 
DISEASES OF PREGNANCY, 
 
 9ir 
 
 of the skin, particularly on the forehead, nose and cheeks, some- 
 times also on the breast. Not infrequently there is nu)re or less 
 change in the general complexion ; the skin may exhibit a certain 
 unusual dryness; or, on the other hand, the amount of perspiration 
 may be greater than usual. These changes, however, do not occur 
 with such certainty or uniformity as to give them value among the 
 signs of pregnancy. 
 
 Among other less constant and therefore less important signs, 
 are caprices in appetite and personal habits. The pregnant woman 
 is sometimes seized with an unconquerable desire to drink vinegar, 
 devour chalk or slate pencils, indeed behave very much like a girl 
 with chlorosis ; the appetite is frequently markedly increased, some- 
 times even to an astonishing extent. Women in this condition often 
 say that they are always hungry, and actually rise two or three times 
 at night and get something to eat. During the same period that 
 the woman suffers from morning sickness there not infrequently 
 occur also other disorders of digestion — among which heart- 
 burn, pain in various parts of the abdomen and diarrhea may be 
 mentioned. Mental characteristics also are sometimes changed 
 remarkably. An unsteady temper, marked by fits of peevishness 
 and irritability, often nervousness and even hysteria are developed 
 in the earlier months. 
 
 W 
 
 
 Diseases of Pregnancy. 
 
 Some of the symptoms just mentioned as indicating pregnancy 
 are such as would be regarded under ordinary circumstances as 
 unnatural and requiring treatment. But pregnancy itself is a 
 natural process, and since many of these symptoms are merely 
 evidence of the sympathy which prevails between the sexual organs 
 and other parts of the body, we are not accustomed to regard the 
 slight disorders usual in pregnancy as indications of disease. So 
 long at least as they do not exceed certain moderate limits they are 
 usually treated by mild measures or even ignored altogether. Ex- 
 perience shows that the gravity of the symptoms manifested varies 
 considerably in different women within the limits of perfect health ; 
 that is to say, the process is carried to a successful termination and 
 the mother regains her usual condition. It is indeed a matter of 
 surprise often to the physician himself to observe how well the 
 
 ! ! 
 
 ^n 
 
 -t, 
 
 f 
 
9i8 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 pregnant woman bears up under physical ailments and annoyances 
 peculiar to her condition, which in the non-pregnant state woulil 
 certainly be followed by serious impairment of her general health. 
 There is therefore sometimes room for doubt as to just where tlic 
 line should be drawn ; some uncertainty in determining what cases 
 demand treatment, and in which ones no interference is required. 
 This is especially true of those derangements manifested by the 
 digestive organs. 
 
 The morning sickness, already referred to, which is exhibited 
 by almost all women to a greater or less extent in the early 
 months of pregnancy, becomes at times the source of serious diffi- 
 culty, and even apprehension. So long as the general health is 
 not impaired thereby, it is certainly best not to attempt any inter- 
 ference with medicines. There is, indeed, a prevalent impression 
 among the laity that morning sickness conduces to the success of 
 the process ; an impression embodied by midwives in the saying 
 that a sick pregnancy is a safe one. Yet at times this symptom 
 becomes so violent that the woman's general health is evidently 
 injured ; in such cases the sickness occurs not merely in the morn- 
 ing, but after every attempt to take food, no matter how bland 
 and unirritating. In some of these cases it seems incomprehensi- 
 ble how the body can be sustained by the very slight amoi'nt of 
 nourishment retained in the stomach. The most violent of these 
 cases usually occur in first pregnancies Sometimes, too, the simple 
 loss of food is aggravated by the violence of the effort occasioned in 
 emptying the stomach — a violence which often causes anxiety lest 
 the womb also should be excited to expel its contents and abor- 
 tion be the consequence. At other times the vomiting is very easily 
 accomplished. In but few of these cases is there any notable 
 emaciation or any interference with the development of the fatus; 
 the usual history is, that after some weeks or months of constant 
 distress, the vomiting ceases as suddenly and inexplicably as it 
 began. At other times, however, there occur emaciation, pain in 
 the stomach, the matters vomited are often mixed with bile, the 
 breath is fetid, and the result is spontaneous abortion, unless 
 this mode of relief be proposed and executed by the medical 
 attendant. 
 
 Trcutment, — The remedies which have been proposed for 
 the relief of the vomiting of pregnancy are innumerable — a fact 
 which in itself indicates that none of them can be always relied 
 
DISEASES OF I'KEGNANCV. 
 
 919 
 
 ■M<il 
 
 upon. Indeed, it can scarcely be otherwise , for the vomiting in 
 this case is dependent not upon any disease of the digestive organs, 
 but upon the presence of the fcetus in the womb ; and so long as 
 this condition remain all attempts to regulate the digestive organs 
 by remedies addressed directly to them are likely to be attended 
 with only partial success. Yet it is fortunate that only partial suc- 
 cess is required, since if the vomiting can be restricted within cer- 
 tain limits there will be no interference with the pregnancy. 
 
 It is best to begin by a regulation of the diet ; by avoiding 
 irritating food ; by confining the diet to liciuid articles of food, at 
 least in the morning. Indeed, it sometimes happens that the 
 vomiting can be very largely relieved by the simple device of 
 taking the breakfast in bed and not rising for an hour or two after 
 breakfasting. In some cases milk and lime water, barley water, 
 soups and broths are retained on the stomach, though everything 
 else be rejected ; occasionally eggs will be well borne, though this 
 is the exception ; sometimes while all warm or hot articles are 
 rejected at once, cold food will be well borne. In short, no rules 
 for diet can be laid down ; the stomach is at this time extremely 
 capricious, and we can ascertain what will suit it best only by trial 
 in each particular case ; but it is desirable to make such trial with 
 various articles of diet before resorting to medicines. 
 
 As to the remedies themselves, there is the same uncertainty 
 of effect ; sometimes a glass of mineral water taken before rising 
 seems to secure the desired result ; or pieces of ice held in the 
 mouth until melted ; brandy and soda, a whisky sling, or a glass of 
 champagne have each, in individual cases, prevented vomiting. 
 The alcoholic beverages are especially valuable for this purpose in 
 those cases in which there is considerable weakness and emaciation. 
 A happy result will sometimes be secured by an effervescent 
 draught, which is also desirable for the purpose of securing regular 
 movements of the bowels. One of the most convenient of these 
 draughts is made by dissolving in water one or two teaspoonfuls of 
 the effervescent citrate of magnesia. If the vomiting do not yield 
 to the use of these simple measures, it is desirable to secure the 
 advice of the medical attendant, since most obstinate cases, which 
 have resisted all changes of diet, and even a great variety of 
 remedies, often yield to applications made directly to the mouth of 
 the womb — a measure which must be, of course, referred to the 
 physician. 
 
 (til 
 
 f5 y: 
 
 Mf 
 
 5. 
 
I 
 
 920 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 A not infrequent .innoyancc of prcj^nancy is constipation. Tliis 
 habit, for it is oftentimes nothinj,' more than a habit, is especially 
 injurious during pregnancy, and j^reat pains should be taken to avoid 
 it. Tliis docs not imply that purgatives should be employed; 
 indeed purgatives should be banished so far as possible during 
 pregnancy. It will be rarely necessary to employ any other means 
 than simple regulation of the diet, regularity in taking air and 
 exercise and in attending to nature's calls. The diet for this pur- 
 pose should include ripe fruits and fresh vegetables, brown bread, 
 oatmeal and the like ; if these measures be inefficient, enemas or 
 the " cascara cordial " may be employed. 
 
 An uncommon annoyance of the pregnant state is diarrhea; if 
 severe or obstinate it should be checked, but otherwise does not 
 require especial interference. In most cases no medicine is 
 required ; by confining herself to milk, barley water, arrow root 
 and rice for a day or two the patent will usually be relieved. At 
 other times the cause is evidently indulgence in irritating food, 
 some of which has remained in the bowels ; in these cases a tal)lc- 
 spoonful of castor oil will usually remove the irritating matters, and 
 thus quiet the diarrhea. 
 
 A number of symptoms which occasion considerable annoy- 
 ance and oftentimes anxiety, occur in the latter part of pregnancy, 
 as the result of the pressure of the enlarged womb upon the veins. 
 It is a familiar fact, that pressure upon the veins causes a swclliiij^ 
 of those parts of the body below the point of pressure, as occurs 
 in the end of the finger when a string is tied around the hand or the 
 wrist. In the same way the pregnant womb presses upon the veins 
 which pass into the body from the legs, and may thus cause a 
 swelling of the lower limbs, usually beginning in the feet. This 
 swelling is naturally greatest in the evening, after the woman has 
 been all day erect, and has usually disappeared more or less when 
 she rises in the morning. If no other symptoms occur to indicate 
 interference with the general health, this swelling need occasion 
 no anxiety, and usually requires no treatment if the woman will 
 remain as quiet as possible, and avoid walking and standing. 
 
 If, however, there be a swelling not only of the feet but also 
 of the hands ; and if such swelling be accompanied by headache 
 and disturbances of vision, especially if the pain be at the back of 
 the head, and if, at the same time, there occur unusual feelings of 
 languor and debility, there is cause for careful attention, for in 
 
DISEASES OF rUEUNANCV. 
 
 <J2l 
 
 ition. This 
 s especially 
 ken to avoid 
 employed ; 
 siblc duiint;- 
 other means 
 
 :ing '^"' '^"'^ 
 for this pur- 
 irovvn bread, 
 it, enemiis t)r 
 
 s diarrheii ; if 
 ,'isc does iint 
 medicine is 
 :r, arrow root 
 relieved. At 
 rritatint; food, 
 cases a tabic 
 ig matters, and 
 
 lerable annoy- 
 of pregnancy, 
 ipon the veins, 
 [ises a swellini;- 
 lire, as occurs 
 ;he hand or the 
 upon the veins 
 y thus cause a 
 ;he feet. 'I'his 
 |thc woman has 
 c or less when 
 cur to indicate 
 need occasion 
 ;he woman will 
 itanding. 
 |he feet but also 
 d by headache 
 at the back of 
 isual feelings of 
 ttention, for in 
 
 these cases there is frequently more or less disorder of the kidney, 
 which may occasion trouble before or subsequent to confinement ; 
 indeed, it is usually desirable to call the attention )f the meilical 
 adviser at once te, Jiis condition, since serious mishap may be 
 thereby averted. Another result of this pressure is the enlarge- 
 ment of the veins of the leg usually just behind antl below the 
 knee, resulting in the condition called varicose veins. This condi- 
 tion is especially liable to occur in women who have previously 
 borne children ; sometimes the varicose veins disappear after con- 
 finement, since the cause — the enlargement of the womb — is now 
 removed. Yet after two or three continenients this enlarged or 
 varicose condition of the veins is usually permanent. 
 
 If this enlargement of the veins cause pain, it will be advisable 
 to support the skin. This may be accomi)lished most simply by- 
 applying an ordinary bandage, but most effectually by the use of 
 an clastic stocking. This garment should be made to order by a 
 surgical instrument maker, since if not accurately fitted it may do 
 more harm than good. It is hardly necessary to add that the pain 
 and annoyance can be greatly diminished If the patient will retain 
 the recumbent posture or keep the feet elevated on a chair when 
 sitting. 
 
 During pregnancy women not infrequently suffer from enlarge- 
 ment of the veins in the lower part of the bowel, known as hiemor- 
 ihoids, or piles. This condition occurs with especial frequency in 
 those who suffer from constipation. It occurs indeed rarely if a 
 movement of the bowels be secured every day. It is desirable, 
 therefore, to avoid haimcrrhoids, by securing regular mcjvements 
 of the bowels. Sometimes, however, this does not suffice ; the 
 luemorrhoids persist and occasion the loss of considerable blood 
 at stool. In these cases there is also usually severe pain. 
 
 Tt'eatment, — Since haemorrhoids which originate during 
 pregnancy usually disappear spontaneously after confinement, the 
 object of treatment consists merely in the adoption of such meas- 
 ures as will make the patient comfortable until the end of preg- 
 nancy. An operation is not required, and may indeed be positively 
 dangerous. The first object is, as has already been stated, to se- 
 cure regular movements of the bowels, which may be accomplished 
 by small doses of cascara cordial, or by injections of warm water 
 every night. If complete relief be not thus obtained, an ointment 
 

 nil 
 
 922 DISEASES OF WOMEN AND CHILDREN. 
 
 made of tannin and opium may be applied to the part after each 
 movement of the bowels. 
 
 Hygiene of Pregnancy. 
 
 It is not our intention to lay down a multitude 01 rules to 
 guide the woman during pregnancy. The general principles should 
 be borne in mind that the health of the mother is of the highest 
 importance, not oaly for her own physical welfare but also for the 
 development of the child ; for the foetus is of course merely a por- 
 tion of the mother's body, which is acquiring the powers necessary 
 for an independent existence. l<'or nine months it remains a part 
 of the maternal body, influenced, therefore, by everything which 
 affects the mother. Moreover, since the powers which the cliild 
 acquires during these nine months are the foundation for its sepa- 
 rate existence, it is evident that causes which induce only a tempo- 
 rary effect in the mother may have a permanent influence on tlie 
 subsequent life of the child. A woman may suffer very poor health 
 during the entire term of her pregnancy, and yet after her confuie- 
 ment recover her usual healthy and hearty condition. liut it is 
 scarcely possible that the child born of that pregnancy, havint,^ 
 therefore a very poor start in physical life, should become as vigor- 
 ous as other children. 
 
 With regard to food, but two points need be especially men- 
 tioned : it should be abundant and taken at short intervals. As a 
 rule the appetite is an ample guide and its promptings should be 
 disregarded only when there is a craving for vinegar, chalk anJ 
 similar useless articles. There is rarely danger that too much fooa 
 will be taken, for especially in the latter part of pregnane) uie 
 demand for nourishment is really much greater than in the non- 
 pregnant state. Preference should be and usually is naturally given 
 to plain and wholesome food — meats, vegetables and fruits; it is 
 desirable to avoid stimulating food — condiments, wines and pastry. 
 It is usually better to take four, five or even six meals a da\' rallur 
 than indulge very heartily at the ordinary meal-times. 
 
 In regard to clothing, especial care should be taken for the 
 sake of the foetus. It may be laid down as a general rule t!iat 
 during pregnancy, especially during the latter months, ilannc 
 underclothing should be worn. It seems scarcely necessary to 
 
'I % 
 
 HYGIENE OF rRKCNANCY, 
 
 923 
 
 le part after each 
 
 remark that the body should be allowed perfect freedom for expan- 
 sion. Diirinn- the first three or four months, it is true, there is but 
 little apparent increase in size, but after that time the corset as 
 usually used causes damage, not only by compression of the fcetus 
 and unfortunate changes in its position, but also by promo'.ing 
 swelling of the feet, varicose veins and the other difficulties result- 
 ing from impaired circulation. If the pregnancy must be concealed 
 from motives of pride or delicacy, such concealment should not be 
 attempted through tight lacing. The clothing everywhere should 
 be loose and suspended so far as possible from the shoulders. 
 Compression of the limbs by garters or otherwise, induces swelling 
 of the feet and troublesome enlargement of the veins. 
 
 While cleanliness is of course especially 'nportant during 
 pregnancy, yet the divers unnecessary features associated with 
 bathing should be avoided. Very hot or cold baths, the shower 
 and douche are undesirable, often dangerous ; sea bathing also has 
 been known to cause miscarriage. As a general rule it is desirable 
 to take only a sponge bath as tlie daily habit with a lukewarm full 
 bath not oftcner than once or twice a week. 
 
 During pregnancy the woman usually requires more sleep than 
 she is otherwise in the habit of taking ; the inclination to lie late 
 in the morning has at this time a physiological basis, and should be 
 indulged. The same disposition inclines her, also, to naps during 
 th'-' day, which ordinarily confer profit as well as pleasure, for it 
 should be borne in mind that a considerable part of the mother's 
 vitality is now required for the development of the new being, and 
 that this increased demand upon her strength must be met by addi- 
 tional hours of repose. It not infrequently hapj)ens, toward the 
 close of pregnancy, that the woman experiences the sense of suffo- 
 cation when she lies down ; this occurs merely from the pressure of 
 the enlarged womb, and can be obviated by supporting the head 
 and shoulders, keeping the patient in the semi-recunibcnt posi- 
 tion. 
 
 The mind of the woman requires not less attention than her 
 
 body during pregnancy, since bt)th the physical and mental welfare 
 
 of the child is but a reflection — or rather continuation — of that of 
 
 the mother. It is indeed a popular belief not only that the men- 
 
 t;il states of the pregnant mother arc impressed upon the mind of 
 
 her unborn child, but even that the sights which she may witness 
 
 are sometimes impressed upon the child's body. We are all familiar 
 60 
 
 Mdl 
 
 H^ 
 
 ' '«'. 
 
 Iff 
 
 i ! 
 
 ir; 
 
 t 
 
 \r 
 
924 
 
 DISEASES OK WOMEN AND CHILDREN. 
 
 with the stories of cases in which infants have presented at birtli 
 various marks and pecuHaritics corresponding with objects whicli 
 had made a decided impression upon the mother's mind during tht: 
 pregnancy. We arc told, for instance, that a baker's wife, who had 
 been accustomed to see every day during the early months of her 
 pregnancy a child who had two thumbs on one hand, gave birth in 
 .due time to an infant which presented the same deformity on the 
 corresponding hand. Another mother, who was shocked one day 
 early in her pregnancy at seeing a child with hare-lip, gave birth 
 also to an infant with a similar deformity. Another lady, who had 
 fainted at seeing leeches applied to the neck of a relative, was deliv- 
 ered of a child on whose neck was a perfect picture of a leech. 
 Another woman who had, during pregnancy, experienced a con- 
 stant desire to look at a watch, was not surprised to see in the eyes 
 of her new-born child a distinct image of the face of a watch. 
 Maria Theresa, Queen of France, is said to have given birth to a 
 black child, the color of which she attributed to the fac*" that she 
 had been startled some months previously by the sudden : nrancc 
 of a black page in her service. And so we might go on multiplying 
 indefinitely these and still more startling instances of the influence 
 of the imagination and emotional excitement of the mother upon 
 her unborn offspring. Yet it is only just to say that not a single 
 instance is recorded by which we are justified in believing tliat the 
 imagination or inclination or emotion of the mother can exert any 
 influence upon the physical conformation of the child. The wide- 
 spread belief in such events is due chiefly to the innate love of 
 mankind, and more particularly womankind, for the mysterious and 
 incomprehensible. In all matters pertaining to the mysteries of 
 life we take far more pleasure in indulging the imagination than in 
 exercisiyg the reason, and are always delighted with an opportunity 
 of displaying our credulity. Most of the instances of the class 
 already indicated are pure fiction , and many of th(?!n chuiis}- fic- 
 tion at that. Jt seems at first wonderful that a woman who had 
 noticed a child with hare-lip should subsequently give birth to an 
 infant similarly deformed ; but when we remember that a certain 
 percentage of all infants are born thus mutilated whether their 
 mothers have seen similar children or not ; and when we remember 
 further that hare-lip is not, strictly speaking, a deformity, but mere- 
 ly an incomplete development exhibited by every foetus at a certain 
 stage of its existence, the wonderful part of such stories is dissi- 
 
 I 
 
snted at birth 
 abjccts which 
 nd during the 
 wife, who had 
 months of \\cr 
 eavo birth in 
 brmity on the 
 ckcd one d;i\- 
 lip, gave birth 
 lady, who had 
 tive, was dchv- 
 ire of a leech, 
 rienccd a con- 
 sec in the eyes 
 :c of a watch. 
 iven birth to a 
 ic fac*" i^hat she 
 den : .araucc 
 > on niultiplyini,^ 
 of the influence 
 le mother iipiMi 
 lat not a single 
 lieving that the 
 r can exert any 
 ild. The wide- 
 ; innate love of 
 mysterious and 
 le mysteries of 
 rination than in 
 1 an opportunity 
 ;cs of the class 
 hetn clumsy tic- 
 voman who had 
 eivo birth to an 
 :r that a certain 
 d whether their 
 en we remeinbcr 
 rmity, but mere- 
 "oetus at a certain 
 stories is dissi- 
 
 IIYGIENK OF PREGNANCY. 
 
 935 
 
 pated. And we can assure the youthful mother that she may gaze 
 with impunity upon a whole museum of deformities and malforma- 
 tions, upon hare-lips, double thumbs, grinning monkeys, and simi- 
 lar attractions without the least danger of bringing a monstrosity 
 into the world as a consequence. Yet at the same time it must be 
 remembered that since the child is but the offshoot of the mother, 
 its general mental qualities and habits will be determined largely by 
 her mental qualities and habits during pregnancy. It is, therefore, 
 desirable that the mother should be surrounded by all those influ- 
 ences which conduce to her contentment and gratification. Tlie 
 mother who is kept in a state of constant excitement and emotional 
 disturbance during pregnancy will probably prixluce a peevish, irri- 
 table, or feeble-minded child ; and conversely, the infant's chances 
 for a well-balanced and easy-going temper are ciMtainly improved 
 if the mother have nothing to torment ard worry her during her 
 pregnancy. If this fact be borne in mind there is, of course, no 
 occasion for specifying any rules nbout the matter. 
 
 It is easy to understand that the physical condition of the 
 mother influences to a marked extent both the mental and physical 
 characteristics of the child ; if the mother be sick, feeble and but 
 poorly nourished during pregnancy, it is scarcely to be expected 
 that the infant will be robust and hearty. Yet there is a limit, 
 doubtless, to the extent of this influence of the mother upon the 
 physical condition of the child ; and we are not prepared to believe 
 those marvelous tales of the repetition upon the unborn child of 
 physical impressions made upon the mother. There is a list (jf 
 i'tories not less wonderful than those to which reference has just 
 been made, illustrating this supposed transmission of physical 
 influences. Thus we are told that a woman was in the latter part 
 of pregnancy bitten in the right hand by a dog ; and that two 
 mcjnths afterwards she was delivered of a child whose right hand 
 presented discolorations corresponding exactly to the marks made 
 by the animal's teeth upon the mother's hand. It is only necessary 
 to state that this and similar stories are not suf^ciently authentic to 
 warrant the conclusion indicated by them. 
 
 A matter requiring attention, especially during the first preg- 
 nancy, is the care of the breasts. It will be found advantageous 
 during the latter weeks to use gentle friction over these organs, rub- 
 bing from the body toward the nipple ; frequent bathing with salted 
 water is also useful. In this way it will be usually possible to avoid 
 
 r I 
 
 kM 
 
 ! I 
 
 M 
 
p."' 
 
 tl ■ 
 
 926 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 the retraction of the nipple, which is not infrequent in the first 
 pregnancy. For the nipples themselves it is desirable to use a mix- 
 ture of glycerine and cologne water in equal parts ; to this may be 
 added in the last week or two before delivery a little alum. If the 
 nipples become sore and fissured, presenting an appearance like a 
 raspberry, they may be kept moist with a mixture of equal parts 
 glycerine and rose-water containing borax — a teaspoonful of the 
 borax being added to four ounces of the mixture. A most impor- 
 tant feature in avoiding soreness and cracks of the nipples is their 
 mechanical protection against friction by the clothing l.iis may 
 be accomplished in various ways, best, perhaps, by the use of nip- 
 ple shields. 
 
 AecklentH of Pvegnancy. — First among these comes natur- 
 ally the premature expulsion of the foetus — an expulsion which is 
 called abortion when it occurs before the seventh month, and miscar- 
 riage when occurring subsequent to that time. The causes whicli 
 may induce abortion or miscarriage are in the ordinary course nf 
 events quite numerous. It is understood, of course, that we are 
 discussing only miscarriage as it results from natural causes, and 
 exclude for the present the artificial induction of abortion, and it 
 may be further said that, adopting the names in common use among 
 women, we shall apply the term " miscarriage" to premature expul- 
 sion of the fcetus at any period of pregnancy. 
 
 Under the conditions now prevalent in civilized society miscar- 
 riage is astonishingly frequent, for the investigation of many thousand 
 cases has shown that one out of every three wives miscarries before 
 she attains the age of 30 years. This, probably, falls below the 
 actual frequency, because in the earlier months miscarriage is often 
 unnoticed by the woman herself, and may even escape the observ- 
 ation of a physician in attendance. Furthermore, this accident 
 occurs more frequently in the later than in the earlier years of chikl- 
 bearing. Abortion may, of course, take place any time subse(|uent 
 to conception ; and it not infrequently happens during the first few- 
 weeks that no symptom is exhibited which attracts especial atten- 
 tion. The ordinary menstrual period fails to appear in a woman 
 previously regular. Her suspicions are perhaps aroused, but if a 
 discharge appears a few days later, she assumes that the period \\a^ 
 simply delayed, and explains in this way also the unusual pain and 
 increased flow. It often happens, indeed, that one monthly period 
 will be passed entirely, but that at the next period there will be an 
 
mmm 
 
 HYGIENE OF PREGNANCY. 
 
 927 
 
 in the first 
 use a mix- 
 ;his may be 
 ;m. If the 
 ■ancc like a 
 equal parts 
 )nful of the 
 most impor- 
 ^les is their 
 7.1 is may 
 ; use of nip- 
 
 comes natur- 
 iion vhich is 
 I, and miscar- 
 causes which 
 iry course nf 
 , that we arc 
 al causes, and 
 Drtion, and it 
 on use amon-t; 
 [mature cxpul- 
 
 iociety miscar- 
 nany thousand 
 [scarries before 
 falls below the 
 :irriagc is i)ften 
 pe the obscrv- 
 this accident 
 years of child- 
 me subsequent 
 ing the first few 
 especial atlen- 
 ar in a woman 
 Iroused, but if a 
 the period was 
 iiusual pain and 
 monthly period 
 Ithere will be an 
 
 unusually abundant and painful menstruation. In such cases the 
 woman rarely suspects that the clots discharged^^ontain a blighted 
 foetus ; yet such is in feict often the case. These instances do not 
 usually require the attention of a physician ; but they are, neverthe- 
 less, important facts for the woman to remember, since they often 
 serve to explain subsequent disease of the womb. Practically, 
 abortion is not usually certainly recognized as such by either patient 
 or physician until the third month of pregnancy, at which time it 
 occurs with especial frequence. It is fortunate, however, that dur- 
 ing this period — the eighth to the twelfth week — abortion is not 
 attended with as much danger to the mother as occurs subsequently. 
 The most dangerous period for the occurrence of abortion extends 
 from the tenth to the twentieth week ; a miscarriage happening 
 during this time usually requires the utmost care and skill of the 
 phj'sician to avert a fatal issue. This should be borne in mind, so 
 that if the symptoms of abortion — to be presently mentioned — 
 occur at this time, a physician should be immediately summoned, 
 since his services arc even more imperatively demanded than in 
 delivery at full term. 
 
 Causes. — Abortion may be induced by causes affecting either 
 the mother or the foetus — more commonly the former. Among the 
 physical causes may be mentioned any serious disease, especially 
 the fevers, accompanied with a rash upon the skin ; for it may be 
 stated, in general terms, that a pregnant woman rarely undergoes 
 an attack of small-pox or scarlet fever without abortion. Mechan- 
 ical injuries also frequently induce miscarriage, which, as is well 
 known, is very apt to follow falls, blows upon the abdomen, exces- 
 sive straining, whether in lifting heavy bodies or in attempts to 
 evacuate the bowels and bladder. Yet it is astonishing to observe 
 what an amount of violence will sometimes be borne without excit- 
 ing miscarriage. For instance, a noted physician of Scotland used 
 to relate that his coachman once drove right over a woman who was 
 in the eighth month of pregnancy, inflicting serious injuries upon 
 licr. The doctor, thinking that miscarriage must necessarily ensue, 
 caused inquiries to be made, but found, to his surprise, that the 
 pregnancy was not disturbed, and that the woman gave birth to a 
 healthy child at full term. 
 
 Excessive emotion, such as fear, anger or grief, may some- 
 times be followed by this accident; so, too, may the abuse of purga- 
 tive medicines. Thus the diseases consequent upon pregnancy — 
 
 1' 
 
 ; i 
 
 P' ' 
 
 ! 6 
 
 .:i^^i 
 
 . [ 
 
928 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 «' 'i. 
 
 
 such as morning sickness, irritation of the bowels and bladdp<- — 
 sometimes, though rarely, proceed to such a degree as to cause 
 abortion. Another fruitful cause of premature expulsion of the 
 fcetus is disease of the womb ; in these cases there is often a cer- 
 tain regularity in the abortions ; that is to say, this accident occurs 
 uniformly at the same period in several successive pregnancies. 
 On the side of the fcetus various causes may induce abortion, f)f 
 which it is necessary to refer to only one: It is a well-established 
 fact that if either parent have been previously subject to a certain 
 contagious disease the wife is very apt, especially in the first years 
 subsequent to this event, to have repeated miscarriages; usually, 
 too, if the fcEtus die from whatever cause, miscarriage generally fol- 
 lows within a few weeks. While we cannot enumerate all the causes 
 of abortion, nor indicate the means for distinguishing these causes 
 one from another, we would impress upon the mind of every 
 woman the necessity of consulting her medical adviser if she have 
 once had an abortion ; for it is a curious fact that women seem to 
 acquire a habit of abortion, and that their chances for miscarrying 
 are very much increased if they have once miscarried, no matter 
 from what cause. 
 
 Symptoms. — The symptoms of miscarriage vary with the 
 period of pregnancy. In the earlier months there is often but 
 little to indicate that this process is interrupted; indeed, as has 
 been remarked, abortion may occur before there is any positive 
 knowledge or even strong suspicion of pregnancy. During the 
 first month or two the symptoms are usually indistinguishable from 
 those of a painful menstruation ; the only sign to arouse suspicion 
 is an excessive flow containing possibly clots of blood. At this 
 time it is not, however, a matter of so much consequence, since mis- 
 carriage is then attended with less danger ; yet even then it is impor- 
 tant to know, if possible, the true state of the case, since although 
 there is no immediate peril to life, yet the foundation for menstrual 
 disorders and diseases of the womb is often laid by neglect to 
 recognize and attend to miscarriage in the early months ; for it 
 must be remembered that the womb increases in size from the very 
 beginning of pregnancy ; and when this process is interrupted, 
 whether at full term or earlier, a certain time is required in order 
 that it shall return to its former size. It is for this reason chiefly 
 that rest and quiet are essential after confinement ; and the same 
 reasons demand that same rest and quiet after an abortion, even in 
 
 III 
 
bladdp«* — 
 as to cause 
 sion of the 
 often a ccr- 
 ident occurs 
 pregnancies. 
 
 abortion, of 
 ,1-established 
 t to a certain 
 le first years 
 ges; usually, 
 generally ful- 
 allthe causes 
 
 these causes 
 ind of every 
 er if she have 
 Dmen seem to 
 ir miscarrying 
 ed, no matter 
 
 vary with the 
 is often but 
 indeed, as has 
 s any positive 
 During the 
 guishablc from 
 •ouse suspicion 
 ood. At this 
 ncc, since mis- 
 then it is impor- 
 since although 
 n for menstrual 
 by neglect to 
 months ; for it 
 ;e from the very 
 is interrupted, 
 quired in order 
 s reason chiefly 
 ; and the same 
 bortion, even in 
 
 HYGIENE OF PREGNANCY 
 
 929 
 
 the early months. If, therefore, there be any reason for suspect- 
 ing the possibility of pregnancy ; if after missing one or two 
 periods there occurs an apparently painful menstruation, accom- 
 panied with an excessive discharge including, perhaps, clotted 
 blood, the woman should observe the usual precautions — should 
 maintain the recumbent posture and avoid all mental and physical 
 effort for some days after the flow has ceased. 
 
 Miscarriage occurring between the tenth and twentieth week 
 is often accompanied by symptoms which indicate serious physical 
 disturbance. Not infrequently one of the first indications is a severe 
 chill, followed by fever, thirst, nausea and, of course, general indis- 
 josition. These symptoms, often accompanied by palpitation of 
 the heart, coldness of the feet and dizziness, sometimes mislead the 
 patient and her friends into suspecting some other difficulty. After 
 some houis or days, however, the seat of the trouble is usually 
 indicated by pain in the lower part of the back and abdomen, often 
 shooting down the thighs. This pain at first continues, then becomes 
 periodic in character, resembling, indeed, the true labor pains ; and 
 at this time there appears, if not already present, a discharge of 
 blood. These two symptoms, pain and flooding, are regarded as 
 characteristic of miscarriage ; but it should be remembered that 
 they may also occur without miscarriage ; and indeed that mis- 
 carriage might occur, on the other hand, with but little pain and 
 slight flooding. 
 
 Tveatnietit, — The object of treatment depends upon the con- 
 ditions, that is, upon the extent to which the miscarriage has 
 already proceeded. Generally speaking it is, of course, desirable 
 to arrest the expulsion and to quiet the womb, so that pregnancy- 
 may be continued to its natural termination. This is usually prac- 
 ticable, but not always, even when the nature of the difficulty is 
 immediately recognized, for if the fuitus be already dead, it is impos- 
 sible to prevent miscarriage when once inaugurated. Yet decision 
 of this question must be referred in every case to medical adviser 
 F who should always be called at once. There are, however, cer- 
 tain measures which may be taken with advantage in every case until 
 the arrival of the physician furnishes more exact instructions for 
 the particular case in question. Whenever flooding occurs during 
 pregnancy, whether accompanied with pain in the back or not, the 
 woman should remain perfectly quiet, retaining the horizontal posi- 
 tion until the flooding ceases ; this is especially demanded if the 
 
 
 
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 930 
 
 DISEASES OF WOk£N AND CHILDREN. 
 
 
 patient have suffered miscarriage previously. She should lie upon 
 a hard bed with no more covering than is necessary to protect her ; 
 should eat only the blandest food — milk, arrow-root, broths ; 
 should avoid all nervous and emotional excitement, and even 
 unnecessary movements in the bed, since every movement will 
 probably be followed by a gush of blood. If these remedies hv 
 inefficient in controlling the flooding, fifteen drops of laudannni 
 may be administered and repeated if necessary after an interval nf 
 two hours. The application of towels or flannel wrung out in culd 
 water over the bowels is sometimes advantageous, but may defeat 
 its own object by inducing contractions of the womb ; it is there- 
 fore better to omit this measure until the arrival of the physician. 
 
 Prevention. — The prevention of miscarriage is theoretic- 
 ally quite simple, but practically not always feasible. It may be 
 summed up in the words of Dr. TilL, who says: " The way to pre- 
 vent miscarriage is to lead a quiet life, particularly during those 
 days of each successive month when, under other circumstances, the 
 woman would menstruate, and to abstain during those days, not 
 only from long walks and parties, but also from marital inter- 
 course. " It is especially desirable that women should observe these 
 precautions during the first pregnancy, since, as has been alreaily 
 remarked, the occurrence of one miscarriage creates a decided j)re- 
 disposition to a repetition of this accident, which may, therefore, 
 happen afterwards upon very slight provocation. If, in spite of all 
 precautions, miscarriage does occur, it becomes necessary to observe 
 especial care in avoiding it during subsequent pregnancies. In such 
 cases it is generally advised that there should be a total abstinence 
 from intercourse until after the sixth month, after which time the 
 dangers of miscarriage are less. 
 
 Placenta Prsevia. 
 
 One of the most serious emergencies of pregnancy arises from 
 the condition known in medicine as placenta pra;via — a condition 
 in which the after-birth is attached to the womb at or near its 
 mouth, and not, as is usually the case, at a considerable distance 
 from this orifice. As a result of this location of the after-birth, there 
 occurs some separation of it from the womb during the latter months 
 of pregnancy, and since the after-birth is made up largely of blood- 
 
mmm 
 
 PLACENTA PR.liVIA. 
 
 931 
 
 Lild lie upon 
 arotect her ; 
 ot, broths ; 
 :, and even 
 vcment will 
 remedies be 
 f lauduniun 
 n interval nf 
 g out in cuUl 
 t may defeat 
 
 ; it is thcrc- 
 
 physician. 
 
 is theorclic- 
 :. It may be 
 e way to pre- 
 • during those 
 imstances, the 
 hose days, not 
 
 marital inter- 
 i observe these 
 s been already 
 a decided pre- 
 nay, therefore, 
 in spite of all 
 
 ary to observe 
 mcies. In such 
 otal abstinence 
 
 which time the 
 
 ncy arises from 
 — a condition 
 at or near its 
 lerable distance 
 ifter-birth, there 
 he latter months 
 argely of blood- 
 
 vessels, this separation from the womb results in more or less 
 flooding. 
 
 Sjfmptoins. — Placenta pr;i;via is fortunately a comparatively 
 rare occurrence; in some instances, this condition is not indi- 
 cated by any symptoms until labor itself begins, when the flooding 
 instead of being slight in quantity, as is usually the case, occurs to 
 a most alarming extent. As to the management of placenta pra^via 
 during labor, we have here nothing to say, except that it is one of 
 the conditions which taxes to the utmost the physician's knowledge, 
 skill and self-possession, and that the bare possibility of its occur- 
 ence is of itself ample reason for securing in advance the attendance 
 of a medical man at every confinement. In many cases, however, 
 ample warning of this condition is given during the last three or four 
 months of pregnancy. For it often happens that a flooding more 
 or less severe occurs without apparent cause, when the woman has 
 been subjected to no physical or mental strain; and this flooding is 
 usually not accompanied by pain. Hence, we may say in general, 
 that while flooding and pain are the usual symptoms of miscarriage, 
 flooding without pain is often a symptom of placenta pra;via. This 
 flooding not infrequently occurs at night, even while the woman is 
 asleep; and she may awaken to find that she has sufi'ercd a consid- 
 erable loss of blood. After an uncertain interval, sometimes at that 
 period which would have been the next menstrual period, flooding 
 again occurs, also without perceptible cause. Such losses of blood, 
 therefore, occurring after the sixth month, considerable in quantity 
 and usually unattended with pain, should arouse a suspicion of pla- 
 centa praivia, in which case a physician should be at once sum- 
 moned, to determine definitely whether this suspicion be well 
 founded. This he is usually able to do as early as the sixth or 
 seventh month, and obtains thereby information of extreme value, 
 which may enable him subsequently to avoid the catastrophe so 
 often inseparable from this condition known as placenta pra:via ; a 
 condition which but too frequently results in loss of life of the child 
 or of the mother, or even of both. 
 
 Treatment, — A woman who is the subject of placenta 
 pra'via should remain, as she values her life and that of her child, 
 under the constant supervision of her medical adviser; it is there- 
 fore not our purpose to indicate the usual measures employed, which 
 can be anyhow carried out only by a medical man. But we may 
 
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 11! 
 
 932 
 
 DISEASES OF WOMEN AND CHILDREN, 
 
 say in general that the same measures advised for the prevention 
 of threatened miscarriage are indicated also in the flooding which 
 occurs in placenta pra;via. The woman should maintain the re- 
 cumbent posture, avoid all excitement of whatever nature, and 
 take bland food. It is not, however, advisable to give laudanum, 
 as was suggested in speaking of threatened abortion. 
 
 There is, however, a form of hemorrhage, or bleeding, which 
 occurs even when placenta pra:via does not exist ; in the latter 
 months of pregnancy a slight escape of blood appearing often in 
 connection with bodily exercise is a not very unusual occurrence. 
 This may be in itself a matter of but little moment, though it is 
 not always possible, even for a physician, to say without a local 
 examination of the parts whether the flooding is due to placenta 
 pfcEvia or not. In any case, the medical adviser should be con- 
 sulted, since a hemorrhage during the latter months is always a 
 symptom of possible mischi^'f. In this connection it should bo 
 said that the bleeding sometimes occurs internally into the cav- 
 ity of the womb itself, and in such cases there may be no loss of 
 blood externally, and, indeed, no symptom which would direct tiic 
 woman's attention to the womb as the source of the difficulty. The 
 symptoms are various : There is sometimes complete collapse, the 
 skin becomes cold and clammy, the breathing difficult, there is pal- 
 pitation of the heart, and often nausea. At other times the symp- 
 toms are such as often attend a colic, and may be mistaken for sucli, 
 while the fact is that the woman is rapidly losing blood, which is 
 escaping from her veins into the cavity of the womb. After a time 
 the womb feels distended, and there may be even a perceptible in- 
 crease in its apparent size. In such cases it is usually desirable to 
 stimulate the womb to contraction by gentle friction of the abdo- 
 men, which may be continued until medical assistance is secured. 
 
 Buration of Pregnancy. 
 
 For ordinary purposes it is sufficient to accept the popular 
 idea as to the duration of pregnancy, namely: that it occupies a 
 period of nine calendar months. To be accurate, however, it must 
 be remarked that the average of a large number of cases observed 
 with considerable accuracy is 280 days or ten lunar months — a 
 
DURATION OK rUEGNANCV. 
 
 933 
 
 period, therefore, equivalent on the average to nine calendar 
 months plus one week. The important thinjf to be borne in mind 
 is, however, that this process, pregnancy, is not limited by iron 
 regulations; that a certain amount of variation from the average 
 period, whether greater or less, is the rule. In fact the term 280 
 days is given as the average, not because it is the actual time in the 
 majority of cases, but because the average time of those periods, 
 greater and less, is about 2S0 days. The determination of the exact 
 duration of pregnane)- in the human female is natural!)- a matter of 
 almost insuperable difficulty ; since it is, in the majority of cases, 
 impossible to ascertain exactly the date of conception, this phe- 
 nomenon not being marked by any features which render the fact 
 of successful impregnation evident to the woman herself. For the 
 same reason it is rarely possible to determine the extreme limits of 
 the period during which the fcetus may remain in the womb — a 
 period whose determination has at times extreme importance for 
 the honor and rights of individuals and of families. Observation 
 upon many of the lower animals has, however, shown that the term 
 of natural pregnancy varies considerably both above and below 
 the average. Thus, M. Tcssier reported to the Academy of 
 Sciences at Paris, a scries of observations upon cows, undertaken 
 for the purpose of determining the natural variations of pregnancy 
 in these animals, whose sexual relations can of course be con- 
 trolled and observed. The results show that, of 140 cows, 
 14 calved between the 241st and the 266th day. 
 53 calved between the 26<jth and the 280th day. 
 68 calved between the 280th and the 290lh day. 
 5 calved between the 290th and the 308th day. 
 The extreme difference was, therefore, sixty-seven days ; a matter 
 of considerable interest, especially because the natural term of 
 pregnancy in the cow averages about the same as in the human 
 female. Observations upon mares luive shown an even greater 
 latitude in this process. Observations have shown a similar and 
 almost equal variation in the duration of pregnancy in woman. 
 The following table of cases observed by Dr. James Reid is a fair 
 example of such observations. Of 500 cases, 
 
 23 were delivered in the 37th week — 255 to 259 days. 
 
 48 were delivered in the 38th week — 260 to 266 days. 
 
 81 were delivered in the 39th week — 267 to 273 days. 
 
 131 were delivered in the 40th week — 274 to 280 days. 
 
 , ii . 1 
 
 % 11 
 
 fO : -t 
 
634 
 
 DISEASES OF WOMEN AND CIIILDKEN. 
 
 1 12 were delivered in the 41st week — 281 to 287 days. 
 
 63 were delivered in the 42d week — 288 to 294 days. 
 
 28 were delivered in the 4.3d week — 295 to 301 days. 
 
 8 were delivered in the 44th week — 302 to 308 days. 
 
 6 were delivered in the 45th week — 309 to 315 days. 
 
 There is, of course, an element of uncertainty as to the exact 
 date of conception in the human species, which from the very 
 nature of our social and sexual relations can rarely be excluded; 
 but making due allowance for this — say two weeks — it is evident 
 that the duration of pregnancy may vary in the human as in other 
 animals over a considerable range of time. This fact is also 
 demonstrated by the observation of instances in which pregnancy 
 had been unquestionably the result of a single sexual act ; in- 
 stances which prove that pregnancy has endured 265, 302 and 
 even 313 days after the last coitus. 
 
 As this matter of the possible limits of pregnancy has often 
 times important legal bearings, enactments with regard to it have 
 been incorporated in the legal code of various nations. The Code 
 Napoleon fixes 300 days as the utmost possible limit for pregnancy, 
 a period adopted also in Scotland ; in Prussia 301 days is the utmost 
 limit recognized by law ; in these countries, therefore, the child of 
 a woman who is confined 302 or more days after the death or 
 departure of her husband, is considered illegitimate. In America, 
 while there is no uniform law upon the subject, yet two cases are on 
 record in which judicial decisions recognized the possibility that de- 
 livery might occur even 317 days after the last intercourse. 
 
 " Some reliable information in regard to this subject may, as we 
 believe, be derived from observation of pregnancy in Jewish women. 
 The author is mainly indebted to a very able physician accoucheur 
 of that persuasion for the following information. Among Jews the 
 sexes are separate juring menstruation, and for seven clear days 
 thereafter. The shortest period allowed for menstruation is five 
 days, even i-h^uid it last for an hour or two, so that the niiiiiiinim 
 period of separation every month is twelve days ; and in anything 
 approaching menorrhagia, of course, much longer. This law is 
 observed by the vast bulk of the Jewish women, the exceptions being 
 very few. After the period of separation, whatever that may be, 
 the woman, besides an ordinary bath for cleansing purposes, must 
 take what is called the 'bath of purification.' She simply dips in 
 this, but does not wash. This gives a fixed day from which a Jew- 
 
TO CALCULATi; Tiir: riMK or conmnemlnt. 
 
 93 f 
 
 Jsh woman reckons, as she knows the day she went to the bath, and 
 calculates accordiii[;ly. Any one who may have an opportiinit)' of 
 making' observations in this direction will fiml, first, that Jewish 
 women calculate more accurately as to the duration of pre^Miancy; 
 second, that according' to their experience thr duralion of pre^^- 
 nancy seems to be rather less than is usually supposed ; and third 
 (althou<;h this has less to do with the subject more immediately 
 under consideration), that, as has been observed by a late writer in 
 Germany, this frecpient and protracted abstinence from sexual inter- 
 course may be admitted as a possible cause of the undoubted vital- 
 ity of the Jewish race." — Lcishinan. 
 
 To Calculate the Time of Confinement. 
 
 Various plans have been devised for estimating; the time at 
 which labor may be expected ; the simplest and most generally 
 adopted is that first suggested by Naegcle ; his rule is to note the 
 last day of the last menstrual period, subtract three months and add 
 seven days. The date thus obtained will give at least apprcjxi- 
 mately the day at which labor may be expected. If, for instance, 
 a woman has ceased to menstruate on the loth of June, the date of 
 her confinement would be found by subtracting three months, which 
 gives the loth of March, and then by adding seven days, making 
 the 17th of March the date at which confinement may be expected. 
 There is in this method no pretense to absolute accuracy, as must 
 be the case, indeed, when wc consider the basis of this calculation; 
 for this plan is based upon the assumption that conception usually 
 occurs about a week after the cessation of the menstrual period; 
 hence the addition of the seven days. Now, while as a matter of 
 fact, conception does in perhaps a majority of cases occur about a 
 week after menstruation, yet there is a considerable minority of 
 instances in which conception does not occur at this date ; indeed it 
 may happen at any time during the month, especially during the 
 week preceding the menstrual discharge. In these latter cases the 
 confinement will naturally occur, not at the date ascertained by the 
 above rule of Nacgele, but usually some two weeks later or a week 
 earlier. 
 
 There are several questions which might be discussed in this 
 connection concerning the possibility of plural pregnancy. It is an 
 
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 936 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 established fact not only that two or more ova maybe impregnated 
 about the same time, but also that a second ovum may be impreg- 
 nated during the earlier weeks after the establishment of pregnancy 
 
 — that is, after the fecundation of the first ovum. It is not neces- 
 sary to enter into any discussion of the conditions under which 
 more than one ovum becomes fecundated ; it may suffice to say that 
 we are quite unable to control such conditions, and indeed even to 
 detect them until the results — plural pregnancy — become appar- 
 ent. If we except the numerous cases in which two or more children 
 are born during the same confinement — within a few hours or days 
 
 — there remain comparatively few cases of plural pregnancy ; in 
 the majority of these the birth of the second infant occurs a few- 
 weeks after that of the first. In these cases it is usually evident 
 that the first was a premature delivery, and that both children were 
 conceived at the same menstrual epoch. There remain, however, 
 a few cases in which a woman has given birth at an interval of three 
 to five months to two children, each apparently at full term ; in 
 these cases the most reasonable explanation is the assumption that 
 a second pregnancy began during the continuation of the fust. 
 There is, indeed, in this assumption nothing opposed to facts ascer- 
 tained with regard to conception. 
 
 Another curious phenomenon, which has been already repeat- 
 edly observed, is the birth of a fcetus within a foetus, a well authen- 
 ticated instance of which recently occurred in Germany. In these 
 cases the inclosed foetus is rarely, if ever, perfectly formed ; in 
 fact, is usually but a portion of a child ; such cases are indeed 
 apparently only examples of twin pregnancy in which one fa'tus is 
 not developed in the usual way. 
 
 In some instances of plural pregnancy, rare it is true, the 
 explanation has been found in a peculiar conformation of the 
 mother — a double womb. In these curious cases two pregnancies 
 may, it is evident, occur quite independently of each other. One 
 instance recorded by an English physician is sufficiently curious to 
 justify repetition, since three children were born within four months. 
 The mother was a woman 33 years of age, and in fourteen years 
 of married life had given birth to si.x children. With one excep- 
 tion, when she was prematurely delivered of a seven months' child, 
 her confinements had all been natural. In February, 1870, she 
 ceased to menstruate ; on the i6ch o.*" July she had strong labor 
 pains, and within twenty-four hours was delivered of twins, which the 
 
TO CALCULATE THE TIME OF CONFINEMENT. 
 
 937 
 
 : impregnated 
 ay be impreg- 
 t of pregnancy 
 ;t is not ncces- 
 s under which 
 fficc to say that 
 indeed even to 
 become appav- 
 jr more children 
 ^v hours or days 
 
 pregnancy ; in 
 mt occurs a few 
 
 usually evident 
 th children were 
 •emain, however, 
 I interval of three 
 r at full term ; in 
 
 assumption that 
 .tion of the first. 
 5cd to facts ascer- 
 
 n already repcat- 
 us,a well authcn- 
 
 rmany. 
 
 In these 
 
 fectly formed ; n\ 
 
 cases are indeed 
 
 Irhich one fa-tus is 
 
 irc it is true, the 
 (forniation of tlio 
 .s two pregnancies 
 each other. One 
 icicntly curious to 
 nthinfour months. 
 in fourteen years 
 With one cNcep- 
 Jven months' chiUl, 
 tbruary, 1870, she 
 had strong labor 
 oftwins, which the 
 
 medical attendant considered to be of about six months' growth. A 
 week afterward she again summoned her physician, and expressed 
 her conviction that there was still another child present in the 
 womb ; an examination confirmed her impression. Yet she began 
 to menstruate and performed this function regularly for three months, 
 at the end of which time, October 31st, she was delivered of a well- 
 developed child. Subsequent examination showed that there was 
 a well-defined partition between two cavities of the womb — in fact, 
 a double womb. The curious features of this case became at once 
 apparent : the two children born in July had been contained in one 
 side of this double womb, the child born in August in the other 
 side ; the menstruation from July to August had proceeded from 
 the former cavity. 
 
 The explanation of that not unusual occurrence (the birth of 
 two or more children at one confinement) is to be found, doubtless, 
 in the fact that two or more ova leave the ovaries at one menstrual 
 period. In other cases it would seem that two ova, which have 
 escaped from the ovaries at successive periods, have both been 
 fecundated. This would doubtless be a more common occurrence, 
 were it not that conception is usually followed at once by an arrest 
 of activity in the ovaries, and therefore by an arrest of menstruation. 
 Yet this arrest is not always immediate. Indeed, cases are known 
 in which menstruation has continued uninterruptedly throughout 
 pregnancy, and it seems by no means strange that one or more 
 periods of ovarian activity should occur after conception; and in this 
 occurrence lies, doubtless, the explanation of twin and triple preg- 
 nancy. It is scarcely necessary to remark that the conditions gov- 
 erning these accidents are practically beyond our control and our 
 knowledge. Hence any detailed consideration of these accidents of 
 conception and impregnation would be quite out of place in a treatise 
 of this sort. One popular impression in regard to this subject 
 may, however, be corrected. It is well known among stock breed- 
 ers and farriers that if a cow gives birth to two calves, one of which 
 is apparently a female, this latter aniii)"' < '-•< igh to all appearances 
 well-formed, is sterile. The reason for this sterility has been ascer- 
 tained by dissection to be an incomplete development or even 
 absence of the ovaries. These imperfect females are commonly 
 known as " free-martins. " It has been assumed and believed by 
 analogy that a human female born as a twin, the other child being a 
 male, is also sterile. This, however, is a mistake. Numerous 
 
 f" 
 
 iMil 
 
 !-!■ ' f 
 
 ; > 
 
938 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 instances are on record (one having come under the personal obser- 
 vation of the writer), in which such females have become prolific 
 mothers. 
 
 The physician is often asked whether it is possible to detect the 
 presence of twins before birth ; also whether it is possible to avoid 
 this accident. To the latter query one can return only an unquali- 
 fied negative. As to the detection of twins before birth, there are 
 no difificulties in the later months of pregnancy. And this leads us 
 to the discussion cf a question which agitates the mind during the 
 early months or years of married life: Whether it is possible to 
 regulate voluntarily the sex of the expected child, and whether it is 
 possible to detect the sex before birth. The latter question can 
 usually be decided during the last two or three months before con- 
 finement ; and this not by the form or size of the mother, which — 
 nurses to the contrary notwithstanding — does not vary uniformly 
 with the sex of the fcetus; nor is it true that the movements of a 
 male foetus are necessarily more vigorous than those of a female. It 
 has been ascertained, however, by many observations, that the heart 
 of the female foetus beats more rapidly, on the average, than that 
 of the male ; indeed, that the heart-beats of the unborn female in- 
 fant are usually more than 135 per minute, and those of the male 
 foetus usually less than that number. Yet it must be understood that 
 this is not an invariable rule, since exceptions have been noted on 
 both sides of the dividing line. Yet it may be assumed, with almost 
 positive certainty, that if the pulse-rate do not exceed 118 or 120 
 per minute the child is a male ; while if it do not fall below 142 
 the infant is a female. The chances of accuracy decrease the nearer 
 the pulse-rate approaches 133 or 135. This detection of the pulse- 
 rate in the foetus must, of course, hj referred to the physician, and 
 even he not infrequently finds difficulty in solving the problem. For 
 the voluntary determinatir/n of the sex of the child in advance there 
 exist several popular rules. Many women, and not a few physi- 
 cians, believe that if conception occur just before the time for a 
 menstrual period, the child will be a male ; .".nd that conception just 
 after a menstrual epoch produces a female child. This may be trnc, 
 but we have no evidence to establish its accuracy, unless we accept 
 as conclusive the results furnished by Thury, of Geneva. It liad 
 been noticed that the first eggs laid by queen-bees produced females, 
 the later ones males. A similar assertion has been made with 
 regard to hens. Thury, assuming these facts as a basis, proposed a 
 

 TO CALCULATE THE TIME OF CONFLXEMENT. 
 
 939 
 
 been noted on 
 led, with almost 
 xceed Ii8 or 120 
 )t fall below 142 
 tcrease the nearer 
 kionof the pulse- 
 
 not a few ph\-si- 
 [re the time for a 
 |at conception just 
 :his may be true, 
 inless we accept 
 jeneva. It had 
 •oduced females, 
 been made with 
 basis, proposed a 
 
 law for the determination of sex in stock-raising, asserting that if 
 conjunction occurred during the early part of heat, female offspring 
 would be produced ; if during the later part, male offspring. 
 
 This plan was submitted to somewhat meager tests in Switzer- 
 land and France ; the results though not invariable seem to sustain 
 Thury's proposition. Thus one observer says : " In the first place, 
 on twenty-two successive occasions I desired to have heifers. My 
 cows were of Schurtz breed and my bull a pure Durham. I suc- 
 ceeded in these cases. Having bought a pure Durham cow it was 
 very important for me to have a new bull to supersede the one I had 
 bought at great expense without leaving to chance the production 
 of a male. So I followed accordingly the prescription of Professor 
 Thury, and the success has proved once more the truth of the law. 
 I have obtained from my Durham bull six more bulls for field work ; 
 and having chosen cows of the same color and height I obtained 
 perfect matches of oxen. My herd amounted to forty cows of 
 every age. In short I have made in all twenty-nine experiments 
 after the new method, and in every one I succeeded in the produc- 
 tion of what I was looking for — male and female. I have not one 
 single failure. " Several other stock-raisers have reported limited 
 observations to the same effect, and several physicians have asserted 
 that the same 'law applies to the human animal; thus one writes : 
 " Whenever intercourse has taken place in from two to six days 
 after the cessation of the menses, girls have been produced; and 
 whenever intercourse has taken place in from nine to twelve days 
 after the cessation of the menses, boys have been produced." He 
 neglects to state what the result was when conjunction had occurred 
 at both of these periods. When we consider the number of in- 
 stances in which the observance of this rule has utterly failed to pro- 
 duce the desired result ; and when we further remember that, as there 
 are but two sexes, any conceivable rule would by the laws of 
 probability be successful in about one-half of the cases, it is evident 
 that Thury's law has just about as much and no more claim upon 
 our credence than any other that might be proposed. 
 
 The most recent sensation in this direction is the report of a 
 
 Texas stock-raiser, who, having tried and abandoned Thury's plan, 
 
 devised one of his own. His theory is that the sex of the fujtus 
 
 is determined by the relative ardor of the parents at the time of 
 
 conjunction — the offspring taking the se.x of the less ardent of the 
 
 two. According to his experience female offspring may be pro- 
 61 
 
 t. 
 
 s SI . 
 
 "i 
 
 » * , 
 
i 
 
 fmi: 
 
 I 
 
 540 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 cured by imposing a period of abstinence upon the male previous 
 to intercourse; and male offspring by the converse method. He, 
 too, produces an array of experiments upon cattle by himself and 
 others to prove the correctness of his proposition, but does not suc- 
 ceed in convincing one familiar with the general principles underly- 
 ing the facts of reproduction. The popular idea ascribes a tendency 
 to female offspring to a union in which the wife is older than tlic 
 husband. For this belief there is no other foundation than tlie 
 general fact that more male children are born than female, and that 
 hus^i^nds are usually older than their respective wives. Others 
 again assert that more females are born during warm years, more 
 males in cold years. This, too, is a pure assumption, so far at 
 least ; •' the human race is concerned. Indeed, we may sum tip 
 this enrir/- natter by saying that we have no exact knowledge by 
 which we c"\ fix at will the sex of desired offspring. 
 
 Upon ti. possible causes which determine sex there has been 
 endless fanciful speculation, and there are indeed many curious and 
 interesting facts concerning the relative numbers of the two sexes 
 at different pc'ods of life and under different social conditions. 
 More males are born than females, the proportion being usually 
 stated at 103 or 104 of the former to 100, yet among the adult pop- 
 ulations women arc almost invariably in considerable excess, in 
 England there are said to be 105 women, in London even 112 
 to every 100 men. In newly-settled countries this ratio is of course 
 liable to great variation ; in some of our own Western States the 
 men outnumber the women eight, ten or twelve to one. This of 
 course results from the peculiarity of social relations and business 
 pursuits, which necessarily exclude most women from these sections. 
 Yet the fact remains that the adult population averaged throughout 
 the world, displays an excess of females, notwithstanding the general 
 excess already stated of male over female infants. The relatively 
 excessive mortality among males indicated in this reversal of numer- 
 ical majority between the sexes, occurs not alone, as we might sup- 
 pose, in early adult life from the accidents, injuries and diseases to 
 which masculine occupations necessarily expose men, but occurs 
 also largely in infancy; for during the first and second years of hfe 
 a larger number of males die than of females, so that in the fifdi 
 or sixth year of life females are already in excess. 
 
\a.\e previous 
 icthod. He, 
 f himself and 
 docs not suc- 
 iples underly- 
 jes a tendency 
 )lder than the 
 ition than the 
 male, and that 
 vivcs. Others 
 rm years, more 
 jtion, so far at 
 ; may sum up 
 ; knowledge by 
 
 c there has been 
 lany curious and 
 of the two sexes 
 ocial conditions. 
 Dn being usually 
 -ig the adult pop- 
 able excess. In 
 ondon even 1 1 2 
 ratio is of course 
 stern States the 
 to one. This of 
 Ions and business 
 ,m these sections. 
 •aged throughout 
 .ding the general 
 The relatively 
 ■cversalof numer- 
 |as we miglit sup- 
 s and diseases to 
 men, but occurs 
 ;ond years of Hf^ 
 that in the fifth 
 
 CONFINEMENT. 
 
 Confinement. 
 
 941 
 
 A preliminary sign of labor, usually observed about two weeks 
 before the onset of the pains, is a sinking of the womb in the pelvis, 
 whereby many of the unpleasant features which had previously an- 
 noyed the woman are relieved. The abdomen usually becomes 
 somewhat smaller, the breathing is rendered much easier, and there 
 is often a general sense of relief and buoyancy, which attracts the 
 attention of friends. Since this indicates approaching labor, it is 
 evident that there should be no indulgence in unusual exercise, 
 however much disposition there may exist. Another usual sign, 
 which may appear from one to two weeks before labor actually 
 begins, is an increased secretion from the genital organs. This is a 
 cause for congratulation rather than for anxiety, and need occasion 
 no interference other than measures of simple cleanliness. In return 
 for these advantages, the woman is now often subjected to new 
 annoyances. The descent of the womb, by which her breathing is 
 relieved, often occasions irritation of the bladder and rectum, so that 
 she has frequent, perhaps painful calls to evacute these organs. So 
 too the increased secretion, which is itself desirable, is often accom- 
 panied by an uncomfortable swelling of the parts, which occasions 
 physical discomfort and mental anxiety. Finally there occur the 
 contractions of the womb, which indicate that this organ is prepar- 
 ing to expel its contents. These contractions usually continue for 
 some days without calling the attention of the patient herself, 
 though sometimes they recur by night so frequently and so severely 
 as to keep the woman in a state of wakefulness and constant appre- 
 hension that labor itself is about to begin. It is well, therefore, to 
 bear in mind that those contractions of the uterus which are directly 
 instrumental inexpelling the foetus, are perceived by the woman, as 
 " pains " in the back, extending down the thighs and often around 
 to the front, and that they occur and recur at regular intervals — 
 intervals which may vary, it is true, from ten to thirty minutes 
 These are the characteristics of the true labor pains, which may be 
 and should be thereby distinguished from various other so-called 
 pains which are apt to occur about this time. During these early 
 pains there usually appears what is known as the " show " — a dis- 
 charge of mucus and blood from the mouth of the womb. Yet this 
 must not be relied upon as the invariable sign of beginning labor, 
 
 mm 
 
 I-,! I 
 
 ! ^! ' 
 
 ^yt 
 
 i' ' :-\ 
 
 fi.y 
 
 itf 
 
 " 
 
 • 1 !-^ 
 
 ii 
 
 ll 
 
 
942 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 since it is sometimes scarcely observed, either because but little 
 blood appears, or because the secretions from the part are already 
 so excessive as to make the further increase pass unnoticed. 
 Although the woman does not necessarily take to her bed during; 
 the early part of labor (in fact, most women cannot be persuaded to 
 recline, but insist upon sitting or walking), yet these early pains 
 should be taken as the signal for preparing the bed and such uten- 
 sils as may be required during labor. 
 
 Much inconvenience and annoyance can be avoided subsequent 
 to delivery by adopting a certain arrangement before labor begins. 
 The bed may be conveniently arranged by placing upon the bed- 
 stead the following articles in the order indicated, from below 
 upward : 
 
 Mattress. 
 
 Newspapers or oilcloth. 
 
 Lower sheet. 
 
 Four-fold sheet (pinned down). 
 
 Oilcloth — four or five feet square. 
 
 Quilt. 
 
 Sheet to cover quilt. 
 
 The three articles last named can be removed without disturbing 
 the patient materially after the labor is over, leaving her comforta- 
 bly placed upon clean linen with ample protection of the mattress 
 from subsequent discharges. 
 
 The woman herself should be provided with certain articles. 
 First, it is of course desirable that her garments shall, so far as pos- 
 sible, escape soiling during labor ; hence, the first requisite is 
 brevity, which may be attained either by turning up and pinning or 
 stitching the ordinary chemise, or, perhaps better, by preparing 
 short gowns for the purpose. Another plan is to have the chemise 
 tucked above the hips, its lower part being substituted by a folded 
 sheet fastened about the waist. A second article which it will be 
 found usually desirable to employ is a bandage. This should be 
 made of unbleached muslin, long enough to encircle the hips and 
 broad enough to extend from above the prominence of the hips 
 half way down the thigh ; its average length, therefore, will be 
 about four feet, its average breadth fifteen to eighteen inches. The 
 size varies, of course, with difi"erent persons, and it may be fitted 
 
!f ; if;-j' 
 
 CONFINEMENT. 
 
 943 
 
 t little 
 
 ilready 
 
 oticcd. 
 
 durini; 
 
 adedto 
 
 y pains 
 
 ;h utcn- 
 
 )sequcnt 
 r begins, 
 the bcd- 
 m below 
 
 disturbing 
 r comforta- 
 ic mattress 
 
 un articles. 
 far as pos- 
 jrcquisite is 
 pinning or 
 preparing 
 Ithe chemise 
 ] by a folded 
 (h it will be 
 Is should be 
 lie hips and 
 of the hips 
 )re, ^viU be 
 Lches. The 
 Lay be fitted 
 
 in advance to each individual ; the pattern may be obtained by 
 measuring the body at about the fourth month of pregnancy. 
 
 For the child there may prepared flannel or woolen under- 
 clothing and a narrow flannel bandage four or five inches in breadth 
 and fourteen or fifteen inches in length. There will be required, 
 also, a bottle of fresh sweet oil and two lengths of twisted or 
 braided thread ; a paper of large pins and one of smaller ditto ; 
 some fine sponges previously washed and pounded so as to be free 
 from sand ; a box of unirritating toilet -powder ; some fine soap ; 
 a small pair of scissors ; an abundance of clean towels ; a piece of 
 old linen or cotton wadding, for dressing the naval string. All 
 these articles should be properly arranged in advance within easy 
 reach ; perhaps the best way is to place them in a basket devoted 
 to the purpose, which may be kept in the room. 
 
 The first stage of labor, which may vary from a few hours to 
 one or two days, consists in the dilatation of the mouth of the 
 womb. During this time the woman ordinarily prefers to remain 
 upon her feet, and thus usually finds relief and comfort. This 
 period is apt to be especially long and tedious at the first confine- 
 ment, and may be quite short in subsequent labors of the same 
 individual. During this time the pains have nothing of that bear- 
 ing-down character which they subsequently acquire ; they are 
 described rather as " grinding," are felt in the front, and have what 
 has been called a " wave-like " course — that is, a regular crescendo 
 and minuendo of intensity. During these pains the abdomen may 
 be felt to become hard, the breathing is somewhat retarded and the 
 pulse increased in frequency. During this time, also, the genital 
 canal becomes bathed with the secretions, which may or may not be 
 tinged with blood. This is the period which is apt to be especially 
 trying to the sou! of the young wife. For hours she is annoyed 
 and made restless by frequently-recurring pains, which seem to 
 accomplish no good and merely exhaust her strength and patience. 
 She should remember that this apparently useless annoyance is a 
 most essential and unavoidable part of the process, and tliat little 
 can be done by herself or by the physician to accelerate or shorten 
 the process. She should not waste her strength by attempting to 
 " bear down," for she will subsequently requu^e all her energies for 
 this purpose. 
 
 When the mouth of the womb has become dilated, the expul- 
 sion of the child begins — a change of programme indicated to the 
 
 B' : 
 
 ■J 
 
 ', r 
 
 :.^-\' 
 
 . 1 
 
 1: ? 
 
 
944 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 mother by the altered character of the pains ; these now become 
 more frequent, severe and prolonged, while at the same time the 
 woman now is conscious of an effort to expel a body from the 
 abdomen, — to bear down — and naturally summons to her aid the 
 voluntary muscles capable of assisting in the accomplishment of this 
 object. This consciousness that she is working to overcome an 
 obstacle usually confers a certain satisfaction upon the woman, who 
 may have been discouraged and exhausted by twenty-four hours of 
 annoying pains which seem to have no object, and hence present no 
 hope of completion. The commencement of this, the second sta<;c 
 of labor, is often indicated by several occurrences which may alarm 
 the inexperienced. Not infrequently the conclusion of the first 
 stage is marked by the occurrence of a severe chill, which may b- 
 so violent as to shake the bedstead upon which the patient reclines. 
 This seems to be a natural part of the process and calls for no inter- 
 ference other than warm coverings, and perhaps a hot drink. A 
 second phenomenon is the escape of the " waters " — an occurrence 
 which usually happens during the latter part of the first or the 
 early portion of the second stage of labor. 
 
 When the pains assume the expulsive character indicating 
 that the second stage of labor has begun, the woman's inclination 
 is usually to take to her bed. Yet to assist in her voluntary efforts 
 of expulsion she almost invariably desires to have something to 
 pull against ; hence it is advisable to tie a twisted sheet to the cor- 
 ners of the bedstead, at the foot, so arranged that the middle of tlie 
 rope thus formed shall be at a convenient distance for the woman's 
 hands. While this ordinarily satisfies the demands of her nature at 
 this time, yet one must be prepared for curious freaks and fancies. 
 
 During the pains of the second stage, the expulsive efforts arc 
 often accompanied by such physical contortions as to excite the 
 alarm as well as the sympathy of friends. It may be said, however, 
 that no damage ever results to the patient from the excessive vio- 
 lence of her own efforts ; no matter how long her respiration be 
 arrested, nor how blue and distorted her face becomes; these are all 
 natural accompaniments of the process, which need occasion no 
 anxiety nor interference on the part of the friends at least. 
 
 It is certainly desirable, in the interest of the patient and her 
 child, that a physician should be called in every case of labor. In 
 many cases, it is true, his services are not imperatively demanded ; 
 in many others, professional skill saves the life of mother or child, 
 
 '■■M:m 
 

 CONFINEMENT. 
 
 945 
 
 E now become 
 same time the 
 body from the 
 to her aid the 
 ishment of this 
 ) overcome an 
 le woman, who 
 y-four hours of 
 cnce present no 
 tie second sta^c 
 hich may alarm 
 ion of the fust 
 I, which may b- 
 patient reclines. 
 :alls for no inter- 
 1 hot drink. A 
 
 an occurrence 
 
 f the first or the 
 
 racter indicating 
 ,man's inclination 
 voluntary efforts 
 |ve something to 
 sheet to the cor- 
 ;he middle of the 
 for the woman's 
 of her nature at 
 ;aks and fancies, 
 lulsive efforts arc 
 as to excite the 
 be said, however, 
 :he excessive vio- 
 icr respiration be 
 ,mes; these are all 
 Ineed occasion no 
 at least, 
 patient and her 
 ;ase of labor. I" 
 itively demanded ; 
 f mother or child, 
 
 or both. Since it is impossible to predict in advance as a rule 
 what cases will proceed quietly and easily and what ones will 
 present serious complications, the only safe plan is evidently the 
 presence of the best medical skill in every instance. Yet in many 
 cases, particularly in the country, it is either impossible to secure 
 the services of a physician, or if a medical man be engaged, he is 
 often unable to arrive until delivery has occurred. In such cases, 
 it is desirable for friends to observe certain precautions in the care 
 of the parturient woman. 
 
 During the first and early part of the second stage of labor, 
 the woman should be allowed complete liberty as to position, food, 
 drink, etc. Care should simply be taken that she be not annoyed 
 by the well-meant, though over-officious attentions and inquiries of 
 friends. But few individuals should be admitted to the lying-in 
 chamber. No examination of the parts by a non-professional per- 
 son will be apt to afford any particular advantage or information, 
 until the head of the child appears at the outlet of the vagina. At 
 this period, it is often possible for the skilled hand, by judicious 
 manipulation, to prevent a rupture of the parts, and subsequent 
 disease of the sexual organs. It is impossible to convey in a few 
 words the information necessary for the performance of such manip- 
 ulation ; it may be useful, however, to remark that if the pains be 
 severe, and the head rapidly advancing, the hand of an attendant 
 (covered by a towel) may be applied at the lower edge of the orifice 
 in such a way as to force the head in its progress toward the upper 
 edge of the opening; never let the child drop into the bed. So soon 
 as the child's head is born, the finger may be applied to the neck to 
 discover whether it be encircled by the umbilical cord ; if such be the 
 case, a gentle effort may be made to slip this coil over the head, 
 whereby two objects are accomplished : the breathing of the child 
 is secured and the escape of its body facilitated. A finger may be 
 passed into the child's mouth to remove mucus, etc. The birth of 
 the head — usually a moment of extreme agony to the woman, indi- 
 cated by a piercing cry — is followed by a period of rest and relief, 
 during which the patient recovers in part her exhausted energy and 
 courage ; then follows with much less effort and pain, the birth of 
 the child's body, usually accompanied by a considerable flow of 
 blood. Both mother and child should now receive especial atten- 
 tion. As to the former, a hand should be placed upon the abdo- 
 men, where a distinct firm ball, occupying the lower part of the 
 
 [im 
 
 M il i 
 
 
 ' iTi 
 
 Ui 
 
946 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 ■I 
 
 ! 
 
 ;1 
 
 Si 
 
 abdominal cavity, should be felt ; this may be gently and continu- 
 ously pressed, whereby a certain amount of contraction of the 
 womb will be secured. Meantime, another attendant should 
 observe whether the child breathes, and if it does not. should take 
 immediate measures to secure this action. Usually, so soon as the 
 mucus has been removed by the insertion of the attendant's finger 
 — or, indeed, without this precaution — the child responds with .i 
 lusty cry ; if not, it may be stimulated by a few gentle taps with 
 the open hand upon the most conveniently situated part of its 
 anatomy, or by a few strokes with the wet end of a towel, or by 
 sprinkling cold water violently upon its body. If one or all of 
 these measures fail to induce vigorous breathing, it will be neces- 
 sary to perform artificial respiration. This is a somewhat rare 
 necessity, and may be most conveniently accomplished, after 
 clearing out the infant's mouth and nostrils by the application oi 
 the attendant's lips to those of the child (the nose of the child mean- 
 while being held), whereby his own breath can be forced into the 
 lungs of the infant — and then, of course, permitted to escripc — at 
 the rate of eighteen or twenty times per minute. This is a delicate 
 and not altogether unobjectionable proceeding, which should bo 
 performed, if possible, by a medical man; and may be performed 
 by others only as a last resort. 
 
 If there be any delay in persuading the child to breathe, tlic 
 cord may remain uncut until respiration is established. So soon 
 as breathing has begun (or before, of course, if any prolonged 
 efforts are necessary to establish the respiratory functions, and 
 there be no pulse in it) the cord may be cut. The piece of twisted 
 thread, previously prepared for this purpose, is tightly tied around 
 the cord at a distance of about two and a half or three inches from 
 the child's body ; a second piece is similarly tied about an inch 
 further from the child, and the cord is then cut between the two. 
 The objection to using tape, as is so often done for this purpose, is 
 merely that the tape, because broad, cannot be made to penetrate 
 the jelly-like substance of the cord, and does not, therefore, secure 
 a compressior of the artery and veins enclosed within the jelly- 
 like material ; '.lence there sometimes occurs a serious loss of blood 
 from the cut end of the cord. The tape, too, slips more readily than 
 thread, and if not very tightly tied, may even after several hours, 
 slip off entirely and permit serious or even fatal hemorrhage. In 
 cutting the cord care should be taken — particularly if the opera- 
 
CONFINEMENT. 
 
 947 
 
 and contimi- 
 ction of tlu 
 dant should 
 :. should take 
 io soon as the 
 ndant's finuov 
 spends with a 
 ntle taps with 
 :d part of its 
 a towel, or by 
 f one or all of 
 ; will be ncces- 
 somewhat rare 
 iplishcd, after 
 i application oi 
 the child mean- 
 forced into the 
 I to escape — at 
 his is a delicate 
 •hich should bo 
 ly be performed 
 
 to breathe, the 
 shed. So soon 
 any prolonged 
 functions, and 
 piece of twisted 
 htly tied around 
 irce inches from 
 about an inch 
 tween the two, 
 ■ this purpose, is 
 ide to penetrate 
 therefore, secure 
 .vithin the jcUy- 
 us loss of blood 
 nore readily than 
 r several hours, 
 icmorrhage. In 
 irly if the opera- 
 
 tion be performed under the bed-clothes — that nothing except the 
 cord, that is, no fingers nor toes of the cliild be accidentally caught 
 between the blades of the scissors. The infant is now removed 
 from the bed and received upon a blanket or piece of flannel held 
 in the hands of a nurse, upon which the child should be transferred 
 to a place of safety, such as a bed in a neighboring room ; some- 
 times, in the excitement of the moment, the infant will be deposited 
 in a large arm-chair or similar receptacle, where it may easily be 
 smothered or crushed by individuals not aware of its presence. 
 Caution is necessary in handling the child ; for being covered with an 
 unctuous material it may readily slip from a careless hand. Indeed, 
 the only way for securing a grasp at once firm and yet not severe. 
 is to place one hand under the back of the neck, so that the neck 
 lies between the thumb and forefinger, while both knees are simi- 
 larly held in the thumb and forefinger of the other hand. The 
 child may be left wrapped up in its blanket or flannels — space 
 being allowed it to breathe — while the mother receives the atten- 
 tion which she requires. 
 
 After the birth of the child there usually occurs a cessation of 
 activity in the womb for ten to thirty minutes. During this time a 
 sense of coldness, even positive chilis, may occur. Within half an 
 hour after the birth of the child it will usually be found that the 
 after-birth has been detached from the womb and is lying in the 
 vagina, whence it may be extracted by gently pulling upon the 
 cord. In every case it is desirable, however, to keep the hand 
 upon the abdominal wall over the womb, as already directed in 
 speaking of the birth of the child. It will be found that after some 
 minutes the womb becomes hardened and presently decreases ma- 
 terially in size, indicating the expulsion of the after-birth. If this 
 do not occur spontaneously in fifteen or twenty minutes the process 
 may be materially hastened by grasping the womb through the ab- 
 dominal wall in the hand, and gently compressing the organ at inter- 
 vals of a minute or two. This kneading movement may be repeated 
 and pressure continued until the afl ^r birth is delivered. Mean- 
 while the cord may be very gently ■)!■'; d, never with any consider- 
 able force, for it should be remembered that if there be any obstacle 
 to the delivery of the placenta the application of force to the cord 
 may result not in pulling the after-birth away, but in tearing in two 
 the cord, or even in turning the womb inside out. 
 
 After the removal of the after-birth, the womb should be dis- 
 
 ■iii:'" 
 
 ■■> - . 
 
 :' 
 
 tH\ 
 
 VV 
 
 If 
 
 r, 
 
94« 
 
 DISEASES OF WOMEN AND CHILDKEN. 
 
 tinctly felt as a very firm, hard body, about the size of a cocoa-nut, 
 in the lower part of the abdomen. And it is important that the 
 condition of the womb be observed from time to time for several 
 hours after delivery. For one of the serious complications of labor 
 arises from a failure of the womb to contract properly or to stay 
 contracted; as a result of which failure hemorrhage may occur to 
 a serious or even fatal degree. If at any time the womb, which 
 has thus properly contracted after delivery, b id to have in- 
 
 creased in size and to have become softer, it is t^.^oable that blond 
 is escaping into its cavity. In this case energetic compression and 
 kneading of the womb through the abdominal wall should be per- 
 formed. 
 
 The three uppermost articles on the bed next to the patient's 
 body may now be moved a little — six or eight inches toward the 
 foot of the bed, so as to give an opportunity for cleansing the 
 mother. This may be best performed by simple washing with warm 
 water, to which a little .ilcohol may be added if desired. If her gar- 
 ments have been soiled, they should at once be replaced by clean 
 ones, and then the upper sheet, quilt and oilcloth may be removed 
 from the bed without disturbing the patient further than by tho ele- 
 vation of her hips. In this way she is brought- rest upo*i a clean 
 four-fold sheet. A large folded napkin shoulc olaccd between 
 
 her thighs, but not brought upward and pinned as is so often done, 
 so as to close the orifice of the vagina. For by this latter plan the 
 fluids which must necessarily escape into the vagina are retained iii 
 that cavity and may give rise to disease by undergoing putrefaction 
 there ; by simply placing the napkin between the thighs we do not 
 impede the escape of these discharges. The bandage may now be 
 applied ; either the one already iwdicated, or, in case this is lack- 
 ing, an ordinary bolster cover will answer the purpose. The band- 
 age should be first fastened in the middle, large pins being placed 
 at distances of one or two inches ; it may be drawn tight enough to 
 feel snug, but nothing is gained by excessive pressure. 
 
 After the mother has been comfortably placed in a clean bed, 
 and after the child has been applied to the breast, she should be 
 left in quiet to repose for an hour or two, with strict injunctions 
 under no circumstances to change her position from the recum- 
 bent posture ; this rule is rendered necessary by the danger of hem- 
 orrhage consequent upon the erect position or even upon raising 
 the body to the sitting posture in the bed. A cup of tea or a glass 
 
ATTENTION To IIIH i lin.u. 
 
 949 
 
 of wine may be refreshing, and should be granted if desired, but 
 need not be forced upon the patient. It will be neccss.ny often to 
 change the napkins, and tlic opportunity should be improved to 
 wash the parts with warm water and alcohol. This process should 
 be repeated at less frequent intervals during the first few days, as 
 often and as long as is necessary to secure perfect cleanliness. 
 Iwery day the bandage maybe loosened and the womb compressed 
 gently for a few minutes, after which the bandage may be reap- 
 plied with a comfortable degree of pressure. This is a most 
 important measure, by which we may hope to avoid not only the 
 severity of the usual after-pains, but also to escape the dangers of 
 puerperal diseases or " child-bed fever, " 
 
 After the first week, the bandage has fulfiUe'! its purpose, and 
 may be dispensed with, unless the patient complains o\ ,-. sense of 
 insecurity, when its adjustment should be moderately loose. 
 
 The bandage is useful so long as it can grasp and compress a 
 solid body, t. c. , the womb. When this can no longer be felt, it has 
 done its real work, and if (tightly) persisted in, may even contribute 
 to prolapsus of the womb. 
 
 ^iri r 
 
 Attention to the Child. 
 
 So soon as the necessary attentions to the mother permit, the 
 child should be washed and dressed. The first step consists in 
 thoroughly lubricating the infant's body with sweet oil, or fresh 
 lard, since with soap alone it is impossible to remove from its skin 
 the unctuous material which naturally covers it. It is best to 
 anoint but a portion of the infant's body at a time, keeping the 
 rest covered meanwhile; then this portion may be thoroughly 
 washed with soap and water itself, covered, and another part of 
 the skin treated in the same way. The object of this measure is, 
 of course, merely to prevent a chilling of the child by evaporation 
 from its skin ; hence, in warm weather or a warm room, one may 
 adopt the more expeditious plan of oiling the entire body, and the 
 immersing of the child in a basin of warm water, where the soap 
 may be applied. One precaution is always necessary : care to 
 avoid the entrance of soap into the infant's eyes. The navel-string 
 is now also dressed by wrapping it with a piece of well-oiled muslin 
 or plain cotton wadding. The flannel bandage is now applied over 
 
 
 I! 
 
 ( , 
 
950 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 the navel-string, and the woolen clothes, already prepared, put on. 
 The infant should then be applied to the breast immediately ; if it 
 refuse to nurse, it may be tempted by applying a little sweetened 
 milk to the nipple. This immediate application of the chil ' to the 
 breast is of extreme importance for both mother and infant ; any tend- 
 ency on the part of the womb to relax, and thus permit the escape of 
 blood — " flooding " — is likely to be at once arrested b}'- the nurs- 
 ing of the child ; the milk channels of the breast are opened, and 
 the dangers of an undue accumulation of milk — " milk fever " — 
 in the third day diminished. The child derives from the first nurs- 
 ings very little nourishment. It is true, but a much needed laxative, 
 which stimulates its digestive organs. It should not be forgotten, 
 if there be any signs of flooding, that the most efficient means for 
 checking this, which a layman can use, are the application of the 
 child to the breast and the kneading of the womb. It sometimes 
 happens that the nipple is so retracted, either from the pressure 
 of the dress during pregnancy or other cause, that the child fails 
 in its efforts to nurse; in this case, it is usually easy to secure a 
 proper protrusion of the nipple by filling a soda-water bottle with 
 hot water, pouring out the contents, and then applying the neck of 
 the bottle around the nipple. During the cooling of the bottle, the 
 contraction of the contained air results in the desired protrusion of 
 the nipple ; the breast-pump may be employed for the same pur- 
 pose. This difficulty is seldom serious if properly managed. At 
 other times the infant, especially if prematurely born, seems unable 
 to nurse — a most unsatisfactory condition, in which the only remedy 
 is to attempt an artificial nursing, by milking the breast into the 
 mouth of the child. 
 
 The most serious difficulty with which the infant has to con- 
 tend at the beginning of his career is the persistent habit of nurses, 
 of substituting for the natural and proper diet which nature ordains, 
 the various mixtures which they themselves prescribe. It should 
 be remembered and insisted upon, that although during the first 
 two days the secretion of the mother's breast docs not resemble 
 milk, yet it contains just the essentials for the infant's nourishment, 
 and that the introduction of sugar and water or catnip tea into the 
 immature stomach of the child may have unpleasant results. If it 
 be absolutely necessary to furnish some artificial nourishment, a 
 mixture of cow's milk and water, three parts to one or thinner st.ll, 
 a little sweetened, will be the best and most convenient substitute ; 
 
CARE OF THE MOTHER AFTER LABOR. 
 
 951 
 
 il.,l 
 
 -pared, put on. 
 nediately ; if it 
 little sweetened 
 tlie chi! ' to the 
 ufant ; any tend- 
 nit the escape of 
 ed by the nurs- 
 are opened, and 
 " milk fever "— 
 m the first nurs- 
 needed laxative, 
 lot be forgotten, 
 fficient means for 
 pplication of the 
 }. It sometimes 
 rom the pressure 
 lat the child fails 
 easy to secure a 
 ■water bottle with 
 Dlying the neck of 
 1 of the bottle, the 
 ired protrusion of 
 for the same pur- 
 ly managed. At 
 orn, seems unable 
 ;i the only remedy 
 be breast into the 
 
 nfant has to con- 
 lit habit of nurses, 
 :h nature ordains, 
 Icribe. It should 
 Ih during the first 
 iocs not resemble 
 mt's nourishment, 
 :atnip tea into tli^ 
 Unt results. If it 
 d nourishment, a 
 or thinner st.U, 
 lenient substitute ; 
 
 but everything else should be abandoned so soon as the mother's 
 milk is sufficiently abundant to nourish the child. So the castor oil 
 and other laxatives so dear to the average nurse's heart are, to say 
 the least, unnecessary for the child. Except under special condi- 
 tions, which will be presently noticed, every mother should expect 
 and be encouraged to nourish her own offspring ; and this, too, not 
 simply for the benefit of the child, but also for her own interest; for 
 the act of nursing promotes the return of the womb to its natural 
 size, which ordinarily happens during the first two months after 
 delivery ; a failure to nui-se is often accompanied by an incomplete 
 reduction in the size of the womb and the subsequent derangement 
 of the sexual organs. Again, it is well known that the process of 
 nursing affords a certain protection against recurrence of menses, 
 and against conception. The child should be accustomed from its 
 birth to take the breast at regular intervals, which may be at first 
 two or three hours, and gradually extended as the infant becomes 
 older. In this way time is afforded for the breasts to fill with nutri- 
 tious milk, while the mother secures opportunity for necessary 
 sleep ; and on the other hand the child's digestive organs obtain 
 the needed intervals of repose. 
 
 Care of the Mother After Labor. 
 
 The diet during the first three or four days should be ample 
 and nutritious, though, of course, in a form which is easily digesti- 
 ble. The old idea of starvation diet after delivery is permanently 
 abandoned. After the first day, during which the woman rarely 
 has much appetite, she may receive as much food, in the shape of 
 broth, soup, beef tea, eggs and milk, as she is inclined to take. 
 One point may be profitably borne in mmd : that she will obtain 
 more benefit and less discomfort by taking food in small quantities 
 at short intervals, than by indulging in larger quantities at longer 
 intervals. After five or six days she will usually have, if everything 
 go on well, both the desire and ability to take ordinary food ; at 
 this time her only care need be to avoid stimulating and highly- 
 spiced food. 
 
 For two or three days after delivery there is usually a torpor 
 of the bowels, and oftentimes of the bladder as well. The time- 
 honored custom of giving a dose of castor oil on the third day is 
 
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 952 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 still largely observed, and it will be doubtless insisted upon during 
 the natural life of the present generation of nurses. With reference 
 to this matter, it may only be said that if a movement of the bowels 
 have occurred just prior to delivery, as should be the case, there is 
 no necessity for an evacuation on the third or fourth day. Further- 
 more, castor oil as ordinarily given usually provokes straining at 
 stool, and sometimes causes hemorrhoids or piles ; hence if it be 
 necessary to administer a laxative at all, one of the saline purgatives 
 — preferably Husband's magnesia — maybe better given instead. 
 In many cases it is quite unnecessary, and therefore undesirable, '.0 
 administer any medicine, since the bowels move spontaneously ; and 
 a simple enema of warm water, with or without the usual addition 
 of soap or salt, will secure the desired resr ithout straining. 
 
 The bladder, too, often requires attention ; sometimes there 
 will be no voluntary evacuation of the urine for one or two days after 
 delivery — a state of inactivity which may be attended with serious 
 local or general effects. The condition of the bladder is one of the 
 first points to which a physician directs his attention in his first visits 
 after delivery ; in the absence of a medical attendant the friends 
 should observe whether the bladder is evacuated, and if this function 
 be not performed, cloths wrung out in hot water may be applied 
 over the lower part of the abdomen. This simple measure will 
 usually suffice to stimulate the bladder to contraction ; if it do not, 
 the catheter must be employed. These measures should be insti- 
 tuted early, so that the urine may be evacuated within twelve hours 
 after the completion of labor, and at equal intervals thereafter. 
 
 After-pains usually ensue upon delivery, and at times constitute 
 a most annoying and even painful feature of the case. These after- 
 pains are the natural accompaniments of those contractions of the 
 womb which continue after the expulsion of its original contents, 
 and which seem to be caused by the presence of blood clots in the 
 womb and by the natural reduction of size which now begins. 
 These may be often modified, or perhaps avoided, by the exercise 
 of proper care to prevent the accumulation of blood clots in the 
 womb. If the directions already given for securing prompt and 
 efiicient contractions of this organ be observed ; if the hand be 
 kept upon the abdomen over the womb for an hour or more from 
 the time of the expulsion of the child ; and if the delivery of the 
 placenta be followed by gentle kneading of the womb ; if the 
 bandage be daily loosened, and any blood which may have collected 
 
 I 
 
CARE OF THE MOTHER AFTER LABOR. 
 
 953 
 
 ;d upon during 
 With reference 
 It of the bowels 
 le case, there is 
 I day. Furthcr- 
 kes straining at 
 ; hence if it be 
 ialine purgatives 
 r given instead, 
 e undesirable, '.o 
 )ntaneously ; and 
 le usual addition 
 )ut straining, 
 sometimes there 
 ; or two days after 
 nded with serious 
 dder is one of the 
 3n in his first visits 
 ;ndant the friends 
 md if this function 
 :r may be applied 
 nplc measure will 
 :tion ; if it do not, 
 s should be insti- 
 ithin twelve hours 
 ids thereafter, 
 at times constitute 
 ase. These after- 
 ontractions of tlie 
 original contents, 
 blood clots in the 
 hich now begins. 
 :d, by the exercise 
 blood clots in the 
 ;uring prompt and 
 d ; if the hand be 
 hour or more from 
 ;he delivery of the 
 ;he womb ; if the 
 may have collected 
 
 in the womb be expelled by stimulating the organ to contraction 
 through the abdominal wall ; if these measures have been duly 
 observed, the after-pains will usually be but slight. These pains 
 are provoked and aggravated by any irritation of the vagina or of 
 the rectum ; hence due care should be observed to remove such 
 causes of irritation so far as possible by avoiding unnecessary 
 manipulation of these parts. The application of the child to the 
 breast is usually followed during the first three or four days by 
 somewhat painful uterine contractions — another indication of the 
 immediate sympathy which prevails between the womb and the 
 breasts. A certain amount of after-pain is then natural and cannot 
 be avoided ; and up to a certain extent no interference is required 
 beyond the application of hot cloths to the abdomen ; if, however, 
 these pains be so severe and persistent as to interfere with sleep, 
 they should not be neglected. Measures should be taken to expel 
 the possible contents of the womb, and to quiet the irritation by 
 the administration of an opiate ; the gentle injection of a quart of 
 warm water into the vagina may also be employed. It may also be 
 a consolation to a young mother to know that she will probably 
 escape after-pains at her first confinement, since these occur with 
 especial force and frequency in women who have previously borne 
 children. 
 
 The Lochia. — For a variable time after delivery, ordinarily 
 eight to twelve days, there is a discharge from the vagina termed 
 the lochia. This discharge results from the changes wliich are 
 going on inside of the womb as a preparation for the return of this 
 organ to its previous condition ; it is ordinarily composed, during the 
 first day or two, of almost pure blood, but becomes in the succeed- 
 ing days lighter in color and less in quantity. The amount and 
 character of this discharge should be carefully noticed, since it 
 furnishes valuable information as to the above-mentioned changes, 
 and therefore as to the probable outcome of the case ; for in certain 
 complications, such as puerperal or child-bed fever, the lochial dis- 
 charge is either suppressed or assumes an extremely oftensive 
 cliaracter. On the other hand, the persistence of a bright red 
 color after the ninth or tenth day indicates that the womb is not 
 undergoing the usual and proper reduction in size. In ordinary 
 cases the lochia requires no interference other than simply cleanli- 
 ness, which must be, however, strictly observed. The external 
 part may be washed without unnecessary violence with warm car- 
 
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954 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 boHzed water ; and if there be any unusual odor, the vagina also 
 should be gently syringed out two or three times a day with a two- 
 per-cent. solution of carbolic acid. To promote the escape of the 
 discharge from the vagina, it may be advisable to change the 
 woman's position, having her lie upon one side and the other ; and 
 so soon as practicable, she may, for the same purpose, elevate her 
 shoulders upon pillows. 
 
 For the first few days after delivery the woman should, in a 
 great majority of cases, maintain strictly the recumbent posture ; 
 on the third or fourth she may be permitted, if all goes well, to sit 
 up in bed for a short time and to assume any other desired posi- 
 tion. But '. must be remembered that this is not equivalent to 
 getting ouc of bed and performing any of her domestic duties; 
 while special cases demand special regulations, it may be stated, as 
 a generally applicable rule, that the woman should not assume tlic 
 erect posture nor even leave her bed for two weeks after delivery. 
 This may seem an unnecessarily long pefiod for those who have 
 been accustomed to the nine-day rule of nurses ; but it should be 
 remembered that the object of repose after delivery is to promote 
 that process whereby the enlarged uterus undergoes a reduction in 
 size — resumes nearly the size, shape and position which characterized 
 it before conception had occurred. This process, whereby the preg- 
 nant womb returns after delivery to the unimpregnated state, is 
 termed the involution of the utertts. This involution is a gradual 
 process which requires from six weeks to two months for its com- 
 pletion ; if, for any reason, the process be arrested, the womb 
 remains, of course, larger than it should be, and, as a result of this 
 increased size and weight, it drags upon and stretches its supports 
 — a condition known as " falling of the womb. " It is of the utmost 
 importance that every opportunity should be allowed the womb to 
 undergo this natural reduction in size ; that no impediment of any 
 sort should be opposed to this involution, since such impediment 
 must necessarily endanger a subsequent falling of the womb. Now, 
 it is a fact easily understood, that in the recumbent posture the 
 decrease in the size of the womb occurs more rapidly and more 
 surely than if the woman be allowed to perform the usual domestic 
 duties, or even to stand and walk. Hence the advice that a woman 
 remain in bed two weeks after delivery, that is, until the process of 
 involution of the womb has been well initiated, and that for at 
 least two further weeks she assume none of the responsibilities of 
 
 ■J " m44 
 
LACTATION. 
 
 955 
 
 :he vagina also 
 lay with a two- 
 e escape of the 
 to change the 
 the other ; and 
 ose, elevate her 
 
 lan should, in a 
 mbent posture; 
 goes well, to sit 
 ler desired posi- 
 lot equivalent to 
 domestic duties; 
 nay be stated, as 
 d not assume the 
 :ks after delivery. 
 ' those who have 
 but it should bo 
 rery is to promote 
 oes a reduction in 
 hich characterized 
 whereby the preg- 
 ,regnated state, is 
 tion is a gradual 
 nths for its com- 
 ested, the womb 
 as a result of this 
 letches its supports 
 lit is of the utmost 
 wed the womb to 
 Impediment of any 
 such impediment 
 the womb. Now, 
 iibcnt posture the 
 rapidly and more 
 Ithc usual domestic 
 .vice that a woman 
 jntil the proce-^s of 
 d, and that f^'i' at^ 
 responsibilities ol 
 
 housekeeping. Many times a more prolonged confinement to bed 
 will be necessary; if, for example, as has been already stated, the 
 lochial discharge retain its bright red color beyond the usual time, 
 it is evident that the involution of the womb is not proceeding with 
 the usual rapidity, and that it will not be wise for the woman to 
 rise even at the expiration of two weeks. 
 
 Lactation. 
 
 During the latter months of pregnancy the breasts usually 
 secrete more or less fluid. The quantity is, in comparison to what 
 occurs after delivery, quite small, and the quality and appearance 
 are not such as characterize the milk. During the first day or two 
 after delivery the breasts present no especial change in most 
 women, but on the third day the secretion of milk, properly speak- 
 ing, begins. This secretion of milk is what is termed by nurses a 
 " rush of milk " to the breasts. It is no uncommon occurrence for 
 this secretion of milk to be accompanied by more or less severe 
 disturbance to the patient. In nearly all cases the breasts swell, 
 become tender upon pressure, and even painful; oftentimes the 
 woman complains of headache ; in some cases there is even a pro- 
 nounced chill, and considerable fever. This is what is ordinarily 
 termed " milk fever," and may be mistaken as an indication of 
 childbed fever. In the latter case there is, however, tenderness 
 over the womb and some derangement of the lochial secretion, 
 while in milk fever the pain and tenderness are located in the 
 breasts. 
 
 Milk fever is especially apt to occur if there have been some 
 neglect in putting the child to the breast during the first two days 
 after delivery, or if the child have refused to nurse. In some 
 cases, too, milk fever may occur even though the babe has nursed 
 properly, simply because of the profuse secretion of the milk — 
 more than the child has been able to absorb. In such cases relief 
 may be obtained by the gentle application of the breast pump two 
 or three times a day, and by gentle friction of the breasts with 
 sweet oil ; the motion of the hand should be from the base of the 
 organ toward the nipple. Friction may be especially directed to 
 any knots or lumps which may be felt in the breast, and which are 
 at first merely accumulations of milk in the tubes, but which sub- 
 da 
 
 
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956 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 i 
 
 ■i i 
 
 sequently may give rise to inflammation and abscess. Another 
 important measure is the application of cooling lotions to the 
 breast, either simple cold water, or perhaps a thin layer of pounded 
 ice enclosed in a cloth. At times the weight of the breast , ^.cd- 
 sions considerable pain, which can be relieved by simply suspctui- 
 ing the organ in a handkerchief tied around the neck. Nurses are 
 in the habit of attempting to relieve this swollen condition of tlu 
 breast by frequent applications of the child. This measure is open 
 to certain objections on the part of both mother and infant; since 
 the effect of the child's nursing is not simply to empty the breasts, 
 but also to stimulate them to an increased secretion of milk, it is 
 obvious that such a course may defeat its own object by increasing 
 rather than diminishing the quantity of milk constantly present in 
 the distended breast; furthermore, such frequency of nursing pro- 
 motes the formation of fissures and abrasions of the nipple. 
 
 The fluid secreted by the breast during the first two days, tech- 
 nically called colustrum, acts as a laxative upon the child's bowels 
 and prepares the way for the digestion of the milk. While it is 
 desirable that the child should imbibe this fluid, yet the two 
 frequent presence of colustrum in the child's intestines may easily 
 induce a state of irritation unfavorable for the digestion of the milk. 
 The result is often vomiting and diarrhea in the infant, when it w ill 
 be apparent that it is r.iirsing too frequently. 
 
 It occasionally happens that a woman will accustom herself 
 from the very first to give but one breast to the child, because per- 
 haps the other nipple is somewhat tender. It is evident that this 
 tends directly to promote the accumulation of milk and subsequent 
 trouble in this breast. It is desirable, therefore, that the child 
 should be applied on every occasion to both breasts. It is much 
 better to partially empty both than to leave one untouched. It 
 sometimes occurs also, in cases where the secretion of milk is t[uitc 
 abundant, or the demands of the child are less than usual, that there 
 is a more or less constant escape of milk during the inter\als 
 between nursing. Thus a certain amount of loss is of frequent 
 occurrence especially during the early period of nursing, yet it is 
 a thing to be avoided if possible, not only because of the discomfort 
 which results from the constant moisture of the breasts and clutliini;, 
 but also because soreness and fissures of the nipple are thus promoted. 
 This condition of things would occur less frequently if the child's nurs- 
 ing were regulated from the very beginning — if it were permitted to 
 
 
LACTATION. 
 
 957 
 
 cess. Another 
 lotions to the 
 lyer of pounded 
 ^c breast ^c.i- 
 simply suspeiul- 
 ck. Nurses lue 
 condition of the 
 measure is open 
 ind infant; since 
 ipty the breasts, 
 .on of milk, it is 
 :ct by increasing 
 tantly present in 
 r of nursing pro- 
 he nipple, 
 sttwo days, tech- 
 the child's bowels 
 milk. While it is 
 .lid, yet the two 
 sstines may easily 
 estion of the milk. 
 ifant, when it will 
 
 accustom herself 
 :hild, because per- 
 cvident that this 
 Ik and subsequent 
 c, that the ehikl 
 |-easts. It is much 
 lie untouched. It 
 Ion of milk is cpiitc 
 |an usual, thai there 
 ring the intervals 
 OSS is of frocpicnt 
 nursing, yet it is 
 ,c of the discomfort 
 •easts and clothing, 
 are thus promoted, 
 ly if the child's nurs- 
 ,t were permitted to 
 
 suckle only at intervals of two hours, and were applied on each 
 occasion to both breasts. When this condition has been once 
 established, this same regulation as to nursing is perhaps the most 
 important feature in the treatment. In addition, one may use the 
 cooling lotion if the overflow of the breasts evidently results from 
 excessive secretion. There are cases, however, which resist all 
 efforts at control. In such instances, the application of the child to 
 the breast often causes a severe neuralgic pain which is often fol- 
 lowed by a contraction of the breast, causing the milk to spurt in 
 jets from the nipple. Indeed, at times, the sympathy between the 
 breasts is so intimate, that the application of the infant to one nip- 
 ple is followed by a spurting of milk from the other. This condition 
 sometimes yields to treatment, but, in exceptional instances, causes 
 such trouble that the woman is compelled to wean her child. 
 
 Attention should be called to one point in connection with the 
 excessive secretion of milk, namely : that this fluid may be abun- 
 dant in quantity and yet deficient in quality. Hence it does not 
 follow because the mother has abundance of milk, that the child is 
 necessarily well nourished ; there may be either an absence of the 
 
 nutritious elements of the milk — which is watery, therefore or 
 
 there may be present certain constituents which arc injurious 
 to the child. The infant may, therefore, starve or be poisoned, 
 even though supplied with an abundance of mother's milk. The 
 existence of such conditions must, of course, be detected by the 
 condition of the child ; derangements of its digestion sometimes 
 demand weaning, even though the mother have an abundance of 
 milk. In such cases medical advice should be sought ; it will some- 
 times be found possible to restore a healthful condition of the milk 
 by regulating the diet and habits of the mother. Sometimes the 
 fault will be found to be an undue richness of the milk a condi- 
 tion which often occurs when the breasts arc over stimulated by too 
 frequent application of the child. The result of such condition is 
 marked derangement of the child's stomach and bowels. In such 
 cases suspicion is rarely directed to the milk, because the general 
 appearance and health of the mother, as well as the quantity or 
 milk furnished, seem entirely satisfactory. In this condition 
 medicines are of no avail ; the remedy is usually to be found in 
 carefully regulating the diet of the mother, by causing her to avoid 
 stimulants and over-feeding, to which she often becomes aildicted 
 by the advice of the nurse; for while admitting the value of malt 
 
 I ' 
 
 
 rri, 
 
 i'll 
 
 ■It 
 
 A'i 
 
958 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 liquors and wines under given conditions of the nursing woman, 
 yet there seems to be a general impression that such beverages 
 should constitute an essential part of the mother's diet. It would 
 be better, of course, in every instance, to take liquors only by the 
 advice of the medical attendant ; yet in every case in which the 
 child exhibits disturbances of digestion without apparent cause, it 
 is advisable for the mother to restrict very materially her indulgence 
 in ales or wines. 
 
 Another complication of lactation, more frequent and more 
 evident than the former, is the failure of the mother to secrete a 
 proper amount of milk. The greatest diversities arc encountered 
 in this particular ; while it is true as a rule that the healthiest and 
 most robust women furnish the most satisfactory nourishment for 
 their offspring, yet no prediction can be made upon this basis alone. 
 It may be stated in general, that the failure to nurse properly 
 is found more common among those accustomed to indolent and 
 luxurious lives — is, therefore, most frequently observed in cities; 
 nor is it certain that the ability to nurse the child will persist 
 throughout the usual time. Among the causes which may arrest 
 the secretion are the various acute diseases, especially those which 
 supervene immediately upon delivery. In such cases the secretion 
 of milk is often resumed after recovery from the disease, though 
 sometimes the quality is so changed as to make the milk unfit for 
 the child. In other cases again the secretion is not established at 
 the usual time, and when it does appear, is present in insufficient 
 quantity. In such cases artificial feeding must, of course, be 
 employed. Though even then it is desirable, for the sake of both 
 mother and infant, that the child should have whatever the mother 
 can furnish, provided, of course, the quality be unobjectionable. 
 
 : 
 
 The Relation Between Lactation and the Sexual Functions. 
 
 Since the nourishment of the child by the secretion of the 
 breast is a part of the reproductive process — and one, too, which 
 abundantly taxes the physical powers of the woman — we would 
 expect to find what we know to be the case, namely, that the other 
 reproductive organs, the womb and ovaries, usually remain in a 
 quiescent state until lactation is completed; hence it is that concep- 
 
EN. 
 
 nursing woman, 
 t such beverages 
 's diet. It would 
 quors only by the 
 case in which the 
 apparent cause, it 
 ally her indulgence 
 
 frequent and more 
 lother to secrete a 
 ;s are encountered 
 t the healthiest and 
 ,ry nourishment for 
 )on this basis alone, 
 to nurse properly 
 led to indolent and 
 observed in cities ; 
 e child will persist 
 ;es which may arrest 
 ,pecially those which 
 h cases the secretion 
 the disease, though 
 ke the milk unfit for 
 is not established at 
 •esent in insufficient 
 ust, of course, be 
 for the sake of both 
 Iwhatever the mother 
 le unobjectionable. 
 
 Sexual Functions. 
 
 I the secretion of the 
 -and one, too, which 
 
 woman — we would 
 lamely, that the other 
 
 usually remain in a 
 Ince it is that conccp- 
 
 LACTATION AND SEXUAL FUNCTIONS. 
 
 959 
 
 tion rarely occurs until the child is weaned. But it should be 
 remembered that this intimate sympathy between the breasts and 
 the sexual organs is one which may react upon the former as well 
 as upon the latter ; and that undue sexual excitement is apt to be 
 followed by injurious influence upon the secretion of milk. For 
 this, among other reasons, it is a matter of the utmost importance, 
 that during the early period of lactation there may be a total 
 abstinence from intercourse, which should be allowed not earlier 
 than the third month after delivery. 
 
 Another most important reason for such abstinence is the fact 
 that a failure to observe it often interferes seriously with the invo- 
 lution of the uterus, which is not always completed within two 
 months after confinement. If the period of nursing be not iniduly 
 prolonged, if the child be weaned between the tenth and twelfth 
 month, menstruation is usually deferred so long as lactation con- 
 tinues. Yet exceptions to this rule do occur; cither because of 
 undue sexual excitement, or for some undetermined reason, men- 
 struation occasionally begins five or six months after delivery. In 
 such cases the woman is often urged to discontinue nursing for the 
 sake of her child. In regard to this we would simply say that the 
 appearance of the menstrual discharge does not necessarily de- 
 mand the discontinuance of lactation; the decision must rest entirely 
 upon the health of the child. If this be evidently impaired from 
 the time when menstruation began, it is always advisable that the 
 infant be weaned, otherwise not. It is observed that in the majority 
 of cases, when menstruation begins so late as the fifth or sixth 
 month, lactation may be prolonged without interference during the 
 usual period. 
 
 Quite otherwise is it, however, if conception occur while the 
 mother is still nursing. For in this case her energies, unequal to 
 the increased demand made by the attempt to perform both func- 
 tions, will be devoted to the child in the womb to such an extent as 
 to interfere seriously with her nursing. This does not necessarily 
 imply that the milk will be dried up,' since the contrary is often 
 observed, but the effect upon the child is always evident. The 
 milk plainly suffers such a change in quality as to render it injurious 
 to the infant, and in every case the child should be weaned just so 
 soon as the fact of conception is apparent. In some cases, indeed, 
 it has been observed that a previously healthy child, thriving upon 
 the milk of a healthy mother, becomes suddenly and unaccountably 
 
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 960 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 ill. Obstinate derangements of digestion, resisting all remedies, 
 either in the shape of drugs or in attention to the mother's did, 
 transform the previously rosy babe into a deathly caricature of it> 
 former self The mystery has been only explained a few months 
 later by the evident pregnancy of the mother. 
 
 Hygiene of Lactation. 
 
 As the nursing mother is furnishing nourishment for her child 
 as well as for herself, she may be expected to exhibit more than 
 the average appetite. Up to a certain degree this is, of course, to 
 be encoure^ged. Yet it may not be forgotten that it is possible to 
 gormandize during lactation as well as at other times, and that arti- 
 cles of diet which may be well borne by the woman herself can 
 nevertheless have an injurious influence upon the child. While it 
 is not desirable to attempt to regulate the diet during nursing by 
 any rigid set of rules, yet it is well for the mother to bear con- 
 stantly in mind the fact that she must eat for the child and not 
 simply for herself. If there be signs that the supply of milk is 
 failing, it is desirable that the mother should first attempt, before 
 weaning her child, to increase her own strength and activity b)- a 
 change of surroundings. Oftentimes marked improvement in the 
 secretion of the breast follows a change of air, increased attention 
 to exercise, regularity of meals and sleep. In such cases, too, the 
 breasts may be stimulated by the frequent application of the ir.faiit, 
 One of the most common and persistent errors in nursing is the 
 hab'.l of using the breast as a means for stopping the child's cryin<.;. 
 This is doubtless a matter of temporary convenience, but one 
 which reacts with pernicious effect upon both parties subsequently. 
 The child which nurses satisfactorily every two hours, does not 
 n6kd and cannot digest more food ; if it cries, the cause must be 
 sought in other grounds than hunger. After the first two or three 
 months the intervals between nursing may be lengthened to three 
 or even four hours by day, and at night the child's nursing may be 
 restricted to three or even two jccasions. Indeed, if the task of 
 nursing be evidently too much for the mother, it is well for her to 
 refrain entirely at night, when tne child may be fed artificially. 
 The evidence of over-nursing occurs in the form of general debility. 
 
1 
 
 HYGIENE OF LACTATION. 
 
 961 
 
 ig all remedies, 
 ,e mother's did, 
 caricature of itN 
 d a few months 
 
 lent for her child 
 diibit more tliaii 
 s is, of course, In 
 it it is possible to 
 Ties, and that aiti- 
 oman herself can 
 ,e child. While it 
 during nursing by 
 )ther to bear con- 
 the child and not 
 supply of milk is 
 rst attempt, before 
 1 and activity by a 
 provement in the 
 lincreased attention 
 iich cases, too, llic 
 ation of the infant. 
 in nursing is the 
 the child's cryine. 
 venience, but one 
 .rties subsequently. 
 o hours, does not 
 I, the cause must be 
 lie first two or three 
 cngthcned to three 
 lid's nursing may be 
 [iced, if the task of 
 it is well for her to 
 be fed artificially. 
 of general debility, 
 
 languor, headache, pains in the back and shoulders, sometimes 
 derangements of vision or hearing. These often disappear if the 
 regularity in nursing, to which attention has been called, be 
 enforced. 
 
 It is generally known that the mental condition e.vcrcises 
 marked influence upon the composition of the milk. Many stories 
 are told — some of them doubtless true — of the disastrous effects 
 induced upon children by giving them the breast immediately after 
 a period of excitement ; and it is certainly true that a woman 
 laboring under constant anxiety or mental strain of any sort is not 
 apt to furnish proper sustenance for a nursing child. It follows, 
 therefore, that the maintenance of proper mental balance, the 
 avoidance of excessive emotion or mental effort, should evidently be 
 one factor in the hygiene of lactation. 
 
 A healthy woman can usually furnish all the nourishment 
 required by her infant during the first five or six months of its 
 existence. During this time the child requires no other food than 
 that obtained from the mother. During the early months the infant 
 requires feeding from ten to fifteen times per day ; but as time 
 advances it becomes capable of absorbing more food at one time, 
 and of satisfying its hunger by indulgence at greater intervals. 
 During the fourth month the child rarely requires feeding more than 
 five or six times in twenty-four hours. A woman's capacity for the 
 secretion of milk rarely exceeds two or three pints ; and as this 
 amount of nourishment is scarcely sufficient to sustain a child of six 
 or seven months, it usually becomes necessary to add artificial food 
 from this time onward. Yet, in the interest of both, the child 
 should not be deprived of its mother's assistance before the comple- 
 tion of its first year. 
 
 The most troublesome complications of* nursing arise from 
 fissures and abrasions of the nipple. The treatment of these must 
 usually be left to the medical attendant, and even then often prove 
 extremely obstinate. The woman herself can, however, ace m- 
 plish considerable in the way of preventing these accidents ; to do 
 this she may attend to two objects — the hardening of the nipples 
 and their protection from injury by her clothing. As has been 
 aheady indicated, the preparation of the nipples for nursing should 
 begin some two or three months before delivery, and should consist 
 of ablutions with cool soft water and gentle friction from the sixth 
 nioiiih of pregnancy onward ; during the last month or two the 
 
 1! iti 
 
 illi I 
 
 
962 
 
 DISEASES t)K WOMEN AND CIIILDUEN. 
 
 m 
 
 wash for the nipple should be employed morning' and night. This 
 may consist of equal parts of glycerine and cologne water ; to this 
 there may be added, if the nipples be at all tender, a little borax. 
 After delivery, considerable protection can be afforded by the use 
 of an ointment made by mi.xing finely-powdered gum arable with 
 pure lard. Protection against the clothing can usually be secured 
 by simple attention to the arrangement of the dress ; but if there 
 be, notwithstanding, decided tenderness of the nipples, protec- 
 tion can be afforded by the use of nipple-shields. If abrasions occur 
 during nursing they may be sometimes healed by the application of 
 astringent ointments. In the preparation of these, care must be 
 taken not to use any substance which could be injurious to the 
 child. One of the best applications may be obtained at the drug 
 store by asking the druggist to make an ointment of the following 
 ingredients : 
 
 Tannic acid, ----- Three grains. 
 Glycerine, ----- One drachm. 
 
 Simple cerate, - - _ - One ounce. 
 
 This may be applied to the nipple three or four times a 
 day, care being taken to remove it and cleanse the nipple before the 
 child is applied to the breast. 
 
 Fissures of the nipple — often called chaps — are even more 
 annoying than abrasions ; the application of the ointment just 
 mentioned, not merely upon, but in the fissure, will sometimes 
 bring relief; if not, and if the use of the artificial nipple be also 
 unsuccessful, the matter should be placed in professional haiuls 
 without delay, since such fissures, when neglected, may rentier 
 nursing impossible. It will be well to avoid any cxperiinentaLiun 
 with different remedies that may be recommended by friends, since 
 such efforts usually result merely in aggravating the condition. 
 
 Another unfortunate complication of nursing is what is termed 
 milk abscess, which sometimes supervenes upon sore nipples, though 
 it may occur also without this provoc; ion, the general bilief 
 
 that its formation is often due t'> aidicious application of the 
 
 breast pump. The beginniuL ae uifiamm 'on which subse- 
 
 quently results in abscess forn. on, is usually indicated by chills, 
 often severe and repeated, and by .1 sh irp pain in a particular part 
 of the breast, aggravated by nursing. In the course of one or two 
 days considerable fever supervenes, accompanied by extr 'le ten- 
 derness of the breasts on pressure. The pain caused by the appli- 
 
s. 
 
 tub: selection ok a wet-nurse. 
 
 963 
 
 nd nifiht. This 
 c water ; to this 
 r, a little borax, 
 (led by the use 
 {rum arabic with 
 ually be secured 
 CSS ; but if there 
 
 nipples, protec- 
 If abrasions occur 
 the application of 
 ic, care must be 
 
 injurious to the 
 :ained at the druLj 
 : of the following' 
 
 iree grains. 
 
 ic drachm. 
 
 ne ounce. 
 
 : or four times a 
 
 le nipple before the 
 
 y are even mere 
 
 the ointment jiisl 
 ic, will sometimes 
 cial nipple be als(» 
 professional h.uuls 
 cctcil, may rentier 
 ly cxperimcntP-tivin 
 od by friends, since 
 the condition. 
 ^ is what is termed 
 .ore nipples, thou!j;li 
 the general belief 
 ipplication of the 
 on which subse- 
 ,adicated by chills, 
 in a particular part 
 ourse of one or Iwd 
 .ed by extr mc tcii- 
 ;aused by the appli- 
 
 cation of the child is so severe that the organ is no longer used 
 for nursing. It is sometimes possible at this early stage to 
 cut the process short by the use of evapoi.aing lotions, and l)y 
 the exercise of care to prevent the accumulation of milk within 
 the organ. In most instances, however, these measures fail; 
 there forms at the site of the pain and tenderness a hard knot which 
 is soon surrounded by a swollen and doughy area. After a variable 
 time — a few days to several weeks — this knot becomes soft and less 
 exquisitely tender; the neighboring portion of the breast, or even 
 the entire organ, is greatly swollen, hot and red; oftentimes the 
 skin appears glazed. These signs indicate the formation of matter 
 within the organ — a condition often indicated by renewed cliills. 
 Sometimes the first abscess formation is followed by the appearance 
 of other abscesses in different parts of th-i breast ; and it may happen 
 that after the first has disappeared othei abscesses will be formed 
 weeks or months later. 
 
 The treatment of this affection must be relegated immediately 
 to the physician ; the symptoms are detailed above merely that the 
 nature of the affection may be early recognized, and hence prompt 
 measures be taken to avert the more serious results. In the major- 
 ity of cases it becomes absolutely necessary to open the abscess — 
 a proceeding which is, in the more favorable instances, followed Ijy 
 speedy disappearance of the symptoms. Yet it must be confessed 
 that the most skillful treatment is often futile in preventing tedious 
 and exhausting disease of the organ. 
 
 The Selection of a Wet-nurse. 
 
 Various circumstances, sometimes quite isncxpected, may 
 compel the mother to cease nursing her infant. Indeed, the in- 
 stances arc not infrequent in which some hereditary taint or 
 acquired disease makes it desirable that the mother sliould not, 
 wen If she can, suckle the child. In such instances the best sub- 
 stitute is, of course, the wet-nurse, though circumstances often 
 compel the employment of another and less expensive mode f ' 
 sustenance — artificial feeding. Methods for accomplishing this 
 latter object will be discussed in subsequent pages, but a word 
 with reference to the selection of a wet-nurse may be in order 
 here. It is desirable that she shall be able to furnish sufficient 
 
 • ! 
 
 I ' 
 
 M 
 
 
 I 
 
964 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 milk of good quality, and free from any constitutional taint. The 
 best index to her physical qunlifications is the condition of her own 
 child. Generally speaking, a wet-nurse should be between eighLeon 
 and thirty years old ; her confinement should hr ve occurred at 
 about the same time, or a little later, than that of tiie woman for 
 whom she is to be a substitute ; one who has previously borne 
 children is to be preferred, not only because of the increased ex- 
 perience gained, but also because the mil) is of better quality in 
 subsequent than after the first confinement. After the applicant 
 has given satisfaction as to her character and history and present 
 condition, she should be submitted to a rigid and thorough exam- 
 ination by a physician in order that no contagious disease whicli 
 may be lurking in her system shall be overlooked; for it should be 
 understood that an apparently healthy woman may be capable of 
 communica<"ing, either through her breast or her lips, a disease 
 which would either destroy the infant's life or prove a life-long 
 curse. 
 
 If the child oe st'U-born, or die soon after birth, the mother's 
 interest will be promoted not by drying up the milk at once, hut 
 by encouraging the secretion for at least six or eight weeks. The 
 object uf this is to promote the involution of the womb, which 
 proce^ ds more rapidly and sureiy if the breasts are kept active 
 The same principle applies if it be necessary for the mother to dis- 
 continue nursing during the first two months of lactation. In 
 either case the best substitute for the child is the judicious applica- 
 tion of the breast-pump, at regular intervals, aided by gentle fric- 
 tion of the breasts toward the nipple. 
 
 Care of the Infant. 
 
 Before birth the child is but a portion of the mother's bod)-, 
 enjoying the advantages of the protection and nourishment which 
 she provides for herself At birth the infant is deprived of those 
 favoring influences and compelled to conduct an existcnc:^ inde- 
 pendent, to a large extent, of assistance from others. It is not sur- 
 prising that the experiment is in many cases a failure ; Ii.it the 
 tender little creature, deprived of the warmth and shelter ^.f the 
 materral body, and thrown upon its own resources, compelled to 
 eat, digest and breathe for itself, instead of having food and air 
 
'«ll 
 
 ti ! .i' 
 
 CARE OF THE INFANT. 
 
 96s 
 
 lal taint. The 
 tion of her own 
 itween eighLcnn 
 ^e occurred at 
 
 che woman for 
 •eviously borne 
 e increased ex- 
 letter quality in 
 :r the applicant 
 ory and present 
 thorough exam- 
 is disease which 
 
 for it should be 
 ly be capable of 
 r lips, a disease 
 )rove a life-Ion;^ 
 
 rth, the mother's 
 
 nilk at once, but 
 
 ght weeks. Tlu; 
 
 he womb, whicli 
 
 are kept active. 
 
 ic mother to dis- 
 
 f lactation. In 
 
 udicious applica- 
 
 d by gentle fric- 
 
 |e mother's boch', 
 lurishment which 
 llcprived of these 
 existenc;' indc- 
 Irs. It is not sur- 
 Ifailure ; hat the 
 |nd shelter v,f the 
 :es, compelled to 
 ling food and air 
 
 furnished it as before, should succumb to the unaccustomed influ- 
 ences, notwithstanding the rr;ost assiduous attention. The mor- 
 tality among infants is accordingly large — one of every ten dies 
 during the first month, and fifteen of every 100 during the first year. 
 Many of those which have survived the first difficulties of life with 
 the assistance of the mother's breast, die when they are compelled 
 to surrender this aid and masticate their own food. Hence it hap- 
 pens that ai the end of four years there remain alive but three out 
 of every four infants born. Yet even without these figures it 
 would be self-evident that the new-born infant demands especial 
 and intelligent care and attention. 
 
 In the cour-e of a few days after birth the navel-string, which 
 has been at delivery enclosed under a flannel bandage, withers and 
 falls off. If, before this happens, there be a decided odor of putre- 
 faction, it is necessary to cleanse and dress the string somewhat 
 frequently. It sometimes occurs that after the stump has dropped 
 off" the navel remains unhealed, raw, perhaps even ulcerated. If this 
 occur, the matter should be brought at once to the attention of a 
 physician, since the result may be serious injury to the child. For 
 some weeks after birth this spot in the abdominal wall remains 
 weak, and may easily be made to protrude when the child strains, 
 especially if the infant be addicted to violent crying and screaming. 
 In srucl; cases there may result a rupture, or hernia — a source of 
 serious iiunoyance and even danger in subsequent years. To guard 
 against this, it is advisable in every case to place a soft pad over the 
 navel and keep it bound on by means of a flannel bandage or ad- 
 hesive plaster. 
 
 While the clothing of the child is to be regulated to a certain 
 extent by the climate and season, yet it will be found advantageous 
 to place flannel next tu its skin all the year round. The advantages 
 comprise not only the maintenance of an equable temperature, 
 but also the absorption of tlie secretions of the skin, which might 
 otherwise be a soi.rce of irritation. TJiis regulation acquires 
 double importauLv. in th.e case of those infants prematurely born, 
 and, therefore, less capable of maintaining an independent temper- 
 ature. 
 
 A most important clement in securing the well-being of the 
 infant is strict cleanliness ; and in nothing else is the difl'erence 
 between an attentive and a careless nurse more evident than in the 
 management of the napkins and in the protection of the child's 
 
 ' i ;| 
 
 ti 
 
 li 
 
 ' 11 
 
 t-» 
 
\ 
 
 966 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 skin from its own discharges. It may be, in general, stated that 
 soreness and rawness about the child's thighs indicate neglect of 
 cleanliness either of the infant itself or of the napkins. So far as 
 the child is concerned, there should be, and is usually, no difficulty, 
 since the warm bath is everywhere procurable. It is, however, to 
 be borne in mind, that the infant can be bathed to excess ; during 
 the first weeks of its existence the child should not be put into the 
 bath more than once a day, nor remain there more than two or three 
 minutes ; feeble children must be bathed with still more caution, 
 since the warm bath is quite e.xhausting. Yet many infants which 
 are regularly and carefully cleansed suffer, nevertheless, from sore- 
 ness of the skin ; and many a mother applies industriously, but 
 unsuccessfully, a variety of baby powders, and Is puzzled to know- 
 why the child's skin remains sore. There is just one slovenly habit 
 which is apparently responsible for much of the trouble of this 
 sort : many mothers, namely, seem to consider that the napkins 
 require washing only after being soiled ; and that if only wet they 
 may be reapplied after drying by the stove. This idea is, of course, 
 a mistake, since the urine contains a number of substances whicli 
 are extremely irritating when applied to the skin ; the napkins should 
 be washed in one case as well as in the other. 
 
 After the first ten or twelve days the child may be carried 
 out thoroughly wrapped up if the weather be properly warm 
 (70'-' F.); and unless the inclemency of the season absolutely 
 forbid it, the infant should receive a daily airing and sunning as 
 regularly as plants. 
 
 Food. — It need hardly be repeated that the most appropriate 
 and desirable nourishment for the new-born child is derived from 
 the mother's breast ; yet it may with propriety be remarked that 
 this nourishment is of itself amply sufticient for <?// the needs of the 
 infant ; and that sugar and water, and a dozen other mixtures which 
 are poured into the helpless child during the first few days of 
 its life, may do harm, but can do no good. If the secretion of 
 milk be delayed beyond the usual time, nothing should be given the 
 child e.xcept a little water sirnply stained wxih cream. So soon as 
 the secretion is established there slKnild be no further administration 
 of artificial food. The best assurance of health to the child diiriiit; 
 the first seven months of its existence, is an ample supply of 
 mother's milk. 
 
 In a considerable minority of cases, however, it becomes neces- 
 
i, stated that 
 Lte neglect of 
 ;. So far as 
 
 no difficulty, 
 ,, hoNV'ever, to 
 ccess ; during 
 e put into the 
 n two or three 
 more caution, 
 infants which 
 2SS, from sore- 
 ustriously, but 
 uzzled to know 
 ; slovenly habit 
 trouble of this 
 at the napkins 
 
 only wet they 
 ca is, of course, 
 ibstances which 
 L" napkins should 
 
 .\y be carried 
 roperly warm 
 ason absolutely 
 ind sunning as 
 
 ost appropriate 
 is derived from 
 
 remarked that 
 the needs of the 
 
 mixtures which 
 st few days (if 
 the secretion of 
 uld be given the 
 ni. So soon as 
 :r administration 
 
 the child duriui; 
 
 ample supply of 
 
 CARE OF THE INKAM', 
 
 967 
 
 sary, on account of some of the causes already indicated, that arti- 
 ficial food should be substituted entirely or in part for the breast. 
 These are the cases which furnish so much sickness or mortality, 
 especially in our larger cities. It must not be understood that arti- 
 ficial feeding implies in itself anything injurious to the child, but as 
 ordinarily employed it is such a poor substitute for the natural food 
 that the results are, as a rule, very unsatisfactory. 
 
 With care and attention a bottle-fed infant may and often does 
 enjoy the most robust health ; and there are certain combinations 
 of artificial food which give, as a rule, excellent results as a substi- 
 tute for mother's milk. Yet while physicians are accustomed to 
 rely upon these sr jstitutes, they are equally well aware that there 
 must be an adaptation of means to meet the requirements of it^di- 
 vidual cases ; that the effects upon the child, as indicated by iie 
 condition of his digestive organs must be carefully observed, as an 
 index to possible modifications of diet. A food which may meet 
 the requirements in four successive cases may require modification 
 in the fifth ; and it is extremely important for mothers to realize 
 the fact that there is no such thing as a universal infants' food ; that 
 the nourishment of infancy must vary, not only according to age 
 and season, but also with individual peculiarities ; and that' her 
 vigilance may not be relaxed, so soon as she has obtained from a 
 friend or physician a formula for preparing infants' food. The best 
 plan in every case in which difficulty is experienced is to place the 
 matter in the hands of a physician. Yet a few directions for the 
 composition of food, which will in many cases answer all require- 
 ments, are appended : 
 
 The simplest substitute for mother's milk is obtained by dilut- 
 ing cow's milk. The milk of the cow diff'ers from that of woman 
 in two essential details : It is considerably richer in solid constitu- 
 ents but CO ,! vins less sugar. To approximate it to human milk it 
 is merely necessary then to add a certain amount of water and 
 sugar, preferably " milk sugar. " The amount of dilution varies with 
 the age of the infant ; since mother's milk is less rich in the early 
 months of nursing than it subseqently becomes, a correspondingly 
 greater amount of water must be added to the cow's milk to secure 
 the proper consistence. The milk, as obtained from the cow should 
 be mixed with its own bulk of water for a child one or two months 
 old ; if the milk be obtained from a dealer it will rarely be neces- 
 sary to add more than half its bulk of water ; the mixture may be 
 
 ■1 't 
 
 
 !' f ' 
 
 m 
 
 t becomes neccs- 
 
 ■ILi. I 
 
968 
 
 DISEASES OF WOMEN AND CHILDREN, 
 
 II 
 
 i : 
 
 # 
 
 sweetened with table sugar, or better with sugar of milk. This 
 preparation often answers admirably as a substitute for the mother's 
 breast, especially in the country ; in large cities the plan is less 
 often successful, since the milk cannot be obtained so fresh, and in 
 warm weather at least, has always undergone fermentation whereby 
 irritating compounds are formed. Yet it is oftentimes possible to 
 obviate, to a certain extent, these disadvantages by previously boil- 
 ing the milk. Yet if it be impossible to secure fresh and pure cow's 
 milk, it will be best to resort to one of several other modes of pre- 
 paring artificial food. A very popular mixture, and one which has 
 rendered valuable service, is an attempted imitation of the natural 
 composition of milk — a popular and ready form of Licbig's food. 
 The ingredients required are : 
 
 Malt, 
 
 Flour, - _ _ 
 
 Skimmed milk. 
 
 Bicarbonate of potassium, 
 
 Water, 
 
 One-half ounce. 
 One-half ounce. 
 Six ounces. 
 Seven grains. 
 One ounce. 
 
 Malt should be crushed or ground in a coftee-rfiill. All the ingre- 
 dients mi / be mixed, put into a clean pan, boiled for eight or ten 
 minutes and constantly stirred ; then strained through an ordinary 
 piece of muslin ; if the child must be fed from the very first, it will 
 be desirable to increase the quantity of water in the above mixture 
 to six ounces. After the first two or three weeks the quantity 
 named will be insufficient, as the child requires two or tlircc 
 teacupfuls. The mixture tastes quite sweet ; no sugar should be 
 employed. The disadvantage of this food is the necessity for this 
 somewhat complicated preparation every twelve or twcnty-nnir 
 hours. 
 
 A most satisfactory and generally applicable food can be 
 obtained from arrow root and cream. Dr. Meigs, of Philadelphia, 
 gives the following directions: " A scruple of gelatine (or a piece 
 two inches square of the flat cake in which it is sold) is soaked fur 
 a short time in cold water and then boiled in half a pint of water 
 until it dissolves — about ten or fifteen minutes. To this is added, 
 with constant stirring, and just at the termination of the boiling, 
 the milk anda rrow root, the latter being previously mixed into a 
 paste with a little cold water. After the addition of the milk and 
 arrow root, and just before the removal from the fire, the cream is 
 
¥ 
 
 milk. This 
 
 • the mother's 
 
 2 plan is less 
 
 , fresh, and in 
 
 ation whereby 
 
 les possible to 
 
 reviously boil- 
 
 and pure cow's 
 modes of prc- 
 one which h:is 
 of the natural 
 
 : Licbig's food. 
 
 If ounce. 
 If ounce, 
 ices. 
 Trains, 
 nee. 
 
 All the ingrc- 
 i for eight or ten 
 U'A\ an ordinary 
 very first, it will 
 ic above mixture 
 ,-ks the quantity 
 s two or three 
 sugar should be 
 necessity for this 
 
 or twcnty-ftnir 
 
 )le food can be 
 of Philadelphia, 
 tlatine (or a piece 
 pld) is soaked for 
 
 a pint of water 
 I To this is added, 
 pn of the boiling, 
 [isly mixed into a 
 Vl of the milk ami 
 
 fire, the cream ii 
 
 CARE OF THE INFANT. 
 
 969 
 
 poured in and a moderate quantity of loaf sugar added. The pro- 
 portions of milk, cream and arrow root must depend on the age and 
 digestive powers of the child. For a healthy infant less than a 
 month old, I usually direct from three to four ounces of milk, half 
 an ounce to an ounce cf cream and a teaspoonful of arrow root to 
 half a pint of water. For older children, the quantity of milk and 
 cream should be gradually increased to a half or two-thirds milk 
 and from one to two ounces of cream. I seldom increase the 
 quantity of gelatine or arrow root. " 
 
 A still simpler food may be prepared simply from arrow root 
 and cream. Two tcaspoonfuls of arrow root are added to half a 
 pint of water, stirred over the fire until pasty, and then strained ; a 
 tablespoonful of cream is then added and given warm. 
 
 The most important feature in the success of artificial fecdin«- 
 is perfect cleanliness of the bottles and tubes employed ; and only 
 such bottles and tubes should be used which can be readily taken 
 to pieces and thoroughly cleansed, from the point of the rubber 
 nipple to the bottom of the bottle. A failure to observe this sim- 
 ple precaution will certainly vitiate any and all attempts at artifi- 
 cial feeding, whatever material be employed ; for there occurs fer- 
 mentation in the milk and other matters collected at the joints and 
 in the crevices of the feeding bottle ; and these fermented matters 
 passing into the child's stomach with the next installment of food, 
 must derange its digestion. For cleansing the bottles and tubes, 
 warm water containing a little borax may be used. The success 
 of the attempt to substitute artificial food will be ultimately meas- 
 ured by the welfare of the infant ; yet careful observation may 
 early indicate the imperfections of the method in use before the 
 child's health has been seriously impaired. Perhaps the most 
 important indications of failure in the character of the food are to 
 he observed in the appearance of the infant's discharges, which 
 should be always carefully inspected by the mother herself and not 
 left entirely to the chance observation of the nurse. Indeed, it 
 may be said as a general truth, that serious disorders of infancy — 
 which are, in a majority of cases, derangements of digestion and 
 their consequences — might be often avoided if the appearance of 
 unnatural stools were always regarded as a demand for a careful 
 supervision of the diet ; and this applies to children at the breast, 
 as well as those artificially nourished. In this way it would be 
 often possible to avoid that scourge of infancy — summer com- 
 
 till 
 
 it; 1 1 
 
 \ 
 
 I" 
 
 liiii 
 
 i 
 
 m 
 
 1 i'|i ■ 
 > 'If 
 
 r 
 
 t 
 
 
 
 l^r 
 
 f ■ 
 
 i'i i 
 
 ' 1 : . 
 
 1 
 
 lii 
 
 
 t( 1 
 
970 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 plaint; the first indications of this affection should be met not so 
 much by medicines as by a regulation of the child's food and gen- 
 eral management. 
 
 Whether sustained by the breast or by artificial means, the 
 infant will usually, in six or seven months, be able to digest other 
 food also ; yet a mistake is often made in permitting the child to 
 have such food at a too early date ; not infrequently a four months 
 babe is supplied with crackers and similar articles, while the mother 
 wonders why the child is not well. As a rule, nothing should be 
 given aside from the regular diet until the completion of the sixth 
 or seventh month, and then it may not feed promiscuously upon 
 whateve ■ chances to be in its way, but must be gradually accus- 
 tomed to the digestion of solid food. As a preparation, it may be 
 well to give the child, even as early as the fourth or fifth montli, 
 some of the artificial food already mentioned, without, however, 
 discontinuing the breast ; later, soups and broths — containing but 
 little fat — r.iay be administered in small quantities. The general 
 principle should not be forgotten, that until the child has some teeth 
 it cannot properly dispose of anything solid ; the attempt will 
 almost certainly result in disaster to its alimentary organs. 
 
 Teething. 
 
 iii 
 
 This term is applied to the period at which the growth of the 
 teeth causes their penetration through the covering of the gums. 
 It is understood, of course, that their development has begun at a 
 period previous to birth, but their growth appears to have no par- 
 ticular influence on the general condition of the child until the com- 
 mencement of the irritation caused by the protrusion of the teeth 
 through the membrane covering the gums. This irritation is 
 doubtless often the cause of troubles manifested in other parts of 
 the body ; yet there is a too prevalent disposition to ascribe all the 
 ills which afflict babyhood during this period, to the process of 
 teething. Any indisposition of the child, whatever its nature or 
 wherever manifested, is often regarded merely as a manifestation of 
 the teething process, the evil result of which is that affections 
 dependent upon other causes which might be detected and removed, 
 a. ; regarded as inevitable because the child is teething. The fact 
 iS; that many a child acquires its milk teeth without suffering any 
 
TEETHING. 
 
 97 T 
 
 be met not so 
 food and gen- 
 ial means, the 
 ;o digest other 
 ig the child to 
 
 a four months 
 hile the mother 
 hing should be 
 on of the sixth 
 liscuously upon 
 gradually accus- 
 ation, it may be 
 I or fifth month, 
 ithout, however, 
 -containing but 
 ;s. The general 
 lid has some teeth 
 
 the attempt will 
 J organs. 
 
 le growth of the 
 ring of the gums. 
 It has begun at a 
 to have no par- 
 liild until the com- 
 Ision of the teeth 
 iThis irritation is 
 ]in other parts of 
 to ascribe all the 
 to the process of 
 iver its nature or 
 [a manifestation of 
 is that affections 
 Icted and removed, 
 lething. The fact 
 Ihout suffering any 
 
 appreciable disturbance of its general health ; and that the troubles 
 ascribed to teething are oftentimes the result of errors of diet and 
 improper management, which originate quite independently of 
 the teeth, and are merely aggravated by the effects of the irritation 
 in the gum. 
 
 The first teeth ordinarily appear during the sixth or seventh 
 month, though there may be variations of several months either 
 way. In fact, instances arc recorded in which some teeth have 
 been cut before birth. If there be any irritation, it is often mani- 
 fested some weeks before the tooth becomes visible — in which 
 fact lies sometimes the explanation of an unusual fretfulness. It is 
 desirable to know and note the periods at which the teeth appear, 
 since in order to avoid the complication of teething, the child 
 should be weaned at one of the longer intervals. The teeth ordi- 
 narily appear in a certain order, and at regular periods, which may 
 be grouped as follows : First. The first to appear are usually the 
 two middle teeth of the lower jaw, technically called incisors; 
 this ordinarily happens in the course of the seventh month. 
 Second. After a pause of one or two months the corresponding 
 teeth of the upper jaw appear, usually followed, after a short in- 
 terval, by two more, one on either side of the two central teeth. 
 Third. There now occurs a pause of six or ten weeks. It is dur- 
 ing this pause, while the child is quite free from any irritation of 
 the gums, that weaning is ordinarily advisable. This pause occurs, 
 it will be noticed, during the tenth and eleventh month. Fourtli. 
 At the completion of the first year there usually appear the first 
 grinding teeth. Fifth. At about the eighteenth month, the eye- 
 teeth appear, ordinarily in the upper jaw first. Sixth. The full 
 set of twenty teeth is completed during the early part of the third 
 year, by the appearance of the remaining grinding teeth, or molars. 
 So long as the process of teething proceeds naturally, and 
 causes nothing more than restlessness, or perhaps even slight fever, 
 no interference is demanded. The advance of the tooth into and 
 through the gum is, of necessity, slow, but cannot be hastened by 
 recourse to the lancet. There are cases in which, undoubtedly, the 
 i;ums should be lanced ; but it is just as certain that the early and 
 frequent use of the lancet is undesirable. We may say, in general, 
 that the gum should be lanced, first, when the child is evidently in 
 pain, and the tooth is so nearly through that a slight incision will 
 relieve the tension of the gum ; second, when the gums are hot, 
 
 63 
 
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972 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 tender, swollen and full of blood, in which case an incision, even if 
 it do not remove an obstacle to the progress of the tooth, \vill 
 nevertheless relieve the congestion of the part; third, when the 
 irritation in the gum is so great as to disturb the child's nervous 
 system, inducing, perhaps, convulsions. In this case, even though 
 the gums be not obviously swollen, an incision will often relieve the 
 difficulty entirely. 
 
 Weaning. 
 
 The separation of the child from the breast is an epoch in its 
 existence which is often attended with more or less constitutional 
 disturbance. The time at which this separation should occur may 
 be fixed by some unforseen conditions which render the mother 
 incapable of providing sufficient and proper nourishment for her 
 offspring. Such circumstances may arise at any time, and impera- 
 tively require that weaning occur at once. Yet, under ordinary 
 circumstances, considerable latitude is allowed as to the choice of 
 the time at which nursing shall cease. It might be, and by some 
 has been, assumed that the child should be more or less sustained 
 by the mother until it has acquired a complete set of teeth ; and it 
 does sometimes happen that nursing is continued for two years. 
 Another inducement for prolonged nursing is the protection thereby 
 afforded to a greater or less extent against conception.. This hope 
 has induced many a mother to prolong lactation beyond the usual 
 limit. While it is impossible to continue nursing for an indefinite 
 time, yet a variety of considerations indicate that the best period 
 for weaning is usually between the tenth and thirteenth months; 
 though, as will be presently explained, circumstances may require 
 a certain departure from this rule. The first consideration must be 
 the health of the child and of the mother. Now, as a rule, the 
 infant begins to take other food than the breast as early as the 
 seventh or eighth month, and usually becomes largely independent 
 of the mother by the tenth or twelfth month. By this time, too, 
 the quality of the milk has usually deteriorated, so that even though 
 nursing be continued the mother's milk furnishes but a part — 
 usually a small part — of the infant's nourishment; at the same 
 time the mother's health is often unequal to the task of furnisliin^ 
 so much nutriment in addition to that required for her own body. 
 
 mij^ 
 
WEANING. 
 
 973 
 
 ision, even if 
 le tooth, will 
 rd, when the 
 iild'3 nervous 
 , even though 
 ;en rcUevc the 
 
 an epoch in its 
 3 constitutional 
 ould occur may 
 der the mother 
 ishmcnt for her 
 me, and impcra- 
 under ordinary 
 to the choice of 
 be, and by some 
 lor less sustained 
 of teeth ; and it 
 for two years, 
 otection therehy 
 tion.. This hope 
 beyond the usual 
 for an indefinite 
 the best period 
 rteenth months; 
 nces may require 
 deration must be 
 ow, as a rule, the 
 St as early as the 
 gcly independent 
 13y this time, too, 
 that even though 
 lies but a part — 
 ent ; at the same 
 Itask of furnishing 
 •or her own body. 
 
 By the end of the first year, therefore, the child is usually abundantly- 
 able to digest its own food, while the mother should be relieved 
 from the additional and no Unv^cr essential burden ; and since there 
 occurs during the last two months of this time, an interval of com- 
 plete freedom from the annoyance of teething, it will be, as a rule, 
 found advisable to wean the child during the eleventh or twelfth 
 month of its life. Yet this is a by no means inviolable rule ; indeed, 
 there are circumstances under which a prolongation of nursing is 
 advisable in the interest of the child. It may be stated, as a 
 general principle, that the child should not be weaned while some 
 of its teeth are cutting through, nor just before the hot weather of 
 summer. If, therefore, an infant be an exception, in that these 
 months of the first year are employed in teething ; or if the child 
 have been born in the early summer it will be advisable, as a 
 rule, to postpone weaning until the objectionable circumstances be 
 removed. So, too, it is necessary to postpone weaning until any 
 ailment which may happen to affect the child — even if only an 
 ordinary catarrh — shall subside. If, in consequence of inability 
 on the part of the mother, it become necessary to wean the child 
 during any such circumstances, it may be desirable to procure a 
 wet-nurse. 
 
 As to the process of weaning, but little need be said, except 
 that it should be gradual ; that an interference with the child's 
 health is far less probable by this plan than if nursing be suddenly 
 discontinued. By withholding the breast altogether at night, and 
 by substituting artificial food on certain occasions during the day, 
 the infant may be accustomed to the new regime without appre- 
 ciable inconvenience or bodily disturbance. If weaning be post- 
 poned until the end of the first year the mother will rarely have any 
 difficulty with the breasts. The gradual decrease in the demand 
 upon them will usually be accompanied by a corresponding decrease 
 in their activity. The breast-pump should not be used ; it will 
 rarely be necessary to adopt any other measures than simple friction 
 with camphorated or sweet oil. 
 
 I' '':i m 
 
 lit 1:'■'il:■ 
 
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i 
 
 III 
 
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 974 
 
 DISEASES OF WOMEN AND CIIILDKEN. 
 
 DISEASES OF CHILD-BED. 
 
 Child-birth is to be regarded as a natural process, not as a 
 disease ; and so the phenomena which necessarily follow contain 
 ordinarily no clement of disease and require no further interference 
 than has been already indicated in the preceding pages. There 
 may be some local difficulty in the breasts during the establishment 
 of activity in these organs; there may be some spasmodic pain in 
 the abdomen during the first few days, constituting the so-called 
 after-pains ; there may be some soreness at the orifice of the 
 vagina from unimportant lacerations and abrasions. But aside 
 from these there should be no marked symptoms ; there should be 
 observed no fever, pain nor soreness ; after four or five days the 
 secretion of milk is established ; after two weeks the lochial dis- 
 charge has ceased and any soreness about the genital organs that 
 may have existed has disappeared ; and after six or eight weeks 
 the womb has returned almost to the size that it had before impreg- 
 nation ; and the woman should be as well in every regard as she 
 was before assuming the duties of maternity. While such is the 
 natural course of events, yet many instances present serious inter- 
 ruptions and ultimately fail in restoring the woman to a condition 
 natural and proper for maternity. The number of women who 
 suffer from ills originating in the genital organs is almost as great 
 as the number of women who have borne children ; and the major- 
 ity of these, at least, date their difficulties from confinement. 
 
 The diseases that can be traced directly or indirectly to child- 
 birth may be properly considered in two categories — the acute 
 diseases that follow immediately upon confinement and the chronic 
 affections, which may first become manifest some months or years 
 subsequently. Chief among the former stands 
 
 Child-bed Fever. 
 
 This affisction, technically kno\/n as puerperal fever, is a term 
 employed to designate several diseased conditions which may affect 
 the sexual organs immediately after confinement, and which have 
 
iccss, not as a 
 follow contain 
 ler interference 
 pages. There 
 c establishment 
 ismodic pain in 
 ig the so-called 
 orifice of the 
 jns. But aside 
 there should be 
 3r five days the 
 the lochial dis- 
 lital organs that 
 s or eight weeks 
 ,d before imprcg- 
 ry regard as she 
 Awhile such is the 
 cnt serious inter- 
 lan to a condition 
 [• of women who 
 s almost as great 
 I ; and the major- 
 onfinement. 
 idircctly to chikl- 
 ■QYics — the acute 
 it and the chronic 
 months or years 
 
 ■al fever, is a term 
 
 is w 
 
 hich may 
 
 iffcct 
 
 It, an 
 
 d which have 
 
 CIIILD-UED FEVER. 
 
 975 
 
 certain symptoms in common, whence they are commonly classified 
 together under the general name puerperal fever. 
 
 Sumptoms, — For the first two or three days after delivery, 
 there may be no indication of anything wrong ; but on the fourth 
 or fifth day the woman becomes somewhat listless, loses her appe- 
 tite and has perhaps a slight headache. A few hours subsequent to 
 the development of these symptoms, there occurs a chill which is 
 often of such violence as to shake the patient's bed ; this is fol- 
 lowed by a high fever, intense pain in the head, flushed face, suf- 
 fused eyes, pain and extreme tenderness in and around the enlarged 
 womb. Within twenty-four hours the abdomen is often some- 
 what bloated ; the lochial discharge ceases, or is at least much 
 diminished and often very offensive ; the milk not infrequently is 
 greatly lessened in quantity. In severe cases delirium occurs after 
 a few hours of intense fever. 
 
 Causes, — The various affections collectively known as puer- 
 peral fever, originate in one of two ways: first, and usually, in the 
 neglect to secure complete evacuation of the womb and subsequent 
 cleanliness of the vagina; secondly, and less often, except in hospi- 
 tals, by infection cither from other lying-in women or from the sub- 
 jects of surgical injuries and infectious disease. It may be said, in 
 general, that the most efiicient means for the avoidance of puerperal 
 fever consists in the most scrupulous care as to all the details 
 already indicated as essential in the conduct of labor. The pres- 
 ence of the hand on the abdomen over the womb from the moment 
 that the child is expelled and until at least an hour have elapsed; 
 the removal of the after-birth by gentle kneading of the womb ; the 
 repetition of this process for several days after delivery, in order 
 to expel clots of blood that may have formed in the womb ; the 
 careful cleansing of the external parts every few hours and of the 
 vagina, by the use of the syringe ; the maintenance of the recumbent 
 posture for twelve or fourteen days after delivery — all these are 
 important aids in avoiding the disasters of child-bed. The disease 
 is, fortunately, rare in private houses, but numbers many victims in 
 hospitals or other institutions where many sick are gathered under 
 one roof. During certain seasons, too, child-bed fever seems 
 epidemic, occurring under the most favorable conditions, even in 
 farm houses far removed from all other human habitations. The 
 treatment of this affection will, of course, be referred to the medical 
 
 
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976 
 
 DISEASES UK WUMKN AND (•IIILDKEN. 
 
 S!' 
 
 i' t 
 
 attendant. Before his arrival it is advisable, so soon as the symp- 
 toms above detailed have established the nature of the case, to 
 adopt at least three measures: first, the administration of five or 
 ten grains of quinine every three houis; second, the administration 
 of a laxative, or if the stomach be irritable, the injection of warm 
 water into the bowels ; third, the application of heat and moisture 
 to the lower part of the abdomen. This latter measure can be best 
 effected by putting the woman bodily into a bath of a temperature 
 of lOO", and permitting her to remain tliere fifteen minutes, after 
 which she may be briskly rubbed with a coarse towel and wrapped 
 in warm blankets. If there be no facilities for a full bath, the next 
 best thing is a hip bath ; in the absence of this, two quarts of warm 
 water may be slowly injected into the vagina by a Davidson 
 syringe. In any case, flannels wrung out in hot water should he 
 applied to the abdomen and covered with oiled silk; these cloths 
 should be frequently changed so as to keep the skin warm and 
 moist. After five or six doses, the quinine should be given at 
 longer intervals or in smaller quantities — about three grains every 
 four hours — since the administration of large doses for a long time 
 is followed by ringing in the ears and a semi-stupor, which may last 
 for several days. 
 
 It is not advisable for the non-professional person to go further 
 than the above treatment, except under medical advice. The piiy- 
 sician may find some source of infection — such as a piece of the 
 after-birth — which it is possible to remove; or he may suggest 
 some additional remedies which the circumstances of the indivitlual 
 case may suggest. The chief indications are as already indicated, 
 to keep the temperature down by the application of hot water and 
 the administration of quinine, and to keep the parts clean and moist. 
 Another distressing incident of child-bed x'r, puerperal mania. Tliis 
 is by no means a rare occurrence. It happened in one in every ten 
 cases observed for a considerable time in Paris — and this is prob- 
 ably a low estimate of its frequency. 
 
 " In the majority of cases, the disease first manifests itself within 
 a fortnight after delivery ; in such cases there is usually, even from 
 the time of delivery, an unusually troubled and agitated manner, 
 a suspicious look upon the face, indicative of anxiety ; a marked 
 peevishness of temper and objection to control or direction ; not 
 infrequently violent fits of passion are exhibited without apparent 
 provocation ; occasionally one of the first indications will be a sul- 
 
"J. 
 
 on as the symp- 
 of the case, to 
 ation of five or 
 e administration 
 ijcction of warm 
 cat and moistiui' 
 isure can be best 
 of a temperature 
 en minutes, after 
 wel and wrapped 
 all bath, the next 
 ro quarts of warm 
 by a Davidson 
 : water shoukl hv 
 silk ; these clotlis 
 - skin warm and 
 lould be given at 
 hrec grains every 
 5es for a long time 
 or, which may last 
 
 rson to go further 
 dvice. The pliy- 
 as a piece of the 
 r he may suggest 
 s of the individual 
 already indicated, 
 
 of hot water and 
 ts clean and moist. 
 /icrai mania. This 
 
 n one in every ten 
 - and this is prob- 
 
 nifests itself within 
 usually, even from 
 
 agitated manner, 
 nxiety ; a marked 
 or direction ; not 
 
 without apparent 
 tions will be a sul- 
 
 cniLi)-ui:i) I'KVKk. 
 
 »^!, !l 
 
 977 
 
 Icn obstinacy or listlessncss and stubborn silence. A patient lici 
 on her hack, and can by no means be persuaded to reply to the 
 questions of her attendants, or she will repeat them as an echo, 
 until all at once, without any »p[)arent cause, she will break cuit 
 into a torrent of language more or less incoherent, and her words 
 will follow each other with surprising rapidit\-. These s)-mi)toms 
 will sometimes show themselves rather suddenly, on the patient's 
 awakening from a disturbed and unrefreshing sleep, or they may 
 supervene more slowly when she has been harassed with watchful- 
 ness for three or four nights in succession, or perhaps ever since 
 her delivery. She will very likely then become impressed with the 
 idea that some evil has befallen her husband, or what is still more 
 usual, her child — that it is dead or stolen ; and if it be brou-dit to 
 her, nothing can persuade her it is her own ; she supposes it to 
 belong to somebody else ; or she will fancy that her husband is 
 unfaithful to her, or that he and those about her have conspired to 
 poison her. Those persons who are naturally the objects of her 
 deepest and most devout affection are regarded by her with jeal- 
 ousy, suspicion and hatred. This is particularly remarkable with 
 regard to her new-born infant, and I have known many instances 
 where attempts have been made to destroy it when it has been 
 incautiously left within her power. Sometimes, though rarely, 
 may be observed a great anxiety regarding the termination of her 
 ov, n case, or a firm conviction that she is speedily about to die. I 
 have observed, upon occasions, a constant movement of the lips 
 while the mouth was shut, or the patient is incessantly rubbing the 
 inside of her lips with her fingers, or thrusting them far back Into 
 her mouth ; and if questions are asked, and particularly if she be 
 desired to put out her tongue, she will often compress the lips forci- 
 bly together, as if with an obstinate determination of resistance. 
 One peculiarity attending some cases of puerperal mania, is the 
 immorality and obscenity of the expressions uttered ; they are 
 often such, indeed, as to excite our astonishment that women in a 
 respectable station of society could ever have become acquainted 
 with such language. " — Ramshotliain. 
 
 In many cases lochial discharge ceases and the milk dries up, 
 though this is by no means an essential feature of the case. It is 
 often difficult to persuade the patient to eat, indeed at times it is 
 necessary to employ force to supply her with nourishment. Another 
 unpleasant feature is an occasional disposition to commit suicide. 
 
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 978 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 This disease is, fortunately, only temporary, as a rule, and but 
 few deaths occur during its course. In a certain number of cases in- 
 sanity persists, and may even become permanent. Yet in the 
 majority of instances the delusions gradually disappear, and in the 
 course of three to six weeks the patient becomes again quite 
 rational. 
 
 Puerperal Convulsions. 
 
 A most distressing as well as serious accident of child-bed, is 
 the recurrence of convulsions. They are, by the way, a feature not 
 merely of the period following delivery, since they may occur dur- 
 ing labor or during the last three months of pregnancy. In dis- 
 cussing the compications of pregnancy, it was noted that persistent 
 swelling of the feet, when accompanied by pain in the top and at 
 the back of the head, was a condition calling for the immediate at- 
 tention of the medical adviser. The physician recognizes in sucli 
 cases the probability that some time, either before, during or sub- 
 sequent to labor, he will have to deal with a case of convulsions. 
 Many times there occur derangements of vision and of hearing, and 
 often pain in the abdomen. Just before a fit the pain in the head 
 becomes aggravated and continuous, and the patient not infre- 
 quently becomes quite blind. The convulsion itself throws the 
 body into the most violent contortions, an extremely painful spec- 
 tacle for the friends. After its subsidence — it may last from two 
 to ten mmutes in all — the patient remains for a time stupid, or may 
 even fail to regain her consciousness before death. If these con- 
 vulsions occur with great irequency before delivery, and if the 
 patient's health is evidently hnpaired, it may become necessary for 
 the physician to induce premature labor to save the life of the 
 mother. If they occur just subsequent to delivery, they need 
 rarely occasion anxiety for the immediate future. In every instance 
 there may be no interference except by professional hands, for most 
 of the agents used — such as chloroform and chloral — may not be 
 entrusted to irresponsible hands. 
 
 Milk-leg. 
 
 This occurs ^"^ the result of an inflammation in some of the 
 large veirs and lymphatics leading from the thigh into the trunk. 
 As a result of the obstruction to the return of blood from the limb 
 
rule, and but 
 2r of cases in- 
 Yct in the 
 ar, and in the 
 ;s again quite 
 
 f child-bed, is 
 ', a feature not 
 aay occur dur- 
 lancy. In dis- 
 that persistent 
 the top and at 
 z immediate at- 
 ;ognizcs in such 
 during or sub- 
 of convulsions, 
 of hearing, and 
 jain in the head 
 tient not uifrc- 
 ;clf throws the 
 ly painful spcc- 
 y last from two 
 stupid, or may 
 If these cor- 
 cry, and if the 
 c necessary for 
 the life of the 
 very, they need 
 In every instance 
 hands, for most 
 ,1 — may not be 
 
 in some of the 
 
 into the trunk. 
 
 )d from the limb 
 
 DISEASES OF WOMEN. 
 
 979 
 
 there occurs a swelling, often of unormous extent, causing a pecul- 
 iar, pearly-white hue of the skin. On account of this color of the 
 skin and from the fact that in this as in the other affections of child- 
 bed, the milk is often suppressed, it was supposed that the milk had 
 been diverted from the breasts into the leg ; whence the rerm. Al- 
 though with the acquisition of more definite knowledge :;his curious 
 fancy was abandoned, the term " milk-leg" is still retained. 
 
 This disease may occur at any time during the first month after 
 delivery, but begins with especial frequency between the tenth and 
 sixteenth days. There is often a premonitory stage, comprising a 
 feeling of weight in the pelvis, and often a pain in the groin or hip. 
 About this time, or previously, there usually occurs a severe chill, 
 followed by fever, after A\hich the swelling begins in the groin and 
 progresses down the leg. Within a few days the entire limb is 
 white and swollen, and feels, as patients often say, as if it were a 
 wooden leg. 
 
 Although this is a painful and troublesome affection, it is, 
 fortunately, rarely fatal. In the course of three or four weeks the 
 limb has usually resumed its original size, and subsequently regains 
 entirely its proper functions. 
 
 Treat nient. — While the limb is swelling, good can often be 
 accomplished by wrapping the leg in flannels wet with hot water, 
 upon which a little turpentine may be sprinkled. The leg should 
 be kept elevated. After the swelling becomes less painful, absorp- 
 tion of the fluid and the return of the limb to its natural size can 
 be promoted by frictions, with stimulating liniments. These are 
 especially desirable in those cases in which convalesence is slow, 
 the leg seeming more or less paralyzed though the swelling has 
 quite disappeared. 
 
 DISEASES OF WOMEN. 
 
 The ills which are peculiar to woman may occur at any time 
 during her sexual life ; indecfl. even before or after this perioa i 
 her existence; yet, they occur with such frequency subsequent to, 
 and oftentimes consequent upon, child-bearing, that the considera- 
 tion of them follows naturally upon the discussion of this process. 
 Most married women whose health is seriously impaired by some 
 form of " female weakness," date the commencement of their troubles 
 to a confinement. In most of these cases there is undoubtedly a cer 
 
 
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 1!f 
 
 980 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 tain amount of correctness in this assumption, though in many in- 
 stances there is antecedent disease of the sexual organs, which iiad 
 occasioned perhaps but Httle trouble, and might have been endured 
 without serious impairment of health, had not these organs been 
 taxed beyond their enfeebled powers by the duties of maternity, 
 A variety of influences to which the organs are subjected during 
 pregnancy and labor, result in tiie aggravation of any diffjcultics 
 that may have existed prior to conception. The enlargement of 
 the womb is necessarily accompanied by a stretching of those 
 bands — technically called ligaments — by which the organ is held 
 in its proper position. Sometimes there has existed before the 
 occurrence of pregnancy a stretching and lengthening of these 
 bands wherec the womb has been allowed to sink furtlur in the 
 pelvis than nature ordained ; in such cases the womb, after delivery, 
 will almost certainly sink still further in consequence of the stretch- 
 ing of these bands during pregnancy, and there results a case of 
 pronounced " falling of the womb." Then, again, the wall of the 
 abdomen affords support to the organs contained in this cavity. 
 This wall is distended and stretched during pregnancy, and r,->-'y 
 returning to its former condition of tension and elasticity, herct. 'iv 
 tendency is for the various organs contained in tlie abdomen am. 
 pelvis to sink still further into the latter cavity. If from these or 
 other causes, the womb assume a more depressed condition than 
 natural, other ills supervene ; the return of the womb to its proijcr 
 size is delayed, or even quite arrested. As a result of its position 
 low down in the pelvis, the lower end, or moiitli, of the WMnib is 
 exposed to mechanical violence from friction against the vagina, as 
 well as during sexual congress ; in its unnatural condition such 
 causes are sufificient to induce ulceration and chronic inflammation; 
 hence, starting in pregnancy and confinement, there arise many of 
 those ills which, though not peculiar to our country, give American 
 women an unenviable distinction throughout the world of mecHcinL'. 
 Herein is usually to be found the cause of those manifold pains and 
 aches which have no apparent cause; those derangements of head, 
 and stomach, and bowels, and sexual functions, of diat nervous- 
 ness and irritability, perhaps even of mental derangement, uliicli 
 may transform a woman, mind and body, within a few years after 
 marriage. 
 
 While, then, the various forms of female weakness are, in die 
 majority of instances, manifested subsequent to marriage and prc^'- 
 
"W 
 
 T 
 
 
 DISEASES OF WOMEN. 
 
 981 
 
 rh in many in- 
 ans, which had 
 e been endured 
 ;e organs been 
 ;;; of maternity. 
 Libjectcd during 
 ■ any difficulties 
 enlargement of 
 tching of those 
 he organ is held 
 istcd before the 
 .hcning of these 
 \k further in the 
 lb, after deUvery, 
 ice of the stretch- 
 results a case of 
 1, the wall of the 
 ;d in this cavity. 
 nancy, and -:"-''y 
 asticity, hence the- 
 the abdomen anu 
 [f from these or 
 cd condition than 
 omb to its proper 
 isult of its position 
 \//, uf the w-mib is 
 inst the vagina, as 
 al condition such 
 Ionic inflammation; 
 here arise many ot 
 Itrv, give American 
 worUl of medicine. 
 Imanifold pains and 
 ngcments of head, 
 /of 'diat ncrvous- 
 crangcmcnt, which 
 in a few years after 
 
 cakness are, m 
 
 tlK 
 
 marriage and prct;- 
 
 nancy,the foundation for them is usually laid bcfoic the assumption 
 of these duties ; were it otherwise, the woman of modern society 
 would have no more difficulty during and subsequent to the per- 
 formance of these duties than her uncivilized sister. 
 
 One of the most eminent and experienced physicians in this 
 department of medicine, Dr. Thomas, of \e\v York, enumerates, 
 as the cliief cause of female difficulties peculiar to civilization and 
 refinement, the following : Neglect of out-door exercise ; exces- 
 sive development of the nervous system ; improprieties of dress ; 
 imprudence during menstruation ; imprudence after delivery ; pre- 
 venting of conception and induction of abortion ; marriage with 
 existing uterine disease. 
 
 Most of these influences have been already mentioned and dis- 
 cussed in these pages during the consideration of the management 
 of puberty, yet a few words may be properly said with regard to 
 the prevention of conception and the induction of abortion. That 
 these practices are extremely prevalent is notorious ; that they 
 are responsible for much of the ill-health that afflicts married 
 women is equally certain ; that the result is to degrade in a score 
 of ways the physical and moral tone of the community, admits of 
 no doubt ; that duty and selfish interest alike dictate the preven- 
 tion of such practices, is equally evident. .All are agreed as to w/iy 
 the practice of abortion — of criiniiia/ abortion — should be rooted 
 out of the community ; but there is a difference of opinion as to 
 how it may be accomplished. To the writer, it appears that the 
 view of this question usually presented in discussions of this sub- 
 ject — by medical men as well as by others — is wholly one-sided, 
 in that the responsibility is laid to the charge of women alone. 
 There is no dearth of warnings and appeals to women, setting forth 
 the criminal nature of abortion and the physical evils which inevi- 
 tably follow, and these the writer, like every other physician, most 
 heartily endorses. Yet, after all, such appeals and warnings can 
 hope to accomplish but little because they come too late ; physical 
 and moral law — the violation of which insures a painful atonement 
 in this world at least — have no terrcn's for a desperate woman ; the 
 disaster to body and soul is realized only as a contingency of the 
 distant future, while the ills of maternity obscure all else with the 
 certainty of the present. This applies, too, not only to those unfor- 
 tunates who become mothers without being wives, but also to a 
 considerable number of duly wedded women, to whom maternity 
 
 
 
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 Ml 
 
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 982 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 means physical wreck, the birth of puny offspring and a life of 
 toilsome poverty. Indeed, in these pages we shall consider the 
 induction of abortion in married women only. 
 
 In a thoughtful address recently delivered before the Medico 
 Chirurgical Society of Maryland, Dr. William Goodell, of Phila- 
 delphia, refers to this subject as follows : 
 
 " TJu Univillingness of Our Women to Become Mothers. — 
 The third and greatest danger of the hour embraces two sins which 
 defile every class of society — sins which, like the plague of the 
 frogs, creep into our 'houses and their chambers and beds.' I 
 refer to criminal abortion and the prevention of conception. They 
 come from the dainty dilettanteism of our women, which shrinks 
 from having its patrician pleasures disturbed by the cares of mater- 
 nity. They come from fashion, from cowardice, from indolent 
 wealth and shiftless poverty. They come from too high a standard 
 of living, which creates many artificial wants and demands many 
 expensive luxuries. Of course immorality has much to do in 
 begetting them ; but while regarding all these practices as gross!}- 
 sinful, I wish to leave out of consideration the question of immo- 
 rality/'^;' sc. It is not the immoral classes which I wish to reach ; 
 not those whose pleasures and profits come from vice ; but tlie 
 wives of our citizens — our fellow-countrywomen — on whose good 
 morals and good health depends the prosperity of our country, and 
 yet who are unwittingly tainting body and tainting soul. 
 
 " I am amazed at the very low standard of morality contained 
 in the community on the sexual relations. So low indeed has it 
 fallen that I have known clergymen committing these sins and 
 physicians of repute teaching their patients how to sin. To these 
 detestable practices do I attribute, in a great measure, the general 
 ill health of our women ; these flagrant sins I hold accountable for 
 much, if not for most, of the wretchedness and misery of this land. 
 Why is it, asks a layman, that ' in the regions of the United States, 
 otherwise most highly favored, nearly every woman under forty is 
 sick or sickly ? ' Why is it, I ask, that the waiting-rooms of our 
 gynecologists are crowded with so many querulous and complain- 
 ing women — women with backaches and headaches and spineaches; 
 women either without sexual feeling or too weak to indui<^e it ? 
 Why do so many women break down, either shortly after marriage 
 or very soon after the birth of their first child ? It is, I answer, 
 because the great majority of them, false to their vows, false to 
 
DISEASES OF WOMEX. 
 
 983 
 
 and a life of 
 1 consider the 
 
 ire the Medico 
 ,dell, of Phila- 
 
 me Mothers. — 
 two sins which 
 
 - plague of the 
 i and beds.' I 
 ception. They 
 1, which shrinks 
 : cares of mater- 
 
 from indolent 
 high a standard 
 1 demands many 
 much to do in 
 ctices as gross])- 
 lestion of immo- 
 I wish to reach ; 
 m vice ; but die 
 
 — on whose good 
 our country, and 
 
 soul, 
 brality contained 
 w indeed has it 
 
 these sins and 
 
 o sin. To these 
 
 (Sure, the general 
 
 accountable for 
 sery of this land, 
 |ie United States, 
 an under forty is 
 ing-rooms of our 
 jus and complam- 
 
 s and spineaches; 
 Ik to indulge it? 
 
 ;ly after marriage 
 It is, I answer, 
 
 ir vows, false to 
 
 their moral and physical obligations, are trying cither not to have 
 children or to limit their number ; it is because by an immutable 
 law of nature there arc no harmless ways by which pregnancy can 
 be interrupted or conception shunned ; it is because the wife, 
 sinning the most and most sinned against, suffers the most. 
 
 " Be the mode of prevention what it may, so much engorge- 
 ment and hyperplasia and disorganization of the uterine structures 
 take place in those women who keep thcmscK'cs sterile, that their 
 health breaks down and they lose all sexual desire. Then, when 
 they adv^ance in life and there comes that inevitable yearning for 
 offspring, they find to their dismay that they cannot conceive. 
 What physician of ripe years within sound of my voice, who has 
 not been begged by women once willfully barren, but now longing 
 for children, to undo the mischief caused by such practices? 
 
 " But there is yet another side to this subject. Statistics show 
 that divorces are multiplying in this land in far greater ratio than 
 the increase in the population. In New England the increase is so 
 alarming as to arouse the attention of patriots and philanthropists, 
 who have formed a Divorce Reform League. At the New Hamp- 
 shire General Association, the Rev. S. P. Leeds, U.D., of Han- 
 over, N. H., read a paper in which he showed that in New Eng- 
 land there is one divorce to every twelve marriages — a proportion 
 even greater than that in France during the general break-up of 
 law, religion and society attending the French Revolution. Dr. 
 Nathan Allen, of Lowell, Mass., in an able essay on the subjct, 
 proves that, excluding the marriages of Catholics, who are rarely 
 divorced, the true ratio of divorces to marriages stands thus (omit- 
 ting fractions): In Massachusetts, one to fifteen ; in Rhode Island, 
 one to nine ; in Connecticut, one to eight, and in Vermont, one to 
 thirteen. He shows further, that since 1S60 the increase in Ver- 
 mont and Connecticut has been nearly one-third. In Massachu- 
 setts, the heart of New England, the increase is more than double. 
 Thus, in i860, there was in this State one divorce to fifty-one mar- 
 riages; in 1878, one divorce to twenty-one marriages. From a 
 lecture delivered last January in Trcmont Temple, Boston, by the 
 Rev. Samuel W. Dike, of Royalton, Vermont, I glean that in 
 1878, by loose laws and loose court practice, the divorces granted 
 in the New England State? broke up 2,113 families and dissolved 
 the marriage tie between 4,226 persons. But these figures do not 
 tell the whole tale of disrupted households, for, mind you, they do 
 
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 984 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 not include the many cases of voluntary separation between hus- 
 band and wife or of the apjilications for divorce which were denied. 
 While admitting that so high a divorce rate docs not, thank God, 
 prevail in the other .States, yet, so far as I can judge without posi- 
 tive knowledge — for very few States collect statistics on this point 
 — it is, to our shame, steadily increasing all over the Union. Vov 
 instance, in the year 18S0 there were 830 divorce suits begun in 
 the Chicago courts — that is to say, one application for t'iv(;rce Uj 
 every eight marriages. In a recent divorce suit which took place 
 in New York City, Justice Lawrence asserted from the bench that 
 there was collusion in one-half of these suits, and that their 
 increase was a subject of 'serious alarm.' In some of the West- 
 ern States, indeed, the ease with which divorces are granted has led 
 to an influx of strangers, who go there not to settle, but to become 
 unsettled. 
 
 " Now, why are there so many ill-sorted marriages ? Wh\ these 
 unhappy homes and broken households? What mean these sepa- 
 rations between husband and wife ? I answer: They mean thic 
 violation of one of nature's immutable laws. Sex is a profound 
 fact which underlies all the relations of life and the fabrics of 
 society, and it cannot be ignored. The sexual instinct is given to 
 mankind for two reasons — to perpetuate the species, and to rivet 
 the tie between husband and wife, not only by offspring, but 
 by mutual endearment. The conjugal relation is, therefore, two- 
 fold in its nature ; it has a moral as well as a physical expression, 
 but so interwoven that it is impossible to dissociate the one from 
 the other without doing moral as well as physical harm. 
 
 " The causes of domestic infelicity and ill-sorted marriages 
 are, then, to my mind, clear enough. The grossness of the carnal 
 union is redeemed by its purpose — the moral union in which is 
 involved the desire for offspring. Deprive the marriage tie of these 
 qualities, strip it of the funily idea, and it loses its cohesiveness in 
 intense personality and self-asserting individualism. Now, when a 
 wife is too sickly to admit the approaches of her husbantl or to 
 respond to them ; when she receives them on suffrance or absolutely 
 refuses to entertain them, as I have known many a wife to do; 
 when she soils the marriage-bed with the artifices and equipments 
 of the brothel, and quenches all passion by cold-blooded safe- 
 guards ; when she puts off an ardent husband to stated times antl 
 seasons; when a wife, I say, behaves in so unwifely a way, can ii 
 
I 
 
 DISEASES OK WOMEN. 
 
 985 
 
 between hus- 
 ;h\vere denied. 
 3t, thank God, 
 c witliout posi- 
 es on this point 
 ic Union. I'/'i- 
 
 suits begun in 
 1 for divorce i' 
 hich took phice 
 , the bench thai 
 
 and that their 
 i^ic of the West- 
 » o-ranted has led 
 c, but to become 
 
 aaes ? \Vh\ these 
 mean these sepa- 
 They mean th.c 
 Dcx is a profound 
 nd the fabrics of 
 ,nstinct is given to 
 icies, and to rivet 
 by offspring, but 
 IS, therefore, two- 
 ysical expression, 
 ate the one from 
 harm, 
 ^-sorted marriages 
 ;ncss of the carnal 
 unicni in which is 
 arriage tie of these 
 its cohesiveness ni 
 ,m. Now, when a 
 ler husband or to 
 •ance or absohitely 
 any a wife to do ; 
 :s and equipments 
 :old-bh)oded safc- 
 o stated times and 
 [ifely a way, can n 
 
 be otherwise tliaa that estrangement or jealousy slioukl take place ? 
 Can a home with such environment be a happy one ? Woukl not 
 most husbands be tcmi)ted to seek elsewhere for those pleasures 
 which arc denied them at home ? These are nature's reprisals ; 
 these, indeed, her never-failing retributions. 
 
 " There is also a patriotic side to this many-sided subject. Time 
 was when every prolific Roman matron received a civic reward. 
 Time was when she would exhibit her children as Cornelia did her 
 twelve, and proudly say, ' these be my jewels.' ' Five hundred and 
 twelve years elapsed from the foundation of Rome before the first 
 formal divorce was granted ; but the divorcer, till his death, was 
 pursued by the obloquy of his fellow-citizens. In those days 
 nothing could withstand the onset of the Roman legions. Then 
 Rome ruled the known world. l?ut, in the time of Julius Cesar, 
 celibacy and childlessness became more and more common ; the 
 family institution fell. The Latin stock in Italy underwent an 
 alarming diminution.' (Mommsen.) Divorces were now obtained 
 on the flimsiest grounds. Criminal abortion was practiced on the 
 slightest pretext; nay, indeed, it was lauded as a commendable 
 domestic economy. Marcus Aurelius foresaw the danger and tried 
 to stem the tide of corruption; but he vas a pagan, without the 
 help of the Christian's God, and he failed. So prevalent had this 
 crime become in Juvenal's day that he leveled one of his most 
 biting satires against it. In it he says that it was commonly 
 resorted to by the Roman ladies lest pregnancy should mar their 
 beauty or spoil their figure. They termed the unborn child the 
 ' shameful burden,' and got rid of it lest its growth should disfigure 
 their skin with scars. But national sins beget national calamities, 
 and the universal Roman ICmpire, overrun by Northern hordes, 
 perished for want of men. 
 
 " Once the family institution was deemed the palladium of 
 Hellas. The contemporary of i'lato, of Sn»-rate>, and of those 
 heroes who fell at ThermopN'lai ' puded hinri'-elf on the nuniber of 
 his sons who could fight fv)i hi-> umtry, a^ii: boasted of tlie num- 
 ber of his daughters who could \\'>\d the di-: iff. ' Then (irrece, fcr 
 her superb heroism a^td magmhcent pluick, won tiie admaation of 
 
 the world. But — alas! :nese huts, "^ century and a half bi-fore 
 
 the Christian era the -.erried rank- >! the Macedonian phalanx 
 quailed before the Roman legif»»- .md tW rirxtk became a vassal. 
 Wliythis dire disaster? BecAit>>c Grceci . ^[^ ed by prosperity, and 
 
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 986 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 •: 1'^ 
 
 warped by vain philosophy, could not brook to have its classic 
 tastes and esthetic cults interrupted by family cares and family ties. 
 Polybius, her own historian, writes that ' the downfall of Greece 
 was not owing to the war or to the plague, but mainly to a general 
 repugnance to marriage and a reluctance to rear large families, 
 caused by an extravagantly high standard of living.' 
 
 " Now, what happened to Rome, what happened to Greece, 
 may yet befall our own beloved country. It may die for want of 
 men. Tlie hour of need may come when, after great national 
 calamities, after portentous reverses, the genius of this Republic, 
 disordered by an imperial grief like that of the Roman Emperor, 
 may catch the burden of his cry: ' Give mc back, oh Varus, give 
 me back my legions ! ' " 
 
 In this eloquent summary of the subject — the most intelligent 
 and admirable plea to and for women that has come under the 
 writer's notice — Dr. Goodell neglects, or seems to neglect, the 
 most responsible party in the whole mischief — the husband. It is 
 not our intention to belittle the responsibility of the wife in this 
 matter, nor to deny that upon her rests directly and necessarily the 
 guilt of abortion, as well as the misery which it entails ; nor can 
 we evade the evident fact that a proper determination on her part 
 would at least avert this crime and its consequences. Yet it is just 
 as evident — as every husband must candidly admit — that tlic 
 necessity for such determination, the need for a choice between 
 abortion and unhappy maternity, arises from the intemperate grati- 
 fication of his own passion. We do not mean to imply by this 
 statement that we adopt the poetical notion that women are devoid 
 of the sexual instinct, that they approach the marriage-bed with 
 the same feeling as martyrs approach the stake. It may be ad- 
 mitted that the wife's feelings reflect, though usually in a less intense 
 degree, those of her husband. Yet it is equally true that the sexual 
 desire of the female is tempered by discretion to a much greater 
 extent than that of the male ; indeed, in most of the lower animals 
 the regulation of intercourse is committed to the instinct of the 
 female. While we may not insist upon following the example of 
 the lower animals, since we are provided with instinct and reason 
 of our own, yet a moment's consideration shows that reason, in- 
 stinct, interest and manhood, all dictate that the wife should be per- 
 mitted the exercise of her own discretion in determining not 
 perhaps when she shall, but certain seasons when she shall not re- 
 
 w 
 
 :vi^fr 
 
 '■■i i:.l^: 
 
DISEASES OF WOMKX. 
 
 9S7 
 
 lavc its classic 
 md family tics, 
 ifall of Greece 
 ly to a general 
 large families, 
 
 ncd to Greece, 
 die for want of 
 • great national 
 f this Republic, 
 oman Emperor, 
 , oh Varus, give 
 
 ; most intelligent 
 come under the 
 s to neglect, the 
 husband. It is 
 the wife in this 
 nd necessarily the 
 entails ; nor can 
 lation on her part 
 es. Yet it is just 
 admit — that the 
 choice between 
 tntemperate grati- 
 :o imply by this 
 [vomcn are devoid 
 arriage-bcd with 
 It may be ad- 
 y in a less intense 
 ■ue that the sexual 
 ;o a much greater 
 the lower animals 
 ,e instinct of the 
 ng the example of 
 Instinct and reason 
 .s that reason, in- 
 vifc should be pcr- 
 detcrmining not 
 she shall not re- 
 
 ceive the approaches of her husband. There arc, doubtless, mar- 
 ried women who would and do abuse such privilege ; there are 
 even those who in order to enjoy in the higlicst degree the outward 
 advantages of their station in life, are even willing to transfer to 
 other women the affections and intimate acquaintance of their hus- 
 bands. Yet these are certainly rare instances compared with those 
 in which the husband assumes the entire right to regulate the sex- 
 ual relations, regardless of his wife's inclinations and interests. It 
 is scarcely an exaggeration to say that the average husband's actions 
 in this matter are based upon the assumption — tacit or expressed 
 — that the one chief and inalienable duty and privilege of his wife 
 is to gratify his inclinations in this regard whenever it may please 
 him to indulge them. As a result there are often times in which 
 this indulgence is granted, not with the usual gratification on the 
 part of the wife, but merely because she, too, has imbibed the same 
 doctrine of duty, or because she fears that a refusal on her part 
 may cause the husband to prefer the same request elsewhere. 
 
 As it may not be forgotten that there is still a third party — 
 perhaps the most vitally interested of all in this transaction — whose 
 rights are none the less sacred because his voice cannot be lifted 
 to maintain them — the possible offspring. To condemn a human 
 being to the vicissitudes of life is, under the most favorable circum- 
 stances, a serious responsibility which may not be assumed by any 
 reasoning being without due forethought and preparation ; the 
 thoughtless assumption of such responsibility as the price of a 
 moment's sensual gratification is one reason why so many of us are 
 inclined to curse the day that we were begotten. 
 
 In a recent essay, entitled " The Unwelcome Child," Mr. H. C. 
 Wright records a few evident truths which may well be pondered 
 upon by those husbands — and they are not few — who seem to 
 regard the persons of their wives as a part of their property. 
 
 " The wife finds that she is pregnant. On discovering the fact 
 it becomes repulsive to her nature. She is not prepared to bear 
 the cross and endure the crucifixion. She does not feel that it is 
 her child, she may regard it as yours, but cannot acknowledge it as 
 her own ; and though it must receive its development in her 
 organism, she cannot tenderly and lovingly cherish and guard it as 
 bone of her bone, flesh of her flesh, and soul of her soul. It is so 
 in fact, but not in her feelings ; she did not ask for it ; her soul 
 repels it as an intruder thrust upon her without her consent, and in 
 
 64 
 
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988 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
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 contempt it may be of her earnest remonstrance — for thus it often 
 is. The child she feels has no right to an existence at her expense 
 An uninvited and hated intruder is exhausting her vital energies 
 and robbing her of that which no earthly treasures can ever restore 
 or recompense. Through her physical suffering and mental anguish 
 an unbidden and loathed guest is feeding and thriving on her heart's 
 blood. Desperation and the bitterness of death are in her heart, 
 murder fills her soul toward your unconscious and innocent babe. 
 
 " Who is responsible, on whom rests the guilt ? It is ymir 
 work. You forced that heavy burden upon her, and compelled her to 
 bear it. You thrust your child as an intruder into the sacred domain 
 of her life, to derive existence through her organism and at lier 
 expense, knowing that she was not prepared to welcome it and to 
 bend the forces of her nature to its growth and support, and con- 
 trary it may be to her earnest entreaties that she might be spared 
 this pain and anguish till she was ready joyfully to welcome them. 
 But you heeded not her prayer; you assumed the right to decide for 
 her when she was prepared to endure these trials, and under w iiat 
 circumstances she should become a mother. You must have 3'()tir 
 stated gratification ; you have abused your manhood and your wife 
 till this indulgence, as you think, has become as essential a want of 
 your life as your daily food — as the drunkard feels that alcohol is as 
 essential as air to his existence and happiness. And so you impose 
 on her a maternity which her soul abhors. You tax her vital ener- 
 gies without her consent. Murder is in her heart toward the 
 uninvited and hated intruder you have introduced into the sanctuary 
 of her life. She pleads that you would spare her this burden at this 
 time, and until her nature calls for it, and is prepared joyfully to 
 meet the martyrdom maternity must bring to her. Heedless of her 
 prayers, you demand the surrender of her person to your passion. 
 Maternity ensues. She tries to get rid of the child, and succeeds. 
 Where rests the responsibility ? On you, primarily and mainly. 
 To gratify your selfish passion, you have driven your wife to the 
 commission of a crime that must forever weigh upon her soul like a 
 mountain of guilt and shame. She has done a deed for which 
 great nature can find no excuse but ignorance; but which, even 
 when done in ignorance, she regards as a violation of her just laws, 
 and punishes as such with appropriate penalties — a deed, after the 
 doing of which no true woman can ever in this life stand proud and 
 stainless, in conscious innocence and dignity before the tribunal of 
 her womanhood." 
 
DISEASES OK WOMEN. 
 
 9S9 
 
 For thus it often 
 at her expense. 
 ;r vital cncrt^ics 
 can ever rcstoix- 
 I mental anguish 
 ng on her heart's 
 re in her heart, 
 nnoccnt babe, 
 lilt ? It is yur 
 , compelled her to 
 le sacred domain 
 nism and at licr 
 elcome it and to 
 support, and con- 
 : might be spared 
 to welcome them. 
 right to decide tor 
 s, and under what 
 3U must have your 
 lood and your wife 
 essential a want of 
 Is that alcohol is as 
 A.nd so you impose 
 tax her vital cncr- 
 heart toward the 
 I into the sanctuary 
 - this burden at this 
 ■epared joyfully to 
 ir. Heedless of her 
 n to your passion. 
 ;hild, and succeeds, 
 aarily and mainly. 
 In your wife to the 
 lipon her soul like a 
 a deed for which 
 ; but which, even 
 _n of her just laws, 
 |__a deed, after the 
 life stand proud and 
 :fore the tribunal of 
 
 This, too, is a onc-sidcd and unfair representation of the sub 
 jcct, because it assumes tliat marria;^e is practically and legiti- 
 mately possible without rendering the wife liable to maternity. To 
 affirm that a woman should have the right to evade conception is 
 equivalent to saying that she should have the right to banish her 
 husband from her bed for a considerable time, or even altogether. 
 This represents, certainly, the other extreme, no less unjust and 
 disastrous to domestic happiness than the former. The solution 
 of this question — the regulation of the sexual relation which 
 shall do justice to all parties concerned — is evidently not to be 
 determined by any set of rules, even were they as admirable as 
 those devised by Jeremy Taylor. It is assumed that the significance 
 of the marriage relation is known to both parties before the 
 ceremony ; that conception is an extreme probability if the 
 sexual function be naturally performed ; that though this prob- 
 ability may be decreased by abstinence at certain periods of the 
 month, yet no security is thereby afforded, since intercourse at any 
 time during the month may be followed by pregnancy ; that none of 
 the popular artifices devised for the prevention of conception are reli- 
 able — these facts may be, and probably are, known to all before the 
 consummation of the wedding — unless it be they are entering upon 
 the marriage state in complete ignorance of its duties. In any case 
 the situation is essentially the same; the propagation of offspring 
 is a natural and usual result of marriage ; for those who are unable 
 or unwilling to provide for such probable offspring there is but one 
 safe plan — to remain unmarried. The attempt to evade, by the 
 destruction of unborn offspring, the assumption of those responsi- 
 bilities which naturally accompany the pleasures of matrimony, is 
 not only murder, but it is the same contemptible and cowardly 
 spirit of murder which prompts the Spanish bravo to plunge the 
 stiletto into the back of his unsuspecting victim. It is utterly 
 absurd and unreasonable to fasten the blame upon the woman, or 
 to shift the burden from her shoulders to those of her husband ; 
 both are partners in the engagement to marry, and in the execution 
 of that engagement which results in the creation of a new being ; 
 and they arc equally guilty conspirators in the murder of their 
 child. It is an utter waste of sentiment to tell us that the wife 
 repels the intruder in her bosom, her husband's child, for in becom- 
 ing a wife she agreed to receive and care for just such intruders. 
 The time for " repelling invaders" is gone by, expired with the 
 wedding ceremony. 
 
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 WEBSTER, N.Y. 14580 
 
 (716) 873-4503 
 

 WJ: 
 
 
 
990 
 
 DISliASliS OF WOMKN AND CHILDREN. 
 
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 Closely allied with this topic is that of the prevention of con- 
 ception, (ienerally speukinj;, it may be said that tlie attempt to 
 prevent conception, like the inchiction of abortion, is a species o( 
 fraud upon nature; ami it is (piite certain that no fraud nor attempt 
 at fraudulent dealiuj^s with nature ever passes undetected or 
 unavenj^cd. And it may be doubted whether, entirely aside from 
 considerations of morality and manhood, the ultimate outcome 
 of those cases in which conception has been successfully pre- 
 vented, is ever a balance on the side of happiness. Yet the case 
 presents an aspect entirely diflferent from that of abortion. The 
 latter is a crime against every recognized form of law — physic I, 
 moral and statute. The former is an evasion of physical and moral 
 obligations. There may be, it is true, circumstances which render 
 pregnancy an unquestionably greater evi! than the avoidance of it, 
 though such circumstances certainly do not arise so often as sonic 
 married people would have us believe. A depraved physical con- 
 dition of husband or wife, the development of hereditary taints in 
 previous children, a depleted condition of the family treasury — 
 these, among other circumstances, may often render it desirable to 
 avoid further increase of the family; but it must be insisted upon that 
 a simple disinclination for the cares and duties of maternity, a per- 
 sonal vanity which objects to the changes of form incident to prt-^'- 
 nancy and maternity, and unwillingness to miss the pleasures of 
 society to the extent demanded by family cares — these may bo 
 good and sufficient reasons for declining matrimony, but are certainly 
 flimsy and cowardly excuses for evading the legitimate i-nd neces- 
 sary results of it. 
 
 It is scarcely necessary to remark that there is a simple and 
 effective method for preventing conception — a method which pro- 
 bably never occurs to those anxious to avoid children— sexual 
 abstinence. This, of course, is not a part of the plan, which aims at 
 some way for devouring the cake and still retaining possession of it, 
 — aims, in other words, at what is practically a somewhat decent 
 and refined sort of prostitution. 
 
 It is not our purpose to discuss in detail the various ills which 
 inevitably follow the successful avoidance of conception, but simply 
 to emphasize the fact that one of these ills is chronic disease of the 
 womb, which sterile women rarely escape entirely. There arc, 
 indeed, certain diseases (tumors of the ovaries and of the womb 
 among them) which are known to afflict with peculiar frequency 
 women who have never been pregnant. 
 
niSlCASKS OF Till'; VUI.VA. 
 
 991 
 
 While there are certain measures whicli may lessen the proba- 
 bilities of conception, a description of them would be wholly out 
 of place in a work <jf this sort; and no physician feels justified 
 in communicating them until satisfied that the knowledge thus 
 acquired will not be abused. There are, of course, numerous pop- 
 ular measures — none of them trustworthy — a knowled^^fc of which 
 is ^renerally diffused. It is ^^eneraily known that conception is most 
 apt to occur during the ten days following the cessation of the 
 menstrual flow ; and that intercourse during this time or during 
 the previous week exposes the woman to the chances of mater- 
 nity. While this is true, yet the converse part of the proposition 
 — that conception does not occur durin^f the intermediate time — 
 is by no means an infallible rule ; it may be admitted, then, that the 
 probabilities of this accident are much less at the time intermediate 
 between two menstrual epochs than during the remainder of the 
 month ; but it is also certain that intercourse at these periods has 
 been followed by conception. 
 
 yVnother pcjpular means to the same end is the use of injec- 
 tions after the sexual act. Of these it must be said not only that 
 liny are extremely unreliable in attaininj^^ the desired end, but also 
 tliat they .'.re very trustworthy in inducing' indammation in the 
 feinalir sexual orjjans ; this applies especially to the injections of 
 cold water, but is also true of warm injections. 
 
 Perhaps the most popular and generally used means for this 
 ])urpose are the various mechanical devices, " barriers," which arc: 
 extensively advertised and even vended around th- streets. 'Ihese 
 nia)- all be aptly characterized by Ricord's comment upon them — 
 tiial they are " a col>vveb a.^ainst danger, a cuirass against jjleas- 
 ure. " More than that, they are (jften absolutely injurious, in con- 
 sequence of the materials used in their composition. 
 
 Diseases of the Vulva. 
 
 The term vulva is applied to the orifice of the vagina and the 
 folds of skin which surround it. The most common affection of 
 this portion of the body is a simple intlammation. 
 
 Sifinptoms, — The parts arc at first dry, red, hot, swollen and 
 itching. After a few hours the surface becomes moist, and finally 
 covered with a profuse secretion of pus; within a day or two small 
 superficial ulcers often appear. If the inflammation extend into 
 
 
 L^ 
 
992 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 <-he vagina, the surface of the latter assumes the same condition. 
 Not infrequently the orifice of the urethra becomes also inflamed ; 
 indeed, the inflammation may extend along the latter into the 
 bladder. In these cases every evacuation of the urine is attended 
 with a violent, scalding pain. In the milder cases, the general 
 health is not specially afifccted ; in the severer ones there may be 
 fever, thirst, headache, and general discomfort. 
 
 CauAeH, — Want of cleanliness ; friction from clothing ; skin 
 affections ; excessive intercourse ; (in children) scrofula. 
 
 One point should be always borne in mind with reference 
 to discharges of matter from the sexual organs of either sex, 
 whatever be the cause. Extreme care is necessary to prevent the 
 transfer of any particle of this discharge into the eye ; special towels 
 must be devoted to the local affection, and the hands carefully 
 washed after any contact with the discharge. A failure to observe 
 these precautions has caused the loss of many an eye by inducing 
 an intense inflammation. This same effect may be produced also 
 upon other mucous membranes than that of the eye ; hence inter- 
 course may be followed by a disease of the husband. Several 
 cases are on record in which this accident has given rise to un- 
 founded suspicions of the wife's chastity. 
 
 If properly and promptly treated, the disease usually subsides 
 within a inw days; but if neglected it proves obstinate, and often 
 causes, moreover, soreness and abrasions of the skin on the thighs 
 from contact with the discharge. 
 
 Tt'enttnent, — Measures for treatment consist, first and al- 
 ways, in local applications. The first essential is cleanliness, whicli 
 may be accomplished by frequent washing with warm water into 
 which a little borax has been stirred. Another measure which is 
 most useful in promoting cleanliness is rest in a recumbent pos- 
 ture, whereby the amount of the secretion is materially diminished. 
 The part should be washed in this way, at least, every three hours, 
 A better and more effectual measure is a hip-bath, containing borax, 
 at the same intervals. After washing, the parts may be protected 
 from the clothing by the applications of cloths dipped in the fol- 
 lowing lotion : 
 
 Tincture of opium (laudanum), - One ounce. 
 
 Sugar of lead, . . - - One drachm. 
 
 Water, . . . - _ One pint. 
 
 This may be applied on each occasion after the parts are bathed. 
 
EN. 
 
 ECZEMA OF THE VI LVA. 
 
 993 
 
 same condition, 
 les also inflamed ; 
 e latter into the 
 
 urine is attended 
 ;ases, the general 
 nes there may be 
 
 >m clothing ; skin 
 icrofula. 
 
 nd with reference 
 ins of either sex, 
 ;ary to prevent the 
 2ye ; special towels 
 he hands carefully 
 V failure to observe 
 an eye by inducing 
 T be produced also 
 e eye ; hence inter- 
 husband. Several 
 s given rise to un- 
 
 ase usually subsides 
 bstinate, and often 
 skin on the thighs 
 
 onsist, first and al- 
 is cleanliness, which 
 1 warm water into 
 measure which is 
 a recumbent pos- 
 \terially diminished. 
 , every three hours. 
 , containing borax, 
 ts may be protected 
 s dipped in the fol- 
 
 3ne ounce. 
 Dne drachm. 
 3ne pint. 
 \ parts are bathed. 
 
 t 
 
 n 
 
 h 
 
 Abscess in the Vulva. 
 
 On either side of the orifice of the vagina are small glands 
 which naturally secrete a watery fluid and communicate by a fine 
 hair-like canal with the surface. At times these canals become 
 closed, and the fluid being no longer allowed to escape, distends 
 the glands themselves, making a doughy, painless swelling. If 
 this condition remain unrelieved there often occurs an abscess in 
 and around the gland. This afi"cction often follows the disease 
 just described — inflammation of the vulva. 
 
 HkjmptomH, — This condition may remain for some time 
 undiscovered, being, perhaps, first detected by pain during inter- 
 course, or by the accidental discovery of a tumor in the part. 
 This tumor is well defined, soft, and may vary in size from that of 
 a hazel-nut to the dimensions of a small hen's egg ; by the time 
 that pus has formed the vulva is very tender and hot. In many 
 cases the abscess opens spontaneously ; indeed, the first intima- 
 tion of its existence is sometimes the discharge of matter. In 
 other cases the abscess dries up and disappears spontaneously ; or 
 becpming less tender and painful, it may remain for months or 
 years without seriously inconveniencing the patient. 
 
 Treatment, — If there be considerable pain and tenderness, 
 these symptoms may be relieved by the application of a flaxseed 
 poultice or of cloths wrung out in hot water ; indeed, this is 
 usually all that is required. At times the si/.e of the tumor and 
 its consequent interference with natural functions require the evacu- 
 ation of the matter by the lancet. This should be left to the phy- 
 sician, since he will at the same time take measures to prevent a 
 recurrence of the abscess — a not infrequent occurrence if no treat- 
 ment be adopted. 
 
 Eczema of the Vulva. 
 
 The skin of the vulva is liable to the same aff*ections as the 
 skin of the body in general ; but there is one afTection which 
 occurs with especial frequency in this part — the condition known 
 technically as eczema and popularly as " salt rheum " or " tetters. " 
 
 yi 
 
w 
 
 r; 
 
 if 
 
 994 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 Eczema is caused by the application of irritating substances to the 
 skin ; hence it occurs with especial frequency in the cases in which 
 an irritating" discharge is permitted to come in contact with the 
 skin, and may indeed result from simple lack of cleanliness, even 
 though there be no noticeable discharge from the vagina. 
 
 Sf/tnptOtn8, — Eczema usually begins by an intense itching of 
 the skin, \vhich is red and hot ; in a few hours there appear a num- 
 ber of minute watery blisters which soon burst and leave a raw, 
 moist surface. In many cases the first crop of blisters is followed 
 within a day or two by a second, and this by succeeding ones ; the 
 effect is a considerable watery discharge and the accumulation of 
 crusts or scabs over the raw surface. 
 
 Ti'eatinent, — In every case the possible cause must be 
 sought ; it will usually be found in a discharge from the vagina. 
 In this case the treatment of the eczema must, of course, include 
 the cessation of this discharge. Eczema of the vulva is a some- 
 what frequent complication during the latter months of pregnancy ; 
 in this case it seems to result from the imperfect circulation, ami 
 cannot be successfully treated until the womb has expelled its con- 
 tents and thus permitted the blond to return from the vulva witli- 
 out obstruction. After removing, so far as possible, the cuse, the 
 eczema itself may be treated by the application of the lotion con- 
 taining laudanum and sugar of lead mentioned above. If there be 
 at the same time eczema upon other parts of the skin, it may be 
 necessary to employ medicine internally as well. 
 
 Pruritus (Itching) of the Vulva. 
 
 Intense itching is a symptom of various diseased conditions of 
 the vulva, some of which have been already mentioned ; but there 
 remain numerous cases in which no cause for the itching is api)ar- 
 ent — there being no visible disease of the vulva or vagina. Sonic- 
 times, while beginning in the vulva, the itching extends so .is U) 
 include the skin around and even down the thighs ; in pregnant 
 women it sometimes spreads also upward over the abdomen. In 
 all these cases the trouble begins in the vulva and usually remains 
 limited to this region for a considerable time before extending. 
 
PRURITUS OF Tllli VULVA. 
 
 995 
 
 tanccs to the 
 Lses in which 
 act with the 
 mliness, even 
 ina. 
 
 nse itching of 
 ippear a num- 
 l leave a raw, 
 :rs is followed 
 ling ones ; the 
 :cumulation of 
 
 ause must be 
 .m the vagina, 
 course, include 
 ilva is a some- 
 5 of pregnancy ; 
 :irculation, and 
 jcpelled its coii- 
 the vulva witli- 
 ;, the c; use, the 
 the lotion coii- 
 c. If there he 
 skin, it may be 
 
 ;d conditions of 
 )ned ; but there 
 [ching is api)ar- 
 /agina. Soinc- 
 Ixtends so as to 
 ; in pregnant 
 abdomen, bi 
 usually remains 
 1 extending. 
 
 At first the irritation is usually slight and transient, so as to 
 occasion the patient but little annoyance ; in many instances it is 
 first observed just before or after menstruation, and may remain 
 for some time limited to this period of the month, lint the malady 
 gradually becomes more intense and prt)longed, and is moreover 
 aggravated by the patient's efforts to relieve the itcliing ; the rub- 
 bing and scratching not infrequently induce also a genuine eczema. 
 The irritation is usually worse at night, and may even deprive the 
 patient of sleep. In most cases the degree of annoyance varies 
 considerably, being aggravated by anything which causes a flow of 
 blood to the sexual organs — a warm bed, menstruation, indulgence 
 in highly-seasoned food, etc. In course of lime there usually 
 results some disease of the skin, which may be mistaken for the 
 cause instead of the result of the affection. 
 
 Cannes*. — Numerous conditions predispose to this annoyance, 
 among which may be mentioned lack of cleanliness, luxurious hab- 
 its, constipation, but chiefly leucorrho^a. Pruritus may be present 
 not only when the whites are abundant, but also where the amount 
 of the discharge seems quite insignificant. In every instance it 
 should be especially noticed whether there is any vaginal discharge 
 of any sort. Yet there remain numerous cases in which no local 
 affection of the vulvr and no general disease can be found to 
 account for this troublesome symptom ; and these are the most 
 intractable cases. 
 
 Trentment. — Since the itching is usually but a symptom, 
 the treatment comprises first of all, the detection and removal of 
 the cause ; in those cases in which leucorrluea, or some affection 
 of the skin, can be detected, we may inikilge a reasonable hope 
 tluit tlie cure of these affections may be followed by cessation of 
 the itching ; in cases of leucorrhtea, the use of hot hip-baths, 
 and of vaginal injections, as previous!)- directed, will often relieve 
 the itching; in such cases, advantage maybe derived from the 
 introduction into the vagina at night of a tampon — a bunch of 
 cotton saturated with glycerine, with a string tied about it ; in 
 many cases of severe itching, these tampons may be kept in the 
 vagina by day as well as by night, a fresh one being substituted 
 every twelve hours. In case there is evident disease of the skin, 
 this should be at once subjected to treatment. In every instance, 
 except when there is considerable abrasion of the skin from 
 
 1 
 
 I.I I 
 
 5. . 1 
 
 ht 
 
 ^.r 
 
996 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 scratching or other cause, one of the following lotions may be 
 applied on cloths to the skin : 
 
 Sugar of lead, . _ > 
 Carbolic acid, _ . - 
 Laudanum, - - - - 
 Water, 
 
 Mix and apply as directed. Or, 
 
 Korax, .--... 
 Morphine, - _ . . 
 Water, 
 
 It is often desirable to have some application which will not 
 evaporate so rapidly as those just mentioned ; such a salve may be 
 made of the following ingredients: 
 
 Dilute prussic acid, ... Two drachms. 
 
 Sugar of lead, . . _ . Fifteen grains. 
 
 Cocoa oil, .... - Two ounces. 
 
 One of these mixtures will, in any case, give temporary relief; 
 but a permanent cure will sometimes require a complete change in 
 the mode of life, perhaps a change of residence and of climate. 
 
 One drachm. 
 Ten drops. 
 One ounce. 
 One pint. 
 
 One ounce. 
 Five grains. 
 Half-pint. 
 
 Excessive Sensitiveness of the Vulva. 
 
 This is an affection sometimes associated with pruritus, but 
 often occurring alone. As a result of this condition, oven gentle 
 contact with the surface causes extreme pain, and may even be ful- 
 lowed by convulsions. This condition is often observed in hyster- 
 ical women, or may occur without such accompaniment at the chaiv^c 
 of life. It is usually brought to the notice of the physician when it 
 occurs as an obstacle in the consummation of marriage. In a con- 
 siderable number of cases improvement of the general health and 
 avoidance of those causes which have been mentioned as predispos- 
 ing to hysteria will usually be followed by relief from this annoyance, 
 In some instances, on the other hand, nothing but surgical interfer- 
 ence has been found effectual. 
 
 In a certain class of these cases contact of a foreign body with 
 the part causes not only the sensation of pain but also a spasmodic 
 
:ions may be 
 
 rachm. 
 ops. 
 mice, 
 int. 
 
 )unce. 
 
 Trains. 
 
 pint. 
 
 rt'hich will not 
 \ salve may be 
 
 drachms, 
 sn grains, 
 ounces. 
 
 mporary relief; 
 plcte change in 
 I of climate. 
 
 |va. 
 
 h pruritus, but 
 i)n, v^ven gentle 
 pay even be ffl- 
 
 :rved in hystcr- 
 Jnt at the chan-;c 
 Ihysician when it 
 la<Te. In a con- 
 licral health and 
 
 :d as prcdispos- 
 
 this annoyance. 
 
 iurgical interfor- 
 
 Ireign body with 
 llso a spasmodic 
 
 DISEASES OF THE WOMB — INt L.\MM.\ llON. 
 
 997 
 
 contraction of certain muscles, whereby the orifice of the vagina is 
 partly closed. In the majority of these instances se.xual intercourse is 
 simply impossible, and sterility usually occurs, as was the case with 
 thirty-two of thirty-four instances recently observed byScanzoni. 
 
 Trent mrnt. — This whole subject may be well summed up in 
 the remark of Dr. Sims: " From personal experience, I can confidently 
 assert that I know of no disease capable of producing so much un- 
 happiness to both parties to the marriage contract, and I am happy 
 to state that I know of no serious trouble that can be so easily, so 
 safely and so certainly cured. " The necessary treatment consists 
 simply in overcoming the muscular resistance by the fingers while 
 the patient is under the influence of ether or chloroform. Yet, 
 though the remedy is so simple and so safe, it is a curious fact that 
 some married women have suffered from this annoyance for twenty 
 and even thirty years ; have, indeed, been for such periods wives in 
 name only. 
 
 DISEASES OF THE WOMB. 
 
 Inflammation. 
 
 Without entering into particulars of classification, we may 
 speakof inflammation of the womb as either acute or chronic. The 
 rrfwA' inflammations of the womb — the diseases of child-bed being 
 excluded — arc of far less frequent occurrence than the slower and 
 more chronic inflammations. 
 
 Causes, — Exposure during the menstrual flow; inflamma- 
 mation of the vagina; suppression of menstruation ; excessive or 
 violent intercourse ; certain constitutional diseases ; attempts at 
 abortion; injections of cold water. 
 
 Sljniptonis, — The patient ordinarily complains of weight 
 and a dragging pain in the small of the back, often extending 
 around to the front and down the thighs ; there is usually also an 
 itching and burning sensation in the vagina, and frequently such 
 irritation of the bladder and rectum as to compel frequent evacua-, 
 tions of these organs. The general symptoms are not usually 
 severe ; some headache, loss of appetite; perhaps slight fever may 
 
 V, 
 
 f : 
 
 Mi ' 
 
998 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 11. 
 
 be observed. After three or four days, or perhaps sooner, there 
 appears a discharge from the vagina, at first clear and ghiiry, 
 subsequently white or yellow, and even bloody. By this time there 
 is usually considerable pain in the lower part of the abdomen, 
 accompanied by an effort to " bear down," such as is felt during 
 labor. It is important that this malady be not allowed to proceed, 
 not because of its own intrinsic danger, but because there usually 
 occur complications in various other of the sexual organs which 
 seriously impair the woman's health. 
 
 Treatment, — The patient should be required to keep quiet 
 in bed. At intervals of three or four hours, she should receive a 
 vaginal douche, for which at least a quart of hot water should be 
 used. In the intervals between these injections, hot, moist flan- 
 nels should be kept applied to the vulva and groins. Twice or 
 three times a day the patient should rest for fifteen or twenty 
 minutes in a hot hip-bath. Internally, it is usually advisable to 
 administer opium in some form — say ten drops of laudanum at 
 intervals of two or three hours until three doses have been taken. 
 After an interval of twelve hours, the same amount may be repeated. 
 
 A vaginal douche may be administered either with a Da\itlson 
 syringe, or, better, from a fountain syringe. The latter may be 
 readily constructed in a few moments by attaching a rubber tube 
 to an opening at the bottom of a wooden or glass vessel ; or still 
 more simply, by making a siphon out of a rubber tube, one end of 
 which remains immersed in the vessel. The vessel containing the 
 'lot water may be suspended by a nail on the wall or held in the 
 hand, while the other end of the tube is introduced into the vagina. 
 Care should be taken not to suspend the vessel more than two or 
 three feet above the level of the other end of the tube, for since the 
 force with which the water flows increases with the height of the 
 vessel, a greater elevation than that named may result in damage to 
 the womb from the violence with which the stream strikes the 
 mouth of the organ (or rather from entrance of fluid into the womb 
 cavity, and even abdominal cavity). 
 
 Chronic Inflammation of the Womb. 
 
 When one considers the exposed position of the mouth of 
 the womb, liable to friction and violence during so many of the 
 ordinary duties of life as well as by the performr nee of the sexual 
 
PKRI-UTHKlNi: INFLAMMATION. 
 
 1005 
 
 sooner, there 
 ir and glairy, 
 this time there 
 the abdomen, 
 
 is felt during 
 red to proceed, 
 50 there usually 
 il organs which 
 
 d to keep quiet 
 hould receive a 
 vater should be 
 hot, moist flan- 
 oins. Twice or 
 fteen or twenty 
 illy advisable to 
 of laudanum at 
 nave been taken, 
 maybe repeated, 
 with a Davidson 
 he latter may be 
 g a rubber tube 
 ,s vessel ; or still 
 tube, one end of 
 :1 containing the 
 all or held in the 
 into the vagina. 
 nore than two or 
 be, for since the 
 lie height of the 
 ,ult in damage to 
 •cam strikes the 
 ,d into the womb 
 
 Lb. 
 
 )f the mouth of 
 so many of the 
 :e of the sexual 
 
 SjftnptoniM. — The symptoms vary according to the severity of 
 the case as well as the previous condition of the patient. There is 
 frequently a pronounced chill, followed by high fever ; pain and 
 tenderness in the lower part of the abdomen, which are aggravated 
 by motion of the body ; sometimes nausea and vomiting occur. 
 In other cases the onset of the difficulty is far more gradual ; there 
 may be no acute symptoms which direct attention to this part of 
 the body, beyond some pain and tenderness and perhaps derange- 
 ment of the menstrual function. In these cases, however, there 
 has usually existed previously some disease of the womb. 
 
 The course and duration of peri-uterine inflammation vary 
 extremely according to the attendant circumstances of the case. 
 The affection may subside bet"ore five weeks, leaving the womb 
 essentially unchanged ; these are the most favorable and the rarest 
 cases. In more numerous instances the result is a displacement of 
 the womb, which becomes bound down in this unnatural position 
 by the products of the inflammatory process. This is the origin of 
 so many of the obstinate cases of uterine displacement which are 
 treated unsuccessfully by one physician after another for years ; 
 they are in fact incurable. Another termination of this difficulty is 
 an abscess in the neighborhood of the womb — a process usually 
 indicated by a rapid succession of severe chills, extreme pain, high 
 fever and general prostration. These abscesses often break spon- 
 taneously into the vagina or the rectum, or even into the bladder; 
 in any case the most obstinate and annoying discharge usually 
 results and the patient's general health is seriously impaired. In 
 other still more unfortunate cases the abscess does not escape 
 externally, but causes a general inflammation of the membrane 
 which lines the abdomen and covers the bowels — an inflammation 
 which is technically called peritonitis. This is one of the gravest 
 affections that can afflict the patient, and usually results either in 
 death or in permanent invalidism. In the most favorable cases the 
 woman's life is made wretched by obstinate and painful derange- 
 ments of menstruation, displacements of the womb, and general ill- 
 health. 
 
 Treatment. — The object of treatment in the early stage is to 
 limit the extent of the inflammation, and thereby to avoid, if 
 possible, not only the more painful, but also the more disastrous 
 consequences of the disease. Whenever, therefore, the symptoms 
 already mentioned as indicating the onset of this afiection are noted 
 
 •'I 
 
 m 
 
 ti 
 
 1; ;' 
 
I006 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 — chills, fever, pain and tenderness in the abdomen — the woman 
 should go to bed and stay there. It is impossible to over-estimate 
 the important, indeed the absolute, necessity for perfect rest durinj^ 
 this condition. The next most important measure is the applica- 
 tion of heat and moisture to the inflamed parts ; this is accomplished 
 first and best by frequently-repeated and long-continued use of the 
 vaginal dotiche, the water being made as hot as can be conveniently 
 endured ; the same object will be furthered by the application of 
 hot moist cloths over the womb and between the thighs. It is 
 important, also, to secure an evacuation of the bowels, which may 
 be best accomplished, not by the use of cathartics, but by an injec- 
 tion of warm water into the rectum. From fifteen to twenty drops 
 of laudanum, the quantity varying according to the amount of pain, 
 may be at once administered and repeated in four hours. The 
 further management of the case must be left to the medical adviser; 
 it would be impossible and impracticable for us to relate to the 
 non-professional reader the steps necessary to ascertain the progress 
 of the disease and to prevent the manifestation of its worst symp- 
 toms, for the treatment consists — aside from the general directions 
 already given — in local examinations and applications through the 
 vagina, which can be performed only by a physician. 
 
 In many of these cases in which the initial symptoms have been 
 so slight that the physician was not called, the damage is done 
 beyond repair before medical advice is finally summoned ; the 
 patient is already an invalid, and is apt to remain one for years. 
 In these cases medical treatment is seldom of much avail ; there is 
 not much hope of restoring the womb and surrounding tissues to 
 the proper and natural condition ; the chief object must be to place 
 the patient in the conditions most favorable to health, in order that 
 she may endure, as best she can, the array of uncomfortable symp- 
 toms constituting " female weakness. " The general directions are 
 essentially those stated in connection with the discussion of chronic 
 inflammation of the womb, and need not here be repeated ; yet 
 especial stress should be laid upon two items : the importance of 
 rest and of abstinence from se.xual intercourse. 
 
 Displacements of the Womb. 
 
 The womb is held in its natural position chiefly by certain 
 bands, which are attached at one end to the sides of the uterus, aiul 
 at the other to various points around the pelvis. The womb, it will 
 
FAL1,IN(; OK THE WOMlt — PROLAPSUS. 
 
 1007 
 
 -the woman 
 vcr- estimate 
 t rest during 
 
 the applica- 
 iccomplished 
 cd use of the 
 
 conveniently 
 application of 
 tliighs. It is 
 ,s, which may 
 ,t by an injec- 
 
 twenty drops 
 nount of pain, 
 f hours. The 
 cdical adviser; 
 > relate to the 
 in the progress 
 ts worst symp- 
 iieral directions 
 )ns through the 
 
 oms have been 
 .amage is done 
 Limmoned ; the 
 |i one for years, 
 avail ; there is 
 ding tissues to 
 ,ust be to place 
 ;h, in order that 
 iifortable symp- 
 l1 directions arc 
 ssion of chronic 
 repeated; yd 
 ,e importance of 
 
 be remembered, is shaped somcvvhat like a pear, and these bands 
 are attached chiefly about midway between thclarge and small ends 
 of the organ. These two ends, therefore, remain somewhat mov- 
 able, that is to say the top of the womb — the- lar^'c em! of the 
 pear — can be bent backward or forward from llic rtstof the organ. 
 Such a bent position of the womb is called technically a flexion. 
 At other times, the entire womb changes the direction of its axis, 
 that is to say the middle where these bands are attached remains 
 fixed, while the top movgs forward and the lower end of the womb 
 backward. Thus the pear may, instead of standing almost verti- 
 cally in the pelvis, turn over so as to lie almost horizi ntally. This 
 displacement is called a version. It may also h.ipnfn that the womb 
 had been for some cause so increased in size and tli< 1 efore so heavy 
 that the natural bands are unable to support it. The result is that 
 these bands stretch and allow the womb to " ik deeper iiV . the 
 vagina than its natural position. This i^; thi condition known as 
 prolapsus, and popularly as " falling of the womb." 
 
 Causes, — One of the most frequent causes of displacement of 
 the womb is the increase in size consequent upon c'lronic inflam- 
 mation of the organ; and another, scarcely less frequent, is the lail- 
 ure of the womb to return to its natural size after delivery, or after 
 abortion. These all act by causing such increase in the weight of 
 the womb that the supporting bands are no longer able to main- 
 tain the organ in its proper position. Then, again, theie are causes 
 which lead to the same result, by weakening the support of the 
 womb or by forcing this organ out of its proper position. Among 
 these are the excessive stretching of all these parts during the pro- 
 cess of delivery; rupture or tearing of the uterine supports by preg- 
 nancy and confinement; the pressure upon the womb from above, 
 exerted by the weight of clothing suspended at the hips, and aggra- 
 vated by the pressure of a tight corset. And last must be mentioned 
 the afi'ection already described under the name of peri-uterine inflam- 
 mation. By far the most important of all these infl.teiices, by rea- 
 son both of their frequency and of their obstinacy, are the results 
 of confinement. 
 
 .I'l 
 
 II 
 
 iiefly by certain 
 
 [f the uterus, and 
 
 [he womb, it will 
 
 Falling of the Womb — (Prolapsus). 
 
 This condition is usually found in married women, as would be 
 expected from the fact that its cause lies so often in pregnancy 
 and confinement. Yet it may occur in girls previous to marriage. 
 
 H4 
 
i i' I 
 
 1008 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 and in women who have passed the child-bearing period. In the 
 former, the cause mi-;.t be sought in improprieties of dress and in 
 the inflammations of the womb consequent upon imnrudence during 
 menstruation. And there is still another factor which is more 
 frequent and obstinate in later years, but which may nevertheless 
 assist in displacing the womb in young women — namely, habitual 
 constipation. In old age there is also a condition peculiar to ad- 
 vanced life, which assists in promoting a falling of the womb — 
 namely, a weakening of the uterine suppprts as a part of the gen- 
 eral debility of the patient. 
 
 SfflHjitoms. — It is a singular fact that the unnatural sensa- 
 tion which accompanies a falling of the womb, does not bear any direct 
 and constant relation to the amount of displacement of this organ ; 
 there are instances in which the womb descends to the orifice of 
 the vagina or even protrudes from that orifice without exciting 
 marked discomfort in the patient. On the other hand, most severe 
 and annoying symptoms arc sometimes experienced for which no 
 other possible cause can be discovered than a slight prolapsus, and 
 which disappear so soon as this prolapsus is remedied. In most 
 cases in which the womb has been forced but a little from its 
 natural position, there will be observed pain in the back and 
 loins, a sense of weight in the pelvis, leucorrhoea, inability for 
 physical exertion, pain and difficulty in evacuating the bowels ami 
 bladder. It is a little remarkable that this particular dispi ce- 
 ment of the womb is not usually accompanied by derangement of 
 menstruation — a point which is of value in distinguishing a simple 
 prolapsus from t.ie other displacements, versions and fle.xions which 
 are usually so accompanied. A simple prolapsus moreover docs 
 not seem to cause sterilit)', while this condition is often associated 
 with other displacements of the womb. The course of this atTcc- 
 tion varies extremely, as has been already indicated, though all 
 cases of it agree in one respect, that there is no tendency to spon- 
 taneous recovery. The patient's health and comfort are impaircil, 
 her ability and disposition for exertion diminished ; but the discasi 
 itself has no tendency to induce a fatal result, unless indeed it ht 
 complicated by some of the other afifections which so often follow 
 in its trail. 
 
 Ti'eatnient, — The treatment of prolapsus comprises two 
 essential features: First, the removal of the cause, if such cause 
 
FALLING OK THE WOMB — PROLAPSUS. 
 
 1009 
 
 can be ascertained ; second, the replacement of the womb in its 
 natural position. Under the former head must be included meas- 
 ures for preventing constipation, for removing the weight of cloth- 
 ing from the hips, and for obviating pressure upon the abdomen. 
 If the patient be especially fleshy and have borne several children, 
 benefit may usually be secured from the use of an abdominal sup- 
 porter also. This part of the treatment may, therefore, consist in 
 a regulation of the diet and the use of such medicines as will secure 
 the daily evacuation of the bowels ; in the use of a corset sus- 
 pended from the shoulders ; and in the employment of a bandage 
 which may be buckled around the hips so as to support the abdom- 
 inal wall. In addition to this, measures of especial caution should 
 be taken during every menstrual period, since at this time the 
 womb is heavier than in the intervals. These measures may con- 
 sist in rest and the recumbent posture. The result of these efforts 
 will be not to restore the womb to its proper position, but simply 
 to remove the obstacles in the way of such restoration by means 
 applied directly to the womb itself. 
 
 First among these come injections with astringent remedies — 
 that is, tannin, alum or oak bark. These may be reinforced by 
 cool hip-baths and vaginal douches. The improvement of the 
 general heeilth will also favor success in the restoration of the 
 womb. 
 
 It is possible that these measures, when faithfully and con- 
 scientiously applied, may in certain mild cases effect the desired 
 result. Yet, in the majority of instances, it will be necessary to 
 employ in addition local mechanical means in order to restore the 
 womb to its proper position and maintain it in that oosition. These 
 means consist in instruments constructed for the purpose and 
 known as pessaries. There is an almost infinite variety of these 
 instruments, though they are all constructed upon one or two gen- 
 eral plans ; in the one the instrument is made to rest upon the 
 vagina and the floor of the pelvis, and upon these supports the 
 uterus is raised and sustained. In the other kind the instrument 
 which sustains the womb is itself supported not by the vagina but 
 by a strap attached to a belt around the waist. The mate- 
 rials employed for the construction of these instruments is 
 '' usually hard rubber, the object being to employ some material 
 which will not be corroded and become unclean through the action 
 of the vaginal secretions. 
 
 lii 
 
 
 i I 
 
 ■t 
 
 H'T- 
 
 1,- ii' 
 
lOIO 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 It is Utterly impossible to attempt to describe rules for the 
 application of these instruments, since each must be adapted to the 
 particular wearer with as much care and accuracy as are employed in 
 the fitting of a garment ; and this it is hardly necessary to say can 
 be accomplished only by skilled hands. The pessary must, there- 
 fore, be selected, adapted and introduced by the physician, who 
 will moreover furnish such instructions as are necessary for the com- 
 fort and profit of the patient. Certain rules must be observed in 
 the wearing of pessaries of any sort. Details as to their introduc- 
 tion and withdrawal vary with the different kinds. Most varieties 
 should be removed every day ; many are to be worn only during 
 the day; and tl ere are but few which can be worn with profit and 
 without discomfort during the menstrual period. In every case 
 e.xtreme care as to cleanliness must be observed. Warm vaginal 
 douches should be employed morning and night, and the pessary 
 carefully washed in lukewarm water after every removal. The neg- 
 lect of these precautions will be followed not only by annoying 
 sensations, but even by serious ulceration of the womb or vagina, 
 or both. In many cases the first attempt at fitting the pessary may 
 be unsuccessful. The instrument may give considerable pain and 
 discomfort. In such cases the patient should at once report the 
 fact to the physician, who will insert an instrument of somewhat 
 different pattern or size or shape. 
 
 In the worst cases these measures will hardly suffice ; for in 
 some instances the displacement is so great that the womb escapes 
 from the body and appears external to the vaginal orifice. In these 
 cases an operation is usually the only resort which affords any hope 
 of success. In the majority of ini:tances this extreme displacement 
 is a gradual process, accomplished during months or years ; yet in 
 some cases the same amount uf displacement — even external to 
 the body — may occur suddenly, as the result of excessive effort in 
 lifting a heavy weight for instance. 1 hese cases have been known 
 to occur even in unmarried women. When the womb is thus ex- 
 posed to unnatural violence, as must, of course, happen in this 
 exposed position, it usually becomes the seat of ulceration and 
 inflammation. One of the first requisites for the treatment of this 
 condition consists, after replacing the organ into the vagina, in ab- 
 solute rest upon the back in bed. 
 
lEN. 
 
 ribc rules for the 
 be adapted to the 
 xs arc employed in 
 icessary to say can 
 ;ssary must, there- 
 lie physician, who 
 lessary for the com- 
 lust be observed in 
 5 to their introduc- 
 is. Most varieties 
 ; worn only during 
 orn with profit and 
 od. In every case 
 ed. Warm vaginal 
 ht, and the pessary 
 removal. The neg- 
 ; only by annoying 
 he womb or vagina, 
 ing the pessary may 
 insiderable pain and 
 at once report the 
 ument of somewhat 
 
 ardly suffice ; for in 
 the womb escapes 
 lal orifice. In these 
 ch affords any hope 
 treme displacement 
 hs or years ; yet in 
 — even external to 
 excessive effort in 
 s have been known 
 e womb is thus cx- 
 rse, happen in this 
 of ulceration and 
 le treatment of this 
 o the vagina, in ab- 
 
 TUMORS OF THE UTERUS. 
 
 Flexions. 
 
 ion 
 
 A bending in the direction of the uterus, so that the top of the 
 organ is curved backward or forward — in other words, a flexion 
 — is one of the most common of uterine complaints. The accom- 
 panying symptoms vary somewhat, not only according to the severity 
 of the complaint, but also according to whether the organ is bent 
 forward or backward. The causes have already been enumerated 
 in discussing displacements of the womb in general. 
 
 Sffniptoms. — A certain degree of displacement, either back- 
 ward or forward, may last for years without directing the attention 
 of the individual to these organs. Yet, sooner or later, some or 
 all of the following symptoms are usually manifested : Pain in back 
 and loins ; irritability of bladder and rectum ; derangements of 
 menstruation ; leucorrhoea ; inability for physical exertion. 
 
 In many cases the patient is actually bedridden and may 
 remain so for years. Some of these cases can be rapidly restored 
 to health by simply returning the womb to its proper position ; 
 yet, in the majority of cases, the long-continued interference with 
 health results in a series of complications which make successful 
 treatment extremely difficult. Among these complications are 
 dysmenorrhoea, sterility, inflammation of the uterus and of adjoin- 
 ing structures, tendency to abortion. 
 
 Treatment. — The same measures which have been recom- 
 mended as promoting the restoration of a prolapsed womb are 
 useful in overcoming the different flexions and versions of the 
 uterus. These latter, too, must be treated by the physician with 
 pessaries ; but he must be the judge of the sort to be employed 
 and the mode of application. It will generally be advisable in 
 these cases of flexions and versions for the woman to remain in 
 bed for three or four days after the first insertion of the instru- 
 ment. 
 
 Tumors of the Uterus. 
 
 The tumors which are developed in the uterus may be de- 
 scribed, for our purposes, tmder three varieties: Fib.'^id, cancer- 
 ous and polypous. The fibroid tumors of the uterus consist essen- 
 
 T 
 
 nljUL.ii 
 
 (I: 
 
 i' 
 
 I 
 
 1' * 
 
 1' 
 
 ; ' 
 
 
 I 
 
 '■i 
 
 I' t 
 V i 
 
m 
 
 loi; 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 tially of the same material as the substance of that organ itself; 
 the tumor is really merely an excessive growth of certain portions 
 of the womb. This growth is an extremely common occurrence, 
 so that in the majority of cases the post-mortem examination of 
 women of 35 or more years old reveals the existence of small 
 fibroid tumors. In most instances, however, these tumors occasion 
 no symptoms during life, so that neither patient nor physician has 
 any suspicion of their existence ; it is only when these growths 
 attain a certain size that they occasion derangement of the sexual 
 organs. There seems to be practically no limit to the size that they 
 may attain ; such tumors have been known to weigh over fifty 
 pounds, and to be so large as to make locomotion impossible. It 
 is only, however, in advanced life that fibroid tumors of the womb 
 attain this enormous size ; indeed, such cases are exceptional any 
 how. It is a curious observation that the occurrence of these 
 tumors is favored by certain conditions of race, and seems to be 
 favored by inactivity of the sexual organs. Thus it is known that 
 fibroid tumors occur with greater frequency among females of the 
 negro race than among white women ; and it seems to be estab- 
 lished that they are more apt to occur in women who have never 
 borne children than in others. It is also believed that the growth 
 of these tumors is favored by menstrual disorders of long standing; 
 though it may be a question whether the sterility which usually 
 accompanies such obstinate menstrual disorders be not really 
 responsible for both disorders and tumors. 
 
 In most cases the development of fibroid tumor of the uterus, 
 which usually begins between the age of 30 and 45 years, is 
 attended by certain complications which attract the attention lon<; 
 before the tumor itself becomes large enough to cause any increase 
 in the size of the abdomen. Among these complications arc 
 inflammations and displacements of the womb ; derangements of 
 the bladder and rectum ; piles and menstrual disorders. Doubtless 
 many of the symptoms which so usually accompany fibroid tumors 
 of the womb as tc be considered characteristic of this affection arc 
 really due to these ordinary complications. 
 
 SipuittoniH. — Among the most prominent symptoms are : 
 
 Profuse menstruation, the interval between the periods being 
 
 usually shortened. Leucorrhcea, the discharge often tinged with 
 
 blood. Pain in the back and pelvis, and pain during menstruation. 
 
 Irritation of bladder and rectum. These symptoms need not all 
 
REN. 
 
 that organ itself; 
 of certain portions 
 Dmmon occurrence, 
 tern examination of 
 existence of small 
 :;se tumors occasion 
 ; nor physician has 
 hen these growths 
 ;ment of the sexual 
 to the size that they 
 :o weigh over fifty 
 :ion impossible. It 
 umors of the womb 
 are exceptional any 
 3ccurrence of these 
 :e, and seems to bo 
 hus it is known thai 
 Tiong females of the 
 
 seems to be estab- 
 men who have never 
 ved that the growth 
 -rs of long standing ; 
 crility which usually 
 •ders be not really 
 
 tumor of the uterus. 
 50 and 45 years, is 
 the attention loui^ 
 o cause any increase 
 c complications are 
 lb ; derangements of 
 sorders. Doubtless 
 pany fibroid tumors 
 of this affection arc 
 
 t symptoms are : 
 
 n the periods beinc; 
 
 e often tinged with 
 
 luring menstruation. 
 
 iptoms need not all 
 
 TUMORS OK THE UTERUS. 
 
 1013 
 
 occur in one and the same case ; nor are they always present in the 
 same relative degree. The differences seem to depend largely 
 upon the position which the tumor occupies in the uterus. Thus 
 those tumors that are situated in the part of the uterus lyin"" next 
 to the bowels do not usually occasion the same amount of leucor- 
 rh(ea or difficulty with the bladder and rectum as the others ; yet 
 these attain the greatest size. Those that project into the cavity 
 of the womb, on the other hand, while early attaining the same 
 dimensions, occasion, nevertheless, more marlced and annoying symp- 
 toms in the early stage of their development. It is extremely difficult 
 for a non-professional person to arrive at a definite and decided 
 opinion as to the existence of a uterine fibroid, because there are 
 several other conditions which may readily be mistaken for this afifec- 
 tion, especially in the early months of their existence. Among these 
 are pregnancy, ovarian tumors, peri-uterine inflammations, and 
 certain disorders of the bowels; indeed, instances have been known 
 in which the results of habitual constipation have been mistaken 
 for a fibroid tumor of the uterus. These mistakes result in part at 
 least from the profound conviction entertained by almost every 
 woman who has attained the age of 30 years, that she has or soon 
 have a tumor. It is the experience of most physicians that 
 
 \vi 
 
 the vast majority of women who sufter from any derangement of 
 the sexual organs are fully convinced before consulting a medical 
 adviser that they are going to have either a tumor or a cancer. 
 With regard to this prevalent dread, it should be remarked that 
 fibroid tumors of the womb have been but very rarely known to 
 cause death, and that the cases in which they attain such size as to 
 seriously incommode the patient, or even attract iier attention, are 
 \cry few indeed. For i' must be remembered, that probably 40 
 per cent, of women who attain the age when the change in life ma f 
 be expected have fibroid tumors of the womb ; and it is no 
 exaggeration to say that nine out of every ten of these have never 
 suspected the existence of such a growth. And there are cases in 
 which the physician, wiiile suspecting the existence of a fibroid, is 
 unable to make a definite decision, because the growth never attains 
 a size sufficient to make it peiceptible. 
 
 The s\'mptoms which ordinarily arouse the woman's suspicions 
 that something is wrong are meiiorr/iiigid or iiictrorr/iagia, leucor- 
 rhrea and painful menstruation. Menorrhagia, or profuse menstrua- 
 tion, may of course occur from various causes ; indeed, some 
 
 '* K 
 
 
 "! Si 
 
 »il 
 
 I 
 
 i 
 
 1 
 
 
 \ 
 
 > ; 
 
 ■ 
 
 ■I 
 
 1 
 
 -i 
 
 Hf 
 
 I 
 
 I! 
 
IOI4 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 women are not at all uniform in the amount of their menstrual dis- 
 charges. Yet the occurrence of several successive profuse men- 
 struations without apparent cause, and especially if the period 
 between the monthlies be shortened, may indicate the existence of 
 a fibroid tumor. Yet it must not be forgotten that this series of 
 events may occur from other causes ; that they do not, therefore, 
 proves conclusively the existence of a fibroid. If such a tumor be 
 actually present there will usually follow, within a few months, a 
 more or less profuse Icucorrhoea (if this have not previously existed), 
 and slight enlargement in the lower part of the abdomen. It may 
 happen that the patient's general health is meanwhile somewhat 
 impaired, though this seems to result rather from anxiety and men- 
 tal worry than from the direct influence of the tumor upon the 
 patient's nutrition. Av the tumor increases in size these symptoms 
 become more and more marked ; the monthly flow becomes very 
 long and so profuse that the woman is much exhausted by the loss 
 of blood — indeed, it is sometimes necessary to adopt certain meas- 
 ures for the repression of this flow as a means of saving the woman's 
 life. The enlargement caused by such a tumor can, ? :er it 
 has attained a certain size, usually be distinguished without diffi- 
 culty from the increase in size due to pregnancy ; the fibroid tumors 
 are usually located on one side or the other of the abdomen, pre- 
 sent a different shape and are harder. Yet it is not so easy to dis- 
 tinguish between these tumors of the womb and tumors of the 
 ovary. 
 
 As has been already stated, fibroid tumors of the womb rarely 
 cause a fatal result. The most disastrous efifects to be expected 
 from them are the physical annoyance occasioned by their size and 
 the exhausting effects of the profuse menstruation and leucorrhaa 
 which so often accompany them. It is, fortunately, to be expected 
 in the majority of cases, that after attaining a certain size the 
 tumor will cease to grow, after which time the symptoms usually 
 diminish somewhat in severity. It is further well established tluit 
 the growth of these tumors is arrested at the change in life, even if 
 they have been rapidly increasing in size up to that time, for this 
 period marks the cessation of activity in all the sexual organs, the 
 womb included. At this time the supply of blood to all the sexual 
 organs and their appendages is much decreased ; as a result of 
 which the fibroid tumors no longer receive the necessary amount of 
 nourishment, and therefore not only cease growing but usually 
 
DREN. 
 
 TUMOR OF THE UTERUS. 
 
 lOlS 
 
 their menstrual dis- 
 essive profuse men- 
 cially if the period 
 cate the existence of 
 ;n that this series of 
 ey do not, therefore, 
 If such a tumor bo 
 bin a few months, a 
 t previously existed) , 
 s abdomen. It may 
 iicanwhile somewhat 
 am anxiety and men- 
 the tumor upon the 
 
 size these symptoms 
 y flow becomes very 
 ;xhausted by the loss 
 o adopt certain meas- 
 of saving the woman's 
 tumor can, ? :er it 
 ruished without diffi- 
 :y ; the fibroid tumors 
 af the abdomen, prc- 
 
 is not so easy to dis- 
 3 and tumors of the 
 
 rs of the womb rarely 
 fleets to be expected 
 ned by their size and 
 ation and leucorrhaa 
 lately, to be expected 
 g a certain size the 
 le symptoms usually 
 well established that 
 hange in life, even if 
 to that time, for this 
 le sexual organs, the 
 lood to all the sexual 
 :ased ; as a result of 
 necessary amount of 
 growing but usually 
 
 undergo a certain decrease in size. Indeed, throughout their entire 
 course they are afl"ected by whatever influences the womb itself. 
 Thus they become larger during menstruation and pregnancy, and 
 they may constitute a serious obstacle to delivery by dropping into 
 the pelvis and becoming wedged there by the advancing child. 
 
 Treatment, — The treatment of fibroid tumors of the ute- 
 rus may be summed up, so far as medicines are concerned, in 
 one measure — the use of ergot. Numerous other remedies have 
 been, it is true, employed and recommended, but nothing else can 
 be relied upon to give definite results. Among other things, elec- 
 tricity has been employed by inserting the poles of tlie battery 
 directly into the tumor by means of needles. Possibly the future may 
 decide that this measure is eflectual in this, as in other desperate 
 cases, but at present our reliance is upon ergot. The effect of this 
 drug is to cause contraction of the blood vessels which supply the 
 uterus and the tumor with blood ; in other words, to starve the 
 tumor. It must be admitted that in some cases of long standing 
 ergot, like everything else, is inefTectual. Yet, it is equally certain, 
 that in the majority of instances, before the tumor has attained a 
 large size, ergot does at least arrest the growth of the fibroid, and 
 may even cause a marked decrease in size or total disappearance. 
 It is advisable always to have the supervision of a physician when 
 ergot is administered, for the drug may occasion a variety of un- 
 pleasant symptoms, among them nausea, vomiting and colicky pains. 
 Indeed, it becomes often necessary to administer the drug as an 
 injection under the skin — hypodcnnically, as it is called — because 
 of the patient's inability to retain it upon the stomach. When 
 taken by the mouth, it is well to begin with a dose not exceeding 
 ten drops of the tincture, which may be repeated three times daily. 
 Kven this amount will sometimes cause severe bearing-down pains 
 for half an hour after taking it. Beneficial effects of this remedy are 
 rarely seen until it has been administered in this way for several 
 months, yet this must be considered not as discouragement but as 
 a stimulus to a faithful trial of the article, for it is to be remem- 
 bered that ergot is the sole hope in the way of medicines. While 
 the attempt is thus being made to remove the cause, several com- 
 plications may require treatment ; these arise from displacement 
 of the uterus, and, therefore, pressure on surrounding organs, and 
 from derangements of menstruation. Some of the uterine displace- 
 ments may, perhaps, be remedied by the use of pessaries, as before 
 
 ir 
 
 ■ 1 ■■ ' 
 
 I 
 ill 
 
 ' 
 
 
 ] ? 
 
 .:| 
 
 Ml, 
 
 
ioi6 
 
 DISEASES OK WOMEN AND CHILDREN. 
 
 : ii:i! 
 
 indicated ; the pressure upon neighboring organs can be, in some 
 instances, relieved by the judicious use of abdominal supporters. 
 The excessive menstrual flow is usually the most alarming and in- 
 jurious feature of the case. In almost every instance where the 
 presence of a fibroid is accompanied by profuse menstruation, it is 
 advisable for the patient to remain in bed for a day or two before 
 and during the flow. It may be possible to accomplish good by 
 the administration of dilute sulphuric acid, ten to fifteen drops in 
 a teaspoonful of water every four hours ; or gallic acid, ten grains 
 in water every four hours. Yet, perhaps, the best measure for 
 controlling hemorrhage is the use of a tampon in the vagina. This 
 may be made by saturating the cotton with a solution of alum. It 
 is advisable, however, not to apply this tampon until after the flow 
 has continued three or four days ; that is, until a sufficient amount 
 for a natural menstruation has escaped. The tampon may be 
 renewed three or four times a day until the flow is somewhat con- 
 trolled, yet all these measures in obstinate cases fail to relieve the 
 difficulty. The hemorrhage may become so profuse and long-con- 
 tinued as to blanch and weaken the patient materially. In such 
 cases, the services of the medical adviser should be at once pro- 
 cured, since the matter is too serious to be longer entrusted to un- 
 skilled hands. 
 
 In all instances, the object must be simply to controi the more 
 unfavorable symptoms, with the hope that the ergot may be suc- 
 cessful in at least arresting the growth of the tumor. If these 
 means fail, there remain no other measures for relief than surgical 
 interference. The danger and the success attendant upon opera- 
 tions for the removal of uterine fibroids depend almost entirely 
 upon the location of the tumor or tumors. When the fibroid pro- 
 jects into the uterine cavity, the chances of its removal by the use 
 of erfjot are most favorable; and, if this fail, it is not seldom acces- 
 sible to the use of instruments through the vagina without expos- 
 ing the patient to extreme danger. Yet one difficulty in these cases 
 is the fact, that uterine fibroids are rarely solitary ; if one be present 
 there is almost an absolute certainty that others are growing in its 
 vicinity. Hence, the removal of one tumor through the vagina 
 does not necessarily cure the disease, nor relieve the sjmiptonis, 
 which may be continued by other fibroids which remain. The 
 complete removal of such tumors can usually be secured only by 
 an operation whereby the abdomen is opened. The results which 
 
 m.d 
 
EN. 
 
 POLYPS. 
 
 IO17 
 
 s can be, in some 
 minal supporters, 
 alarming and in- 
 istance where the 
 menstruation, it is 
 day or two before 
 coniplish good by 
 to fifteen drops in 
 lie acid, ten grains 
 best measure for 
 the vagina. This 
 lution of alum. It 
 until after the flow 
 a sufficient amount 
 tampon may be 
 N is somewhat con- 
 s fail to relieve the 
 )fuse and long-con- 
 laterially. In such 
 Id be at once prn- 
 rer entrusted to un- 
 to control the more 
 ergot may be suc- 
 tumor. If these 
 relief than surgical 
 ndant upon opera- 
 nd almost entirely 
 en the fibroid pro- 
 emoval by the use 
 Is not seldom acces- 
 na without expos- 
 culty in these cases 
 ; if one be present 
 :ire growing in its 
 Ihrough the vagina 
 ve the symptoms, 
 liich remain. The 
 secured only by 
 The results which 
 
 have thus far attended this operation are not such as to encourage 
 surgeons to undertake it. It is advisable in those cases which 
 cannot be relieved by other means than such an operation, to 
 employ all possible means for arresting the growth until the occur- 
 rence of the change in life, after which time no further danger is to 
 be apprehended. 
 
 Polyps. 
 
 By a polyp of the womb we understand a tumor which projects 
 into its cavity, or even hangs into the vagina. These growths are 
 often merely enlargement of the mucous membrane which lines the 
 cavity of the womb. 
 
 Causes. — While it is impossible to say, with certainty, what 
 induces such growths, it is well ascertained that they occur with 
 especial frequency after along-continued inflammation of the womb, 
 and after obstinate derangements of menstruation. 
 
 Symptoms, — The earliest manifestations of a polyp in the 
 womb do not differ materially from those of other uterine affections; 
 there is pain in the back and loins, derangement of menstruation, 
 which is usually more profuse and painful. Sooner or later, there 
 appears leucorrhcea ; the menstrual discharge contains abundant 
 clots, yet it will be seen these symptoms alone do not afford 
 positive proof of the existence of a polyp — since they may be 
 also induced by other conditions. The final proof consists in the 
 detection of a tumor by a vaginal examination. 
 
 Polyps of the womb are attended with no danger to the life 
 of the patient ; though so long as they remain the woman's health 
 will be more or less seriously impaired, and the performance of 
 her sexual functions interfered with. In some cases, nature effects 
 a spontaneous cure, whereby the tumor is made to drop off and 
 escapes by the vagina. Yet these are exceptional cases ; in the 
 majority of instances, the symptoms already mentioned persist, 
 and increase in violence, until the patient's life may be rendered 
 unendurable. 
 
 Treattnent, — Until the symptoms have become such as to 
 seriously annoy the patient, it may be well to attempt palliation, 
 rather than cure, since the latter measure is not wholly devoid of 
 
 .f. )£ 
 
I'l!!' 
 
 I 
 
 IO18 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 danger. To mitigate the severity of the symptoms, several 
 measures maybe employed; first, the uterus maybe replaced — 
 for it is usually somewhat displaced by the tumor — and held in 
 position by a pessary ; care may be taken to transfer the weight 
 of the skirts from the hips to the shoulders ; constipation should 
 be avoided, and the bladder regularly evacuated. During the 
 intervals between the monthlies ergot may be administered in the 
 quantity mentioned when speaking of fibroid tumors, with the 
 hope of securing the separation and expulsion of the growth. 
 During the menstrual flow the patient should be kept in bed, and 
 after the escape of the quantity of blood usual to her natural monthly 
 periods — say after two or three days — a tampon saturated with a 
 solution of alum may be introduced into the vagina, with the hope of 
 arrestin;:; the flow. If the hemorrhage be found steadily to increase at 
 successive menstrual epochs, so that the loss of blood becomes a 
 serious factor in the case, it becomes necessary to resort to curative 
 measures. These consist simply in the removal of the growth — 
 a proceeding which must, of course, be relegated to the medical 
 attendant. The danger attendant upon this operation will depend 
 very much upon the position and the size of the tumor ; in the 
 majority of instances, there is little difficulty and no danger in the 
 operation ; exceptional cases occur, in which serious results may 
 follow. The question as to the advisability of the operation will, 
 of course, be determined by the physician. 
 
 Cancer of the Uterus. 
 
 
 This, one of the most dreadful of the ills that flesh is heir to, 
 is certainly the most dreaded by women ; and it must be admitted 
 that this dread iic well founded, not only in the incurability of the 
 disease, but also in the frequence of its occurrence. Cancer may, 
 of course, affect males as well as females, and many other organs 
 as well as the uterus ; yet it is definitely established by the observ- 
 ation of thousands of cases, that cancer attacks three times as 
 many women as men, and that in one out of every three cases in 
 which the disease occurs in woman it begins in the womb. Yet it 
 must be remembered that these are relative, and not absolute, 
 figures ; in other words, that although one-third of all women who 
 become victims of cancer have cancer of the womb, yet these con- 
 
CANCER OF THE UTERUS. 
 
 IOI9 
 
 nptoms, several 
 ^ be replaced — 
 r — and held in 
 nsfer the weight 
 istipation should 
 d. During the 
 ninistered in the 
 umors, with the 
 I of the growth, 
 kept in bed, and 
 2r natural monthly 
 :i saturated with a 
 a, with the hope of 
 adily to increase at 
 
 blood becomes a 
 3 resort to curative 
 1 of the growth — 
 ed to the medic;il 
 eration will depend 
 the tumor ; in the 
 ,d no danger in the 
 erious results may 
 
 the operation will, 
 
 lat flesh is heir to, 
 must be admitted 
 incurability of the 
 nee. Cancer may, 
 many other organs 
 ihed by the obscrv- 
 icks three times as 
 |very three cases in 
 the womb. Yet it 
 I, and not absolute, 
 of all women who 
 mb, yet these con- 
 
 stitute a very small minority of women ; that the great majority 
 can rest assured of entire freedom from this affection. This fact is 
 so self-evident that it seems scarcely worthy of especial attention ; 
 but stress is laid upon it from the fact, that almost every woman 
 who suffers from any afiection of the womb — and a great many 
 others — live in constant dread of becoming victims to this disease. 
 
 There is a prevalent belief, even among physicians, that the 
 development of disease may be hastened, or even started, by the 
 use of the imagination ; and that an individual who entertains a 
 profound dread of a given disease, and is constantly indulging his 
 thoughts and fears with regard to his chances of becoming a victim, 
 is more liable to acquire the disease than would have been other- 
 wise the case. In accordance with this idea some arc inclined to 
 attribute the frequency of cancer of the womb to the general dread 
 of the disease entertained by women whose fears lead them to 
 attribute the symptoms of even the simplest uterine difficulties to a 
 supposed cancer. It is not necessary to discuss here just how 
 much value may be attached to this belief, but it is certain that 
 the general health of many a woman has suffered seriously from her 
 groundless anxiety as to the existence of cancer in her own person. 
 
 Causes, — Imagination always riots in the attempt to explain 
 the mysterious and unknown ; a principle of which no better illus- 
 tration could be found than in the popular ideas concerning the 
 nature of cancer. Until recently the popular explanation of cancer 
 — as well as of all other diseases, in fact — has been that the " blood 
 is impure." It is scarcely necessary to say at this latter day that 
 cancer is not a disease of the constitution, not an impurity of the 
 blood, but a local affection entirely. Another popular belief, which 
 is shared by some medical men even to the present day, is that can- 
 cer is hereditary ; that children of parents who have had cancer are 
 more liable than other individuals to the disease. This, too, must 
 be classed among the exploded, or at least the unprovcn, beliefs 
 with regard to this affection. It is, doubtless, true that cancer does 
 frequently occur in individuals some of whose relatives have been 
 also afflicted in the same way, but it is ascertained that in the 
 majority of cases — about nine out of ten — it is impossible to dis- 
 cover any previous history of the disease in the family. The facts 
 as at present known all indicate that cancer is a local disease, de- 
 veloped without any constitutional tendency of the individual or 
 
 hereditary disposition in the family. 
 66 
 
 Hi 
 
 It 
 
 I 
 
 M '• 
 
' il' 
 
 i f 
 
 i\y 
 
 I020 
 
 DISEASES OK WOMEN AND CHILDREN. 
 
 Hull"! 
 
 Now, it may be asked, what is the cause? To this it may he 
 replied that two influences are known which certainly exert a power- 
 ful effect in inducinj; the disease. One of these is local irritation, 
 the other a defect in the orjjanization of the foetus. With regard 
 to the latter — the discussion of which would be a strictly physi- 
 ological matter — nothing need be said hero ; as to the former — 
 the local irritation — it seems unquestionable that the development 
 of cancer is favored, if not induced, in this, way. It is a familiar fact 
 that those parts of the body which in both sexes are especially 
 prone to the development of cancer, are also in nearly all cases 
 especially exposed to mechanical irritation. Thus a common seat 
 of cancer in man is the lower lip ; and it is the experience of every 
 surgeon that these cancers occur with especial frequency in those 
 addicted to the excessive enjoyment of clay pipes — the usual pic- 
 ture presented being a cancer on the lip corresponding in position 
 to the hollow which has been worn into the teeth by which the pipe 
 has been habitually held. Among women the most frequent seats 
 of cancer are the mouth of the womb and the breast — two organs 
 which are in the natural course of events especially exposed to local 
 injury ; among unmarried women cancer of the womb is a rarity. 
 Yet it must be acknowledged that in a considerable number of cases 
 of cancer this cause cannot be fairly assumed as the starting point 
 of the disease. It seems, too, that no cause is capable of develop- 
 ing cancer during the earlier years of life. Cancer is extremely rare 
 in individuals under 30 years of age, and occurs with greatest fre- 
 quency between 40 and 60 years. This is true of cancer affecting 
 the womb as well as other organs. It is also established that the 
 disease is most frequent among women who have borne many chil- 
 dren. Hence, every woman under 40 years of age, especially if 
 she has not been often pregnant, should in justice to herself foe! 
 assured that she is safe from this terrible malady ; even if she have 
 some of the symptoms which will be presently described as those of 
 cancer ; even though there may be a tradition in her family that her 
 grandmother's aunt had a cancer, let her dismiss at once ail icars 
 and anxiety upon this score. 
 
 Symptotns, — As a general rule, it is impossible even for 
 the trained physician to recognize at the very onset of the difificulty 
 a cancer of the womb, for the disease begins with the same symp- 
 toms and presents to the eye the same appearances as other affec- 
 
CANCER OK THE UTLKUS. 
 
 102 I 
 
 t\i9 it may be 
 jxcrt a powcr- 
 ocal irritation, 
 With regard 
 strictly pliysi- 
 thc former — 
 e development 
 is a familiar fact 
 s arc especially 
 learly all cases 
 a common seal 
 crience of every 
 pjency in those 
 _ the usual pic- 
 iding in position 
 ,y which the pipe 
 3St frequent seats 
 ast — two organs 
 T exposed to local 
 womb is a rarity, 
 fe number of cases 
 he starting point 
 ipablc of develop- 
 is extremely rare 
 with greatest fre- 
 f cancer affecting 
 tablished that the 
 borne many chil- 
 age, especially if 
 ce to herself feel 
 even if she have 
 'scribed as those of 
 her family that her 
 at once ail tears 
 
 npossible even for 
 set of the difficulty 
 Ith the same symp- 
 other affcc- 
 
 ices as 
 
 tions which are not cancer. It is possible, indeed, that some t)f 
 these other affections become tranv'"-^ med into cancer after months 
 of existence. The first manifestations have been, indeed, already 
 mentioned as those of other uterine complaints — pain in the back 
 and pelvis, leucorrhcjea, profuse and fretpient menstruation. Thus 
 far there is nothing characteristic of cancer ; but in a short time the 
 patient and her friends will notice that the discharge is peculiarly 
 offensive ; that the leucorrhcjea is replaced by a bloody, fetid dis- 
 charge, which often contains clots and shreds of flesh. In some 
 cases the pain becomes a marked feature ; it is usually intermittent, 
 being sharp and obstinate during one day for example, and then 
 almost unnoticed on succeeding days. Pain is not, however, neces- 
 sarily present in these cases. The general healtli of the patient 
 always suffers and may, indeed, attract attention before the local 
 symptom- le especially noticeable. The patient becomes weak, 
 appetite i.. 'mpaired, and indeed all the functions are performed 
 in a way which indicate a vital failure, A usual, though not invari- 
 able characteristic of this affection is a peculiar hue of the skin, 
 which may be best described as straw color. 
 
 The patient's suspicions as to the cancerous nature of the com- 
 plaint are usually first aroused by this group of symptoms — pro- 
 fuse menstruation, fetid discharge and beginning failure of health. 
 In the majority of cases the physician is not consulted until these 
 symptoms appear in other words, until ulceration has already be- 
 gun. Yet it must be admitted that previous to this time it is not 
 always possible to establish certainly the nature of the disease, and 
 even then cases arise in which there is a possibility of doubt. Yet 
 an examination with the finger usually decides the question. The 
 mouth of the womb is hard, unyielding and rough, and bleeds 
 readily upon the lightest totich. Indeed without this examination 
 a positive decision is usually impossible, since there arc several 
 other conditions which may give rise to the group of symptoms 
 above mentioned, including even the fetid discharge and failure of 
 health. Among these are fibroid tumors in the cavity of the womb, 
 polyps and severe ulcerations from other causes. Not the least 
 common of these is the ulceration in the vagina and rectum, which 
 occurs from syphilis. This mistake has been often made, especially 
 since this disease may occur in women who, conscious of their own 
 rectitude, do not conceive the possibility that they have contracted 
 this affection. 
 
 \ 
 
 ; I 
 
 !^ M , 
 
1022 
 
 DISEASES OF WOMEN AND CHILDREN 
 
 Treatment. — The only possible hope of recovery from a 
 uine cancer of the womb — or of any other organ for that matt 
 consists in the complete removal of the diseased tissue and of 
 healthy flesh in its immediate vicinity. It cannot be too often 
 too emphatically stated that the time spent in employing less 
 ical measures, in applying salves and pastes and plasters, is nic 
 affording the cancer a better chance for spreading further intc 
 body, and thus becomirg utterly incurable. The history of rr 
 cine records not a single instance in which a cancer, properlj 
 called, was cured unless removed. There are, it is true, numc 
 cases in which different ulcers, falsely styled cancers by indivic 
 who profess to cure this malignant affection, have been hcalci 
 treatment. Yet these are not cancers. The choice of mean 
 removal must depend upon the location of the tumor and upor 
 extent of its ravages. Could we be sure of removing al) the 
 eased structures, we might be confident of our power to hea 
 disease. In some locations — of the lip for example — the c 
 removal of the growth is followed in most instances by entire f 
 dom from the affection subsequently ; but in caicerous disease 
 the womb an operation is not accompanied by the same assura 
 of success, for in consequence of the anatomical position of 
 organ, the disease is not detected so readily nor so early as in 
 former instance, and for the same reason its removal present 
 many difificulties as to be but seldom followed by entire succ 
 Yet whatever hope exists must be based upon the attempt al 
 moval. It is not necessary to detail the measures and mctl 
 employed for this purpose ; it may suffice to say that at an e 
 stage of the disease the necessary operation docs not imperil 
 life of the patient, and should be always performed, since m 
 cases are recorded in which life has been saved, or at least proloii 
 in comfort. In the more advanced cases the disease has usually 
 vadcd the deeper parts of the uterus as well as surrounding org 
 Even in these instances a complete cure has been effected by 
 removal of the entire womb, though this operation has not as 
 been employed with sufficient frequency to determine the chai 
 of success offered by it. 
 
 If the disease be too far advanced to warrant an operation 
 treatment resolves itself into an effort to make the patient as c 
 tortable as possible. To accomplish this, two measures are ne 
 sary : first, the use of opium to such an extent as to render 
 
) CHILDREN. 
 
 DISEASES OF TliP n,r. 
 
 lUh OVARIES. 
 
 patient insensible to pain • • i ^ ^^^^ 
 
 become a., habilual opium-'eatcr' '' """^ ^' ^'^^''•able for her . 
 from pain and runs no dan^o; ,"" ^'^^^^^^ ^1- -cures freed„ 
 patient be incaoabl^ -,= ^liortoning her Iffp c, '^^'^^"^ 
 
 other narcoH^ . " '°"^^ ''""'^n arc of toT ^^^°"'^ ^he 
 
 -"--..- .....4 jr;;i;:;T*-^^ 
 
 Carbolic acid, . 
 
 Alum, . ' . _ " - One teaspoonful. 
 
 Glycerine and water, - " " ^''^ " pound. 
 Two tablespoonfuls of this „,„ u " ' '^""'^ °"'^ P'"'- 
 and used for vagina, injec.io"„ ^..t":; "'° ^. ^-rt of „,™ ,„,,„ 
 on the patient „ay take a war™ Jo Z', """=' " "'"y- 'n add 
 
 wou.y '<c.„ibedXcrp:;:~« -pon o'/r ';:!• 
 
 . There is no hope of cure h, ="'™ntaBe. ^ 
 
 -^y. it is true, take with advan'ar?' "' "^^-■-- The patient 
 'or the purpose of increasing he" ,1, T' "'°" ""'' ^^1"=. mc-l 
 "-. Her diet should be bind d *" " ■''"'' ™P™"''S '-- dig ! 
 ;ns; milk would be found of gre t KeTirT'^' *«'S'' ""-t - 
 -0 qualities^ „efore the Ine'Xbl f L .e '"" '"""'"'"^ •"' 
 't 'v,]l be found necessary to exercise ,1 '""""'-"ion of the case 
 ■ng measures both for the physte r r "'"^ '■"K'--"-'y in invem! 
 -staming her flagging strengt tT" ' "' "'" P^"="' -"d for 
 '- ar.se, and cannot be desc'ri edl d^ail"' "' ""' =^ ™-S- 
 
 Diseases of the Ovaries. 
 
 The ovaries are nrpi„ «.u 
 C".«plicat,on of other d tt' "tI, "' "'"""'"■•^'1°" ex-cept as a 
 ■nvolvmg the tissue around he won!b ''"T"'"'-- '""an.mation 
 "var-cs, one or both, in the inflamma, ""^^'1"--'"'ly includes th 
 
 ■nfla,„ma.io„ may result as ."n^rL^rfTh: in^f ''"'■'■'"^- 
 
 ' tne inflammatory pro- 
 
 
 f n 
 
 i .' 
 
 ill 
 
I024 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 ! :} 
 
 cess from the womb, or even from the vagina. It occurs wit 
 especial frequency as a result of the contagious disease of the vag 
 ina known as gonorrhoea. Except in connection with other dii 
 eases, acute inflammation of the ovaries rarely or never occur; 
 though it is possible that some of the symptoms attendant upo 
 derangements of menstruation are due to inflammation of th 
 ovaries. 
 
 The more frequent occurrence is a chronic inflammation of tli 
 organs. This, too, is commonly associated with or results fro! 
 inflammation of other tissues, especially of the womb ; yet it doc 
 seem to occur as a primary affection, causing a certain group ( 
 symptoms without involving the other sexual organs. It seen 
 certain that many of the puzzling causes of so-called womb di: 
 ease — cases in which the symptoms are entirely too severe to t 
 explained by the slight derangement of the womb — are reall 
 instances of ovarian and not uterine disease. 
 
 Among the symptoms of a chronic inflammation of the ovarie 
 are pain and tenderness over these organs (on either side of tli 
 womb in the groin) ; sometimes derangement of menstruation, bi 
 more frequently interference with locomotion, so that such patieni 
 are often unable to walk across the room ; hysteria is a not infrc 
 quent complication. In these instances, the tendency to hysteria i 
 especially manifested during and previous to the menstrual epocl 
 at which time, too, the pain and weight in the pelvis are greatl 
 aggravated. All sources of sexual excitement increase the dilT 
 culty, so that intercourse is sometimes impossible. If both ovarie 
 are di'^pa=cd the woman is usually sterile. 
 
 Trefitnietit. — The best hope of restoration to health lies i 
 the avoidance of everything which can induce a flow of blood t 
 the ovaries ; hence all sexual excitement should be avoided an 
 the patient should rest before iuid during the monthlj- flow. Fru 
 quent and copious vaginal injections of warm water ,ind the use ( 
 hot hip-baths will also tend to subdue the inflammation. A con 
 stantly used, though not very efficient remedy, consists in applyiii 
 fly-blisters or the tincture of iodine to the abdomen over the loca 
 tion of the ovaries. Instances have been known in which this con 
 dition has entirely disappeared after conception had occurred - 
 presumably because during pregnancy the ovaries escape the usua 
 monthly congestion with blood. 
 
,DREN. 
 
 ina. It occurs with 
 IS disease of the vag- 
 iction with other dis- 
 ely or never occurs, 
 ptoms attendant upon 
 inflammation of the 
 
 ic inflammation of the 
 with or results from 
 he womb ; yet it does 
 ng a certain group of 
 lal organs. It seems 
 f so-called womb dis- 
 tirely too severe to be 
 he womb — are really 
 
 mmation of the ovaries 
 ; (on either side of the 
 it of menstruation, but 
 n, so that such patients 
 hysteria is a not infrc- 
 
 tendency to hysteria is 
 the menstrual epoch, 
 
 the pelvis are greatly 
 nent increase the diffi- 
 ible. If both ovaries 
 
 ration to health lies in 
 uce a flow of blood t(i 
 hould be avoided ami 
 c monthly flow. Vr^ 
 n water .md the use of 
 nflammation. A con- 
 ]y, consists in applying 
 ibdomen over the loca- 
 own in which this con 
 :ption had occurred - 
 varies escape the usual 
 
 OVARIAN TUMORS. 
 
 Ovarian Tumors. 
 
 1025 
 
 The ovaries are subject to tumors of several varieties which it 
 is not necessary to specify here ; they may exhibit among other 
 kinds fibroid and cancerous tumors, though with far less frequency 
 than others. The two most common varieties are the so-called 
 ovarian cysts and the dermoid cysts. The latter though less fre- 
 quent, may be described first. They consist each of a sac with 
 fluid contents, in which are contained skin, fat, hair, teeth, bone, 
 cartilage and other tissues. These sacs are not peculiar to the 
 ovary, since they may be found in other organs of the body. The 
 interesting feature with regard to these dermoid cysts, is the fdct 
 that they may be present in cliildhood, or even well-developed at 
 birth. An instance is recorded in which delivery was impossible 
 because of some unknown obstruction ; the physician destroyed 
 the child and removed it in pieces, when he discovered that the 
 unknown obstacle was simply an enormous dermoid cyst, which 
 rendered natural delivery of the foetus impossible. The contents 
 of these cysts may vary as to the quantity and kind of human tis- 
 sues contained therein ; they are rarely larger than an adult head, 
 though they have been known to contain over a hundred teeth. 
 These tumors, since they do not grow beyond a certain size, do 
 not threaten the existence of the patient's life directly ; yet, on the 
 other hand, they are especially liable to excite inflammation of the 
 surrounding tissues, which may result fatally. So long as they 
 remain of their usual small size, they require no treatment ; indeed 
 it is not unusual to find after death such a tumor, whose existence 
 was never suspected during life. 
 
 The majority of ovarian tumors are the so-called cysts which 
 seem to result from the imperfect performance of menstruation. It 
 will be remembered that the c<^g is contained in a minute sac, 
 which lies in the substance of the ovary ; and that at the ni'-nstrual 
 periods this sac swells, bursts and permits the escape of the egg. 
 Now if this minute sac fails to burst, but continue increasing in 
 size by the addition of a watery liquid, the result is a so-called 
 cyst, that is a membranous sac full 'of fluid ; such seems to be the 
 origin of ovarian tumors. It is not infrequent to find that the cyst 
 is subdivided into compartments by partitions running- through it, 
 that it is indeed a collection of cysts, and not a single sac. 
 
 '^% 
 
 •m 
 
 if 
 
 % 
 
 Hi 
 
 
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 III 
 
 M 
 
 •I P 
 
 ! 
 
 j i 
 
 t.' 
 
 ■4 
 
 
 
 i! ■ 
 1 ii 
 
 '■ ' i 
 
 JL 
 
1026 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 The size which these cysts may attain seems to be limited or 
 by the strength and endurance of the patient, since instances i 
 on record in which the sacs have contained over lOO pounds 
 Hquid, The contents are usually clear fluid, containing more or It 
 albuminous material, and sometimes a jelly-like matter. The rig 
 ovary is more frequently affected than the left. 
 
 Causes, — We have no definite information as to the causes 
 ovarian cysts, that is why these little sacs should fail to ruptui 
 and continue their growth. Certainly it occurs only during a pcri( 
 of ovarian activity, as a rule, since the formation of an ovarian c) 
 before puberty is a rare occurrence. It is, however, possible ev 
 for a child to have a true ovarian cyst. These tumors have be 
 discovered and removed from girls six years of age. These cy< 
 may last a considerable time without causing noticeable sympton 
 and even after their presence has been discovered they may grc 
 so slowly as to occasion no serious difficulty for five, ten or cv< 
 twenty years. Sometimes, indeed, nature effects a spontanco 
 cure, the fluid is absorbed, and the tumor disappears as quietly 
 it came. These are, however, the exceptional cases. It may n 
 be expected that such a favorable issue will occur. The usii 
 course is a gradual but uninterrupted increase in size, until tl 
 pressure upon surrounding organs occasions serious interfercn( 
 with the functions of life. Sometimes an even less favorable cour 
 occurs. The cyst may rupture, discharge its contents into the al 
 dominal cavity, and occiision a serious, even fatal inflammation ; ( 
 the wall of the cyst may undergo spontaneous inflammation, resul 
 ing in high fever and, perhaps, blood-poisoning. 
 
 If none of these accidents happen, and if the growth of tl 
 tumor is not so rapid as to impair the performance of other fum 
 tions, no operative interference will be necessary until the usu 
 complications occur. These consist of derangements of the bowc 
 and bladder, dropsy, interference v .Ih digestion. Relief from tl 
 immediate symptoms can be obtained by tapping the cyst, siiu 
 the patient obtains a temporary respite by the withdrawal of ll; 
 fluid. 
 
 Si/inptoms, — During the earlier development of the tunic 
 but few symptoms are ordinarily manifested, and even after it h; 
 attained the size sufficient to attract attention it becomes difficult t 
 decide definitely upon the nature of the growth. This is espcciall 
 
 :»' 
 
:.DREN. 
 
 ms to be limited only- 
 it, since instances are 
 over lOO pounds of 
 3ntaining more or less 
 ke matter. The right 
 
 ion as to the causes of 
 hould fail to rupture, 
 rs only during a period 
 tion of an ovarian cyst 
 lowever, possible even 
 cse tumors have been 
 5 of age. These cysts 
 T noticeable symptoms, 
 ■ovcred they may grou- 
 ty for five, ten or even 
 i effects a spontaneous 
 disappears as quietly as 
 Mial cases. It may not 
 will occur. The usual 
 rcase in size, until the 
 ,ns serious interference 
 en less favorable course 
 ts contents into the ab- 
 . fatal inflammation ; or 
 lus inflammation, resuU- 
 
 ning. 
 
 Id if the growth of tlu 
 lormance of other fuiic- 
 [ccssary until the usual 
 Ingements of the bowels 
 Ition. Relief from the 
 [tapping the cyst, since 
 the withdrawal of the 
 
 kopment of the tumor 
 
 , and even after it has 
 
 \\ it becomes difficult to 
 
 Ivth. This is especially 
 
 OVARIAN TUMORS. 
 
 1027 
 
 the case if, as sometimes happens, the menses are suppressed, for 
 if the woman be a wife she naturally suspects pregnancy. Later 
 there may occur some of the ordinary symptoms of pregnancy, due 
 to the pressure upon different organs by the increasing tumor; 
 nausea and vomiting and even unusual sensations in the breasts 
 have been known to accompany the growth of ovarian cysts. So, 
 too, the tumor may occasion the same derangements of the bowels 
 and bladder which result from the presence of the pregnant uterus. 
 On the other hand there are various affections — fibroid tumors of 
 the womb especially — which can be with difficulty distinguished 
 from ovarian tumors even by the physician. It is not our purpose 
 to discuss the various means for distinguishing a tumor of the ovary 
 from the various other enlargements which the abdomen may pre- 
 sent ; the matter must be entrusted to the medical adviser in each 
 case. 
 
 Treatment. — Medicines are utterly unable to effect a cure of 
 this complaint ; they may of course be useful in supporting the 
 strength of the patient, and thus enabling her to bear the diftcrcnt 
 surgical measures necessary for her relief. The first and less 
 formidable of these consists in tapping, whereby the greater part 
 of the fluid can be withdrawn ; although this measure is not entirely 
 devoid of danger, it is far safer than the attempt at radical cure 
 by operation. 
 
 In some cases, too, repeated tappings, as they became necessary 
 after intervals of several months, have been followed by complete 
 relief, the tumor having failed to reappear after the last tapping. 
 This, however, cannot be regularly nor even usually expected ; in 
 the majority of instances tappings accomplish merely temporary 
 relief c.nd the postponement of the operation for cure. In the last 
 decade this operation — technically called ovariotomy — has become 
 so devoid of danger that surgeons now strongly advise against 
 tapping, since the final operation is thereby rendered more compli- 
 cated and less certain of a good result. 
 
 As for the operation itself — the removal of the ovaries with the 
 tumor in question — it is unnecessary to say anything except that 
 nowhere has a greater advance in surgical procedures been manifest 
 than in this very operation. By improvements in methods the 
 mortality following the operation has been so reduced that ovari- 
 otomy has lost much of the terror that the word formerly inspired. 
 
 ; 
 
 
 ^ 
 
 ■i-Tri 
 
 I, -1 
 
 Hn 
 
 H 
 
 >w 
 
 i 
 
 I' 
 
 1 
 
 •il: ' 
 
 ■ ■ ■ i I I 
 
 ' ' 1 
 
 1 i-' ! 
 
 iJ 
 
 I! 
 
 II' 
 
 
I028 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 In the latter years the death rate after this operation has be 
 reduced to one case in ten, fifteen or even twenty. 
 
 Sterility. 
 
 ' ;; 
 
 To comprehend the nature of sterility, one must bear in mi 
 the different factors necessary for conception. In the first pla 
 the male fluid must be capable of fecundating the ovum ; sccoi 
 it must have access to the cavity of the womb ; and, third, 1 
 lining membrane of this cavity must be in a healthy condition 
 receiving and nourishing the fecundated ovum. In view of th( 
 facts, it is evident that any one of several conditions may prevc 
 the accomplishment of conception. 
 
 And first of all, let it not be forgotten that the husband m 
 be and often is responsible for the failure to procreate. In abc 
 one case out of six unfruitful marriages, the fault lies in the f; 
 that the male fluid is either incapable of fecundating the ovum, 
 is prevented by some fault or disease of the male sexual org? 
 from escaping into the vagina. This is peculiarly often the a 
 with men who have, in their earlier years, been unfortunate in th 
 indiscretions. In the majority of instances, however, the difficu 
 lies in the female. Evidently any one of four causes may prcvc 
 conception, even though the male clement be of proper qualit 
 first, any obstacle to the entrance of the seminal fluid into t 
 womb ; second, any condition which prevents the formation in t 
 ovaries of perfect ova ; third, any obstacle to the escape of the 
 ova into the womb ; fourth, any condition which prevents t 
 fecundated ova from lodging and receiving nourishment from t 
 lining membrane of the womb. Among the obstacles to t 
 entrance of the seminal fluid into the womb are displacements 
 this organ, extreme minuteness of the opening into its cavi 
 fibroid or other tumors, and vaginismus (the condition of unnatu 
 sensitiveness which renders intercourse impossible). Among t 
 causes which may prevent the formation of perfect ova are infla 
 mation and tumors of the ovaries. Among the obstacles to t 
 proper lodgment and proper growth of the ovum are the vario 
 forms of uterine inflammation, menorrhagia and metrorrhagia. 
 is scarcely necessary to refer in detail to the different ways in whi 
 
IP 
 
 LDREN. 
 
 ; operation has been 
 enty. 
 
 one must bear in mind 
 5n. In the first place, 
 ing the ovum ; second, 
 womb ; and, third, the 
 a healthy condition for 
 ^um. In view of these 
 conditions may prevent 
 
 n that the husband may 
 to procreate. In about 
 the fault lies in the fact 
 xundating the ovum, or 
 the male sexual organs 
 peculiarly often the case 
 t,cen unfortunate in their 
 ., however, the difficulty 
 four causes may prevent 
 ,t be of proper quality : 
 seminal fluid into the 
 .nts the formation in the 
 .^ to the escape of those 
 [ion which prevents the 
 g nourishment from the 
 g the obstacles to the 
 jb are displacements cf 
 pening into its cavity, 
 [e condition of unnatural 
 possible). Among the 
 f perfect ova are inflam- 
 ,ng the obstacles to the 
 he ovum arc the various 
 |a and metrorrhagia. U 
 different ways in which 
 
 DISEASES OV INFANTS — INDIGESTION. 
 
 1029 
 
 these various conditions prevent conception ; nor is it possible to 
 point out the means for ascertaining what the particular difficulty is 
 in every case. In justice to wives, however, who, in the popular 
 mind, are usually held responsible for sterility, and who keenly feel 
 the reproach attaching to this condition, it should be said that the 
 first step in ascertaining the cause for the sterility of a married pair 
 should be an examination as to the capabilities of the husband. 
 By a microscopic examination it can readily be determined which 
 party is responsible for the failure to produce children. Whether 
 or not the condition can be remedied depends, of course, upon the 
 source of the difficulty. Many of the causes above enumerated as 
 preventing conception can be readily removed. In every case the 
 matter must be placed in the hands of the medical adviser, who 
 alone can determine the cause of and responsibility for the diffi- 
 culty. 
 
 DISEASES OF INFANTS. 
 
 rious 
 
 While infants may be afflicted with the ordinary contagi 
 
 diseases by which older persons are attacked, yet there is a certain 
 number peculiar to infancy because dependent upon the relations 
 which exist during that period. The majority of these are affections 
 of the digestive organs — indigestion and its consequences — which 
 may be in nearly all instances traced to improper feeding. These 
 may occur not only by the administration of improper articles of 
 food, but also in consequence of errors in diet or in personal ci 
 on the part of the mother. 
 
 Indigestion. 
 
 care 
 
 The occurrence of indigestion is a common incident in the life 
 of nearly all infants. In most cases it is but temporary and sub- 
 sides without serious interference with the general health ; at other 
 times it becomes obstinate, induces derangement of the bowels, 
 and results in marked emaciation and even in death. Indigestion 
 is indicated first by vomiting ; by this we must not understand the 
 usual act whereby a certain amount of curdled milk is rejected by 
 
 f: 
 
 I 
 
 '; 
 
 '(■1 ._ 
 
 I 
 
 ,' . 
 
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 \: ' 
 
 P 
 
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 ■ \i 
 
 i 
 
 u 
 
 t I 
 
 
 
 1 
 
 
 I "■ 
 
 
 s 
 
1030 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 il !' 
 
 the infant, as usually happens after hearty nursinpf ; this is a har 
 less procedure which occasions the baby no effort, no pain i 
 exhaustion, and is consistent with good digestion. If, howev 
 there be introduced into the stomach substances unfit for digesti 
 or if there be persistent over-feeding of even good materia 
 vomiting occurs ; the child makes violent efforts, becomes pale a 
 languid. If this continue for a few days there ensues a loosent 
 of the bowels, the stools being ordinarily green and offensive, 
 many cases the appetite seems unimpaired ; the child takes t 
 breast eagerly, but is unable to retain the nourishment. This cone 
 tion often supervenes also upon sudden weaning or upon an abru 
 change of diet ; it may even occur when a wet-nurse is substituti 
 for the mother, and is especially liable to happen if this change 
 made in the early months. In not a few cases it is to be attribute 
 to the habit of giving the child the breast at very short interval 
 especially when this plan is employed as the sovereign remedy f 
 fretfulness. The treatment must consist first in ascertaining tl 
 cause; sometimes it is simply necessary to lengthen the perioi 
 between nursing ; at other times it will be found that the troub 
 depends upon some error of diet on the part of the mother, i 
 every instance the nature of the child's food and the manner i 
 giving it should be carefully investigated before resort is had i 
 medicine. During the time of indigestion the stomach should b 
 allowed to rest by withholding all except small quantities of food ; 
 the vomited matters emit a sour odor benefit will be obtained b 
 mixing half a tcaspoonful of lime-water with a teaspoonful of mil 
 — the latter being obtained from the mother's breast if the child i 
 still nursing ; this may be repeated three or four times a day. ] 
 the difficulty persist more than two or three days, medical attendanc 
 should be secured ; since it cannot be too much emphasized tha 
 the foundation for the stomach and boivel troubles of infancy i 
 usually laid in some, at first trifling, error in digestion. 
 
 Thrush. — One of the incidents of indigestion, though some 
 times occurring independently of it, is the condition known a 
 thrush, wherein the tongue, inner surfaces of the cheeks, in fac 
 almost the entire cavity of the mouth, is covered with a thick whit 
 coat, that first appears in minute dots and small patches, and sub 
 sequently extends. This white material is a mass of vegctabl 
 matter — in fact a fungus similar to that which forms the mould oi 
 jelly and bread. The result of this presence is extreme irritatioi 
 
ILDREN. 
 
 DISORDERS OF THE BOWELS. 
 
 1031 
 
 irs'inpc ; this is a harm- 
 10 effort, no pain nor 
 gestion. If, however, 
 ices unfit for digestion, 
 even good materials, 
 brts, becomes pale and 
 lere ensues a looseness 
 een and offensive. In 
 . ; the child takes the 
 irishment. This condi- 
 iiing or upon an abrupt 
 vet-nurse is substituted 
 ippen if this change be 
 es it is to be attributed 
 at very short intervals, 
 l: sovereign remedy for 
 irst in ascertaining the 
 lengthen the periods 
 found that the trouble 
 art of the mother. In 
 wd and the manner of 
 before resort is had to 
 le stomach should bo 
 1 quantities of food ; if 
 fit will be obtained by 
 a tcaspoonful of milk 
 s breast if the child is 
 four times a day. If 
 ays, medical attendance 
 much emphasized that 
 troubles of infancy is 
 n digestion. 
 gestion, though some- 
 condition known as 
 of the cheeks, in fact 
 :red with a thick white 
 nail patches, and sub- 
 a mass of vegetable 
 h forms the mould on 
 e is extreme irritation 
 
 of the mucous membrane lining the mouth ; and it may grow into 
 the throat and gullet. When these patches are removed there 
 appears a red, perhaps bleeding, surface underneath. The treat- 
 ment consists in applying a saturated solution of borax say one 
 
 part in thirty— to these white patches by means of a soft cloth, 
 which may be gently rubbed over the surface in question. The 
 repetition of this application after every act of nursing will usually 
 be followed by a disappearance of this symptom. If the child is 
 using a bottle, especial care should be directed again to the cleans- 
 ing of the rubber nipple, tube, and everything with which the food 
 can come in contact. If this be unsuccessful, as is sometimes the 
 case, relief may be obtained by using in the same way a s,;iturated 
 solution of the sulphite of sodium, which may be obtained at the 
 druggist's. 
 
 Disorders of the Bowels. 
 
 The bowel complaints of infancy constitute a large part of the 
 disorders requiring the attention of a medical adviser. Indeed, the 
 alimentary canal of the child may be regarded in general as an 
 index to its general condition, since any departure from health is 
 soon signalized by the derangement of this most susceptible por- 
 tion of the individual. It should be understood that a certain 
 amount of latitude in the frequency and character of the intestinal 
 evacuations is consistent with a healthy condition. It may be 
 stated in general terms that during the first year of life the child 
 should have two movements of the bowels in twenty-four hours, 
 and during the second and subsequent years at least one during 
 tile same period. Yet just as certain variations and peculiarities 
 are observed among different individuals in adult life, so a certain 
 amount of departure from the usual rule is not inconsistent with 
 the natural condition of the infant, and it should be always remem- 
 bered, and cannot be too emphatically insisted upon, that a 
 derangement of the bowels is, in the majority of cases in infancy, 
 not a disease of the intestine, but a symptom of an unnatural 
 condition elsewhere ; and the first indication is always to seek the 
 cause of the difficulty — to ascertain the unnatural conditions to 
 which the child may have been in any way exposed. The indis- 
 criminate use of drugs in the treatment of bowel complaints is 
 
 I 
 
 :. ' 
 
 :! ! 
 
 ".- '^1 
 
 V 
 
1032 
 
 DISEASES OF WOMEN AND CHILDREN, 
 
 often productive of harm ; first, because the attention is there 
 directed and confined cxchisively to the bowels, while the ti 
 cause of the difficulty often lies elsewhere ; and, second, becai 
 the disordered action of the bowels is often merely a safety-va 
 for the relief of some other condition, and the effort to check t' 
 disorder may favor the continuance of the primary difficulty. 
 
 Diarrhea. 
 
 M,: 
 
 A simple looseness of the bowels, unaccompanied by pr 
 straining or notable change in the character of the discharges, i 
 frequent occurrence in the life of an infant, especially during 
 warmer months. This condition often occurs as the result and 
 companimcnt of indigestion ; it is therefore commonly accompan 
 by vomiting. In many instances it seems to result from simple 
 posure to cold, and can often be traced to improper clothing. In 
 these instances there is rarely any occasion for the adniinistrat 
 of drugs ; the detection of the cause — the needed change in 
 diet or in the clothing ; the exercise of ordinary care in avoid 
 exposure to draughts — is usually sufficient to restore the nati 
 condition of the bowels. 
 
 A second form of diarrhea is often accompanied by consid 
 able fever, indisposition for the breast and general restlessne 
 not infrequently vomiting occurs both at the beginning of the atte 
 and repeatedly after attempts at nursing. While such sympto 
 often usher in a serious illness, yet in numerous instances a lit 
 careful management completely restores the health of the child wit 
 a few days. The first requirement is to afford the stomach a 
 bowels an opportunity for repose, as a preparation for their reti 
 to the natural condition. Hence the breast should be withh 
 for half a day, during which time the child may be either entin 
 deprived of nourishment or fed with a little thin barley water; a wa 
 bath, followed by the application of clean warm flannel clothii 
 will usually suffice to accomplish the desired object. In some 
 these cases it may be necessary to administer four or five drops 
 castor oil with a single drop of laudanum or five to ten of pai 
 goric if the child be di year old; the latter agents, however, indc 
 all forms of opium, should be withheld from infants under thi 
 
[LDREN, 
 
 SUMMER COMPLAINT. 
 
 1033 
 
 e attention is thereby 
 owcls, while the true 
 and, second, because 
 1 merely a safety-valve 
 ;he effort to check that 
 rimary difficulty. 
 
 naccompanied by pain, 
 • of the discharges, is a 
 It, especially during the 
 ;ur^ as the result and ac- 
 commonly accompanied 
 to result from simple ex- 
 improper clothing. In all 
 1 for the administration 
 e needed change in the 
 rdinarycare in avoiding 
 It to restore the natural 
 
 :companied by consider- 
 md general restlessness; 
 e beginning of the attack 
 While such symptoms 
 lerous instances a little 
 health of the child within 
 afford the stomach and 
 paration for their return 
 ast should be withheld 
 may be either entirely 
 hin barley water; a warm 
 warm flannel clothing, 
 ed object. In some of 
 ter four or five drops of 
 _ or five to ten of parc- 
 I agents, however, indeed 
 cm infants under three 
 
 months of age, except when given by the direction of the physi- 
 cian ; for children are peculiarly susceptible to the action of this 
 drug, which may therefore have unexpected and serious effects. 
 
 While, then, the simple diarrhea of infancy already tiescribed 
 need rarely occasion anxiety or interference by the use of medicine, 
 yet there are circumstances which may modify this general state- 
 ment. First of all is the occurrence of these troubles during the 
 process of teething ; for at this time there may occur, in consequence 
 of the nervous excitability which results from the irritation in the 
 gums, more serious and obstinate difficulty than would otherwise 
 result. During teething, then, even the slight and simple diarrhea 
 should not be ignored. It is often asserted and generally believed by 
 mothers that teething is in itself sufficient to induce diarrhea ; this 
 is, indeed, possible, but in fact the frequent occurrence of diarrhea 
 during teething is to be ascribed not to this process, but to some 
 of the usual causes which exert at this time more than the usual 
 effect. Let not the mother, therefore, delude herself into the belief 
 that the diarrhea is unavoidable and requires no attention ; it is 
 extremely important that these diarrheas of teething be at once 
 controlled, in order that the child be not compelled to endure this 
 additional irritation and drain upon its strength. In these cases a 
 simple change of air, especially from the city to the country, will 
 often restore the bowels at once to their natural condition. 
 
 Summer Complaint. 
 
 The dreaded " summer complaint " of children enrolls upon 
 its list of victims a much larger number than are destroyed by 
 all the other diseases of infancy combined during the hot sum- 
 mer months; during one week in July, 1866. more than 1,200 
 babies died of this complaint in New York City 
 
 The condition generally begins, or rather is preceded for 
 some days, by diarrhea ; this is soon followed by violent vomiting, 
 and for a time the vomiting and purging constitute the prominent 
 features of the complaint. After two or three days, sometimes 
 only hours, the vomiting ceases, while the looseness of the bowels 
 persists. The child loses all inclination for the breast ; is peevish, 
 fretful, and subsequently listless and apathetic ; the head is hot, 
 
 m 
 
 rl I 
 
 ■ I 
 
 . i' 
 
 :♦ 
 
 i I 
 
 1 1 
 
 ■i 
 
 y.' 
 
 '. 
 
 
 li 
 
 ii 
 
 F,'' 
 
 fc 
 
 r 
 
'034 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 the abdomen usually swollen and often tender. In severe case: 
 the stools, at first ^rcen and frothy, become quite watery anc 
 almost devoid of all the usual characteristics. Such cases ofter 
 terminate fatally within four or five days or sooner ; during tht 
 latter part of the attack the infant becomes cold, its features pallit 
 and sunken, the abdomen retracted ; the general appearance sug 
 gests an emaciation such as follows a long and wasting sickness. 
 
 Such is the rapid course of this complaint during the very ho 
 weather and in the more closely settled parts of our cities. If the 
 heat be not so intense the affection is usually of longer duration o 
 of less immediate severity; for weeks and months, indeed, through 
 out the entire summer, the child is tormented with diarrhea ; vom 
 iting is frequent ; the stools arc usually green and very offensive 
 there is but little inclination for food, and whatever is swallowet 
 usually re-appears within an hour, so that it seems impossible 
 for the child to subsist upon the small quantity of nourishmeni 
 retained. The infant emaciates rapidly and often becomes a reall> 
 painful object to look upon. All the symptoms arc aggravatcc 
 during the unusually hot days, and improve correspondingly when 
 the temperature falls ; indeed, if the child be kept at home the result 
 seems to depend largely upon the weather. This affection is espe- 
 cially apt to attack the child during the teething process, and rarely 
 occurs after all the teeth have been cut. 
 
 So far as the home management is concerned, the treatment 
 must be simply an attempt at prevention ; and if certain measures 
 can be adopted, it will be usually possible cither to avert this trouble 
 entirely or to cut it short upon the manifestations of the first 
 symptoms. The mother of every child born during the warmer 
 season should anticipate and prepare for this trouble during the 
 following summer. The first measure for prevention consists in 
 the precautions already mentioned for che avoidance of intestinal 
 derangements in general ; precauti.Hi. as to the quality and quan- 
 tity of the diet, as to the regularity in the times of nursing, and 
 as to the observance of proper intervals between these times ; care 
 in the arrangement of clothing, etc. If, in spite of all precaution, the 
 symptoms of the disease manifest themselves, there remains one, and 
 but one, sovereign remedy — removal of the child into the country. 
 This change, made of course with all due precaution, will almost cer- 
 tainly save any child in the early stage of the disease, and will 
 often even restore the emaciated infant that has been for weeks 
 
 •'W.V 
 
T 
 
 DUF.N. 
 
 ;r. In severe cases 
 c quite watery and 
 Such cases often 
 sooner; during the 
 d, its features pallid 
 jral appearance sug- 
 wasting sickness, 
 t during the very hot 
 of our cities. If the 
 of longer duration or 
 iths, indeed, through- 
 with diarrhea ; vom- 
 II and very offensive ; 
 •hatever is swallowed 
 it seems impossible 
 ntity of nourishment 
 jften becomes a really 
 Dtoms are aggravated 
 correspondingly when 
 <cpt at home the result 
 This affection is espe- 
 ng process, and rarely 
 
 crned, the treatment 
 ,d if certain measures 
 r to avert this trouble 
 stations of the first 
 rn during the warmer 
 s trouble during the 
 rcvention consists in 
 ^oidance of intestinal 
 the quality and quan- 
 mes of nursing, and 
 ecn these times ; care 
 of all precaution, the 
 here remains one, and 
 ;hild into the country, 
 ution, will almost cer- 
 Ithe disease, and will 
 t has been for weeks 
 
 CONSTIPATION. 
 
 >035 
 
 wavering between life and death. The unfortunate thing about 
 this is, that summer complaint affects with especial frequency and 
 malignancy the children of those who are pecuniarily unable to 
 secure the advantages of country air for their infants, l-'or them 
 there remains merely tlie effort to secure as much of these advan- 
 tages as their means afford ; the child may be not only carried in 
 the parks and on the shores of neighboring streams, but should be 
 taken out for the day, at least, away from the debilitating in- 
 fluences of the city. It is often surprising to observe how much 
 good results from these simple daily excursions out of the city, 
 even though the child must be brought back every evening. The 
 value of this principle has been well illustrated in the floating hos- 
 pitals in operation in several of our larger cities. 
 
 These are charitable organizations whereby infants with their 
 mothers or nurses are transported upon the water, and receive the 
 beneflts of fresh air and cooler temperature for several hours dur- 
 ing the hot days of summer. The marked improvement resulting, 
 even in desperate cases of summer complaint, should encourage all 
 parents to repeat in a small and private way, if necessary, this plan 
 of securing a change of surroundings for the sick child during the 
 day, even if a sojourn of several weeks in the country be impos- 
 sible. 
 
 As for the employment of drugs in this affection it is unadvis- 
 able for any but a medical man to attempt their use. 
 
 Constipation 
 
 Is an occasional difficulty in infancy as well as in later cnild- 
 hood. It is advisable to check this disposition of the infant, since 
 after it has become habitual considerable difficulty may be experi- 
 enced. The favorite remedy of nurses, manna, is always effectual 
 but not desirable, since the habitual administration of laxatives 
 will in the course of time render them necessary. Hence it is ad- 
 visable, in case the bowels fail to move with the usual regularity, 
 to employ a small injection of warm salted water in the lower 
 bowel, or a small piece of soap may be introduced for the same 
 purpose. Yet even these measures are not called for by a simple 
 delay of a day or two unless some indisposition, such as slight fever 
 67 
 
 '■ f, i 
 
 u; >F! 
 
 I: 
 
 i 
 
 ' if 
 
 ;'W.1I 
 
 4 '1 
 
 * 
 
 0' 
 
 ■ ■ 1 
 
 
 M'. 
 
I036 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 and restlessness, be manifested. The majority of these cases 
 over-treated, a plan which often results in the production of 
 very evil which it is intended to avoid, habitual constipation. 
 a laxative must be used, five or ten drops of " cascara cordi 
 once a day, will be the best remedy. 
 
 Croup. 
 
 y 
 
 I : 
 
 Genuine croup, which means an inflammation in the upper j 
 of the air passages accompanied by the formation of a false m( 
 brane, is a most serious and justly dreaded affection. But 
 greater number of cases commonly termed croup are not of 
 inflammatory nature, and do not expose the life of the infan 
 serious danger. The former — true croup — taxes the utmost i 
 of the physician, and often requires surgical interference ; the la 
 — false croup — is usually relieved by simple household measu 
 It is therefore important to note the points of difference betw 
 the two, as indicating corresponding differences in the treatn 
 required. 
 
 False croup is one of the most frequent troubles of infai 
 The attacks occur usually at night ; the child goes to bed wel 
 least so far as its breathing is concerned ; though these att; 
 occur with especial frequency in children suffering from some of 
 usual indispositions, especially the bowel complaints so freqi 
 during teething. Sometimes there is a slight degree of fever ( 
 ing the afternoon before the attack occurs. The mother is awake 
 by the child's violent coughing ; the infont is usually in a stati 
 great agitation, gasping for breath in the intervals between a Ic 
 hoarse, ringing cough. The effects of imperfect breathing 
 £een in the flushed, often bluish color of the skin, as well as in 
 child's violent efforts at respiration ; if the chest be exposed, it i 
 often be observed that the spaces between the ribs are marki. 
 depressed during the effort to take breath, indicating that thcM- 
 an obstruction to the entrance of air into the lungs. After 
 attack has subsided spontaneously, or under the influence 
 domestic remedies, the trouble often recurs withui an hour; imli. 
 the entire night may be passed in a state of alarm and an.xii 
 caused by the rapid recurrence of successive attacks. 
 
ILDREN. 
 
 CROUP. 
 
 1037 
 
 ity of these cases arc 
 the production of the 
 litual constipation. If 
 of " cascara cordial," 
 
 mation in the upper part 
 rmation of a false mem- 
 ded affection. But the 
 ed croup are not of an 
 the life of the infant to 
 — taxes the utmost skill 
 ;al interference; the latter 
 ;ple household measures. 
 ,ts of difference between 
 ferences in the treatment 
 
 lent troubles of infancy, 
 aild goes to bed well, at 
 d ; though these attacks 
 suffering from some of th. 
 I complaints so frequent 
 light degree of fever dur- 
 I. The mother is awakened 
 it is usually in a state of 
 1 intervals between a loud, 
 imperfect breathing arc 
 [the skin, as well as in the 
 chest be exposed, it may 
 ■n the ribs are markedly 
 " indicating that there is 
 ito the lungs. After the 
 under the influence of 
 -swithmanhour; indeed. 
 lite of alarm and anxiccy, 
 live attacks. 
 
 If the affection be simply false croup there need be no anxiety 
 as to the ultimate recovery of the patient. That the disorder is 
 falsecroupmayberecognized by its sudden occurrence in a previously 
 healthy child; by the absence of fever, which, if present at all, is ob- 
 served in only slight degree, and is rarely noticeable until the attack 
 has begun; by the suddendevelopment of the sharp barking," croupy" 
 cough, which when once heard is never forgotten. This cough, it 
 is true, may also occur in true croup, but in that case is not devel- 
 oped so suddenly. After one attack sometimes, or more fre- 
 quently after several, the child recovers its usual condition, except 
 that it betrays a certain amount of exhaustion, and usually continues 
 to cough hoarsely at intervals during the following day. In true 
 croup the fever continues, and the child's condition in the morning 
 is usually worse than during the previous night. 
 
 The chief element in the production of false croup is a spasm 
 of the upper part of the air passages — technically known as the 
 glottis. This affection is doubtless also the feature in true inflam- 
 matory croup, though but one of s jveral phenomena which constitute 
 the latter disease. 
 
 Tt'eattmint. — The object of treatment in false croup is to 
 relieve the spasmodic condition of the glottis, an object best 
 attained by the application of warmth and moisture to the throat, 
 both internally and externally. The first measure is, therefore, to 
 procure a warm and moist atmosphere ; all windows should be 
 closed and other draughts avoided ; the room should be heated to, 
 and maintain -d at a temperature of 80 or 90 degrees Fahr. , and 
 filled with steam most readily and quickly obtained from a kettle. 
 Meanwhile hot and moist applications should be made to the throat; 
 either pieces of flannel wrung out in hot water or poultices of flax- 
 seed, bread and water, or other convenient material should be 
 applied to the throat and renewed at intervals of fifteen -^t- twenty 
 minutes. If the young mother have a preference 101 an onion 
 poultice — as most have — that may be employed i;?stead. The 
 object is simply to apply heat and moisture as quickly and effect- 
 ually as possible ; the benefit of the poultice lies in this quality and 
 not in any virtue of flaxseed or onions. The desired result may 
 be hastened by the application of mustard plasters to the feet or by 
 the immersion of the feet and legs in hot water with or without the 
 addition of a little mustard. The most effectual means for avoiding 
 the recurrence of these attacks is to maintain the high temperature 
 
 '!! 
 
 vl 
 
 ■■ I ■■ I- I 
 
 1 i <■■ 
 
 '\ 
 
 J ■ 
 
 HI 
 
1038 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 and moist condition of the air for several hours. In the mih 
 cases some of these measures may be unnecessary, but they v 
 never be out of place. 
 
 True Croup, also called fibrinous, membranous and infla 
 matory croup, differs from the preceding, in that there is not oi 
 a spasm of the glottis, but also the formation of a false membrane 
 the upper portion of the air passages. This membrane, togctl 
 with the swelling of the inflamed surfaces, obstructs the entrance 
 the air into the lungs ; the immediate danger to the child is me; 
 ured by the amount of this obstruction, and one of the aims 
 treatment, as will be presently mentioned, consists in the effort 
 remove this obstruction. 
 
 True croup is distinguished from false croup by distinct! 
 features at the commencement, during the course, and at t 
 decline of the disease ; for our purpose it is, of course, especia 
 important to note the differences at the commencement. It m 
 be said in general that the onset of true croup is more gradual a 
 of longer duration than that of spasmodic croup ; the latter m 
 affect a child which was at bed-time apparently well, or at Ic; 
 devoid of fever ; in cases of true croup, the child is usually e 
 dently indisposed, often feverish, and not infrequently suffer! 
 from a cough for two or three days prior to the occurrence of t 
 first spasm of breathing. In true croup the child is unmistakal 
 ill ; the skin is hot and dry, the mouth parched in addition to t 
 interference in breathing ; after the first paroxysm subsides, t 
 fever and general indisposition persist ; and the breathing ne\ 
 becomes so free as is usually the case after the first spasm of fa 
 croup 
 
 Sf/mptonis, — Most of the symptoms of spasmodic croup ; 
 found also in the membranous disea.''^ — as would be expected sin 
 the same feature, the spasm of the glottis, is common to both. T 
 same harsh breathing and brazen cough, the same change in t 
 voice and difficult breathing as occur in false croup, though it is to 
 remembered that these symptoms do not appear usually until af 
 one or two days of warning in the shape of general indispositi 
 and fever. At this time there is intense thirst, and swallowing 
 usually accomplished without difficulty. 
 
 The first spasm often occurs in true as in false croup diiri 
 the night, and this may be followed in one case as in the other 
 successive spasms before morning. Yet in the morning if the ch 
 
LDRF.N. 
 
 CROUP. 
 
 •039 
 
 hours. In the milder 
 ccssary, but they will 
 
 ibranous and inflam- 
 that there is not only 
 of a false membrane in 
 is membrane, together 
 structs the entrance of 
 jr to the child is meas- 
 'nd one of the aims of 
 consists in the effort to 
 
 e croup by distinctive 
 e course, and at the 
 ,s, of course, especially 
 3mmenccment. It may 
 Dup is more gradual and 
 croup ; the latter may 
 irently well, or at least 
 ;he child is usually evi- 
 t infrequently suffering 
 :o the occurrence of the 
 he child is unmistakably 
 lu-chcd in addition to the 
 ^ aroxysm subsides, the 
 ^nd the breathing never 
 the first spasm of false 
 
 , of spasmodic croup arc 
 Iwould be expected since 
 k common to both. The 
 
 I the same change in llic 
 croup, though it is to be 
 
 [ppear usually until after 
 ]of general indisposition 
 Ithirst, and swallowiui; is 
 
 as in false croup during 
 
 case as in the other by 
 
 the morning if the child 
 
 have membranous croup, there will be present as much or more 
 fever than on the previous day, the breathing will still be difficult, 
 the cough croupy and the child evidently indisposed. During the 
 succeeding day the condition usually becomes worse ; by the end 
 of the second or third day the disease has attained its height ; the 
 fever is now intense, the face and lips often purple, the veins dis- 
 tended, the voice often not more than a whisper, the child lies with 
 
 its head thrown back, tossing from side t 
 
 o side, 
 
 ant 
 
 eviclcn 
 
 tly 
 
 struggling for breath — its condition becomin<r more distressino- 
 during and subsequent to every fit of coughing, which usually 
 occurs now at short intervals. At this time, although the thirst 
 persists it can be but imperfectly quenched because swallowing is 
 difficult. If the disease approach a fatal termination, the cou-di 
 usually diminishes in force and frequency or even stops alto"-ether ; 
 the breathing is still more labored, the blueness increases, the hands 
 and feet become cold, and death occurs from exhaustion or from 
 suffocation or both. 
 
 Ti'eatiaent. — The appearance of any symptoms which justify 
 a suspicion that an attack of membranous croup is impending should 
 be a signrl for calling in the services of the medical attendant ; for 
 croup is justly dreaded — by physicians as well as by others — as 
 one of the most serious and intractable diseases. Yet it is often 
 possible to accomplish much good during the interval that must 
 elapse before professional aid can be obtained. The same measures 
 recommended for relieving an attack of spasmodic croup are essen- 
 tial. It is especially impi^rtant that the room should be kept hot, 
 filled with steam, and all draughts avoided. One should be careful 
 not to gratify an almost natural instinct at such a time : the strug- 
 gles of the child for breath usually suggest to some one that a win- 
 dow should be opened to give it air. This measure, however, would 
 defeat its own object, since the cold would simply increase the 
 spasm in the air passage already existing. I lot applications — cloths 
 or poultices — should be at once made to the throat. Another 
 measure is important as soon as the signs of impaired breathing 
 become apparent, r. amely, that vomiting should be provoked. A 
 favorite and often effectual mode for inducing vomiting is the ad- 
 ministration of warm water containing a little salt or mustard or 
 both, yet it is often impossible to get anything into the child's stomach 
 because of the difficulty in breathing and its consequent struggles. 
 The quickest and most effectual way for inducing vomiting at this 
 
 < A 
 
I040 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 time is by tickling the child's throat either with a feather or with the 
 finger. The object in promoting vomiting at this time is to secure 
 the detachment and expulsion of the false membrane formed in the 
 throat, and constituting the part of the impediment to the entrance 
 of air and in securing free prespiration to lessen fever. 
 
 While these measures are being taken a hot bath should be 
 prepared, into which the child is to be placed as soon as possible. 
 After remaining for ten minutes the patient may be rubbed briskly 
 with a coarse tow^l and then warmly wrapped in flannel. These 
 measures usually secure relief from the more pressing symptoms, 
 the breathing becomes easier, and the child often drops off to sleep. 
 The heat and moisi>i-e in the room and the hot applications to the 
 throat should be coii'an' d without intermission, for repetitions of 
 the attacks may be expcrted at anytime. It should also be remem- 
 bered that an attack of fal. . or spasmodic croup may be merely the 
 forerunner of the onset of membranous croup. 
 
 Causes, — The cause of false croup is usually to be found in 
 exposure to cold draughts of air, sudden checking of perspiration. 
 True croup often appears to be the result of the same causes. Yet 
 it is established that membranous croup is a highly communicable 
 disease ; not that every case results from contact with a previous 
 case of the same afTection, but that every case is capable of com- 
 municating the disease to other children. Hence the necessity for 
 care in avoiding possibilities of such exposure. 
 
 Influenza. 
 
 Under this name is commonly known a catarrh of the nose or 
 "cold in the head," an affection to which infants are especially 
 susceptible. The condition may occur from any exposure to cold, 
 and is indicated first by the tendency of the child to take in breath 
 through the mouth rather than through the nose, and later by the 
 appearance of a watery discharge from the nostrils. There is 
 often considerable indisposition and even some fever, while the 
 local symptoms in the nose occasion both child and attendant 
 considerable annoyance. It not infrequently happens that influenza 
 will appear almost epidemic, a considerable number of cases being 
 affected in the same neighborhood at once. 
 
•REN. 
 
 CONVULSIONS. 
 
 IO41 
 
 , feather or with the 
 lis time is to secure 
 brane formed in the 
 lent to the entrance 
 I fever. 
 
 hot bath should be 
 as soon as possible, 
 y be rubbed briskly 
 I in flannel. These 
 pressing symptoms, 
 m drops off to sleep, 
 t applications to the 
 an, for repetitions of 
 lould also be remem- 
 ip may be merely the 
 
 sually to be found in 
 :king of perspiration. 
 
 he same causes. 
 
 Yet 
 
 highly communicable 
 ntact with a previous 
 is capable of com- 
 :nce the necessity for 
 
 atarrh of the nose nr 
 infants are especially 
 any exposure to cold, 
 ;hild to take in brcalh 
 nose, and later by the 
 nostrils. There is 
 amc fever, while the 
 child and attendant 
 happens that influenza 
 \umber of cases bein^^ 
 
 Treatnwnt — Should consist merely in a warm bath at nieht 
 careful though not excessive clothini;-, and the application of some 
 oily material to the nostrils if the discharge be excessive and have 
 provoked soreness of the skin, and a drop of ipecac syrup, in 
 water, every hour or two. 
 
 Convulsions. 
 
 .-hich 
 
 Children are generally said'to be especially susceptible to fits, by 
 
 )f 
 
 intended that a less degree 01 u-ritaiion suHices to niduce 
 convulsions in infancy than is required in later years. For a fit can 
 generally be taken as an indication that there is somewhere in the 
 body an unnatural source of irritation. In the child this irritation 
 is frequently occasioned by growth of a tooth through the gums, 
 by the presence in the stomach of improper food which cannot be 
 digested, by the distension of the bowels in constipation, and some- 
 times (though not so often as mothers would have us believe) by 
 the presence of worms in the lower bowel. Many of the diseases 
 of infancy — scarlet-fever, measles, whooping-cough, meningitis 
 among others — are not infrequently accompanied at some period 
 of their course by convulsions. Then again, extreme emotional 
 excitement, either of the child or of the nursing mother, may be 
 followed immediately by convulsions. 
 
 The appearance of the child during a fit varies with the cause 
 and with the condition. In many cases a certain premonitory con- 
 dition is observed ; the child is fretful, restless, perhaps grinds the 
 teeth while asleep. The fit often begins by a twitching of the 
 muscles of the face, which soon extends through the body and the 
 limbs ; the arms and legs are violently bent and straightened, the 
 head often thrown back, the eyes widely open. In many instances 
 the breathing is temporarily arrested, causing a blueness of the face 
 and lips. Meanwhile the child may scream violently or seem simply 
 bewildered. In another class of cases — called by nurses " inward 
 fits " — the limbs are rigid, the body undergoes but little movement, 
 the eyes roll unnaturally, the consciousness is lost. Whatever be 
 tlie nature of the convulsion, it usually lasts but a minute or two, 
 after which time the child falls into a deep sleep ; at other times, 
 especially during some of the diseases already mentioned, a series 
 
 * I'.' 
 
 • ti 
 
1042 
 
 DISEASES OF WOMEN AND CHILDREN. 
 
 of convulsion'' occur in rapid succession leaving the child exhausted 
 and half unconscious. 
 
 Treatment.- ■ ix. is to be remembered that a convulsion is 
 not a disease, but merely an indication of disease ; and that the 
 first step in treatment consists in finding out if possible what the 
 source of the irritation is. In many cases such source can be readily 
 detected by a little care and patience ; at other times it seems im- 
 possible to ascribe the fits to anything else than a nervous 
 condition of the child ; indeed there are many infants which seem 
 to inherit a predisposition to convulsions ; in such children fits 
 occur without apparent cause. These infants are usually the ofi"- 
 spring of unhealthy parents, and are themselves sickly and ill- 
 nourished. During the fit it may be well to loosen the child's 
 clothing and dash cold water from the hand into its face ; the child 
 should be la d H .* , ithout a pillow and fresh air admitted ; if a hot 
 bath be convenient the child may be placed in it. 
 
 If the infant be '^p'; thing, and it be found that one or more 
 teeth are just on tiie point of coming through the gum, subsequent 
 fits can usually be averted by a judicious use of a lancet ; and in 
 every instance the treatment consists not in curing the convulsion, 
 but in removing the cause whenever that can be discovered. If 
 there be constipation and the abdomen be swollen, an injection 
 of soapy water or of the milk of asafoetida (one tablespoonful) 
 may be given at once. If irritating food has been taken, an emetic 
 of mustard and water may be given. If the head be hot and the 
 face flushed, applications of cold cloths may be beneficial. 
 
 lUsi 
 
 ili'Sf- 
 
[LDREN. 
 
 ig the child exhausted 
 
 '. that a convulsion is 
 disease ; and that the 
 : if possible what the 
 1 source can be readily 
 er times it seems im- 
 ;lse than a nervous 
 y infants which seem 
 
 in such children fits 
 s are usually the off- 
 selves sickly and ill- 
 
 to loosen the child's 
 ito its face ; the child 
 air admitted ; if a hot 
 a it. 
 
 md that one or more 
 ; the gum, subsequent 
 
 of a lancet ; and in 
 uring the convulsion, 
 an be discovered. If 
 
 swollen, an injection 
 a (one tablespoonful) 
 been taken, an emetic 
 head be hot and the 
 je beneficial. 
 
Jt 
 
 -^f^ 
 
 A^RTERIES. 
 
ANATOMY AND PHYSIOLOGY. 
 
 In order to appreciate many of the facts of disease, it is 
 necessary to understand the elements at least of the structure and 
 functions of the body. The essential facts will be presented in 
 the following pages. 
 
 The following extracts are taken from a " Brief View of the 
 Human Body," by Dr. Beard : 
 
 " That we may understand for wnat purpose the human body 
 is made to consist of such a variety of parts, why it possesses such 
 a complication of nice and tender machinery, and why there was 
 not a more simple, less delicate and less expensive frame, it is 
 necessary that we in our imagination make a man; in other words, 
 let us suppose that the mind, or immaterial part, is to be placed in 
 a corporeal fabric in order to hold intercourse with other material 
 beings by the intervention of the body, and then consider what 
 will be wanted for its accommodation. In this inquiry we shall 
 plainly see the necessity, advantage and wonderful adaptation of 
 most of the parts which we actually find in the human body ; and 
 if we consider that in order to answer some of the requisites, 
 human wit and invention would be very insufficient, we need not 
 be surprised if we meet with some parts of the body whose use we 
 cannot yet perceive, and with some operations and functions which 
 we cannot explain. 
 
 " First, then, the mind, the thinking, immaterial agent, must 
 be provided with a place of immediate residence, which shall have 
 all the requisites for the union of spirit and body ; accordingly it 
 is provided with the brain, and is governor and superintendent of 
 the whole fabric. 
 
 " In the next place, as it is to hold a correspondence with all 
 external material beings, it must be supplied with organs fitted to 
 receive the dififerent kinds of impressions which they will make. 
 
 1043 
 
 »h I 
 
 V. -m 
 
 'M' I 
 
1044 
 
 ANATOMY AND PHYSIOLOGY. 
 
 •ni 
 
 In fact, wc sec that it is provided with the organs of sense, as we 
 call them ; the eye is adapted to light ; the ear to sound ; the nose 
 to smell ; the mouth to taste, and the skin to touch. 
 
 " Furthermore, it must be furnished with organs of communi- 
 cation between itself in the brain and those organs of sense, to 
 receive information of all the impressions that are made upon them, 
 and it must also have organs between itself in the brain, and every 
 other part of the body, fitted to convey its commands and to in- 
 fluence the whole. 
 
 " For these purposes the nerves are actually given. They are 
 soft white cords which rise from the brain, the immediate residence 
 of the mind, and disperse themselves in branches through all parts 
 of the body. They convey all the different kinds of sensations to 
 the mind in the brain, and likewise carry out thence all its com- 
 mands to the other parts of the body. They are intended to be 
 occasional monitors against all such impressions as might endanger 
 the well-being of the whole or of any particular part. 
 
 " Moreover, the mind in this corporeal system must be en- 
 dowed with the power of moving from place to place for the sake 
 of intercourse with a variety of objects, of escape from such as 
 are disagreeable, dangerous or hurtful, and for the pursuit of such as 
 are pleasant or useful. Accordingly it is furnished with limbs, 
 muscles and tendons, the instruments of motion, which are found 
 in every part of the fabric where motion is necessary. 
 
 " But to support, to give firmness and shape to the fabric ; to 
 keep the softer parts in their proper places ; to give fixed points for 
 and the proper directions to its motions, as well a« to protect some 
 of the more important and tender organs from external injuries, 
 there must be some firm prop-work interwoven through the whole, 
 and in fact for such work the bones are given. 
 
 " This prop-work is not made with one rigid fabric, for that 
 would prevent motion. Therefore there are a* number of bones. 
 
 " These pieces must all be firmly bound together to prevent 
 their dislocation, and this end is perfectly answered by the liga- 
 ments. 
 
 " The spaces between these different organs must be filled up 
 with some soft matter, whicli shall keep them in their places, unite 
 them, and at the same time allow them to move a little upon one 
 another. These purposes are answered by the cellular membrane 
 or fatty substance. 
 
 ^w..iji- 
 
GENERAL REMARKS. 
 
 1045 
 
 " Lastly the mind, beinjj formed for society and intercourse 
 with beings of its own kind, must be endowed with powers of ex- 
 pressing and communicating its thoughts by some sensible marks 
 or signs, which shall be both easy to itself, and admit of great 
 variety, accordingly it is provided with the organs and faculty of 
 speech, by which it can throw out signs with amazing facility and 
 vary them without end. 
 
 " Thus we have built up an animal body which would seem to 
 be pretty complete; but as it is the nature of matter to be altered 
 and worked upon by matter, so in a very little time such a living 
 creature must be destroyed. If there is no provision for repairing 
 the injuries which it must commit upon itself, and those to which it 
 must be exposed to from without, therefore a treasury of blood is 
 actually provided in the heart and vascular system, full of nutri- 
 tious and healing particles, fluid enough to penetrate into the 
 minutest parts of the animal ; impelled by the heart and conveyed 
 by the arteries it washes every part, builds up what was broken 
 down, and sweeps away the old and useless materials; hence the 
 necessity or advantage of the heart and arterial system. 
 
 " What more there is of the blood than enough to repair the 
 present damages of the machine, must not be lost, but should be 
 returned again to the heart ; and for this purpose the venous sys- 
 tem is provided. These requisites in the animal explain the circu- 
 lation of the blood. 
 
 " The old materials which have become useless, and are swept 
 off by the current of blood, must be separated and thrown out of 
 the system. Therefore glands, the organs of secretion, are given 
 for straining whatever is redundant, vapid or noxious, from the mass 
 of blood, and when strained, they are thrown out by organs of 
 excretion. 
 
 " But as the machine is constantly in action, the reparation 
 must be carried on without intermission, and the straiiitr! must 
 always be employed. Therefore, there is actually a perpetual cir- 
 culation of the blood, and the secretions are always going on 
 
 " All this provision, however, would not be sufficient, for that 
 store of blood would soon be consumed, and the fabric would break 
 down if there was not a provision made for fresh supplies. These, 
 we observe, are profusely scattered around us in the animal and 
 vegetable kingdoms, and hands, the fittest instruments that could 
 
 I ' 1 
 
 ! : 
 
 * . 
 
 i 
 
 II 
 
 i' 
 
 
 ■■^ 
 
 Wi 
 
 i! f 
 
 ;|f! 
 
 ■ ■V- 
 
1046 
 
 ANATOMY AND PHYSIOLOGY. 
 
 ill 
 
 
 i 
 
 II i 
 
 iiij 
 
 be contrived, are furnished for t,'athcring them, and for preparit 
 them in a variety of way;; for the mouth. 
 
 " But these supplies which we call food, must be considerab 
 changed — they must be converted into blood. Therefor are pre 
 vided teeth for cutting and bruising the food, and a stomach f( 
 melting it down. In short, all the organs subservient to digestio 
 The finer parts of the aliment only can be useful in the constitutiot 
 These must be taken up and conveyed into the blood, and the dre 
 must be thrown off. With this view the intestinal canal is providec 
 It separates the nutritious part, which we call chyle, to be conveyc 
 into the blood by the system of absorbent vessels, and the coarse 
 parts pass downward to be ejected. 
 
 " We have now got our animal not only furnished with what 
 wanting for its immediate existence, but also with powers for pre 
 tractingthat existence to an indefinite length of time. But its dur; 
 tion, we may presume, must necessarily be limited, for as it 
 nourished, grows, and is raised up to its full strength and perfectioi 
 so it must in time, in common with all material beings, begin t 
 decay and then hurry on to final ruin. Hence we see the necessit 
 for a scheme for its renovation. Accordingly a wise Providence, t 
 perpetuate as well as to preserve His work, besides giving a stron 
 appetite for life and self-preservation, has made animals male an 
 female, to continue the propagation of the species to the end o 
 time. 
 
 " Thus we see that by the very imperfect survey which humai 
 reason is able to take of this subject, the animal man must neces 
 sarily be complete in his corporeal system and in its operations. 
 
 " If we consider the whole animal structure in this light, an( 
 compare it with any machine in which human art has exerted it 
 utmost skill, we shall be convinced beyond the possibility of doubt 
 that intelligence and power have been exerted in its formation fa 
 surpassing anything of which men can boast. 
 
 " One superiority in the animal economy is peculiarly striking 
 In machines of human contrivance there i5 no internal power, n( 
 principle in the machine itself by which it can alter and accommo 
 date itself to any injury which it may sufier or remedy any mischie 
 which admits of repair. But in the animal body this is most won 
 derfully provided for by the internal powers of the system, manj 
 of which are not more certain and obvious in their effects than the) 
 are above all human comprehension as to the manner and means o 
 
{. 
 
 I, and for preparing 
 
 Tiust be considerably 
 Therefor arc pro- 
 and a stomach for 
 servient to digestion, 
 ill in the constitution 
 e blood, and the dreg 
 nal canal is provided, 
 chyle, to be conveyed 
 issels, and the coarser 
 
 furnished with what is 
 ) with powers for pro- 
 of time. But its dura- 
 e limited, for as it is 
 trengthand perfection, 
 iterial beings, begin to 
 ice we see the necessity 
 y a wise Providence, to 
 besides giving a stron; 
 -nade animals male an 
 species to the end of 
 
 ;t survey which human 
 imal man must neces- 
 d in its operations. 
 [Cture in this light, and 
 Ian art has exerted its 
 lie possibility of doubt, 
 id in its formation far 
 
 is peculiarly striking. 
 
 |no internal power, no 
 
 m alter and accommo- 
 
 [r remedy any mischief 
 
 )ody this is most won- 
 
 of the system, many 
 
 their effects than they 
 
 manner and means of 
 
 IIIL: SKliLETON. 
 
 1047 
 
 their operation. Thus a wound heals by a natural process ; a 
 broken bone is made firm again by a deposit of new bony matter ; 
 a dead part is separated and thrown off; noxious juices are driven 
 out ; a bleeding naturally stops of itself ; a grc:at loss of blood from 
 any cause is in some measure compensated by a contracting power 
 in the vascular system, which accommodates the capacity of the 
 vessels to the quantity contained. The stomach given information 
 when the supplies have been exhausted ; gives intimations with 
 great exactness of the quantity and quality of what is wanted in the 
 present state of the machine ; and in proportion as it meets with 
 neglect, rises in its demands and urges its petition in a louder tone 
 and with more forcible arguments. 
 
 " For the protection of the animal amidst the fluctuations in the 
 heat of external bodies, a power of generating warmth has been 
 provided ; and to prevent its undue accumulation in a heated 
 atmospheie, or its excessive loss in a cold one, the quantity carried 
 away is regulated with wonderful nicety to its wants ; so that an 
 equal temperature is preserved in all the range of climates, from the 
 extreme point of habitable existence near the poles to the intense 
 heat of the equatorial regions. 
 
 " A farther excellence in the natural machine, and, if possible, 
 a still more astonishing and more beyond all human comprehension 
 than that of which we have been speaking, is the capability indi- 
 viduals possess of reproducing beings like themselves, which are 
 again endowed with similar powers for producing others, and so of 
 multiplying the species without end. 
 
 " These are powers which mock all human invention or imita- 
 tion. They are characteristics of the Divine Architect. " 
 
 The Skeleton. 
 
 r^. 
 
 The human skeleton, when fully developed, contains two hun- 
 dred and six bones. These vary in their chemical composition as 
 well as in their size and shape. In general the bones consist of 
 lime and magnesium salts deposited in the meshes formed by a 
 hard glue-like substance. 
 
 The bone in the living animal is furnished with blood vessels 
 and nerves, and is just as much a living tissue as the skin or any 
 other organ. The long bones are hollow on the inside to contain 
 
 t'- 
 
 i« 
 
,if 
 
 1 ! 
 
 1048 
 
 ANATOMY AND PHYSIOLOGY. 
 
 the marrow which has a certain function to perform in the n 
 ment of the bone. The greater part of the nutrition of th 
 comes, however, from a membrane which covers, its outside 
 the periosteum. When this membrane is torn off, the bone 
 and often dies ; this is what happens in many cases of felon 
 In early life the bones consist chiefly of gristle or car 
 the salts of lime and magnesium are deposited in this gristl 
 ter during childhood and youth. Some of the bones ren 
 this cartilaginous condition for years after birth ; the thigh 
 indeed, becomes completely converted into bone only abf 
 twentieth year of life. Hence it happens that the bones of c 
 are less liable to fracture than those of adults. 
 
 The Spine, — The spine consists of twenty-six pieces 
 vertebrae. Each of these is a ring of bone surrounding a < 
 canal which contains the spinal cord. The lower vertebra 
 prise also a thickened part called the l)0{/)^, which rests up< 
 corresponding part of the vertebr.'e below, and serves to tr; 
 the weight of the body to the lower limbs. 
 
 The vertebra; are provided with numerous bony projt 
 which serve for the attachment of muscles and ligaments. 
 
 The first vertebra, the one just below the skull, is calk 
 atlas. It is so arranged as to permit a movement of the 
 which rests upon it, forward and backward. The movement i 
 head from side to side is accomplished by the rotation of thi 
 tebra around a pivot which projects from the second vertebni 
 
 The Head, — The head comprises twenty-two bones, 
 of which are included in the cranium, fourteen in the face. 
 
 The cranial-bones arc thin curved plates, united to each 
 by serrated edges known as stttiirts. Each of the bones fo 
 the vault of the skull is composed of two plates, between 
 there is a layer of spongy, bony tissue. The outer one of 
 plates is somewhat elastic, while the inner one is very brittl 
 inelastic. It sometimes happens that a blow upon the head 
 turcs the internal brittle plate, while the external escapes by 
 of its elasticity. 
 
 The occipital bone constitutes the back part of the hca 
 the base of the .skuU. 
 
 The sides of the cranium are the parietal bones. 
 
T't" 
 
 SIOLOGY. 
 
 1 to perform in the nourish- 
 i{ the nutrition of the bone 
 ich covers. its outside, called 
 is torn off, the bone suffers 
 many cases of felons, 
 efly of gristle or cartilage ; 
 :posited in this gristly mat- 
 ne of the bones remain in 
 ftcr birth ; the thigh-bone, 
 I into bone only about the 
 ns that the bones of children 
 adults. 
 
 of twenty-six pieces called 
 bone surrounding a central 
 The lower vertebra; com- 
 dod)/, which rests upon the 
 low, and serves to transmit 
 lbs. 
 
 numerous bony projections 
 Ics and ligaments, 
 slow the skull, is called the 
 : a movement of the skull, 
 ird. The movement of the 
 by the rotation of this ver- 
 n the second vertebra. 
 
 ;s twenty-two bones, eight 
 
 )urteen in the face. 
 
 )lates, united to each other 
 
 vich of the bones formiiit,' 
 
 wo plates, between which 
 
 The outer one of these 
 
 ner one is very brittle ami 
 
 blow upon the head frac- 
 
 external escapes by virtue 
 
 )ack part of the head and 
 
 rictal bones. 
 
 l/Hmfai 
 
 
 [iHlarBc>i4 
 
 
 
 
 
 i^f'ta^ Carpus. 
 
 
 
 Pk(t.la.ntie>s. 
 CTbes. I 
 
 I. 
 
 '.ft 
 
 iX' 
 
 V^'':\ 
 
 S*" 
 
! H 
 
 t H 
 
 
THE SKELETON. 
 
 1049 
 
 The forehead is made of the frontal bone. 
 
 The lower part of the side of the skull is made up of the tem- 
 poral bone. The structures composing the internal ear are con- 
 tained in this bone. 
 
 The bridge of the nose is formed by the 7iasal bones. 
 
 The upper jaw is made up of the two superior maxillary bones. 
 This bone is hollowed out so as to constitute a cavity which com- 
 municates with the mouth. 
 
 The prominence of the cheek is formed by the malar bone. 
 
 The turbinated bones are contained in the nostrils. 
 
 The partition between the nostrils is made :ip in part of a bone 
 called the vomer. 
 
 The lower jaw is a semicircle of bone, its ends terminating in 
 an upright piece, the whole being shaped much like an inverted 
 horse-shoe. The upright pieces lie in contact with the lower surface 
 of the temporal bone, making the joint of the jaw. 
 
 The tongue is attached at its base to a small bone shaped like 
 a letter U, and hence called the hyoid bone. 
 
 The Chest. — The chest is a space bounded by the spinal col- 
 umn behind, the breast bone in front, and the ribs on the side. 
 The breast bone is composed of three pieces, and terminates in a 
 projection of gristle or cartilage, which is situated just above the 
 pit of the stomach. 
 
 The ribs are twenty-four in number, twelve on each side. They 
 are all connected with the spinal column at the back. The upper 
 seven on each side are joined by means of cartilages to the breast 
 bone. The next three ribs are joined by their cartilages to the car- 
 tilages of the ribs above ; the lowest two ribs arc connected with 
 the backbone only. The seven upper ribs arc called the true, the 
 remaining five the false ribs. The direction of the ribs is obliquely 
 downward and forward from the backbone. By n\cans of the car- 
 tilaginous attachments to the breast bone, the ribs are capable of 
 cdnsiderablc motion, whereby the size of the chest can be increased 
 .md diminished, as in the acts of breathing. 
 
 H' ilH 
 
 ;:M 
 
 -m 
 
 The T^pitei' l^jrfveittiftj, — This consists of the shoulder, the 
 arm, the forearm and the hand ; the bones included are the shoulder- 
 blade, the collar-bone, the arm-bone (humerus), the two bones of 
 
 6S 
 
loso 
 
 ANATOMY AND PHYSIOLOGY. 
 
 the forearm (ulna and radius), the eight bones of the wrist, five ( 
 the hand, and fourteen in the fingers. 
 
 The only bones of the upper extremity requiring special noti( 
 are those whereby the rotary movements of the hands are effectec 
 The ulna is firmly fixed at the elbow joint, where it is attached 1 
 the bone of the arm. At the wrist, on the other hand, it const 
 tutes but a small part of the joint. The radius is scattered to tl 
 arm-bone, as to enjoy free rotary movement, while it is fixe 
 firmly to the bones of the wrist, which, therefore, accompany i 
 movements. The rotation of the hand is effected by the movemei 
 of the radius around th ulna. When the hand is held with tl 
 palm upward, the two uones of the forearm are almost paralle 
 when the hand is turned over, so that the back is upward, the radii 
 lies obliquely across the ulna, the latter bone not having change 
 its position. 
 
 The Lower Extretnity. — This includes the hip, the thigl 
 the leg and the foot. The projection called the hip is the uppi 
 margin of the bony ring called the pelvis. This bony basin coi 
 tains some of the important organs of the body. On either side 
 a deep socket, which receives the head of the thigh-bone. 
 
 The thigh-bone (femur) is the largest, the longest and tl 
 strongest bone in the entire skeleton. The part which fits into tl 
 socket in the pelvis is connected with the shaft of the bone at ii 
 obtuse angle. The lower extremity of the thigh-bone is very bro;i 
 and thick, so as to afford a large surface for the transmission of tl 
 weight of the body to the leg. 
 
 The front of the knee-joint is covered with a disk-shaped bon 
 — the knee-pan or patella. This bone is contained in the sinew < 
 tendon of the large muscle which constitutes the front of the ma; 
 of the thigh. 
 
 The back part of the foot is composed of seven bones, wliic 
 together are called the tarsus. The largest of these is the bon 
 which forms the projection of the heel. To this bone is attache 
 the tendon of the muscles forming the calf of the leg. 
 
 The Joints. 
 
 The joints are of various kinds. Some permit an extcnsiv 
 range (.'. movement, like the ball and socket-joint of the shoukU 
 and hip; others permit movement in one direction only, such £ 
 
 h\i 
 
 .iijl*t 
 
THE MUSCLES. 
 
 IO51 
 
 ; of the wrist, five of 
 
 luiring special notice 
 le hands are effected, 
 -here it is attached to 
 other hand, it consti- 
 ius is scattered to the 
 ent, while it is fixed 
 •efore, accompany its 
 cted by the movement 
 hand is held with the 
 a are almost parallel; 
 ^ is upward, the radius 
 
 e not having changed 
 
 ies the hip, the thigh, 
 
 d the hip is the upper 
 This bony basin con- 
 
 ody. On either side is 
 
 le thigh-bone. 
 
 t, the longest and the 
 
 part which fits into the 
 
 shaft of the bone at an 
 
 high-bone is very broad 
 
 the transmission of the 
 
 vith a disk-shaped bone 
 )ntained in the sinew or 
 :s the front of the mass 
 
 of seven bones, which 
 [st of these is the bone 
 
 :o this bone is attached 
 I of the leg. 
 
 the hinge-joints of the elbow and knee. In some cases but a lim- 
 ited movement is required, as occurs between ihe vertebra con- 
 stituting the spinal column. 
 
 The contiguous ends of the bones constituting the joints are 
 covered with thin layers of cartilage or gristle ; this substance 
 serves the purpose of a cushion in transm.itting pressure from one 
 bone to another. 
 
 The cartilages are covered by a thin delicate membrane, called 
 the synovial membrane. This is arranged in the shape 01' a closed 
 sac which is interposed between the adjacent ends of the bones. 
 The object of this membrane is to diminish the friction occasioned 
 by the movements of the bone ; for this purpose the membrane 
 secretes a fluid resembling the white of an egg. 
 
 The joints also comprise strong bands of inelastic tissue, called 
 ligaments, which bind the ends of the bones together. 
 
 The Muscles. 
 
 [no permit an extensive 
 ,t-joint of the shoulder 
 direction only, such as 
 
 The muscles are divided into two general classes, voluntary 
 and involuntary. The former are under the control of the will, and 
 contract quickly. The involuntary muscles are contained in the 
 digestive organs, and in the walls of the blood vessels. They are 
 stimulated to action, not by the will, but by other nervous 
 influences; they do not contract quickly, for a certain appreciable 
 interval elapses between the application of a stimulus and the con- 
 traction of the muscle. 
 
 The voluntary muscles are in most cases attached to two or 
 more different bones; when they contract or shorten, these bones 
 are brought closer together. Thus the act of bending the forearm 
 is accomplished chiefly by the contraction or shortening of a muscle 
 which is attached above to the shoulder, and below to the radius. 
 
 3Ius<'les of the Head. — The forehead is wrinkled and the 
 eyebrows drawn upward by a thin muscular sheet which is attached 
 to the top of the head. 
 
 The eyes are closed by a muscular ring which passes around 
 the opening of the eye and is attached at its inner angle. 
 
 The eyeballs are moved by six small muscles, which are 
 attached at the bottom of the cavity in which the eye rests, and are 
 
 * ifi 
 
1052 
 
 ANATOMY AND PHYSIOLOGY. 
 
 ■\W 
 
 inserted into the outer coat of the eyeball at different points aro 
 its circumference. 
 
 The lower jaw is pulled upward by four pairs of muscles, 
 of which can be seen and felt on the outside of the face when 
 teeth are firmly pressed together. The jaw is pulled downward 
 muscles which are attached to the bone of the tongue in the neck 
 
 Muscles of the Tt'unk. — Some of the largest and n 
 powerful muscles of the body are attached along the backbone 
 ribs. These extend in different directions, some onto the lin 
 some upward to the back of the skull. 
 
 The cavity of the abdomen is enclosed in front and at the si 
 by broad muscles which pass around from the side of the sp 
 column and ribs. 
 
 The muscles of the breast are few but powerful ; two of th 
 extend from the side of the chest to the arm, and by their contr 
 tion draw the arm forward over the chest. 
 
 Muscles inside of the hody. — One of the most import 
 of these is the diaphragm. This is a broad sheet which separr 
 the chest from the abdomen. It is attached to the lower enc 
 the breast-bone, to the ribs, and to tho spinal column. During 
 act of expiration, the center of the diaphragm is raised above 
 edges where it is attached to the ribs, so that the muscle has 
 shape of an inverted wash-basin. When breath is taken into 
 lungs, the muscle contracts, pulling its central part downward, 
 that the cavity of the chest is enlarged. The diaphragm theref 
 is an important agent in breathing; in fact breathing can be carr 
 on by the action of this muscle alone. 
 
 Moremettts in walkimf and running. — " The mo 
 
 ments of walking, running, leaping, etc., are performed as follo\ 
 When the body stands upright, the feet arc planted flat upon 
 ground, bearing at once upon the heels behind and the ball of 
 toes in front, the weight of the body resting between the iwo u\ 
 the arch of the foot. The body is maintained in this position 
 we have seen, by the various muscles which act in such a way as 
 keep it^s different parts carefully balanced, and to retain the wei 
 of the whole suspended exactly over the ankle-joint. 
 
 " Now, in walking, when a movement is to be executed 
 advance, the body is first made to lean a little forward, so that 
 
Ill 
 
 3Y. 
 
 dififerent points around 
 
 r pairs of muscles, two 
 le of the face when the 
 is pulled downward by 
 e tongue in the neck. 
 
 the largest and most 
 ilong the backbone and 
 ;, some onto the limbs, 
 
 in front and at the sides 
 a the side of the spinal 
 
 powerful ; two of them 
 m, and by their contrac- 
 
 2 of the most important 
 Id sheet which separates 
 hed to the lower end of 
 nal column. During the 
 ^ragm is raised above the 
 that the muscle has the 
 breath is taken into the 
 ntral part downward, so 
 The diaphragm therefore 
 breathing can be earned 
 
 bui/Wf/. — "The move- 
 lire performed as follows : 
 [re planted flat upon the 
 jehind and the ball of the 
 |ig between the two upon 
 
 iined in this position, as 
 fh act in such a way as to 
 
 1 and to retain the weight 
 
 ^nklc-joint. 
 
 Mit is to be executed in 
 
 flittle forward, so that its 
 
 THE MUSCLES. 
 
 '053 
 
 weight no longer remains above the ankle but is thrown forward 
 so as to rest entirely upon the toes ; the heel is then lifted from the 
 ground by the action of the very strong muscles situated on the 
 back part of the leg ; these muscles, which come down from above, 
 form the fleshy mass which is known as the " calf of the leg. " 
 They terminate in the strong, cord-like tendon, called the " tendon 
 of Achilles," which is easily felt at the back part of the ankle-joint 
 and which is attached tc the projecting bone of the heel. When 
 these muscles contract, Lhey draw the heel upward by means of 
 the tendon inserted into it, and lift in this way the ankle-joint and 
 the whole body, carrying it upward and forward, its principal 
 weight resting, as already mentioned, over the ball of the toes. 
 
 " The action of the leg and foot in this movement is the same as 
 that by which we might lift a weight from the ground with the aid 
 of a lever. Suppose one end of a strong stick to rest upon the 
 ground, and that this stick bears upon its middle a heavy weight. 
 Then by taking in the hand the other end of the stick, we may lift 
 the weight exactly as the body is lifted in walking by the muscles 
 of the leg and the ankle-bones. 
 
 " At the moment that the body is raised and tilted forward in 
 this way, the other foot is lifted entirely from the ground and swung 
 forward so as to take a step in advance. As soon as the body has 
 been carried far enough in an onward direction, the second foot is 
 also raised in the same manner as before, while the first is swung 
 forward in its turn to take another step. In this way the two legs 
 act alternately, the weight of the body being carried forward first 
 by one and then by the other; all the muscles, however, upon the 
 two sides combining harmoniously in their action, so as to produce 
 an easy, graceful and continuous movement. 
 
 " In the act of walking as above described, one foot is always 
 upon the ground, and the weight of the body is mainly supported 
 ill this way by bearing upon the toes ; it is only lifted forward 
 alternately on the two sides by the leverage of the bones of the 
 foot. Consequently no violent muscular exertion is required, and 
 the movement can be kept up for a long time without fatigue. 
 
 " The act of running, however, instead of being a series of steps, 
 is performed by a succession of leaps or springs, in each of which 
 the whole body is thrown clear of the ground, and carried forward 
 by the impetus which it has received. In order to accomplish this, 
 at the moment the heel is about to be raised by the action of the 
 
 1 ! i 
 
 ■H; 
 
1054 
 
 ANATOMY AND PHYSIOLOGY. 
 » 
 
 muscles above described, the knee and hip-joints are first bent, a 
 then instantly straightened by the sudden contraction of th 
 extensor muscles. The whole limb thus acts like a power 
 spring, which by a sudden extension throws the entire body off1 
 ground and carries it through the air in an onward direction. 1 
 opposite limb is at the same time thrown forward to receive 1 
 weight of the body, and to perform in its turn, and with simi 
 rapidity, the same movements. The speed of the runner depet 
 on the vigor of the muscular contractions, and the swiftness w 
 which the successive motions are performed. 
 
 The act of jumping is accomplished in a similar way with tl 
 of running, except the same motions are executed by both lin 
 together, so that each leap is performed by itself, and is not co 
 bined with the others in a continuous movement. " — Dalton. 
 
 The Nervous System. 
 
 The nervous system comprises the brain, spinal cord 
 nerves. 
 
 The brain includes a number of different nervous cent 
 which it is not necessary for us to name. It is composed of 1 
 halves or hemispheres, which are separated from each other b 
 deep fissure running from before backward. The outer part 
 these hemispheres is arranged in the shape of convohitions ; 
 inner part of the brain is composed largely of nerve fibres, wb 
 conduct nervous force from the brain to different parts of 
 body. 
 
 The hemispheres are the seat of mental activity ; there i 
 general relation between the size and depth of the convolutionH 
 the one hand and the intellectual power of the individual on 
 other. Certain functions are localized in different parts of 
 brain ; that is, these parts are known to originate the nerv 
 force by which certain functions are performed. Thus it is knc 
 that the nervous power whereby the limbs are moved is produ 
 in the front part of the upper surface of the brain ; and it is \ 
 established that the faculty of speech is a function of a cert 
 convolution (the third frontal) on the left side of the brain. Wl 
 this convolution is destroyed by disease, the individual loses 
 
THE NEFVOUS SYSTEM. 
 
 1055 
 
 ints are first bent, and 
 contraction of their 
 acts like a powerful 
 the entire body off the 
 nvvard direction. The 
 forward to receive the 
 turn, and with similar 
 of the runner depends 
 and the swiftness with 
 
 a similar way with that 
 xecuted by both limbs 
 y itself, and is not com- 
 ;ment."— ^^/'''«- 
 
 brain, spinal cord and 
 
 iifferent nervous centers 
 It is composed of two 
 ;d from each other by a 
 lard. The outer part of 
 [ape of convolutions; the 
 ;ly of nerve fibres, which 
 ;o different parts cf the 
 
 Intal activity; there is a 
 Ith of the convolutions on 
 lof the individual on the 
 in different parts of the 
 lo originate the nervous 
 Irmed. Thus it is known 
 Is are moved is produced 
 The brain ; and it is well 
 
 a function of a certain 
 Iside of the brain. When 
 
 the individual loses the 
 
 power of articulating words, though the vocal organs remain unaf- 
 fected. Beyond this we have no reason for assuming that different 
 mental faculties are located indifferent parts of the brain; there 
 is, in other words, no physiological basis for the assertions of 
 phrenologists. The skill which many of these gentlemen exhibit 
 is the result of close observation of faces, rather than of knowledge 
 derived from " bumps on the head." 
 
 The part of the brain which lies at the back part of the base 
 of the skull and constitutes the beginning of the spinal cord, the 
 mediilla oblongata, is an extremely important portion of the 
 nervous system ; among its various functions is the important duty 
 of presiding over the act of breathing. If this part of the nervous 
 system be injured, breathing ceases; this is often shown as a 
 physiological experiment ; if an instrument, such as a shoemaker's 
 awl, be introduced into the base of the brain so as to break up the 
 medulla, breathing ceases, simply because the animal no longer 
 feels the necessity for air, and makes no effort to breathe. 
 
 The spinal cord is composed partly of nerves which pass from 
 the brain to the muscles, and from the skin to the brain. The 
 former nerves transmit the nervous influence which causes the 
 muscles to contract ; the latter transmit the impressions made upon 
 the skin to the brain. Aside from these nerves, the spinal cord 
 contains nervous centers which are capable of originating impulses 
 independently of the brain ; thus, if a chicken's head be chopped 
 off, separating entirely from the rest of the body, the animal con- 
 tinues to move violently until the nervous centers in the cord are 
 exhausted from lack of blood. Many familiar actions illustrate the 
 fact that the same independent action of the spinal cord takes place 
 in the human animal ; thus, if the sole of the foot be tickled, or a 
 pin be inserted into the flesh of the leg, the limb is violently moved 
 without any voluntary action on the part of the individual, in fact, 
 often before the person is aware of the irritation. 
 
 The Nerves. — The nerves are white cords which serve as 
 telegraph wires for connecting the brain with the different parts of 
 the body. From every portion of the skin nerves run upward to 
 center in the brain, so that every impression made upon the skin is 
 communicated at once to the organ of the mind ; the eye, the ear, 
 and the other organs of special sense, stand in similar communica- 
 tion with the brain. 
 
 :l''i 
 
 
 . 
 
 i ■ 
 
 it 
 
 irsii 
 
 ^:il 
 
 I'.i 
 
1056 
 
 ANATOMY AND PHYSIOLOGY. 
 
 Every muscle in the body which is controlled by the will 
 similarly connected with the brain ; every muscular action is ori{ 
 nated by nervous force, which is generated in the brain and trar 
 mittcd along the nerves to the muscles. If the nerves be cut 
 injured, the transmission of the nervous force is interrupted; ii 
 pressions made upon the skin are not perceived in the brain ; a 
 voluntary efforts to move the limbs exert no effect upon 
 muscles. 
 
 The OiHjann of Circulation. — These arc the heart, art 
 ries, veins, and capillaries. 
 
 The heart is a mass of muscle so arranged as to surround t\ 
 cavities which communicate with the arteries and veins of the bod 
 It is shaped somewhat like an inverted cone, and is placed in t 
 chest a little to the left and behind the breast-bone, between tl 
 third and the seventh ribs. The greater part of it is covered I 
 the left lung, which intervenes between the heart and the ribs. 
 
 The heart is enclosed in a membranous sac called the perica 
 dium. The weight of the heart in adults is eight or nine ounce 
 being usually about an ounce heavier in man than in woman. 
 
 The blood is brought to the right cavity of the heart by t 
 veins of the body, and is propelled by the muscular wall of tli 
 cavity into the lungs, where it is purified by contact with the a 
 and returned to the left side of the heart. The large and powerf 
 muscle surrounding the left cavity of the heart drives the bloc 
 through the arteries into the different parts of the body. 
 
 This action of the heart in pumping the blood through tl 
 body consists of a scries of beats, or pulsations, which ordinari 
 occur from seventy to eighty times per minute ; hence the hea 
 beats more than 100,00c times every twenty-four hours. 
 
 TJie Arteries — are strong, elastic tubes or channels which coi 
 ducft the blood from the heart to all parts of the system. The Ic 
 side of the heart is continuous with a large artery called the aort 
 into which all the blood of the body passes. This artery dividi 
 and gives off branches whereby the blood is conducted to all tl 
 different organs. These arteries in turn divide into smaller branche 
 and finally terminate in a scries of delicate tubes cdWf^Aeapillaric 
 so called because of their small, //rt/V-like size. The fact is, th; 
 they are far more minute than hairs. 
 
 The blood passes through these capillaries into the tubes whic 
 are continuations of them, called veins. These veins unite t 
 
trolled by the will is 
 jscular action is origi- 
 n the brain and trans- 
 f the nerves be cut or 
 •ce is interrupted ; ini- 
 ived in the brain ; and 
 t no effect upon the 
 
 jsc are the heart, arte- 
 
 Ted as to surround two 
 ; and veins of the body. 
 , and is placed in the 
 east-bone, between the 
 art of it is covered by 
 heart and the ribs, 
 i sac called the pericar- 
 s eight or nine ounces, 
 in than in woman, 
 irity of the heart by the 
 p muscular wall of this 
 by contact with the air 
 The large and powerful 
 heart drives the blood 
 |of the body, 
 the blood through the 
 .tions, which ordinarily 
 linute ; hence the heart 
 -four hours, 
 or channels which con- 
 If the system. The left 
 artery called the aorta, 
 s. This artery divides 
 is conducted to all the 
 ,e into smaller branches, 
 tubes called capillaries, 
 size. The fact is, that 
 
 lies into the tubes whicli 
 These veins unite to 
 
 THE NERVOUS SYSTEM. 
 
 1057 
 
 ! I 
 
 form larger trunks, and are finally combined into two large veins 
 which empty into the right side of the heart. 
 
 Oi'ffans of Respiration.— The air passes down the wind- 
 pipe, or trachea, through its branches — the bronchial tubes — 
 into the air cells. These are little cavities hollowed out in the sub- 
 stance of the lung ; the bronchial tube and the air cells in which 
 it terminates have the same general form and arrangement as a 
 bunch of grapes. 
 
 The walls of these little air cells contain capillary blood vessels 
 tnrough which the blood circulates in order to be purified. The 
 lung itself is composed of elastic, rubber-like tissue, which is 
 stretched when the chest is expanded, so that the air is forced into 
 the air cells, and which collapses when the chest is contracted, so 
 that the air is forced out of the air cells. In this way provision is 
 made for a constant change of the air in the air cells. 
 
 Organs of Digestion. — These are the mouth, teeth, pharynx 
 (throat), gullet, stomach, intestine, liver and pancreas. 
 
 The stomach is a membranous sac where the first part of the 
 process of digestion is performed. It is placed in the upper left 
 corner of the abdominal cavity, extending somewhat to the 
 right of the middle of the body. The capacity of the stomach can 
 be much varied by distension of its walls ; it may be stated on the 
 average as about three pints. 
 
 The stomach is provided with a sheet of muscle whereby it 
 can be moved so that its contents are transferred from one part to 
 another, and thoroughly mixed with the gastric juice. 
 
 The Intestines. — The portion of the alimentary canal below 
 the stomach consists of the small and the large intestine. The 
 former is from twenty-five to thirty feet in length, and the latter 
 about five feet. 
 
 The upper part of the intestine continues the process of diges- 
 tion which was begun in the stomach ; a large part of the nutri- 
 tious portion of the food is absorbed from the intestine into the 
 blood and lymph vessels. 
 
 The Liver. — This is one of the most important organs of the 
 body, as well as one of the largest, weighing about four pounds. 
 It is located in the upper right-hand portion of the abdominal 
 cavity, situated under the ribs of the right side, and extending over 
 
 );i 
 
 
 
I058 
 
 ANATOMY AND I'llYSIOI.OGY. 
 
 the left of the middle line. It secretes the bile and serves a; 
 storehouse for the starchy ingredients of the food. 
 
 The Pancreas. — This body, which is also known as the sive 
 bread, is a long, somewhat pointed gland which lies just behind t 
 stomach. It secretes a fluid which is an important agent in t 
 process of digestion. 
 
 Orffans of Ereretion. — The materials which have been us 
 in the animal economy, and are no longer fit to remain in the boc 
 are cast out or excreted by various organs, chiefly the kidneys, t 
 lungs, the skin and the intestines. 
 
 The kidneys are located one on either side of the spinal colui 
 at the level of the lowest rib. Each is four or five inches long, a 
 two or three inches wide. 
 
 The kidneys cast out from the body a large quantity of matt 
 which has been used ; this matter is washed out and escapes in t 
 form of the urine. This fluid, excreted by the kidneys, flows dov 
 a membranous tube about the size of a goose quill, called t 
 ureter, which empties it into the bladder. 
 
 The .f/t«« has an important duty to perform in throwing o 
 waste materials from the body. These materials escape in the for 
 of perspiration, the suppression of which causes serious interfe 
 ence with the health. 
 
 
QUANTITY OK lOOD. 
 
 1059 
 
 \ • 
 
 HYGIENE. 
 
 Quantity of Food. — The qiiiintity of food required varies vith 
 the individual, with the climate, the season and the habits of ,,fe. 
 It is unnecessary to lay down any rules as to the exact quantity 
 required. 
 
 It is a generally recognized fact, that in this country, at least, 
 more food is eaten than is required by the wants of the body. This 
 fact is especially impressed upon an American who resides for a 
 time on the continent of ICurope, and observes the difference 
 between the habits of eating there and here. 
 
 In cold climates and in cold seasons more food is required by 
 the same individual than under other circumstances ; one who is 
 engaged in manual labor needs more food than a person of seden- 
 tary habits. A sudden change from active habits of life to em- 
 ployments which are sedentary and confining, is apt to be followed 
 by disturbances of digestion. This is often observed in persons 
 who have suffered severe injuries, in consequence of which they are 
 compelled to keep the bed; when the appetite is gratified to its 
 full extent, such persons are usually troubled by indigestion. 
 
 Yet while the tendency among us is to excessive eating, there 
 are those who go to the other extreme, and follow some rigid plan 
 of diet. Such a habit is frequently followed by disorders of diges- 
 tion no less marked and obstinate than those which result from 
 over-eating. 
 
 Another cause of digestive disorders is the prevalent habit of 
 eating between meals. There is no harm in regular indulgence in 
 more than the usual three meals a day. In fact, it is customary in 
 many parts of the continent of Europe to take five meals a day. 
 The important point is that food should be taken at the same hours 
 every day. The exact hours selected may vary with the con- 
 venience of the individual ; he should simply be careful to have his 
 meals with regularity. 
 
 One of the most serious errors which are so prevalent with 
 regard to eating, is the habit of eating too fast. The act of chew- 
 ing is an essential part of the process of digestion ; if it be imper- 
 •ctly done, digestion cannot be complete, and indigestion or 
 dyspepsia results. This fact is so evident, and is so amply demon- 
 
 I . 
 
 I;, :■ 
 
 I 
 
 II 
 
 ;ii 
 
 l! ■ 
 
 11 1 
 I i 
 
'I^llii 
 
 ^*:.| { 
 
 : I , I 
 
 ;,,; 
 
 •liM 
 
 1060 
 
 HYGIENE. 
 
 stratcd around us on every hand, that further discussion sec 
 superfluous. 
 
 Much has been said in popular works upon medicine aga': 
 the habit of drinicing at meal times ; it is generally advised tl 
 liquids be avoided, on the supposition that, by diluting the gast 
 juice, they interfere with the process of digestion. It seems c( 
 tain, however, that the one objection which can properb be urg 
 against taking liquids with the food is the fact that there is, unc 
 such circumstances, a tendency to swallow the food premature 
 before it has been properly chewed. The result is that the stoma 
 is compelled to perform the work of the teeth as well as its om 
 and usually shows itself incapable of performing the task ; d) 
 pepsia results. If care be taken to masticate the food properly, 
 harm results from the use of the ordinary table beverages at m( 
 times. 
 
 As to the articles of food which are best adapted to the tnai 
 tenance of health, no exact rules ca.i be given. The general pri 
 ciple should be borne in mind that both animal and vegetable foi 
 \% absolute!)^ essential to the perfection of the body. It is possib 
 for a man to livf^ upon flesh alone or upon vegetables only ; b 
 neither diet cohducv.. to the most perfect performance of the bodi 
 and mental functions. 
 
 Foods may be divided into two general classes: Those >vbii 
 contain compounds of nitrogen in considerable quantity, and a 
 hence called nitrogenous substances. These are found largely 
 the flesh of animals. The second class of foods are those whi( 
 consist largely of sugar or starch, and are called saccharine (sugary 
 These are obtained chiefly from plants. Since both nitrogenous ai 
 starchy substances enter largely into the composition of the hum; 
 body, it is evident that the best diet comprises both animal and ve 
 etable food There is a third class of substances, the mineral co 
 stitucnts of the bod}', which are just as essential as the nitrogeno 
 and saccharine ingredients ; yet, since these mineral substances a 
 contained in both animal and vegetable food, it is not necessary 
 make special provision in our food for securing these elements. 
 
 The nutritious value of food is measured chiefly by the amoui 
 of the nitrogenous and saccharine matter which it contains. Tl 
 following tables indi-ate the relative values of some of the con 
 moner articles of food: 
 
IHMRBPI 
 
 nm 
 
 :her discussion seems 
 
 ipon medicine agahist 
 generally advised that 
 jy diluting the gastric 
 estion. It seems cer- 
 can properl- be urged 
 ict that there is, under 
 the food prematurely 
 suit is that the stomach 
 leth as well as its own, 
 )rming the task; dys- 
 te the food properly, no 
 able beverages at meal 
 
 st adapted to the tnain- 
 \/en. The general prin- 
 imal and vegetable food 
 he body. It is possible 
 ,n vegetables only; but 
 prformance of the bodily . 
 
 al classes: Those which 
 :rablc quantity, and are 
 se are found largely in 
 foods are those which 
 Ucd saccliarine (sugary), 
 cc both nitrogenous and 
 Imposition of the human 
 ■;es both animal and vcg- 
 Itanccs, the mineral con- 
 ntial as the nitrogenous 
 mineral substances arc 
 d, it is not necessary to 
 ing these elements. 
 
 chiefly by the amount 
 
 which it contains. The 
 
 s of some of the com- 
 
 QUANTITY OF FOOD. 
 
 1061 
 
 Quantity Required to Yield 1,220 Grains of Nitrogenous Matter. 
 
 Cheese 4 pounds. | Rice 2.8 pounds. 
 
 Lean meat 9 " Milk 4.2 " 
 
 Whitefisli I 
 
 l'"at meat 1.3 
 
 Hread 2.1 
 
 I'otatocs 8.3 
 
 Parsnips 15.9 
 
 Beer 158.6 
 
 The following table shows the relative amounts of nitrogen in 
 the dry substances, human milk being regarded as 100: 
 
 Animal Substances. 
 
 Cow's milk 237 
 
 Yolk of egg 301, 
 
 Oysters 302 
 
 I'igeon 756 
 
 Mutton 773 
 
 Salmon 776 
 
 Lamb 833 
 
 Vhite of egg 845 
 
 Lobster 859 
 
 Skate 856 
 
 Cheese. 
 Eel.... 
 
 331 
 
 434 
 
 Mussel 52S 
 
 0.\-livcr . , 570 
 
 Voal 873 
 
 Beef 8S0 
 
 Pork S93 
 
 Turbot 89S 
 
 Ham. . , 
 Herrinij 
 
 910 
 914 
 
 Vegetable Substances. 
 
 Rice 81 Oals ,38 
 
 Potatoes 84 White bread 142 
 
 Maize 100 Black bread ,«, 
 
 Rye 106 Peas 239 
 
 Radi?h 106 i Haricots 2S3 
 
 Wheat 119 , Be.Mis 320 
 
 Bariey 125 1 
 
 While the fats used as food arc largely derived from animal 
 substances, a certain amount is furnished also by vegetables. 
 
 The following table shows the j)crcentagc of fat in some of the 
 familiar vegetable substances : 
 
 Wheal flour 2.0 Pi tatoes 2 
 
 Oatmeal 5.6 T.irniiis 2 
 
 Indian meal <>. « I'arsnijs 5 
 
 Rye flour 2.0 Peas 2.1 
 
 Barley meal 2.4 lea 4.0 
 
 Buckwheat i.o t'olTcr 13.0 
 
 Rice ... .7 I Cocoa 50.0 
 
 Most of the vegetable substances used as food contain a large 
 quantity of starch. It exists in large proportion in potatoes, arrow 
 root, sago and tapioca. The starch contained in these substances 
 
 i 
 
 ll 
 
 '1*1 
 
 V i 
 
 ill 
 
 -■/I % 
 
 \< 
 
 t ■. 
 
 ;. "I 
 
il> 
 
 1062 
 
 HYGIENE. 
 
 is largely converted into sugar by the action of the gastric juice anc 
 of the intestinal fluids. After being thus changed into sugar, it i 
 readily soluble, and can be absorbed into the blood. Many plant 
 contain sugar also. This can be absorbed without being acted upoi 
 by the digestive organs, and is hence better adapted to the fcedinj 
 of children whose digestive apparatus is not yet fully developed. 
 
 While plants contain a large amount of material which canno 
 be digested, and is hence worthless as food, yet because of thi 
 starch and sugar which they contain, vegetables are fattening food 
 This was well understood by Mr. Banting, who devised the famou 
 method which bears his name, for reducing the flesh 
 
 " His original dietary table," Mr. Banting tells us, " consistet 
 ■of bread and milk for breakfast, or a pint of tea with plenty of milk 
 sugar and buttered toast ; meat, beer, much bread and pastry fo 
 dinner ; the usual meal of tea similar to that of breakfast, an( 
 generally a fruit tart or bread and milk for supper. " For this hi 
 substituted : Breakfast at 9 a. m.; five to six ounces of either beef 
 mutton, kidneys, broiled fish, bacon or cold meat of any kind 
 except pork or veal, a large cup of tea or coffee without milk o 
 sugar, a little biscuit, or one ounce of dry toast, making togethc 
 six ounces of solids and nine of liquids. Dinner at 2 p. m. ; five o 
 six ounces of any fish, except salmon, herrings or eels, any mea 
 except pork or veal, any vegetable except potato, parsnip, beet root 
 turnip or carrot, one ounce of dry toast, fruit out of a puddinj. 
 not sweetened, any kind of poultry or game, and two or thret 
 glasses of good claret, sherry or madeira — champagne, port anc 
 beer forbidden — making together ten to twelve ounces of solids anc 
 ten of liquids. Tea at 6 p. m. ; two or three ounces of cooked fruit 
 a rusk or two and a cup of tea without milk or sugar, making twt 
 to four ounces of solids and nine of liquids. Supper at 9 p. m. 
 three or four ounces of meat or fish, similar to dinner, with a glas! 
 or two of claret or sherry and water, making four ounces of solid: 
 and seven of liquids. With this change of diet, Mr. Banting state: 
 that he fell in weight from fourteen stone six pounds to elcvci 
 stone two pounds in about a year. — Pavy. 
 
 Milk is a typical food containing all of the elements requirec 
 for nutrition during the early part of life. The nitrogenous ma 
 terial is a foriji of casein ; the saccharine ingredient is the sugar o 
 milk, and there is present, in addition, a quantity of fat and 
 
Ithc elements required 
 The nitrofjenous m;i- 
 Iredient is the sugar of 
 quantity of fat ami 
 
 QUALITY OF FOOD. 
 
 1063 
 
 of mineral salts. The average composition of cow's milk is as 
 follows: 
 
 Casein, 
 
 Butter, 
 
 Sugar, 
 
 Salts, 
 
 Water, 
 
 4.48 
 313 
 
 4.77 
 .60 
 
 87.02 
 
 Human milk differs from that of the cow, in that it contains a 
 larger amount of sugar and a smaller amount of casein and fat. 
 
 Butter is the fat of milk, which is separated from this fluid by 
 the process of churning. It contains only the fatty elements of the 
 milk, and lacks, therefore, many of the ingredients necessary for u 
 perfect food. 
 
 An artificial butter is now extensively manufactured from beef 
 fat. This is obtained by cutting and melting the suet ; after cooling 
 and becoming solid, the oily part is pressed out from the mass. 
 This oil is called oleomargarine ; by churning it with a small quan- 
 tity of milk, a substance is produced which much resembles butter 
 in appearance. There is nothing objectionable in the article, 
 though it lacks some of the qualities found in the best butter; it is 
 preferable in every way to the cheaper grades of butter. 
 
 Cheese is the nitrogenous part of milk — the casein. If it be 
 made from unskimmed milk, the cream or fatty portion is also con- 
 tained in it. Cheese is therefore a highly concentrated nitrogenous 
 food, and should be eaten only in small quantities. It constitutes 
 a fair substitute for lean meat. 
 
 Cheese, also, is now made by substituting oleomargarine for 
 the cream of the milk. 
 
 Eggs contain nitrog ous material in large quantity, but no 
 starch nor sugar ; hence tiiey do not constitute a complete diet. 
 
 Meat contains all the elements necessary for food, though not 
 in the proportions required by the animal body ; hence the neces- 
 sity for supplying certain elements by vegetables. Moat is espe- 
 cially rich in the nitrogenous and fatty elements of food, but lacks 
 the starchy matter. 
 
 Fish contain less nutritious material than the warm-blooded 
 animals ; the flesh is lacking in nitrogenous and fatty matters. 
 
 Wheat contains about ten per cent, of nitrogenous matter, 
 over sixty per cent, of starchy substances, and a large amount of 
 
 w 
 
 pi 
 
 Hi;' 
 
 1 
 
 V: 
 
 w\ 
 
 ,-. if 
 
 'm 
 
 V 
 
 tm I 
 
 m 
 
 I: 
 
 ¥■ 
 
 \\ 
 
 I'! 
 
5'ii' vr 
 
 i r 
 
 
 1064 
 
 HYGIENE. 
 
 salts. The innermost part of the wheat kernel consists largely 
 starch ; around this is a layer which contains the nitrogenous 
 terial, gluten ; and on the outside is the shell which consists par 
 of mineral substances. In grinding wheat the outermost porti( 
 are separated during the process of bolting from the starchy ingre 
 ents. The latter constitute the finest flour, while the outer pc 
 tions of the wheat are separated as bran. The coarser flou 
 therefore, contain the nitrogenous and mineral constituents of t 
 grain to a greater extent than the fine flour. 
 
 Rye contains less nutritious material than wheat. Its avera 
 composition is stated as follows : 
 
 Nitrogenous matter, 8.0 per 
 Fat, - - - 2.0 per I 
 Water, - - - 45.0 per 
 
 Starch, - - 70 per cent. 
 Sugar, - - 3.5 percent. 
 Salts, - - 1.8 per cent. 
 
 Indian corn has a composition somewhat similar to that 
 rye; it contains more nitrogenous matter and fat, and less sugar. 
 
 (^rt/w/^^/ contains less starch than the other ordinary grain 
 but more nitrogenous matter and fat. 
 
 Rice is stated to have the following composition : 
 
 - 7- 
 
 - 5. 
 
 - 13- 
 
 Its chief value is, therefore, as a source of starch;, for the remaii 
 ing elements of the food we must employ other articles. 
 
 Potatoes contain much less nutritious matter than the otht 
 common vegetables. Their average composition is as follows : 
 
 Nitrogenous matter, 
 
 - 6.3 
 
 Fat, 
 
 - 
 
 Starch, 
 
 - 79- 1 
 
 Salts, 
 
 - 
 
 Sugar, 
 
 - 4.0 
 
 Water, 
 
 - 
 
 Starch, 
 
 - 18.8 
 
 Salts, 
 
 Nitrogenous matter, 
 
 2.1 
 
 Fat, 
 
 Sugar, - 
 
 - 3.2 
 
 Water, 
 
 - o. 
 
 Fruits — Contain, as a rule, but little nitrogenous matte 
 though many of them furnish a large quantity of sugar and salts. 
 
 Clothing. 
 
 The primary object of clothing is to retard the escape of he; 
 from the body, though this object has become subordinate to pui 
 poses of ornamentation and display. Difi"erent fabrics posse 
 various qualities which render them more or less adapted for tl; 
 
¥^ 
 
 EXERCISE. 
 
 1065 
 
 n wheat. Its average 
 
 starch •, for the remain- 
 ler articles. 
 
 matter than the other 
 ition is as follows : 
 
 ird the escape of heat 
 lie subordinate to pur- 
 ;rent fabrics possess 
 - less adapted for the 
 
 purposes of clothing at different seasons and under different cir- 
 cumstances. 
 
 Cotton — Possesses to an unusual degree the power of absorb- 
 ing the moisture ; hence it is especially adapted for use as under- 
 clothing under circumstances which result in excessive perspiration. 
 It is largely used as underwear in tropical regions. 
 
 Linen — Is softer and less irritating to the skin than cotton. It 
 is, however, a good conductor of heat, and hence less adapted for 
 preserving the warmth of the body. 
 
 Wool — Is a non-conductor of heat, and hence commonly em- 
 ployed to preserve the warmth of the body. Its roughness and 
 its power of generating electricity by friction, render it unsuited 
 for immediate contact with the skin. 
 
 In the selection of materials which are to touch the skin, care 
 must be taken that they contain no injurious coloring material. 
 The dyes which are now extensively employed for coloring under- 
 wear often contain arsenic and other poisonous substances, as a 
 result of which severe imflammation of the skin and even constitu- 
 tional effects have occurred. 
 
 A disadvantage in the employment of flannels next to the skin 
 is the fact that they retain moisture, and offer a favorable soil for 
 the development of vegetable parasites. The parasitic growth on 
 the skin popularly known as " liver spots " is observed with especial 
 frequency in those who wear flannel. 
 
 Exercise. 
 
 As to the particular variety of exercise which should be taken, 
 no rules can be given. It is, however, a general principle that no 
 exercise is especially beneficial which does not interest and amuse 
 the mind as well as exert the muscles. 
 
 As to the time for exercise, it may be said that the muscles 
 should not be called into action immediately before or after meals. 
 By exercise at these times the process of digestion is retarded, and 
 the alimentary canal is not permitted the proper degree of repose. 
 
 The degree of exercise must vary with the individual ; in no 
 case should the bodily activity be so violent or so prolonged as to 
 cause exhaustion. A feeling of languor without exercise on the 
 69 
 
 \ ■Ik' 
 
io56 
 
 HYGIENE. 
 
 
 lif! 
 
 other hand is often relieved by brisk muscular effort. This is 
 proper remedy for the fee'ing of lassitude which is common in 
 climate during the spring, and which is often designated " spi 
 fever. " 
 
 Massage is a process whereby the circulation of blood in 
 muscles is artificially promoted. The feeble muscles are strol 
 rubbed, slapped and kneaded. The result becomes manifest 
 once in a redness of the skin and increase of temperature 
 many cases permanent benefit is secured by the patient emp 
 ment of these measures. 
 
 For invalids who are unable to take exercise in the ordin 
 form, there remain several substitutes. The best known of tl 
 are Massage and the Szucdish Movonent. 
 
 The Sivedish inovcment consists of a series of movemc 
 active and passive, performed sometimes with and sometimes w 
 out the will and assistance of the patient. The performanc 
 these movements requires considerable knowledge of anatc 
 and physiology, and need not be described in detail. The sys' 
 makes a good substitute for the usual forms of active exercise. 
 
 Ventilation. — In no one point perhaps is so much inj 
 done to the health as in the neglect to procure a sufficient quan 
 of fresh air. Many people have an aversion to admitting air to 
 house, especially at night; except during the warm weather, it 
 comparatively rare thing to find any provision made for the adn 
 sion of air to bed-rooms at night. While it certainly is desirabU 
 avoid draughts of air which shall strike directly upon the bed wl 
 a person is asleep, it is just as certainly desirable to have a 1 
 circulation of air through the room. An adult requires ab 
 twenty-five cubic feet of oxygen every day. That is about 
 cubic feet of fresh air. When we consider this fact, we can apf 
 ciate the lack of proper air which prevails in many of our b 
 rooms, where several persons sleep in a small apartment, v 
 windows and doors tightly closed. 
 
 Attention to the skin is an important item in personal hygic 
 not simply for appearance's sake, but also for the maintenance 
 health. The skin is not alone .a covering for the protection of 
 body; it is one of the most active and extensive channels for 
 separation fro; > the body of those materials which have been u 
 up in the func':ions of the animal economy. It is a familiar f; 
 that if a rabbit be varnished, so as to close the pores of the skin ; 
 
THE CARE OF THE SICK. 
 
 .067 
 
 liar effort. This is the 
 rhich is common in our 
 ten designated " spring 
 
 ulation of blood in the 
 )le muscles are stroked, 
 It becomes manifest at 
 ase of temperature ; in 
 t)y the patient employ- 
 
 xercise in the ordinary 
 rhe best known of these 
 
 a series of movements 
 /ith and sometimes with- 
 nt. The performance of 
 knowledge of anatomy 
 d in detail. The system 
 IS of active exercise, 
 haps is so much injury 
 >cure a sufficient quantity 
 n to admitting air to the 
 the warm weather, it is a 
 sion made for the admis- 
 it certainly is desirable to 
 •ectly upon the bed while 
 desirable to have a free 
 n adult requires about 
 ay. That is about 125 
 |r this fact, we can apprc- 
 ils in many of our bcil- 
 a small apartment, with 
 
 item in personal hygiene. 
 lo for the maintenance of 
 
 I for the protection of the 
 
 ttcnsive channels for the 
 
 lis which have been used 
 
 It is a familiar fact, 
 
 1 the pores of the skin ami 
 
 arrest the usual function of this organ, the animal dies in a few 
 hours. The effect is just the same as if those important organs of 
 excretion, the kidneys, be removed from the body. The skin sep- 
 arates from the system almost as much waste material as the 
 kidneys, the lungs and the intestines together. 
 
 THE CARE OF THE SICK. 
 
 One of the first items to be attended to in the management of 
 the sick room is proper ventilation. Fresh air is of extreme 
 importance for a healthy person, but doubly so for one who is sick. 
 For the system of the latter requires every possible assistance to 
 regain its natural condition; indeed, medicines and nursing are of 
 no avail if the patient is compelled to breathe the emanations from 
 his own diseased body, and thus to keep up a continual supply of 
 material injurious to the system. 
 
 No odors of any kind should ever be perceptible in the sick 
 room ; their presence is evidence that the ventilation is imperfect. 
 Care must, of course, be taken not to injure the patient by chilling 
 him while providing for a proper supply of fresh air. By fresh air, 
 we mean not air which has passed through other rooms, but air 
 admitted directly from the outside. If there be a fire-place in the 
 room, a draught of air sufficient for most purposes of ventilation 
 can be secured by lowering the sash of a window a few inches from 
 the top, and by keeping a fire burning in the grate. 
 
 The temperature is another point of importance in the care of 
 the sick room. There is generally such an anxiety to avoid chilling 
 the patient, that the room is kept at a very high temperature. It 
 should be remembered that there is most danger of taking cold 
 when the room is heated to an improper degree, since under 
 such circumstances, the admission of air from the outside, even 
 during the opening and closing of the door, causes a decided im- 
 pression upon the patient, which may be sufficient to chill him. 
 
 The temperature of the room should, as a general thing, be 
 somewhat higher in the morning than in the afternoon ; for this there 
 are two reasons : first, that the outside air is usually warmer in the 
 
 1^1 f 
 
 ;!1 
 
 I 
 
 ■I 
 
 It 
 
 I 
 
 I 
 
 
 
 a»f: 
 
 '1 
 
 'f 
 
io68 
 
 THE CARE OF THE SICK. 
 
 !'"'■ '^ 
 
 afternoon, and second that the patient's vital powers are less vigc 
 ous after the night's rest. 
 
 It is extremely important that the excrement of the patient 
 at once removed from the room. If it be necessary to use 
 vessel at short intervals, it should be kept well covered in 
 adjoining closet. Such vessels should be frequently emptied at 
 cleansed ; a failure to do so results in the formation of noxio 
 gases which escape into the room and exert injurious effects. 
 
 While the exact temperature of the room may vary to advar 
 age under different circumstances, the best general average will 
 found to be about 70 degrees F. A feeble patient, one who 
 exhausted by some wasting disease, may require a temperatu 
 several degrees higher than this ; a patient suffering from son 
 inflammation such as " lung fever " may, on the other hand, I 
 benefited by a temperature of 60 or 65 degrees F. 
 
 An important auxiliary in the treatment of the sick is it'g/i 
 Vigorous plants become pale and sickly in a dark room ; and v 
 cannot expect a pale and sickly person to become vigorous und 
 the same conditions. Light is essential, not only to a healthy pe 
 son, but also to the restoration of health in a sick person. The: 
 are, it is true, certain affections of the eyes which can be cure 
 only when no light is admitted to the room ; but aside from the; 
 a sick room should be well lighted. 
 
 The cleanliness of the house, while always a matter of impor 
 ance, is absolutely essential in the treatment of the sick. B 
 cleanliness is meant not simply the absence of dust and dirt froi 
 the floors, but also freedom from noxious gases in and around tli 
 dwelling. In the country the most frequent source of these is tli 
 collections of water and of refuse in the yard or under the houst 
 A little stagnant water and refuse in the yard or under tli 
 house is a frequent cause of disease, and serves to prolong an illnc; 
 which may have originated from other sources. The premise 
 about the house, as well as underneath it, should always be kcj 
 dry and clean. 
 
 In cities and towns a frequent source of sickness is defcctiv 
 drainage. It is a familiar experience in city practice to fin 
 several cases of typhoid fever in the same family living in a hous 
 whose atmosphere is permeated with gases derived from the escap 
 pipes. Inspection often shows that the traps and pipes of th 
 house are so defectively arranged as to permit the sewer gases t 
 escape into the rooms. 
 
 
i 1 
 
 THE CARE OF THE SICK. 
 
 1069 
 
 ,owcrs are less vigor- 
 
 cnt of the patient be 
 necessary to use a 
 ; well covered in an 
 quently emptied and 
 formation of noxious 
 ijurious effects. 
 1 may vary to advant- 
 ^neral average will be 
 patient, one who is 
 •equire a temperature 
 t suffering from some 
 n the other hand, be 
 
 ees F. 
 
 nt of the sick is light. 
 1 dark room ; and we 
 ecome vigorous under 
 t only to a healthy per- 
 1 a sick person. There 
 es which can be cured 
 ; but aside from these 
 
 lys a matter of import- 
 ncnt of the sick. By 
 1 of dust and dirt from 
 Ises in and around the 
 ^ source of these is the 
 [d or under the house, 
 he yard or under the 
 /cs to prolong an illness 
 purees. The premises 
 Ihould always be kept 
 
 |)f sickness is defective 
 city practice to find 
 Lnily living in a house 
 lerived from the escape 
 japs and pipes of the 
 lit the sewer gases to 
 
 " The importance of a good supply of pure air is not nearly so 
 well appreciated generally as is the necessity for free supplies of pure 
 water. Mankind has ever sought to get a clear and sparkling water, 
 and objects to it if its smell be unsavory ; but of the finer and 
 subtler contaminations he has remained, until recently, profoundly 
 ignorant. The curious relations of cholera to water supply furnish 
 a case in point. In one outbreak in London thirty-seven per ten 
 thousand of those who drank the water from the Thames above 
 the city died ; but one hundred and thirty per ten thousand of 
 those who drank water brought from the Thames below London 
 died. Here is an unquestionable piece of evidence that a con- 
 stantly impure water supply leaves the system less equal to resist 
 an epidemic form of disease. It is not that water is often the direct 
 source of disease, as diarrhea and typhoid fever, but it is com- 
 monly a cause of a gradual steady deterioration of the health, which 
 is revealed by the inability of the system to withstand the strain of 
 some acute intercurrent disease. If temperance, or rather teetotal- 
 ism, be a good thing, its advocates ought at least to secure their 
 adherents from the dangers to which they are thus exposed, for 
 outbreaks of typhoid fever have been found to seize the water 
 drinkers of a house, while the beer drinkers have been free from 
 attack. In our relations to the public as medical men, we must be 
 impartial, and sentiment must not warp our intelligence ; we must 
 be as ready to acknowledge the dangers of water drinking as we 
 are to admit the destructive consequences of excessive indulgence 
 in alcohol. It is not in towns only that the evil effects of a con- 
 taminated water supply are felt ; indeed they have been too rudely 
 awakened by irrefutable facts to be any longer oblivious to the 
 consequences ; but also in the country, where wells lie close to 
 sinks and midden steads ; where the village stream furnishes to 
 those at one end of the hamlet as a beverage, the sewage of the 
 houses placed further up. In few villages is the water to be trusted, 
 unless it be the product of some well-cared for spring or some 
 exceptional well. The repeated outbrc'is of typhoid fever have 
 accumulated evidence on this matter which is sufficient to convince 
 the most skeptical. 
 
 " Closely connected with our water supply is that of our 
 sewage. We know that many outbreaks of disease are occasioned 
 by our water carriage of sewage. Not only is sewer-gas apt to 
 diffuse itself from the water-closet trap, and so to poison the 
 
 
 I 
 
 ^l 
 
 ,t 1 .! 
 
 
 % 
 
 
 W" • 
 
I070 
 
 THE CARE OV THE SICK. 
 
 inhabitants of the house ; but leakage from sewer-pipes is ap 
 penetrate the water supply, and so cause disease. When 
 water supply its cut off sewer-gas finds its way into the en 
 tubes, which exercise a suction action as the water runs ou 
 them, and then follows disease. If there be any typhoid fcvc 
 the town, the poison will get universal diffusion when the wate 
 again on, and an outbreak will result. The possibilities of w 
 contamination by our sewage are so numerous that it wouk 
 simply impossible here to indicate a tithe of them. 
 
 " A great source of danger in connection with the water-cl 
 is the liability to so introduce sewer-gas into the house. W 
 the water supply or waste-pipes of closets in the upper part of 
 house are in communication with those beneath, the rush of w 
 to the lower outlets causes a rush of air to take the place of 
 vacuum so made, and sewer-gas is often so introduced int 
 house. At other times, especially in houses, at the summit of c 
 sewage area the pent up sewer-gases rush up the waste-pipes, 
 from the water-closets infect the upper rooms of the houses. Ee 
 cially is this the case if the sewerage opens into a tidal ri' 
 The waste water-pipe should be broken in its course, so that sev 
 gas may escape without rising into the house ; or a shaft sho 
 be carried up and out beyond the roof, so that if pent-up sew 
 gas should rise in the pipes it would find a ready outlet into a cc 
 paratively safe external air. " — Fothoegill. 
 
 Disinfection, — The objects of disinfection are two-fo 
 first, to destroy noxious odors, that is, to deodorize ; second 
 destroy poisonous principles which are capable of inducing disc 
 — that is, to disinfect, in the proper sense of that word. Tli 
 two processes are not always identical ; that is, we may remove 
 unpleasant odors without destroying the noxious substances wli 
 induce disease. Most agents which arc used for disinfect! 
 however, are capable of both deodorizing and disinfecting, 
 following substances are those in common use for purposes of ( 
 infection. 
 
 For the cleansing of water closets and vaults, the most c^ 
 venient disinfectant is the sulphate of iron (green vitriol). A poi 
 of this should be thoroughly dissolved in a gallon of water ; 
 emptied into the vault. The substance commonly known 
 "chloride of lime" is another excellent agent for deodorizing. 
 
DISINFi;CTlON. 
 
 1 07 1 
 
 K. 
 
 1 scwer-pipes is apt to 
 
 2 disease. When the 
 ts way into the empty 
 the water runs out of 
 je any typhoid fever in 
 ision when the water is 
 le possibilities of water 
 erous that it would be 
 f them. 
 
 on with the water-closet 
 
 into the house. When 
 
 in the upper part of the 
 
 neath, the rush of water 
 
 to take the place of the 
 
 n so introduced into a 
 
 cs, at the summit of each 
 
 L up the waste-pipes, and 
 
 ,ms of the houses. Espc- 
 
 jpens into a tidal river. 
 
 its course, so that sewer- 
 
 louse ; or a shaft should 
 
 o that if pent-up sewci- 
 
 ready outlet into a coni- 
 
 isinfection are two-fold : 
 ;o deodorize; second, to 
 lablc of inducing disease 
 Lc of that word. These 
 at is, we may remove all 
 ()xious substances which 
 Ire used for disinfection, 
 and disinfecting. The 
 use for purposes of dis- 
 
 Id vaults, the most con- 
 l(grcen vitriol). A pt>uiul 
 In a gallon of water and 
 |e commonly known as 
 Lent for deodorizing. A 
 
 pound of this dissolved in a gallon of water is usually sufficient to 
 remove unpleasant odors. 
 
 For disinfecting bed-pans and similar vessels and for cleansing 
 water closets, listerine is a most agreeable and effective agent. 
 One part of this to five of water is usually strong enough to remove 
 such odors. 
 
 For disinfecting rooms which have been occupied by patients 
 suffering from infectious diseases, it is necessary to have some dis- 
 infecting agent which will diffuse itself through the air of the room. 
 The best agents for this purpose arc bromine and chlorine. 
 Bromine, which is a liquid, may be placed in a saucer and allowed 
 to stand for twenty-four hours. Chlorine can be best obtained 
 by placing about two tablespoonfuls of chloride of lime in each of 
 several saucers which arc to be placed upon the floor and furniture 
 of the room ; the formation of gas (chlorine) can be hastened by 
 adding a few ounces of very weak vinegar to the chloride of lime. 
 After such rooms have thus been disinfected the furniture should 
 be removed, — to the open air if possible — the floor should be 
 thoroughly scrubbed with a solution of carbolic acid (one part to 
 twenty-five of water) ; the walls and ceiling should be washed and 
 freshly calcimincd or whitewashed. Articles of clothing which 
 have been used by a patient suffering from an infectious disease 
 should be burned ; so should newspapers, journals, books, etc. If 
 such articles are too valuable to destroy they should be exposed to 
 a heat sufficient to disinfect them thoroughly ; garments may be 
 boiled for an hour, or kept in an oven at a temperature of at least 
 200 degrees Fahr. for two or three hours. It is important that 
 these measures be observed, since disease is often spread by the 
 agency of articles of clothing, books, and the like, which may be 
 circulated around from one person to another. 
 
 Heaps of dirt and filth should be covered with charcoal, or 
 quicklime, or with dry earth, to a depth of three inches. A mix- 
 ture of charcoal and quick lime can be obtained under the name of 
 " cal.x powder. " 
 
 For disinfecting drains, ditches, sewers and the like, the best 
 method is the use of the chloride of lime. 
 
 A most important point in cases of infectious fever is to 
 isolate the patient. It is important that no one be allowed to see 
 him except those whose personal attendance is absolutely neces- 
 sary. The well-meant visits of sympathizing friends usually annoy 
 
 
 ii^p 
 
 I 
 
 I, 
 
 '.:» 
 
'M 
 
 *'!" 
 
 1072 
 
 THE CMiE Ol TIIK SICK. 
 
 and exhaust the patient himself, and ; pread the disease to otli 
 This latter feature is often neglected ; people who have had snl 
 pox or have been repeatedly vaccinated, for instance, seem to til 
 it incumbent upon them, as a religious duty, to visit their frit 
 who may bo suffering from the disease. While this may be dl 
 with the most benevolent motives, and with perfect impunitj 
 far as the visitor is concerned, it is often the means of diss^ 
 inating the disease. For an individual who will not take small- 
 himself, can nevertheless communicate the poison to others \^ 
 whom he may come in contact. 
 
 Soiled linen should be immersed in a disinfecting solutl 
 before being carried out of the room. For this purpose a solutl 
 of carbolic acid, one part in twenty of water, or chloride of lil 
 should be used. All slops and excrement from the patient shol 
 be thoroughly disinfected in the same way before being remove 
 A sheet saturated with the carbolic acid solution or some otl 
 disinfectant, should be hung across the doorway ; this should 
 frequently moistened with the disinfectant. Saucers containi 
 chloride of lime should be placed in the room. 
 
 " As to the patient, the sulphite of soda may be administer 
 in lemon juice ; and if the case be small-pox or scarlet fev( 
 the patient may be washed with tar soap or salicylic or carbo 
 acid soap. At the latter stages, when the dry crusts of small-pi 
 or the scales of scarlet fover constitute special sources of danger, 
 carbolized oil or ointment should be rubbed over the body, ai 
 the patient should be bathed every day or two ; then the disi 
 fectant should be smeared over the whole surface again, and at t 
 regular time the bath be resorted to. By such means the infecti 
 matter given off from the surface is rendered harmless. 
 
 " Such are the measures to be carried out when fever has on 
 entered a house. It is not sufficient merely to see the patie 
 through the fever in scarlatina, small-pox and typhoid ; the nu 
 infectious period is that of early convalescence. Such convaU 
 cents should be kept away from the healthy, in separate roon 
 until the last scab has fallen off in small-pox, and until the k 
 particle of skin has exfoliated and come away in scarlatina." 
 
 The bed on which the patient lies should receive carel 
 attention. The prevalent habit is to place two or three mattress 
 on the bed with the idea of making the patient comfortable, and 
 leave these undisturbed for days or weeks at a time. It is n 
 
• ' 
 
 FOOD I'OK Tin: SU K. 
 
 >o73 
 
 
 ' , I 
 
 the disease to others. 
 le who have had small- 
 instance, seem to think 
 y, to visit their friends 
 hile this may be done 
 ith perfect impunity so 
 the means of dissem- 
 will not take small-pox 
 poison to others with 
 
 a disinfecting solution 
 this purpose a solution 
 iter, or chloride of lime 
 from the patient should 
 before being removed. 
 1 solution or some other 
 orway ; this should be 
 jt. Saucers containing 
 om. 
 
 da may be administered 
 ll-pox or scarlet fever, 
 ) or salicylic or carbolic 
 dry crusts of small-pox 
 ial sources of danger, a 
 cd over the body, and 
 r two ; then the disin- 
 urface again, and at the 
 uch means the infective 
 Id harmless, 
 ut when fever has once 
 [rely to see the patient 
 nd typhoid ; the most 
 ence. Such convales- 
 ly, in separate rooms, 
 ox, and until the last 
 |y in scarlatina. " 
 hould receive careful 
 Iwo or three mattresses 
 nt comfortable, and to 
 at a time. It is not 
 
 sufficient to " shake up " these mattresses occasionally ; they should 
 be well aired every day as certainly as the sheets. There may be, 
 it is true, cases in which the patient's condition absolutely forbids 
 even the slight movement necessary to remove a mattress from 
 beneath him; but a little care and skill can accomplish the required 
 change with but little discomfort to the patient. 
 
 The mattress upon which the patient rests — and it is usually 
 sufficient to have one — should be nt)t be too soft, since the emana- 
 tions from the patient's body are more apt to permeate such soft 
 materials. In hospitals, where especial attention is given to details, 
 the beds are usually provided with a woven wire mattress, upon 
 which one of horse-hair is laid. Whatever material be employed, it 
 is necessary to air the bed frequently, and if possible to permit a 
 circulation of air under the mattress. 
 
 Patients are usually burdened with too much covering, under 
 the idea that because the individual is sick he must be kept very 
 warm. The result is bad in different ways ; in the first place the 
 patient is practically enveloped in a poultice, a measure which may 
 be beneficial in some exceptional instances, but is certainly unde- 
 sirable, as a general rule. In the ne.xt place the patient is kept so 
 warm that the slightest exposure may cause him to take cold. 
 
 An essential item in the care of a patient is attention to his 
 personal cleanliness. This is even more important when an indi- 
 vidual is sick than in health, since the system is not so able to 
 endure the presence of the materials which should be thrown out 
 of the body by the skin. Furthermore, there is often an addi- 
 tional reason for frequent cleansing of the skin, because there are 
 certain matters present in the body which must be eliminated by 
 the skin. A patient should be bathed at least twice a week with 
 soap and warm water. If his condition be such as to prevent his 
 removal from the bed, a sponge bath should be given. In ba':h- 
 ing a patient it is advisable to uncover only a little of the surface 
 at a time, and to rub this dry before e.xposing other parts of the 
 skin. 
 
 Food for the Sick. 
 
 Beef Tea. — This article has sometimes considerable value, 
 though it is not a proper article of food in all cases of illness, aii 
 is generally supposed. Beef tea is indeed much overrated, since it 
 possesses but little nutriment. It is rather a stimulant than a food. 
 
 
 I 
 

 y,-.■..^-'T:^ll'^^ 
 
 I074 
 
 FOOD FOR 'IHE SICK. 
 
 It may be made by cutting into small pieces about half a po 
 of fresh beef from which the fat has been separated; this should 
 put into a vessel into which a pint of boiling water is then poui 
 The vessel is then allowed to stand by the fire ; after this it may 
 boiled for five or ten minutes and the contents of the vessel pla 
 upon a sieve, so as to separate the liquid ; this may then be seaso 
 with salt to suit the taste. 
 
 Liebig's beef tea is made as follows : One pound of lean b 
 free of fat and separated from the bones, in the finely chopped si 
 in which it is used for mince meat, is uniformly mixed with its ( 
 weight of cold water slowly heated to boiling ; and the liquid, a 
 boiling briskly for a minute or two, is strained through a towel fi 
 the coagulated albumen and fibrin. Thus wc obtain an equal wei 
 of the most aromatic soup, of such strength as cannot be obtai: 
 even by boiling for hours from a piece of flesh. 
 
 C/i'cJieil liroth. — " Clean half of a chicken and pour o 
 one quart of cold water ; add a little salt and one tablespoonfu 
 rice ; cover the vessel closely and boil for two hours ; throw in r 
 the end of the boiling, a little parsley chopped fine; skim the br 
 before using. 
 
 " Thii is one of the most valuable articles of diet at the cc 
 mand of the physician in the low stages of disease, when 
 patient's system requires support, but his digestive pov/ers will 
 adm.it of solid food." — FJ/is. 
 
 Mntton Uroth. — A pound of lean mutton may be placec 
 a quart of water with a little bread and salt ; it should be boi 
 about two hours, and skimmed before using. 
 
 OrtieJs, — The ordinary gruel is made by adding two tal 
 spoonfuls of CO iimeal to a teacupful of cold water ; it should 
 well stirred and placed in a suitable vessel ; an additional pin 
 water is added and it is allowed to boil gently for half v.n hour, 
 desired, half a pintcf nilk may be used instead of the same qu 
 tity of water. It is to be seasoned before using. 
 
 Oatmeal gruel may be made in a similar way, adding f 
 tablespoonfuls of oatmeal to a pint and a half of soft water. 
 
 fTcllh's — A variety of starchy articles can be made into cxi 
 lent food for invalids. 
 
 Iceland Moss ca" be made into a jelly in the following way : 
 
FOOD FOR THE SICK. 
 
 1075 
 
 CCS about half a pound 
 aratcd; this should bo 
 • water is then poured, 
 e ; after this it may be 
 Its' of the vessel placed 
 s may then be seasoned 
 
 3ne pound of lean b- f, 
 he finely chopped state 
 mly mixed with its own 
 g ; and the liquid, after 
 ed through a towel from 
 
 re obtain an equal weight 
 
 h as cannot be obtained 
 
 iesh. 
 
 I chicken and pour on it 
 
 and one tablespoonful of 
 
 wo hours ; throw in near 
 
 .pcdfine; skim the broth 
 
 ,ticles of diet at the com- 
 ^•s of disease, when the 
 digestive pov/ers will not 
 
 pound of the dried moss should be soaked for twenty-four hours in 
 water, and then dried by pressing it in a coarse ^.loth. It is then 
 placed hi water, an ounce of the moss being sufficient for a quart of 
 water. It should be boiled until about half the fluid has evapo- 
 rated, and then strained through a sieve. The jelly or mucilage 
 may be sweetened or mixed witl^ milk. 
 
 Irisli Moss makes an excellent jelly. An ounce of it should be 
 boiled with a pint and a half of water until it becomes of moderate 
 consistence upon cooling. It has but little taste, but may be sweet- 
 ened or mixed with milk. 
 
 Tapioca mucilage is made in this way : A tablespoonful of 
 tapioca is put in a pint of water and allowed to stand upon the 
 stove for t-'^o hours, after which it is boiled for ten minutes, being 
 stirred briskly at the same time. It should be sweetened with sugar 
 and may be flavored with lemon-juice. It is often served with 
 
 milk. 
 
 Rice may be made into jelly by steeping an ounce of it in a 
 quart of water for three hours upon the stove ; it should then be 
 boiled gently for an hour and strained through a sieve. The jelly 
 may be sweetened or assidulatcd. 
 
 These jellies contain but little nutritious matter, and should 
 never constitute the entire diet. 
 
 ,>' 
 
 I I 
 
 Inuitton may be placed in 
 [salt; it should be boiled 
 
 Ide by adding two tablc- 
 
 Icold water ; it should be 
 
 lol; an additional pint <.t 
 
 Intiy for half :m hour, li 
 
 Instead of the same quan- 
 
 : using. 
 
 similar way, adding four 
 (half of soft water. 
 
 can be made into cxcel- 
 
 1 in the following way : A 
 
 % 
 
' i 
 
 ■ iiV 
 
 M 
 
 1076 
 
 MEDICINAL PLANTS, 
 
 MEDICINAL PLANTS. 
 
 Plate 1. 
 
 Saffron. — This is a familiar garden flower of a deep orange 
 color. It is used as a decoction ; an ounce of the leaves is boiled 
 in a pint of water. 
 
 This is used as a gargle for sore throat and as a remedy for 
 levers. It is supposed to favor the eruption in scarlet fever, 
 measles, etc. 
 
 Meadow Sweet. — The root, bark and leaves of this plant arc 
 used in diarrhea, especially in children. A decoction can be made 
 by boiling an ounce of the root or bark in a pint of water. Two 
 or three tablespoonfuls of this decoction may be taken four times 
 a day. 
 
 Mustard. — Powdered mustard seeds, ordinary table mustard, 
 are chiefly used in medicine for two purposes . first, to promote 
 vomiting. One or two teaspoonfuls stirred I'p in a glass of warm 
 water usually suffice to excite vomiting. This quantity may be 
 repeated in five minutes if necessary. 
 
 The second use of mustard is in the shape of mustard plasters 
 or poultices, which are used to relieve pain and to promote the cir- 
 culation. 
 
 Nettle. — The juice of the nettle is sometimes valuable in cases 
 of bleeding from the lungs, nose, bowels and urinary organs. A 
 decoction can be made of the seeds or leaves. 
 
 li ;' 
 
 Plate 2. 
 
 : i: 
 
 Buckthorn. — The bark is sometimes used as a cathartic, though 
 it is apt to purge violently. Tiiis plant is not ordinarily used by 
 physicians. 
 
 Fennel. — The seeds of this familiar plant are used to flavor 
 medicines. They are also employ^id to relieve the griping pains of 
 colic ; the drug is usually given as an infusion of the leaves. 
 
 1-5 
 
■If^ 
 
 I \ 
 
 MEDICINAL PLANTS. 
 
 1077 
 
 er of a deep orange 
 the leaves is boiled 
 
 md as a remedy for 
 on in scarlet fever, 
 
 Lves of this plant are 
 xoction can be made 
 pint of water. Two 
 • be taken four times 
 
 linary table mustard, 
 ;es . first, io promote 
 'p in a glass of warm 
 his quantity may be 
 
 |e of mustard plasters 
 d to promote the cir- 
 
 limes valuable in cases 
 urinary organs. A 
 
 Tansy. — This familiar herb is employed in the shape of an 
 infusion. It is popularly supposed to be useful in bringing on the 
 menstrual flow, for which purpose a wincglassful of a strong 
 infusion may be given. An oil is extracted from the plant and 
 used occasionally in medicine. This plant is supposed to be 
 capable of inducing abortion. 
 
 Wood Sorrel. — This plant was formerly supposed to have 
 great value in the treatment of cancer, but is now but little em- 
 ployed in medicine. 
 
 Plate 3. 
 
 Stavcsncrc. — An ointment made from the seeds of this plant 
 is sometimes used for the purpose of destroying vermin on the 
 head. 
 
 Golden Rod. — An infusion made by adding an ounce of the 
 leaves and tops of the sweet golden rod to a pint of water, may be 
 given to relieve the pains of colic. A wincglassful of this infusion 
 is the ordinary dose. 
 
 Lime. — The juice of the fruit is mixed with water to make a 
 cooling drink for fever patients. Large quantities of this juice arc 
 carried on shipboard as a preventive against scurvy. 
 
 Bcarberry. — This remedy was formerly much used in the 
 treatment of chronic diseases of the bladder. It renders the urine 
 less irritating, and hence decreases the pain of inflammation of the 
 urinary organs. A decoction (one ounce of the leaves to a pint of 
 boiling water) is the best form for administering this remedy ; two 
 tablespoonfuls of this may be given at a dose. 
 
 ti, 
 
 \a 
 
 Plate 4. 
 
 las a cathartic, though 
 |>t ordinarily used b)' 
 
 It are used to flavor 
 the griping pains of 
 lof the leaves. 
 
 Henbane. — This plant has an important place in medicine, 
 being used for nearly the same purposes as belladonna. 
 
 It is a violent poison, and must be carefully distinguished from 
 the root of the parsnip, which it closely resembles in shape and 
 appearance. 
 
 Henbane is used as a narcotic to quiet pains in inflammations. 
 Under such circumstances it has the advantage over opium that it 
 
Ml M 
 
 1078 
 
 MEDICINAL PLANTS. 
 
 does not cause any excitement in the patient, but is directly sedat 
 in its action. It is especially valuable as a narcotic in the treatni 
 of children. 
 
 Henbane is frequently used in the treatment of delirium, m 
 ingitis, and other affections of the brain in which opium cannot w 
 be employed. 
 
 Calamus. — An infusion of the root is sometimes used for 
 the relief of flatulent colic in children. 
 
 Sage. — An infusion of this familiar plant is a household reme 
 for the promotion of perspiration. It is given during the co 
 mencement of fevers and inflammation. 
 
 Plate 5. 
 
 Thorn Apple. — This plant belongs to the same class of remed 
 as henbane and belladonna. The dried leaves rolled in cigaret 
 are often effectual in relieving the paroxysms of asthma. 
 
 Asparagus. — This plant is sometimes used for the purpose 
 promoting the secretion of urine. 
 
 Marsh Malloiv. — A decoction of the root is used as a soothi 
 injection in inflamed conditions of the vagina. 
 
 Hop. — The powdered root is employed as a pill to quiet irrit 
 bility of the urinary organs. It is also employed to relieve the pa 
 of gonorrhoea. 
 
 Plate 6. 
 
 Scurvy Grass. — This plant is so named because of its suppose 
 efficacy in relieving scurvy. 
 
 Meadow Saffron (colchicum). — This plant is chiefly known fi 
 its use in the treatment of gout and rheumatism. In employiniL,'^ 
 care must be tak'-Mi not to give it in excess, since it causes vomitii 
 and purging. 
 
 Garlic. — The garlic, onion and leek arc all used for bronchit 
 and colds in the head. Made into poultices, they are applied t 
 local inflammations. 
 
 Vi- 
 
MEDICINAL PLANTS. 
 
 1079 
 
 DUt is directly sedative 
 fcotic in the treatment 
 
 lent of delirium, men- 
 lich opium cannot well 
 
 ometimes used for the 
 
 t is a household remedy 
 :Tiven during the com- 
 
 e same class of remedies 
 Lves rolled in cigarettes 
 ^s of asthma, 
 used for the purpose of 
 
 )ot is used as a soothing 
 na. 
 
 as a pill to quiet irrita- 
 lloyed to relieve the pain 
 
 because of its supposed 
 
 lant is chiefly known for 
 litism. In employiiv^ ii 
 Isince it causes vomiting 
 
 all used for bronchitis 
 Ics, they are applied to 
 
 Horse Radish. — This is sometimes used as a tonic for the di<:es- 
 tion and to promote the secretion of the kidneys. 
 
 Plate 7. 
 
 Juniper. — An infusion made by boiling an ounce of the bruised 
 berries in a pint of water is frequently used to stimulate the action 
 of the kidneys. Hence this remedy is used in dropsy and in some 
 diseases of the kidney. It is usually combined with cream of 
 tartar. 
 
 Black Currant. — The juice of the berries is used as an astrin- 
 gent in diarrhea of children. 
 
 White Horehound. — An infusion is given in catarrhal troubles, 
 and sometimes in dyspepsia. 
 
 Coltsfoot. — An infusion of the dried leaves of coltsfoot is 
 employed to loosen the phlegm in a chronic cough. 
 
 Plate 8. 
 
 Plantain. — This was formerly employed to increase the secre- 
 tion of urine ; at present it is rarely used except as a poultice made 
 o'i the bruised leaves. 
 
 Poppy. — The dried juice from incisions made into the capsules 
 holdin"' the seeds of the poppy is familiar to all under the name of 
 opium. This drug is chiefly used for the relief of pain, and is also 
 employed in the treatment of inflammations. 
 
 Pennyroyal. — This variety of mint is employed as an infusion 
 for the relief of griping pains in the abdomen. It is popularly sup- 
 posed to be beneficial in cases of retarded painful menstruation. 
 
 Plate 9. 
 
 Peony. — An infusion is made b boiling an ounce of the pow- 
 dered root in a pint of water. Haifa teacupful may be given four 
 times a day. It was formerly considered a nerve tonic, and was 
 used in epilepsy and St. Vitus' dance. 
 
 
 1t 
 
 11 
 
-} 
 
 iiUhi 
 
 |i 
 
 '\ ■ 
 
 .jir'i 
 
 1080 
 
 MEDICINAL PLANTS. 
 
 Sf. Johns Wort. — This plant was formerly used as a decocti 
 to promote menstruation, but is now seldom employed. 
 
 Aconite. — This is one of the most powerful drugs employe 
 It is useful in the early stages of fevers and of inflammations, su 
 as pneumonia, erysipelas and rheumatism. The tincture of 1 
 root may be given in doses of one drop every hour until six do- 
 have been taken; the remedy should not be given in excess, sui 
 it will cause weakness of the heart and perhaps fainting. 
 
 Plate 10. 
 
 Flax. — The ground seeds are much employed in the prepar 
 tion of poultices ; the oily matter which they contain serves 
 retain the heat and moisture, as well as to make a soft, soothir 
 application. 
 
 Woi'uizvood. — An infusion made by adding an ounce of tl 
 plant to a pint of boiling water, may be taken for the relief of ce 
 tain forms of dyspepsia ; a wineglassful of this infusion constituti 
 a dose. 
 
 This infusion, mixed with equal parts of vinegar, is employe 
 as an application for sprains and bruises. 
 
 A peculiar intoxicating liquor known as absinthe, is prepare 
 by distillation from wormwood 
 
 Carrot. — The roots of the ordinary carrot can be made into 
 very good poultice. Internally the medicine is not used, though 
 was formerly employed occasionally in cases of dropsy. 
 
 Horse-chestnut. — A decoction of the bark has been used in cast 
 of ague and other malarial fevers. 
 
 Plate 11. 
 
 Licorice. — Powdered licorice is commonly used to cover th 
 taste of other medicines ; it is largely employed in the manufactui 
 of pills. 
 
 Dandelion. — This plant has long been used as a remedy fo 
 torpor of the liver, and dyspepsia associated with Home disorder t 
 
nerly used as a decoction 
 m employed. 
 
 owerful drugs employed. 
 i of inflammations, such 
 1. The tincture of the 
 /ery hour until six doses 
 be given in excess, since 
 haps fainting. 
 
 nploycd in the prepara- 
 they contain serves to 
 make a soft, soothing 
 
 xdding an ounce of the 
 :en for the relief of cer- 
 this infusion constitutes 
 
 >f vinegar, is employed 
 
 IS absintJie, is prepared 
 
 rot can be made into a 
 sis not used, though it 
 . of dropsy. 
 
 k has been used in cases 
 
 only used' to cover the 
 ^'cil in the manufacture 
 
 used as a remedy for 
 with Home disorder of 
 
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 11 iJ 
 
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 Hedge-Mustard. 
 
 ^^ Hedge-Nettle. 
 
 
 ri-ATi'. I. 
 
v^ 
 
 Meadow-sweet. 
 
 Hedge-Nettle. 
 
 'II 
 
 f ' '. 
 Ii « 
 
 i1 : ' 
 
 Wood Sorrel. 
 
 F!,ATK II 
 
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 Bear Berry. 
 
 PLATE III. 
 
Golden Rod. 
 
 ??^\/ 
 
 m 
 
 n 
 
 mm 
 
 1 
 
 Bear Berry. 
 
 '4 
 
 '■' » 
 
 Mustard. 
 
 PLA'IK IV 
 
i' i 
 
 i I 
 
 
 Marsh Mallow. 
 
 platp: v. 
 
Asparar^us. 
 
 .d.y 
 
 y,\ 
 
 Hop. 
 
 Garlic. 
 
 Horse-radish. 
 
 PLATI'; 
 
mi 
 
 
 
 ! * 
 
 
 :,,;. 
 
 
 
 li 
 
 ' .i 
 
 1 
 
 ■f I 
 
 .: ^ 
 
i: I 'I 
 
 White H«reno«nd 
 
 Coltsfoot. 
 
 PLATE VII. 
 
Black Currant. 
 
 <^fci. 
 
 
 Isfooi 
 
 Pennyroya 
 
 'i} 
 
 % 
 
 J,:: 
 
 h 
 
 Bearsfoot. 
 
 PLATK VI II. 
 
''I 
 
 

 i,i'' 
 
 Aconito or Monkshood 
 
 Lily o( the Valle 
 
 IM.\ri': IX. 
 

 St. John's Wort. 
 
 Carrot. 
 
 I- 
 
 Lily ol the Valley. 
 
 PLAT1-: X. 
 
' V 
 
 
Bramble. 
 
 TLATl': XI. 
 

 Jramble. 
 
 !•' I 
 
 I I 
 
 iif] 
 
 i'l 
 
 Nettle. 
 
 Deadly Nightshade. 
 
 M ' 
 
 I'l. Alt': XII 
 
1?'^ 
 
 If 
 
( 
 
 ! i 
 
 
 f 
 
J I. 
 
 iili 
 
 I 
 
 i 
 
 
 
 
 PLATE XIII. 
 
Valerian. 
 
 f' •'^ 
 ■'?j' 
 
 'I 
 
 Crowfoot. 
 
 
 Hemlock. 
 
 
 
 
 >>' ii 
 
 ( 
 
 |:iH 
 
 s 
 
 i< 
 
 PLATE XIV. 
 
- ':. 'i 
 
I ■ 
 
 
 il 
 
 1 
 
 1 
 
 1 
 
 ♦j 
 
 
 1 
 
 t 
 
 J' 
 
I' J 
 
 1^: r 
 
 
 
 Chamomilo. 
 
 Caraway. 
 
 ^1' 
 
 Herb Robert. 
 
 PLATE XV. 
 
Chamoniile- 
 
 I) 
 Herb Robert. 
 
 Black Bryony. 
 
 PLATK XVI. 
 
. ;; !^- 
 
 
 
MEDICINAL plants! 
 the ]■ A '°^^ 
 
 fluid «:;actartttrL?,t'"'''' "' *= ^-'^ 'eavo, .„, 
 
 Plate 12. 
 
 i^«//^/«.-An infusion of ti^ , 
 to a pint of boiling wa'er^ i ^ '"^ ^^"^ «"nce of the I.n 
 
 Rosewarv ^Ax^ ■,^f • "^^'^ ^"^ bladder. 
 
 "'J'- /\n infusion of tu;^ i 
 
 employed for haslening delav./ P'"" "''i' 'ormcrlv m.,.1, 
 
 -ed as a tonic Cor the L™:3 1:::'™"'™ ' " '^ "-' --«::!;, 
 
 this country ; the deadly niltsh'^f ' ""^'^'^'^^ family .^ovv i. 
 used in medicine. Its ffu^t t ,t J"'"''"^ r^^^^^^^^) >^ th 
 at first green, then red anr! fi , "Somewhat the cherrv h 
 
 -e„Mesit.,o™e„,.at;r r&':- ^'^ '^^^'^^^^^^ 
 belladonna, and become ,„ite blacT 1"- '"""" "^ "-'e of 
 The root and the leaves of 11,7 "I'"- 
 
 ..c. used in „eura,,ia and ot ler tw ,""' ^™'™' Poison. 
 
 Cine. 
 
 '• - much used in „e I a ;;""„'" '--- "-e,, a viofen 'p :„ 
 employed in varions discos 'f 'tZ'""' '^^^--^ ^ i''-*. 
 lepsy- ""• ""™us system, such as cpi- 
 
 Helladonna is a hspAiI ^ i- . 
 
 -^--;asa;ir\:-^X'v:,:^ 
 
 other condition of debility Sr'""" • '''"" '^'^"^""^Pt-'on or in 
 f^ .^.ents; it is also used't^^t^'h:-"'" "^ our most vaKj 
 children. ""^^^ the incontinence of urine in 
 
 The active principle of belhdnnnn , 
 -treme importance i.. the tr^ m^^^ '^ ^ --edy of 
 
 'y'^' ""'^ °^ ^-'^•••o^s affections of the 
 
 Plate 13. 
 
 -*:T:^Tr::;ttrx£riTdr:' --"-- -- 
 
 <° promote the menstrual flow T 1 h "•'"'" ■■'^^"■"mended 
 
 ^.Pplied to nursing breasts, to prevem 'c'Sg.""" "' '°""'™- 
 
 'I' 
 
 -. 
 
 
I082 
 
 MEDICINAL PLANTS. 
 
 Valerian. — This remedy is used almost exclusively for cases of 
 " nervousness," however it may be manifested. In hysteria, and 
 the hysterical paroxysms which often occur about the time of the 
 menstrual epoch, this remedy is invaluable. It is also useful in 
 cases of nervous headache. 
 
 Foxglove. — This remedy is chiefly used to strengthen the 
 action of the heart. It is, therefore, valuable in many cases of 
 heart disease, and, in some instances, of kidney disease. When- 
 ever the disease of the heart causes a rapid and weak pulse, short- 
 ness of breath, and dropsy, digitalis (foxglove) is of value. 
 
 In many cases of dropsy dependent upon heart disease, dig- 
 italis is the most efficient agent in relieving the swelling. In some 
 cases of delirium tremens, digitalis is valuable in stimulating the 
 heart, and thus counteracting the effects of the whisky. 
 
 Plate 14. 
 
 Hemlock. — This is one of the most violent poisons. It is 
 chiefly used for its sedative and narcotic effects, but because of its 
 unreliability it is not employed with great frequency. It has been 
 used in the treatment of various nervous diseases, such as delirium 
 tremens. 
 
 Barberry. — The bark of the root is sometimes used in the 
 shnpe of an infusion as a cathartic. 
 
 Elder. — A decoction of the bark, or of the berries, is useful 
 in promoting t'le action of the bowels and of the kidneys. The 
 variety used in medicine bears black berries. 
 
 Oak. — A decoction of the inner bark is a valuable astringent. 
 It is used as a gargle in sore throat, as an injection in cases of the 
 ■" whites," and as a medicine in diarrhea and night sweats. 
 
 Plate 15. 
 
 Bittersweet. — There are two plants popularly known by this 
 name. One of them is a shrubby stem, with blue or purple flowers 
 and red berries. 
 
 A decoction is made by boiling an ounce of the leaves with a 
 pint and a half of water, and continuing the boiling until the liquid 
 
MEDICINAL PLANTS. 
 
 1083 
 
 isively for cases of 
 
 In hysteria, and 
 
 ut the time of the 
 
 [t is also useful in 
 
 to strengthen the 
 ; in many cases of 
 :y disease. When- 
 i weak pulse, short- 
 is of value, 
 heart disease, dig- 
 swelling. In some 
 ; in stimulating the 
 i whisky. 
 
 IS reduced to a pint. The dose of this is two or three tablespoon- 
 fuls, taken three or four times a day. 
 
 This decoction is often used in eruptions on the skin in which 
 scales are formed. 
 
 Chamomile. — This is one of the few household remedies which 
 possess decided value. It is a good tonic in cases of indigestion, 
 with the formation of gas in the stomach. It is best taken in the 
 shape of a cold infusion, which is made by adding half an ounce of 
 chamomile flowers to a pint of cold water. In cases of indigestion 
 and nausea, the chamomile tea can be taken with a little -ginger or 
 myrrh. 
 
 Caraxvay. — The seeds of caraway are used to cover the taste 
 of nauseous medicines. 
 
 I 
 
 ;i-i 
 
 Plate 16. 
 
 lent poisons. It is 
 :ts, but because of its 
 iucncy. It has been 
 ises, such as delirium 
 
 uc 
 
 times used in the 
 
 the berries, is useful 
 the kidneys. The 
 
 valuable astringent, 
 ection in cases of the 
 light sweats. 
 
 ly kn 
 
 luiar 
 
 )luo or pur 
 
 own 
 
 by th 
 
 i-ple fl 
 
 IS 
 
 owers 
 
 th a 
 
 )f the leaves wi 
 loiling until the liquii 
 
 Pcppcnnint. — A hot infusion of peppermint is a valuable rem- 
 edy in cases of pain in the bowels from the accumulation of gas in 
 the intestines. The oil of the essence may be used for the same 
 purpose. Two or three drops of the essence are valuable in reliev- 
 ing the colic of Infants. 
 
 Laurel. — The shrub known as mountain or sheep's laurel is a 
 poisonous plant, the leaves of which are sometimes used in medi- 
 cine. It has been employed in hemorrhage from the bowels and in 
 dysentery. An ointment made of the leaves stewed in lard is often 
 employed in the household in the treatment of itch. 
 
 Black Briony. — Briony root was formerly used in medicine. 
 An infusion of the dried root — half an ounce to a pint of boiling 
 ^vatcr — may be given in wineglassful doses, three ir four times a 
 ^^ay. It may be used in treating dropsy, and in inflammations of 
 the joints. It is an active purgative, producing watery stools. 
 
 Aloes. — The dried juice of the plant is used in medicine. It is 
 one of the best purgatives which we have for promoting and im- 
 proving the action of the large intestine. By securing a flow of 
 blood to the organs of the pelvis, aloes is often valuable in pro- 
 moting the menstrual flow ; in these cases it is usually combined 
 with iron and myrrh. 
 
 f 
 
 'S 
 
 m' 
 
io84 
 
 MEDICINAL PLANTS. 
 
 Aloes is of use in habitual constipation, but should not be em- 
 ployed by persons suffering from piles. Because of its tendency 
 to increase the menstrual flow, it should be avoided during the 
 monthly period, especially by women who flow profusely at such 
 times ; it should not be employed during pregnancy. 
 
 The dose is from five to fifteen grains, usually in pill form 
 combined with other drugs. 
 
 Assafoetida. — The dried juice of this plant is a powerful jtimu- 
 lant in many nervous affections, of females especially. Its mosi 
 frequent use is in the treatment of hysteria. 
 
 The ordinary dose is five to ten grains ; fifteen to twenty drops 
 of the tincture may be given at a dose. 
 
 Black Cohosh (Black Snake Root). — This plant was extensively 
 used in the treatment of rheumatism before the introduction of sali- 
 cylic acid. It has also been employed to promote menstruation, 
 
 From fifteen to thirty drops of the tincture constitute a dose. 
 
 Blood Root. — This is an excellent expectorant, and is fre- 
 quently employed in bronchitis and other affections of the lungs 
 as an ingredient in cough mixtures. In large doses it is a power- 
 ful emetic, and has even produced death. 
 
 The dose of the tincture is twenty to thirty drops. 
 
 Bnchii. — This remedy is one of the best known agents for 
 relieving irritation of the urinary organs. It has been used in 
 catarrh of the bladder and in cases of painful urination. It is best 
 given in the form of an infusion, made by adding one ounce of the 
 leaves to a pint of boiling water. Two or three tablespoonfuls ol 
 this should be taken four or five times a day. A fluid extract is 
 also made, the dose of which is one-half to one teaspoonful. 
 
 Calabar Bean. — Thi^' ..t one of the most powerful and poison- 
 ous remedies used. The plant grows in Africa, where the bean is 
 said to be used as an ordeal in detecting criminals : The person 
 suspected of having committed a crime is compelled to eat these 
 beans ; if vomiting ensue, the individual's life may be saved, and 
 he is then declared innocent; otherwise death occurs, a result 
 which is regarded as a proof of guilt. 
 
 Calabar bean has been employed in the treatment of lockjaw, 
 and as an antidote in cases of belladonna poisoning. One-tenth of 
 a grain of the e.xtract is the ordinary dose. This remedy should, 
 
MEDICINAL PLANTS. 
 
 1085 
 
 ; should not be em- 
 use of its tendency 
 avoided during the 
 / profusely at such 
 lancy. 
 asually in piU fo"""^. 
 
 is a powerful itimu- 
 :specially. Its most 
 
 fteen to twenty drops 
 
 , plant was extensively 
 ,e introduction of sali- 
 romote menstruation, 
 ure constitute a dose. 
 
 pectorant, and is fre- 
 ffections of the lungs, 
 re doses it is a power- 
 
 rty drops. 
 
 ,est known agents for 
 It has been used in 
 ,1 urination. It is best 
 ding one ounce of the 
 fhree tablespoonfuls of 
 y. A fluid extract is 
 no teaspoonful. 
 powerful and poison- 
 Irica, where the bean is 
 iminals : The person 
 impelled to cat these 
 life may be saved, and 
 ,eath occurs, a result 
 
 I treatment of lockjaw, 
 
 isoning. One-tenth of 
 
 This remedy should, 
 
 however, never be given except upon the prescription of a physi- 
 cian, since serious results may follow its incautious use. 
 
 Camphor. — This is obtained from a tree in the East Indies. 
 Camphor is a sedative for the nervous system in many disorders, 
 especially the hysterical affections of women. It is often useful in 
 quieting the restlessness of fevers. The dose of the tincture is 
 from ten to thirty drops. 
 
 Cascara Sagrada. — This remedy, which has been recently in- 
 troduced, is now recognized by the medical profession as the best 
 known laxative for the relief of habitual constipation. By its con- 
 stant use the bowels are strengthened rather than^veakened. When 
 other laxatives are used habitually, torpidity of the bowels is aggra- 
 vated, so that constantly increasing doses of the remedy are required 
 to secure the desired effect ; the complaint is rendered worse rather 
 than better by the laxative. Cascara, on the other hand, seems to 
 strengthen the bowels, so that the constipation gradually becomes 
 less. By its use the torpidity of the bowels is diminished. 
 
 In administering cascara, it is necessary to conceal its objec- 
 tionable taste in some way, as well as to secure the genuine drug. 
 Both of these objects can be best attained by using the cascara 
 cordial manufactured by Parke, Davis & Co. 
 
 Catechu. — This is a powerful astringent, which is used largely 
 for the relief of diarrhea. It can also be employed with advantage 
 in discharges, such as the whites. As a gargle, it has been used in 
 relaxed conditions of the throat. 
 
 Cinchona Bark. — This familiar drug is now less extensively 
 employed than formerly. It has been replaced by quinine and the 
 other alkaloids obtained from the bark. 
 
 These alkaloids are the best of the vegetable tonics, as well as 
 the most reliable remedies for the relief of malarial fevers. Quinine 
 is also extensively employed for reducing temperatures in fevers and 
 inflammations. The prejudice which many persons have against the 
 use of quinine, seems to be based upon the fact that an excessive 
 amount of the drug causes headache, buzzing in the cars and other 
 unpleasant symptoms. These effects are, however, transient, and do 
 not constitute any objection to the proper use of the remedy. 
 
 Copaiba. — This balsam is obtained from trees found in South 
 America. It is chiefly used to relieve the irritation in inflammations 
 of the urinary passages, especially in gonorrhoea. 
 
 % 
 
 .■ w 
 
 % 
 
 H 
 

 1.%' 
 
 1086 
 
 MEDICINAL PLANTS. 
 
 Elateritini. — This is a powerful cathartic, which is often use 
 to carry away the water in cases of dropsy. 
 
 Ergot of Rye. — This is chiefly used to promote contractions c 
 the womb ; he-ice it is especially valuable to arrest the flooding 
 which occur after delivery, and to check the flow in excessive men 
 struation. It is also used for the removal of fibroid tumors of th 
 womb. 
 
 Ergot is sometimes employed to assist the expulsion of th 
 child in cases of protracted delivery. This should never be at 
 tempted, however, except by a physician, since the injudicious us 
 of the drug may result in the death of the child and in seriou 
 danger to the mother. 
 
 The only reliable preparations of ergot are a fluid extract an( 
 the so-called " normal liquid ergot. " The dose varies according ti 
 the object desired — from ten to forty drops. 
 
 Ipecac. — Ipecac is chiefly used as an emetic and expectorant 
 It is used as an ingredient of cough mixtures in order to loosen th 
 phlegm or mucus. It has also been used in large doses as a remed; 
 for dysentery. 
 
 Jaborandi. — This remedy produces profuse perspiration, usu 
 ally attended with an increased flow of saliva. It is therefore use 
 ful when the kidneys are inactive, and is accordingly employed fo 
 the relief of dropsy and in cases of urcemia. It is generally admin 
 istered in the shape of pilocarpine, half a grain of which consti 
 tutes a dose. 
 
 Konsso. — This plant, found in Abyssinia, is one of the mos 
 certain remedies for expelling tape-worms. An infusion is made b; 
 adding two drachms to four ounces of boiling, water. This i 
 allowed to cool and then swallowed. 
 
 Mandrake {Mayapple). — The active principle of this plant 
 podophyllin, is an excellent cathartic, especially in cases of tor 
 pidity of the liver. It is often employed as a substitute for prepa 
 rations of mercury. The dose is one-fourth to one-half of 
 grain. 
 
 Male Fern. — This is one of the best remedies for tape-worm 
 Half a teaspoonful of the oil should be taken in a little mucilage o 
 in capsules. 
 
 Nnx Vomica. — This is one of the most valuable tonics as wel 
 
 ■-•V.M. 
 
T 
 
 Imedies for tape-worm, 
 in a little mucilage or 
 
 MEDICINAL PLANTS. 
 
 1087 
 
 vhich is often used 
 
 note contractions of 
 arrest the floodings 
 w in excessive men- 
 ibroid tumors of the 
 
 ;he expulsion of the 
 should never be at- 
 ;e the injudicious use 
 child and in serious 
 
 re a fluid extract and 
 se varies according to 
 
 .etic and expectorant, 
 in order to loosen the 
 irge doses as a remedy 
 
 )fuse perspiration, usu- 
 
 a. It is therefore use- 
 
 :ordingly employed for 
 
 It is generally admm- 
 
 grain of which consti- 
 
 lia, is one of the most 
 |An infusion is made by 
 )iling. water. This is 
 
 Irinciple of this plant, 
 Icially in cases of tor- 
 la substitute for prepa- 
 Kth to one-half of a 
 
 as dangerous poisons which we possess. These properties depend 
 chiefly upon the alkaloid, strychnia, which it contains. 
 
 Nux vomica is a good bitter tonic, and an especially good tonic 
 lor the nervous system. It is frequently used in the treatment of 
 constipation and dyspepsia. 
 
 Pumpkin Seeds. — These are largely used for the purpose of 
 expelling tape-worms from the bowels. To accomplish this purpose 
 the patient should take no other food for twenty-four hours than 
 pumpkin-seeds and milk, eating the seeds freely whenever hungry. 
 At the end of this time a dose of castor oil should be taken. 
 
 Rhubarb. — This is employed as a tonic and purgative. In the 
 latter capacity it is useful in cases of habitual constipation attended 
 with piles, and for the constipation of pregnancy. 
 
 Senua. — This is a violent cathartic, producing watery stools ; 
 an objection to its use is a tendency to cause griping pains. Hence 
 some aromatic is usually given with it. The most serviceable form 
 for administering this remedy is what is known as the " compound 
 licorice powder. " 
 
 Turpentine. — This is used largely for controlling bleeding from 
 the nose, stomach, bowels and bladder. It is occasionally em- 
 ployed, in combination with other remedies, in various diseases of 
 the intestine. 
 
 Locally turpentine may be used for the same purposes as mus- 
 
 ^-ard that is, to cause an irritation of the skin. A piece of folded 
 
 flannel should be saturated with hot water, wrung dry, and then 
 sprinkled with spirits of turpentine. 
 
 4 
 
 in 
 
 »i; 
 
 fi 
 
 
 ::a. 
 
 m 
 
 ft 
 
 valuable tonics as well 
 
Jo88 
 
 ADMINISTRATION OF MEDICINES. 
 
 ADMINISTRATION OF MEDICINES. 
 
 The doses of medicines vary not only with the drug itself, but 
 also with the age, sex and condition of the patient. A list of 
 doses for adults is appended; in giving medicine to children the 
 following general rules may be followed : 
 
 For a child of one year the dose is usually one-twelfth of that 
 given to an adult. 
 
 Between one and two years, - - One-eighth. 
 
 Between two and three years, - - One-sixth. 
 
 Between three and four years, - - One-fifth. 
 
 Between four and five years, - - One-fourth. 
 
 Between five and eight years, - - One-third. 
 
 Between eight and twelve years, - One-half. 
 
 Between twelve and sixteen years, - Two-thirds. 
 In every case the general condition and strength of the indi- 
 vidual must be taken into account in giving the medicine ; in 
 administering powerful drugs it will be better to give rather less 
 than the amount indicated in this table. 
 
 Medicines are prescribed in this book according to the usual 
 custom of physicians, by the weights and measures used by apothe- 
 caries ; it is advisable for families who are compelled to prepare 
 their own medicines to have a set of weights and graduated glasses 
 for this purpose. In most instances sufficient accuracy in measure- 
 ment at least can be obtained by using spoons, after the following 
 table : 
 
 A teaspoonful contains 
 A tablespoonful contains 
 A wineglass contains 
 A teacup contains 
 
 One drachm or 60 drops. 
 Four drachms or half an ounce. 
 Two ounces. 
 Four ounces. 
 
 For measuring solid substances we may also employ spoons ; 
 this is not, however, an accurate method, since the weight of solid 
 substances varies extremely. Hence it is not advisable to employ 
 this method in measuring out the doses of powerful drugs. 
 
 A teaspoonful contains - One drachm or 60 grains. 
 
 A tablespoonful contains - Four drachms or half an ounce. 
 
 In these measurements of solids the spoon should be filled 
 level full. 
 
ADMINISTRATION OK MEDICINES. 
 
 1089 
 
 NES. 
 
 le drug itself, but 
 tient. A list of 
 le to children the 
 
 ne-twelfth of that 
 
 )ne-eighth. 
 
 Dne-sixth. 
 
 3ne-fifth. 
 
 3ne-fourth. 
 
 One-third. 
 
 One-half. 
 
 Two-thirds. 
 
 ength of the indi- 
 ; the medicine ; in 
 • to give rather less 
 
 rding to the usual 
 es used by apothe- 
 ipelled to prepare 
 graduated glasses 
 curacy in measure- 
 after the following 
 
 or 60 drops, 
 ns or half an ounce. 
 
 s. 
 
 o employ spoons; 
 the weight of solid 
 ivisable to employ 
 jful drugs. 
 
 \\ or 60 grains, 
 is or half an ounce. 
 
 m should be filled 
 
 In administering medicine to children it should be remembered 
 that rather less than the proportionate dose should be given in 
 using certain drugs. Thus opium has an unusual influence over 
 children, who are especially susceptible to its action. In adminis- 
 tering any form of opium, therefore, less of the drug should be 
 indicated by the above table of comparative ages. In fact opium 
 should never be given to a child less than a year old, except upon 
 the advice of a physician. 
 
 List of Medicines and Doses for Adults. 
 
 In the following table the effects of the different drugs are 
 indicated in the second column by words which designate in a 
 general way the properties of the various substances. 
 
 Some of these terms require explanation, since they are not 
 employed outside of medicine. 
 
 An astringent is a drug which seem to cause contraction of the 
 tissues. They are used to diminish discharges, and are hence 
 employed in diarrhea, in ulcers of the skin, etc. 
 
 A ionic is a remedy which increases the strength of the indi- 
 vidual either by supplying some element which his system lacks, 
 such as iron, or by improving the condition of his stomach so that 
 this organ is better able to digest and absorb the nutritious ele- 
 ments of the food. The simple bitters, such as quassia, belong to 
 this latter class of tonics. 
 
 A stimulant is a remedy which increases the strength of the 
 heart's action. As a result, the blood is propelled in greater quan- 
 tity to different parts of the body, and the various functions are 
 therefore performed in a more satisfactory manner. Familiar 
 examples are hartshorn and whisky. 
 
 A sedative is a remedy which decreases the strength of the 
 heart's action ; they are required in cases of inflammation and 
 sometimes in over-excitement of the brain, as in delirium. Aconite 
 and prussic acid are examples of this class. 
 
 A narcotic is a remedy which diminished the activity of those 
 parts of the brain concerned in consciousness ; most of these 
 remedies therefore decrease sensibility to pain. Opium is a familiar 
 example. 
 
 An alterative is the name applied to remedies which induce 
 
 
 t 
 
 
logo 
 
 ADMINISTRATION OF MEDICINES. 
 
 certain effects in improving the constitutional condition. Arsenic 
 and mercury arc examples. 
 
 A diuretic is a remedy which increases the quantity of urine 
 excreted. Sweet spirits of niter is an example. 
 
 A diaphoretic is a medicine which increases the quantity of 
 perspiration. Alcohol and sweet spirits of niter are examples. 
 Many of the diaphoretics are also diuretics. 
 
 An expectorant is used to promote the separation of mucua 
 from the air passages. Ipecac and senega are examples. 
 
 An eminenagogue is a remedy which promotes the menstrual 
 flow. Tansy is a drug used for this purpose. 
 
 Various other designations are employed in medicines to indi- 
 cate the special effects of different drugs ; but those already given 
 will suffice for our purpose. 
 
 Medical Name. 
 
 Properties. 
 
 Dose for Adult. 
 
 For Chilli's Dose see page 1088. 
 
 Aconite Leaves, Tincture of. 
 
 Sedative, Narcotic 
 
 10 to 15 drops 4 times daily- 
 X lo K grain 3 times daily. 
 
 Aconite Root, solid Extract of 
 
 Sedative and Narcotic 
 
 Aconite Root, Tincture of. . 
 
 Sedative and Narcotic 
 
 S or 6 drops 4 times daily. 
 
 Aloes, Socotrine, powdered. 
 Alum 
 
 Cathartic 
 
 5 to 15 grains at bed time. 
 
 5 to 15 grains. 
 
 ID to 20 drops in water. 
 
 Astringent 
 
 Ammonia, Aromatic Spirits of 
 
 Stimulant 
 
 Ammonia, Carbonate of 
 
 Stimulant and Expectorant. . 
 
 3 to 5 grains every 3 hours. 
 
 Ammonia,Water of (Spirits ) 
 of Hartshorn) j" 
 
 Stimulant 
 
 5 to 20 drops in water. 
 
 Ammonium, Bromide of ... 
 
 Sedative 
 
 5 to 20 grains. 
 
 Ammonium Chloride (Sal- | 
 ammoniac) \ 
 
 Expectorant, Diuretic 
 
 5 to 20 grains. 
 
 Angelica Root, Fluid Ext. of 
 Anise Seed, Oil o{ 
 
 Aromatic 
 
 Teaspoonful 4 times daily. 
 5 to 10 drops on sugar. 
 2 to 5 grains. 
 
 2 teaspoonfuls. 
 5 to 10 drops. 
 
 3 to 6 drops. 
 ^ of a grain. 
 
 5 to 20 grains (in pills). 
 15 to 30 drops. 
 ( One grain to an ounce of 
 
 Aromatic 
 
 Antimonial Powder (James') 
 Antimonial Wine 
 
 Diaphoretic 
 
 Emetic 
 
 Arsenic, Donos'an's Solution 
 
 Alterative 
 
 Arsenic, F^owler's Solution. . 
 
 Alterative 
 
 Arsenic, white 
 
 Alterative 
 
 Asafnetida 
 
 Antispasmodic 
 
 Antispasmodic 
 
 AsafcL'tida, Tincture of 
 
 Atropia (Active Principle \ 
 of Belladonna) ^ 
 
 Narcotic 
 
 
 j v.iseL'ne as an ointment. 
 
 Balsam of Copaiba 
 
 Diuretic 
 
 3t» d«op» 4 times a day. 
 
 ■^v.M* 
 
ADMINISTRATION OF MEDICINES. 
 
 IO9I 
 
 ondition. Arsenic 
 
 J quantity of urine 
 
 ses the quantity of 
 liter are examples. 
 
 eparation of mucua 
 
 examples. 
 
 lotes the menstrual 
 
 in medicines to indi- 
 : those already given 
 
 Medical Name. 
 
 Properties. 
 
 Dose for Adult. 
 
 For Child's Dose see page 1088^ 
 
 10 to 15 drops 4 times daily 
 X to >^ grain 3 times daily. 
 5 or 6 drops 4 times daily. 
 5 to 15 grains at bed time. 
 5 to 15 grains. 
 10 to 20 drops in water. 
 3 to S gi-ains every 3 liours. 
 5 to 20 drops in water. 
 5 to 20 grains. 
 5 to 20 grains. 
 Teaspoonful 4 times daily. 
 5 to 10 drops on sugar. 
 I2 to 5 grains. 
 I2 teaspoonfuls. 
 I5 to 10 drops, 
 to 6 drops, 
 of a grain. 
 I5 to 20 grains (in pills). 
 Iljtc 30 drops. 
 
 1 ( One grain to an ounce of 
 \ \ v.iseLine as an omtment. 
 
 \io diops 4 tiwes a day. 
 
 Dose for Adult. 
 
 Tor ('liiM\ liiisc >ec \i.ige 1088. 
 
 Balsam of Peru | Expectorant 
 
 Balsam of Tolu, Syrup ' Expectorant 
 
 Bearberry Leaves, Decoction, Diuretic 
 
 Bearberry Leaves, Fluid F.xt. 1 Diuretic j Teaspoonful. 
 
 BclLidonna, Plaster 1 Anodyne i.\,r external use, 
 
 15 droi)s every 3 hours. 
 One tci^piiuiiful. 
 Wincglassful. 
 
 Belladonna, solid Extract ... Narcotic 
 
 Bell.ndonna, Tincture of Narcotic 
 
 Benzoic Acid Expectorant 
 
 Bismuth, Subnitrate of Anti-emetic 
 
 Bittersweet, Decoction of. . . Narcotic 
 
 Black Drop Narcotic 
 
 Blackberry Root Astringent 
 
 Blackberry Root, Syrup Astringent 
 
 Blood Root, Tincture Expectorant 
 
 Blue Mass Alterative 
 
 Boneset, infusion Diaphoretic .... 
 
 Buchu, Fluid Extract Diuretic 
 
 Buckthorn, Fluid Extract.. . . Cathartic 
 
 Caffein ] Nerve stimulant. 
 
 Alterative 
 
 Calomel, . 
 Calomel. . 
 
 Camphor, Gum. ... 
 Camphor, Spirits of. 
 
 Cascara Cordial 
 
 Purgative.. 
 
 Stimulant 
 
 Stimidant 
 
 Cathartic for habitual con- 
 
 stipation. 
 
 Cascarilla, Infusion j Tonic 
 
 Castor Oil | Purgative 
 
 Catechu, Powdered 
 
 Catechu, Tincture 
 
 Catnip, Decoction 
 
 Chalk, Prepared 
 
 Chamomile Flowers, Infusion. 
 Chamomile, Fluid Extract.... 
 
 Chloral Hydrate 
 
 Chloroform 
 
 Colchicum Root, Fluid Ext. 
 
 Astringent 
 
 Astringent 
 
 Diaphoretic , 
 
 Astringent 
 
 Tonic and Diaphoretic 
 
 Tonic 
 
 Narcotic 
 
 Anaesthetic and Stimulant. . 
 Diuretic and Sedative 
 
 1 to .i grain. 
 10 to 30 drops. 
 5 to 10 grains. 
 20 to 30 grains. 
 
 Wincglassful. 
 
 5 to 10 drops. 
 
 Wincglassful. 
 
 Teaspoonful. 
 
 Half a teaspoonful. 
 
 3 to 5 grains. 
 
 Tablespoonful. 
 
 Teaspoonful. 
 
 Teaspoonful at bed time. 
 
 I to 2 grains. 
 
 1 to 2 grains, twice daily. 
 
 5 to 15 grains at night fol- 
 lowed liy a dose of salts in 
 the morning. 
 
 2 to 6 grains. 
 20 to 30 drops. 
 
 i to I teaspoonful. 
 
 2 tablespoonfuls. 
 
 I to 2 tablespoonfuls. 
 
 10 to 20 grains. 
 
 li to I teaspoonful. 
 
 Tablespoonful. 
 
 10 to 30 grains. 
 
 I to 2 tablespoonfuls. 
 
 Teaspoonful. 
 
 10 to 20 grains. 
 
 10 to 30 drops in whisky. 
 
 5 to 15 drops. 
 
 f 
 
 I'l 
 
 11 f 
 
1092 
 
 ADMINISTRATION OF MEDICINES. 
 
 Medical Name. 
 
 Colchicuni Root, Wine 
 
 Colchicum, Seed, Tincture, . . 
 Colocynth, Compound Ext. . . 
 
 Colombo, Tincture 
 
 Cubebs, Powdered 
 
 Dandelion, Fluid Extract,.. . . 
 
 l)over'.s Powder 
 
 Elateriuni 
 
 Elder Flowers, Decoction. . . 
 
 Epsom Salt.s 
 
 Ergot, Fluid Extract 
 
 Fennel .Seed, Infusion 
 
 Fever Root, Decoction 
 
 Fleabane, Infusion 
 
 Foxglove, (Digitalis) Infusion 
 
 Foxglove, Fluid Extract 
 
 Foxglove, Tincture '. . . . 
 
 Cialls, Powdered 
 
 Gamboge, Povvdered 
 
 Gelsemium, Fluid Extract . . . 
 
 Gentian, Tincture 
 
 Geranium, Decoction 
 
 Ginger, Powdered 
 
 Glauber .Salts 
 
 (.Juaiac, Tincture 
 
 Hemlock l?ark, Powder 
 
 Hemlock, Solid Extract 
 
 Henbane, Solid Extract 
 
 Henbane, Tincture 
 
 Ilydrastin 
 
 Indian Hemp, Decoction. . . . 
 
 Iodoform, Powdered 
 
 Ipecac, Powdered 
 
 Ipecac, Syrup 
 
 Ipecac, Wine 
 
 Iron and Ammonia, Citrate. . 
 Iron and Quinine, Citrate. . . 
 
 Properties. 
 
 Diuretic and Sedative 
 
 Diuretic and Sedative 
 
 Cathartic 
 
 Tonic 
 
 Diuretic 
 
 Diuretic 
 
 Diaphoretic 
 
 Cathartic ... 
 
 Diaphoretic 
 
 Cathartic 
 
 To arrest bleeding 
 
 Aromatic 
 
 Cathartic and Diuretic 
 
 Diuretic 
 
 Stimulant and Diuretic 
 
 Stimulant and Diuretic 
 
 Stimulant and Diuretic 
 
 Astringent 
 
 Cathartic 
 
 Sedative and Anodyne 
 
 Tonic 
 
 .\stringent ... 
 
 Aromatic and Stimulant 
 
 Cathartic 
 
 Diaphoretic 
 
 Narcotic 
 
 Narcotic 
 
 Narcotic and ^inodyne 
 
 Narcotic and Auodyne 
 
 Tonic 
 
 Diuretic 
 
 Diaphoretic and Emetic . . . . 
 
 Diaphoretic and Expectorant 
 
 Diaphoretic and Expectorant 
 
 Tonic 
 
 Tonic 
 
 Dose for Adult. 
 
 For (.'hilJ's Ooje see page 1088. 
 20 to 30 drops. 
 30 to 40 drops. 
 5 grains. 
 Teaspoonful. 
 15 to 20 grains. 
 One teaspoonful. 
 10 grains. 
 
 1 to 2 tablespoonfuls. 
 
 2 teaspoonfuls. 
 15 to 30 drops. 
 Tablespoonful. 
 Tablespoonful. 
 VVineglassful. 
 Teaspoonful. 
 
 2 to 3 drops. 
 
 10 to 30 drops. 
 
 10 to 20 grains. 
 
 2 to 5 grains. 
 
 5 to 15 drops. 
 
 >^ to I teaspoonful. 
 
 Tablespoonful. 
 
 lo to 20 grains. 
 
 I to 2 teaspoonfuls. 
 
 /4 to I teaspoonful. 
 
 I to 3 grains. 
 
 I to 2 grains. 
 
 I to 2 grains. 
 
 ^ to I teaspoonful. 
 
 I to 2 grains. 
 
 Tablespoonful. 
 
 External use. 
 
 5 to 30 grains. 
 
 Teaspoonful. 
 
 Teaspoonful. 
 
 5 grains. 
 
 5 grains. 
 
ES. 
 
 Dose for Adult. 
 
 or Child'i Doie tee page 1088. 
 
 to 30 drops. 
 
 to 40 drops. 
 ;rains. 
 Mspoonful. 
 
 to 20 grains, 
 le teaspoonful, 
 
 grains. 
 
 grain. 
 
 o 2 tablespoonfuls. 
 
 easpoonfuls. 
 
 to 30 drops. 
 
 blespoonful. 
 
 blespoonful. 
 
 ineglassful. 
 
 aspoonful. 
 
 3 3 drops. 
 
 to 30 drops. 
 
 to 20 grains. 
 
 ) 5 grains. 
 
 ) 15 drops. 
 
 ;o I teaspoonful. 
 
 )lespoonful. 
 
 20 grains. 
 
 1 2 teaspoonfuls. 
 o I teaspoonful. 
 > 3 grains. 
 
 2 grains. 
 
 2 grains. 
 I teaspoonful. 
 
 2 grains, 
 lespoonful. 
 ;rnal use. 
 30 grains, 
 spoonful, 
 spoonful, 
 lins. 
 lins. 
 
 Alm.NlSTKATH,^ or Mm.crXKS. 
 
 Medical Name. 
 
 Iron, llroniide 
 
 Iron, Carbonate 
 
 Iron, Chloride, Tincture of. 
 
 Iron, Citrate 
 
 Iron, Iodide, .Syrup..., 
 
 Iron, Phosphate 
 
 Jalap, Powderwl 
 
 Juniper Berries, Infusion. 
 
 Laudanum 
 
 Leptandrin 
 
 Liverwort, Decoction 
 
 Lobelia, Infusion 
 
 L()l)elia, Tincture 
 
 M.ignesia 
 
 Manna 
 
 Marsh Mallow, Infusion .... 
 ■Mayapple, Decoction.... 
 M.-iyappIe, Resin (Podo- 
 
 '093 
 
 Properties. 
 
 phyllin) 
 
 Tonic. 
 
 Tonic . . . . 
 
 T(jnic 
 
 Tonic 
 
 Tonic 
 
 Tonic 
 
 <-"athartic. 
 
 I^iuretic. 
 
 Narcotic. .. 
 
 t'athartic. .. 
 
 Astringent.. 
 
 IJiaphoretic. 
 
 '•-xijcclorant. 
 
 I.a.\ative 
 
 La.xative . . . . 
 
 Diuretic 
 
 Cath.irtic. 
 
 ive 
 Alterative . 
 Narcotic . . 
 Anodyne . . 
 
 Maya |.ple Root, Powdered. 
 
 Mercury, Bichloride, (Cor- ) 1 
 rosive .Sublimate) [ Alterative 
 
 Mercury, Biniodide Luterative 
 
 Mercury, Iodide 
 
 Morphine 
 
 Mullein Leaves, Infusion 
 
 Musk . , ... 
 
 •Stimulant 
 Mustard Seeds, Ground.... 
 
 Myrrh, Tincture 
 
 Nux Vomica, Solid Extract 
 
 Nux Vomica, Tincture.... 
 
 Opium, Powdered 
 
 Opium, Tincture 
 
 Opium, Vinegar 
 
 Opium, Wine 
 
 Paregoric 
 
 Antihilious 
 
 '\ntibilious and cathartic. . 
 
 Emetic 
 
 Exjjcctorant 
 
 Tonicand Stimulant. . 
 Tonic and Stimulant.., 
 Xarcotic and Anodyne. 
 Narcotic and Anodyne. 
 
 Anodyne 
 
 Narcotic 
 
 Dose for Adult. 
 
 ' '" ■! grains. 
 5 '" 10 grains, 
 'o to j„ ,|r„(„. 
 S grains. 
 20 to 30 drops. 
 5 graiii'i. 
 
 5 lo 10 grains, 
 
 Wineglassfiil. 
 
 ■5 '" JO drops. 
 
 - '" 5 grains. 
 
 ''■il'Icpoiinfiil. 
 2 teaspoonfuls. 
 
 'i I" I teaspoonful. 
 Iz lo I teaspoonful. 
 Teaspoonful. 
 Tablesiioonful. 
 I'ablespoonfiil. 
 
 + t" X grain. 
 
 10 to 20 grains. 
 1/ '" i\; grain. 
 
 5 1' t" Tu grain. 
 '+' t" I grain. 
 /'"■ to ,'4: grain. 
 Wincglassful. 
 - to 10 grains. 
 Toa>poo:-ful. 
 20 to 30 drops. 
 '+ to }< giMin. 
 10 to 20 drops. 
 K to I grain. 
 10 to 30 dro]i.s. 
 5 to 7 drops. 
 10 to 30 drops, 
 t to 2 teaspoonfuls. 
 
 Anodyne 
 
 I'areira, Decoction Lj^,^,;^ 
 
 Parsley Root, Infusion I Diuretic Tablespoon fwl. 
 
 Tablesjwonful. 
 
 k. 
 
 h 
 
 V 
 
 t;.i 
 
 i- 
 
1094 
 
 ADMINISTRATION OF MEDICIXKS. 
 
 ;( 
 
 I 
 
 Medical Name. 
 
 IVMinyroyal, Infusion 
 
 Peruvian Bark, Decoction . . 
 Peruvian Bark, Powdered . . . 
 Peruvian Bark, Tincture. . . . 
 
 Pink Root, Infusion 
 
 Pleurisy Root, Infusion 
 
 Podophyllin 
 
 Pond Lily Root, Decoction 
 
 Potassium, Bromide 
 
 Potassium, Chlorate 
 
 Potassium, Citrate 
 
 Potassium, Iodide 
 
 Potassium.Nitrate (Saltpetre) 
 
 Quassia, Infusion 
 
 Quassia, Tincture 
 
 Quinine, Sulphate 
 
 Raspberry Leaves, Infusion . 
 Raspberry Leaves, Syrup. . . 
 Rhatany Root, Decoction . . 
 Rhatany Root, Tincture. . . . 
 Rhubarb, Aromatic Syrup . . 
 
 Rhubarb, Powdered 
 
 Rhubarb, Tincture 
 
 Rochelle Salts 
 
 Rue, Decoction 
 
 Siiffron, Infusion 
 
 Sage, Infusion 
 
 Salicin 
 
 Santonin 
 
 Sarsaparilla, Decoction 
 
 Sarsaparilla, Fluid Extract. . 
 
 Sassafras, Infusion 
 
 Savine leaves. Infusion 
 
 Savine, Oil 
 
 Scammony, Powdered 
 
 Senega Root, Decoction 
 
 Senega Root, Fluid Extract 
 
 Properties. 
 
 Diaphoretic 
 
 Tonic 
 
 Tonic 
 
 Tonic 
 
 To remove worms 
 
 Tonic and Diuretic 
 
 Antibilious and Purgative... 
 
 Astringent 
 
 Sedative 
 
 Expectorant 
 
 Diuretic and Laxative 
 
 Alterative 
 
 Diuretic 
 
 Tonic 
 
 Tonic 
 
 Tonic 
 
 Astringent , 
 
 Astringent 
 
 Astringent 
 
 Astringent 
 
 Cathartic and Astringent. . . . 
 
 Cathartic 
 
 Cathartic. , 
 
 Laxative 
 
 Emmenagogiic 
 
 Diaphoretic 
 
 Diaphoretic 
 
 Tonic 
 
 To destroy Intestinal Worms 
 
 Alterative 
 
 Alterative 
 
 Diaphoretic 
 
 iMiimenagogue and Diuretic , 
 Emmenagogue and Diuretic . 
 
 Purgative 
 
 Expectorant and Diuretic. . . , 
 Expectorant and Diuretic. . . . 
 
 Dose for Adult. 
 
 For Child's Dose see page io8S. 
 
 Wineglassful. 
 
 Wineglassful 
 
 Teaspoonful. 
 
 ^ to I teaspoonful. 
 
 Tablespoonful. 
 
 Wineglassful. 
 
 j^ to I grain. 
 
 Tablespoonful. 
 
 20 to 40 grains. 
 
 10 to 20 grains. 
 
 20 to 30 grains. 
 
 5 to 15 grains. 
 
 10 to 20 grains. 
 
 Tablespoonful. 
 
 Teaspoonful. 
 
 1 to 5 grains. 
 Tablespoonful. 
 Teaspoonful. 
 Tablespoonful. 
 Teaspoonful. 
 
 2 teaspoonfuls. 
 15 to 20 grains, 
 Teaspoonful. 
 
 2 teaspoonfuls. 
 Tablespoonful. 
 Tablespoonful. 
 Wineglassful. 
 2 to 5 grains. 
 '4 to 2 grains, 
 Teacupful. 
 Teaspoonful. 
 Wineglassful. 
 2 teaspoonfuls, 
 I to 5 drops. 
 5 '.o 15 grains. 
 Tablespoonful. 
 15 to 30 drops. 
 
NES. 
 
 Dose for Adult. 
 
 For Child's Dose see page io83. 
 
 ^^ineglassful. 
 iVineglassful 
 reaspoonful. 
 
 4 to I teaspoonful. 
 'ablespoonful. 
 Vineglassful. 
 
 j^ to I grain, 
 'ablespoonful. 
 o to 40 grains. 
 o to 20 grains. 
 o to 30 grains. 
 
 to 15 grains, 
 o to 20 grains, 
 'ablespoonful. 
 'easpoonful. 
 
 to 5 grains, 
 'ablespoonful. 
 'easpoonful. 
 'ablespoonful. 
 "easpoonful. 
 
 teaspoonfuls. 
 
 5 to 20 grains, 
 'easpoonful. 
 
 teaspoonfuls. 
 'ablespoonful. 
 'ablespoonful. 
 Vineglassful. 
 
 to 5 grains. 
 i. 1<J 2 grains, 
 eacupful. 
 easpoonful. 
 Vineglassful. 
 
 teaspoonfuls. 
 
 to 5 drops, 
 '.o 15 grains, 
 ablespoonful. 
 ; to 30 drops. 
 
 PREPARATION OF MEDICINES. 
 
 Medical Name. 
 
 1095 
 
 Properties. 
 
 Senna, Decoction ~ 
 
 Senna, Fluid Extract 
 
 Skull-cap, Infusion 
 
 Stramonium, Tincture 
 
 Strychnia 
 
 ."^•ilphur. Flowers 
 
 Tansy, Decoction 
 
 Tansy Oil 
 
 Thornapple (See Stramonium) 
 Thyme, Infusion 
 
 '^"'■J'""''"'^ I Stimulant 
 
 Valerian, Tincture 
 
 Veratrum Viride, Tincture. . 
 
 White Oak Bark, Decoction 
 
 Wild Cherry Bark, Infusion 
 
 Wild Cherry Bark, Syrup.... 
 
 Yellow Dock, Decoction. 
 
 Yellow Jessamine, Tincture ^ Nerve Tonic 
 
 Yellow Root. Decoction. . . . j Tonic . 
 
 Cathartic „-—; — ' — 
 
 • i ablespoonful. 
 
 • I Teaspoonful. 
 
 • Wineglassful. 
 
 Dose for Adult. 
 
 tic 
 
 Cathartic 
 
 Tonic 
 
 Narcotic and Sedative. 
 Tonic and Stimulant 
 
 Laxative 
 
 Emmenagogue .... 
 Emmenagogue .... 
 
 to 
 
 >o drops. 
 
 Aromatic 
 
 and Diuretic. . 
 
 Antispasmodic 
 
 Sedative and Diaphoretic. 
 
 Astringent 
 
 Sedative 
 
 Sedative 
 
 Alterative . . 
 
 • A to ^j grains. 
 
 • I f'J 2 teaspoonfuls. 
 
 • 'l'ables])oonfuI. 
 
 • 5 to 10 drops. 
 
 i 
 
 ■ Wineglassful. 
 
 1 or 2 teaspoonfuls. 
 Teaspoonful. 
 
 2 or J drops. 
 Fcjr external use. 
 rablcsjjoonful. 
 
 ■ Teaspoonful. 
 Wine.i,'!assful. 
 10 to 30 drops. 
 Tablespoonful. 
 
 Preparation of Medicines. 
 
 fo. two or three' irt':::t:: ':::'-'■ ,-^f--'a„.i„, 
 
 -a,ned. Mo. infusions e.e„ a Brr,'..;:T l,; ';;' ,r;;- ^^ 
 
 Decoctio7is are nnde h„ . i i- • " \\'^rm. 
 
 o^ceo., ,..----- ---^- to. „ 
 
 ii 
 
 1^ 
 
 ■i 
 
 
HOW TO CHECK THE SPREAD 
 
 CONTAGIOUS ORlNFECTIOUS DISEASES 
 
 SCARLET FEVER, DIPHTHERIA, SMALL-POX, ETC. 
 
 1 \ 
 
 i f 
 
 (No 4.) Document issued by the Provincial Board of Health of Ontario. 
 
 These diseases are spread by means of infectious particles going 
 from person to person, and can be stopped if care and systematic means 
 are taken to destroy these disease germs, and to prevent their being 
 carried from one person to another. 
 
 Those parts of the body which are the breeding places of the con- 
 tagious particles give off the poison in the greatest amount — for 
 example : — 
 
 In Scarlet Fever, the mouth, throat, nasal passages and skin. 
 
 In Diphtheria, the mouth, throat and nasal passages. 
 
 In Small-Pox, the pustules, chiefly of the skin. 
 
 In Measles, the skin and air passages. 
 
 In Whooping Cough, the air passages. 
 
 In Typhoid Fever and Cholera, the discharges from the bowels. 
 
 The portions of the body thrown off, and containing the contagion, 
 may pass into the air, or find their way into water or food, and in this 
 way be introduced by breathing, drinking or eating, or through broken 
 surfaces of the body. 
 
 It will be seen that the first five diseases in the above enumer- 
 ation are very readily communicable through the atmosphere. The 
 contagion of the first three remains virulent for a great length of time 
 and at great distances ; and as these diseases are very serious in their 
 effects, our consideration will at present be chiefly directed to them in 
 the following rules for checking their spread : — 
 
 71 
 
 r-i 
 
1098 
 
 HOW TO CHECK THE SPREAD OF 
 
 What the General Public may reasonably expect from persons 
 
 afiOicted with Contagious Diseases, from their Friends, 
 
 and from the Municipal Authorities. 
 
 ii' 
 
 1. When anybody, especially a child or young person, has sore 
 throat, bad breath or fever, he should be kept separated from all other 
 persons except necessary attendants, until it be ascertained whether 
 he has Scarlet Fever, Diphtheria or some other communicable disease. 
 
 2. Every case of Diphtheria, Scarlet Fever or small-Pox should be 
 at once reported to the Health Officer appointed by Local Board of 
 Health. ^See Sees. 18, 19 and 20, Public Health Act of 1882.) 
 
 3. On ■ ceipt of such notices, the Local Health Officers should 
 immediately .' i y the reports of cases. If the medical attendant 
 reports the cese ''ms will be sufficient verification. 
 
 The Board si ■ _:ld secure the isolation of those sick with or 
 exposed to these diseases ; 
 
 Give notice of infected places ; 
 
 Regulate funerals of persons dead from infectious diseases ; 
 
 Disinfect rooms, clothing and premises ; 
 
 Give certificates of recovery and of freedom from liability to com- 
 municate the disease. 
 
 4. Every person known to be sick with Scarlet Fever, Diphtheria 
 or Small-Pox, should be promptly and effectually isolated from the 
 public ; no more persons than are necessary should have charge 
 of patient, and these should be restricted in their intercourse with 
 other persons. 
 
 5. Notices should be placed on the house in which a case of 
 Scarlet Fever, Diphtheria or Small Pox exists, and no unnecessary 
 persons allowed to enter. 
 
 (In regard to above, see Public Health Act, 1882, and Caps. 190 
 and 174, R.S.O.) 
 
 Management of the Sick Room and Duties of Attendants. 
 
 6. The bed room of a person sick with Scarlet Fever, Diphtheria, 
 Small-Pox or any other infectious disease should be cleared of all need' 
 less clothing, carpets, drapery, or any material liable to harbour the 
 poison of the disease. The room should be large, having an absolub; 
 air space of at least 1,000 cubic feet for each individual, and should 
 \^di\Q. Vi liberal supply of fresh air — at least 3,000 cubic feet per head 
 
.D OF 
 
 expect from persons 
 a their Friends, 
 lorities. 
 
 oung person, has sore 
 eparated from all other 
 36 ascertained whether 
 communicable disease. 
 or small- Pox should be 
 d by Local Board of 
 th Act of 1882.) 
 Hcaltli, Officers should 
 he medical attendant 
 >n. 
 jf those sick with or 
 
 "ectious diseases ; 
 
 1 from liability to com- 
 
 irlet Fever, Diphtheria 
 
 ally isolated from the 
 
 y should have charge 
 
 their intercourse with 
 
 se in which a case of 
 s, and no unnecessary 
 
 :t, 1882, and Caps. 190 
 
 es of Attendants. 
 
 •let Fever, Diphtheria, 
 1 be cleared of all need- 
 liable to harbour the 
 je, having an absolute 
 individual, and .should 
 3 cubic feet per head 
 
 (2) 
 
 (3) 
 
 per hour I" summer the supply should h ,• ^^^ 
 
 open,and draughts on the paden' n " l'/, T^^'T' ' "'"^^^ ^^-own 
 t.ng.slantmg from the top of thesa'^ to , , f/' '"^^ ^"^^^ ^ -- net- 
 
 . ^^"^/-''^-fromthroat^noso.nr "''"°'^^^^-'"''"S- 
 
 immediately placed, in vessels "onH "'°""' '''°"'^' ^e received or 
 named for that purpose in s g oT' ""^ ^' ^'^ '-^'^^^Z 
 should be immediately burned ' " ''^' ""' ^handkerchiefs, thet 
 
 Likewise, the discharges from t; , 
 passed into vessels contain!;,, a pi^t o di'^'r '"' '^^^^^'^ «'-"'^' be 
 
 chbride of zinc: water , „,i , , 
 
 2i"c,4ozs ■ comm ^ ' '"'P''="= "f 
 
 " chlorid ofe'a r" T ' "™ ""■ 
 
 "■■-ate of ,ead ,•„ a qu« of rj^ .7 '™'™^ °^ 
 vessel containing a gallon of >vate/';;7 ^^ '" '^ '"'«" 
 spoonfuls of common salt 7mT m °'^'="™ 'able- 
 'he two solutions to ehe/atn"; f^"'"™^^ ">« 
 
 The above will answtfo '7' '" '"'>- "'''=■ 
 fecion, discharges, linZ cu s^ ^ '""^^^ °' "-■- 
 
 (4) Carbolic acid solution-sav ono n . • 
 
 of water, for dischargefand dot^ " '"'"^^ '' '^''y 
 etc.. and washing hlndl "' ^""'^'^'"^ «°°-. 
 
 (5) Copperas solution— one nnH . t u- 
 
 snlp,,ateofironto:el^,:'ttr"^-'^™™-->' 
 (o) Carbolate of lime. 
 
 The two last for discharges • the rnn,. 
 
 for privies; the carbolate ^flLT''^^^ 
 
 ••n rooms, shed.s. ,,^'°'"'^ °^ ^'"^^ for sprinkling dry 
 
 The carbolic acid solution may be madp .. 
 the air by spray from an atomic and tT."'' 
 germs in breathable air by act::r:;::att^^ 
 9- Purification of Clothes and Beddi„<r n u 
 practjcableisbythe agency ofheat. Dr S./of\l ?^"^' ^^'"^^ 
 fected scarlet fever clothing by exposure to fUp^;"'^''^'^"' ^'^'■"- 
 -c. oven or portable f^-ce^l,Lrt;;;r;osrtrc;^^^^^ t 
 
 
 >i \ 
 
IIOO 
 
 HOW TO CHECK THE SPREAD OF 
 
 be disinfected being hung on wires. Boiling clothes is not so good 
 as baking, but ei-'U is useful. To every ten gallons of boiling water 
 add half or three-quarters of a gallon of commercial solution of chlor- 
 ide of lime ; or the clothes may be laid for twenty-four hours in a solu- 
 tion of sulphate of zinc in the proportion of i to 120, or of chloride of 
 zinc in the proportion of 1 to 240, or in the chloride of lead solution 
 (Sec. 8), and then should be washed with soap and water if they 
 cannot be baked. 
 
 10. Nurses and Attendants should be required to keep themselves 
 and their patients as clean as possible, disinfecting their hands 
 frequently by chlorinated soda or other disinfectant. 
 
 Attendants should also wear cotton or linen (not woollen) clothes 
 or overalls, to which particles will not so readily adhere, and which 
 may be uic • easily disinfected. 
 
 1 1. Ill, I y person recovering from Diphtheria should be considered 
 dangerous, and should not be permitted to associate with others, or 
 attend any- 'lubli'' -rsembly until the throat and sores on the lips and 
 nose are hea.led for some days; nor before, in the judgment of the 
 physicians, he can do so without endangering others, nor until all his 
 clothing has been thoroughly disinfected. These restrictions, of 
 course, extend to churches, schools, etc. Every apartment of the 
 house must also be thoroughly disinfected before patient is permitted 
 to go at large. 
 
 After recovery from Scarlet Fever and Small-Pox, a still longer time 
 must elapse to allow all particles of disease-bearing skin to be thrown off. 
 
 12. The body of a person who has died of Diphtheria, Scarlet 
 Fever or Small- Pox, should be washed with a strong chloride of lead 
 or zinc solution, double the strength of those in Sec. 8, wrapped in a 
 sheet wet with the same, and at once buried. In no case should the 
 body be exposed to view ; no public funeral held, and as few persons 
 as possible should attend. 
 
 Disinfection of Dwellings and Premises after Recovery or Death. 
 
 1 3. In addition to thorough cleansing of all wood work with soft 
 soap, and with water to which carbolic acid has been added, (one pint 
 of the common liquid to four gallons of water), and to removing and 
 washinsr all fabrics which can be removed in the manner described in 
 Sec. 9, and brushing the walls, the rooms should be fumigated for a 
 period varying from three to twenty-four hours with sulphurous acid. 
 A metallic dish should be suspended over a tub of water, or should 
 
es is not so good 
 of boiling water 
 solution of chlor- 
 ir hours in a solu- 
 », or of chloride of 
 I of lead solution 
 nd water if they 
 
 o keep themselves 
 cting their hands 
 
 t. 
 
 ot woollen) clothes 
 
 adhere, and which 
 
 ould be considered 
 iate with others, or 
 )res on the lips and 
 le judgment of the 
 :rs, nor until all his 
 ;se restrictions, of 
 • apartment of the 
 patient is permitted 
 
 \ox,astilllongeriiine 
 ;kin to be thrown off. 
 Diphtheria, Scarlet 
 ,ng chloride of lead 
 jec. 8, wrapped in a 
 no case should the 
 and as few persons 
 
 lecovery or Death. 
 
 iood work with soft 
 [en added, (one pint 
 
 [id to removing and 
 
 aanner described in 
 be fumigated for a 
 
 Ith sulphurous acid. 
 
 [of water, or should 
 
 CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 IIOI 
 
 have ashes placed in it. All doors, windows, and the chimney being 
 tightly closed, sulphur, mixed with a little saltpetre, is to be then 
 placed into the dish and lighted. The proportions should be two 
 pounds of sulphur for every i,ooo cubic feet of space. In a very long 
 room it is best to have the sulphur in two or more places. After tlie 
 fumigation is completed, the doors and windows should be opened, 
 and kept open for several hours. In disinfecting in this manner with 
 sulphurous acid, the person setting fire to the saltpetre and sulphur 
 must make a precipitate escape from the room the instant the sulphur 
 is burning. Carpets fumigated on the floor by this method should 
 afterwards be removed to the open air and thoroughly beaten. Pil- 
 lows and feather beds, mattrasses, and upholstered furniture, after 
 being disinfected on the outside, should be cut open and their con- 
 tents exposed to the fumes of burning sulphur. In no case should 
 the disinfection of clothing and bedding be omitted. VVliere articles 
 of clothing, towels or anything used by sick persons are considered 
 too valueless to be kept, they must not be burned in the house or 
 open air before they have been completely disinfected. A bad epide- 
 mic at Philadelphia resulted from neglect of this precaution. 
 
 Precautions for Well People to avoid Scarlet Fever, Diphtheria 
 
 and Small-Pox. 
 
 14. Avoid exposure to special co7itagioti. There is more danger for 
 children than for adults ; do not, therefore, let a child go near a case. 
 Do not permit any person or thing, dog, cat or other animal, play tiling, 
 letters, etc., to come direct from a case of these diseases to a child, unless 
 previously disinfected under competent supervision. If you do visit 
 a case, bathe yourself, especially your hands, face and hair, in a dis- 
 infectant solution, and change and disinfect your clothing before you 
 go where there is a child. Sec that your residence, premises etc., are 
 kept clean and dry ; that th^ Mcn'cr connections are well trapped and 
 drains well ventilated. Never allow \.\\e passages from any person sick 
 with the disease to be placed, without previous disinfection, in water 
 closets or privies, but have them attended to as in Sees. 7 and 8. Give 
 special attention as to the purity of your milk supply. Do not allow a 
 child to ride in any vehicle lohere there is suspicion of infected persons 
 having travelled. Avoid exposure to high winds and cold, dry air. Do 
 not wear or handle clothing worn by a person during sickness or con- 
 valescence from these diseases. Beiuare of any person who has a sore 
 throat or running at the nose. Do not kiss or take the breath of such 
 
 In 
 
 I ' I 
 
 % 
 
 
 1; 
 
II02 
 
 HOW TO CHECK THE SPREAD OF 
 
 a person. Do not drink from the same ctip or put in your mouth any- 
 thing used by a person who has any of the above diseases. This 
 should be especially attended to in the case of children. 
 
 15. In case of all of these diseases, remember \kvdX \\\g. contagion 
 may be stored tip from one season to another if not destroyed. Do not 
 let it be so stored ; and see that your children do not visit a house 
 where one of the above diseases has been, even though some months 
 have since elapsed, unless you know that the house, clothes, etc., have 
 been thoroughly disinfected. 
 
 16. In the case of SMALL-POX, too much care cannot be 
 taken to see that every person who has not been vaccinated within 
 seven years be vaccinated or re- vaccinated, 
 
 17. If vaccination has " taken well " a few years before, this is, if 
 anything, an extra reason for re-vaccination. Persons who have had 
 Small-Pox may take it again. 
 
 18. With regard to all these diseases, remember that a mild form 
 in one person may originate a severe form in another. 
 
 19. In connection with this subject, it should be remembered that 
 too much attention cannot be paid to surroiinditigs in general, such as 
 drainage, ventilation, food, warmth, etc. Temperature and rainfall 
 have much to do with the spread of some of these diseases. Diph- 
 theria, for example, is generally least prevalent in August, increases 
 until January, and declines again with the same regularity until 
 August. It is also most fatal in the lowest and worst drained parts 
 of cities. Examine the relative positions of wells and privies. Where 
 city water is used, investigate the source of water supply, and the place 
 of debouchure of sewers. (An outbreak of Diphtheria in Naples, 1872, 
 was clearly traced to contaminated water.) In country districts iso- 
 lated outbreaks, traceable to cesspool effluvia, are not at all uncommon. 
 Frequently the water-closet drain will be found discharging into a cess- 
 pool cleaned out only at rare intervals, the gases generated in the 
 cesspool having no outlet except through the water-closet and into 
 the house. Proper attention to the trapping of waste pipes leading to 
 sewers is too frequently taken for granted, hence examine carefully 
 into the arrangement and ventilation of drains. Ascertain whether, 
 in consequence of attention not having been duly paid to the trapping 
 of overflow, lavatory, and every other waste pipe, gases are not being 
 conveyed in sundry ingenious ways into the various apartments from 
 which they were presumed to be excluded ; that, in other words, the 
 house drains and sewers have not been ventilated into the bed rooms. 
 
CONTAGIOUS OK INFECTIOUS DISEASES. 
 
 I 103 
 
 n your mouth any- 
 ve diseases. This 
 dren. 
 that the contagion 
 destroyed. Do not 
 3 not visit a house 
 ough some months 
 :, clothes, etc., have 
 
 ich care cannot be 
 1 vaccinated within 
 
 ars before, this is, if 
 rsons who have had 
 
 jer that a mild form 
 ler. 
 
 be remembered that 
 s in general, such as 
 erature and rainfall 
 ese diseases. Diph- 
 in August, increases 
 me regularity until 
 worst drained parts 
 and privies. Where 
 ;upply, and the place 
 |eria in Naples, 1872, 
 lountry districts iso- 
 ot at all uncommon. 
 ;charging into a cess- 
 les generated in the 
 ater-closet and into 
 aste pipes leading to 
 e examine carefully 
 Ascertain whether, 
 paid to the trapping 
 gases are not being 
 us apartments from 
 , in other words, the 
 into the bed rooms. 
 
 ON THE DISPOSAL OF SEWAGE. 
 
 (No. II.) Issued by the Provincial Board of Health of Ontario. 
 
 In most localities in Canada the supply of drinking-water is taken 
 from wells, and the household slops and excrement are deposited in 
 privies. In many cases the well is in such close proximity to the 
 privy as to give good grounds for the unpleasant suspicion that there 
 may be communication between them. That the well-water has a 
 good appearance and taste and is odourless, is no proof that it has not 
 suffered contamination, since highly-polluted water often has these 
 characteristics ; nor is the fact that the privy may be on lower ground 
 than the Avell, a sufficient guarantee of safety, as it may still be many 
 feet above the bottom of the latter. It is a matter of general observa- 
 tion that a deep hole in the ground has a tendency to drain shallower 
 holes in its neighbourhood. In addition to polluting drinking-waten 
 privies poison the air by their filthy emanations, and their ill-effects 
 are aggravated on account of the long intervals that elapse between 
 the times of emptying them. Many instances in various parts of this 
 Province of wells polluted by sewage matter, and of the baneful effects 
 of air rendered injurious in the manner indicated above, have come 
 under the notice of the Board : and it has therefore been thought 
 advisable to issue a pamphlet, pointing out the principles and the best 
 methods to be adopted in order to avoid these results. 
 
 In view of the evils mentioned above, the advisability of abolish- 
 ing the privy-pit system and of substituting something better in its 
 place will not be questioned. The first point to be considered by each 
 municipality is what system is best suited to its own requirements and 
 condition. There can be very little doubt that a properly constructed 
 and connected system of sewers and water-works affords the best 
 means of disposing of the slops and cxcremental waste ; but, in certain 
 cases, the construction of works of this kind may be considered to be 
 out of the question, and some other solution of the problem must be 
 looked for. In many cases conditions very objectionable, from a 
 sanitary point of view, have been introduced, from the fact of the 
 municipal authorities not having considered the system of sewage- 
 
 til- 
 
 l^li 
 
 ■-■X 
 
 
II04 
 
 HOW TO CHECK THE SPREAD OF 
 
 disposal best adapted to the circumstances of the municipality, and 
 not having decided upon plans in accordance therewith. Drains and 
 sewers have been built without regard to proper outfall ; closets and 
 cess-pools have been connected with drains quite unfitted to receive, 
 and safely carry off their contents. Solid refuse, again, has been 
 deposited and left to decompose in very unsuitable places, and, in 
 many instances, houses have subsequently been built on such un- 
 healthy collections of " made soil." It will save a great amount of 
 subsequent expense, confusion and annoyance, if the municipality 
 decide, in the first place, the system best adapted to it and proceed 
 on some settled plan. 
 
 This pamphlet will present certain considerations which may be 
 of assistance in arriving at such decision, the services of a competent 
 engineer being at the same time called into requisition in each case. 
 
 I. — Dry Systems of Removal. 
 
 First, then, attention will be directed to the best methods of dis- 
 posal m those cases where the water carriage system cannot with 
 advantage be adopted. 
 
 In this connection it will be found expedient to consider the ques- 
 tion of the disposal of the whole refuse of the household. This con- 
 sists of (i) ashes, dust, waste-paper, and other dry refuse not prejudical 
 to health ; (2) kitchen-slops and vegetable and animal refuse; (3) bed- 
 room slops, a mixture of wash-water and urine ; (4) faecal matter and 
 the accompanying urine. The usual method of disposal is to throw 
 the first and second into the ash-heap, the third and fourth into the 
 privy. From an examination of the numerous methods which have 
 been tried with varying success both in Europe and the United States, 
 one is led to the general conclusion that the true principle in these 
 cases is to keep the liquid refuse separate from the solid and to dis- 
 pose of the two in different ways. It is a matter of common observa- 
 tion that solid organic matter, if kept comparatively dry, is not subject 
 to offensive putrefaction, while the reverse is the case when there is a 
 certain quantity of water present, and a practical attention to this fact 
 will obviate those putrefying masses which now form such offensive 
 abominations in our midst. 
 
 The subject naturally divides itself, then, into two portions, which 
 require separate consideration, viz. : the disposal of {a) solid refuse, 
 and {b) liquid refuse. 
 
CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 1105 
 
 municipality, and 
 irith. Drains and 
 tfall ; closets and 
 jnfitted to receive, 
 
 again, has been 
 lie places, and, in 
 Duilt on such un- 
 i great amount of 
 
 the municipality 
 , to it and proceed 
 
 ions which may be 
 :es of a competent 
 ion in each case. 
 
 lest methods of dis- 
 ystem cannot with 
 
 o consider the ques- 
 [isehold. This con- 
 efusenotprejudical 
 lal refuse ; (3) bed- 
 \) fajcal matter and 
 disposal is to throw 
 
 and fourth into the 
 icthods which have 
 
 the United States, 
 principle in these 
 
 [\c solid and to dis- 
 
 if common observa- 
 dry, is not subject 
 
 ase when there is a 
 tention to this fact 
 
 "orm such offensive 
 
 [two portions, which 
 of {a) solid refuse. 
 
 Solid Refuse.— Oi the various methods hitherto tried for the 
 disposal of solid excrement there are three which seem to have met 
 with a fair degree of success. These arc : 
 
 /. The Hull Ash-closet system. 
 
 2. The Dry Earth System. 
 
 J. The Rochdale Pail System. 
 
 HULL ASH-CLOSET. (Section.) 
 
 Intended to receive all the dry refuse of tlie household 
 
 m addition to e.vurement. 
 
 I. Tlie Hull Ash-closet 
 system. — In this closet the 
 back, ends and floor of the 
 receptacle under the scat are 
 built of brick, laid in cement. 
 The front side of the recepta- 
 cle is a removable wooden 
 piece, and the seat may be 
 hinged. The floor is not sunk 
 below the ground level, but 
 slopes slightly from front to 
 back. The whole is properly 
 roofed in and ventilated. In 
 the receptacle are deposited all the ashes, dust, waste-paper, solid 
 kitchen refuse and excrement of the household. The small amount of 
 urine that accompanies the excrement is absorbed by the ashes. All 
 kinds of slops arc rigidly excluded from the closet. When it is 
 considered desirable to screen coal ashes, they may Oc screened into 
 the closet after raising the hinged seat. 
 
 In Manchester a modification of this system exists, the floor 
 being made level and the excrement being received into a pail, mixed 
 with the ashes, as in the Hull closet. In some instances a fi.xed cinder 
 sifter is arranged at the side of the closet, which directs the ashes on 
 to the excrement and allows the cinders to fall into a box. 
 
 Mr. Netten Radcliffe made a careful examinati' 'r. of the Dry 
 Ash system in Manchester, where 6,000 such privies were already in 
 use, and thus reports : — 
 
 " In the series of inspection I made with reference to the working 
 of this new system, I had occasion first to .observe the contrast as to 
 nuisance between the dry-ash closet and the old midden closet. In 
 several streets where the process of reconstruction had been only 
 partially completed, it was possible to compare the old and new 
 
 
1 106 
 
 liuVV TO CIIliCK Till; SI'RKAl) OF 
 
 I 
 
 arrangements in contiguous premises. It was the contrast between 
 open, big, uncleanable cavities, containing a greater or less amount 
 of decomposing fecal matter, and emitting a liorrible penetrating 
 odour, and small receptacles, emitting hardly any appreciable smell, 
 even with the nose above the privy seat, and admitting of thorough 
 cleansing. Most significant testimony was given to the benefit of the 
 change by some householders, Many houses in Manchester are '""'It 
 in parallel rows, a back passage running between the rows, and 
 house having a small yard, in the rear of which the privy is placed. 
 Since the reconstruction of the privies Ht has been possible to open the 
 baek ivindoivs of the houses' The change, moreover, has affected 
 beneficially the value of cottage property, and tenants are quite 
 willing to give 3d. more rent weekly since the reconstruction of the 
 privies for the gain in decency and comfort. Soakage of excremcntal 
 matter into the soil, and its passage into and accumulation in the 
 drains, is of course obviated by the reconstruction, and the smaller 
 space occupied by the new closet is not an unimportant matter. The 
 removal of the excrement is, with the most ordinary care, free from 
 offensiveness, and if commonly conducted as I saw the operation, it 
 may well be executed during the daytime, and the abomination of 
 night-scavenging done away with. 
 
 "The use of cinder-sifters has been adopted by householder 
 a readiness which proves how accurate the corporation was in depend- 
 ing upon their co-operation in the working of the scheme. The high 
 price of coal during the last two years has contributed to this good 
 result, from the value of the cinders, in encouraging its use. It is 
 found, also, that a class of the population, commonly believed to be 
 unmanageable in regard to any niceties of arrangement for excre- 
 ment disposal, have rapidly appreciated the advantages of the new 
 closet and taken to the use of the cinder sifter." 
 
 The removal is made once a week by the town authorities, and the 
 material stored under waterproof sheds, where it undergoes a gentle 
 fermentation, and is then sold for manure. It is said to be quite as 
 inoffensive in appearance and odour as barn-yard manure. 
 
 A modified form of the dry-ash closet has been used successfully 
 in some parts of the United States and Canada, In it two pails are 
 used — one under the seat to receive the excrement and the other in 
 some convenient position for the ashes. Each time the closet is 
 used a quantity of ashes is thrown in with a scoop. 
 
CONTAGIOUS OR IM'KCTIOLS hlSKASKS. 
 
 1 107 
 
 contrast between 
 r or less amount 
 rible pcnctratinij 
 appreciable smell, 
 ittinti of thorough 
 
 the benefit of the 
 inchester are '"''It 
 he rows, and 
 le privy is placed. 
 possible to opin the 
 3ver, has affected 
 
 tenants arc quite 
 onstruction of the 
 ifTc of excremcntal 
 cumulation in the 
 Dn, and the smaller 
 rtant matter. The 
 ary care, free from 
 .w the operation, it 
 the abomination of 
 
 y householder' 
 
 tion was in depend- 
 
 scheme. The high 
 
 ibuted to this good 
 
 (ring its use. It is 
 
 only believed to be 
 
 ngeinent for excre- 
 
 antages of the new 
 
 Authorities, and the 
 [undergoes a gentle 
 ^aid to be quite as 
 lanure. 
 
 [n used successfully 
 In it two pails are 
 Int and the other in 
 Itime the closet is 
 
 I'RIVV USED IN THE UNITED S'TATKH. 
 At Excrement Tub ; 11, Tub uf Dry Earth ur Aslies ; C, Hinged portion of l!.iik of I'rivy. 
 
 Where pails are used, that for the excrement may be cut out of 
 a petroleum barrel, and should, for ordinary families, contain about 
 ten gallons. In isolated cases a soap box will answer the purpose. 
 The ash-receiver should be larger and may be rectangular in form. 
 
 The principal advantage in the use of pails seem to be in the 
 convenience attending the removal of their contents. They are also 
 less liable to be injured, and can be more easily repaired than masonry 
 receptacles. 
 
 The above closets are all out of doors. 
 
 2. The Dry Earth Systevi.—TKi'i system is substantially the same 
 as the dry-ash system above described, with the exception that earth 
 is substituted for ashes. The earths best adapted for the purpose are 
 moulds and loams. Pure sand possesses little or no deodorizing 
 power, while pure clay is difficult to bring into the proper powdery 
 condition, and has a tendency to absorb too much water. 
 
 
 'r' 
 
 Hi 
 
iio8 
 
 HOW TO CHECK THE SPREAD OF 
 
 It is not necessary that the earth should be absolutely dry, the 
 drying that it receives from exposure to the atmosphere being suffic' 
 ent. For use it must be free from lumps and in a powdery condition. 
 This is best effected by screening it. 
 
 After being used it may be placed in a barrel, where it will un- 
 dergo a slight heating and fermentation, after which it may be thrown 
 out on the floor of the shed and exposed to the air in order to dry, and 
 may then be used again. It is said that this proceess may be repeated 
 ten or a dozen times with the same earth before it becomes offensive. 
 This, however, is not recommended, especially in a country like ours, 
 unless for the manurial value of the product ; but it shows the 
 value of dry earth as an absorbent and deodorizer. Anthracite coal 
 ashes have been found to answer in this respect fully as well as 
 loam. Wood ashes act much more powerfully than coal ashes as a 
 deodorizer. When it is considered no longer desirable to use the 
 material it is sold for manure. 
 
 House-closets on the dry earth system have been found to 
 ai.swer the purpose very well. They are usually constructed with 
 some patent device for throwing the earth on the faces each time the 
 closet is used. One of the principal objects of their inventor, the 
 Rev. Henry Moule, was to find a substitute for the water-closet in 
 dwellings, factories, schools, etc. 
 
 With dry earth the soap box or barrel, with a scoop, may be 
 used as in the case of the ash system, and will answer every purpose. 
 Some excellent automatic earth closets, not very extravagant in 
 price, are, however, made in this province. The addresses of various 
 manufacturers of them may be obtained on application to the Secre- 
 tary of this Board. 
 
 The principal objections to the earth closet are the large quantity 
 of earth required (estimated at from 4 to 5 lbs. per diem for each per- 
 son if used only once), and the executive difficulties in applying the 
 system to a large population. 
 
 It has proved a success under private management, or where regu- 
 lations can be enforcod, as for instance, in barracks, factories and 
 various public institutions. 
 
 3. The Rochdale Pail System. — This system differs fromthedry ash- 
 pail method before described principally in the fact that no absorb- 
 ents are used. The pails are frequently removed, being fitted with 
 tight covers, and clean pails left in their places. 
 
 The removal of dry refuse, ashes, etc., forms a part of the system. 
 The excrement and the ashes are brought to a depot, where the 
 
CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 nog 
 
 isolutely dry, the 
 lere being suffic' 
 )wdery condition. 
 
 where it will un- 
 it may be thrown 
 . order to dry, and 
 s may be repeated 
 lecomes offensive, 
 country like ours, 
 but it shows the 
 Anthracite coal 
 t fully as well as 
 an coal ashes as a 
 sirable to use the 
 
 ;e been found to 
 r constructed with 
 ices each time the 
 Lheir inventor, the 
 the water-closet in 
 
 Ih a scoop, may be 
 
 jver every purpose. 
 
 ry extravagant in 
 
 dresses of various 
 
 tion to the Secre- 
 
 1 the large quantity 
 
 diem for each per- 
 
 |cs in applying the 
 
 :nt, or where regu- 
 [cks, factories and 
 
 rsfromthcdry ash- 
 
 Zt that no absorb- 
 
 being fitted with 
 
 jart of the system. 
 I depot, where the 
 
 latter are spread out on the floor to a certain depth. The excrement 
 is then emptied into trenches formed in the ashes and treated with a 
 small quantity of dilute sulphuric acid ; the whole is then thoroughly 
 mixed, becomes, after a few weeks, quite inodorous, and forms a 
 valuable manure. The removal and subsequent treatment iias of 
 course to be carried out by the municipal authorities. 
 
 Mr. Radcliffe reports as follows : — 
 
 " That the system had been thoroughly approved of by all who 
 had had experience of it, and that it had not failed under the most 
 varied circumstances, having proved equally efficacious in the highly 
 rented house with its own closet, in the lodging-house, where great 
 numbers were accomodated, and in the factory and workshop. 
 
 It need hardly be mentioned that this system is suited to out- 
 door closets only. 
 
 ''aaoura L'acc 
 
 ROCHDALE PAIL CLOSET. 
 A, Excrement Pail ; B, Ash-tub ; C, Seat Cover (raised) ; V, Iron Collar below seat (retichinR into Pail 
 when cover isdown) ; E, Hinged Upright of Seat ; 1\ Door admitting from outride to Excrement Pail. 
 In this Closet ashes are not mixed with the excrement. 
 
 Under the old privy system in Rochdale <-he cost of the removal 
 of the excrement of one thousand persons for one year was .^71. 
 
mo 
 
 HOW TO CHECK THE SPREAD OF 
 
 Under the pail closet system it was ;^I9 ; the resulting manure selling 
 for three-fourths of the cost of collecting and preparing it. 
 
 Mr. Radcl'ffe makes the following estimate of the cost of the dry- 
 earth system applied to a village of i,ooo inhabitants : — Original 
 plant, ;^250; weekly outlay for earth and labour, £4 iS-y. ; annual 
 cost, including interest on plant, ^260. The product will be 730 tons 
 of manure selling at seven shillings per ton. 
 
 In Hull the removal is made by contract. The contractor, in 
 addition to receiving the material he collects and which he sells for 
 such profit as he can obtain, is paid by the sanitary authority from 
 two shillings to three shillings yearly for each house i' j district. 
 
 Whatever system may be adopted, the old privy pits should be 
 thoroughly cleaned out and filled with fresh earth. 
 
 In many country towns and villages there is sufficient garden 
 space to enable the excretal manure to be utilized ; wherever this is 
 not the case the removal and disposal of the excreta should be under- 
 taken by the municipal authorities, and in all cases they should have 
 an efficient system of inspection carried out. 
 
 Liquid Refuse. — In any of the proposed methods of dealing 
 with solid excreta, the kitchen and chamber slops must on no account 
 be mixed therewith. 
 
 Wherever practicable a system of pip'' sewers should be devised 
 for the purpose of disposing of these and should be connected with 
 the house yards by properly arranged traps. The entrance to these 
 pipes should be under cover, but should not be within the walls of the 
 house. Since the volume of this concetrated sewage will in general be 
 small, the pipes should be smaller and laid with steeper gradients than 
 those used in connection with the water-carriage system. They should 
 also be provided with flushing pipes at intervals, rising to the street 
 surface so as to admit of periodical flushing by means of a hose to be 
 connected with the street watering-cart. It may be advisable also, 
 for the same purpose, to connect the sewer, at a few points, with the 
 drains and gutters which carry off the rainfall during storms, but 
 great care must be taken to make the connection in such a manner as 
 to prevent the entrance of mud and other street debris. The sewage 
 should not, on any account, be allowed to flow into any open-jointed 
 water-drains, since at particular points in these, and during some 
 seasons of the year, the level of the sub-soil water may sink below the 
 drain, in which case the sewage would soak out into the surrounding 
 
cr manure selling 
 
 ngit. 
 
 le cost of the dry 
 
 itants -.—Original 
 
 ^4 1 5 J. ; annual 
 
 t will be 730 tons 
 
 he contractor, in 
 which he sells for 
 ry authority from 
 i' j district, 
 ivy pits should be 
 
 ; sufficient garden 
 , ; wherever this is 
 1 should be under- 
 ; they should have 
 
 nethods of dealing 
 must on no account 
 
 should be devised 
 De connected with 
 entrance to these 
 lin the walls of the 
 c will in general be 
 ;per gradients than 
 item. They should 
 rising to the street 
 ans of a hose to be 
 bo advisable also, 
 ;w points, with the 
 luring storms, but 
 such a manner as 
 :bris. The sewage 
 any open-jointed 
 and during some 
 lay sink below the 
 Ito the surrounding 
 
 CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 nil 
 
 soil. Lamp-holes and man-holes, for the proper examination and re- 
 moval of accidental obstructions, and ventilating shaft" should also 
 be constructed at proper points. Any urinals on the premises should 
 be connected with the sewer and not with the closet. It is almost 
 unnecessary to remark that no sewerage system should be constructed 
 without the superintendence of a competent engineer. 
 
 It may be incidentally pointed out here that the trenches in 
 which the tight pipe sewers are laid act as blind drains to a great 
 extent in carrying off the sub-soil water. 
 
 The disposal of the liquid sewage when it has reached the outlet 
 of the sewer system presents many diffirilties. It may be allowed to 
 flow into large bodies of water, such as our inland lakes, or into large 
 streams, the water in which is not used for drinking purposes, and in 
 which it is so diluted as to be comparatively harmless. There are, 
 however, many objections to the latter method of disposal. If, from 
 the situation of the town or village, neither of these methods is prac- 
 ticable, it may be collected in a large tank, from which it is periodically 
 removed, and used as liquid manure, for which, on account of its con- 
 centration, it is peculiarly adapted. This removal may be automatic 
 or otherwise. 
 
 Intennittent Dozvnward Filteration. — In some places where it has 
 been found impracticable to use it as a manure, the following method 
 has been adopted : A small quantity of waste land is under-drained 
 at a depth of from four to six feet ; the surface is then intersected 
 with open ditches, which are so arranged that when the sewage is 
 poured into them it flows only over a portion of the land at a time. 
 By the action of the air contained in the soil and of the roots of vege- 
 tation, it is purified and then flows through the sub- soil drains into the 
 nearest water-course. The same process is repeated on another portion 
 of the land and then on another, and by the time the whole surface 
 has been treated in this manner, the first portion is ready again to 
 receive the sewage, the soil having had time to dry and re-absorb air. 
 By this method, which is known to sanitarians as " intermittent down- 
 ward filteration," the soil can never get soaked with water and the 
 organic impurities arc thoroughly destroyed by the action of the air 
 and the roots of vegetation. 
 
 « The requisite extent of filtering area, as estimated by the Rivers 
 Pollution Commissioners (England), is one acre drained to a depth of 
 six feet for every 3,300 of the population, but this racio must vary 
 according to the nature of the soil. 
 
 The soil should be porous and have an easy slope. 
 
I W' 
 
 IL I 
 
 ■ »: 
 
 I ff) 
 
 III2 
 
 HOW TO CHECK THE SPREAD OF 
 
 Irrigation. — When used as manure the fields are irrigated with 
 the liquid, either by means of surface trenches or open-jointed drain- 
 tile pipes, laid about a foot below the surface. The former method is 
 the cheapest and requires less care to maintain it in good working 
 order. The soil should be under-drained and the sewage should be 
 applied on the intermittent downward-Alteration principle explained 
 above. 
 
 Sewage farms have been worked for a good many years in Eng- 
 land and on the Continent of Europe, and although at first they were 
 looked upon in mar / instances as public nuisances, yet of late years, 
 with increasing c.^jerience and resulting improved methods, they 
 have been gradually growing in public favor. It seems to be the 
 general testimony of medical men, chemists and others, that, when 
 properly managed, they are in no wise injurious to the health of the 
 people in the neighbourhood, and that the produce of such farms, 
 both animal and vegetable, is fully as wholesome as that of any other. 
 
 On a sewege farm there should be at least three sets of fields, 
 viz. : one for summer irrigation, a second for winter irrigation, and a 
 third for what may be called storm-water and residual irrigation. 
 
 The fields for summer irrigation are treated regularly with the 
 sewage during the growing period of the crop. When the harvesting 
 of the crop or other circumstances render it necessary to stop the 
 irrigation on the fields, it is directed onto the residual irrigation 
 fields. This is also done during storms or floods, in cases where the 
 storm-water passes through the sewers, when the volume of sewage is 
 too great to be used on the ordinary fields. The fields for residual 
 irrigation are best kept in grass and may be used for pasture. 
 
 During the winter the sewage is directed on to another set of 
 fields. These are ploughed in the spring and cultivated during the 
 ensuing season without any further addition of sewage : that received 
 during the winter generally proving sufficient. 
 
 The experience of Dantzic on the Baltic has shown that winte. 
 irrigation is possible even in a cold climate. The mercury is said to 
 fall to 6° or 8° below zero every winter, and in the winter of 1874-5, 
 when it reached 17° below zero, the irrigation was interrupted only 
 three times, and only for a few days each time. " The ground is 
 u.sually frozen to a depth of three or four feet for about three months ; 
 the snow is often several feet deep. The sewage flows out under the 
 snow through the many furrows prepared for it, leaving a thick crust 
 to ue ploughed into the land in the spring. About thirty feet from. 
 
CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 III3 
 
 ire irrigated with 
 en-jointed drain- 
 former method is 
 in good working 
 sewage should be 
 rinciple explained 
 
 any years in Eng- 
 . at first they were 
 , yet of late years, 
 ed methods, they 
 : seems to be the 
 others, that, when 
 
 the health of the 
 uce of such farms, 
 s that of any other, 
 three sets of fields, 
 ter irrigation, and a 
 dual irrigation. 
 
 1 regularly with the 
 /hen the harvesting 
 cessary to stop the 
 
 residual irrigation 
 ;, in cases where the 
 . olume of sewage is 
 ^e fields for residual 
 Ifor pasture. 
 1 to another set of 
 Itivated during the 
 age : that received 
 
 shown that winte. 
 mercury is said to 
 le winter of 1874-5, 
 las interrupted only 
 " The ground is 
 |bout three months ; 
 lows out under the 
 Javing a thick crust 
 3ut thirty feet from. 
 
 the conduits the sewage often freezes. During the months of extreme 
 cold, though the sand is so porous that the sewage sinks into it readily 
 at all times, Alteration alone can be depended upon. Nevertheless, if 
 the plots of land are large and frequently changed, the purification of 
 the sewage is, even in winter, more complete than can be accom- 
 plished by any of the chemical processes." 
 
 The experience of the State Insane Asylum, Augusta, Maine 
 has further tested the practicability of this method of sewage 
 disposal in winter. " When the mercury stood at o" Fahr., and the 
 ground was frozen hard, the sewage was found to disappear very 
 soon after it was put on the land. In spring the early rains wash any 
 refuse that there may happen to be deep into the soil and no offensive 
 odours are noticed. The surface of the ground is then sometimes 
 found covered with a brownish scum." 
 
 In the smaller towns and villages of Canada, where there is usually 
 a sufficient supply of garden-space attached to each house in the sub- 
 urbs and outskirts, similar methods to those described above may be 
 employed on a small scale by householders. Care must be taken to lead 
 the sewage by a tight drain pipe through the ground where there is any 
 danger of its contaminating the drinkingTwater ; it may then be dis- 
 charged into the garden by a system of open-jointed drain-pipes, 
 placed ten inches or a foot below the surface. If the soil is not very 
 porous it should be under-drained. 
 
 In the winter it may be discharged on the surface of the ground 
 if the underground drains are found to choke with ice. Any method 
 of disposal on the surface of well under-drained ground provided it be 
 at a sufficient distance from the house is better than depositing sewage 
 
 in cess-pits, which experience has shown to be almost invariably in a 
 
 leaky condition. 
 
 The central and more thickly populated portions of the town 
 
 should be sewered as previously described. 
 
 If in any case a cess-pit is considered an absolute necessity it 
 
 should be built of brick laid in cement with bottom and top arched. 
 
 It should be surrounded with a clay puddle and lined inside with a 
 
 coating of cement. The drain emptying into it should be well trapped, 
 
 and both drain and pit ventilated at a safe distance overhead. The 
 
 pit should not be more than six or seven feet deep, and should be 
 
 emptied periodically by the odourless process. 
 
 In some public institutions in England where earth closets are 
 
 used the slops are collected in tanks and sold as manure. 
 
 
 ^•ii 
 
 i4 
 
in ^ I 
 
 t 
 
 \ 
 i 
 
 
 1114 
 
 HOW TO CHECK THE SPREAD OF 
 
 In bringing this subject to a close it may be well to recapitulate 
 some of the facts upon which the above proposed methods of sewage 
 disposal are founded. These are as follows : — Solid organic refuse if 
 kept sufficiently dry does not undergo a putrefacative and offensive 
 decomposition. Coal and wood ashes and most kinds of earths 
 possess great deodorizing properties, and when mixed with solid 
 feeces in the proper proportions will in a short time, through a process 
 of inoffensive fermentation, form a valuable manure. Soils may be 
 repeatedly soaked with liquid sewage provided they are well under- 
 drained and a sufficient time is permitted to elapse between each 
 application so as to allow the soil to fill up again with air, which of 
 course takes the place of the water as the latter filters through. This 
 air oxidises the organic portion of the sewage, and if the under-drains 
 are deep enough the water flows from them sufficiently purified to 
 be allowed to pass into the neighbouring streams when these are not 
 used for drinking or washing purposes. 
 
 The action of the air may be supplemented with advantage by 
 that of the roots of vegetation, and hence it will be found expedient 
 in many cases to establish sewage farms. 
 
 No system of sewage disposal has yet been made to pay its own 
 expenses by direct money returns The most that can be hoped from 
 the use of sewage as manure is to keep down in some degree the 
 necessary expenses of the process. If the ultimate object of all 
 systems of sewage disposal, the health and comfort of the population, 
 is secured at the cost of a not undue outlay there will be good reason 
 for satisfaction. 
 
 II.— The Water-Carriage System. 
 
 It is not intended in this work to deal with all the questions 
 which would need to be considered in connection with a proper system 
 of sewerage. To do so would unduly augment its dimensions, and 
 many such details relate to those parts of the subject which must of 
 necessity presuppose the presence and superintendence of a profes- 
 sional engineer. The pamphlet will therefore take up only those 
 points which may not necessarily or presumably come under the 
 notice of an engineer, and errors in regard to which are constantly 
 causing unsanitary conditions and producing disease. 
 
 The primary question of deciding as to whether there a.re proper 
 facilities for outfall and a sufficient water supply, has already been 
 
Arell to recapitulate 
 methods of sewage 
 id organic refuse if 
 itive and offensive 
 it kinds of earths 
 1 mixed with solid 
 i, through a process 
 ure. Soils may be 
 hey are well under- 
 apse between each 
 I with air, which of 
 Iters through. This 
 i if the under-drains 
 fficiently purified to 
 3 when these are not 
 
 with advantage by 
 be found expedient 
 
 made to pay its own 
 lat can be hoped from 
 in some degree the 
 timate object of all 
 )rt of the population, 
 : will be good reason 
 
 bem. 
 
 lith all the questions 
 Iwith a proper system 
 its dimensions, and 
 ibject which must of 
 tendence of a profes- 
 take up only those 
 )ly come under the 
 /hich are constantly 
 lease. 
 
 Ither there Sire proper 
 \y, has already been 
 
 CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 uiS 
 
 considered in the first portion of the pamphlet. Its importance before 
 commencing or allowing the construction of sewers cannot be too 
 strongly insisted upon. 
 
 The materials and joints of drains have also been incidentally 
 alluded to, as also their shape, course, and foundation. In this 
 connection the too common practice of using wooden box-drains must 
 be condemned. They allow sewage to soak out, they soon break 
 down, and they rermit of deposit and choking, especially when laid 
 on the flat, as they rommonly are. If they are used to avoid expense 
 for any temporary purpose, they should be laid with the angle down, 
 so as to secure a better flow and less deposit. But for a permanent 
 drain, glazed tile pipes, with impervious joints should be used ; or, 
 inside of houses, cast iron pipes, which when hot have been dipped in 
 pitch. The joints of these should be filled with lead and caulked. 
 These inside iron drains should, when possible, be left exposed to 
 view. In some cities this object is carried out by fastening them 
 along the basement walls. Any leakage is in this way made visible, 
 and can at once be remedied. 1 iiis precaution holds true of all inside 
 plumbing. 
 
 The errors which are most frequently coming under notice as 
 detrimental to health are those which allow of the entrance of setuer 
 gases into houses. . 
 
 It is no conclusive proof of the absence or sewer gases that they 
 cannot be perceived by the sense of smell. 
 
 Some injurious gases reveal themselves unpleasantly to the nose, 
 whilst others do not. These last are so insidious in their nature as to 
 be doubly dangerous. As examples, the baneful results which ensue 
 from living in houses under which water lodges and becomes stagnant 
 may be referred to. There are few medical practitioners who have not 
 witnessed these results. The miasmatic poison of ague is similarly 
 inodorous, or has no necessarily unpleasant odour. In like manner 
 sewers have sometimes very little unpleasant smell. In some cases 
 we have a smell somewhat similar to that produced by those burning 
 fluids into the composition of which fusel-oil enters. People living 
 in a house become so accustomed to these faint odours as to take 
 little notice of them ; and with some people the sense of smell is not 
 very acute. Hence we must be careful how we accept negative 
 evidence as to the presence of noxious gases. And hence, too, we 
 must be all the more careful to avoid their existence and presence, and 
 to devise means to this end. 
 
 ' 
 
Iii6 
 
 HOW TO CHECK THK SPREAD OF 
 
 It is plain that to prevent the constant accumulation of noxious 
 gases, we must in the first place, get rid, as far as possible, of decom- 
 posable material before it begins to decompose ; and, secondly, we 
 must see that the noxious gases from any decomposing material 
 which has evaded our care does not reach us. These two proposi- 
 tions may seem very simple, but in practice we often find that they 
 have not been carried out. 
 
 As regards the first of them it has become an acknowledged de- 
 sideratum amongst sanitarians that all decomposable material enter- 
 ing sewers should pass out of the sewer-system within twenty-four 
 hours. For the accomplishment of this object many points need 
 careful consideration, such as the materials of which drains and sewers 
 are to be constructed, their course, their slope, their bed or founda- 
 tion, the construction of their joints, the course of their junctions, the 
 facilities for flushing them, etc. Some details in connection with 
 these points have been referred to above ; others will necessarily come 
 under the direct superintendence of an engineer. 
 
 It will be found that with all possible care in carrying off rapidly 
 the material thrown into the drains, we cannot entirely prevent the 
 collection of a certain amount of noxious gases in them. We find 
 that such gases are in practice disposed of in three principal ways : — 
 
 1. In a very large number of cases they are allowed to escape 
 into the inside of dwellings. To such an extent is this the case that 
 some sanitarians advise us to abolish sewers altogether, an advice 
 which is not practicable under existing circumstances. 
 
 2. In some instances they are supposed to discharge through 
 gratings in the centre of the road bed. 
 
 But in many cases they discharge at the edge of the sidewalk 
 through the traps of gullies emptied by evaporation. Examples of 
 this may be seen at many street corners in winter time. 
 
 The ventilating gratings of sewers are often so clogged with dirt 
 that they are of little value in disposing of the total amount of sewer- 
 gas. In winter they are very often completely closed. 
 
 3. In a few cases the sewer-gas is discharged above the house- 
 tops. Very little consideration will suffice to show that this is the 
 proper method. It is surely safer to discharge it away above our 
 heads than at our very feet. 
 
 This method is illustrated in the diagram on page 1117. 
 
CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 1117 
 
 ition of noxious 
 sible, of decom- 
 nd, secondly, we 
 posing material 
 icse two proposi- 
 ^n find that they 
 
 :knowledged de- 
 e material enter- 
 thin twenty-four 
 lany points need 
 irains and sewers 
 r bed or founda- 
 leir junctions, the 
 connection Avith 
 necessarily come 
 
 irrying off rapidly 
 itirely prevent the 
 1 them. We find 
 principal ways :— 
 allowed to escape 
 this the case that 
 jgether, an advice 
 ;s. 
 ischarge through 
 
 |e of the sidewalk 
 )n. Examples of 
 ime. 
 
 clogged with dirt 
 amount of sewer- 
 Id. 
 
 above the house- 
 ]\v that this is the 
 away above our 
 
 ige III7- 
 
 D I A O II A M.— IlliiBtrating' 
 points in liouse-Urainat'o, inelu- 
 ilinj,' a nioilc of sccurinf; a, 
 current of uir in the siiil-pipo, 
 liy pipes BO placed as to lie 611I1- 
 jectcU to different temperatures. 
 
 I 
 
 <)t 
 
Iii8 
 
 HOW TO CHECK THE SPREAD OF 
 
 It is almost superfluous to say that every precaution should be 
 taken to prevent sewer gas from disposing of itself in the first mode, 
 by finding its way into houses ; and yet a very great deal of careless- 
 ness exists on this point. 
 
 It will be necessary then to consider how sewer-gases obtain en^. 
 trance into houses : — 
 
 1. In some cases there is no "trap" interposed between the drain 
 or sewer and the interior of the building served by that drain or sewer, 
 no attempt at any mechanical impediment to the return of sewer- 
 gas. This, of course, should not be the case. Some form of trap 
 should be placed as near as possible to the commencement of every 
 waste-pipe. 
 
 2. Where there are traps they are liable to be forced. Some per- 
 sons think that if they have a trap all is right, but a trap without a 
 vent is of hardly any practical value. A trap with a protecting depth 
 of water (commonly called the "seal") of three inches, (a three inch 
 seal), only resists a pressure of some two ounces to the square inch. 
 Any person can readily convince himself of the insufficiency of a water 
 trap without a vent by filling such an one and blowing through it. 
 Without any great exertion he can displace the water and force his 
 breath through the trap. If he now make a vent between his mouth 
 and the water he cannot displace the latter no matter how hard he 
 blows. 
 
 Let us next consider what influences are at work to force gas 
 back through traps : — 
 
 a. The expansive force caused by pouring water into a drain ; two 
 bodies cannot occupy the same space at the same time, and if the 
 lower part of the drain be full, or its mouth be closed by water in the 
 sewer into which it empties, then the sudden pouring in of water will 
 cause the confined gas to burst its way back through the trap. 
 
 b. Storm-water suddenly filling the sewers has the same action. 
 
 c. The expansive force of hot water entering increases the tem- 
 perature and consequently the bulk of the air. If raised suddenly 
 from 50° to 150" the result would be a pressure equal to nearly seven 
 feet head of water. 
 
 d. Direct afilation through the sewer ; the wind blowing up the 
 sewers will force the sewer-gas backwards. Some engineers have 
 proposed flap gates- at the mouths of sewers. But it is better to let 
 the fresh air blow up, and make sufficient vents for it to sweep 
 through and purify the sewers. 
 
lution should be 
 in the first mode, 
 t deal of careless- 
 
 r-gases obtain en-« 
 
 between the drain 
 lat drain or sewer, 
 e return of sewer- 
 )me form of trap 
 ncement of every 
 
 breed. Some per- 
 t a trap without a 
 1 protecting depth 
 ches, (a three inch 
 ) the square inch, 
 fficiency of a water 
 lowing through it. 
 ater and force his 
 tjetween his mouth 
 itter how hard he 
 
 work to force gas 
 
 r into a drain ; two 
 
 e time, and if the 
 
 ed by water in the 
 
 ng in of water will 
 
 1 the trap. 
 
 s the same action. 
 
 increases the tem- 
 
 f raised suddenly 
 
 al to nearly seven 
 
 la blowing up the 
 engineers have 
 t it is better to let 
 s for it to sweep 
 
 CONTAGIOUS OR INFECTIOUS DISEASES 
 
 III9 
 
 e. Partial choking of the drain gives rise to confined air con- 
 stantly increasing, expanding and being displaced. A vent allows 
 the escape of all gas which would otherwise force the trap, 
 
 3. Again, sewer-gas may be admitted on account of the trap 
 being emptied by syphoning. If to the end of the trap a tube bent 
 downward be added, it forms the long leg of a syphon, the portion of 
 the trap to which it is added being the short leg ; if a full stream be 
 poured through the trap, the water will syphon out of it, leaving the 
 seal broken, as may be proved by actual experiment. An opening or 
 vent at the arch of the syphon will of course prevent this. 
 
 4. A large body of water rushing full bore down a pipe into 
 which a trapped tube empties will suck the water out of the trap. 
 
 This, again, will be prevented by a vent pipe. 
 
 5. Alterations may leave some pipe open or unsealed. 
 
 6. Disuse of a trap for a long time will allow evaporation and 
 emptying of the trap, giving room for free passage backwards of gas. 
 
 7. Corrosion of pipes and traps, or bad workmanship in joints, 
 will often allow escape of gas. 
 
 8. By absorption through the contents of traps, gas is often taken 
 up and given off. Dr. Fergus, of Glasgow, experimented with am- 
 monia, and found it transmitted through an ordinary trap in about 
 twenty minutes. 
 
 This may be obviated by having a second main ventilating-tube, 
 and these two will form a circulation (as shown in the tubes A and B 
 in the diagram), preventing foul air from accumulating — stagnant — 
 at the trap. 
 
 In a system of house-drainage, one of these two tubes may be 
 secured by running a three or four inch pipe (B) from the sewer, just 
 outside the house wall, up to the roof, clear of cornices, chimneys and 
 windows ; whilst the other will be obtained by continuing the soil- 
 pipe (A) up through the roof, A difference of temperature in the 
 pipes will cause the air to circulate through them. The last named 
 pipe (A) will save the traps opening into it from being forced by gas 
 from the sewer and drain. The traps of the baths and lower closet — 
 all traps in fact below the uppermost one — must be saved by their 
 own vents (v, v, v, v,) from being syphoned by sudden liberations of 
 water above. These vents may open into the extended soil-pipe 
 above the highest trap. 
 
 f'f 
 
 .,» I 
 
II20 
 
 HOW TO CHECK THE SPREAD OF 
 
 In the diagram, pipes (k, k, k,) will also be seen rising from a 
 point below the hopper of the closet, a little above the water in the 
 trap. These pipes may serve a double purpose. By branches from 
 the water-closet tanks they may act as flushers to the water-closet 
 traps, and they may also ventilate the water-closets. They may lead 
 to the outer air or the chimney-flue of an isolated kitchen in constant 
 use, but never into a bed-room chimney or any other not used con- 
 stantly in the strictest sense of the word. And never should any tubes 
 which have direct connection xvith the drain open into the chimney of a 
 dwelling-house. 
 
 As for the trap shown between the house wall and the street sewer 
 it might be left out, were the system to become generally adopted 
 as it should be by by-law), the drain being then carried directly to the 
 sewer as shown by the dotted lines, for, as remarked before, a point 
 away up thirty feet or so above our heads is surely the best place to 
 discharge the gas from our sewers, and not at our feet. But if the 
 plan were not general then it would not be advisable for the indi- 
 vidual to make his ventilating tubes the means for ventilating the 
 whole sewer of his street ; though even that would be better, than 
 ventilating the whole sewer by a grating opposite his hall door and 
 sitting-room windows. The best plan even in a general system would 
 be to leave the trap in the position shown and have a third ventilating 
 pipe running up on to the roof from a point just outside of the trap 
 and between it and the sewer. We would thus lessen the danger of 
 even diluted se.wQY-gdiS finding its way into apartments through cor- 
 roded pipes or defective plumbing, whilst at the same time overhead 
 ventilation of the sewers would be secured. 
 
 In no case should weeping-drains, wastes from refrigerators or 
 other like appliances have direct connection with the drains or drain- 
 age pipes of the house. 
 
 Dry-traps are not to be relied upon, as they do not entirely pre- 
 vent reflux of gas. 
 
 Great care must be taken to prevent the contnmina ion ui 
 drinking-water by the gas or "foul air" of water-r^ Irains. 
 
 For this reason closets should be supplied by pipes a separate 
 
 tank, and never from the general system of water supi Epid'mics 
 
 of Typhoid Fever have arisen from neglect of this caution ; a^'d also 
 from contamination by interchange of contents through leaky pipes 
 carrying respectively water and sewage. 
 
n rising from a 
 he water in the 
 
 branches from 
 :he water-closet 
 
 They may lead 
 ihen in constant 
 :r not used con- 
 should any tubes 
 'he chimney of a 
 
 the street sewer 
 :nerally adopted 
 d directly to the 
 d before, a point 
 the best place to 
 feet. But if the 
 ble for the indi- 
 )r ventilating the 
 1 be better, than 
 lis hall door and 
 ral system would 
 third ventilating 
 tside of the trap 
 en the danger of 
 ts through cor- 
 le time overhead 
 
 refrigerators or 
 drains or drain- 
 
 |not entirely pre- 
 
 jntnmina ion «ji 
 
 1 rains. 
 
 ci separate 
 
 Ij Epidi mics 
 
 lution ; a- d also 
 
 )Ugh leak)- pipes 
 
 CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 I 121 
 
 BEAT 
 
 CI«OR 
 
 Water Closets.— 1\. may be well here to utter a warning against 
 that very common form of closet, the pan-closet, of which a diagram 
 is here shown. The passage from the bowl into the receiver, is closed 
 
 by the pan, holding water and 
 preventing the constant passage 
 backward of gas when the closet 
 is not in use. Kut when the 
 handle is drawn up the pan is 
 ueilectcd downwards so as to 
 discharge its contents into the 
 receiver, as shown in the dia- 
 gram ; and, as two bodies cannot 
 occupy the same space at the 
 same time, we have forced up from the receiver the gas rendered 
 doubly foul by the repeated coatings of faecal matter adhering to its 
 wall as it is dropped on to it from the pan. 
 
 There are good forms of patent closets, but the simple hopper 
 with a good swirl of water to keep its walls washed clear of fa;ces 
 whilst in use, and with an occasional flush, will meet every sanitary 
 requirement and will be free from the objections to which many forms 
 of patent closet are open. The hopper should be of glazed earthen- 
 ware or porcelain : metal fouls more readily. Its trap should be 
 placed above the floor so as not to leave a long tube between the 
 bottom of the hopper and the surface of the water in the trap. This 
 lessens to a minimum the surface for filth accumulation. The trap is 
 also more accessible in case broken tumblers or other impediments 
 should get into it. 
 
 A foul odour often proceeds from the fact of a space being left 
 between the seat and the top of the hopper of water-closets, through 
 which urine or other water may slop over. 
 
 LcvtrUies. — It now seems to be no longer a matter of doubt 
 that the water-carriage system may be employed in this country in 
 connection with out-door closets and latrines. In the densely popu- 
 lated districts in which the water-carriage system is established, these 
 should be made to supersede the privy-pit. 
 
 When numbers of persons of various classes have to use closets, 
 they cannot be relied upon for care and cleanliness. Hence it becomes 
 necessary to use latrines, which may be attended to by some servant 
 of the corporation, or other person, who shall, from time to time, 
 change their contents, and supply them with water. 
 
 fM 
 
 :',ii 
 
 
 ^i 
 
II22 
 
 HOW TO CHECK THE SPREAD OF 
 
 Of the various forms of these Latrines, the following may be 
 mentioned : — 
 
 1. TJie Liverpool Trough Closet. — " This may be described as con- 
 sisting of a series of closets communicating with a long trough [T], 
 situated beneath and behind the seat [C], which receives the excreta 
 from each closet in the series. The lower en(' of the trough 
 communicates with a drain [D], leading to the sewer by an opening 
 
 [K] which is closed by a plug 
 [P]. Behind the back wall of 
 the closet there is a small space 
 [X] to which no one has access 
 but the scavenger, and from 
 which alone the plug can be 
 raised by means of a handle. 
 The scavenger visits daily, emp- 
 ties the trough, washes it out 
 with a hose connected with a 
 hydrant [A], and again charges 
 it with water. As much water 
 is let in as will cover the excreta 
 received during twenty-four 
 ho.irs, and so prevent any 
 smell. The closets are kept 
 clean by the users." 
 
 2. The Bristol Eject. — "This consists of a strongly constructed 
 dip-trap, interposed between the privy-trunk, as the receptacle is 
 termed, and the drain. It thus admits of the ready extraction of 
 foreign matters which may have been thrown in ; it is not easily 
 broken ; and, as it is flushed and kept clean by the servants of the 
 corporation, it is found to answer much better than ordinary water- 
 closets among the poorer classes of large towns." 
 
 3. Other forms of Latrines, on the same principal, are thus spoken 
 of in Wilson's " Hand-book of Hygiene :" — 
 
 " For barracks, prisons, etc., water-latrines of a much simpler cr"- 
 struction than either of the above answer exceedingly well. An open 
 metal trough, roofed in, and with the necessary partitions and doors, 
 receives the excreta, while its anterior upper margin constitutes the 
 seat. In order that the excreta may be constantly covered, the trough 
 should be kept one-third full of water. It should also be well flushed 
 
 TECa. 
 
)llowing may be 
 
 described as con- 
 long trough [T], 
 jives the excreta 
 of the trough 
 r by an opening 
 ;losed by a plug 
 he back wall of 
 : is a small space 
 
 one has access 
 ;nger, and from 
 :he plug can be 
 ans of a handle. 
 
 visits daily, emp- 
 
 [h, washes it out 
 
 connected with a 
 
 .nc' again charg:;s 
 
 As much water 
 
 1 cover the excreta 
 ring twenty-four 
 io prevent any 
 closets are kept 
 isers." 
 
 DPgly constructed 
 the receptacle is 
 ady extraction of 
 it is not easily 
 le servants of the 
 in ordinary water- 
 
 al, are thus spoken 
 
 much simpler c,n- 
 ly well. An open 
 rtitions and doors, 
 ;in constitutes the 
 :overed, the trough 
 Iso be well flushed 
 
 CONTAGIOUS OR INFECTIOUS DISEASES. 
 
 II 23 
 
 at least twice daily, and the contents allowed to run off into a drain 
 connected with a sewer. A plug, or flap-door, at the lower end of the 
 trough will be required to prevent the water from draining off during 
 the intervals. 
 
 " There is a further advantage, common to all closets of the trough 
 system, which may here be pointed out. In the event of an epidemic 
 of cholera or enteric fever raging in the crowded courts where these 
 closets are in use, it will be an easy matter to throw disinfectants into 
 the troughs, and thus destroy the infectious power of the alvine 
 discharges." 
 
 In some latrines water does not stand in the receptacle, but is 
 admitted daily to sweep out the contents with a sudden flush. Those 
 in which the faeces are received into the water, the whole being 
 suddenly let off and flushed, are to be preferred, where the receptacle 
 can be placed at a depth sufficient to protect it from frost, as is done 
 now with our water-pipes, hydrant-services and drains, always 
 remembering, however, that the open troughs are more exposed to 
 atmospheric changes of temperature. In this Province out-door water- 
 closets have, in some instances, been introduced, and, when carefully 
 constructed, have been found to work satisfactorily in the winter 
 season. Great cart, however, needs to be exercised. 
 
 4. In various cities on this Continent, so-called "Iron St>il's" are 
 manufactured, and are being largely introduced. 
 
 In New York the change from the old system to the new is being 
 ^■ladually made. No new pits are allowed to be dug ; and when any 
 existing one becomes a cause of complaint, the following order is 
 issued by the Board of Health and must be carried out : — 
 
 " That the privy vault thereat be emptied, cleaned and disinfected, 
 and filled with fresh earth. That a receptacle, vault or sink be con- 
 structed thereat, of a depth not grrr-ter than two feet, which shall be 
 impermeable and secured again.st any saturation of the walls or 
 ground, and shall be connectc .' at the upper end with the Croton 
 water, and at the lower end with the street sewer, and provided with 
 an ouilet at the lowest point and on *.he bottom, so as to admit of the 
 complete discharge of the contents, and of being daily flushed with 
 water. The bottom thereof shall be so inclined that the lowest point 
 at the outlet shall be at least six inches below the lowest point at the 
 opposite end." 
 
 In these privy sinks the hopper and trough are all in one piece. 
 They are similar in principle of construction to the trough-closets 
 
 
 i 
 
1 124 
 
 HOW TO CHECK THE SPREAD OF DISEASES. 
 
 above noticed. They are very moderate in price, one with two holes 
 costing about $15.00 ; with three holes, $20.00 ; and so in proportion. 
 
 Some places, such as factories on the course of our largest rivers, 
 may be so favourably situated as to allow of troughs with a continu- 
 ous stream ; but extreme vigilance, as regards outfall, must be 
 exercised in connection with this practice. Numerous cases of drink- 
 ing-water polluted by excrementitious sewage have come under the 
 notice of this and other boards. 
 
 TlrvnCbls. — Urinals become offensive for want of proper provision 
 for preventing the incrustation of them with deposits from the urine, 
 and of proper means of frequently cleansing or removing surfaces 
 which collect the droppings. A tray of ashes or saw-dust in front of, 
 and beneath, the urinal will meet this latter requirement, the contents 
 of the tray being frequently changed. For the first mentioned cause 
 of offensiveness, it seems necessary to have a flow of water washing 
 the urinal, whilst in use. Disinfectant contrivances should also 
 be used. 
 
 Intercepting Tanks.— In many places where the natural 
 facilities for outfall are not very good, the mixed contents of sewers 
 are received into tanks, the solid portions allowed to settle, the liquid 
 portion removed and disposed of in the methods described in connec- 
 tion with liquid refuse in the first part of this work, and the solid 
 settlings also removed, mixed with earth, ashes or chemicals, and 
 used for manure 
 
LASES. 
 
 le with two holes 
 d so in proportion, 
 our largest rivers, 
 IS with a continu- 
 outfall, must be 
 )us cases of drink- 
 ; come under the 
 
 )f proper provision 
 ts from the urine, 
 •emoving surfaces 
 w-dust in front of, 
 ment, the contents 
 t mentioned cause 
 of water washing 
 ices should also 
 
 where the natural 
 ;ontents of sewers 
 o settle, the liquid 
 iscribed in connec- 
 ork, and the solid 
 3r chemicals, and 
 
 TREATMENT OF THE DROWT^ED. 
 
 {No. II.) Issued by Provincial Board of Health of Ontario. 
 
 Rule i. — Proceed at once to employ means to restore breathing. 
 Do not delay this in order to procure shelter, warmth, stimulants, etc. 
 
 Rule 2. — Remove all obstructions to Breathing. — Instantlv loosen 
 or cut apart all neck and waist bands ; turn the patient on his face, 
 with the head lower than the feet ; stand astride the hips, with your 
 face towards his head, and, locking your fingers together under his 
 
 
 belly, raise the body as hi h as you can without lifting the forehead 
 off the ground, and give tl. Dody a smart jerk, to remove mucus and 
 water from the mouth and windpipe. Hold the body suspended long 
 enough to slowly count one, two, three, four, five, repeating the jerk 
 more gently two or three times. 
 
 Rule 3. — Next place the patient on his back on a fl; t surface, 
 inclined a little from the feet upwards, raise and support the head 
 and shoulders on a firm cushion or folded article of dress, placed 
 under the shoulder blades. Cleanse the mouth and nostrils, open the 
 mouth, draw forward the patient's tongue, securing it there either by 
 holding it with the fingers, or by a piece of string or an elastic band 
 placed over it and under the chin. 
 
 •( 
 
1126 
 
 TREATMENT OF THE DROWNED. 
 
 ■A 
 
 Rule 4. — Grasp the patient's arms just above the elbows, and 
 draw them gently and steadily upwards until they meet above the 
 head. (This is for the purpose of drawing air into the lungs.) 
 
 Keep the arms in this position for two seconds, then turn them 
 down and press them gently and firmly for two seconds against the 
 sides of the chest, pressing at the same time on the breast and 
 abdomen. (This is with the object of pressing air into the lungs.) 
 
 Pressure on the breast-bone and abdomen by an asststa.it will ai<l tliis action. 
 
 Repeat the measuf s alternately and deliberately until a spon- 
 taneous effort to breathe is perceived, immediately upon which cease 
 to imitate the movements of breathing, and proceed to induce circula- 
 tion and warmth. 
 
 Rule 5. — To excite Respiration. — During the employment of the 
 above methods excite the nostrils with snuff or smelling-salts, or 
 tickle the throat with a feather. Rub the chest and face briskly, and 
 dash cold and hot water alternately upon the patient. 
 
■T 
 
 TREATMENT OF THE DROWNED. 
 
 1127 
 
 aiil ilii-- action. 
 
 Do not be too soon discouraged. Remember that at any time 
 within two hours your efforts may be successful. 
 
 Rule 6. — To induce circulation and zvarvith. — After breathing is 
 commenced wrap the patient in warm blankets, and apply bottles of 
 hot water, hot bricks, or anything to restore heat. 
 
 Warm the head nearly as fast as the body, lest convulsions should 
 be induced. Rubbing the body with warm cloths, or with the 
 hands, and slapping the fleshy parts may assist to restore warmth 
 and breathing. 
 
 If the patient can swallow witJi safety ^\v<i\\\m. hot coffee, tea, 
 milk or spirits. Allow the patient to have abundance of fresh air. 
 
 IIINT.S TO WHARF OWNERS, AND TO OTHER PERSONS RESIDING 
 
 NEAR THE WATER. 
 
 Keep a coil of rope and pieces of boards in some convenient 
 place, ready for immediate use. 
 
 TO PERSONS WHO CANNOT SWIM. 
 
 If you get into water beyond your depth do not plunge, struggle, 
 nor throw your hands and arms out of the water. " Tread water" in 
 the erect position, by moving the feet up and down, at the same time 
 slowly paddling with the hands, keeping them under water. If any 
 person approaches to rescue you preserve your presence of mind 
 and do not grasp him ; do what he tells you. If any small object 
 of support be thrown to you, place it under your chest or arm-pits, 
 and do not struggle to raise yourself out of the water ; your head will 
 not go under if you follow these directions ; and you may keep your 
 mouth and nose above water long enough for assistance to arrive. By 
 considering these directions carefully noiv, j-ou will be less apt to lose 
 your presence of mind should occasion arise for acting on them. 
 
 Parents should have their children taught to swim. Many deaths 
 might be thereby averted. 
 
 N. B.— In Suffocation by Sinohe or any Poisonous Gas, as also in 
 cases of Hanging or Choking, proceed in the same way as in drowning 
 seeing that no obstruction exists in the mouth and throat, but omitting 
 the efforts to expel water, etc., from the lungs. 
 
 1 
 
 ^1 
 
 S .1 
 
 I 
 
INDEX 
 
 
 ■ ) 
 
 A. 
 
 Page. 
 
 Abdomen 915 
 
 Abdominal Muscles 916 
 
 Abortion 926 
 
 Abortion, Cause of 927 
 
 Abscess of Breast 962 
 
 Abscess of the Liver 253 
 
 Abscess in the Vulva 993 
 
 Accidents of Pregnancy 926 
 
 Acid, Carbolic, Poisoning by 86 1 
 
 Acid, Oxalic, Poisoning by 861 
 
 Acids, Poisoning by 859 
 
 Aconite 1080 
 
 Aconite Leaves, Tincture of 1089 
 
 A90inte Root, solid Extract of 1089 
 
 Aconite Root, Tincture of 1089 
 
 Acute Articular Rheumatism 98 
 
 Acute Bright's Disease 263 
 
 Acute Chorea 313 
 
 Acute Inflammation of the Livur 252 
 
 Acne " Pimples " 372 
 
 Addison's Disease 287 
 
 Administration of Medicines 1087 
 
 Affections of the Laynx 117 
 
 Affections of the Lungs 121 
 
 After Pains 952 
 
 Alcholism 322 
 
 Alkalies, Poisoning by 860 
 
 Aloes 1083 
 
 Aloes, Socotrine, powdered 10S9 
 
 Alterative 1088 
 
 Alum 1089 
 
 Ammonia, Aromatic Spirits of. 1089 
 
 Ammonia, Carbonate of 1089 
 
 Ammonia, Water of 10S9 
 
 Page 
 
 Ammonium, Bromide of 1089 
 
 Ammonium, Chloride (Sal-ammoniac). 1089 
 
 Anatomy and Pliysiology 1043 
 
 Aneurism of the Aorta 175 
 
 Angina Pectoris 1 74 
 
 Angelica Root, Fluid Extract of. 10S9 
 
 Anise Seed, Oil of 10S9 
 
 Animal Substances 1061 
 
 Ankle, Dislocation of. 833 
 
 Antidotes for Poisons 853 
 
 Antimonial Powder (James') 1089 
 
 Antimonial Wine 10S9 
 
 Aorta, Anuerism of 175 
 
 Apoplexy 296 
 
 Arm-bone near Elbow, Fracture of. . . . 755 
 
 Arm-bone, Fracture of (Humerus) .... 750 
 
 Arrest of Development 897 
 
 Arteries 1056 
 
 Artificial Eyes 623 
 
 Arsenic, Poisoning by 862 
 
 Artificial Breathing in the New-Born. . 946 
 
 Artificial Eye, Instructions for Wearing 625 
 
 Arsenic, Donovan's Solution 1089 
 
 Arsenic, Fowler's Solution 1089 
 
 Arsenic, white 1089 
 
 Asafoetida 1089 
 
 Asafcetida, Tincture of 1089 
 
 Asafoetida 1084 
 
 Asparagus 1078 
 
 Asthma 138 
 
 Astringent 1088 
 
 Ataxia Locomotor 342 
 
 Atropia (Active Principle of Belladonna) 1089 
 
 Attention to the Child ... 949 
 
 r 
 
 
 B. 
 
 Baldness 407 
 
 Balsam of Copaiba 1089 
 
 Balsam of Peru 1090 
 
 Balsam of Tola, Syrup 1090 
 
 Bandages for Broken Bones 722 
 
 Barbadoes Leg 435 
 
 73 
 
 II 29 
 
1I30 
 
 INDEX. 
 
 Page. 
 
 Barber's Itch — (Sycosis) 406 
 
 Barberry 1082 
 
 Bearberry Leaves, Decoction 1090 
 
 Bearbcrry Leaves, Fluid Ext 1090 
 
 Beef Tea 1073 
 
 Bearberry 1077 
 
 Belladonna, Solid Extract 1090 
 
 Belladonna, Tincture of logo 
 
 Belladonna, Plaster 1090 
 
 Belladonna, Poisoning by 866 
 
 Benzoic Acid 1090 
 
 Bilious Colic 223 
 
 Bismuth, Subnitrate of 1090 
 
 Bites and Stings of Insects 707 
 
 Bittersweet 1082 
 
 Bittersweet, Decoction of 1090 
 
 Black Briony 1083 
 
 Black Drop 1090 
 
 Blackberry Root 1090 
 
 Blackberry Root, Syrup 1090 
 
 Black Cohosh 1084 
 
 Black Currant 1079 
 
 Bladder, Stone in 277 
 
 Bleeding from the Bowels 677 
 
 BlV-eding from the Mouth 675 
 
 Bleeding from the Nose 675 
 
 Bleeding from the Urinary Organs. , . . 678 
 
 Blindness, Color 550 
 
 Blister, Fever — (Herpes) 403 
 
 Bites, Snake 708 
 
 Blood Poisoning — (Pyivmia) 731 
 
 Blood Root . . 1084 
 
 Blood Root, Tincture 1090 
 
 Blue Mass 1090 
 
 Bodies, Foreign in the Ear 626 
 
 Bodies, Foreign in the Eyes 
 
 Bodies, Foreign inthe Throat 
 
 Boil — (Furuncle) 
 
 Bones, Broken — (Fractures) 
 
 Bones of the Foot, Dislocation of 
 
 Bones of the Foot, Fractures of 
 
 Bones, Non-union after Fractures 
 
 Both Bones of the Leg, Fractures of. . . 
 
 Boneset, Infusion 
 
 Bowels, Bleeding from 
 
 Bowels, Disorders of. 
 
 Bowels, Inflammation of 
 
 Bowels, Inflanimalion of — Peritonitis. . 
 
 Brain, Chronic Dropsy of 
 
 Brain, Drop.sy of • 
 
 Brain, Inflammation of. 
 
 Brain, Inflammation of. 
 
 Bright's Disease, Acute 
 
 Bright's Disease, Chronic 
 
 Bright's Disease — Inflannnation of the 
 
 Ki<lney 
 
 Broken Bones, Bandages for 
 
 Broken Bones — (Fractures) 
 
 Broken Bones, Setting of. 
 
 Bromide of Ammonium 
 
 Bromide of Iron 
 
 Bronchitis 
 
 Bronchitis, Chronic 
 
 Burns and Scalds 
 
 Bruises 
 
 Buchu 
 
 Buchu, Fluid Extract 
 
 Buckthorn 
 
 Btickthorn, Fluid Extract 
 
 Butter 
 
 Page. 
 
 661 
 64. 
 713 
 836 
 
 795 
 797 
 790 
 
 1090 
 677 
 
 1 03 1 
 230 
 
 251 
 
 249 
 290 
 
 743 
 263 
 266 
 
 263 
 722 
 
 713 
 719 
 10.S9 
 1091 
 131 
 133 
 844 
 
 844 
 1084 
 1090 
 1076 
 1090 
 1063 
 
 0. 
 
 Caflfein 1090 
 
 Calaber Bean 1084 
 
 Calamus 107S 
 
 Calculate Time of Confinement 935 
 
 Calomel 1090 
 
 Calomel 1090 
 
 Camphor 10S5 
 
 Camphor, Gum 1090 
 
 Camphor, Spirits of logo 
 
 Cancer of the Tongue 658 
 
 Cancer of the Lip 654 
 
 Cancer of the Stomach 207 
 
 Capricious Appetite 917 
 
 Caraway 10S3 
 
 Carbonate of Irjn 1091 
 
 Carbonate of Ammonia 10S9 
 
 Carbonate of Lime 1070 
 
 Carbolic Acid, Poisoning by 861 
 
 Carbuncle 646 
 
 Care of Breasts 925 
 
 Care During the Monthly Changes. . . . 888 
 Care of Nipples 962 
 
 ,< ^ 
 
Page. 
 
 F.ycs 5^7 
 
 Throat f*» 
 
 64, 
 
 uies) 7«3 
 
 location of 8,^6 
 
 ctures of 795 
 
 r Fractures 797 
 
 , Fractures of. . . 790 
 
 ICXJO 
 
 677 
 
 1031 
 
 of 230 
 
 of— Peritonitis. . 227 
 
 yrot 251 
 
 249 
 
 f. 290 
 
 f. 743 
 
 tc 263 
 
 onic 266 
 
 lammation of the 
 
 263 
 
 ges for 722 
 
 tures) 7 '3 
 
 2 of. 719 
 
 m 10S9 
 
 logi 
 
 131 
 
 133 
 
 S44 
 
 844 
 
 10S4 
 
 1090 
 
 1076 
 
 tract 1090 
 
 1063 
 
 ^^^^imm 
 
 h 207 
 
 917 
 
 10S3 
 
 1091 
 
 ua 1089 
 
 1070 
 
 ling by S61 
 
 646 
 
 925 
 
 ithly Changes. .. . 888 
 962 
 
 tni)f:>c. 
 
 II3I 
 
 Page. 
 
 Care of the Infant 964 
 
 Care of the Mother after Labor 95 1 
 
 Causes of Abortion 927 
 
 Care of the Sick 1067 
 
 Care of Eyes in Childhood 554 
 
 Carrot loSo 
 
 Cartilages of the Knee Joint, Disloca- 
 tion of 830 
 
 Cascara Sagrada 1085 
 
 Cascara Cordial 1090 
 
 Cascarilla, Infusion 1090 
 
 Castor Oil 1090 
 
 Cataract, Congenital 612 
 
 Cataract 611 
 
 Catalepsy 310 
 
 Catarrh of the Laryn.K 117 
 
 Catechu 1085 
 
 Catechu, Powdered 1090 
 
 Catechu, Tincture 1090 
 
 Catnip, Decoction 1090 
 
 Cerebro Spinal Meningitis 294 
 
 Cessation of Menstruation 914 
 
 Chalk, Prepared icxjo 
 
 Chamomile Flowers, Infusion 1090 
 
 Chamomile, Fluid Extract 1090 
 
 Chamomile 1083 
 
 Changes in the I5rea.sts 915 
 
 Changes in the Skin 916 
 
 Chaps of Nipples 962 
 
 Cheese 1063 
 
 Cheese, Poisoning from ,S58 
 
 Chemicals, Poisoning by S59 
 
 Chest 1049 
 
 Chest, Dropsy of 248 
 
 Chicken Broth 1074 
 
 Chicken-Po.x 39 
 
 Child, Attention to 949 
 
 Child-bed Fever 974 
 
 Child-bed, Diseases of 974 
 
 Children and Women, Diseases of. . . . 871 
 
 Childhood, Care of Eyes 554 
 
 Chloral Hydrate £090 
 
 Chloride of Iron 1091 
 
 Chloroform 1090 
 
 Colchicum Root, Fluid Extract 1090 
 
 Cholera 88 
 
 Chorea, Acute 313 
 
 Chronic Dropsy of the Brain 251 
 
 Chronic Inflammation of the Womb., 998 
 
 Chronic Enlargement of the Womb. .. 1001 
 
 Chronic Bronchitis 133 
 
 Chronic Brighl's Disease 266 
 
 Page. 
 
 Chorea — (St. Vitus' Dance) 311 
 
 Chronic Dy.sentcry 216 
 
 Chronic Inflammatit)n of the Liver. . . . 254 
 
 Chronic Indigestion 194 
 
 Clironic Meningitis 292 
 
 Chronic Peritonitis 229 
 
 Chronic Rheumatism 103 
 
 ("inchona Bark 1085 
 
 Cirrhosis of the Liver — Gin Liver 255 
 
 Citrate of Iron logi 
 
 Clap — (Gonorrhoea) 515 
 
 Cleanliness 1068 
 
 Clothing During Pulierty 885 
 
 Colchicum Root, Wine 1091 
 
 Colchicum Seed, Tincture 1091 
 
 Colic, Lead 224 
 
 Collar-bone, Fracture of 748 
 
 Collar-bone, Dislocation of 806 
 
 Colocynth, Compound Extract 1091 
 
 Colombo, Tincture 1091 
 
 Color Blindness 550 
 
 Colored Fabrics, Poisoning from 856 
 
 Coltsfoot '079 
 
 Compounds of Ixad, Poisoning by. . . . 863 
 
 Compound F'ractures, Troatment of. . 794 
 
 Colic, Bilious 223 
 
 Conception, Prevention of 990 
 
 Condylomata /\.\ ,\ 
 
 Confinement, To Calculate Time of. . . 935 
 
 Confinement 941 
 
 Congenital Cataract 612 
 
 Conjunctivitis — Inflammation of the 
 
 I'-y" 589 
 
 Constipation 21S 
 
 Constipation of Pregnancy 920 
 
 Consumption 141 
 
 Convulsions 1041 
 
 Convulsions, Puerperal 978 
 
 Constitutional Diseases 21 
 
 Copaiba 1085 
 
 Copper, Poisoning by 863 
 
 Copper Poisoning from Food 855 
 
 Cordial, Cascara 1090 
 
 Corns 456 
 
 Co ea, Inflammation of 604 
 
 Cornea, Ulcers of 666 
 
 Corsets 80s 
 
 Cosmetics, Poisoning from 857 
 
 Cotton 105s 
 
 Cramp, Writer's 353 
 
 Croup 1036 
 
 ! l\ 
 
"32 
 
 INDEX. 
 
 0. 
 
 Page. 
 
 Dandelion ' loSo 
 
 Diiiulelion, Fluid Extract logi 
 
 Dandruff 377 
 
 Deadly Nightshade 1081 
 
 Deafness, Nervous 638 
 
 Defective Drainage 1068 
 
 Delirium Tremens 328 
 
 Detection of Sex before IJirth 93S 
 
 Diabetes Insipidus 286 
 
 Diabetes — Sugar in the Urine 2S0 
 
 Diarrhea 1032 
 
 Diarrhea 2U 
 
 Diarrhea of Pregnancy 920 
 
 Diaphoretic 10S9 
 
 J )iet in Diseases of the Skin 463 
 
 Digestive Organs, Diseases of 179 
 
 Digitalis, Poisoning by 866 
 
 Dilatation of the Stomach 204 
 
 Diphtheria 51 
 
 Disease, Addison's 287 
 
 Diseases, Constitutional 21 
 
 Diseases of the Digestive Organs 179 
 
 Diseases of the Ear 626 
 
 Diseases of the Eye 543 
 
 Diseases of the Eye and Ear 543 
 
 Disease, Fish-skin 429 
 
 Diseases of the Heart 161 
 
 Diseases of the Intestines 211 
 
 Disopses of the Kidneys 260 
 
 Diseases of the Liver 252 
 
 Diseases of the Organs of Circulation. 161 
 
 Diseases of the Nervous System 289 
 
 Diseases of the Skin 365 
 
 Diseases of the Skin, Diet in 463 
 
 Diseases of the Stomach 187 
 
 Diseases, Surgical 645 
 
 Diseases of the Teeth 846 
 
 Diseases of the Throat and Chest 117 
 
 Diseases of Women and Children 871 
 
 Disinfection 1070 
 
 Dislocations 8<X) 
 
 Dislocation of the Ankle 833 
 
 Page. 
 
 Dislocation of the Cartilages of the 
 
 Knee-joint 830 
 
 Dislocation of the Elbow 813 
 
 Dislocation of the Fingers 818 
 
 Dislocation of the Hips 820 
 
 Dislocation of the Knee-joint 832 
 
 I )islocation of the Lower Jaw 805 
 
 Dislocation of the Knee-pan 828 
 
 Dislocation of the Shoulder 807 
 
 Dislocations, Symptoms of 802 
 
 Dislocations of the Thumb 817 
 
 Dislocations, Treatment of 802 
 
 Dislocation of the Toes 837 
 
 Dislocation of the.Vertebra: 818 
 
 Dislocation of the Wrist 816 
 
 Displacement on the Back of the Hip- 
 bone 821 
 
 Displacements of the Womb 1006 
 
 Dislocation of the Bones of the Foot , . 836 
 
 Diuretic 1039 
 
 Dizziness — (Vertigo) 341 
 
 Double Womb 936 
 
 Dose for Adults 1087 
 
 Dose for Children 1087 
 
 Dover's Powder 1091 
 
 Dressing of F'ractures 723 
 
 Dropsy 244 
 
 Dropsy of the Brain 249 
 
 Dropsy of the Chest 248 
 
 Drowned, Reviving (Howard's Method) 868 
 
 Drum of the Ear, Inflammation of. . . 632 
 
 Drum of the F2ar, Injuries to 637 
 
 Drying up of the Milk 964 
 
 Duration of Pregnancy 932 
 
 Dry Tetter — (Psoriasis) 390 
 
 Dyes, Hair 410 
 
 1 )ysentery 213 
 
 Dysentery, Chronic 216 
 
 Dysentery, Epidemic 215 
 
 Dysmenorrhcea — (Menstruation) 892 
 
 Dyspepsia 193 
 
 E. 
 
 Ear, Diseases of 626 
 
 Ear, Foreign Bodies in 626 
 
 Ear, Inflammation of the Drum 632 
 
 Ear, Injuries to the Drum 637 
 
 Ear, Polyp of 642 
 
 Ear, Running from 63O 
 
 I'lar, Wax in 628 
 
 Earache 641 
 
Pagf. 
 ilages of the 
 
 830 
 
 ' 813 
 
 s 818 
 
 820 
 
 oint 832 
 
 •Jaw 805 
 
 •pan 828 
 
 der 807 
 
 of 802 
 
 lb 817 
 
 of 802 
 
 837 
 
 brw 818 
 
 816 
 
 :k of the Hip- 
 
 821 
 
 omb 1006 
 
 i of the Foot,. 836 
 
 1039 
 
 341 
 
 936 
 
 1087 
 
 1087 
 
 \ 1091 
 
 723 
 
 244 
 
 , 249 
 
 248 
 
 vard's Method) 868 
 nmation of. . . 632 
 
 Esto 637 
 
 964 
 
 932 
 
 390 
 
 410 
 
 213 
 
 216 
 
 215 
 
 uation) 892 
 
 193 
 
 642 
 630 
 628 
 641 
 
 INDEX. 
 
 113 
 
 Page. 
 
 Eating too fast 1059 
 
 Eating between meals 1059 
 
 Ecthyma 426 
 
 Eczema of the Vulva 993 
 
 Ecezma — Salt Rheum 382 
 
 Eggs 10.S6 
 
 Elaterium 10S6 
 
 Elaterium 109 1 
 
 Elbow, Dislocation of 813 
 
 Elder Flowers, Decoction 1091 
 
 Elder 10S2 
 
 Emphyema 1 26 
 
 Emphysema 135 
 
 EmmenagogUL" 1089 
 
 Emissions, Seminal — (Spermatorrhea). . 534 
 
 Enlargement of Abdomen. ^ 915 
 
 Enlargement, Chronic, of tlic'Womb. . looi 
 
 Enlargement of the Tonsils 65S 
 
 Enlargement of the Uvula 660 
 
 Enlarged Veins in Pregnancy 920 
 
 Endocarditis — (Heart Disease) 164 
 
 Epidemic Dysentery 215 
 
 Epilepsy — Falling SicKness 302 
 
 Epsom Salts 1091 
 
 Ergot, Fluid Extract 1091 
 
 Page- 
 Ergot of Rye io8b 
 
 Eruptive Fevers 23 
 
 Erysipelas 414 
 
 Erysijielas 730 
 
 l'>ysipelas, Treatment of 736 
 
 l''.rylhema, Redness 418 
 
 Excessive Eating 'osfll" 
 
 Exercise 1065 
 
 Exhaustion fi'om Nursing 960 
 
 lv\h;iustion, Ncrvoi's 355 
 
 Exophthalmic Goitre 170 
 
 Expectorant 10S9 
 
 Eye, Inflammation of — Conjunctivitis. 589 
 
 I^Iyc, Injuries of 613 
 
 Eye, Scum on (Pterygium) 603 
 
 I'-ye and Ear, Diseases of 543 
 
 Eye, Diseases of 543 
 
 I'.ycs, (jonorrhoeal Inflammation of . . . 595 
 
 Eyelids, Tumors of 621 
 
 Eyelashes, Inflammation around 617 
 
 Eyes, Foreign ISodies in 567 
 
 Eyes, Artificial 623 
 
 Eyes, Purulent Inflammation of 592 
 
 Eyelids, Inversions of 602 
 
 Eyelids, Injuries of 615 
 
 > 
 
 P. 
 
 Fabrics, Colored, Poisoning from 856 
 
 Facial Paralysis 35 1 
 
 Falling of the Womb 1007 
 
 Falling of the Womb — (Prolapsus). . . . 1007 
 
 Falling Sickness — (Epilepsy) 302 
 
 Fainting 679 ' 
 
 Far-sight 581 
 
 Favus 400 
 
 Felon 64S 
 
 Fennel 1076 
 
 Fennel Seed, Infusion 1091 
 
 Fever Blister — (Herpes) 403 
 
 Fever, Child-bed 974 
 
 Fevers, Eruptive 23 
 
 Fever, Intermittent 66 
 
 Fever, Scarlet 40 
 
 Fevers, Specific 21 
 
 Fever, Relapsing 65 
 
 Fever, Remittent 78 
 
 Fever Root, Decoction 1091 : 
 
 Fever, Typhoid 57 
 
 Fever, Typhus 63 ' 
 
 Fever, Yellow Si 
 
 Fibula, Fractures of 7S7 
 
 Filaria Sanguinis Ilominis 243 
 
 Fingers, Dislocation of 818 
 
 Fingers, Fractures of 764 
 
 Fish £063 
 
 Fish, Poisoning from S58 
 
 Fish-skin Disease 429 
 
 Flax 1080 
 
 Fleabane, Infusion 1091 
 
 Flexions . 101 1 
 
 Food, Copper Poisoning from 855 
 
 Food for Breakfast 1062 
 
 Food for Dinner 1062 
 
 Food for the Sick 1073 
 
 Food for Supper 1062 
 
 Food of Infant 966 
 
 Food, Poisons which Occur in 853 
 
 Foot, Fractures of the Bones 795 
 
 Foreign Bodies in the Ear 626 
 
 Foreign Bodies in the Eyes 567 
 
 Foreign Bodies in the Throat 661 
 
134 
 
 INDEX. 
 
 Page. 
 
 Foxglove 1082 
 
 Foxylove, (Digitalis) Infusion 1091 
 
 Foxglove, Fluid Extract 1091 
 
 Foxglove, Tincture 1091 
 
 Freckles 452 
 
 Fruits 1064 
 
 Fractures of the Arm-bone, Treatment 
 
 "f" 752 
 
 Fractures of the Arm-bone (Humerus) . 750 
 
 Fractures of Arm-bone near the Elbow 755 
 Fractures of Arm-bone near Elbow, 
 
 Treatment of 756 
 
 Fractures — Broken Bones 713 
 
 Fractures of the Bones of the Foot . . . 795 
 
 Fractures of Both Bones of the leg. . 790 
 
 Fracture of the ColIar-bi>ne 748 
 
 Fracture of the Collar-bone, Treatment 
 
 "f 74S 
 
 Fractures Compound, Treatment of. . . 794 
 
 Fractures, Dressing of 723 
 
 Fractures of the Fibula 787 
 
 Fractures of the Fingers 764 
 
 Fractures of Fingers, Treatment of. . . 764 
 
 Fractures of the Fore-arm 758 
 
 Fractures of the Fore-arm near Elbow 758 
 Fractures of the Fore-arm near Elbow, 
 
 Treatment of 759 
 
 Fracture of the Fore-arm, near Wrist. 761 
 Fracture of Fore-arm, near the Wrist, 
 
 Treatment of 762 
 
 Fracture at the Middle of the Fore-arm 760 
 
 Fractures in the Middle of Arm-bone. . 754 
 Fractures in the Middle of Arm-bone, 
 
 Treatment of 754 
 
 rage 
 Fracture of the Middle of the Fore-arm, 
 
 Treatment of 761 
 
 Fractures of the I land 764 
 
 I'racturcs of the Hand, Trcatmeni "f . 764 
 
 Fractures of the Hip 769 
 
 Fractures of the Hip, Treatment of. . . 770 
 
 I'Vacturcs just above the Knee 781 
 
 ■■'ractures of the Knee-pan 783 
 
 Fracture of tiie Leg 787 
 
 Fractures of the Lower Jaw 745 
 
 Fractures of the Lower Jaw, Symp- 
 toms of 745 
 
 Fractures of the Lower Jaw, Treat- 
 ment of 745 
 
 I'racturcs of the Neck of the Tliigh- 
 
 Bonc 778-822 
 
 Fractures, Non-union of Bones 797 
 
 Fracture of the Nose 747 
 
 l''racture of the Nose, Treatment of. , 747 
 
 Fractures, Results of 727 
 
 Fractures of the Ribs 765 
 
 Fractures of the Ribs, Treatment of. . 766 
 Fracture of the Skull, Treatment of. , y.yo 
 Fracture of the Shoulder-blade, Treat- 
 ment of 750 
 
 Fracture of the Shoulder-blade 750 
 
 Fractures of the Spine 767 
 
 Fracture of the Skull . 738 
 
 Fractures of the Thigh-bone 770 
 
 Fractures nf the Thigh-lione, Signs of. 770 
 
 Fracluri's of Tliigli-boni', Treatment of 771 
 
 Fractures of the Tibia 78S 
 
 Fracture of the Upper Jaw 747 
 
 a 
 
 Gall . Stones, Passage of 225 
 
 Galls, Powdered 1091 
 
 Gamboge, Powdered logi 
 
 Garlic 1078 
 
 Gastrodynia — Pain in the Stomach. . . . 205 
 
 Gelsemium, Fluid Extract 1091 
 
 General Paralysis of the Insane 352 
 
 Gentian, Tincture 109 1 
 
 Geranium, Decoction 109 1 
 
 Ginger, Powdered 1091 
 
 Gin Liver (Cirrhosis of the Liver) 255 
 
 Glauber Salts 1091 
 
 Gleet 526 
 
 Goitre 663 
 
 Goitre Exophthalmic 170 
 
 Golden Rod 1077 
 
 Gonorrhwa, Clap 515 
 
 Gonorrhieal Inflammation of the Eyes. 595 
 
 Gout, Rheumatic no 
 
 (jout 105 
 
 (Granular Lids 599 
 
 (jravel 274 
 
 Gruels 1074 
 
 Guinea Worm 242 
 
 Gullet, Strictures of 662 
 
 Gum Camphor 1090 
 
 Gunshot Wounds 694 
 
Page, 
 f the Fore-arm, 
 
 761 
 
 7('4 
 
 Treatment of . 764 
 
 7(>9 
 
 'iLMtment of. .. 77° 
 
 le Knee 7*^' 
 
 pan 783 
 
 787 
 
 ■Jaw 745 
 
 •cr Jaw, Symp- 
 
 745 
 
 rer Jaw, Treat- 
 
 745 
 
 k of the Thiyh- 
 
 778-822 
 
 of Bones 797 
 
 747 
 
 Treatment of. . 747 
 
 727 
 
 765 
 
 , Treatment of. . 766 
 , Treatment of. , J.\o 
 der-blade, Treat- 
 
 75° 
 
 ikler-blade 75° 
 
 le 767 
 
 73« 
 
 ;h-bone 77° 
 
 h-hune, Signs of. 770 
 ni', Treatment of 771 
 ia 78« 
 
 r Jaw 747 
 
 170 
 
 1077 
 
 5<S 
 
 lition of the Eyes. 595 
 
 no 
 
 105 
 
 599 
 
 274 
 
 1074 
 
 242 
 
 '"//. 662 
 
 1090 
 
 694 
 
 INDEX. 
 
 "35 
 
 Page. 
 Hair Dyes 410 
 
 I Faiul, Fractures of 764 
 
 1 lead 1048 
 
 Headache 338 
 
 Hare-lip 652 
 
 Heart Disease — Endocarditis 164 
 
 Heart, Organic Disease 166 
 
 Heart, Palpitation of 171 
 
 Heart, the Diseases of 161 
 
 Henbane 1077 
 
 Hemiplegia 348 
 
 Hemlock 1082 
 
 Hemlock liark. Powder 1091 
 
 Hendock, Solid Extract icwjl 
 
 Hemui rliagica Purpura 114 
 
 Henbane, Poisoning by 866 
 
 Henbane, Solid I'Lxtract 1091 
 
 Henbane, Tincture 1091 
 
 Hernia, Rupture S37 
 
 Hernia, Strangulated 840 
 
 Page, 
 
 Herpes — Fever Blister 403 
 
 Hii)-lione, Displacement on the IJack. 821 
 
 Hip, Dislocation of 820 
 
 Hip, Fractures of 767 
 
 Hop 1078 
 
 Horse-radish 1079 
 
 Horse-chestnut 1080 
 
 Housemaid's Knee 667 
 
 Howard's Method of Reviving the 
 
 Drowned 868 
 
 Humerus, Fractures of the Arm-bone. 150 
 
 Hydatid Tumors of the Liver 256 
 
 Hydrastin 1091 
 
 Hy(lro[ihobia 318 
 
 Hygiene 1059 
 
 Hygiene of Lactation 950 
 
 Hygiene of Pregnancy 922 
 
 Hygiene of Puberty 883 
 
 Hysteria (Hysterics) 905 
 
 Hysterics, Hysteria 905 
 
 I. 
 
 Iceland Moss 1074 
 
 Impetigo 425 
 
 Impotence 530 
 
 Indian Coin 1064 
 
 Indian Hemp, Decoction 1091 
 
 Indigestion 1021 
 
 Indigestion, Chronic 194 
 
 Infant, Care of 964 
 
 Infants, Diseases of 1029 
 
 Infa nt. Food of 966 
 
 Infantile Paralysis 352 
 
 Inflammation Around the Eyelashes. . . 617 
 
 Inflammation, Chronic, of the Womb. . 998 
 
 Inflammation, Gonorrheal, of the Eyes. 595 
 
 Inflammation of the Bowels 230 
 
 Inflammation of the Bowels — Perito- 
 nitis 227 
 
 Inflammation of the Brain 290 
 
 Inflammation of the Brain 743 
 
 Inflammation of the Brain, Symptoms 
 
 of • 743 
 
 Inflammation of the Brain, Treatment 
 
 of 744 
 
 Inflammation of the Cornea 604 
 
 Inflammation of the Drum of the Ear. 632 
 
 Inflammation of the Eye (Conjunctiv- 
 itis) 589 
 
 Intlammationof the Iris (Iritis) 609 
 
 Inflammation of the Kidney (liright's 
 
 Disease) 263 
 
 Inflammation, Peri-uterine 1004 
 
 lullanmiation, Purulent, of the I'.yes, . 592 
 
 Inllammation of the Skin 450 
 
 Inflammation of the Stomach 187 
 
 Inflammation of the Tear-duct 621 
 
 Inflammation of the Womb 997 
 
 Influenza 1040 
 
 Injuries of the I'^ye 614 
 
 Injuries to the Drum of the Ear 637 
 
 Injuries of the Eyelids 615 
 
 Insect Powders, Poisoning from 858 
 
 Insects, Bites and Stings of 707 
 
 Insipidus Diabetes 2S6 
 
 Instructions for Persons Wearing an 
 
 Artificial Eye 625 
 
 Intercostal Neuralgia 337 
 
 Intermittent Fever 66 
 
 Intermittent F'ever, Pernicious 74 
 
 Intestinal Worms 231 
 
 Intestines 1057 
 
 ''^■, 
 
II36 
 
 INDEX. 
 
 Page. 
 
 Intestines, Diseases ol 211 
 
 Inversion of the Eyelids 602 
 
 Iodide Mercury 109 1 
 
 Iodide of Iron 1091 
 
 Ipecac, Powdered 1091 
 
 Ipecac, Syrup 109 1 
 
 Ipecac, Wine 109 1 
 
 Iodoform, Powdered ,.... 109 1 
 
 Irish Moss 1075 
 
 Iris, Inflammation of (Iritis) 609 
 
 Iritis, Inflammation of 6og 
 
 Iron and Ammonia, Citrate of 1091 
 
 Page. 
 
 Iron, Bromide 1092 
 
 Iron, Carbonate 1092 
 
 Iron, Chloride, Tincture of 1092 
 
 Iron, Citrate 1092 
 
 Iron, Iodide, Syrup 1092 
 
 Iron, Phosphate 1092 
 
 Iron and (Quinine, Citrate 1091 
 
 Irritability of Bladder 9:5 
 
 Itch, Barber's (Sycosis) 406 
 
 Itching of the Vulva (Pruritis) 994 
 
 Itching (Pruritus) 440 
 
 Itch— (Scabie';) 378 
 
 J. 
 
 Jalap, Powdered 1092 1 Jellies 1074 
 
 Jaundice 258 | Joints 1050 
 
 Jaw, Lower. Dislocation of 805 Juniper 1079 
 
 Jaw, Mollification of 656 i Juniper Berries, Infusion 1092 
 
 K. 
 
 Kidneys, Diseases of 260 1 Knee-pan, Fractures of 783 
 
 Kind of Food 1060 Knee, Housemaid's 669 
 
 Knee-pan, Dislocation of 82S I 
 
 L. 
 
 I' ^ 
 
 Labor, Care of Mother After 
 
 Labor Pains 
 
 Lacti tion 
 
 Lactation and Sexual Functions, Rela- 
 tionship Between 
 
 Lactation, Hygiene of 
 
 Larynx, Affections of 
 
 Lirynx, Catarrh of 
 
 Larynx. Tmnors of 
 
 LaudanuM 
 
 Laurel 
 
 Lead Colic 
 
 Leg, Barliadoes 
 
 Leg, Fracture of 
 
 Leg, Ulcers of 
 
 Lcptandrin 
 
 Leucorrhaja( Whites) 
 
 Licorice 
 
 Lice 
 
 Lichen 
 
 Lids, (jraniilar 
 
 Liglit 
 
 Lime 
 
 Linen 
 
 951 
 941 
 
 955 
 
 95S 
 960 
 "7 
 •17 
 121 
 
 lO(;2 
 
 I jS 5 
 224 
 4,i5 
 7S7 
 650 
 
 1 1192 
 903 
 
 loSc 
 
 42S 
 
 5<ii) 
 loiS 
 1077 
 io(>5 
 
 Li;), Cancer of 654 
 
 l-eprosy 430 
 
 List of Medicines 1088 
 
 Liver 1057 
 
 Liver, Abscess of 253 
 
 Live Acute Inflammation of 252 
 
 Liver, Chronic Inflammation of 254 
 
 Liver Gin (Cirrhosis of the Liver) 255 
 
 Liver, Diseases of 252 
 
 Liver, Hyilalid Tumors of 256 
 
 Liver Spots 402 
 
 Liverwort, Decoction loc)2 
 
 Lobelia, Infusion 1092 
 
 Loljclia, Tiiiclure 1092 
 
 Lochia " • " ■ 953 
 
 Lock-jaw — (Tetanus) 315 
 
 Locomotor Ataxia 342 
 
 Lower Extreuiitics 1050 
 
 Lower Jaw, Dislocation of ; S05 
 
 Lower Jaw, Fractures of 745 
 
 Lunar Caustic, Poisoning by 864 
 
 Lungs, AITections of 121 
 
 Lupus 422 
 
Page. 
 
 1092 
 
 1092 
 
 of 1092 
 
 1092 
 
 1092 
 
 1092 
 
 e 1091 
 
 <J!5 
 
 406 
 
 ruritis) 994 
 
 440 
 
 378 
 
 1074 
 
 1050 
 
 1079 
 
 1092 
 
 783 
 
 669 
 
 654 
 
 430 
 
 10S8 
 
 «os7 
 
 253 
 
 jii i)f 252 
 
 I'on of 254 
 
 lol.ivcr) 255 
 
 252 
 
 )f 2S(> 
 
 402 
 
 1092 
 
 1092 
 
 1092 
 
 953 
 
 3'5 
 
 342 
 
 1050 
 
 )f ; S05 
 
 745 
 
 liy S04 
 
 121 
 
 422 
 
 INDKX. 
 
 II37 
 
 Page 
 
 Magnesia 1092 
 
 Malarial Fevers 66 
 
 Male, Sterility in • . . 5^2 
 
 Maligna Scarlatina a.3 
 
 Manna 1092 
 
 Marks, Mother's 45S 
 
 Marriage 909 
 
 Marsh Mallow 1078 
 
 Marsh Nhi.llow, Infusion 1092 
 
 Mayapple, Decoction 1092 
 
 Mayapple, Kcsin (Podophyllin) 1092 
 
 Mayapple 1 oot, Powdered 1092 
 
 Meailow Saffron 1078 
 
 Meadow-Sweet 1076 
 
 Measles 47 
 
 Meat 1063 
 
 Meats, Poisoning from 858 
 
 Medicinal Rashes 459 
 
 Medicinal Plants 1078 
 
 Medicines, Poisoning by S59 
 
 Meningitis, Chronic 292 
 
 Meningitis, Cercbro-Spinal 294 
 
 Meningitis, Spinal 293 
 
 Meningitis, Tuberculosis 292 
 
 Menorrhagia (Profuse Menstruation) . . 894 
 
 Menstrual Flow, Suppression of 895 
 
 Menstruation, IJeginning of 873 
 
 Menstruation Dining Nursing 959 
 
 Mestruation, Dysmenorrhea 892 
 
 Menstruation, Painful 893 
 
 Mercury, Bichloride (Corrosive Subli- 
 mate) 1092 
 
 Mercury, Biniodide 1092 
 
 Page. 
 
 Mercury, Iodide 1092 
 
 Metrorragia 895 
 
 Middle of the Arm-bone, Fractures of. 754 
 
 Middle ot the Fore-arm, Fractures of. 760 
 
 Miliaria, Sweat Rash 4.15 
 
 Milk-leg 978 
 
 Milk 1062 
 
 Mlscarri:»ge, Symptoms of 928 
 
 MoUuscum 425 
 
 ?.-orning Sickness 914 
 
 Morphine 1092 
 
 Mortification of the Jaw 656 
 
 Mother, Care of after Labor 951 
 
 Mother's Marks 458 
 
 Mothers, Unwillingness to be 9S2 
 
 Mouth, Bleeding from 675 
 
 Mouth, Tumors of 657 
 
 Monthly Changes, Care During SSS 
 
 Movements in Walking and Running., 1052 
 
 Mumps 184 
 
 Mullein ro8i 
 
 Mullein Leaves, Infusion 1092 
 
 Muscles 1051 
 
 Muscles Inside the Bodv 1052 
 
 Muscles of the Head 1051 
 
 Muscles of the Trunk 1052 
 
 Muscular Rheumatism 104 
 
 j Musk 1092 
 
 Mustard 1076 
 
 Mustard Seeds, Ground 1092 
 
 Mutton Broth 1074 
 
 Myrrh, Tincture 1092 
 
 N. 
 
 Nails 461 
 
 Narcotic 1088 
 
 Neck of the Thigh-bone, Fractures of. 778 
 
 Neck, Tumors of 665 
 
 Nerves 1055 
 
 Nervous System, Diseases of 289 
 
 Nervous System 1054 
 
 Nervous Deafness 638 
 
 Nervous Exhaustion 355 
 
 Nettle 1076 
 
 Nettle-rash— (Urticaria) 419 
 
 Neuralgia 332 
 
 Neuralgia, Intercostal 337 
 
 Non-union of Bones after Fractures. . . 797 
 
 Nose, ^>leedin^■ from O75 
 
 Nose, Fraclure of 747 
 
 Nose, Polyj) of 656 
 
 Nursing, Inability for 881 
 
 Nux Vomica. Poisoning by 866 
 
 Nux Vomica, Solid Fxtract 1092 
 
 Nux Vomica, Tincture 1092 
 
II38 
 
 INDEX. 
 
 0. 
 
 Page. 
 
 Oak 10S2 
 
 Oatmeal 1064 
 
 Obstruclions to Menstruation 8g6 
 
 Oleander, Poisoning by 866 
 
 Oil, Castor logo 
 
 Oil of Anise Seed 1089 
 
 Opium, Poisoning by 864 
 
 Opium, Powdered 1092 
 
 Opium, Tincture 1092 
 
 Opium, Vinegar 1092 
 
 I'age. 
 
 Opium, Wine 1092 
 
 Organic Disease of the Heart 166 
 
 Organs of Circulation, Diseases of. . . . 161 
 
 Organs of Circulation 1056 
 
 Organs of Digestion 1057 
 
 Organs of Excretion 1058 
 
 Organs of Respiration 1057 
 
 Ovarian Tumors 1025 
 
 Ovaries, Diseases of 1023 
 
 Oxalic Acid, Poisoning by 861 
 
 #. 
 
 Painful Menstruation 893 
 
 Pain in the Stomach (Gasirodynia). . . . 205 
 
 Palpitation of the Heart 171 
 
 Palsy, Sliaking 352 
 
 Palsy, Wasting 345 
 
 Paralysis 346 
 
 Paralysis, Facial 351 
 
 Paralysis. Oeneral, of the Insane 352 
 
 Paralysis, Infantile 352 
 
 Paraplegia 350 
 
 Paregoric 1092 
 
 Pareira, Decoction 1092 
 
 Patsley ioSf 
 
 Parsley Root, Infusion 1092 
 
 Pectoris Angina 1 74 
 
 I'l'iuphigus 436 
 
 PiMinyroyal 1079 
 
 Pennyroyal, Infusion 1093 
 
 P'ony 1079 
 
 Peppermint [083 
 
 Pericarditis 161 
 
 Peritonitis, Chronic 229 
 
 Peritonitis — Inflammation of Bowels. . 227 
 
 Pernicious Intctrniittent Fever 74 
 
 I'eriivian Hark, Decoction 1093 
 
 Peruvian Hark, Powdered '093 
 
 Peruvian Bark, Tincture 1093 
 
 Pessaries 1009 
 
 Pharyngitis — Sore Throat 179 
 
 Phosphate of Iron io<(i 
 
 I'hysiology md ,\natoniy 1043 
 
 Piebald Skin 446 
 
 Piles during Pregnancy 921 
 
 Pimples — (Acne) 372 
 
 Pink Root, Infu.-ion 1093 
 
 Pityriasis 447 
 
 Placenta Prxvia. 
 i'kxntain 
 
 PUister, Belladonna 
 
 Pleurisy 
 
 Pleurisy Root, Infusion 
 
 Plural Pregnancy 
 
 Pneumonia 
 
 Pond Lily P it. Decoction 
 
 Podoj)hyllin 
 
 Potassium, iiromide 
 
 Potassium, Chlorate. . 
 
 Potassium, Citrate 
 
 Potassium, Iodide 
 
 Potassium, Nitrate (Saltpetre) 
 
 Poisoned Wounds 
 
 Poisoning Blood (Pyxmia) 
 
 Poisoning by .Vcids 
 
 Poisoning by Alkalies 
 
 Poisoning by Arsenic 
 
 Poisoning :<y Boiladoniia, Ilenlnme, 
 Stramonium and 1 ligitalis 
 
 Poisoning by Carbolic Acid 
 
 Poisoning by Compounds of Lead. . . . 
 
 Poi.soning by Cojijier and its Compounds 
 
 Poisoning by Lunar Caustic 
 
 Poisoning by Medicines and Chemicals 
 
 Poisoning by Opium 
 
 Poisoning by Oxalic Acid 
 
 Poisoning by Pnissic Acid and its Com- 
 pounds 
 
 Poisoning by Quicksilver Compounds. . 
 
 Poisoning by .Stryclminc, Niix X'oniica, 
 While Hellebore, Oleander ami Spi- 
 gelia 
 
 Poisoning by Zinc Com])iPunds 
 
 I'oisoning from Colored Fabrics 
 
 930 
 1079 
 1090 
 
 121 
 
 io();, 
 
 93''> 
 
 127 
 
 1093 
 
 1093 
 
 1093 
 
 '093 
 
 1093 
 
 1093 
 
 1093 
 
 703 
 
 731 
 
 859 
 
 860 
 
 862 
 
 866 
 861 
 863 
 863 
 863 
 
 *^59 
 864 
 <S6i 
 
 862 
 863 
 
 866 
 863 
 856 
 
I'age. 
 
 I0g2 
 
 Heart 166 
 
 diseases of. ... 161 
 
 1056 
 
 1057 
 
 1058 
 
 «o57 
 
 1025 
 
 1023 
 
 by 861 
 
 930 
 
 1079 
 
 1090 
 
 121 
 
 100;, 
 
 93f' 
 
 127 
 
 lion 1093 
 
 «093 
 
 1093 
 
 '093 
 
 '093 
 
 1093 
 
 petro) 1093 
 
 703 
 
 ia) 731 
 
 «59 
 
 .S60 
 
 862 
 
 iia, Henbane, 
 
 l;ilis 866 
 
 U-i<l 861 
 
 Is of Lead. . . . 863 
 its Compounds 863 
 
 istii- 863 
 
 and Chemicals 850 
 
 .S()4 
 
 1 ;S6i 
 
 il and itsCom- 
 
 862 
 
 (oniponnds. . 865 
 , Nux Vomica, 
 Andor and Spi- 
 
 866 
 
 p.iunds 863 
 
 labrics 856 
 
 ^» 
 
 TNDFA' 
 
 Poisoning from Cosiri' tics 
 
 Poisoning from Insect Powders 
 
 Poisoning from Meats, Fish and Cheese 
 
 Poisons and Their Antidotes 
 
 Poisons in Sugars 
 
 Poisons which Occur in Food 
 
 Polyp of the Ear 
 
 Polyp of the Nose 
 
 Polyps of the Uterus 
 
 Poppy 
 
 Potatoes 
 
 Powders, Insect, Poisoning from 
 
 Pox — (Syphilis) 
 
 Psoriasis — Pry Tetter 
 
 Pravia Placenta 
 
 Pregnancy 
 
 Pregnancy, Accidents of 
 
 Pregnancy, Diseases of 
 
 Pregnancy, Duration of 
 
 Pregnancy, Hygiene of 
 
 Pcri-utei'ine Inllanimation 
 
 Page. 
 
 857 
 858 
 S58 
 
 «53 
 
 855 
 
 SS3 
 
 642 
 
 656 
 
 1017 
 
 1079 
 
 1064 
 
 S58 
 
 471 
 390 
 930 
 
 913 
 
 926 
 
 917 
 
 932 
 
 922 
 
 1004 
 
 II39 
 
 Page 
 
 Prevention of Conception 990 
 
 Private Disea.ses, or Venereal 471 
 
 Profuse Menstruation (Menorrhagia). . S94 
 
 Prolapsus, Falling of the Womb 1007 
 
 Piiirigo 438 
 
 Pruritis (Itching of the Vulva) 990 
 
 Pruritus, Itching 444 
 
 Prussic Acid, Poisoning by 862 
 
 Pterygium, Scum on the F,yo 602 
 
 Puberty, Disorders of 874 
 
 j Puberty, Education during S77 
 
 I Puberty. I lygiene 883 
 
 Puberty, When Delayed 8S9 
 
 Puerperal Convulsions 978 
 
 Punctured Wounds 687 
 
 Pure Air 1069 
 
 I'urpura Hemorrhagica 1 14 
 
 Pyxmia, Plood-Poi.soning 731 
 
 Py;x:mia, Synipt(5nis of 732 
 
 Pyajmia, Treatment of 733 
 
 Quantity 'Quickening 916 
 
 Quantity of Food 1059 ; Quicksilver Compounds, Poisoning by S63 
 
 Quassia, Infusion 1093 Quinsy 182 
 
 Quaisia, Tincture . . 1093 I Quinine, .Suljihate 1093 
 
 R. 
 
 Race in Menstruation 
 
 Rashes, Medicinal 
 
 Raspberry Leaves, Infusion 
 
 Raspberry Leaves, Syrup 
 
 Redness ( Erythema) 
 
 Relapsing Fever 
 
 Relation between Lactation and Sexual 
 
 Functions 
 
 Remittent Fever 
 
 Remarks 
 
 Results of Fractures 
 
 Reviving the Drowned — Howard's 
 
 Metiiod 
 
 Rhatany Root, Decoction 
 
 Rhatany Root, Tincture 
 
 Rheumatic (lout 
 
 Rlieumatism 
 
 Rheumatism, C!hronie 
 
 Rheumatism, Acute Articular 
 
 S90 
 
 4.S9 j 
 
 1093 I 
 
 '093 I 
 
 41S i 
 
 1 
 
 958 1 
 
 7S 
 21 
 
 727 
 
 868 
 
 •093 
 
 1093 
 
 no 
 
 98 
 
 103 
 
 98 
 
 Rheumatism, Muscular 104 
 
 Rhubarb, Aromatic Syrup 1093 
 
 Rhubarb, Powdered 1093 
 
 Rhubarb, Tincture '093 
 
 Ribs, Fractures of 765 
 
 Rice 1064 
 
 Rice 1075 
 
 Ringworm 594 
 
 Rochelle Salts 1093 
 
 Roman 909 
 
 Rosemary 1081 
 
 Roseola 4() 
 
 Rue, Decoction 109^ 
 
 Running from the Ear, Treatment of. . 635 
 
 Running from the Ear 630 
 
 Rupia 44S 
 
 Rupture (Hernia) S37 
 
 Rye 1064 
 
.?«.*:' 
 
 II40 
 
 INDEX. 
 
 s. 
 
 Page. 
 
 Saffron 1076 
 
 Saffron, Infusion icx)3 
 
 Sage 1078 
 
 Sage, Infusion '093 
 
 Salicine 1093 
 
 Salts, Epsom 1091 
 
 Salt Rhtnim (Eczema) 382 
 
 Sang\iinis 1 loniinis Filaria 243 
 
 Santonin 1093 
 
 Sarsaparilla, Decoction 1093 
 
 Sarsaparilla, Fluid Extract 1093 
 
 Sassafras, Infusiun 1093 
 
 Savine Leaves, Infusion 1093 
 
 Savine, Oil 1093 
 
 Scalds and Burns 844 
 
 Scammony, Powdered 1093 
 
 Scarlatina Maligna, or Malignant Scar- 
 let Fever 45 
 
 Scarlet Fever 40 
 
 Sciatica 337 
 
 Scum on the Eye (Pterygium) 603 
 
 Scurvy-grass 1078 
 
 Seborrhea 449 
 
 Secondary Syphilis 48 1 
 
 Sedative 1088 
 
 Selection of a Wet-Xurse 963 
 
 Selection of Spectacles 585 
 
 Self-Abuse 900 
 
 Seminal I'hnissions (Spermatorrhea). . 534 
 
 Senega Root, Decoction 1093 
 
 Senega Root, Fluid Extract. . . . ^^i. . . . 1093 
 
 Senna, Decoction 1094 
 
 Senna, Fluiil Extract 1094 
 
 Setting of a Broken Bone 719 
 
 Shaking Pal.sy 352 
 
 Shock •.-••• ('99 
 
 Short-Sightedness 571 
 
 Shoulder-blade, Dislocation of S07 
 
 Shoulder-blade, Fracture of y^o 
 
 Shoulder, Dislocation of 807 
 
 Sickne.s.s, Falling (Epilepsy) 302 
 
 Sight, Far 581 
 
 Sight, Weak 563 
 
 Signs of Fractures of 'rhigh-t,)one 770 
 
 Signs of Pregnancy ylj 
 
 Sinew, Weeping 668 
 
 Skeleton 1047 
 
 Skin 106'^) 
 
 Skin, Diseases of 365 
 
 Skin, Inflammation'of 450 
 
 Skin, Piebald ^-,.. 
 
 Skull-cap, Infusion 1094 
 
 Skull, Fracture of 738 
 
 Small-pox 24 
 
 Smothciing 867 
 
 Snake liites 708 
 
 Soft Chancre — (Venereal Ulcer) 506 
 
 Sore Throat — Pharyngitis 179 
 
 Specific Fevers 21 
 
 Spectacles, The Selection of 585 
 
 Spermatorrhcea (Seminal Emissions). . 534 
 
 1 Spigelia, Poisoning by S69 
 
 Spinal Meningitis 293 
 
 Spine 1048 
 
 Spine, Fractures of 767 
 
 Spiralis Trichina 237 
 
 .Spirits of Ammonia 1089 
 
 .Spots, Liver 402 
 
 Sprains 843 
 
 Squinting 583 
 
 Stavesacre 1077 
 
 Sterility 1028 
 
 Sterility in tiie Male 532 
 
 Stimulant 1088 
 
 .Stings and Bites of Insects 707 
 
 St. John's Wort 1080 
 
 Stomach 1057 
 
 Stomach, Cancer of 207 
 
 .Stomach, Dilatation of 204 
 
 Stomach, Diseases of 187 
 
 Stomach, Inflammation of 187 
 
 Stomach, Pain in (tiastrodynia) 205 
 
 Stomach, Ulcer of. 189 
 
 Stone in the Bl.adrler 277 
 
 Stoppage of the Menses S95 
 
 Stramonium, Poisoning by 866 
 
 Stramonium, Tincture 1094 
 
 Strychnia 1094 
 
 Strangulated Hernia 840 
 
 Stricture of the Gullet 662 
 
 Strychnine, Poisoning by 866 
 
 St. Vitus' Dance (Chorea) 311 
 
 Stye 619 
 
 .Sugar in the Urine (Diabetesl 2S0 
 
 Sugars, Poisons in . . , S55 
 
 Sulphate of Iron 1070 
 
 Sulphur, Flowers 10(14 
 
 .Summer Complaint 1033 
 
 Sunstroke 361 
 
 Suppression of the Menstrual Flow... S95 
 
I094 
 
 738 
 
 24 
 
 867 
 
 7o» 
 
 [ Ulcer) 506 
 
 s 179 
 
 21 
 
 lof 585 
 
 1 Emissions) . . 534 
 869 
 
 293 
 
 104S 
 
 767 
 
 237 
 
 10S9 
 
 402 
 
 S43 
 
 58J 
 
 1077 
 
 1028 
 
 532 
 
 108S 
 
 Icls 707 
 
 1080 
 
 1057 
 
 207 
 
 204 
 
 187 
 
 of 187 
 
 odynia) 205 
 
 189 
 
 277 
 
 895 
 
 by 866 
 
 1094 
 
 1094 
 
 840 
 
 662 
 
 y 866 
 
 a) ill 
 
 619 
 
 Ihotes) 2S0 
 
 S5S 
 
 1070 
 
 ia)4 
 
 1033 
 
 3«" 
 
 trual Flow. .. 895 
 
 INDEX. 
 
 I 141 
 
 T'a 
 
 gc. 
 
 Surgicol Diseases 645 ■ Symptoms of Inflammation of the Brain 
 
 Sweat Rash— (.M''iaria) 441; i Symptoms of Miscarriage 
 
 Swedish Mover -nt 1066 : Symptoms of Pregnancy 
 
 Sycosis, |}a«)cr's Itch 406 i Symptoms of I'yremia 
 
 Syniptonr.-. of Dislocations S02 Sy]i]iilis, Secondary 
 
 Symptoms of I'ractiires of the Lower 
 Jaw 745 
 
 Syphilis — Pox. . 
 Syrup of Ipecac. 
 
 Page. 
 
 743 
 928 
 
 914 
 
 732 
 481 
 
 471 
 1091 
 
 T. 
 
 Table Exhibiting the Differences Be- 
 tween Small-Pox, .Scarlet Fever and 
 
 Measles 50 
 
 Table Indicating the Relative Fre- 
 cpiency of Consumption in Different 
 
 Parts of the Union 157 
 
 Table of Food, Giving Comjjarative 
 
 Digestiblity 203 
 
 Table Comparing Food 1061 
 
 Tansy, Decoction 1094 
 
 Tansy Oil 1094 
 
 Tansy 1077 
 
 Tape- Worms 234 
 
 Tapioca 1075 
 
 Tear-Duct, Inflammation of 621 
 
 Teething 970 
 
 Teeth, Diseases of 846 
 
 Temperature 1067 
 
 Tetanus— Lock Jaw 315 
 
 Tetter, Dry — (Psoriasis) 390 
 
 Thigh bone. Fractures of 770 
 
 Thornapple 107S 
 
 Thornapple (See Stramonium) 1094 
 
 Threail Worms 233 
 
 Throat and Chest, Diseases of 117 
 
 Throat, Foreign Bodies in 664 
 
 Thumb, Dislocations of 817 
 
 Thyme, Infusion 1094 
 
 Time of Confinement, To Calculate.. 935 
 
 Tincture, Colombo 1091 
 
 I'incture of .Vconite Root 1089 
 
 Tincture of Blofidroot I0()0 
 
 Tincture of Foxglove 109I 
 
 Tincture of Aconite Leaves 1089 
 
 Tincture of Assafcjctida 1089 
 
 'Toes, FJislocation of 837 
 
 Tohi, Balsam of I0()0 
 
 Tongie-tic 657 
 
 Tongue, Cancer of 658 
 
 'Tonic io,S8 
 
 'Tonsils, Enlargement of 658 
 
 'Toothache Ss.? 
 
 'Treatment of Fractures of the Fore- 
 arm, near Elbow 7159 
 
 'Treatment <if Inll-immation of the Brain 744 
 
 'Tremens, Delirium 32S 
 
 Trichina .Spiralis 237 
 
 Tuberculosis Meningitis 292 
 
 Tumors of the Larynx 121 
 
 'Tumors of ' vj Mouth 657 
 
 Tumors of the Neck 665 
 
 Tumors of the Uterus 101 1 
 
 Tumors, Ovarian 1025 
 
 'Turpentine 1094 
 
 'Tyi)hoid F^ . ^ r 57 
 
 'Typhus Fever 63 
 
 u. 
 
 Ulcers of the Cornea 606 
 
 Ulcers of the Leg 650 
 
 Ulcers of the Stomach 189 
 
 Upjier I'-xtremities 1049 
 
 Upper Jaw, Fracture of 747 
 
 Urinary Organs, Bleeding from 67S 
 
 Urine, Sugar in (Diabetes) 2S0 
 
 Urticaria, Nettle-rash 419 
 
 Unwillingness of \it Women to Be- 
 come Mothers 9S2 
 
 Uterus, Cancer of 1018 
 
 Uterus, Polyps of 1017 
 
 Uterus, Tmiiors of loi I 
 
 Uvula, Enlargement of 660 
 
1 14: 
 
 I> 
 
 i, 
 
 m 
 
 t. 
 
 Page. 
 
 Vaccitiatio n 33 
 
 Valerian 10S2 
 
 Valerian, Tincture 1004 
 
 Variolcjicl 34 
 
 Veiatrim Viriclc, Tincture 1094 
 
 Vegetable Substances 1061 
 
 Veins 1056 
 
 Venereal or Private Diseases 471 
 
 Pagt-, 
 
 Vent jl't Chancrt,. ^0(1 
 
 Ventilai 1066 
 
 Vertebra:, Dislocation of •. • SiS 
 
 Vulva, Abscess in (193 
 
 Vulva, Diseases of 991 
 
 V'tlva, Eczema of 903 
 
 Vulva, !ixces>ive Sen-it iveiiess of 596 
 
 Vulva, Itching of 994 
 
 w. 
 
 Wasting Pali-y 345 
 
 Wax in the Ear 62.S 
 
 Weak Sight 56.-; 
 
 Weaning 972 
 
 Weeping Sinew 668 
 
 Wet-Nurse, Sclectioii of 903 
 
 Wheat 1063 
 
 When Puberty is Delayed 889 
 
 White Hellebore, Poisoning by S66 
 
 White Oak Bark, Decoction 1094 
 
 White Ilorchotnid 1079 
 
 Whites in tlirls 903 
 
 Whites, Leucorrhwa 903 
 
 Wild Cherry Bark, Infusion 1094 
 
 Wild Cherry Park, Syrup 1094 
 
 Womb, Chronic Enlargement of looi 
 
 Womb, Chronic Inflammation of 998 
 
 Womb, Diseases of 997 
 
 Womb, Displacements of 1006 
 
 \V()mb, Falling of (Prolapsus). .. . ;. 1007 
 
 \N onib, Inllammation of 997 
 
 Women and Children, Diseases of. .. 871 
 
 Women, Disease.-, of 979 
 
 Wood Sorrel 1077 
 
 Wool 1065 
 
 Worm, Guinea 2.|2 
 
 Worms, Intestinal 231 
 
 \V urm.-,. Tape 234 
 
 Worms, Thread 233 
 
 Wounds 670 
 
 Wounds, (Junshot 694 
 
 Wounds, Punctured 687 
 
 Wounds, Treatment of 682 
 
 Wonnds, Poisoned . 703 
 
 Writer's Cramp 35,3 
 
 Wris', Dislocation of 816 
 
 Wry Neck 667 
 
 y, z. 
 
 Yellow Dock, Decoction 1094 
 
 Yellow Fever 81 
 
 Yellow Jessamine, Tincture 1094 
 
 Yellow Root, Decoction 1004 
 
 Zii:c C'ompcunds, Poisoning by 863 
 
 36 
 
 1 
 
 7 3 9 4 
 
i 
 
 ^-n 
 
 Page. 
 
 ChancTtr. 150(1 
 
 lo66 
 
 n of «. . HiH 
 
 'm 
 
 99' 
 
 ■•; 993 
 
 ?itive)ic"is of 596 
 
 ■ 994 
 
 'rokpsus). ... ;. 1007 
 
 "' 997 
 
 , Diseases of. . . 87 1 
 
 979 
 
 •■ 1077 
 
 1065 
 
 2.|2 
 
 • 23' 
 
 234 
 
 • ^33 
 
 (•)o 
 
 604 
 
 6S7 
 
 I" 682 
 
 7<>3 
 
 .1S3 
 
 816 
 
 667 
 
 in , . 1094 
 
 ioning by 863