HOW TO KEEP WELL HOW TO KEEP WELL OR THE PRESERVATION OF HEALTH AND THE RECOGNITION OF DISEASE / ANDREW F. CURRIER, A.B., M.D. Associate Editor of Foster's Encyclopaedic Medical Dictionary; Contributor to Reference Handbook of the Medical Sciences and Encyclopaedia Americana NEW YORK THE CENTURY CO. 1924 Copyright, 1924, by The Century Co. PRINTED IN U. S. A. To My Wife MARY LANSING CURRIER MY COLLEAGUE AND INSPIRATION IN PREPARING THIS BOOK FOREWORD With the radical changes which have taken place in the last fifty years in the principles and practice of medical science, placing them upon a rational, intelligent, and firm basis, has come also a correspond- ing change in the requirements for a book of the character of this volume; that is, a book to be placed in the household and consulted as occasion may require for information upon subjects which are of vital importance to all of us, the reciprocal relations of health and disease. It sufficed, or seemed to suffice, in former times, in making a book of this character, to provide what was practically a mere receipt book, often of doubtful value and authority, and yet such books were fre- quently treasured possessions and were perhaps held in greater esteem than they really deserved. The object of books of this kind at the present day is not merely to tell people what to do in times of emergency, and particularly in those localities in which it may not be easy to get a competent doctor with promptness, when promptness is very essential, but to educate and inform them in regard to many of the variations from a state of health, first informing them what a state of health really means. In other words such a book is, or should be, a teacher and a preacher of preventive medicine. Everybody knows that a great many of the diseases which people suffer from are preventable and therefore un- necessary. They cause pain and suffering and sorrow and expense, which are avoidable. Of course this is not true of all of them; it especially is not true of many of the surgical diseases and disorders, but it is true of many diseases both medical and surgical. If everybody were properly vaccinated there would be no small- pox ; hence vaccination is an example of preventive medicine. The same reasoning applies to typhoid fever, diphtheria, hydrophobia, ery- sipelas, and various other diseases which are preventable when such measures are taken as have been thoroughly tested and found efficient. VII VIII FOREWORD It pays to know something about these things; and therefore while books like this do not and should not aim to make doctors out of ordinary folks, nor to supersede the well-equipped and well-educated doctor, they ought to inform them as to the outstanding likenesses of disease and permit them, if they have ordinary intelligence and com- mon sense, to take such precautions as will enable them to keep them at a safe distance. The author of this book was a practitioner of medicine and surgery for many years. For more than nine years he was the health editor of the New York "Globe" with a very large circle of appreciative read- ers, for whose expressed appreciation he here and now offers thanks and gratitude. When the "Globe" was swallowed up by the "Evening Sun," the health department was continued for the ensuing ten months and then abandoned. This book is based upon the product of these years and many have expressed to the author the wish that it might be pre- served in permanent form. It therefore seemed a happy coincidence that The Century Co. should generously offer to undertake the publi- cation of such a work. Additions to some of the chapters have been made by Drs. F. M. Crandall (deceased), M. H. Foster, L. W. Hubbard, and S. T. Arm- strong, for which the author is grateful. The anatomical drawings are from the volumes of the great French anatomist Sappey and are as accurate and beautiful as any that have ever been published. The author hopes that the volume may find a welcome in many households, and that it will serve as a guide, counselor, and friend to those who may consult it. A. F. C. CONTENTS PART I-THE BODY IN HEALTH CHAPTER PAGE I The Structure of the Body ... ... 3 II The Function or Work of the Body .... 56 III Sanitation and Hygiene in Their Relations to Health . 92 PART II-THE BODY IN DISEASE IV Disease . 159 V Inherited Disease 165 VI Infection and Infectious Disease 171 VII Nutritional Disorders 181 VIII Diseases of Infancy and Childhood 190 IX Diseases of the Skin 233 X Parasitic Diseases 275 XI Diseases of Joints and Tendons 282 XII Diseases of the Feet 299 XIII Muscle Troubles 308 XIV Diseases of the Bones 315 XV Diseases of the Blood-Vessels 320 XVI Diseases of the Blood 339 XVII Diseases of the Nervous System 348 XVIII Abnormal Mental Conditions 375 XIX Concerning Sleep 395 IX CONTENTS X CHAPTER PAGE XX Diseases of Glands 400 XXI Diseases of the Eyes .......... 423 XXII Diseases of the Ears 445 XXIII Diseases of the Nose 452 XXIV Diseases of the Mouth 460 XXV Diseases of the Tongue 467 XXVI Diseases of the Throat 470 XXVII Diseases of the Stomach 474 XXVIII Diseases of the Intestines 491 XXIX Diseases of the Lungs and Air Apparatus . . 510 XXX Diseases of the Heart 526 XXXI Diseases of the Kidneys 535 XXXII Diseases of the Bladder 547 XXXIII Diseases of the Liver and Gall-Bladder . . . 551 XXXIV Diseases of the Pancreas 558 XXXV Fevers 563 XXXVI Conditions Peculiar to Women 572 XXXVII Diseases of Surgical Character 591 XXXVIII Some Special Methods of Treatment .... 618 XXXIX Poisons, Poisoning and Antidotes 627 XL Various Medical Substances and Their Proper Use 637 XLI Tumors 656 XLII Cancer 662 XLIII Miscellaneous Subjects 676 Index 681 LIST OF ILLUSTRATIONS PAGE Lateral Aspect of the Skull 5 Lateral View of the Spinal Column. Antero-Lateral View of the Spinal Column. Posterior View of the Spinal Column . . 7 Anterior View of the Chest Cavity. Posterior View of Chest Cavity 8 Male Pelvis 11 Teeth of the First and Second Dentition . 14 Ligaments on the Top and Side of the Foot 15 Anterior Ligaments of the Wrist Joint 17 Muscles of the Skull and Face 19 Superficial Layer of Muscles on the Posterior Wall of the Body . 22 External Aspect of Leg Muscles. Internal Aspect of Leg Muscles 25 Vertical Section of the Skin, Magnified 27 Main Carotid Artery and External Carotid Artery . Facing page 28 Internal Jugular Vein and Its Branches . . . Facing page 29 Lymphatics of the Head and Neck. Great Lymphatic Vein . . 31 Glands of Arm-Pit and Lymphatic Vessels Proceeding From Them 32 Distribution of the Facial and Trigeminal Nerves ..... 33 Upper Aspect of the Hemispheres of the Brain 34 Lower Surface of the Brain 35 Distribution of the Pneumo-Gastric and Other Nerves .... 37 Cervical and Thoracic Portions of the Great Sympathetic Nerve 38 Parts of the Great Sympathetic Nerve 40 XI XII LIST OF ILLUSTRATIONS PAGE Insertion of the Four Muscles which Move the Eye, also the Iris and Pupil. Insertion of the Globe of the Eye, with the Lachrymal Gland 41 Vertical and Anterior-Posterior Sections of the Eye 42 General View of the Sense of Hearing 43 Median Section of the Mouth and Pharynx 44 Relations of the Stomach with the Liver, Spleen, Mesentery and Other Abdominal Viscera 46 The Pancreas and Its Relations 48 Primary Iliac Arteries Branching Off From the Aorta, also the Kidneys 49 Trachea, Bronchi, and Bronchial Divisions 51 Relations of the Trachea and the Bronchi, also Showing the Heart 52 Anterior Aspect of the Heart 53 PART I THE BODY IN HEALTH 1 HOW TO KEEP WELL CHAPTER I THE STRUCTURE OF THE BODY The structure of the body may be not inappropriately compared with one of the great buildings which are now so common in all our large cities, with its steel frame, which gives stability to the entire building, the coverings or layers outside and inside the frame, the pipes and wires which carry water, heat, gas, and electricity to all its parts, the furnaces, dynamos, and reservoirs which are the sources from which these supplies proceed. Similarly, in the body, we have the bones as the framework or foundation, the muscles, and their sheaths, fat, and skin which are its outer layers or coatings, the mucous and serous membranes which are its inner coatings or the linings of its cavities, and vessels and nerves which carry blood, lymph, and nervous energy to every portion, while the internal organs are the furnaces, dynamos, and reservoirs by means of which it is enabled to do its work. The facts or matters which relate to the structure or substance of the body form the science which is known as anatomy. Those which relate to the work which the different parts of the body perform constitute the science of physiology. The Skeleton.-In dealing with the structure of the body, the first subject to be considered is the bony framework or skeleton. This framework not only gives stiffness and solidity to the body but also serves a number of other useful purposes. Bone is the hardest substance in the body. Notwithstanding this fact it is quite porous. The outer portion of bone is much harder than the inner, the pores in the latter being far larger than in the former. Some of the bones are nearly solid; others have a canal running through them which contains a substance called marrow. The bones, like the other parts of the body, are living tissues 3 4 HOW TO KEEP WELL and are supplied with vessels and nerves, which pass into them and through them and give them their nutriment and life. If a bone were unprovided with these structures it would be like a stone or a dead tree and of no use to the living body. Bones are long, short, flat, and irregular. Long bones are in the limbs, hold up the body, and enable it to move and do its work. They have a canal which contains marrow and are expanded at the ends, where the joints are formed. Short bones have no canal, and are hard outside and rather spongy inside. They are found in the wrist and foot and give strength to those parts. Flat bones also have no canal but have an outer and an inner plate of firm, tough material and a middle one which is more spongy. Such are the bones of the head, the shoul- der-blades, the haunch, the breast, the ribs, and the knee-caps. The irregular bones are formed like the flat ones and include the spinal column, certain bones within the head, the jaws, and a bone in the neck called the hyoid. If you examine a bone, you will find that it is never perfectly smooth, but has irregularities and depressions. These are for the attachment of muscles or for better union with other bones. It has also holes for the passage of vessels and nerves, grooves along which tendons may glide; in fact, it is an object which will bear much study to determine the various purposes for which it is intended. Omitting the teeth, the small bones of the ear, and a few small bones called the sesamoid bones, there are in the body two hundred bones divided as follows: Spinal column 26 Skull 8 Face 14 Breast, ribs and hyoid bone 26 Upper limbs 64 Lower limbs 62 The Periosteum.-By this term is meant the fibrous covering or sheath by which bones are surrounded except at the ends, where they are or may be covered with cartilage. It is thicker and more noticeable in young persons than in old, and with good reason, for it contains the elements from which bone is formed, and the bones THE STRUCTURE OF THE BODY 5 are not completely formed until adult life has been reached. Its importance is so great that if a portion of the bone is deprived of it that portion is likely to die. Surgeons in operating upon bones are always careful, if they understand their business, to preserve this membrane to the great- est possible degree. In many cases of disease in which bones have been removed, restoration has taken place if the surgeon has been wise and skilful enough to scrape away and save the periosteum, replacing it after the removal of the diseased bone. The Head.-If all the soft parts of the head, inside and outside, were removed, it would be found that it was not one piece but LATERAL ASPECT OF THE SKULL. I. Frontal bone. 2. Parietal. 3. Occipital. 4. Temporal. 5. Wing of the sphenoid. 6. Lambdoidal suture. 7. Fronto-parietal suture. 8. Suture. 9. Junc- tion of parietal and temporal. 10. Spheno-parietal suture. n. Spheno-temporal suture. 12. Spheno-frontal suture. 13. Limit of temporal fossa. 14. Malar bone. 15. Union of malar with frontal bone. 16. Union of malar with zygomatic process. 17. Union of malar and superior maxillary. 18. Superior maxillary. 19. Sub- orbital space. 20-22. Nasal bones. 23. Lachrymal duct. 24. Nasal boss. 25. Inferior maxillary. 26. Depression on chin. 27. Angle of jaw. 28. Coronoid process. 29. Condyle of lower jaw. 30. Neck of condyle. 31. External auditory canal. 32-33. Styloid and mastoid processes. 34. Union of occipital and temporal. twenty-two, all united closely together so that they could not easily be pulled apart. Eight of these pieces are in the skull and fourteen in the face. 6 HOW TO KEEP WELL These all fit together, like the pieces in a child's puzzle, which only shows the complete picture when each part has been joined to that which perfectly fits into it. It is hardly necessary to confuse the reader with the names of these bones. The bones of the skull are very strong, very firmly united, and are designed to protect very carefully that most im- portant organ, the brain. The bones of. the face are less strong (except of the jaws and the cheek-bones) and less firmly united than those of the skull but receive protection from the strong structure of the skull. The Spinal Column.-While the bones of the head are so joined together as to produce the most complete immobility, those of the spinal column are so united as to produce the most perfect mobility. When you see a person with a rigid back, as if it were supported by a steel ramrod, you may be sure he is either affecting an un- natural position, is a soldier, or has some disease of his spinal column. So well are the joints of the spinal column arranged that the most perfect motion is possible to the body in all directions. This is the more wonderful since a canal runs through it and another on either side, through which pass the spinal cord and the spinal nerves, serious injury to which means utter helplessness of all the body which is below the injured part. The accuracy with which these bones are fitted the one to the other, and the tremendous strength and firmness given them by the tendons and ligaments which are attached to them, are a most convincing argument against the fallacy that they are dislocated or subluxated with great frequency. The bones of the spinal column are called vertebrae and are thirty-three in number.1 In the haunch or pelvis, five are fused into one, called the sacrum; and at the very end of the spine four are fused into one called the coccyx. The bones in each of these groups have a general resemblance to each other and a distinct difference from those of the other groups. In the cervical group, however, the uppermost, called the atlas, and the next below it, called the axis, differ materially from the remaining bones of the group. We need not go into the details of these peculiarities. 'For purposes of convenience, principally, they are named cervical (seven) in the region of the neck; dorsal (twelve) in the region of the back; lumbar (five) in the region of the loins. THE STRUCTURE OF THE BODY 7 LATERAL VIEW OF THE SPINAL COLUMN. 1-2. Cervical vertebrae. 8-19. Dorsal vertebrae. 20-24. Lumbar vertebrae. A. Spinal projections. B. Facets on dorsal vertebrae. C. Facet on sacrum. D. Opening between the vertebrae. ANTERO-LATERAL VIEW OF THE SPINAL COLUMN. 1-8. Transverse processes of vertebrae. 9-12. Articular processes of vertebrae. 13-19. Bodies of vertebrae. 20. Anterior aspect of the hollow of the sacrum. 21. Coccyx. i~3. Transverse processes of vertebrae. 4-6. Laminae of the vertebrae. 7-10. Spinous processes of vertebrae. 11. Lateral process of the atlas. 12. Odon- toid process of the axis. 13-14. Posterior aspect of sacrum and coccyx. POSTERIOR VIEW OF THE SPINAL COLUMN. 8 HOW TO KEEP WELL The spinal column is not straight, but has a number of graceful curves which give it a wavy outline. Hogarth called it the "line of beauty." It is situated at the middle line at the back portion of the body, its average length in the adult being two feet and two or three inches. The arrangement is such that strength and flexibility are at- tained to the greatest possible degree, and the various irregulari- ties and prominences make admirable attachments for muscles, and channels for the passage of vessels and nerves. The Thorax or Chest.-The appearance of this portion of the skeleton is very suggestive of a cage. It is formed by a part of the spinal column behind, to which are attached the twelve pairs of ANTERIOR VIEW OF THE CHEST CAVITY 1-3. Breast bone. 4. Top of chest cavity. 5. Base of chest cavity. 6-8. Seven upper ribs. 9. Three lower ribs. 10. Two floating ribs. n. Costal car- tilages. POSTERIOR VIEW OF CHEST CAVITY. 1-3. Projections of vertebrae. 4. Points of attachment of spinal muscles. 5. Angle of the ribs. ribs, and ribs passing around and to the front where ten pairs of them are secured to the breast-bone (sternum). The other two pairs have no attachment in front and hence are called floating ribs. At the end of each rib in front is attached a THE STRUCTURE OF THE BODY 9 piece of very strong gristly material called cartilage. Each rib in the seven upper pairs is attached by this cartilage directly to the breast-bone, but the cartilage on each rib in the next three pairs is attached to the cartilage of the next rib above it. The cartilage at the end of the two lower pairs floats freely, as has been stated, without attachment to the ribs above them. The seven upper pairs are called true ribs, the five lower ones false ribs. The breast-bone unites the ribs (except the two lower pairs) completely together and completes the formation of the chest cage. It has the shape of a short Roman sword and is in three pieces, the upper representing the handle, the middle the blade, and the lower the point. These three pieces allow a limited amount of motion to the breast-bone. The ribs are very irregular in shape, being flattened at the back of the body curved at the side, and flattened again in front. They have smooth surfaces or facets where they are joined with the vertebrae of the spinal column, and roughnesses or prominences for the attachment of muscles. The cartilages add greatly to the elasticity and mobility of the chest, which rises and falls with each inhalation and exhalation of air, each expansion and contraction of the lungs, in the operation of breathing which goes on practically continuously as long as life continues. The great importance of a well-adjusted framework of this kind is evident, for it contains the lungs and heart, structures which are essential to life. A word may be said at this time concerning the hyoid bone, which was mentioned in this group, in the table giving the general division of the bones. (See page 4.) It is situated in the upper part of the neck and resembles a horseshoe in shape. It is of con- siderable importance because it forms the base of attachment for the different groups of muscles which form and proceed from the tongue. The Upper Limbs or Extremities.-Each of the two upper limbs consists of the hand, wrist, forearm, and arm. Each is attached to the body, and its power of motion, as a whole, is completed by means of the shoulder-blade behind and the collar-bone in front. The collar-bone or key-bone forms the front part of the shoul- der. It is curved like the letter S and is attached at its inner end to the top of the breast-bone, just above the first rib. At its outer end, it is attached to a projecting portion of the shoulder-blade. 10 HOW TO KEEP WELL It gives stiffness to the upper portion of the body and also enables the arm to have greater range of motion at the shoulder. Its exposed position renders it very liable to accident, and it is often broken. The shoulder-blade (scapula) forms the back of the shoulder and is attached to the upper and outer part of the back of the chest. It is flat, triangular in shape, the apex pointing downward; it is smooth on its inner face but has a projecting ridge which crosses its outer face transversely, one third of the way down, extending outward beyond the body of the bone and forming a part of the socket for the arm-bone. Another portion of this socket is formed by a projection from the upper part of the body of the bone. Many of the strong muscles of the body are attached to the shoulder-blade, which is perhaps the most important part of the shoulder-joint. The upper arm-bone is long and very strong. At its upper end it is rounded and smooth and fits into its socket at the shoulder-joint. The shaft of the bone is irregular, for the better attachment of strong muscles. The lower end is irregular with an outer and inner projection for muscle attachment, and between them are two well-marked grooves, into which the ends of the two bones of the forearm are fitted, forming the joint. The forearm has two bones, an outer which is called the radius, and an inner, the ulna. The outer one (i.e., on the same side of the forearm as the thumb) has a smooth, round upper end, with a flat top, which fits and plays in the outer groove at the lower end of the arm-bone; the shaft is somewhat twisted, the lower end ex- panded, and terminates in a pointed projection at its lower end. The inner bone (i.e., on the same side as the little finger) is very irregular at its upper end and terminates in a curved projec- tion, which forms a kind of cap at the back part of the elbow-joint. The shaft is nearly straight, and the lower end is quite smooth except for a pointed projection at its inner end. Muscles are at- tached to both these bones, and it will be observed that they are so adjusted as to permit great variety of motion. The lower ends of the bones are attached to the bones of the wrist to form the wrist- joint. There are eight bones in the wrist arranged in rows of four each. These are set closely together and give firmness rather than motion to that part of the body. The lower row of these bones is THE STRUCTURE OF THE BODY 11 closely united to the five long and quite regular bones which form the palm of the hand. These in turn are connected with the bones of the fingers. Of these there are three to each finger except the thumb, which has only two. To the bones of the hand and wrist muscles are attached, and tendons or sinews pass along the front and back and permit the great variety of motion in all directions which makes the hand so useful and indispensable a member. The Lower Limbs or Extremities.-Each of the two lower limbs consists of the foot, ankle, leg, and thigh, practically the same elements that are in the upper limb. The similarity is further car- ried out in the method of attachment to the body, which in the lower limb is by means of the large and very irregular haunch-bone. The haunch-bone is difficult of description, even by an anato- mist and to those who have technical knowledge. How much more difficult, therefore, is it to reduce its description to the plain terms of the non-professional reader! The bone is extremely irregular in shape; it is a flat rather than a long bone and may be considered I. Upper part of pelvic cavity. 2. Sacrum. 3. Symphysis pubis. 4. Iliac crest. 5. Cotyloid cavity. 6. Portion of the ischium. 7. Opening below the pubis. 8. Spines of the ilium. 9. Triangular space within the pelvis, on either side. MALE PELVIS. a fusion of three bones which, in fact, are distinct in very early life and retain their nam-es after they have grown together. The two haunch-bones come together in the middle line of the body in front, while behind they are connected with the two lower- most segments or divisions of the spinal column. Suppose we call 12 HOW TO KEEP WELL the three portions of the bone "upper," "lower," and "inner." The upper portion is broad and flat, flares outward more prominently in women than in men, and has strong muscles attached both on its outer and inner surfaces and at its broad and thick border. The lower portion is thick and firm; a part goes downward, its lowest portion being that on which the body rests, while sitting; and another part leaves this lowest portion, passing upward and inward to join the inner portion of the bone. The latter passes upward until it comes in contact with the similar portion of the bone on the opposite side and forms with it the top of a well-marked arch. Having reached this highest point, the bone passes outward, a thick irregular mass, until it comes in contact with the upper and the lower portions already described. The three parts converge to form on their outer aspect a cavity or socket with a well-marked rim in which the thigh-bone is seated. Adjoining this socket, with the inner and lower portions of the bone as its boundaries, is a large oval opening. Notches and ir- regularities abound along the entire circumference of the bone for articulation with other bones, the attachment of muscles, and the passage of vessels and nerves. The union of the two haunch-bones with the lower portion of the spinal column forms the important structure called the pelvis or basin, important because of the great support it gives to the body and because within it are most important organs. In women it contains those organs without which the continuance of species would be impossible. The thigh is the longest and strongest bone in the body. It has a shaft and two extremities. The upper extremity is broader and thicker than the shaft, and it has a cylindrical projection or outgrowth on its inner side which ends in a smooth rounded sur- face forming the head of the bone. This fits very accurately into its socket in the haunch-bone, forming the hip-joint. The strong muscles of the thigh are at- tached to the roughened portion of the upper extremity of the bone and also along the shaft, which is smooth and nearly cylindrical. The lower extremity also is expanded, and it has an outer and an inner projection with a deep groove between them in which is placed the knee-cap. The knee-cap is a flat irregularly triangular bone which is fixed as stated above, in the deep groove upon the front aspect of the THE STRUCTURE OF THE BODY 13 thigh-bone. It is surrounded by the tendon which comes from the great and thick muscle of the thigh, the lower end of which is fastened to the upper part of the inner bone of the leg. The knee- cap is an important element in the knee-joint. There are two bones in the leg, the same as in the arm, the inner called the tibia, and the outer the fibula, the latter being a buttress or brace to the former. The tibia is a long and strong bone with a shaft and expanded ends. The upper is very broad and strong and fits very accurately upon the two projections of the thigh-bone. The shaft, like that of the thigh-bone, is quite smooth and sym- metrical. The lower end is broad, but not so broad as the upper, and joins one of the bones of the ankle. Many muscles are attached to it. The fibula is a long and slender bone only slightly expanded at either end. Both ends are in contact with the tibia, but the lower end has a long projection which forms the prominence at the outer portion of the ankle. It serves as an attachment for several muscles. The ankle contains seven bones irregularly joined together. One, quite a large one, is at the heel; four others are in a row be- yond this; while the other two are at the top and on the inner side of the heel. Beyond the ankle are five long and rather slender bones in the foot, and beyond these are the bones of the toes, three for each except the great toe, which, like the thumb, has only two. The bones of the body can best be studied, of course, by direct comparison of this brief description with the skeleton. The Teeth.-The teeth are often considered a part of the bony system, though their structure is different from that of bone. They are fixed in a bony socket attached to each jaw-bone called the alveolar process, which is covered with fibrous tissue and this again with mucous membrane, which is a part of the membrane lining the entire mouth cavity. There are twenty temporary teeth and thirty-two permanent ones, and of the latter there are in each jaw four front teeth or incisors and two canines for cutting and tearing food, four bicuspids for preliminary grinding, and six molars for final grinding and triturating. The temporary teeth are gradually crowded forward as the 14 HOW TO KEEP WELL permanent ones develop, the position of the latter being governed by the shape of the jaw-bones, by the conditions of nutrition, and by the care which has been given the temporary teeth. 1-2. Temporary incisors. 3. Temporary canines. 4-5. Temporary molars. 6-7. Permanent incisors. 8. Permanent canines. 9-11. Permanent molars. TEETH OF THE FIRST AND SECOND DENTITION. The permanent teeth usually begin to appear at the seventh year, the third molars or wisdom-teeth coming from the seven- teenth to the twenty-fifth. Of course there are exceptions to this rule. The Joints or Articulations of the Body.-In the building up of the body, it is evident that there must be some plan by which the bones are united, each to each, that they may work harmoniously and effectively. This plan consists in the presence of joints or ar- ticulations. They are not all of the sam^ variety, nor do they give the same degree of mobility. In some cases mobility is not neces- sary; in others only a moderate degree is requisite; but in others there must be the freest play of part upon part in all directions. THE STRUCTURE OF THE BODY 15 These varying conditions are met in different parts of the bony system and the result is a beautiful adaptation of means to ends. Of immobile joints, we have those which are made by bones with tooth-like or saw-like or beveled edges or margins, or the I. Anterior ligament of the ankle joint. 2-5. Lateral ligaments. 6-8. Lateral ligament in the middle of the ankle joint. 9. Ligament on the top of the foot bind- ing the bones of the foot and leg. xo. External ligament of the same joint. 11-12. Ligament binding three bones of the foot. 13. Ligament joining two other bones of the foot. 14-15. Ligament joining two bones of the foot to one long (metatarsal) bone. 16. Ligament between the fourth and fifth long bones. 17. Ligament between the fourth and third long bones. 18-19. Ligament joining a bone of the ankle with the third long bone. 20. Ligament joining the second and third long bones. 21. Ligament joining the second long bone with one of the ankle bones. 22-25. Ligaments of the bones of the toes. LIGAMENTS ON THE TOP AND SIDE OF THE FOOT. simple insertion of one bone into a fixed socket in another; for ex- ample, the bones of the skull called the parietal are joined by tooth- like edges, those called the frontal by saw-like edges, the frontal with the parietal by beveled edges, while the teeth are inserted into a fixed socket. Of joints in which there is a moderate play of bone upon bone, an example consists in the union of the haunch-bone with the sacrum, or lower segment of the spine. Here there is also a cartil- age upon each bony surface to make the motion more free and smooth. Of freely movable joints, in which the structure is more com- 16 HOW TO KEEP WELL plex, we have the gliding motion between the breast-bone and the collar-bone; the ball-and-socket joint moving in all directions, as at the hip and shoulder joints; the hinge-joint, moving backward and forward, as at the elbow, ankle, and knee; and the rotatory joint, or movement around a pivot, as in the rotatory movement of the bones of the forearm upon each other. There must also be ligaments or bonds of firm, tough tissue holding opposing bones in place, and this tissue is usually lined with a miembrane which yields a sticky fluid which keeps the ends of the bones well lubricated. In addition, there are sac-like structures yielding this same sticky fluid, which are placed in cavities over which tendons or sinews must glide, that their motion may always be with the least possible degree of friction. In general, therefore, it may be said that wherever bones are brought in close contact with each other there must be some provision whereby they will either be firmly united or will move more or less freely upon each other, and they must be so protected and secured that under ordinary conditions they will not be thrown out of place. The particular description of the ligaments and joints of the different bones is not essential in the brief outline which is here given. The Muscles and the Sheaths Which Surround Them.-Muscu- lar tissue is essential for good work on the part of the body. It matters not how well developed other parts may be, if the muscles are weak or poorly developed the amount of work of which the body is capable will be small. They are supplied to every portion of the body and may be regarded as a system of levers to raise certain weights; that is, they tend to produce motion. A muscle is composed of a great many minute elements called fibrils or fibers, arranged in parallel lines so that they may all act together. Their action consists in alternate shortening and length- ening, contraction and relaxation. The voluntary muscles are those which are under the control of the will; for example, the strong biceps muscle of the arm. The involuntary muscles are those which are not thus con- trolled ; for example, the layer of muscle which is supplied to the intestine. The fibrils of the voluntary muscles have markings or bars upon them (striae) ; the involuntary or smooth muscles have none. THE STRUCTURE OF THE BODY 17 This is the simplest way to distinguish the two great classes of muscles. As the fibers of a muscle are arranged to act in har- mony, so also groups of muscles act together, and one group of ANTERIOR LIGAMENTS OF THE WRIST JOINT. 1-3. Lower end of inter-osseous ligament. 4-10. Antero-external ligament of the radio-carpal joint, n. Internal lateral ligament of the radio-carpal joint. 12. External lateral ligament of the radio-carpal joint. 13. Pisiform bone. 14. End of a wrist bone. 15. Ligament uniting 13 and 14. 16. Ligament joining the pisi- form and the fifth metacarpal bones. 17. Ligament joining two wrist bones. 18. Projection on the scaphoid bone. 19. Ligament joining two wrist bones. 20. Trapezium. 21. Ligament joining the scaphoid and trapezium. 22. Ligament between two wrist bones. 23-29. Ligaments joining wrist bones. muscles may act in a manner precisely opposite to another group which acts with it. Thus, in walking, the muscles on the front of the leg and thigh extend or stretch them out, while those on the back of the leg and thigh flex or draw them back. The action and reaction of the two groups make walking possible. The muscles are arranged upon 18 HOW TO KEEP WELL the skeleton in planes or layers, each muscle having its particular name and work. In dissecting the muscles, they are peeled away, one after another, like the layers of an onion; though they are not so readily removable as the latter, for they sometimes intersect and interlap with each other. In general, but not always, the end of the muscle from which it acts or pulls is called its origin, the other end its insertion. These ends are attached to bones most frequently, but also to cartilages, to other muscles, etc. The insertion of a muscle is often effected by means of a ten- don, which is a tough white fibrous structure, long or short as occasion requires. The tendons of the fingers and toes are very long and assist greatly in the complex motions of these parts. Closely associated with the muscles are the fasciae or bandages which hold the muscles together and add greatly to their power for action. The superficial fascia is a sort of general bandage for the body lying just under the skin, containing large meshes and holding, be- sides vessels and nerves, the particles and globules of fat which are found in varying quantity over the entire body and are very important in keeping an even temperature for the body. The deep fascia or bandage is the structure which is around the muscles (or around many of them,) sometimes being thin, some- times very thick and stout, glistening white in color, and adding greatly to the efficiency of action of the muscles; in fact, giving to each muscle its own individuality. Most of the muscles are arranged in pairs on opposite sides of the body, which sometimes act together and sometimes separately. The study of the muscles is facilitated by dividing the body into a number of regions or parts. Beginning from the top of the body and working downward, we have as the first region: The Skull and Face.-In this part are ten groups, each group having a particular work, divided as follows: i The skull. 2 The ear. 3 The eyelids. 4 The eye-socket. 5 The nose. 6-io Related to one or both jaws. In the first group is one thin muscle with its sheath or tendon. THE STRUCTURE OF THE BODY 19 Its action is to raise the eyebrows, wrinkle the forehead, and move the scalp backward and forward. MUSCLES OF THE SKULL AND FACE. 1-3. Posterior, superior and anterior auricular muscles. 4. Occipital muscle. 5-6. Fibrous membrane. 7-8. Superficial temporal muscle. 9. Frontal muscle. 10. Pyramidal muscle. 11. Boundary between 9 and 10. 12-14. Orbicular muscle of the eyelids. 15-16. Muscle raising the wing of the nose and the upper lip. 17- 18. Zygomatic muscle. 19. Canine muscle. 20. Unnamed muscle. 21. Trans- verse muscles of the nose. 22. Dilator of the nostril. 23. Buccinator muscle. 24. Orbicular muscle of the lips. 25. Triangular muscle of the lips. 26-27. Muscle of the chin. 28-30. Muscle of the jaw. 31. Risorius muscle of Santorini. 32. Mas- seter muscle. 33. Digastric muscle. 34. Sterno-mastoid muscle. 35. Trapezius muscle. The ear group has three smlall muscles, which may have slight power in producing motion of the ear. 20 HOW TO KEEP WELL The eyelid group has four muscles, which move the eyelids and, to a certain extent, the skin of the face. The muscles of the eye- socket are seven in number. Six are attached to the eye and move it in different directions, while the seventh moves the upper eyelid. In the region of the nose are seven muscles, which act not only upon the nose but upon the eyebrows and give expression to the countenance. Of the five groups of muscles connected with the jaws, the first has four which move the upper lip, the second has three which act upon the lower lip, the third has three which act upon the lips and cheeks, the fourth has two which are used principally in chewing, and the fifth has two which are also used in chewing. The Neck.-In this region are nine groups of muscles: (i) those which are just under the skin; (2) those which lower the larynx and the hyoid bone; (3) those which raise the larynx and hyoid bone; (4) the muscles of the tongue; (5) the muscles of the throat (pharynx) ; (6) the muscles of the soft palate; (7) the muscles con- nected with the front portion of the cervical vertebrae (i.e., the seven upper bones in the spinal column) ; (8) the muscles connected with the sides of the cervical vertebrae; (9) the muscles of the larynx. (1) There are two muscles in the first group, one of which is thin but quite broad, and when in action wrinkles the skin of the neck and helps to pull down the lower jaw, as well as the lower lip and the angle of the mouth. The other is much stronger and lowers the head upon the neck, the neck upon the chest. (2) The second group has four small muscles, which pull down the larynx and the hyoid bone in the act of swallowing. (3) The third group has four muscles, which raise the hyoid bone and the base of the tongue in swallowing, and also pull down the lower jaw in the act of swallowing. (4) This group has five muscles, which control the various movements of the tongue. (5) This group has five muscles, which act upon the food in the process of swallowing; it also modulates the voice, especially in the production of the higher tones. (6) This group has five muscles, which are also used in the act of swallowing. (7) This group has four muscles, which strengthen the back portion of the throat. THE STRUCTURE OF THE BODY 21 (8) This group has three muscles, which act to bring the head to its natural position after it has been drawn backward. (9) This group contains eight muscles, part of which open and close the cleft into which the air passes in the act of talking or breathing, while the other muscles of the group regulate the vocal chords or bands by which sounds or noises or speech are made possible. The Trunk or Body.-These muscles are divided into four groups, those of the (1) back, (2) abdomlen, (3) chest, and (4) the region between the external genitals and the outward end of the intestinal canal, called the perineum. (1) The muscles of the back are most of them quite large and strong and are arranged in five layers. The first has two, which are very large and strong, the second three, the third four, the fourth eleven, and the fifth twelve. They control the great variety of complicated movements in which the back plays a part, such as lifting weights, bending the body backward, carrying heavy burdens, etc. (2) The abdomen has six muscles, which compress the ab- dominal organs in expelling the contents of the bowels, the womb, the bladder, and the stomach (in vomiting). They also assist in breathing (expiration), climbing, etc. (3) The chest has four groups of muscles attached to the ribs and one muscle attached to the breast-bone. They are chiefly used in raising and lowering the chest in the operation of breathing. (4) The region which is called the perineum is very important in binding together the structures in the lowermost part of the body and also in controlling the motions of the genital organs and those of the lower bowel by which its contents are expelled in the act of defecation. There are fewer muscles in this region in the male than in the female, and in the latter they play a very import- ant part in the act of childbirth, assisting in expelling the child through the vagina. The Diaphragm.-This is a thick muscle in the interior of the body and serves as a partition between the cavity of the chest and that of the abdomen. It is an extremely important structure, the great vessels of the body passing through it, while it contracts and relaxes in connection with breathing, sneezing, vomiting, laughing, etc. It modifies the size of the cavity above and the one below it, and presses against or draws away from the organs which lie near 22 HOW TO KEEP WELL SUPERFICIAL LAYER OF MUSCLES ON THE POSTERIOR WALL OF THE BODY. i. Fibrous membrane on the back. 2-3. Dorsal muscle and its attachment. 4. Triangular space. 5. Angle of the great muscle of the back. 6. Muscle. 7- 11. Trapezius muscle and its attachment. 12-13. Insertion of 7 upon the skull. 14. Posterior auricular muscle. 15. Occipital muscle. 16. Sterno-cleido-mastoid muscle. 17. Splenius muscle. 18. Deltoid muscle. 19. Sub-spinal muscle. 20. Muscle. 21-22. Triceps muscle. 23. Abdominal muscle. 24. Muscle of but- tocks. THE STRUCTURE OF THE BODY 23 it in the two cavities. It moves with every breath which is drawn, and should it become paralyzed life could not continue. The Upper Limbs.-These muscles are subdivided into those of the (i) shoulder, (2) arm, (3) forearm, and (4) hand. (1) The shoulder has ten muscles, some of which are also spread over the chest and others over the back. Most of them are very strong, acting against the strong muscles of the back, and are used in lifting, bearing heavy burdens, and other severe efforts. (2) The arm has three muscles in front and two behind, the action of the former being opposed to that of the latter. The former draw the arm up, the latter lower it when raised, in all the forms of work in which these motions are used. (3) The forearm has five layers of muscles, two in front, one on the outer side, and two behind. The outer layer in front has five muscles, the inner layer three. The layer on the outer side of the forearm has three muscles. Behind, the outer layer has four muscles and the inner five. These muscles not only control all the various movements of the forearm but by means of their tendons, which extend over the hand and fingers, control also the varied and complex motions which belong to them. (4) The hand is one of the most important parts of the body and very complex in structure. In addition to its muscles, it has important tendons. In front, across the wrist, is a strong ligament which forms an arch, under which the tendons, from the muscles of the forearm which extend to and control the motion of the fingers, may work in their proper grooves. On the back side of the wrist is a similar band to guide the tendons from the forearm which control the movements upon the back of the hand. Over the palm of the hand and extending outward over more or less of the back is a thick and strong sheet of fibrous tissue which binds the muscles down and gives great strength to the hand. The muscles of the hand are in three groups, (1) those of the thumb, (2) those of the little finger, and (3) those of the middle of the palm. (1) the first group contains four muscles, and they con- trol the motions of the thumb. (2) The second contains four, and they control the action of the little finger. (3) The third contains three groups, which are upon and between the bones in the palm of the hand and have more or less control over the motions of the fingers. The Lower Limbs.-The muscles of the lower extremity are 24 HOW TO KEEP WELL many in number, and some of them, notably those about the hip and thigh, are large and very powerful. The arrangement is in layers the same as in the upper extremity, but the muscles are not the same in number, and they necessarily must have a different function and different requirements. Besides, there is a group of muscles in the interior of the body, in relations with the haunch- bones, which have no parallel group in the upper extremity. These last-mentioned muscles are found in what is termed the iliac region. The other groups are found upon the (i) thigh, (2) hip, (3) leg, and (4) foot. (1) There are three muscles in the first of these groups. They are spread over the entire inner surface of the great haunch-bones and extend upward along the sides of the vertebrae as far as the twelfth or lowermost dorsal vertebra. They are covered with a firm, fibrous sheath, and this sheath is covered by peritoneum, the membrane which forms the lining for the cavities of the pelvis and the abdomen, and the outer coating for the organs in those cavities. The action of these muscles is to help bend the thigh upon the pelvis, and also to turn the thigh outward. They also help to hold the body in the erect position. (2) The muscles of the thigh are divisible into two groups, one on its front or anterior aspect and the other on its inner aspect. The former contains seven and the latter five muscles. The former are much larger and more powerful than the latter, their purpose being to help support the body when in the standing position and again when the body is moved from the standing to the squatting posture. They are called extensor muscles, while the others are called adductors and draw the thigh inward, as when one thigh is placed over the other. Over the muscles which have been de- scribed, as well as over practically the entire area of the thigh, are two layers of thick fibrous tissue, an outer and an inner, which bind all the muscles firmly in place. (3) In the region of the hip are two groups of great muscles, one at the buttock and the other at the back of the thigh. The former has nine muscles, which move the thigh outward, their general action being that of abduction, or motion away from the body. The latter has three muscles, which have long and strong tendons at their lower ends, these ends being attached to the upper ends and at the back of the bones of the leg. They are commonly known as the hamstring muscles and bend the leg upon the thigh. THE STRUCTURE OF THE BODY 25 EXTERNAL ASPECT OF LEG MUSCLES. 1. Anterior muscle. 2. Tendon of muscle moving great toe. 3-4. Long extensor muscle of toes. 5-6. Anterior peroneal. 7-8. Long lateral peroneal. 9-10. Short lateral peroneal. 11. Internal twin muscle. 12. Soleus. 13. Achil- les tendon. 14. Short muscle of foot. 15. Muscle of little toe. 16. Extensor muscle. 17-18. Vastus externus. 19. Tendon of biceps. 20. External lateral liga- ment of knee. 21. Tendon of popliteus. INTERNAL ASPECT OF LEG MUSCLES. 1-3. Anterior muscles and tendons. 4. Tendons of extensor of toes. 5-6. In- ternal twin muscle. 7. Soleus. 8-9. Achilles tendon. 10-15. Tendons. 16. Ad- ductor of great toe. 17. Vastus internus. 18-20. Sartorius and tendons. 21- 22. Rectus internus. 23-26. Tendons. 26 HOW TO KEEP WELL They are also brought into play when the body is bent backward. (4) The muscles of the leg are divided into three groups, placed upon its front, back, and outer side. They are covered, like the muscles of the thigh, over almost their entire extent by a strong membrane or sheath, a second or deep sheath being between the upper and lower muscles at the back of the leg. In the front group there are four muscles, ending in long tendons which pass over the top of the foot and the toes. Two of them bend or flex the ankle upon the leg; the other two first extend or stretch out the toes and then also bend the ankle upon the leg. When one is in the standing position, these muscles fix the bones of the leg and give strength to the ankle-joint. In the group at the back of the leg are two layers, the upper one containing three muscles which form the calf. Two are very large and thick, and the third is very small. These muscles are used in standing, walking, leaping, and dancing. The lower layer contains four muscles, one at the back of the knee being thin, flat, and triangular, the others extending the en- tire length of the leg and terminating in tendons which pass over the bottom of the ankle and foot and end upon the lower surface of the bones of the toes. The triangular muscle helps to bend the leg upon the thigh and also to turn it inward. The others extend the ankle and foot upon the leg and also assist in holding the body in an upright position. In the outer group of leg muscles there are but two, placed one over the other. They extend to the ankle, and each ends in a long tendon, which is attached, in the case of the upper muscle, to the lower surface of the bone, which is next to the bones of the great toe, and in the other to a simdlar bone which is next to the bones of the little toe. These muscles help extend the foot upon the leg. They also steady the leg upon the foot, and the upper one bends the sole of the foot outward. Where the tendons of the leg muscles bend upon the ankle, they are held down se- curely, as in the case of the muscles of the arm at the wrist, by three strong ligaments or bands in front, outside and inside, which form canals through which the tendons can move with the least possible friction. (5) In the region of the foot, there are five layers of muscles, one on the top and four on the sole, while outside of those which are upon the sole is a very thick and strong sheath of fibrous tissue, the strongest and toughest in the body. There is also a much thinner membrane upon the top of the foot. THE STRUCTURE OF THE BODY 27 The Skin.-As the bones are covered by the muscles and their sheaths, so are the latter in their turn covered by the skin. The latter is separated from the muscles, however, by a layer of tissue, which is thin in some parts of the body and thick in others, and which contains more or less fat. Upon the abdomen the accumulation of fat is some- times very great and may even be several inches in thickness. The skin is not only a covering; it is the principal seat of the sense of touch and is also a channel through which substances may be taken into the body and given out from the body. It consists of two layers, the outer one being constantly worn away and thrown off, while the inner one contains the nerve-endings which make the skin the organ of touch, and also the struc- tures which supply the hairs, the sweat or perspiration, and the oily or greasy material of the surface of the body. The skin also con- tains arteries, veins, lymphatics, and nerves. The nails are merely a hardened portion of the skin. The Arteries.-The discovery of the circulation of the blood throughout the body is due to the immortal Harvey (a.d. 1619). Before his discovery, the way in which the blood moved through the body was not clearly understood. It may be described, in brief, as follows: The heart is the central station or pump. It forces the blood from one of its channels or cavities (the left ventricle) through the arteries. From these it is gathered up by a series of mi- nute vessels called capillaries. These pour it into veins, which grow larger and larger, and finally empty into one of the compartments of the heart (right auricle). From this it is poured into another From "Prompt Aid to the Injured," by Alvah H. Doty, M.D. CopyrightedLand published by D. Appleton & Co. Used by permission. VERTICAL SECTION OF THE SKIN, MAGNIFIED a, Scarf-skin; b, pigment-cells; c, papillae; d, true skin; e, f, fat-cells;, g, sweat glands; h, outlets of sweat-glands; L their openings on the surface of the skin; k, hair-follicle; Z, hairs projecting from the skin; m, hair-papilla; n, hair-bulb; o, root of hair; p, openings of oil-glands. 28 HOW TO KEEP WELL compartment just below it (right ventricle). From this compart- ment it is forced into the lungs, where it is changed from venous to arterial blood by the addition of oxygen, which is inhaled or taken in with air, in breathing in and by the removal of the carbonic acid, which is given out or exhaled in breathing out. From the lungs it goes back to another compartment of the heart (left auri- cle),from this to another compartment just below it (left ventricle), and from this it is pumped out to go over the same course again. The arteries are firm tubes distributed to almost every part of the body. The largest of them (the aorta) is an inch or more in diameter; the smallest may be no thicker than a pin. In many parts of the body an artery and a vein are side by side. The arteries do not lie loosely in the body but are fixed or embedded in fibrous tissue or in the substance of muscle, bone, skin, etc. In some portions of the body an artery, a vein, and a nerve are near each other and may be surrounded by a common sheath. The arterial system may be compared to a great river which sends out branches or tributaries in all directions, irrigating the land through which they flow and often combining and recom- bining with each other. The course of the arteries is sometimes straight and sometimes twisted or tortuous, so that they may be greatly lengthened if occasion requires. Beginning with the heart, this organ has two very important arteries called coronary arteries, which, with their branches, nour- ish the tissues of which it is composed. The principal artery of the body (the aorta) begins at the lower left chamber of the heart (left ventricle) ; it passes upward and then downward, forming an arch. From the top of this arch arise three large vessels. The one on the right side, after passing upward about an inch and a half, divides into two branches; and these, with the other two which start from the top of the arch, divide and subdivide as they proceed upward, and nourish the tissues of the head, face and neck, shoul- ders, upper extremities, and part of the chest. There are more than one hundred and fifty arteries in this division which have particular names, while there are many others which branch off from them which are not of sufficient importance to be named. The main artery after arching upward passes downward in a nearly straight line along the front of the spinal column (except at the upper part, where it lies to the left of the spinal column). I. Main carotid artery of the right side. 2. Internal carotid artery. 3. Exter- nal carotid artery. 4. Superior thyroid artery. 5. Lingual artery. 6. Facial artery. 7. Inferior labial artery. 8. Superior labial artery. 9. Artery of the septum of the nose. 10. Artery of the wing of the nose. 11. Branch of ophthalmic artery. 12. Sub-dental artery. 13. Inferior dental artery. 14-16. Occipital artery. 17. Posterior auricular artery. 18. Internal maxillary artery. 19. Super- ficial temporal artery. 20. Transverse artery of the face. 21-22. Branches of superficial temporal artery. 23. Supra-orbital artery. 24. Internal frontal artery. 25. Sub-clavian artery. 26. Internal mammary artery. 27. Supra-scapular artery. 28. Posterior scapular artery. 29. Vertebral artery. 30. Inferior thyroid artery. MAIN CAROTID ARTERY AND EXTERNAL CAROTID ARTERY. INTERNAL JUGULAR VEIN AND ITS BRANCHES. I. Sub-clavian artery. 2. Sub-clavian vein. 3. Main carotid artery. 4. In- ternal jugular vein. 5. Anterior jugular vein. 6. Omo-hyoid muscle. 7. Sterno- hyoid muscle. 8. Trunk of the pneumo-gastric nerve. 9-11. Hypoglossal nerve. 12-13. Internal descending branch of the cervical plexus. 14. External carotid artery. 15. Superior thyroid artery and vein. 16. Lingual and facial arteries. 17. Facial artery and vein. 18. Occipital artery. 19. Branches of the first four cervical nerves. 20. Superior lingual nerve. THE STRUCTURE OF THE BODY 29 giving out large branches as it goes, from front, back, and sides, and, when it reaches the top of the pelvis, subdivides into two main branches, each of these subdividing into two others, one of which (the inner), with its branches, supplies the structures of the pelvis, while the other (the outer), with its branches, supplies the lower extremities. Between the arch of the aorta and its point of division at the pelvis, more than fifty vessels are given off, part of them going to one side of the body and part to the other. Part of these supply the muscles and other tissues of the body, while the others supply the various organs of the interior. From the inner of the two branches into which each great branch of the aorta subdivides at the pelvis, about twenty vessels are given off on each side (of the body) to supply the organs of the pelvis and also some of its muscles and other tissues. From the outer branch are given off nearly one hundred vessels, which, as already stated, supply all the tissues of the lower ex- tremities. A most important vessel not mentioned in the foregoing is the pulmonary artery. This vessel conveys the blood from the right side of the heart to the lungs. After proceeding upward and backward for two inches, it divides into two branches, one of which goes to each lung. Of course, these statements can only be regarded as sketchy and defective, for it would be impossible to give accurate and de- tailed descriptions of the various parts of the body in so brief a compass. The blood, having been forced to the ends of the arteries, large and small, is taken up by the countless minute capillaries which are too small to be visible to the naked eye and begins its return journey to the heart. The Veins.-The veins differ in important particulars from the arteries. Their blood, being charged with certain impurities and waste material, which they have gathered from the body, and con- taining relatively little oxygen, is dark red, while that in the arteries is bright red, this color being due to the oxygen which they con- tain. They are not thick and firm tubes like the arteries but thin and rather flabby. Many of them have projections or valves in their interior which are probably designed to prevent the column of blood within them from backing up or going otherwise than onward. No pulsation or throb can be felt by pressing them, while it is 30 HOW TO KEEP WELL always felt by pressing upon arteries. If a vein is cut, the blood either stops flowing or flows in a steady stream. If an artery is cut there is a spurt or jet, and the flow is intermittent, corresponding with the contraction of the heart. The blood in the arteries flows away from the heart, while that in the veins flows toward it. The arrangement of the veins is far less regular than that of the arteries, though in many parts of the body an artery and a vein (sometimes two veins) run side by side. The veins in the lower portion of the body converge to one great vessel, which runs upward on the right side of the aorta, finally emptying into the upper right cavity of the heart, while from the upper part of the body they converge to one which is nearly or quite as large which passes down the right side of the spinal column and empties into the same chamber of the heart as the other. From the root of each lung proceed two veins which carry the entire volume of blood of the body, which has been aerated (charged with oxygen) while going'through the lungs. These four veins end in the upper left cavity (left auricle) of the heart. These veins carry arterial blood as the pulmonary artery carries venous blood, which of course is an exception to the general rule. Where a vein runs near or in company with an artery, its name corresponds with that of the artery, but many veins have an independent course and a name unrelated to the arteries. Portal Vein.-One of the most important veins is the portal vein. It carries the great volume of venous blood from the organs of digestion to the liver. After it has traversed this organ, it is carried by the veins of the liver to the great trunk vein which empties into the heart. The Lymphatics.-The lymphatics form a system of vessels, some very minute and some quite large, distributed to every por- tion of the body and carrying a watery fluid, part of which results from the digestion of the food and is absorbed from the intestine (chyle), and part from the wasting or wearing out of the different structures of the body, and is absorbed from them. These vessels gradually increase in size, converge to two great vessels on the right and left side of the upper part of the chest, and there empty into two of the great veins of the neck. The one on the left side is very much larger and longer than the one on the right and is known as the thoracic duct. Connected with these vessels at varying but irregular intervals THE STRUCTURE OF THE BODY 31 is a series of small solid bodies so constructed that the contents of the lymph vessels will normally pass through them. They are known as lymphatic glands and are very often the seat of disease. LYMPHATICS OF THE HEAD AND NECK. GREAT LYMPHATIC VEIN. I. Lymphatics converging at the parotid gland. 2-3. Inferior and superior frontal lymphatics. 4-5. Parietal lymphatics and their origin. 6-8. Anterior sub- occipital lymphatics. 9-10. Posterior, sub-occipital vessels and glands. 11. Hori- zontaltrunkvessel. 12. Vessels arising from the superior mastoid glands. 13. Par- otid glands. 14. Cervical glands and efferent vessels. 15. Lymphatics of the skin of the nose. 16. Lymphatics of the lips. 17. Sub-maxillary glands. 18. Lym- phatic vessels of the lower lip. 19. Sub-hyoid gland. 20. Great lymphatic vein. The Nervous System.-The nervous system is composed of a variety of elements, including the brain, spinal cord, numerous 32 HOW TO KEEP WELL nerve centers or ganglia (i.e., centers from which nervous influences proceed), nerves which go to almost every part of the body, like wires from an electric battery, and certain modifications of the nerve-endings which form the organs of certain of the senses. GLANDS OF THE ARM-PIT AND LYMPHATIC VESSELS PROCEEDING FROM THEM. I. Glands in the arm-pit. 2. Superficial lymphatic vessels. 3. Large lym- phatic trunk. 4. Gland connected with 3. 5. Lymphatic vessels from the front and upper part of the thorax. 6. Lymphatic vessels from the skin of the chest and abdo ren. 7. Lymphatic vessels from the back. The spinal cord is really the continuation of the brain, occupies the central cavity or canal in the spinal column, and gives out the spinal nerves, which are distributed to all parts of the body. It is about sixteen inches long and has a number of fissures or grooves THE STRUCTURE OF THE BODY 33 in it which divide it into a series of columns or segments each of which has important functions. The outer portion of the cord is composed of soft white ma- DISTRIBUTION OF THE FACIAL AND TRIGEMINAL NERVES. 1-17. Trunk of the facial nerve and its various branches. 18. Superficial temporal nerve. 19-20. External and internal frontal nerves. 21. End of the lachrymal nerve. 22. End of the external nasal nerve. 23. End of the malar branch. 24. Naso-lobal branch. 25. Branches of the superior maxillary nerve. 26. Branch of the inferior maxillary. 27. Branches of the inferior dental. 28. Pos- terior branch of the second cervical. 29-32. Auricular mastoid and transverse cervical branches of the cervical plexus. terial; while the inner portion of gray material is arranged in projections, two in front and two behind, called anterior and posterior horns. The cord is surrounded by three membranes; an outer one (dura mater) composed of firm fibrous tissue, a slender 34 HOW TO KEEP WELL middle one (arachnoid), and a slender inner one (pia mater), which is firmly attached to the cord. The brain is the substance which occupies the interior of the UPPER ASPECT OF THE HEMISPHERES OF THE BRAIN. 1. Fissure of Rolando. 2. Anterior parietal convolution. 3-4. Parietal con- volutions. 5. Deep fissure. 6. Internal frontal convolution. 7. Convolution. 8. Middle frontal convolution. 9. External frontal convolution. 10-12. Internal middle and external occipital convolutions. 13. Fissure between the hemispheres. 14-15. End of the corpus callosum. skull and is divided into four principal parts (cerebrum, cerebellum, pons Varolii, and medulla oblongata), all of which are connected with each other by bands composed of nerve-fibers. In general the more brain substance there is the more intelligent the individual who possesses it. Its average weight is 49% ounces. It is covered, like the cord, with three membranes, the membranes of the cord being really the continuations of those of the brain. It is composed like the cord of white and gray matter, but, unlike the cord, the gray matter is outside and the white inside. The cerebrum or hemispheres, or upper part of the brain, is believed to be the organ of thought, the seat of the mind. THE STRUCTURE OF THE BODY 35 The different parts of the brain are very irregular and complex in their formation. The cerebrum or hemispheres are especially irregular and have many folds or convolutions, and the larger and I. Anterior lobe of the brain. 2-3. Posterior lobe. 4-5. Median fissure. 6. Fissure of Sylvius. 7. Perforated quadrilateral. 8. Pituitary body. 9. Mamil- lary tubercles. 10. Space. 11. Cerebral peduncles. 12. Annular protuberance. 13. Medulla oblongata. 14. Anterior pyramids. 15. Olivary bodies. 16. Resti- formbody. 17. Cerebellum. 18. Fissure. 19-20. Convolutions. 21. Crossing of the optic nerves. 22. Olfactory nerve. 22. Section of olfactory nerve. 23. Gang- lion of olfactory nerve. 24. Crossing of optic nerves. 25. Motor nerve of the eye. 26. Pathetic nerve. 27. Trigeminal nerve. 28. External motor nerve of the eye. 29. Facial nerve. 30. Auditory nerve. 31. Glosso-pharyngeal nerve. 32. Pneu- mogastric nerve. 33. Spinal nerve. 34. Hypo-glossal nerve. LOWER SURFACE OF THE BRAIN. better developed these are the more powerful usually is the intellect. The structure of the brain and the various subdivisions and centers which are connected with it are too complicated to permit an attempt to describe them here. 36 HOW TO KEEP WELL Cranial Nerves.-There are nine pairs of nerves which proceed from the brain, forming most important structures and performing most important functions, for they have to do with the five senses with which every normal individual is endowed, and with other functions (especially breathing) which are essential to life. These nerves are nerves of the special senses, of ordinary sen- sation, of motion of the eye, face, and tongue, and mixed nerves so called, whose integrity is essential to life.2 The Spinal Nerves.-These nerves originate from the spinal cord, passing from it through openings on either side of the spinal column. There are thirty-one pairs in all, from the vertebrae at the top of the column to the coccyx at its very lower end.3 The point from which each nerve originates is called a root, and each nerve has two roots, an anterior or motor root and a posterior or sensory one. In other words, there are two sets of fibers for each nerve, one set which has to do with motion of the parts to which it is distributed and one which has to do with sensation or feeling in those parts. A nerve is composed in part of white fibers and in part of gray. The white fiber is surrounded by a membrane or sheath, within which is a white substance (white substance of Schwann), and within this a delicate though elastic material, the essential part of the nerve and called its axis cylinder. The gray fibers, which are found principally in the sympathetic nervous system (p. 39),are composed of fine,granular fibrils surrounded by a sheath. On each of the posterior roots of the spinal nerves is a small ganglion or swelling. After the spinal nerves have proceeded a short distance, they become grouped together at short intervals in "The nine pairs of nerves are named as follows: (i) olfactory (smell); (2) optic (sight) ; (3) motor oculi (motion of the eye) ; (4) pathetic (supplied to one of the muscles of the eye) ; (5) trifacial (supplied to the face by three great branches) ; (6) abducens (supplied to one of the eye muscles) ; (7) facial and auditory (nerve controlling expression of the countenance, and also the hearing) ; (8) glossopharyngeal, pneumogastric, and spinal accessory (a triple nerve supplied to the tongue, pharynx, lungs, heart, larynx, etc., whose serious injury means death) ; (9) hypoglossal (supplying motion to the tongue). These nerves pass out of the brain in the order in which they have been mentioned. Various ganglia are connected with them which are centers of either sensation or motion. Many anatomists consider the two portions of the seventh and the three portions of the eighth as separate nerves, in all twelve pairs instead of nine. 3 They are arranged in the following order: cervical, eight pairs; dorsal, twelve; lumbar, five; sacral, five; coccygeal, one. THE STRUCTURE OF THE BODY 37 DISTRIBUTION OF THE PNEUMO-GASTRIC AND OTHER NERVES, I. Trunk of the right pneumo-gastric. 2. Nerve plexus. 3. Junction with spinal nerve. 4. Junction with hypo-glossal nerve. 5. Branch going to the throat. 6. Superior laryngeal nerve. 7. External laryngeal nerve. 8. Laryngeal plexus. 9. Inferior laryngeal nerve. 10-11. Superior and middle cardiac branches. 12. Lower thoracic plexus. 13. Posterior pulmonary plexus. 14. Lingual nerve. 15. End of the hypo-glossal nerve. 16. Glosso-pharyngeal nerve. 17. Spinal nerve. 18-23. Second to eighth cervical nerves. 24. Ganglion of the great sympathetic. 25-26. Middle and lower cervical ganglia. 27-30. Second to fifth dorsal ganglia. 38 HOW TO KEEP WELL CERVICAL AND THORACIC PORTIONS OF THE GREAT SYMPATHETIC. I. Right pneumo-gastric. 2. Glosso - pharyngeal. 3. Spinal nerve. 4. Hypo - glossal. 5. Central part of great sympathetic. 6-7. Superior cervical ganglion. 8. Jacobson's nerve. 9. Geniculate ganglion of the facial. 10. External motor nerve of the eye. 11. Ophthalmic ganglion. 12. Spheno-palatine ganglion. 13. Optic ganglion. 14. Lingual nerve. 15. Sub- THE STRUCTURE OF THE BODY 39 maxillary ganglion. 16. Plexus of the external carotid artery. 17-20. Superior, external and inferior laryngeal nerves. 21. Arch formed by first two cervical nerves. 22-26. Anterior branch of the third to the eighth cervical nerves. 27-28. Middle cervical ganglion and its ascending branch. 29. Inferior cervical ganglion. 30-31. Branches to middle cervical ganglion. 32-34. Superior, middle and inferior cardiac nerves. 35-36. Cardiac plexus and its ganglion. 37. Nerve fibers of the right coronary artery. 38. Intercostal nerves. 39-41- Great splanchnic and its ganglion. 42. Little splanchnic. 43. Solar plexus. 44-45. End of the left and right pneumo- gastrics. 46. End of left phrenic. 47. Part of right branch of 46. 48. Arch of aorta. 49- Right auricle and vena cava superior. 50. Right ventricle. 51-52. Pulmonary artery and its right branch. 53- Right half of stomach. 54. Section of diaphragm. what are known as plexuses or networks. These plexuses may be a kind of reservoir for the accumulation of nervous energy. After leaving the plexuses, the nerves subdivide and are distributed over all the tissues of the body, giving them vitality. Destroy the nerves which go to a certain tissue and you destroy its power of sensation or motion or both. The Sympathetic Nerves.-The system consists in a series of ganglia (small roundish bodies) on either side of the vertebral column, from top to bottom, connected by cords or strings of nerve material. A few additional ganglia are found within the skull, connected with the fifth (trifacial) pair of cranial nerves. The two lines of ganglia converge at the sacrum and unite in a single ganglion when they have reached the end-piece (coccyx) of the spinal col- umn. In each series of ganglia there are twenty-nine (including those which are within the skull), and they are arranged and named similarly with the different classes of vertebrae (cervical, dorsal, lumbar, sacral, coccygeal). From these ganglia as centers, branches or nerve-cords run to (i) other ganglia in the two series mentioned, (2) the nerves connected with the brain or spinal cord, (3) arteries, the various organs in the interior of the body, and to other ganglia which are located in the chest, the abdomen, or the pelvis. The ganglia and the connecting cords are composed of white and gray matter like the other nerve-tissue. There seems to be no symmetry in the plan by which the sympathetic nerves are distributed. There is a marked tendency to the formation of plexuses or complicated collections of knots of nerves, and in some of the organs (the heart, uterus, etc.) there are many secondary ganglia. The work of the sympathetic nerves is very important. If they are injured or destroyed, it means serious injury or death to the tissues or organ to which they are supplied. They, therefore, are essential to nutrition, and they also have to do with the contractile power of organs. Organs of Sense.-These include the organs of touch, taste, smell, hearing, and sight. The skin is the principal seat of the 40 HOW TO KEEP WELL i. Diaphragm. 2. Lower end of gullet. 3. Section of stomach showing solar plexus. 4. Upper end of large intestine. 5. Sigmoid flexure of the colon. 6. Rec- tum. 7. Bladder. 9-10. Ends of the left and right pneumo-gastric nerves. 11. Solar plexus. 12-13. Lower ends of the great and small splanchnic nerves. 14- 15. Ganglia of the great sympathetic. 16-17. Branches of the great sympathetic. 18-24. Plexuses of the great sympathetic. 25. Hypogastric plexus. 26. Branches between the great sympathetic and the hypogastric plexus. 27. Branches from the third and fourth nerves to the hypogastric plexus. 28-30. Tenth, eleventh and twelfth dorsal nerves. 31-33. First, second and third lumbar nerves. 34. Branch of the genito-crural nerve. 35. Fourth lumbar nerve. 36. Lumbo-sacral trunk. 37. Sacral plexus. 38-39. Fourth and sixth sacral nerves. PARTS OF THE GREAT SYMPATHETIC NERVE. THE STRUCTURE OF THE BODY 41 sense of touch. The tongue is the organ of the sense of taste. It is entirely covered with mucous membrane, the entire mouth being lined with the same tissue. It is also covered with little elevations (papillae), those at the back of the tongue, ten or twelve in number, being much larger than the others. In these papillae are the ends of nerves which give to the tongue its capacity for the sense of taste. The tongue is also supplied with a nerve (hypoglossal) which gives it the power of motion in all directions. The nose is the organ of the special sense of smell. Its structure is such that it is also a means of protection to the lungs in breath- ing, preventing the introduction of matter which would be injurious to them. It has bones and cartilage and is lined with a very sensi- tive mucous membrane. It is supplied by the olfactory nerve, by means of which it has the power of smelling, as well as by others which give vitality to its tissues. The eye is the special organ of sight and derives its power of vision chiefly from the optic nerve, which is one of the cranial nerves heretofore mentioned. INSERTION OF THE FOUR MUSCLES WHICH MOVE THE EYE, ALSO THE IRIS AND PUPIL. INSERTION OF THE GLOBE OF THE EYE, WITH THE LACHRYMAL GLAND. i. Muscle which raises the upper eyelid. 2. Muscle which raises the pupil. 3. Muscle which abducts the pupil. 4. Muscle which lowers the pupil. 5. Small oblique muscle. 6-7. Lachrymal gland. 8-9. Ducts of the lachrymal gland. 42 HOW TO KEEP WELL The eye or eyeball or globe of the eye is fitted into its socket, called the orbit, in the skull, and is moved in various directions by appropriate muscles. It is composed of three coats or layers con- VERTICAL AND ANTERIOR-POSTERIOR SECTIONS OF THE EYE. 1. Optic nerve. 2-3. Middle and posterior portions of the sclerotic coat. 4-5. External and internal layers of the optic nerve. 6-7. Portions of the sclerotic coat. 8. Superior and inferior rectus muscles. 9-10. Cornea. 11. Membrane of the aqueous humor. 12-13. Junction of the sclerotic and the cornea. 14. Canal of Schlemm. 15. Choroid coat. 16-17. Ciliary muscle. 18. Ciliary body. 19- 21. Retina. 22-23. Central artery of the retina. 24. Hyaloid membrane. 25. Zone of Zinn. 26. Posterior part of hyaloid membrane. 27. Anterior wall of the zone of Zinn. 28. Crystalline lens. 29. Iris. 30. Pupil. 31. Posterior chamber. 32. Anterior chamber. sidered from without inward: (i) sclera and cornea; (2) choroid, iris, and ciliary processes; (3) retina. It has also three different fluids or substances for the refraction of the rays of light: (1) aqueous humor; (2) crystalline lens and capsule; (3) vitreous humor. The structure of the eye is extremely complicated, and it would hardly be profitable to describe it in detail. It may be said, however, that it is a very delicate optical instrument, into which rays of light pass which are modified by the different substances through which they pass, finally reaching the so-called light spot in the retina, and thence transmitted through the optic nerve to the brain, which thus receives the impression of a visible object. The eye is protected by the eyelids, eyelashes, and eyebrows; it is also supplied with the tear-ducts and glands, which supply the tears or lubricating-fluid for the delicate membrane (conjunctiva) which covers its front portion. THE STRUCTURE OF THE BODY 43 The ear is the organ of hearing and contains an external por- tion and an internal portion. Sounds are collected by the external ear, passed through its canal into the chamber which forms the middle ear, where are the drum membrane and the chain of small GENERAL VIEW OF THE SENSE OF HEARING. I. External ear. 2. Glands. 3. External auditory canal. 4. Junction of the external ear and external auditory canal. 5. Wax glands. 6. Drum membrane. 7-10. Bones of the middle ear. 11. Cavity of the drum. 12. Eustachian tube. 13-15. Semi-circular canals. 16. Labyrinth. 17. Internal auditory canal. 18. Facial nerve. 19. Great superficial petrous nerve. 20-21. Branches of the auditory nerve. bones of the ear, and thence to the internal ear, where is the com- plicated structure or labyrinth which contains the different branches of the auditory nerve. From this nerve the impression of sound is communicated to the brain. Organs of Digestion.-The alimentary canal, which is the organ for the reception and digestion of food, begins at the mouth and terminates at the end of the bowel. If it were drawn out in a straight line, it would measure thirty feet. It is lined inside with mucous membrane throughout its entire extent and has numerous glands which supply necessary substances for accomplishing digestion. 44 HOW TO KEEP WELL The mouth, containing the tongue, teeth, and salivary glands, receives the food and chews or grinds it, the saliva moistening it and furnishing the first material for digestion. It is then received MEDIAN SECTION OF THE MOUTH AND THE PHARYNX. i. Left nostril. 2-3. Lateral cartilage of the nose. 4. Cartilage of the wing of the nose. 5-7. Superior middle and inferior meatus. 8. Sphenoidal sinus. 9. Posterior cavity of nasal fossae. 10. Orifice of Eustachian tube. 11. Depression of the posterior cavity of the nasal fossae. 12. Uvula. 13. Vestibule of the mouth. 14. Palatal arch. 15. Opening of the mouth. 16-20. Tongue and its muscles. 21-22. Pillars of the throat. 23. Tonsil. 24-25. Tongue. 26-27. Cavity of the pharynx. 28-29. Larynx. 30. Epiglottis. 31. Hyoid bone. 32-33. Thyroid car- tilage. 34. Thyroid membrane. 35-36. Cricoid cartilage. 37. Crico-thyroid membrane. by the throat and gullet (pharynx and oesophagus), and, by the contractions which are caused by the muscles which act upon them, it is carried to the stomach. There it is churned about, and a por- tion of it (albuminoids) is digested. It is then forced into the THE STRUCTURE OF THE BODY 45 first part of the small intestine (duodenum), where other portions are digested by the secretions of the pancreas and liver, which are there poured upon them'. It is then carried along the other portions of the small intestine (jejunum and ileum), where other changes take place, and some of it is absorbed in its completely digested condition by the lym- phatics and then carried into the blood to be distributed over the body for nourishment to the cells of which the body is composed. That which is not absorbed is carried into the large intestine and thence is discharged from the anus or end of the bowel as waste or fecal matter. The importance of the teeth, thirty-two in number, cannot be overestimated. They are fixed in the jaws, which are operated by strong muscles. The salivary glands are five in number and are under the tongue, under either lower jaw, and under each ear; they pour the saliva into the mouth. The pharynx, or throat, for swallowing the food is controlled by appropriate sets of muscles. The gullet (oesophagus) is the tube, nine inches long, which extends from the throat to the stomach. The abdominal cavity, the largest in the body, contains the organs of digestion. It is lined and all the organs which are in it are covered with a strong membrane called the peritoneum, which is also called a serous membrane because it produces in abundance a watery fluid called serum. The Stomach.-The organs within the abdominal cavity are as hereafter mentioned and described. The stomach is a great pouch or sac, somewhat conical in shape, in the upper portion of the ab- dominal cavity, just under the diaphragm, which separates the ab- dominal from the thoracic cavity. It is covered with peritoneum, lined with mucous membrane, and has a layer of muscle, between these two membranes. It contains many glands which secrete or supply a fluid called the gastric juice, which dissolves and breaks up the albuminous portion of the food, which is poured into it through the gullet after it has been chewed. Food which is al- buminous (meat, eggs, etc.) is digested in from two to four hours, according to its quality and the strength of the gastric juice, and when digested is reduced to a liquid form. Digested and undigested materials are gradually forced out of the stomach by a contracting, or squeezing process, through a small 46 HOW TO KEEP WELL opening called the pylorus, into the first portion of the small in- testine, which is called the duodenum and is eight or ten inches in length. RELATIONS OF THE STOMACH WITH THE LIVER, SPLEEN, MESEN- TERY AND OTHER ABDOMINAL VISCERA. I. The diaphragm pulled back. 2-3. Upper surface of the right and left lobes of the liver. 4. Suspensory ligament. 5. Top of the gall bladder. 6. Front aspect of the stomach. 7. Front aspect of th& spleen. 8. Fold at the bottom of the spleen. 9. Mesentery covering the intestines. 10. Loop of large intestine. 11. End of the large intestine. 12. Part of the large intestine. 13. Top of the bladder. Digestion of the non-albuminous material (starches, fats, sugars) is largely accomplished in this portion of the intestine, the pancreatic fluid from the pancreas and the bile from the liver being mixed with it. THE STRUCTURE OF THE BODY 47 The digested and undigested materials then go to the jejunum, the second portion of the small intestine, which is about seven feet in length, where other glandular fluids continue the digestive pro- cess, and then into the ileum or third portion, which is about twelve feet in length and has numerous glands whose fluids complete the work of digestion. It also has a system of minute structures called villi, which suck up or absorb the digested material, which is eventually passed into the blood and carried over the body to give it nutriment. The undigested and unabsorbed material next passes through a strong valvular structure (ileocecal valve) into the large intestine, where it is further softened and lubricated by glandular fluids, passing out from the body by the anus, which is the end of the intestinal tube. The structure of the intestines is in three coats or layers, like the stomach, the small intestine lying in coils or folds in the cen- tral and lower portion of the abdominal cavity, while the large intestine passes up the right side of the cavity, then across, then down the left side, terminating in the rectum and that in the anus. The Liver.-The liver is the largest glandular organ in the body. (A glandular organ or gland secretes or produces a fluid which varies in character according to the work which it has to do.) It weighs from three to five pounds and is placed in the upper portion of the abdominal cavity on the right side. The product of the liver is called bile, and important changes are produced in the blood as it passes through the liver. It is not composed of one piece or part but has five portions or lobes. The bile which it secretes passes out of it by a channel or duct (hepatic duct) and is poured into the duodenum, while any surplus which is not re- quired at the time is stored up in a sac, which is connected with it, called the gall-bladder. The liver is made up of a great number of minute bodies called lobules in which the bile is prepared. The gall-bladder is the reservoir for the surplus bile. It is located on the under surface of the right lobe of the liver, is a firm membranous sac, and receives and empties its contents by a duct or channel (cystic duct) which joins the hepatic duct, the two combining in the common bile-duct which empties into the duodenum. The liver is also the storage reservoir for the glycogen or liver sugar into which the glucose or digested starch and sugar brought 48 HOW TO KEEP WELL to it by the blood have been changed, and this glycogen is changed back again to glucose when more glucose is required for the body's use. The Pancreas.-The pancreas is a small but very active organ which lies transversely across the posterior part of the abdominal cavity and is connected by the pancreatic duct with the duodenum THE PANCREAS AND ITS RELATIONS. 1-3. Duodenum. 4-8. Pancreas and its ducts. 9-13. Upturned liver. 14. Gall bladder. 15. Hepatic duct. 16. Cystic duct. 17. Common bile duct. 18. Portal vein. 19. Celiac artery. 20. Hepatic artery. 21. Coronary artery of the stomach. 22. Cardiac portion of the stomach. 23. Splenic artery. 24. Spleen. 25. Left kidney. 26. Right kidney. 27. Superior mesenteric artery and vein. 28. Vena cava inferior. It furnishes a powerful fluid (pancreatic juice) which is poured into the duodenum and is very efficient in digesting the starches and fats which may be there. The Spleen.-The spleen is an organ five inches long on the left side of the abdominal cavity under the stomach, near the pan- creas, which has no duct or channel. Its principal object is proba- bly to make the white cells or corpuscles, which form one of the constituents of the blood. THE STRUCTURE OF THE BODY 49 The Kidneys.-The kidneys are two organs for the separation of urine from the blood; they lie embedded in fat on either side of PRIMARY ILIAC ARTERIES BRANCHING OFF FROM THE AORTA, ALSO THE KIDNEYS. i. Aorta. 9. Iliac artery. A. Kidney. B. Supra-renal capsule. C. Ureter. D. Bladder. the spinal column, within the abdominal cavity, between the eleventh rib and the top of the haunch-bone. The average dimen- sions are four inches in length, two in width, and one in thickness. The kidney contains, beside its cover or capsule, an outer or cortical portion, a middle or m'edullary portion, and a lower portion or pelvis, which is the reservoir into which the urine is received. 50 HOW TO KEEP WELL In the cortical or medullary portion is a complicated system of small tubes in close relation with an infinite number of small blood- vessels. As the blood passes through these vessels the urine con- taining waste and worn-out materials is separated and passes into the small tubes and then into the larger tubes in the medullary portion, those larger tubes all converging and emptying their contents into the pelvis of the kidney. From the pelvis of each kidney the urine passes out through a tube called the ureter, which descends along the side of the spinal column into the cavity formed by the haunch-bones, where it enters the bladder at its lower portion and from this is discharged from the body through the urethra. In front of the upper part of each kidney is a small body one to two inches in length called the supra- renal capsule. It has no duct or opening, and its complete object or purpose is not clearly known. The Bladder.-The bladder lies in the front and lower portion of that cavity of the body called the pelvis and formed by the union of the two haunch-bones with the lower portion of the spinal column. It is a membranous bag or sac, somewhat triangular in shape, but becoming more round or oval as it is distended by urine. It has three layers or coats like the other hollow organs and expels the urine by the contraction of its middle or muscular layer, through the urethra or water passage. This latter is very short, one to one and a half inches in the female, and five to six in length in the male, for it passes through the entire length of the penis or male organ of generation. The pelvis also contains the lower end of the intestine and structures which belong to the genital apparatus. The Female Generative Organs.-In the female these are the womb, the ovaries and the tubes which lead on each side of the womb to the ovary. The ova or eggs are carried by the tubes (Fallopian tubes) to the womb, and there, by the union of the ova with the vital elements in the semen, impregnation takes place. The female pelvis also contains the vagina, which is the tube in which the womb is fixed and the organ by which sexual intercourse is accomplished. The Male Generative Organs.-The male generative organs are the penis, which corresponds with the vagina in the female, and the testicles, which correspond to the ovaries. There is an organ at the root of the penis called the prostate gland which is sometimes THE STRUCTURE OF THE BODY 51 regarded as corresponding with the womb, but of course it has no such function as the womb. The testicles provide the vital elements which when combined with the ova of the female result in impregnation by which the re- I. Thyroid cartilage. 2. Cricoid cartilage. 3-4. Trachea and its bi-furca- tion. 5-6. Right and left bronchi. 7. Part connected with the upper lobe of the right lung. 8-9. Middle and inferior lobes of right lung. 10-11. Upper and lower lobes of left lung. 12. Final ramifications of the bronchial tubes. 13-15. Lungs in outline. TRACHEA, BRONCHI, AND BRONCHIAL DIVISIONS. production of species becomes possible. The complicated structure of the generative organs need not be described in detail. Belonging to the genital apparatus are also the mammary glands or milk-producing apparatus. They exist in both sexes but are usually most prominent in the female. They are usually 52 HOW TO KEEP WELL covered by a mass of fat and are composed of a number of small masses or lobes, each with its proper duct, all opening finally into one or several main ducts or canals which have their termination at RELATIONS OF THE TRACHEA AND THE BRONCHI, ALSO SHOWING THE HEART. I. Left heart. 2. Right heart. 3. Anterior coronary artery. 4. Left auricle. 5. Right auricle. 6-8. Pulmonary artery. 9. Pulmonary veins. 10-11. Aorta 12. Section of vena cava superior. 13. Section of azygos vein. 14. Larynx. 15. Trachea. 16. Bifurcation of trachea and beginning of bronchi. 17-18. Section of right and left sub-clavian arteries. 19-20. Section of left and right carotid arteries. 21-22. Trunk of right and left pneumo-gastric nerves. 23-24. Right and left lungs. 25. Diaphragm. 26. Seventh ribs. the nipple or most prominent portion of the breast. The glands are abundantly supplied with blood-vessels, and from these the material for the milk is derived. The Thorax or Chest.-This is a most important cavity, for it contains the heart and lungs and the structures which are associ- THE STRUCTURE OF THE BODY 53 ated with them. It forms the upper cavity of the body or trunk and is separated from the abdominal cavity by the muscle called the diaphragm. The lungs are on either side of it, while the heart is placed between them. The heart is covered by a membranous sac called the pericardium. This membrane covers the organ itself and is then reflected about it so as to form quite a cavity or space. Its purpose is probably to protect the organ from harmful influence. I. Right ventricle. 2. Left ventricle. 3-4. Right auricle. 5-6. Left auricle. 7. Pulmonary artery. 8. Aorta. 9. Vena cava superior. 10. Anterior coronary artery. 11. Branch of coronary vein. 12. Lymphatic vessels on the anterior surface of the heart. ANTERIOR ASPECT OF THE HEART. The Heart.-The heart is conical in form, with its broad portion lying upward and to the right and its narrow portion or apex down- ward and to the left. It is about five inches long, three and a half 54 HOW TO KEEP WELL wide, and two and a half thick, and weighs from eight to twelve ounces. It is divided by a longitudinal wall and again by a transverse one, the two upper cavities thus formed being called auricles, the two lower ones ventricles. The right auricle receives the blood that has passed through the body by the ascending vena cava and the descending vena cava. The left auricle receives the blood after it has passed through the lungs by the four pulmonary veins. The right ventricle sends out the blood into the lungs by the pulmonary artery; the left ventricle sends out the blood over the body by the aorta. Between the auricles and ventricles are valves which open and close with each contraction of the heart. The valve between the left auricle and ventricle is the mitral; the one between the right auricle and ventricle is the tricuspid. Valves are also at the en- trance of the aorta, and-at the entrance of the pulmonary artery. These valves are often the seat of disease. If they do not open and close regularly, or if they fail to fit accurately at their respective openings, the entire circulation is thrown into confusion. The general structure of the heart is that of a thick muscle, the left ventricle being the thickest, the right ventricle thinner, and the two auricles thinnest of all. The Lungs.-The lungs are two in number, one on either side of the chest cavity. They are covered like the heart with a thin membrane (pleura), which is reflected to the sides of the chest, leaving a cavity between each lung and the chest wall. This per- mits the free expansion of the lungs with each act of breathing. The lung is composed of soft tissues and is divided into lobes or masses, the left lung having two lobes and the right three. Each lung contains a great number of elastic tubes called bronchial tubes. They are quite large when they enter the lung but become smaller and smaller as they divide and subdivide, each tube finally ending in a little vesicle or sac, which expands like a small balloon as air enters it and collapses as air goes out of it. Blood-vessels also go to every part of the lungs, and these are in close contact with the air vesicles. The construction is such that the oxygen from the air in the tube passes through its wall and through the wall of the blood- vessels into the blood. The blood also gives up to the air vesicles the carbonic acid which it contains; that is, oxygen is taken into THE STRUCTURE OF THE BODY 55 the lungs in the act of breathing in (inspiration), and carbonic acid is given off in the act of breathing out (expiration). The shape of the lung is conical, the broad part being below and the narrow part or apex above. The air gets to the lungs through a long elastic tube, the wind- pipe (trachea), which begins in the lower part of the neck, passes down the middle of the chest until it almost reaches the top of the heart, and there divides to right and left and enters the inner side of each lung. Here it quickly divides and subdivides, forming the air-tubes which have been referred to. Above the windpipe is the larynx, the organ of voice, which extends upward in the middle line of the neck as far as the base or root of the tongue. It is narrow and cylindrical below and broad above, forming a kind of box which projects on the front of the neck in what is commonly called Adam's apple. Within this box are the so-called vocal chords, extending from the front to the back. The upper pair, or false vocal chords, are not essential to the formation of sounds and may not be directly concerned in the act of speech. The lower pair or true vocal chords by their contraction regulate to a great degree the vocal sounds, and as they are injured or destroyed the voice is impaired or lost. CHAPTER II THE FUNCTION OR WORK OF THE BODY As long as life continues the different parts of the body have work to perform : for the muscles, it is to contract and produce mo- tion and lifting power; for the blood, it is to move through the body, carrying nutriment and removing waste; for the various organs, it is to make their respective secretions or juices, or other- wise carry on the processes which make up the experience of physical life. Knowledge of these matters is therefore not only very interest- ing but very useful and should enable one to avoid many mistakes which might prove (and often do prove) very costly. The science which treats of all these varieties of work which are going on in the body, under ordinary or normal conditions, is called physiology. It is necessary to note that the action of the body and its various parts when diseased is not physiology, such data belonging to another science called pathology. Composition of the Body.-The tissues of the body, in every part and organ, are constantly undergoing change, wearing out and being replaced by new elements. In this respect they are simply following the universal rule of change throughout all nature. Beneath this starry arch Naught resteth or is still, But all things hold their march As if by some grand will. Moves one, move all, Hark to the footfall, On, on, forever. The substances into which the body may be broken up are organic and inorganic; organic because originating with or 56 THE FUNCTION OR WORK OF THE BODY 57 associated with life, with the structure of living beings; and inor- ganic because originating in inert or dead matter. As an example of the first may be mentioned the albumen found in the blood. It is similar to the white of eggs, which is sometimes used as the type of albuminous substances. Albumen is never found except as a product of animal or vegetable life. An example of the second is the lime which is in the bones and which makes them "firm as a rock." This substance exists in various combina- tions in various parts of the earth's crust and may be entirely inde- pendent of life in any form. The body is also composed of solid and fluid material, the latter being greatly in excess; that is, if the body were placed under a pump capable of extracting every particle of water in it, every- thing else being left, seven tenths by weight would be thus re- moved. Thus if a person weighs one hundred pounds, seventy of them will consist of water. Chemical analysis would show that the solid parts consisted of a great variety of different substances. The chemical constitu- ents into which the body may be divided may be considered in five great classes: (i) inorganic, (2) hydrocarbons, (3) albuminoids, (4) coloring material, (5) crystallizable nitrogenous material. These terms will be explained in due course. Inorganic Substances.-These are derived from inert matter outside the body as mentioned in a preceding sentence. They are ingredients of the food, are taken into the body in a state of solu- tion or are dissolved after entering the body, and are distributed by the blood to those parts which require them. Life could not be sustained without them. They consist of water and the com- pounds of sodium, potassium, lime, and magnesium. There are also iron, silica, fluorin, and som'e other minerals in the body. These inorganic substances are best assimilated when they are in a col- loidal form; that is, the form in which they are present in animal and vegetable tissues which may be used for food. WATER is the most important of all the substances of the body. It is the basis of all the fluids and is also an element in all the solid tissues; perspiration, urine, milk, blood, gastric juice, etc., are composed almost entirely of water. It is an element of food as well as of drink; no food is so dry as to be without it. A little more than a quart is the average requirement for an adult per day. 58 HOW TO KEEP WELL Besides the water taken as food and drink, additional water is produced as the result of chemical changes in the body, so that a person may often pass off more fluid than he takes in. Of the water which is thrown off by the body two tenths are thrown off by the lungs as watery vapor, three tenths as perspiration and five tenths as urine and feces (the waste material which is discharged from the bowels). LIME is next in importance to water and as lime phosphate is found in all animal solids and fluids. It is the principal ingredient in the teeth and bones, and is an important element in cartilage, milk, blood, bile, and urine. It gives stiffness and firmness to the bones and teeth. Lime carbonate is found in the bones, teeth, blood, lymph, chyle, saliva and urine but is far less abundant than lime phosphate. Lime is obtained with the food and drink, being found in meat, eggs, milk, cereals, roots, fruits, etc. A small quantity is passed out with the urine and with the feces. MAGNESIUM PHOSPHATE is also found in all the tissues and fluids of the body. There is less of it in the bones than of lime phosphate, but there is more of it in the muscles and brain than of lime. It is taken in with the food, and a small quantity is daily passed out with the urine. SODIUM CHLORIDE or common salt is found in all tissues and fluids, and is used in abundance as an important element of food. It is taken up with the digested food by the blood and dis- tributed over the body. It is passed off with the urine, mucus, and perspiration. POTASSIUM CHLORIDE is found in most of the tissues and fluids but is not abundant. It is taken in with the food and dis- charged with mucus, urine, and perspiration. SODIUM AND POTASSIUM PHOSPHATES are found in all the solids and fluids of the body and give to them their alkaline reaction. All the fluids of the body have such a reaction (that is, when tested with appropriate chemicals they respond to alkalis rather than to acids), except the gastric juice, perspiration, vaginal mucus, and urine, which are normally acid. Hence, these sub- stances, alkaline phosphates they are called, are of great import- ance. They are derived from the food and are discharged with the perspiration, mucus, and urine. SODIUM AND POTASSIUM CARBONATES. These, the THE FUNCTION OR WORK OF THE BODY 59 alkaline carbonates, are usually found with the phosphates in the fluids of the body. They are derived from the food, especially from fruits, but are also formed within the body by chemical changes which take place there. They are passed out with the urine. SODIUM AND POTASSIUM SULPHATES. These sub- stances are found in small quantities in blood, Imyph, aqueous humor (one of the fluids of the eye), milk, saliva, mucus, perspira- tion, and urine. They are taken with food and drink, in cereals, fruits, meat, and eggs and are passed out with urine and feces. Hydrocarbons.-These substances are of organic origin and are found originally in both vegetables and animals. They all contain as chemical elements carbon, hydrogen, and oxygen. Starch, sugar, and fat are the principal substances of this class. STARCH is one of the most abundant of all vegetable substances. There is probably no plant which does not contain it at some time in its life. It is found in seeds, roots, bulbs, pith of stems, even in bark. It is an abundant element in corn, wheat, rye, oats, rice, potatoes, peas, beans, sago, and many other vegetables which are used for food. Starch when subjected to great heat (4000 F.') is changed into dextrine, which is more easily dissolved than starch and hence more digestible as an article of food. Starch may also be changed into sugar. This takes place naturally in plants under the effect of heat and moisture and is a well-known product of many plants. It also takes place in the body as one of the results of digestion. SUGAR. There are three well-known forms of sugar: grape, milk, and cane sugar. Grape-sugar is not only found in vegetables; it is found in the body, in the juices of the liver, in the blood, lymph (the fluid found in the lymphatics), etc. Milk-sugar is obtained from milk. It is a very important element in the food of infants. Cane-sugar is obtained from the sugar-cane, sorghum, maple- sap, honey, and various other vegetables. It is well to remember that sugar is more easily dissolved than starch and that under favoring conditions it is always susceptible of fermentation, alcohol being the principle product. The alcoholic liquors all result from the fermentation of substances that contain sugar. Sugar is also one of the products of the liver in animals and human beings, this form being called glycogen. It results from grape-sugar which has been absorbed in the process of digestion. 60 HOW TO KEEP WELL It is deposited in the substance of the liver and is afterward changed again into grape-sugar or glucose and carried away. FAT. This substance is obtained from both vegetables and animals. In the human body it may amount to one twentieth or more of the entire weight of the body. Three kinds of fat are recognized by physiologists-stearin, palmitin, and olein-the first being chiefly that which is found in animal bodies, while the second is found in palm'-oil and other animal and vegetable fats, and the third in oils or liquid fatty sub- stances in general. In the body the fats which have been taken as food must first be emulsified (that is, divided into infinitesimally minute particles) before they can be absorbed. This condition is brought about by the pancreatic juice and will be alluded to in the consideration of the subject of digestion. Fat is taken into the body with the food, but it is also formed in the body as a portion of its chemical pro- cesses. It is especially liable to accumulate with those who eat abundantly of starches, sugars, and fats, particularly if there is associated with such a diet an idle and indolent life. Another substance in this class is cholesterin, which is obtained from the bile. It is also present in various other fluids of the body and in some of the vegetables. Albuminoids.-This name is given to a very large and import- ant class of substances which form a part of the animal body. They are so called because of their general resemblance to albumen, which is familiar to everybody in the white of eggs. Albuminoids are also obtained from plants, but in much smaller quantities than in animals. About one fifth of the blood and the muscles is com- posed of albuminoids, and three to four tenths of the bones and cartilages. Albuminoids differ from the hydrocarbons in containing nitro- gen, and many of them also contain sulphur. They have the prop- erty of changing from the fluid to the solid state (as when a clot forms from fluid blood), this property being called coagulation. They do not dissolve sufficiently to be readily absorbed in the process of digestion, except when taken as food in one form which is known as peptone, this being readily taken up by the absorbing structures of the intestine. Albuminoids develop agreeable odors and flavors under the action of prolonged heat. An example is the flavor developed in THE FUNCTION OR WORK OF THE BODY 61 meat by cooking. They decompose readily, putrefy, under the in- fluence of heat and moisture. As has been mentioned, the most familiar form in which albu- minoids appear is in the white of eggs. The albuminoids of the blood are serum albumen (also found in several other fluids of the body), paraglobulin, and fibrinogen. Milk contains an albuminoid called casein which when coagulated becomes cheese. Musculai tissue (meat) contains two albuminoids, myosin and syntonin. Pep- tone is the albuminoid which results from the digestion of albumi- nous materials by the pepsin of the stomach. Another series of albuminoids includes the ferments. Of these ptyalin is in the saliva and changes boiled starch into sugar. Pepsin is an element of the juice which is secreted by the stomach and changes the al- buminous substances of the food into peptone. The pancreas provides five ferments which digest starch and fat; there is in the blood an albuminous material, namely fibrin ferment, which acts with fibrinogen to coagulate the blood, and diastase is found in the cereals and changes starch into dextrine and sugar. The final series of albuminoids includes mucin, which is found in the mUcus of the mucous membrane; gelatin, which is found in bones, tendons, ligaments, etc.; chondrin, which is found in cartil- age (gristle) ; elastin, which is found in arteries, ligaments, etc.; and keratin, which is found in hair, nails, feathers, etc. .Coloring Material.-This is a small but very important class of substances which give color, to various tissues and fluids. The most important is that which gives the red color to the blood (hemoglobin). The others are the black substance (melanin) which colors all the dark tissues, (skin, hair, etc.), red and green sub- stances which give color to the bile (bilirubin and biliverdin), yellow (urochrome) which colors the urine, and green (chlorophyl) which gives color to plants. Crystallizable Nitrogenous Materials.-These are colorless, con- tain nitrogen like the albuminoids, and unlike the latter are crystal- lizable. They are found in the yolk of eggs, in the brain, in the pancreas and some other organs, in the bile, in muscles, and in urine. The Food.-The food substances which are taken into the body are albuminoid matter or proteids, fats, and carbohydrates. These ultimately are changed chemically and discharged from the body as urea, carbonic acid, and water. The mineral substances taken 62 HOW TO KEEP WELL into the body are eventually passed out unchanged. The substances taken into the body are digested, absorbed in the intestines, and assimilated by the various portions of the body where they are needed for the nutrition of the body cells. They may not be assimilated in the exact form in which they were introduced, for the chemical laboratory within the digestive apparatus transforms some of them into substances differing from the original ones. All these introduced substances contribute to the maintenance of life, and no single class or group of them is capable alone of doing this. The inorganic matter, while not a means of nutrition, is necessary to balance the substances, to give strength and solidity to the frame, or to help in other ways. Water does not supply nutrition to the body, but is absolutely indispensable.1 The same is true of sodium chloride, or common salt. It does not follow that it is always necessary to take a quan- tity of water or of sodium chloride as such, for both are present in abundance in the animal and vegetable substances taken in food. The food substances are differentiated by the fact that some of them contain nitrogen while others do not. Those which do not contain nitrogen are the carbohydrates and fats, the former con- taining carbon plus oxygen and hydrogen in the proportions which form water, the latter containing carbon plus oxygen and hydrogen, but not in the proportion in which water is formed. The carbohydrates are the starchy substances, starch being the essential product of vegetable life. It is therefore very abundant in the cereals, which contain, besides starch, a varying quantity of nitrogenous matter, the so-called vegetable albumen, sugar, fat, and mineral salts. The principal cereal used as food is wheat. It contains a larger quantity of vegetable albumen, called gluten, than any other cereal. The cereal next in importance on account of its vegetable albumen is oats. Rice contains more starch than any other cereal. Potatoes also contain an abundance of starch, but little albumen or sugar. Fats are derived from both animals and vegetables. In a cer- tain sense the mineral oils may also be called fats, but they are not assimilated, as are the animal and vegetable fats. The fats undergo a change in the process of digestion, called emulsification by which their globules are very minutely divided before they can *0f course by this is meant pure or distilled water which does not add to the tissues of the body. THE FUNCTION OR WORK OF THE BODY 63 undergo absorption, and they are added to the tissues in many cases as the fatty layer which is abundant over the entire body in health. Some vegetables are important foods because of their starch and albumen and others because of their sugar and water. Beans are valuable as food and contain much starch and albumen and but little fat, oils and water. Celery, spinach, lettuce, and fruits of various kinds are valuable for their salts or vegetable acids, but they contain very little that is really nutritious. The vitamines in these substances are also important. The nitrogenous substances enter largely into the structure of the tissues and fluids of the body and are the most important of the food-stuffs. Milk leads these foods in importance and is the sole food of man and the higher animals in the early period of life. It contains all the elements necessary for nutrition: albumen in the cheese, fat in the butter and sugar. Meat is the structure of the muscles and contains nitrogenous matter, fat, mineral salts, and water. Eggs are a condensed form of food and contain albumen, fat, mineral salts, and water. More food is necessary in cold than in warm weather, more for those who work hard than for the idle, and more for those who are muscular than for those who are fat, a properly regulated appetite being the guide for all of them. A good daily ration for an average adult calls for meat, 453 grams; bread, 540; butter, 100; water, 1530; besides vegetables, milk, sugar, and fruits if you can get them. Reduced to other terms this would mean: albumen, 130 grams; starch and sugar, 300; fat, 100; mineral salts, 20; water, 2000. Properly to burn or decompose all these substances, oxygen taken in from the air is imperative, the final products of this combustion being carbonic acid and water, which are constantly being elimi- nated from the body. A few years ago great stress was laid by dietitians on the im- portance of reducing to heat-units or calories the necessary food and the necessary kinds of food for conversion into heat and energy; that is, for metabolism, as it is called. Each article of food has its particular heat-value; and knowing or assuming the requirements in a given person in calories per day, 1500, 2000, 2500, as the case might be. it was not difficult to arrange a diet which should fulfil this requirement, but of course heat-units are only one of the fac- tors entering into the problem of a suitable diet. The calory is 64 HOW TO KEEP WELL the amount of heat necessary to raise one kilogram of water from o° to i° C., and the entire question of heat-units excites little inter- est compared with the attention paid to it a few years ago. Vitamines also have held an important place on the stage since the outer covering of rice was found by Funk in 1912 to cure beriberi. This led to the discovery that similar substances in very minute quantity were present in the husk of wheat, corn, rye, oats, and barley, and that these substances are essential to good health and to life itself. Other diseases of nutrition such as scurvy, pel- lagra, rickets, osteomalacia, and many others are believed to be due to insufficient vitamines. There are three forms of vitamine at present discovered, one being relatively abundant in cod-liver oil, cream, egg yolk, and green leaves. The second is in yeast, germs of seeds, rice millings, grains, nuts, vegetables, orange-juice, and skimmed milk. The third is in lemon-juice, tomato, fresh vegeta- bles, sprouted seeds, and fresh milk.1 Digestion.-Digestion means the preparation of substances used as food for the nourishment of the body. The body cannot be sus- tained and built up as you would pile bricks one upon another, or as you would stick plaster on a wall; the process is far more com- plicated. It is necessary first to choose the right kind of food for a given individual. The same food does not suit all people equally well, while food for summer must be different from that which is appropriate for winter; the body needs an abundance of heat in winter; it has an oversupply in summer. Food must also be given in the right quantity; too much may cause the digestive apparatus to reject it or to pass it along unchanged; too little gives a sense of discomfort and unrest, a feeling that something is wrong within, that a want is unsatisfied. It must be given at regular intervals, as often as the supply on hand has been disposed of and got out of the way: an infant must be fed at short intervals, an old person at much longer intervals. The food when taken into the body may be solid or fluid, but it must be fluid before it can be distributed as nourishment to the various parts of the body. Even when fluid it must be subjected to the influence of various digestive materials before it can be ab- sorbed as nutriment. The structure in which these changes take place is called the 1 Very recently a fourth vitamine, Bios or Vitamine D, has been recognized and isolated. THE FUNCTION OR WORK OF THE BODY 65 alimentary canal; it is about thirty feet long, begins at the mouth, and ends at the anus, the opening at the terminal portion of the large intestine. The food, having been suitably cut or torn or compressed, is first received in lumps or boluses into the mouth to be submitted to mastication or chewing. This implies the action of the two jaws, operated by strong muscles, and supplied with teeth for cutting, grinding, and rubbing or triturating the food. The tongue also, operated by obedient muscles, assists in moving the food about. The mouth cavity is lined with a substance called mucous mem- brane, which also extends through the entire alimentary canal. This is kept moist by the mucus which it produces. Within it are also the openings of five glands, one under the tongue, one on the lower aspect of each side of the lower jaw, and one under each ear. These glands secrete or make what is called saliva or spittle. The saliva not only moistens the food; it contains an albuminous sub- stance (ptyalin), which begins the digestive process by changing more or less of the starchy substances in the masticated food into sugar. The average product of the salivary glands is between two and three pints a day. The tongue forces the masticated or chewed mass backward into the throat or pharynx, where it is seized by the muscles of swallow- ing, and forced downward into the esophagus or gullet. The muscles which act upon the gullet force the food downward until it drops into the stomach. This is a large sac or pouch of somewhat conical form, the structure of which was referred to in the previous chapter. Being lined with mucous membrane, it produces a large quantity of sticky mucus. This lubricates the food which the stomach contains but does little if anything to aid digestion. In fact, when the mucus is too plentiful it may delay the digestive process. The mucous membrane of the stomach also contains a great number of minute glands or tubes which produce gastric juice. This is produced, as a rule, only when there is food in the stomach to be digested. It is composed of two elements, hydrochloric acid and pepsin, the latter an albuminoid ferment. Gastric juice has little or no effect upon any substances except albuminoids (meat, eggs, fish, a portion of the cereals, etc.). These are moistened, disintegrated, and liquefied by it. The process is as- sisted by the contractions of the stomach, which roll and churn 66 HOW TO KEEP WELL its contents about as water in a barrel might be moved about by shaking the barrel. It is probable that about six pints of gastric juice are produced every day in the stomach of an average healthy adult, one third of it being required for the digestion of each meal. The digestion of an average meal by the gastric juice requires about three hours. Some albuminoids are digested more rapidly than others. The digested product is called peptone, and as fast as it is produced it is poured out of the lower or remote opening of the stomach with the substances which have not been digested (starches, fats, etc.), with the surplus of the gastric juice (part of it being reabsorbed, however, by the blood-vessels of the stomach), into the intestine preparatory to absorption and distribution over the body. In all the stages of digestion it must be remembered that the process is more perfect and satisfactory in a state of health than in disease; indeed, digestion may be stopped entirely by fever, fright, intense emotion, or low temperature. Thus, if a quantity of ice were taken into the stomach digestion would not go on until it was melted and the temperature of the stomach restored to its normal elevation (98.4° F.). It is easy enough to prove the foregoing statements, for albumi- nous substances can be digested outside the body as well as in the stomach. All that is necessary for such an experiment is a glass tube or vessel of any kind, a small piece of meat, a few grains of dry pepsin (ten or fifteen), obtainable at any apothecary's, and a teaspoonful of dilute hydrochloric acid, over all of which two or three tablespoonfuls of hot water may be poured. The experiment is a simple and interesting one. The stomach having performed its work and emptied its con- tents into the first part of the small intestine, the duodenum, the digestion of starches and fats begins. The duodenum is not a dis- tinct organ like the stomach but merely the first portion of the small intestine, eight or nine inches long, lying under the stomach and somewhat to the right of the middle line of the body. Within it are two openings through which pour the pancreatic juice and the bile, the secretions of the pancreas and the liver. The peptone which is the product of digestion of albuminoid substances within the stomach passes along unaffected by these two secretions, to be absorbed by the absorbent structures of the intestines. This portion of the food which has been taken into THE FUNCTION OR WORK OF THE BODY 67 the body we can dismiss for the present. The pancreatic juice pro- ceeds from the pancreas which lies under the stomach and to the left of the duodenum, about one and three quarters pints being produced daily. It consists of five substances: pancreatin, trypsin, steapsin, an emulsive ferment, and a milk-curdling ferment. The pancreatin changes the starchy substances which have been poured into the duodenum into sugar. The trypsin completes the digestion and solution of any albuminoid substances which may have escaped the action of the gastric juice. The steapsin element of the pan- creatic juice decomposes fatty substances. Fat which has been decomposed and emulsified by the pancreatic juice is called chyle. Into the duodenum is also poured the secretion of the liver, the bile. This is a greenish fluid which is always present in the in- testine, whether digestion is going on or not. More than two pints are produced in the average healthy adult per day. It dissolves fats to a moderate extent, and it stimulates the intestines to contraction, but its exact influence in the process of digestion is not yet clearly understood. A portion of it is reabsorbed in its progress through the intestine. It is evidently a necessary element in the functions of nutrition, but to what extent is not clearly known. The food mass in its progress through the alimentary canal is further influenced by the secretions of certain glands in the small intestine, one set of which, Brunner's glands, are in the upper part of the duodenum, and the other, Lieberkuhn's glands, are scattered throughout the entire length of the small intestine. The quantity of fluid which they produce is small, and it has a slight action in the digestion of starches and fats. Peptone, chyle, and sugar have thus been produced as the pro- ducts of digestion, and these are absorbed in the different portions of the small intestine. The residue which is not absorbed is passed into the large intestine, the secretions of which give it the disa- greeable fecal odor, and it is discharged eventually as excrement. Absorption.-Not every substance which is taken into the mouth as food undergoes digestion; there is even a residue of digestible material in many cases. Inorganic substances are not digested; they are often absorbed when in solution, but they also are often passed through the alimentary canal unchanged. In cases in which the digestive secretions are weak or the quantity of food very large or the general condition of the individual bad, digestion is incomplete, the residue passing off as feces may be very large, and 68 HOW TO KEEP WELL the individual suffers from the very common ailment of indigestion. Absorption means the taking in of material which is in a state of solution. A sponge or a piece of blotting-paper absorbs, and so do the walls of blood and lymph vessels. Absorption may take place in any portion of the alimentary canal; in fact, almost any of the tissues of the body, by virtue of a kind of porosity, absorbs to a greater or less degree, but absorption occurs most readily and abundantly in the small intestine where there are millions of little structures called villi, which are there for that purpose and which are bathed in the digested material which has been referred to. Each of these villi is a minute tube scarcely visible to the naked eye, standing up on the intestinal mucous membrane like a cone, and covered with a layer of delicate cells. A minute artery enters it at the bottom and breaks up into a network of capillaries inside, while a minute vein leaves it again at the bottom. Within the tube is also a small lymphatic vessel. In addition to the villi in the small intestine there are two series of minute lymphatic glands scattered over it, called solitary and agminated glands, which assist the villi and the lymphatic vessels which are connected with them in absorbing the digestive fluids. As the contents of the intestine are swept along by the con- tractions of its muscular coat, the thoroughly digested and dis- solved portion is absorbed or sucked in by the villi and the lym- phatic glands referred to, the more solid portion being pushed forward into the large intestine. Part of this fluid is taken directly into the blood-vessels of the villi, being then transported elsewhere as we shall presently see; but the fatty materials are mainly taken up by the lymphatic vessels of the intestine, with which they are connected, carried into larger and larger channels, and finally enter the great lymph vessel on the left side of the body called the thoracic duct, which pours its contents into one of the great veins (subclavian) on the left side of the neck, after which they become a part of the blood- current going toward the heart. The fluid which is absorbed by the blood-vessels (veins) of the villi, consisting of peptone, sugar (glucose), and a portion of the fat, is carried to and through the liver and to the great vein of the lower part of the body (ascending vena cava), whose blood-current empties into the upper right cavity of the heart (right auricle). Once in the blood-current, these substances are no longer dis- THE FUNCTION OR WORK OF THE BODY 69 tinguishable in their original form, and they undergo various chemi- cal changes as the blood carries them on its errand of nutrition to all parts of the body. It may be remarked, however, that much of the sugar is deposited in the liver, and that soon after absorption peptone, sugar, and fat may all be found in the blood in the form in which they were taken up. The Composition of the Blood.-A few words must be said in regard to the composition of the blood, which has just been con- sidered as a kind of transportation company to furnish the various parts of the body with nutriment. It is a bright red fluid in the arteries, dark red or purple in the capillaries or veins. It is made up of an alkaline, colorless fluid called plasma and of minute red and white globules or corpuscles, six parts of the former to four of the latter. The plasma is com- posed of water, albuminous matter, and mineral salts in solution. The red globules are many times more numerous than the white. They absorb moisture freely and swell up, or they may lose mois- ture and become shriveled. They contain the coloring-matter (hemoglobin) which makes the blood red. This coloring-matter contains iron and has the very valuable property of absorbing oxygen freely. This is taken from the air which is inhaled by the lungs as the blood circulates through these organs and changes it from the dark (venous) to the bright (arterial) red color. The white globules are larger and less numerous than the red, and have the peculiar power of lengthening or stretching out a portion, like a leg or an arm (amoeboid movement). They are now known to have the immensely important property of selecting and grasping poisonous substances, germs, etc., which are in the blood, absorbing and digesting them. Of course if the poisons are in too great force the white corpuscles are overcome, which means serious disease or even death to the individual. An important property of the plasma of the blood is coagulation or clotting. This happens when blood is drawn from the vessels and allowed to stand a short time. A clot will often form spon- taneously in the opening of a torn or cut vessel, stopping the bleeding, and perhaps saving life. Less frequently the clotting may take place within the unbroken vessels, when it may become a source of great danger or even of death. Clotting is caused by the uniting of a substance called fibrinogen, which is always present in the blood, with another substance, fibrin ferment, which is possibly 70 HOW TO KEEP WELL in the walls of the vessels, the combination making the substance called fibrin. The action of fibrin upon the fluid blood results in a clot. The quantity of blood in the body is about one tenth in weight of the weight of the entire body. If a person weighed one hundred pounds and was in good condition, ten of those pounds, or a little more than a gallon, would represent blood. The Circulation of the Blood.-The course which the blood- current takes, from the heart through the body and back to the heart again, has already been outlined (see pp. 27-28) and also the functions it has of providing oxygen, heat, and nutriment, carrying away waste matter, etc.-in fact, in doing a general transportation business-have been noted from time to time. We have also given in general terms (see pp. 53-54) the structure of the heart and the systems of vessels or tubes by which the fluid is transported. The sounds of the heart may be recognized by anybody, but only a trained ear can detect their irregularities. The first sound may be best heard over the fifth rib and the space between it and the sixth rib, to the left of the middle line of the body; the second is best heard over the breast-bone at about the level of the third rib. The first sound is twice as long in duration as the second. Just after the second sound there is a brief pause. Thus, if a heart pulsation be divided into four equal periods of time, two would be consumed by the first sound, one by the second, and one by the pause which immediatly follows. The sounds are thought to re- semble the words "lub-tub," but this is rather fanciful. With the first sound of the heart its lower end or apex is thrown forward and its movement can usually be seen upon the surface of the chest. The first sound is caused by the simultaneous closure of the valves which separate the two upper cavities of the heart from the two lower ones, the second by the simultaneous closure of the valves at the entrance of the aorta and the pulmonary artery. (The aorta is in the left, and the pulmonary artery is in the right lower cavity.) These sounds are disturbed and unnatural if the valves do not close tightly with each contraction of the heart. The first sound occurs immediately after the two upper cavities have squeezed out the blood which was in them into the two lower ones, while the second sound follows the squeezing out of the blood from the two lower cavities into the aorta and pulmonary artery, that in THE FUNCTION OR WORK OF THE BODY 71 the former going out over the body, while that in the latter goes directly to the lungs. As the blood is squeezed out of the lower cavities of the heart, that is, as the heart contracts, the impulse is felt in all the arteries of the body, or all of any size, and this impulse is repeated with each similar contraction of the heart. This constitutes the pulse and may be felt by pressing any artery which is near the surface of the body. Consequently there are as many beats in the pulse as there are contractions of the heart. In the adult the number is about seventy per minute; in children during the first three years of life the number is about one hundred per minute; and in the aged it is often less than seventy. The con- tractions of the heart, and also the pulse, are quickened in some forms of disease and retarded in others. Fear, shame, remorse, anger, and other emotions also quicken the pulse. The more fre- quent the pulse and heart-action the feebler they also are, as a rule. When the pulsations are too rapid and feeble to be counted, a fatal issue is at hand. The blood-stream traverses the entire body and is ready to repeat its course in twenty seconds. The Lymphatics.-I have referred in the chapter on anatomy to the very extensive distribution of the lymphatic vessels and glands over the entire body. I have also referred to the fact that the lym- phatics carry off and empty into one of the great veins near the heart (left subclavian) the fats which have been digested and also certain waste or worn-out materials which have been collected from all parts of the body. The lymphatics, therefore, work with or as a supplement to the work of the veins. The Urine.-It has been stated (p. 49) that the urine is filtered out of the blood in the kidneys, and that it passes down from each kidney by a long tube called the ureter to the bladder and thence is discharged from the body by the urethra. In addition to water, which is its principal ingredient, it contains normally certain or- ganic and inorganic substances, and abnormally certain others. There may also be an excess or a deficiency of the normal elements. These substances represent waste or worn-out materials of the tissues of the body. If these materials were not carried away from the body by the urine, the feces, the perspiration, and the carbonic acid and watery vapor of the breath they would act as poisons within the body. The urine in a normal condition is clear and yellow when passed 72 HOW TO KEEP WELL but becomes turbid after standing for a while. This is due to the settling of the substances which were in solution when it was first passed. Substances which are heavier than water, like the mineral salts, quickly settle to the bottom of the containing vessel; those which are of about the same specific gravity remain in sus- pension as a cloud in the entire quantity. Normal urine has very little odor at first, but it becomes offensive from decomposition in a few hours, the odor of ammonia being always present, and often other odors which are very disagreeable. From three pints to two quarts may be passed normally per day; if the quantity is very much less or much more it is an indication of disease. Normally the urine has a specific gravity of 1020, less or more than this indicating disease. Its reaction to litmus-paper is normally acid; that is, it turns blue litmus paper red. Its general characteristics are greatly influenced by the food which is used. More urine is passed in cold than in warm weather, for in warm weather the skin does much of the work which falls on the kidneys in cold weather. The condition of the urine has so great a bearing upon the general physical condition that any con- siderable variation in quantity, appearance, frequency, and ease of passing, etc. should be a subject for careful investigation. Respiration.-Breathing or respiration includes the process of taking in oxygen and the changes which accompany it. Oxygen is the indispensable necessity of all life, whether animal or vegeta- ble. There are some low forms of life among the bacteria called anaerobes which get it not directly, but through the disintegrating and decomposing changes in animal or vegetable matter with which they are brought in contact. The developing animal fetus is out of direct contact with oxygen, but it obtains it by way of the blood of its mother. Those who go down to the sea in submarines of course have no direct access to the atmosphere when submerged, but they obtain a supply of oxygen by producing the requisite chemical changes in substances with which it is combined. Should this supply give out or the machinery which produces it fail to work, they would inevi- tably suffocate; and this is one danger which is ever present with them. Plants that are exposed to the sunlight absorb carbonic acid and water from the atmosphere to form their cellulose, starch, and fat, and they exhale oxygen. This is one of the great sources of the THE FUNCTION OR WORK OF THE BODY 73 illimitable supply of oxygen in the atmosphere, which forms one fifth of its volume. Another great reservoir of oxygen is that which is dissolved in the waters of the sea and maintains their teem- ing life. The absorption of oxygen is an essential part of the process of germination in seeds, and in the expansion of the buds of leaves and flowers. Animals consume the organic material provided by plants, ab- sorb oxygen from the air or from substances which contain it, and give out carbonic acid and water. Animals and plants are thus mutually dependent. The respiration of the lower types of animals is through the skin. Even those as high in the scale as frogs and reptiles, though they have a well-constructed breathing apparatus, depend largely upon the skin for their supply of oxygen, which explains the facility with which they remain under water. In birds and mammals breathing is much more active than in reptiles and fish. The point in respiration is that the circulating fluid is on one side of a more or less porous membrane, while oxygen is on the other, the oxygen passing through the membrane and being taken up by the circulating fluid. On the other hand carbonic acid passes out of the circulating fluid through the membrane and is conveyed out of the body as waste matter. The respiration of fish is accomplished by means of gills, which are bathed in water which contains oxygen in solution. The gills are principally a mass of blood-vessels which form the membrane serving as the medium for the interchange of oxygen and carbonic acid. In animals above a certain grade respiration is performed by means of lungs and their accessory parts. In man the respiratory apparatus begins with the larynx or glottis, the movements of which are synchronous with the expan- sion and contraction of the lungs. From the larynx depends a flexible tube called the trachea or windpipe, which divides at its lower extremity into the right and left bronchi or bronchial tubes. These divide again and continue to divide until the ultimate sub- division becomes a thin membranous tube terminating in an elastic sac, suggestive of a child's toy balloon. The interior of this sac is divided into compartments which expand and collapse as air enters and leaves them, their walls being filled with capillary blood-vessels, through which oxygen passes to the circulating blood, while car- bonic acid comes through them from the blood and is passed out 74 HOW TO KEEP WELL with the exhaled air. Of course the spaces between these thousands and tens of thousands of tubes are filled with soft tissue to give the lungs the requisite shape and firmness, while the organs as a whole are completely covered with a membrane called the pleura, which passes over to the wall of the chest and forms the internal lining of the chest cavity. Removed from the body, the lungs, trachea, and larynx are not a little suggestive of a huge bunch of grapes and its stem. The surface included in this enormous number of minute blood-vessels is very great, and a large volume of blood in a very thin layer can consequently be exposed at once to the influence of oxygen. Besides this compressible, expansible, elastic mass of tissue in the lungs and their thousands of little air-sacs, we have as assistants in the mechanism of respiration the muscular force of the dia- phragm, which is the muscular partition wall between the cavities of the chest and the abdomen, the muscles between the ribs, the other muscles of the chest and abdomen, and the animating force of the nervous system-all of which, combined, cause the chest wall to rise and fall, the lungs to expand and collapse, the larynx with its vocal chords to open and close rhythmically and regularly in a healthy adult about twenty times a minute. The rate is somewhat higher in children, and it may be lower during sleep and in the aged; it is considerably higher in some diseases like pneumonia and pleurisy, and it is very low-perhaps not more than three or four a minute-in poisoning by opium. When the chest is rigid from disease or otherwise the abdominal muscles endeavor to help out and relieve the difficulty, and when there is disease in the ab- domen-for example, peritonitis-the abdomen is rigid, and the chest muscles become unusually active. In inhalation and exhalation, which are parts of one act, in an average adult 320 cubic centimeters of air are taken in and expelled. That is, about ten thousand liters a day are essential. This furnishes a basis for making calculations on the air capacity of rooms where large numbers of people are to be assembled; and it may be said in passing that it is very important to have this air in motion. Only from ten to thirteen per cent of the air which is taken in at one inhalation is expelled with the succeeding exhalation. In other words, there is always a large volume of residual air in the lungs, and eight or ten respirations will be necessary before these will contain an entirely new supply. THE FUNCTION OR WORK OF THE BODY 75 Air that is used in respiration consists mainly of one part of oxygen and four of nitrogen. When it gets to the lungs the blood pays no attention to the nitrogen, which is loosely combined with the oxygen, but selects only the latter, the hemoglobin of the red corpuscles absorbing it and carrying it by means of the arteries to all parts of the body. Air that is exhaled, therefore, is deprived of more or less of its oxygen, and during its stay in the lungs it has acquired from the circulating blood, watery vapor, carbonic acid, and a certain amount of waste matter. The blood that goes from the lungs into the arteries charged with oxygen is bright red in color, while that which comes back to the lungs, by the veins after a journey over the body, has lost its oxygen, has been charged with carbonic acid and waste matter, and is dark red, purple, or even black in color. If the oxygen of the air is reduced to one half of its ordinary vol- ume it becomes unfit for respiration. When a great many people are breathing a limited volume of air, as in a public building, the air becomes overcharged with carbonic acid, and it may also have insufficient oxygen. It is this excess of carbonic acid which often makes us drowsy in public gatherings, and perhaps gives us a headache which is relieved as soon as we get into the open air. All of these facts should teach us the indispensable necessity of fresh air at all times and in all places, if we can get it. We must remember that if the blood is deprived of its essential oxygen, which is its food, the whole body becomes or may become a prey to ills of various kinds, because it lacks the resisting power which may be supplied by this necessary element. Animal Heat.-One of the peculiarities of living animal bodies is that they have normally a temperature of their own which may be entirely different from the medium, whether earth, air, or water, in which the animal is accustomed to live. This body temperature varies in different species of animals; in birds, it is very much higher (1060 to 1080 F.) than in man; in lizards, fish, and other so-called cold-blooded animals, it is several degrees lower than in man. In man it is normally 98.4° F., this rate applying, of course, to the interior and not to the exterior of the body. This heat in the body is kept up by fires which do not go out until extinguished by death, when the temperature falls many degrees. The fuel for the fire is the food which we eat; the fur- naces are the organs within us by which the food is adapted to our 76 HOW TO KEEP WELL use; and the vessels and nerves are the pipes and conductors by which heat is transmitted to all parts of the body. The body radiates or sends out heat just as a stove or furnace does. Try it-when very cold-by standing close to a person who is in perfect health and in a warm room. The clothes we wear are not so much to furnish us with heat as to prevent the heat of the body from getting out. Furs, being non-conductors, prevent the extreme cold from reaching the body. White clothing prevents heat-rays from the sun from reaching the body and hence is worn when the weather is hot. Heat is generated by work, by activity of any kind; and the perspiration, by moistening the body, tends to reduce extreme heat. Heat is also generated in certain diseases (fevers, etc.), the temperature sometimes going six or seven degrees above the normal. In other diseases it may go below the normal. Death usually comes when the temperature goes to 1070 or 1080 F. or when it drops to 900 or 910 F. A sudden emotion will sometimes bring an excess of blood to the surface and increase its heat, as when the face gets intensely red and feels hot to the touch. Again the emotion may drive the blood from the surface to the interior of the body, the skin becoming ashy pale and cool to the touch. During sleep, when the body and its functions are least active, the temperature drops. In animals which sleep most of the winter it may drop thirty to forty degrees. The Nervous System.-The object or function of the nervous system has been defined by Dalton to be the association of the different parts of the body in such a manner that stimulus applied to one organ may excite the activity of another. In other words, the nervous system is a vast chain of connecting links or threads which permits one part to be in direct or indirect communication with all the others. It is also more than that; it is an essential element in the vitality of an organ or tissue, as essential as its blood-supply, and when the nerve-supply of an organ or tissue is injured or destroyed, that part suffers in its power of motion or sensation, or in its nutrition. Like an electrical circuit it has a central station or battery and distributing wires or branches. Influences may proceed from the center to the branches, or from the branches to the center, or from the branches to the center and back upon the branches again. THE FUNCTION OR WORK OF THE BODY 77 There is scarcely a portion of the body, however minute, which is not controlled by the nervous system; hence the great importance that its normal healthy condition be constantly an object of care, also the importance of at least elementary knowledge relating to it. The nervous system not only controls the organs and tissues but it compels them, in a state of health, to act harmoniously with each other. When one part is irritated or excited, other parts are necessarily excited with it through the influence of the nervous system; thus, in the act of running, the unusual use of the muscles which are employed calls for an unusual supply of blood to them; this also requires more rapid action of the heart to get the additional supply to the actively working muscles, but this implies an unusual cur- rent through the lungs and hence more rapid breathing in order to give it enough oxygen. All these forces are intended to work in harmony and be complementary to each other in a state of health Nerve-tissue or substance is soft and lacks compactness but is firmer in the branches or nerves than in the central portions of the system (brain and spinal cord). It is of two kinds, white and gray: the former is composed mainly of fibers or filaments, some of which are parallel to and some cross one another; the latter is composed of cells with branches or processes coming from them, the cells being embedded in a substance or cement (granular mat- ter) which holds them together. The white substance is found in the interior of the brain and on the exterior of the spinal cord and nerves. The gray substance is on the outside of the brain but in the interior of the cord and of the various ganglia which form the essential portion of the sympathetic nervous system. A nerve filament or fibril consists of three parts: the outer part or sheath, the middle or medullary substance, and the inner or axis cylinder. There are some nerves, however, that lack the middle layer. The medullary substance is rather sticky and protects the axis cylinder, which is the portion of the nerve along which nerve influences travel, and hence the essential part. All nerves, whether large or small, are simply accumulations of nerve filaments which are bound together in more or fewer bundles, protected by a sheath, and nourished by small blood- vessels. These nerves divide and subdivide and cross each other according to the requirements of the tissues which they supply, 78 HOW TO KEEP WELL finally ending in some portion of the skin or the muscles. At the origin of the nerves in the brain and spinal cord, and at their termi- nation in the skin and muscles, the medullary substance and the sheath are absent; there is nothing but the axis cylinder. The en- tire surface of the skin is one vast collection of nerve-endings. They are closer together in some parts of the body than others, hence some parts of the body are much more sensitive than others. The nerve-endings are less numerous in the muscles than in the skin. The nerves which end in the skin are called sensory or sensi- tive nerves; those which end in the muscles are called motor nerves. The former are associated with feeling or sensation, the latter with muscular contraction or motion. An impression upon the skin of whatever character travels along the appropriate nerve or nerves to the brain, which interprets the impression as feeling, whether it be a touch, a blow, a cut, heat or cold, or whatever else may be the cause. On the other hand, contractions of the muscles or motion are caused by an impulse from within, from the brain, which travels outward along the nerve-fiber and, reaching the muscle in which it ends, causes it to contract and so perform the work which that particular muscle or group of muscles is designed to perform. The central termination of the nerve and nerve-fibers (cer- tainly in many if not in all of them) is in the cells of the gray matter of the brain and spinal cord, and these cells are believed to be the centers or headquarters at which impressions of sensations are re- ceived and from, which impulses or orders to produce muscular con- traction proceed. If a nerve is cut off from its center, or head- quarters, motion or sensation for the part which is supplied by the nerve becomes impossible. The process by which an impression or sensation transmitted from the surface to the center is converted into an impulse pro- ducing motion, perhaps in a part of the body remote from that which received the original impression, is called reflex action. Very many actions of the body are of this character. A simple il- lustration would be the tickling of the nose by a fly or bug: a disa- greeable sensation is announced at the center in the brain; this is at once followed by an impulse to blow the nose (perhaps also to sneeze; perhaps also there is a feeling of anger) and another im- THE FUNCTION OR WORK OF THE BODY 79 pulse to contract those muscles which will raise the hand and brush away or destroy the bug. Arrangement of the Nervous System.-Before proceeding fur- ther with the study of the functions of the nervous system, it may be well to recall its arrangement. It consists of (i) the cerebrospinal system, (2) the sympathetic system; the former including the brain, spinal cord, and cerebral and spinal nerves, and the latter a double row of small bodies or ganglia on either side of the spinal column connected by nerves with each other and with the spinal nerves, and also with the various organs of the body. The brain occupies the cavity of the skull and is composed of various parts which are connected with each other by bands or links of white nerve-tissue. It also gives origin to the twelve pairs of cranial nerves. It is connected by other bands of white nerve-tissue with the spinal cord, which occupies the canal within the spinal column (vertebral canal) and gives origin on either side to thirty-one pairs of spinal nerves, which are distributed to all parts of the body. The Spinal Cord.-The outside of the spinal cord is composed of white matter, the inside of gray. The white matter is the medium of connection between the nerves which go to all parts of the body and the brain; the gray matter consists mainly of cells which are nerve centers. An important fact in connection with the white matter of the cord is that the filaments of which it is composed cross one another just before they reach the brain and enter the brain on the opposite side of the body from that which they occupied while in the cord. The result of this is that an impression which is received upon the skin on one side of the body enters the proper center in the brain upon the opposite side of the body. An impulse which proceeds from the brain upon one side produces contraction of the muscles and motion on the opposite side of the body. This crossing of the nerves is constantly shown in certain forms of paralysis, in which one side of the body is helpless and unable to move, the injury which causes it being found in the brain on the opposite side of the body. If, however, there is an injury to the spinal cord below the point where the fibers begin to cross to the other side, then the paralysis will be on the same side of the body as the injury in the cord. In some cases the injury is one which affects the entire .width of the cord. Such an injury is followed by complete paralysis 80 HOW TO KEEP WELL and helplessness of both sides of the body below the seat of the injury. The spinal cord has also an important function as a nerve- center entirely independent of the brain. Movements of the limbs which occur without any exercise of the will-for example, the movements which are made during sleep, involuntary movements -are due, not to the brain, but to influences from the spinal cord alone. The nerve influences which control the muscles in standing and walking proceed mainly from centers in the spinal cord, and when these are injured standing and walking become difficult or impossible. The spinal cord also controls the action of the bladder and the lower portion of the bowels, and inability to control the contents of the bladder and bowels (the urine and feces) follow its serious injury. The Brain.-The complicated structure and functions of the brain cannot receive in this brief chapter anything like an adequate consideration. I shall endeavor to describe the principal features of its principal elements, which are called the cerebrum, the cere- bellum, and the medulla oblongata. Of these the cerebrum and cerebellum are each composed of two symmetrical portions on op- posite sides of the skull cavity. The medulla oblongata consists of several parts which are more or less closely united in one piece. The cerebrum, or hemispheres as it is also called, forms four fifths of the entire brain. It lies uppermost with regard to the cerebellum and medulla oblongata, conforms to the curved outline of the skull cavity, contains numerous depressions or fissures, and is composed of gray matter on its outer aspect and white matter within. The peculiar characteristics of these two substances have been already noted. In general it is believed that the more marked the fissures and convolutions of the cerebrum the greater the intel- lectual power of the individual. Under the cerebrum are certain masses of brain substance (ganglia) which are connected by bands of white matter with it and which have well-marked functions as nerve-centers. The cerebrum, as has been stated, is the organ of thought or in- telligence. Its integrity is not absolutely essential to life, for it has often been injured by accident or disease without materially shortening life, although certain important qualities or attributes may have been permanently impaired. Memory, reason, judgment, THE FUNCTION OR WORK OF THE BODY 81 and other faculties are often impaired by injury or disease of the cerebrum. The control of speech, of sensation, of motion, etc., is dependent upon a sound and normal condition of the cerebrum. The cerebellum is situated in the posterior or back part of the cranial cavity directly under the cerebrum. It is constructed like the cerebrum with gray matter on its outer aspect and white mat- ter within. It is connected with the cerebrum, moreover, by bands of white matter. Its principal function seems to consist in con- trolling the muscles which are concerned in walking and moving about, and when it is injured or diseased one staggers or stumbles instead of walking naturally. The medulla oblongata is a small but vitally important collec- tion of nerve-tissue. It lies between the cerebellum and the spinal cord and is in fact the direct continuation of the cord. Its gray matter is within, as in the cord, and its white matter without. From the gray matter of the medulla oblongata arise all the cranial nerves with the exception of two (olfactory and optic). Its serious injury at once destroys life. A less serious injury would destroy all power of motion and sensation in the body and limbs. The center for respiration or breathing is located here, and its injury would at once destroy life, by producing inability to breathe. It controls also the act of swallowing, the use of the voice, the pro- duction of articulate sounds, and the use of the tongue and lips. There is no portion of the body which is more essential to life than this and which resents injury of any kind to the same extent. The Cranial Nerves.-These nerves are in a certain way more important than those which spring from either side of the spinal cord (spinal nerves) throughout its entire length, not only because they originate (excepting the optic and olfactory) from the medulla oblongata, the most sensitive and vital part of the body, but because they preside over the most important functions of the body. The power of general sensation and motion which depends upon the spinal nerves may be entirely abolished and the individual be a helpless paralytic, unable to move hand or foot, and yet if the cranial nerves are uninjured he may continue to live for years. There are twelve pairs of cranial nerves, which are numbered in the order in which they originate in the brain, from front to rear, and each pair has a particular name. (As stated in the chapter on anatomy, some anatomists reckon twelve pairs of cranial nerves, and others nine.) First are the olfactory nerves or special nerves 82 HOW TO KEEP WELL of the sense of smell. They terminate in a ganglion or egg-shaped mass of gray matter called the olfactory bulb, which is placed on one of the bones in the front part of the skull called the ethmoid bone. From this bulb a great many nerve-filaments are given off and distributed to the mucous membrane which lines the nasal cavities. If the olfactory bulb and the nerves which it gives off are destroyed the sense of smell will be lost. If the sense of smell is defective, this is due to imperfect development of these nerves or to disease or injury which they may have received. Second are the optic nerves, which control the sense of vision. These nerves cross one another on the under surface of the cerebrum (hemispheres) and are then distributed by many fibers or filaments to the retina of each eye. The rays of light falling upon the retina stimulate these nerves, and the impression of light is carried by them to the proper portion of the brain, where it is interpreted as an object which has been seen. Injury of these nerves does not produce pain, but if they are cut or destroyed vision will be lost. They also control the movements of the pupil of the eye, which contracts or dilates according to the stimulation which the nerves receive. The sight may be impaired but not destroyed when a portion of the fibers going to one or both eyes is injured. The third, fourth, and sixth pairs of cranial nerves (oculo- motorius, patheticus, and abducens) are distributed to the eyeballs, the upper eyelids, and the pupils. They control muscular action and allow the parts to which they are distributed to have the power of motion. Injury to the filaments which go to the eyelid prevents the power of raising it and causes it to droop. Injury to the fila- ments which go to the iris would cause the pupil to remain wide open in a fixed stare. Injury to the nerves which supply the muscles of the eyeballs would paralyze the power of motion on the injured side. The other side being uninjured, its muscles would pull the eyeball in that direction, as is the case with those who are squint-eyed. If all the eye-muscles are paralyzed on account of injury to their nerves, the eyeball will be fixed and immovable, like a glass eye. The fifth pair (trigeminus) constitute the great sensitive nerves of the face. They also contain fibers which go to certain muscles of the face and contribute to their power of motion. Each nerve has three principal branches. The upper one gives sensitiveness to the skin of the forehead, side of the head, nose, and a portion THE FUNCTION OR WORK OF THE BODY 83 of the skin in the vicinity of the eye, also to the mucous membrane of the nasal passages, and to the mucous membrane which covers the eye. The middle branch gives sensitiveness to the cheek, fore- head, lower eyelid, side of nose, and upper lip, to the teeth and gums of the upper jaw and to the mucous membrane of the upper jaw, a part of the nasal cavity, and the upper lip. The lower branch con- tains motor fibers which give power of motion to the muscles which are used in chewing, while its sensitive fibers supply the teeth and gums of the lower jaw and the skin and mucous mem- brane of the cheek, lips, ear, tongue, and lower portion of the chin, also the glands which secrete saliva. Pain in any portion of the surface of the face, nose, cheeks, or teeth is due to disturbance in some portion of the fifth pair of nerves. The sense of touch and of taste in the tongue is derived from this source; the sense of smell is in part dependent upon it; a portion of the structure of the eye is similarly dependent; while the power to chew or masticate the food proceeds from the motor- fibers of these nerves. The seventh pair (facial) of nerves is the great source of mo- tion for the face as the fifth is of sensation. The muscles of the external ear, the nose, and some of the muscles of the lips, eyes, and mouth are controlled by them. If they should be seriously injured the eyelids could not be closed on the injured side, the nose could not be moved, and the corner of the mouth would droop, all ex- pression to the face would be lost, the lips could not control the food and drink which they grasp, and the saliva would constantly drip from the corner of the mouth. The sense of taste (in the tongue) and of hearing may be modified by injury to one or both of the nerves of the seventh pair, since a communicating branch goes from each to the tongue and to the drum membrane of the ear. The eighth pair (auditory) are the special nerves of hearing and are distributed by many filaments over the structure of the internal ear. The sound-waves are conveyed along these nerves to the proper center in the brain, which interprets them acording to their various characteristics. The ninth pair of nerves are distributed to the tongue and the pharynx, or throat (glossopharyngeal). They are mixed nerves; that is, they cause both sensation and motion, giving the sense of taste to the posterior third of the tongue and general sensi- tiveness to this portion of the throat. The motor-fibres are dis- 84 HOW TO KEEP WELL tributed to the muscles of the throat and control the act of swallowing. This act, after the food has passed beyond the tongue, is not under the control of the will; that is, the food would be squeezed down into the gullet whether one wished it to go or not. It is a good illustration of reflex action. The food having reached the back part of the tongue, the sensation of taste is car- ried by the ninth pair of nerves to the center in the medulla oblongata. It is here converted into a motor impulse, which travels back over the motor-fibers of the nerves to the proper muscles of the throat, which, as they contract, grasp the mass of food which is near them and crowd it down without any regard to the wishes of the individual in the matter. The tenth pair (pneumogastric) are the most important and vital of all the cranial nerves. They are both sensory and motor. Branches go to the larynx to give it sensation and others to the muscles which control it to give it motion. Many other branches go to the gullet (esophagus), lungs, stomach, and liver. Other branches go directly or indirectly to the heart and have a most im- portant influence upon its action. The regular and rhythmical action of the lungs in breathing is interfered with when these nerves are injured or destroyed. Suf- ficient air does not enter them for the proper aeration of the blood, and this will result in death after a period of about six days. The voice also suffers by such an injury, and both articulate and in- articulate sounds are entirely abolished when these nerves are cut across. Paralysis of the gullet which attends injury to these nerves causes the food which has been brought to it by the contractions of the pharynx to lodge or stick there; that is, the act of swallowing is checked before it is completed, the gullet (esophagus) having lost its power of contracting and so of forcing the food downward into the stomach. In like manner paralysis of the stomach attends injury to these nerves, the motion (and sensibility, too) of this organ, which are essential to the digestion of food, being absent. The eleventh pair (spinal accessory) combines in part with the fibers of the tenth and especially with those which go to control the vocal power of the larynx, while another branch goes to two of the great muscles of the neck and back, controlling in part their power of motion. The twelfth pair (hypoglossal) are those which give to the tongue its power of motion. Their fibers are supplied not only to THE FUNCTION OR WORK OF THE BODY 85 the tongue itself, but to those muscles connected with it which draw the tongue backward. Injury or destruction of these nerves causes interference with chewing or swallowing and also with the production of articulate speech. The Sympathetic Nervous System.-The sympathetic system is not an independent nervous system like the cerebrospinal. It is composed of a double series of ganglia and nerve-cords beginning in the cavity of the skull and continuing on either side of the spinal column through the neck, chest, and abdomen. The ganglia are connected by cords or filaments with the cerebrospinal nerves and send out branches to all the organs and mucous membranes within the body. The nerves of the cerebro- spinal system supply the power of sensation and motion to the various parts of the body, while those of the sympathetic system are concerned in influencing the functions of circulation, secre- tion, and growth, though to a limited degree. They may also exert the power of sensibility and of motion; thus the power of motion in the intestines, and the dilatation of the pupil of the eye, are due to the influence of sympathetic nerves. An important feature of the sympathetic system is its influence upon the blood-vessels of the body, especially the arteries. One set of nerve-fibers to these vessels when irritated will contract the caliber of the vessels and diminish the volume of blood which passes through them, while another set will dilate them, when irritated, and permit a larger quantity of blood to flow through them. The Senses.-General sensation, or the impression upon the mind of any object or thing external to the body of the person ex- periencing the sensation, is distinguishable from the special senses of touch or general sensibility, taste, smell, sight, and hearing. TOUCH OR GENERAL SENSIBILITY is the consciousness of contact with external objects. It exists on every portion of the surface of the body and in more or less of the mucous membrane which lines the cavities. It is more acute in some portions than in others: on the tip of the tongue it is most highly developed; on the middle of the back it is least so. The ends of the fingers are particularly apt in distinguishing sensations of the greatest variety. Sensations of heat, cold, and pain are modes or varieties of the sense of touch. TASTE is appreciated through the mucous membrane which lines the mouth, being localized in the tongue, the soft palate, and 86 HOW TO KEEP WELL the entrance to the throat. The base, tip, and edges of the tongue are the portions which are most sensitive to taste. The appreciation of savors and flavors is of course distinct from general tactile sensibility, which these parts also possess to a marked degree. Substances must be in solution, that is, in a liquid form, in order that a distinct taste may be appreciated as belonging to them. When the mouth is moist with saliva the difference in the taste of substances is more readily detected than when it is dry. THE SENSE OF SMELL is limited to the upper portion of the nasal passages, which is covered with mucous membrane. This membrane is abundantly supplied with filaments from the olfactory nerve, but it also contains filaments or fibers from the fifth pair (trigeminal) and from the sympathetic system. The sensation of smell is derived from the inhalation of odoriferous gases or vapors. THE SENSE OF SIGHT is perhaps the most important of all the senses. While it is not indispensable to life or to gaining a livelihood, how immeasurably it adds to the satisfaction of living, and how extensively it informs us of the world in which we are staying and of the objects which are in it! The elementary facts in regard to the structure of the eye will be found in the chapter on diseases of the eye, and to these the reader is referred. The minute structure of the eye is too complicated for the purpose of this book. It is well to remember certain peculiarities of the eye: its great mobility in all directions, controlled as it is by different sets of muscles which are attached to its sclerotic coat; the dilating and contracting power of the pupils, according as weak or powerful rays of light pass through them; the various elements of protection against injury, the eyelashes, the projecting ridge of bone above the eye, in a word, the structure of the eye itself; the adjustment of the two eyes so that under normal conditions only one object, in- stead of two, is seen; the adjustment or accommodation of sight to objects with different distances, enabling one to see even very remote objects with perfect distinctness, etc. The eye, being an optical instrument in its construction, gives different results, as to vision, according as it agrees with or varies from a certain type. This type, the normal eye, enables one to see objects four or five inches away, accommodating readily to changes in the size of objects and to changes in the distance. But as age ad- vances, the shape of the globe of the eye changes, tending to be- THE FUNCTION OR WORK OF THE BODY 87 come flat, and consequently making it difficult to see near objects with distinctness. This difficulty (presbyopia) is remedied by the use of convex glasses, the flatness of the globe being overcome. Those who have this difficulty are far-sighted. In other cases the globe of the eye becomes lengthened, instead of flattened; this re- quires that objects be brought very close to the eye (myopia) for clearness of definition. Those who have this very common trouble are near-sighted, and the remedy consists in the use of concave glasses. THE SENSE OF HEARING is perhaps next in importance to that of sight. For the description of the organ of hearing the reader is referred to the chapter on diseases of the ear. The development of either the eye or the ear may be naturally defective; that is, one may be born blind or deaf with no possibility of remedying it. Sight or vison may also be impaired or destroyed. The result of disease or injury of the ear is much more apt to be overlooked than defects and disease of the eye. As age advances the structures of the ear become impaired and wear out as do those of the eye, but in a much smaller number of cases. Perhaps the protected position of the ear or the lesser degree of abuse to which it is necessarily subjected may explain the fidelity with which the sense of hearing stands by us, like an old and tried friend, often to the very verge of life. Reproduction.-Life is continued by transmission from one in- dividual to another. No living being can originate independently; there is no such thing as spontaneous generation. Life does not exist in minerals. They are formed by crystalliza- tion or by the accumulation of their elements by various mechanical means. Life in plants presents many analogies to life in animals. The simplest form of animal life is derived by division, one cell becoming two cells, and so on continually. It would be enter- taining to follow the successive changes in the process of reproduc- tion as stage after stage is reached in the upward progress of animal life, but time and space will not permit. We must jump the wide interval from the lowest to the highest form of animal life and briefly refer to reproduction in man. The essential elements in human reproduction are the egg and the spermatozoon, female and male respectively. Life without both of these is impossible. The spermatozoon or male cell, or a part of it, works its way into the egg or female cell and combines 88 HOW TO KEEP WELL with its contents. This is impregnation or fecundation and is the beginning of a new life. There are appropriate organs in the male and in the female for the accomplishment of reproduction, for the continuation of the species, which are as necessary to a complete human being, physically, as are the digestive organs, or any other organs. It is quite as important to know what they are, and what are their functions, as to know about the other organs. I shall describe those which are essential. The female generative or reproductive organs which we shall refer to at this time are the vagina, womb (uterus), oviducts (Fallo- pian tubes), and ovaries. The vagina is an elastic tube about four inches long lined with mucous membrane and composed in addition of muscular and fibrous tissue. It is the female organ of sexual in- tercourse and the canal through which the fetus or child passes at birth. The womb (uterus) is a pear-shaped structure three to three and a half inches long, attached an inch above its smaller end to the upper and inner end of the vagina. It is composed of a thick muscle covered with peritoneum, and it has in its center, and lined with mucous membrane, a canal which is narrow in the lower part and wide in the upper, somewhat like the figure of a triangle. In this canal the impregnated ovum is developed, the child enlarg- ing and maturing during 280 days, surrounded by protecting membranes, floating in a watery fluid which diminishes as the child enlarges, the womb meantime expanding to a corresponding degree. At the navel of the child a thick cord is attached which extends to a round mass of soft tissue anchored upon the side of the womb and called the placenta or afterbirth. This cord may be two or three feet long to permit the freest motion on the part of the child. When the child is fully developed it is like a ripe fruit ready to leave the parental attachment. Then what is known as labor oc- curs : the womb contracts, and the child is slowly pushed downward and outward, out of the womb, out of the vagina, and into the world, a new-born baby. Membranes and afterbirth soon follow, and the womb after a few weeks resumes the condition it had be- fore impregnation occurred. At the upper end of the womb-canal at either angle of the base of the triangle (to which it was compared) is a small opening which leads on either side to the oviduct or Fallopian tube. This tube is THE FUNCTION OR WORK OF THE BODY 89 about four inches long, very flexible and constructed, like the womb, with muscle in the middle, peritoneum outside, and mucous membrane inside. Each tube expands at its outer end to a fringe, one portion of which is attached to the ovary which lies just below it. A narrow canal runs through the tube from the attachment at the womb to the attachment at the ovary, and it is along this canal that the egg, after its escape from the ovary, is pushed by the contractions of the tube until it reaches the womb. The ovaries are small ovoid bodies, flattened on the front and back, each one lying below the Fallopian tube and connected by one end with the fringed extremity of that tube. The other end of the ovary is attached by a ligament about an inch and a half long to a double layer of the peritoneum, which stretches from the womb to the side of the pelvis in which all these generative organs are located. This attachment is just under the Fallopian tube where it starts from the womb. The ovary in a mature woman is about the size of half an English walnut, cut through lengthwise. It is composed largely of fibrous tissue and is covered with peri- toneum. It is also provided with countless little pockets or de- pressions called Graafian follicles, and in these follicles are the ova or eggs. Egg-bearing is a function of the ovary perhaps from birth, and it continues until the child-bearing period is over, which with most women is between the ages of forty-five and fifty. Egg-bearing or ovulation becomes a prominent function, however, when the girl becomes a woman, at the age of puberty it is called, and when it becomes possible for her to become pregnant and bear children. No one has found out how often an egg is discharged by a woman. The idea that this occurs only at the time the woman has her monthly sickness is not correct. In a healthy young woman proba- bly few days pass in which one or more eggs are not discharged; hence impregnation is possible at almost any time. When an egg is ripe the cover or top of the Graafian follicle in which it is embedded breaks open, and the egg with a certain quan- tity of blood and granular matter flows out. The blood and other material drop into the pelvic cavity and after a time are absorbed, for the peritoneal lining of the abdominal and pelvic cavities is like a great sponge. The egg may sometimes share the same fate. The proper course for it to take is to be grasped by the fringed end of 90 HOW TO KEEP WELL the Fallopian tube and then be pushed along by the contractions of the tube toward the womb. If it should happen to be met while in the tube by a sperma- tozoon, impregnation might take place then and there. It often does take place there, and often the egg stays there, develops, bursts, and causes great damage, even loss of life, for this is not the proper place for the development of the child. If the egg, whether impregnated or not, pushes its way onward, it eventually gets into the womb, and there it may become impregnated if this condition has not yet been accomplished; but if no spermatozoon comes along (for impregnation is the normal thing to occur) it disappears, perhaps disintegrates, perhaps is swept out with the mucus which is secreted by the uterine mucous membrane. At any rate, it is never missed, for it is so small that it cannot be seen with the naked eye. All these organs are abundantly supplied with blood and lymph-vessels and nerves, and the vagina and womb with multi- tudes of glands which supply quantities of mucus for lubricating purposes. The essential generative organs in the male are the penis and rhe testicles. The penis is the organ in the male by which the sexual act is accomplished. It also contains the canal (urethra) by which the urine is conveyed from the bladder out of the body. It varies in length from three or four inches to five or six, being much larger and firmer when its spongy erectile tissue is distended with blood. The same canal which gives exit to the urine is also the medium for the passage of the spermatic fluid which is discharged into the vagina during the sexual act. If this fluid is of normal quality, that is, if it contains living and active sperm cells (spermatozoa), and if it comes in contact with the opening of the womb-canal, and if in addition the womb-canal is in a normal condition, one or more of the sperm-cells will be taken into the canal. Its vitality may be quickly exhausted and it may die and disappear, or it may work its way forward and upward along the womb-canal and perhaps into the canal of one or the other Fallopian tube. Should one of the sperm-cells come in contact with an ovum either stationary or moving in the opposite direction to itself it will perforate and penetrate the ovum, its head, or anterior seg- ment combining with the contents of the ovum and producing im- THE FUNCTION OR WORK OF THE BODY 91 pregnation, its tail or posterior segment being dropped or cast off as of no further use. The testes or testicles are two oval bodies which are contained in a sac or bag called the scrotum, which is attached to the body just behind the penis. These bodies are protected by a series of coverings or membranes, and within their interior is formed a re- markable substance called seminal fluid. This substance consists of a watery fluid, a granular material, and the actively moving bodies which are known as spermatozoa. Each spermatozoon consists practically of a head and tail, is microscopical in size, and suggests, with the waving motion which it has, a very minute tadpole. The seminal or spermatic fluid is conveyed out of the testicles by twisted tubules into one large tube called the vas deferens. This deposits it into a pouch or sac called the vesicula seminalis, and from this it is ejected into the urethra and so is carried out of the body. The process by which the spermatozoon comes in contact with the egg has been described. One spermatozoon fertilizes one ovum. If two spermatozoa invade a single ovum we have a twin preg- nancy. It is possible that more than one ovum may be fertilized at the same or nearly the same time, resulting in twin, triple, or quadruple pregnancy, but it is probable that in almost all impreg- nations one spermatozoon enters a single egg. CHAPTER III SANITATION AND HYGIENE IN THEIR RELATIONS TO HEALTH General Remarks.-One of the most effective ways of stamping out disease is to have regard for those laws and conditions by which the body may usually be kept in a state of health. This is the essence of the science of preventive medicine, attention to which is being persistently urged alike by the medical profession and the laity. No one of intelligence or experience would deny that many people come into the world with such a legacy of physical sins handed down from their ancestors, near and remote, that they are fatally handicapped and succumb after a short struggle, sometimes hastening the issue by disregard or ignorance of their inherited weakness, and sometimes yielding after every precaution which they and their friends may have taken to rid them of the fatal burden. These facts are now widely recognized, and upon them is based the above-mentioned science of preventive medicine which regards the prevention of disease of at least as great importance as its cure, when a cure is possible. The human machinery may be disarranged and got out of order in so many ways that it would seem only the part of common sense to give a little time to the consideration of the problems which affect at least the physical well being of every one. Climate.-The bearing of climate upon health is a very import- ant one. It is a matter of common experience that residence in a region which is perfectly compatible with health for one individual is equally unsuitable for another. This is abundantly proved by the removal of a sick person to a different location or climate and his restoration to health. That is, there is something about the at- mosphere which tends to be beneficial or harmful to people accord- ing to their physical peculiarities. Upon this fact has been based 92 SANITATION AND HYGIENE 93 the science of climatology, which has accumulated abundant ma- terial in regard to the climate of different regions of the globe and has led to the establishment of hospitals and sanitaria in which the treatment by climate forms a conspicuous feature. Residence in a City Compared with Residence in the Country. -The tendency of the majority of our American people at the pres- ent time is to congregate in large communities, to live in cities rather than in the wide spaces of the country. This movement is very often at the expense of vitality. It is not denied that it is possible to live as simple and natural a life in the city as in the country; but as a matter of fact, and especially among the poor, life in the city is not so simple and natural as in the country. In the city there is the bustle of crowded streets, the unsanitary condi- tion of dwelling-houses, and especially of tenement-houses, the long hours of work in shops and factories and offices, the dissipa- tions, the insufficient sleep, and too often the improper food con- ditions, which do not so often prevail in the country, or certainly not to the same extent. It cannot be denied that there are many at- tractions in the city which the country does not possess, attractions which appeal particularly to the social side of one's nature; but it is a question whether these attractions are not more than counter- balanced by the bad results which come sooner or later, and which should influence teachers and writers upon matters pertaining to the public health to urge a return to the more healthful surround- ings of rural life, and to occupations which keep one as much as possible in the open air. This advice is especially directed to those for whom the restraints and confinement of indoor life are un- suitable because of deficient physical vitality. Influence of Various Climatic Conditions upon Health.-Many people are skeptical about the influence of climate upon health, but tnese are principally the fortunate ones who are never sick and the young whose experience with the physical problem of life is im- mature. Most of us who have had healthy parents and comfortable surroundings have wondered in our youth at the moanings and lamentations of our elders, who were constantly complaining of "crick in the back'' or "rheumatiz," and perhaps mocked at their grimaces and contortions as each new movement of the body seemed to develop a new pain; and we have been incredulous as to the necessity of their limping and hobbling as they followed their task from day to day as best they could. 94 HOW TO KEEP WELL We understand such things better now, we who have reached the period of life when pains and aches are familiar acquaintances; and these physical weaknesses which mark the changes taking place in our tissues are greatly influenced, as we now know, by weather; that is, by climate. They are all worse in stormy weather and better when the weather is clear and dry. There are some folks who could live and thrive in a moist atmosphere, that of an island like England, for instance; but very many cannot do so and require sunshine, dry and pure air, and low atmospheric pressure. The reason why there are so many valetudinarians or seekers after health is because there are so many whose atmospheric surround- ings do not fit their physical conditions and requirements. But there is no perfect climate equally suited to sufferers from all kinds of disease. One whose lungs are diseased must have air that is rich in oxygen, bracing enough to stimulate the heart to activity, of low barometric pressure, and free as possible from dust and bacteria. This person must seek an altitude of two to three thousand feet, where there are no factories with their smoke and dust, no bacteria from the exhalations of thousands of human beings, but a pure, dry air constantly revivified by the growing forest. Another whose lungs are diseased does better in the pure, dry, hot air of the desert, and yet another in the pure moist air of the wide-spreading ocean. Again, one who is subject to pains and aches, as the thermo- meter and barometer move from low to high, must go where the record of these changes from year to year shows that they are slight, compared with other regions, and where the air, moreover, is pure and exhilarating. Those who suffer with rheumatism and joint and muscle pains need, therefore, to seek a mountain climate of moderate elevation, like that of the Carolinas and Georgia, the lower slopes of the central Rockies, and the southern ranges of California. Experience shows the adaptability of certain localities for cer- tain particular diseases, and that is the basis upon which many health resorts throughout the world have been built up. The Adirondacks and the hills of Sullivan County have become recog- nized as the proper places for many who are tuberculous, and the hot springs of Virginia and Arkansas and Michigan for those who are rheumatic or gouty. SANITATION AND HYGIENE 95 Thus the application of climate for the treatment of disease becomes not only an important study but one that must take into account the requirements of each individual case. In a tropical climate or in one in which heat and moisture are excessive during a large portion of the year, we do not find that exuberance of vitality which is so noticeable in temperate and cold climates. Great heat, a temperature of 900 to ioo° F. and over, especially if the atmosphere is heavy with moisture, is enervating and de- prives one of the power of continuous and successful exertion. Those who live in tropical climates are slower in their movements, less active mentally, and less capable of great achievements than those who live in colder climates. Great as is the vitality of the English they have found that they are capable of doing good work in their tropical possessions only if they remain there for a portion of the year, going to cooler regions during the hottest weather and abandoning the tropics altogether after a few years of residence. So great is the influence of intense heat upon vital force that it is said a continuous residence in the tropics for two generations of members of a race native to a temperate climate will destroy the power of reproduction. THE POWER OF INTENSE COLD is also detrimental to vitality. It is possible for white men to live and work in an arctic climate, and we have seen what can be accomplished in the case of many who have gone to the gold region of Alaska and of those who have penetrated even farther to the north for purposes of explora- tion and adventure. Those who go to these extreme northern lati- tudes must contend not only against cold but against the depressing effects of darkness during the long arctic night. The experience of these men seems to show that continuous residence and occupation in such a climate and ability to repro- duce the species is possible to very few. Even the Eskimos, who have been there for generations and have become habituated to the climate, increase in numbers very slowly and do not as a rule reach the age which is reached in a less trying climate. It is therefore probable that the arctic regions will never become to any great degree the abode of human beings. On the other hand those regions which lie well to the north in the temperate zones, in which the winters may be long and severe and the summers short but very productive of the substances 96 HOW TO KEEP WELL which sustain life, are most favorable to physical and mental vital- ity. Nowhere do we find stronger and more vigorous nations and races than those which live under such climatic conditions. The evidence is, therefore, quite conclusive that the best and most favor- able climate for physical development and for good results in physical and mental work is to be found where there is the stimu- lating effect of cold during a considerable portion of the year. Some of the Effects of Cold.-Cold, of course, is a relative term. It would be hard to say where cold ends and heat begins. The same may be said of cold's effects. A degree of temperature which makes one person uncomfortable or sick would have no effect upon another, or it might even stimulate him and make him feel better. When the shock of a cold bath is over in a healthy individual, it is usually followed by a sense of warmth, indicating stimulation of heart and blood. Cold when accompanied by a north or east wind and dampness is more uncomfortable and trying than the same temperature would be with a south wind. Cold and dampness always are more uncomfortable by night than by day; sunlight often makes intense cold tolerable or even agreeable. Travelers in arctic regions and mountain-climbers have re- corded the great differences in the effect of climate and tempera- ture upon different individuals with varying susceptibilities. Rosse, in a disquisition upon the effects of cold, quite properly differen- tiates physiological from physical cold, and the distinction is per- fectly obvious. The ability to resist a temperature much lower than the temperature of the body is due to the heat-generating mechanism within the body. It is this which permits warm- blooded animals like whales and the arctic animals to adjust them- selves to cold surroundings which are practically constant. The influence of this heat-generating mechanism is seen, as Rosse remarks, in the chilly period in fevers, when, with shaking, chatter- ing, and a feeling of intense cold, there may be a body temperature several degrees above normal. The effect of the mind and the nervous system upon the senses, in relation to cold, may be diametrically opposed in different cases. In nervous diseases like locomotor ataxia the victim is unusually sensitive to cold; so also are new-born infants and most aged peo- ple. One who is fired with religious fervor, on the other hand, goes into a cold stream for baptism and is unconscious of its coldness; so also is a swimmer who may have been immersed for hours in SANITATION AND HYGIENE 97 water with almost freezing temperature. Multitudes of women at the dictates of fashion bare their chests, legs, arms, and feet to the cold, and many will tell you they do not suffer discomfort. We do not know in how many of these cases serious or even fatal disease follows as a consequence. Cold carried to the freezing-point produces anesthesia, and it may produce stupefaction and death. Tissues may be frozen and destroyed not only by cold air but by the rapid evaporation of alcohol or ether or by the action of various drugs. Cold which freezes does not necessarily destroy or kill. We are told that fish when frozen may sometimes be thawed out and restored to activity. 'Cold makes fish torpid and inactive, as every fisherman knows. Some birds resist cold very well, for their body temperature is several degrees higher than that of human beings. Crows, blue- jays, starlings, and some other birds which remain with us through the winter seem unaffected even by very low temperature, while robins, bluebirds, larks, and other migrating song-birds become inactive and apparently very uncomfortable as cold weather ap- proaches, their song-notes losing their joyous nature and becoming few and feeble. People in normal health and not yet enfeebled by age are stimu- lated by a moderate degree of cold and their mental activity is in- creased, but even they are unfavorably influenced by intense cold, their muscles becoming stiff and unresponsive, their will-power weakened, and their memory dulled, and the anemia of the brain which is induced makes them drowsy and stupid. The activity of bacteria is inhibited by intense cold, and some varieties are killed by it. Others are merely dormant and resume their baneful influence when the temperature becomes sufficiently high. The effect of cold upon drunkards, as is well known, is fre- quently disastrous, their resisting power being weakened by alco- hol. If they are exposed to severe cold, particularly at night, they are likely to freeze to death. The effect of severe cold also is inten- sified by hunger, fatigue, fear, and mental depression. Retreating armies in winter suffer terrible losses. Of this there are many ex- amples in history, one of the most noteworthy being Napoleon's Grand Army in its retreat from Russia. Cold is a direct inciter of many diseases which we may properly call winter diseases. They include particularly pneumonia, in- 98 HOW TO KEEP WELL fluenza, rheumatism, gout, felons, neuralgia, chilblains, and eczema. When the surface of the body is chilled the blood rushes to the organs within the body, producing congestion; that is why pneu- monia is so common in cold weather. Its effect upon the brain, however, is the opposite: it causes anemia, with resulting drowsi- ness and stupidity. The blood itself is injured by severe cold, more or fewer of its red cells being destroyed or mutilated, and a condition of anemia, even of extreme or pernicious anemia, may be produced. We should not forget, however, the beneficial therapeutic action sometimes obtained from cold. A dash of cold water frequently will revive one who has fainted; a draft of cold air may stimulate the lungs and heart to action; and the contracting influence of cold will arrest hemorrhage when it is not too violent. It often is used in fevers in the form of the bath or the wet pack to reduce tempera- ture, and it will stimulate the kidneys to increased activity, as al- most everybody realizes in the early days of winter. Altitude.-The effect of altitude, that is, of elevation above the sea-level, upon physical force, is much greater than is generally known and believed. At the sea-level and for a few hundred feet above it the air contains much more moisture and more impurities than at greater altitudes. Vigorous people have little trouble in obtaining plenty of air for respiration at the sea-level. The breath of the sea, heavy with moisture, brings stimulation and health to many whose mucous membranes are not already surcharged with moisture. In other words, those with whom there is tendency to dryness of the nose and throat and the mucous surface in general, find their tonic at the sea-shore or by some large body of water where evaporation is abundant and the air is moist. On the other hand, those who are troubled with catarrh of the nose and throat, who are sufferers from bronchitis and are constantly spitting and expectorating, must go to a climate where the air is dry, where the temperature varies little from day to day, and where the rarity of the atmosphere may require more frequent breathing than is neces- sary at sea-level. A moderate elevation, fifteen hundred to two thousand feet, is usually sufficient to produce this desirable result. Our Eastern health-resorts do not greatly exceed this altitude, and many have found health and a stay to disease in the Adirondacks, Catskills, and the lower mountains of Tennessee and the Carolinas. SANITATION AND HVGIENE 99 A still greater altitude of six, seven, or eight thousand feet, as in the Rockies in Colorado, Arizona, and New Mexico, is required by many, and the list of invalids who have peopled these regions and have found health and usefulness is a very long one. Forest and Plain.-The relative influence of forest and plain upon the atmosphere and so upon physical vitality is also a subject of great importance. The question of altitude enters materially into this subject. Plain and forest may be at the sea-level or below, or they may be elevated as in a mountain plateau. A plain of broad extent, if soil and drainage are good, has the advantage of abundant air circulation, and this in itself tends to make at least the surface of the ground dry and to favor rapid evaporation of standing water. Our Western prairies, especially when remote from water- courses, have generally furnished a salubrious climate, and so have the steppes of Russia and the plateaus or table-lands of various mountainous regions. Even the vast solitudes of the desert have ever been the home of hardy races, for the exceptionally dry air, though very hot, may be well tolerated, and it may even prove bene- ficial in relieving extreme moisture and excessive secretion of the surfaces of the body. Residence in the forest, from many points of view, is the reverse of beneficial. The dense foliage excludes the sunlight and prevents evaporation from the soil and the free movement of the air. It is still less desirable because favorable to many forms of annoying insects. Many of our city and village streets, lined with beautiful trees, are unwholesome and unsanitary from their abundance of shade and moisture. We must not be forgetful, however, of the great importance of the forest in preserving the moisture of the soil, in favoring the precipitation of rain from the atmosphere, in consuming the car- bonic acid of the atmosphere and yielding in return an abundance of oxygen; so that while residence within the forest, especially during the hot portion of the year, is neither comfortable nor healthful, residence in a sufficiently open space near the forest, especially if at a moderate altitude and upon a dry soil, often furnishes conditions that are ideal. Wind.-The influence of the wind upon climate is important and not to be overlooked in choosing a residence, especially when the individual has been found sensitive to such influences. The quality of the wind will of course depend upon the regions over 100 HOW TO KEEP WELL which it blows: if from an ice-covered region, it will be cold; if it blows over a great body of water, it will be moist; and if over a desert or a wilderness, it will be very dry. The characteristics of the wind are, therefore, constant or nearly so only with regard to particular localities or regions. This, therefore, must be a matter of study and observation for any particular region. A region in which the topography favors hurricanes, squalls, cyclones, etc., is not pleasant and may be unsafe for residence. Much of our Atlantic sea-coast has a disagreeable prevalence of wind from the sea which is irritating to the skin and the respiratory organs, while other portions of the country are afflicted with strong winds which are laden with sand or other undesirable substances, and a climate which would otherwise be salubrious may be in- tolerable from such a cause. These regions in which the winds are strong and cold, even though dry, are not usually sought for resi- dential purposes, especially by those who are lacking in robustness of constitution. Sunlight.-However essential any other elements of climate may be, there is none which exceeds in importance that of sunlight. Without it healthful existence is impossible. Nothing will do as a substitute, for either animal or vegetable life. The pallor and anemia of those who spend most of their time in the dark is note- worthy. We read of those who exist in prisons and dungeons for years, but it is for them and for all who must live apart from the blessed sunlight only a bare existence.1 A residence in valleys in which the sun's rays are felt from morning till night, and in which the hills are barriers against cold winds, has compensation for many features which may be objection- able. It is well to have your house face the east or south, to greet the rising sun, and to let him look into your windows at every change in his march. 1 The air in Mammoth Cave is wonderfully rich in oxygen, which is freely liberated from the mineral substances with which it is in combination. In many parts of the cave the air is also very dry. These facts induced several sufferers with pulmonary tuberculosis to build small houses in the cave and live there. My recollection is that one speedily died and the others soon abandoned the experiment. No better illustration of the need of sunlight can be given than the effects of its absence upon the forms of life in this cave. The vegetation is pale and stunted; the insects are sluggish in their motions and have but a feeble song; the fish in the streams are small and transparent and move about as if preoccupied or indifferent to their very existence. SANITATION AND HYGIENE 101 Sun-baths for invalids are often refreshing and life-giving. In- deed, to bask in the sunlight, particularly of a bright hazy after- noon in October, is one of the most pleasurable experiences in animal existence. Who has not envied a cat or dog, curled up and sleeping, warmed with generous sunlight, and oblivious of all the ills and discomforts of life? The increasing use of solaria, not only in public institutions but in private dwellings, is an evidence of a renewal of interest in a means of affording health and comfort which was most highly appreciated in the civilizations of ages ago. Of course the debilitating effect of the summer sun and of the gun in the tropics needs no discussion at this time. The best re- sults of sunlight as a health-producing and curative agency must come from association with a dry and cool or cold atmosphere. Moisture.-An atmosphere which is heavily charged with mois- ture is not usually healthful. This is especially the case when it is combined with high temperature. A moist atmosphere is not neces- sarily unhealthy; many individuals become entirely habituated to it, and there may be compensating elements which may render it innocuous. There are no more healthy people than many of those who live along our sea-coast, sailors, fishermen, and others who are oftener in a moist than in a dry atmosphere, many of them showing the utmost disregard of the ordinary rules for health preservation. The atmosphere of London and of many of the English and Scotch towns and cities is as moist and disagreeable as it is possible to be, and yet multitudes thrive under it, and some even seem to enjoy it. The question of its deleterious influence is, therefore, en- tirely relative to the individual, and there are multitudes, of course, who find it entirely incompatible with health or comfort. Choice of a Climate.-Admitting, therefore, that an individual in a fairly robust condition is in very many instances capable of habituating himself to almost any condition of climate without seriously encroaching upon his vitality, what are the elements which must be considered by one of defective vitality in selecting for himself a place of residence? This question may be regarded as a kind of summary of the remarks which have preceded. The first requisite would seem to be that there should be no great extremes in temperature, and particularly that there should be no sudden and extensive variations. A variation of forty or fifty degrees in twenty-four hours could not fail to make an un- 102 HOW TO KEEP WELL favorable impression upon a sensitive and delicate physical con- dition. The climate which at present seems to be considered most favorable for invalids from whatever cause must have a pretty uni- form temperature during the greater portion of the year. In respect to altitude, there are many places both at the sea- level and at elevations of one thousand to five thousand feet in which the variations of temperature are neither very great nor very sudden. The sea-level or its vicinity may be selected if the individual has dryness of the skin and mucous membrane, and a higher elevation when there are moist skin and catarrhal mucous membranes. A region which is often visited by strong winds, whether dry or moist, whether containing irritating substances or not, should be avoided if possible. A forest region, especially of the evergreen variety, may be particularly beneficial for those who are suffering with affections of the throat and lungs. An elevated plateau, if the winds are not strong, is also a favorable location in many in- stances. A location in which it is possible to have an abundant supply of sunlight, apart from the tropics or the depressing heat of summer in temperate zones, is most desirable. A climate in which the atmosphere is constantly charged with moisture is un- desirable and is almost certain to intensify disease in which there is moisture of the skin and debilitating discharges from the mucous membranes. Change of climate and removal from the familiar surroundings of home are not recommended for those who are far advanced in disease of whatever nature. However balmy the atmosphere or exhilarating the breezes or soothing the sunlight, it is not home, and one has the feeling of an exile. Such a removal often hastens the final issue, and while in hopeless cases this may not be a decided objection because of the relief to suffering which it affords, it re- mains a fact that with most of us, if we were allowed to choose our method of departure, there would be a preference to close our eyes to the present stage of existence in the company of those we love and who love us, and with the objects around us to which we have become accustomed and which association has made almost a part of us. Change of climate and of residence is for those whom disease may have attacked but not overcome, and who still have good re- sisting power. It is astonishing how many in this category find SANITATION AND HYGIENE 103 recovery and restoration to health by migration to a climate suited to their condition and are enabled to continue their life-work in the new environment, or in some cases to go back again with safety to their former home. The Soil.-The average individual pays very little attention to the conditions of the soil in his environment. When it is realized that it is one of the most important sources of disease, and that the investigations of sanitarians and bacteriologists have referred pesti- lence and destruction to its influence, it would seem to be desirable that the fundamental facts concerning it should be generally known. Quality of the Soil.-The elements of soil are varied; their arrangement is equally varied; and their influence should be con- sidered in selecting a site for residence. A soil may be very light, like the mold which has accumulated for ages where vegetation has decayed; it may be sandy and very dry; it may be very heavy like clay; it may consist largely of rock and stone; and the stone may be soft and easily broken, or it may be hard and obstructive to any efforts to work it. Of the properties of the soil so far as productive- ness is concerned we are not now speaking, but rather of those which pertain to its healthfulness or unhealthfulness. Dryness.-One of the most important requirements is dryness. This implies great porosity of the soil. A light or a sandy soil allows moisture to drain through it like a sponge; an exposure to the sun evaporates that which does not drain away; and the tem- perature of the air and of the surface of the ground, not being very different from each other, result in favoring conditions so far as they relate to healthful residence. On the other hand, a heavy soil, clay or rock, retains moisture, evaporation being slow if exposure to the sun is wanting, and the air too moist if evaporation is abun- dant. Swampy and marshy regions, or regions with a heavy, non- porous soil or subsoil, are not favorable for residence, though they often become so by the use of careful systems of drains and ditches. A moist soil may become a source of discomfort and disease, not only because it yields too much water to the atmos- phere by evaporation but because it yields poisonous germs which, by the decomposition of animal and vegetable substances, are liber- ated and are inhaled with the atmosphere by those who may be within the range of their influence. 104 HOW TO KEEP WELL Residents in badly drained villages and river-bottoms suffer in this way, and we call the condition malarial poisoning, which means poisoning by bad air; that is, by air which contains infectious animal or vegetable germs. These germs produce the very com- mon disease which is known as intermittent fever, or fever and ague, though this is by no means the only disease which is derived from infectious germs residing in or obtained from the soil. The opinion that malarial fever is due entirely to the bite of a certain variety of mosquito is now quite generally held. It does not seem to me it is the only cause. Drainage.-It must be evident from the foregoing that a soil which is not relieved of its superfluous moisture by natural drain- age should be thus relieved by artificial measures. A light soil of considerable depth, a sandy soil, or one which slopes toward a run- ning watercourse will usually furnish sufficient natural drainage to carry off superfluous moisture, but a heavy soil in a level or nearly level region must be relieved by ditches and drains, which should vary in depth with the degree of saturation of the soil and should lead, if possible, into some stream or pond remote from the location of human residence. The construction of the drains need not con- cern us particularly; they may be trenches loosely filled with ir- regular stones along which the water will find a channel, or they may be of porous hollow tiles which will absorb all the moisture which approaches them. The annoyance from the exhalations of cesspools and privy-vaults cannot be too strongly insisted upon. Where it be- comes necessary to use them they should be as far as possible from the place of residence, a hundred feet or more if possible, and they should be freely supplied with disinfectants, such as chloride of lime or chloride of iron, to destroy their noxious influence. In large towns and cities systems of sewerage should be adequate to carry off all waste material; vaults and cesspools should be disin- fected and closed, and particular care should be taken that there should be no possible communication between sewer-pipes and those which are used for the public water-supply. In some localities a system of drainage is used for the surface water, that is, the water which is derived from the rainfall, and another for sewerage. This should be avoided if possible and a common outlet provided for all waste material of a fluid or semi- fluid nature. The more dilute such waste material may be the less SANITATION AND HYGIENE 105 its capacity for inflicting injury. Besides, there ought to be a way of utilizing surface water. To allow millions of gallons to be wasted when its utility for flushing streets, watering lawns, putting out fires, washing clothing, etc., is distressingly apparent means a loss of thousands of dollars, and is not an evidence of wise govern- ment. Pavements.-Good pavements of whatever nature in a city, and hard dry roads elsewhere, are not only more easily kept in repair than inferior ones but are the more favorable for the removal of waste material; they are, therefore, important adjuncts to good sanitary conditions. Accumulations of dust and mud are not only a source of discomfort but unsanitary, the one from the liberation of more moisture than is desirable, the other from the possible liberation of irritating or poisoning substances from which the eyes, the nose, or even the whole body may receive detriment. Local Environment.-For the best results from a sanitary stand- point, one must not be unmindful of the immediate surroundings of the home. The grass must be frequently cut, the vegetation not allowed to decompose, shade should be sufficient to shelter from the fierce rays of the sun but not sufficient to prevent free circulation of air; and it is always desirable to diversify the prospect with the bright colors of flowers and to enter into sympathy as far as pos- sible with our humbler relatives of the vegetable world. Water-Supply.-When we realize that from two thirds to three quarters of the entire weight of the body is water, that most of our food is combined with water, and that many people are taking one or two quarts of it in an undiluted condition every day of their lives in addition to that which is constantly taken with their food, it becomes a matter of decided importance to know that it is pure and potable. Potable Water.-Potable water may be defined as a fluid which is reasonably free from noxious germs and from harmful ingredi- ents of all kinds, whether in solution, in suspension, or in sediment. It should have no disagreeable taste nor offeusive odor, and its attractiveness is increased when it is clear and transparent and of sufficiently low temperature to produce an agreeable sense of cool- ness, not only in the mouth and stomach, but throughout the entire body. Source of Water-Supply.-The water-supply to an individual or a household is private or public: private if derived from wells, 106 HOW TO KEEP WELL springs, streams, or cisterns appertaining to the individual or house- hold ; public if supplied by a company or corporation. It is diffi- cult to say which is preferable, a private or public water-supply. In certain cases one or the other must be depended upon. A private supply is often impure because of the carelessness or ignorance of the individual. A public supply cannot long be impure and harmful without endangering the health of the community and consequently exposing the company or corporation to the risk of litigation for heavy damages. Water drains through porous soils or flows along the surface, taking a course which is influenced by the slope and inclination of the ground over which or through which it may flow. It flows in streams along the surface, or sometimes under the surface, collects in springs and pools in the course of its drainage below the surface, and is collected in cisterns and reservoirs, either natural or arti- ficial, as it falls from the clouds. The great expanse of water over the surface of the earth is constantly undergoing evaporation. The particles of moisture thus obtained are collected in watery vapor and clouds, and when the air is sufficiently saturated with this vapor to be unable to hold it in suspension it drops to the earth again in the form of rain. Water can be and indeed is largely produced by the combina- tion of the two gases of which it is composed; namely, two parts of hydrogen and one of oxygen. Watersheds.-In the collection of large volumes of water for the supply of communities not only must the streams, pools, lakes, etc., in the given regions be considered, but also the land over which the water flows, after its fall from the clouds, to get into these streams. A ridge of country or a series of ridges is there- fore selected down the sides of which the water runs in brooks and mountain torrents or is drained through the sloping soil, to be collected in large streams or ponds at the foot of the hill, and then to be gradually impounded in a reservoir either natural or artificial, from which it is forced by its own weight and pressure, or by artificial force, if the former is insufficient, to the premises of the consumer. The region which thus drains the natural water-supply in a given locality is called its watershed; and a good watershed, that is, one in which the streams of water have such a course that they are easily controlled, is of great value to a community. SANITATION AND HYGIENE 107 Where there is no public supply, premises become the more valuable as they are supplied with springs and streams which be- come available with the minimum outlay of force and expense. Constituents of Water.-Water is a complete substance; it is never absolutely free from organic and inorganic material or both except when produced by the direct combination of oxygen and hydrogen or when derived from distillation. The dissolving or solvent power of water being great, it gathers many substances in a dissolved condition as it flows along or as it remains stationary in the location where it may have been col- lected. Animal and vegetable life make large contributions to the constituents of water, but the inorganic or mineral elements, which are also constituents, are far more abundant. Animal sewage, decayed and decomposing vegetation, the eggs and larvae of countless insects, the germs of numerous diseases are of such frequent occurrence in water and are capable of doing so much mischief that rigid tests of public water-supplies are often re- quired. Unfortunately the test may not be made until disease or death has awakened the community to a sense of the necessity of making it. Typhoid fever in countless cases has been communi- cated by drinking water contaminated with the germs of the disease. Cows have been seen wading in a stream filled with vegetation upon which they were grazing, this stream forming the water- supply of a city a short distance away. The same stream was alleged to have been infected with sewage flowing from a large public institution near-by. This water was passed through filter- beds, but mere filtration is insufficient; and chemical treatment, though effective, is frequently at the expense of impaired potability. It is not strange that typhoid fever prevailed in the community which had this water-supply, nor that bacteria which are peculiar to the large intestine in man and animals should be repeatedly found in water which was derived from this source. Many equally fla- grant cases would doubtless be revealed if the water-supplies of other communities were carefully investigated. Is not this a suf- ficient proof that our public water-sources cannot be too rigorously protected? All our so-called mineral springs contain inorganic matter in so- lution, and in some of them the quantity is large and materially affects the quality and influence of the water. Water which con- 108 HOW TO KEEP WELL tains lead, sulphur, lime, iron, magnesia, lithia, etc., is of such common occurrence that it is hardly necessary to mention it, while the water of the ocean contains not only sodium chloride or com- mon salt in abundance but often bromine, iodine, and other minerals which are useful in some instances and harmful in others. Water is hard or soft according as it contains much or little inorganic mat- ter : lime-water is hard; rain-water is soft. It is commonly stated that water purifies itself of impurities after flowing a certain number of miles. Such a statement is very misleading. It is doubtless true that many substances which are heavier than water are dropped or settled after flowing a greater or less distance, but there is no reason for supposing that substances which are in perfect solution or which are of a microscopic size are thus rendered innocuous; indeed, these are the substances from which most harm is likely to be derived. The water which contains them may be as clear as crystal, and yet it may abound in deadly poisons. It is not well to trust, therefore, to the appearance of water in deciding as to its potability and healthfulness. How May Water Which is of Doubtful Purity Be Rendered Harmless? It is not always easy to change one's water-supply; it is always possible to render it absolutely free from harmful influence. Among the methods which are in use for artificial purification of water may be mentioned filtration, the use of chemicals, boiling, and distillation. Water which is simply turbid, without materials which are actually injurious, a condition which is of usual occurrence after a storm or other exciting cause which disturbs the bottom over which it flows, may be rendered clear by simply allowing it to stand for a few minutes before it is used. The substances which are in suspension then sink to the bottom of the containing ves- sel ; the clear fluid can be poured off; and the lower portion con- taining the sediment can be discarded. Filtration is a very common method of treating water which is impure. Sometimes it is effective, and often it is ineffective. It consists in passing the water through a porous substance, the im- purities being left behind if possible. Sometimes a porous stone, SANITATION AND HYGIENE 109 soapstone, porcelain, etc., is used; sometimes sand, charcoal, or other substances are used as percolators, the theory being that the pure water filters through and leaves the impurities behind. This may be effective for large particles; it is not effective for sub- stances which are in solution. Besides, if the filtering-material is not frequently renewed, the pressure of the water may be sufficient to force through the material which has accumulated from the first filtrations, and the filter becomes of no use whatever. Many forms of filtering-ap- paratus are on the market; the most of them are worthless so far as furnishing protection from water impurities is concerned. A piece of coarse linen toweling wound about the water-tap and frequently changed will catch the coarser materials as the water flows through it; it is as effective as the expensive forms of apparatus, most of which can do little more than this. If one is about to buy a filtering-apparatus it is better first to talk the mat- ter over with an intelligent physician or expert chemist, rather than trust to the plausible arguments of the man who has filtering- apparatus to sell. In many cities filtering-beds are used on a large scale and sometimes with satisfaction.3 The addition of certain chemicals to water which is of doubt- ful purity will destroy animal or vegetable germs which it may contain and render it innocuous. One of the least objectionable substances which may be used for this purpose is dilute hydro- chloric acid. A teaspoonful of this in a quart of water will slightly acidulate it, without rendering it unpalatable. It is better to use this than to use the stronger, more corrosive acids, which are very dangerous in the hands of the careless or ignorant. More effective than the use of weak acids, and positively with- out danger, is the subjection of suspected water to a boiling tem- perature for half an hour. This will positively destroy all noxious germs. There are many germs which will resist a freezing tem- perature, but none have yet been found which would endure 2 As an example of the above, the city of Poughkeepsie, New York, which is on the Hudson River, has derived its water-supply from that river for many years. The tide-water is of course salt, but with the outgoing tide the supply from above the city is fresh. This is pumped into beds of sand, which are near the river, and then forced into a reservoir at an elevation of several hundred feet, from which, with ample force, it is distributed over the city. , 110 HOW TO KEEP WELL boiling. If any sediment remains after the water has been boiled, straining or filtering through a linen towel will remove it. When such water has been cooled it is by no means unpalatable and is absolutely safe. The dead taste, which is the more apparent when it is not cold, may be overcome by forcing air into it with a bel- lows, or by hanging the vessel containing it in a draft where it will swing back and forth and absorb air, its temperature being lowered at the same time. Distillation is an equally efficient mode of obtaining absolutely pure water, but it is more troublesome than boiling where small quantities only are desired. At the present time the distillation of water in large quantities is an important industry and is to be commended and encouraged when the question of expense is not important. Ice which is artificially made from distilled water is far safer than the natural supply for reasons which were given. General Summary.-The general conclusion in regard to a water-supply, whether public or private, may be, therefore, that it should be abundant, from twenty-five to fifty gallons a-day for each individual, sufficient for drinking, washing, for the use of animals, and for keeping premises surrounding one's residence suf- ficiently moist; that it should be pure; that it should be kept in motion as much as possible (stagnation in metallic pipes, in cis- terns, or in pools often contaminates it), and that it should be without offensive taste or odor. Air.-If a salubrious climate, a suitable soil, and a proper supply of water are indispensable requisites to health, certainly not less indispensable is a sufficient volume of pure air. From the moment a human being enters the world, when the lungs ex- pand for the first time and give expression to it in a cry, till the last gasp of physical existence, there is one important requirement which must ever be satisfied, the requirement for air. It matters not what the condition of the individual may be-savage or sage, saint or sinner, pauper or millionaire-air he must have or die. Composition of Air.-Air is a mixture, four of its parts being nitrogen and one oxygen, in general terms, the latter being the essential element and being taken into the blood in connection with the process of breathing. The two gases are so loosely mixed that the oxygen is easily separated from the nitrogen. Air also contains argon, watery vapor, carbonic dioxide, dust, smoke, and various other impurities. SANITATION AND HYGIENE 111 The higher we ascend the rarer and purer the air, and the purer the air the more the mucous membrane of the lungs is stim- ulated, and the faster we breathe. In cities where the air is loaded with the smoke from factories, the gases from the breaking up of various chemicals, the carbonic acid gas from the exhalation from the lungs of countless men and animals, and the effluvia from de- composing animal and vegetable waste material, it is far less wholesome than in the country where vast areas of open space permit the free movements of atmospheric currents, where the vegetation is constantly yielding oxygen and absorbing carbonic acid, and where the number of men and animals which are drawing upon the supply is far too small to make the slightest effect upon the total volume which is drawn upon, or to interfere with its purity. Unless a house or other inclosure which is occupied by men or animals is in free communication with the external air it is far less capable of sustaining life than the external air. In winter many houses have a totally inadequate air supply. They are overheated from stoves or furnaces; windows are sealed; the burning of lamps, candles, and illuminating-gas consumes much oxygen; and the air-supply is further contaminated by the escape of deadly coal-gas and the carbon dioxide which is exaled from the lungs of the occupants. It is not strange that for this reason much more sickness prevails in winter than in summer, and that, too, in a season when the cold external air is more stimulating and bracing than at any other time in the year. There is little doubt that a large proportion of the disease which prevails during the winter season could be entirely avoided if greater wisdom were shown in admitting to our houses a sufficient volume of pure air, the freest and most abundant of all the gifts of nature. Air in Motion.-Air in motion is much more salubrious than air which is stagnant. We realize this in the sultry days of sum- mer when a cool breeze or the brisk action of a fan gives an agreeable change to our feelings. We realize it, too, after reach- ing the top of a hill or mountain, where we are at once exhilarated and revived by the wind and the lighter atmosphere. Moving air, even when it contains impurities, has less chance of doing harm than stagnant air. Air which moves with too great rapidity, as in cyclones, hur- ricanes, and tornadoes, becomes an agency of great mischief. 112 HOW TO KEEP WELL Since it is powerful enough to overturn great trees, deeply rooted, we can realize its enormous force when we reflect that the ordinary atmospheric pressure, which makes no impression upon ordinary objects, is sixteen pounds to the square inch. Impurities in the Air.-We have already stated that the or- dinary atmospheric air contains much that is unnecessary, much that is harmful to animal life. Some of the more common impur- ities should be well considered, for they may often be avoided or disposed of. Air which contains much watery vapor is both disagreeable and depressing in its effects upon vitality, especially when it is associated with elevated temperature. The artificial disturbance of such air with fans brings relief, and the general use of electric fans is one of the most useful applications of that beneficent force. Probably the most common of all the impurities in the atmos- phere is carbon dioxide, or carbonic acid gas as it is commonly called. This is a result of combustion, and its most common source in our houses is the exhalations from the lungs of those who oc- cupy them. It is usually abundant in rooms in which large numbers of people are gathered, especially at night, when the oxygen in the air is also consumed by the burning of lamps and illuminating-gas. It produces drowsiness and inability to concen- trate the mind, but this feeling quickly disappears when the gas is replaced by a sufficient supply of pure air. The exhalations from the body and from the lungs of many individuals yield other gases which may be offensive and even nauseating to those who may be compelled to breathe the atmos- phere which has been contaminated by them. A far more deadly gas is the carbonous oxide or carbon mon- oxide which we commonly know as coal-gas and which is the result of imperfect combustion. It is very irritating to the breath- ing apparatus and is at once perceived when proceeding from a leaky stove or furnace or one in which the fuel burns imperfectly. The imperfect combustion of petroleum in automobile engines also liberates carbon monoxide; when this occurs in a closed garage it may have fatal consequences, and has in numerous cases. Impurities in the air proceeding from decomposing animal and vegetable material of all kinds are not always directly danger- SANITATION AND HYGIENE 113 ous to life, though they are often very offensive and nauseating, especially when the air-space in which they are diffused is a limited one. Exhalations from sewers, privy-vaults, etc., which permeate a house from defective structure or defective plumbing are not always offensive; they may be odorless. They are probably re- sponsible for disease, but perhaps not for as much as is charged to them. It is for the interest of certain tradespeople and others to keep up an agitation of this kind, and particularly when, as in this case, there is a foundation of truth. Poisoning of the atmosphere from wall-papers is probably mythical'. The metallic paints which are used in coloring them are not sufficiently volatile to be liberated in the form of gas at the ordinary house temperature. The air is frequently tainted by the presence of fresh paints. Here the oils used are volatile, and the vapors which are liberated are acrid and nauseating. Much dis- comfort and sickness are caused by the air of freshly painted house interiors. Such interiors should be abandoned until the paint is thoroughly dry. The air is often vitiated by coarse particles of substances which are liberated in the prosecution of various employments, such as those of coal-heavers, chimney-sweeps, coal-miners, grinders of various substances; also by the liberation of irritating gases in factories and shops where volatile chemicals are extensively used. All these occupations have a morbidity which is distinctly trace- able to the poisoned atmosphere which is necessarily associated with them. Those who employ human beings in such hazardous occupations should be compelled to throw all possible safeguards around their workmen. That in many cases they do not is more than probable; a more considerate and humane social community will insist in the near future that a fellow-being shall not be con- stantly jeopardizing his life and health for a mere pittance, as is too often the case at present. The atmosphere may be vitiated by a countless multitude of disease-germs too small for ordinary detection. Their very method of gaining access to the interior of the body and accomplishing this destructive work is often obscure; we see only their results. The germs of intermittent fever, tuberculosis, and the various eruptive diseases are communicated to a greater or less extent through the medium of an infected atmosphere. The same may be 114 HOW TO KEEP WELL true of typhoid fever and other serious diseases, though this does not exclude transmission by water and other media, both animal and vegetable. There are many other possible sources by which the atmos- phere may be defiled and rendered unfit for respiration. Enough has been said to demonstrate the complexity of the subject as well as its great importance. The Home.-The consideration of the home from the hygienic standpoint is susceptible of a great variety of treatment, according as it is in the country or the city, isolated or united more or less closely with other buildings, massive or flimsy in its construction, costly or inexpensive. And yet there are certain conditions which ought to be satisfied wherever and whatever the home may be. We are considering the home particularly as the abode or place of living of human beings. It goes without saying that the home should be built of sub- stantial materials, having in view always the corroding effects of the elements, heat, moisture, and time. If you are building the home, give the contract by all means, to a builder who has ex- perience and character. Otherwise, and especially if he finds he has miscalculated as to his profits, you may expect he will use unseasoned timber, untempered mortar, and workmen who will bear watching. A home built under such unfavorable conditions will always be a source of vexation, expense, and dissatisfaction. Dryness.-Dryness in a home is essential to health. Cellars and ground adjacent to the house should be well drained. Walls that are likely to be moist should be dried by throwing doors and windows open and letting in the air and sunlight, and also by artificial heat if the former method is ineffective. If this does not avail and the walls persist in being moist, abandon the house; it is unfit for residence. In many towns and small cities are frequently seen wooden houses with a space of a very few feet between them. This may mean a larger immediate profit to the landowner, and that is as far as many men look, but it means in addition unpicturesqueness and unattractiveness in appearance; they will, therefore, not draw the most desirable class of residents, and in the moist season they will be damp and unwholesome. Air and Sunlight.-The best houses are those which are open to the air and light on all sides. If this is impossible to obtain. SANITATION AND HYGIENE 115 and it is impossible for all but a very few in the city, try and get a home where at least the sitting-room faces east or south and where a draft from windows in front and rear and from air-shafts, if possible, will stir up the atmosphere two or three times a day and blow out impurities. Alas, how many homes so-called there are in tenement-houses big and little, pretentious and unpretentious, where the blessed sunlight never comes, and the air is constantly loaded with the im- purities of the ages and various other things! Pure air sometimes strays in by accident, but it may be unwelcome, so accustomed do people become, after a time, to darkness and filth and foul odors. Air in the Sleeping-Room.-It is especially desirable that the sleeping-room should communicate with the external air. Air- shafts, especially in tenement-houses, are often most imperfect means either of getting rid of foul air or supplying that which is pure; and the small rooms, closets, which are so common in cities, which have neither air-shafts nor windows, which may con- nect with a gloomy hall by a transom over the door, ought to be suppressed by law. They are hardly fit for store-rooms. To state in figures the air-space which is necessary for the average human being, the cubic feet of air inhaled and carbonic acid gas exhaled, and the volume of inflowing air required to satisfy the normal respiration would only confuse the average reader; so we will condense the matter by advising every one to have as large a sleeping-room as he can get, with walls at least ten feet high, with a window facing the east or the south, if pos- sible, so that the sun may look cheerily in and bid him good morning; and let him see to it that this window is open when he goes to bed. Ventilation.-Ventilation, as applied to the home, means the removal of impure air and gases and the admission of pure air. Of course this definition is equally applicable to any and all build- ings. The air in any limited space becomes exhausted as it is used in respiration. At the same time it becomes impure and unsuitable for respiration through the addition of carbonic acid gas which is exhaled with every expiration of the lungs. It is further con- taminated by exhalations from the body, by vapors from cooked food, by coal- and sewer-gas, by the contamination of lamps and 116 HOW TO KEEP WELL illuminating-gas, by dust and dirt which find an entrance into every house, and by the germs of disease. The problem is, therefore, to get rid of the impure air and to have a constant supply of fresh and pure air. Few, if any, houses are so carefully made that air cannot enter by cracks in doors and windows, and by the loose joints which have resulted from bad workmanship or shrinking materials. But this will seldom result in effective ventilation even when the winds are high and resist all attempts to shut them out, except of course, in the most primitive or the most dilapidated houses. In warm weather ventilation is easily effected by keeping doors and windows open most of the time. In cold weather (except, of course, in the extreme of cold weather) let the house be freely opened morning and evening for half an hour or so and flushed, as it were, with fresh air. In the meantime try and arrange a draft by the stairways, or by the air-shafts and windows and doors, if one's home is on a single floor, which shall provide a continuous inflow of pure air and an outflow of impure air. Ventilation may be provided in windows or in walls, one for the heavy gases at the bottom and another for the lighter ones at the top of the room. Many systems of ventilation involving more or less expense have been advocated; but for private dwell- ings, especially when the question of expense is to be considered, an efficient system can always be devised with the exercise of ordinary common sense, by utilizing doors, windows, and stair- ways. For public institutions or very large buildings there should be some definite system of ventilation, just as one would follow a definite system of lighting and heating. In all cases the simplest method should be followed when possible. Heating.-Not the least important question in the hygiene of the home is that of heating during the months when artificial heat must be used. In the kitchen the question is present during all periods of the year and is most difficult, the elevation of tem- perature in small and poorly ventilated rooms being often almost insufferable. If this excess of heat cannot be conducted to some point where it may be utilized, it would seem that flues or drafts might be arranged whereby it might be conducted away. When one thinks of the enormous amount of force which is wasted by the present methods one cannot help looking forward with great longing to the already nearly perfected methods of SANITATION AND HYGIENE 117 supplying heat in the kitchen by illuminating-gas and electricity whereby only so much heat will be used as is required to accom- plish a certain amount of work. The increased comfort of those who have to work in the kitchen should in itself be a stimulus to investigation in this field, to find some method by which the excessive radiation of heat from cooking-stoves may be avoided. Various methods are in vogue for heating houses with hot air, oil,3 steam, hot water, illuminating-gas (i.e., coal-gas), electricity, etc. The subject is one which is undergoing rapid evolution and will result in a few years, in all probability, in the general use of electricity as a means of heating houses. Each method of heating has its advocates and each its good features. Hot air from furnaces if suitably mixed with pure, cold air is, if not the oldest, the most commonly used method; it is in most cases cheaper than other methods and open to few ob- jections which are not remediable. Hot air obtained by steam and hot-water plants is merely another way of obtaining heat by radiation. Many writers, especially those who write from a standpoint of personal interest, assert the superiority of these methods of heating to that of the hot-air furnace; the latter continues to be used, however, by many who are not yet convinced of its inferiority. Heating by elec- tricity may obviate the objections to the other methods and be the chosen one of the near future. It must be remembered that all methods of artificial heating dry, to an unwholesome degree, the atmosphere which has been heated. They also introduce into it, not infrequently, many objection- able elements, offensive odors, dust, coal-gas, etc. The excessive dryness of the atmosphere can always be remedied by the evapo- ration of water in the room to which the heat is applied, and a good plan of ventilation will keep the air tolerably pure. As a matter of fact, the majority of houses which are heated artificially are unhealthy. Plumbing.-The introduction of running water into places of residence, with the accompanying series of waste-pipes leading to sewers and cesspools, has added greatly to the comfort of living. 3 Heating by petroleum oil is in vogue in many communities with varying degrees of satisfaction. It has advantages over heating by means of coal, but the necessary apparatus is still susceptible of decided improvement, particularly in the matter of expense. 118 HOW TO KEEP WELL In many communities it has done away with the inconvenient and unsanitary outhouse; it has vastly increased the use of the bath; it has diminished the labor of transporting the water-supply to the various parts of the house, often a matter of great impor- tance when the house is large and its occupants many; and in numerous other ways it has been of great benefit to the com- munity. It is not surprising that the blessing which has resulted has not been an unmixed one. Pipes made of lead (and plumbing means working in lead) seem to have been usually preferred for the conveyance of the water, partly for economy's sake, partly because lead is easily worked. They may also be corroded and dissolved, and not a few cases of lead poisoning are doubtless traceable to drinking water which has been contaminated by standing in lead pipes which have yielded more or less of their substance to it. Very hot water is, of course, much more likely to dissolve the lead through which it passes than is cold water, and the experience of corroded pipes riddled with holes from such a cause is not an unfamiliar one. A more resisting, more durable substance for water-pipes in houses, and one not more expensive than lead, is desirable. At the present time brass pipes are being used to a considerable extent; whether they are sufficiently advantageous to supersede lead pipes remains to be seen. Leaks in water-pipes often occur where they are difficult to reach and repair; and the leaks often do much damage and are a source of ill health from the dampness which results from them. An attempt to remedy this has been made by having all pipes exposed, but this is no complete remedy, and water-pipes are not usually objects of beauty. Too often these bad results are due to unskilful workmanship; joints are badly made, bends are too sharp or are poorly protected, or bad materials are used. In many houses the waste-pipes are badly constructed; they become clogged with more or less solid material, especially with filth, and they often fail to prevent the upward passage of noxious gases from sewers and cesspools, which may be the more harmful because odorless. The trap is merely an obstruction which is formed by a crooked pipe and a column of water. It is not impossible that many gases may penetrate this obstruction and not lose their power to produce SANITATION AND HYGIENE 119 mischief. It is therefore a very difficult matter to make sure that one is sufficiently protected from such evils. The use of suitable disinfectants in traps, like chloride of lime or chloride of iron, will be of service, but the complete remedy will come only when a more perfect system of house plumbing has been developed. The abandonment in many houses of the systems of water- pipes is a confession of weakness. Besides, even when this has been done it has usually been done only in part, the bath-room and water-closet pipes being retained; if infection were present in a given house, it would still be present even though in a minor degree when any waste-pipes at all remain. General Considerations.-In addition to the foregoing there are certain general considerations which should always be regarded, if the home is to be considered as satisfying fundamental sanitary requirements. It must be kept clean and free from dust and dirt. Cleanliness is next to godliness in more respects than one. The home should be kept free from bad odors that is, the air-supply should be ample. It should not be overloaded with furniture and particularly with curtains and hangings, which shut out air and light and accumulate filth, disease-germs, etc. From the sanitary standpoint it would be better to do away with these things and substitute those which can be freely washed and scrubbed and which can harbor no elements of disease. From an esthetic point it is to be feared that such a crusade would at least be premature. Beds and bedding must be an especial object for sanitary regula- tion. Iron or brass bedsteads, hard and clean hair mattresses, sheets of cotton or linen always clean, blankets also clean, and everything well aired and ventilated, these will produce sleep and promote health. Habits Haste in Eating.-The hasty eating habit is a very common and pernicious one, particularly in cities and in locations in which the greatest activity must be compressed into the limits of a few hours. Many who are thus pressed and hurried either omit the noon meal or hurriedly swallow it half masticated and immediately plunge again into their absorbing work. This means delayed digestion, imperfect digestion, and, before very long, a whole series of digestive troubles from which the suffering may be in- tolerable. 120 HOW TO KEEP WELL Worry.-The worrying habit takes toll and saps vitality in countless cases. Sometimes this is an inherited fault, not caught and regulated in early life when it was manageable and sometimes it is the consequence of unfavorable experience. It is one of the most destructive habits from which human beings suffer and is the cause of more unhappiness and more suicides than anything I know of. Sometimes worrying is justifiable, but if only that portion could be eliminated which is unnecessary, it would free the human race of a large portion of the misery and unhappiness for which it is responsible. Unpunctuality.-Unpunctuality is getting to be one of our most provoking and widely diffused habits. A church service, a theater, a public or private entertainment of any kind, even a session of court or a business engagement, is seldom begun on time and often means unnecessary annoyance and loss of time for other matters to those who are disposed to be punctual. Athletics.-One of the habits almost universally popular at the present day, but too generously stressed, as it seems to me, con- cerns devotion to athletics. Brutal prize-fighting is objectionable and demoralizing from every point of view, and I marvel that any self-respecting man or woman can in any way lend encourage- ment to that which is so debasing. But every form of athletics, however good it may be in its proper place, is being worked too hard, not only because it is too prominent in the scheme of life's activities, but because it so often reacts unfavorably upon those who are unwise in their way of using it. Clothing.-Of course, the first requisite of clothing is that it must be adapted to the purpose for which it is to be used: the mechanic must have coarse clothing or overalls; the house-servant must have an apron over a dress suitable for her work; children must be equipped for the various mishaps to which they are liable; and the idle butterflies, male and female, must be so robed as to attract attention and excite remark, if possible. It must also be remembered that the primary object of clothing is not to communicate heat to the body but to furnish a barrier between the temperature of the atmosphere and the temperature of the body. The latter in health is nearly constant (98.4° F.) ; the former is constantly varying. Savages, except in very cold clim- ates, do not require clothing, the skin being toughened by ex- posure and becoming an efficient non-conductor of heat and cold. SANITATION AND HYGIENE 121 We wear light clothing in summer because this prevents the passage of heat-rays through it to the body. We wear dark clothes in winter because they absorb heat-rays and exclude rays of light. Furs and woolens are agreeable and suitable in cold weather because they are excellent non-conductors. Whether one should wear cotton, wool, silk, or linen next to the skin must be settled by choice, by experience, and not infrequently by the stern cri- terion of cost. Each of these different materials has its advocates who assert its superiority to the others. Personal experience in- clines me to prefer woolen undergarments, but never very heavy ones, for all weather except the heated months of summer. They absorb the perspiration readily, do not, when moist, give to the body the unpleasant chilly sensation given by damp cotton under- garments, and seem to be the most efficient non-conductors, especially for great variations in temperature. It seems hardly necessary to say that loose clothing in summer is the more comfortable, the body moving the more freely, and the radiation from the body being less than with clothing that restricts and binds. In cold weather, on the other hand, snug- fitting garments prevent too free radiation of the body heat and also prevent the access of cold currents of air which rapidly neu- tralize the body heat. Clothing should never be so tight as to constrict the body and interfere with the circulation. Soft hats are more salubrious than firm and stiff ones. The covering for the feet should be broad of sole, low of heel, and ample of upper. The present ridiculous fashions in shoes are bringing their just penalty in deformities and diseases of the feet. Garments which are made wholly or in part of rubber are almost impervious to air. Radiation of heat from the body out- ward is prevented, and except in cold weather or in very wet weather they are exceedingly uncomfortable. They are most valuable in protecting the body from rain and snow, but are un- suitable, as a rule, for any other purpose. Occupation.-It is rational and desirable that human beings, when in health, should have continuous and useful occupation. It is by no means a misfortune that for the majority of people occupation is a necessity to existence. An idle life if not mis- chievous is at least very selfish; and when we realize the brevity 122 HOW TO KEEP WELL of life and the great number of helpless and suffering ones who need assistance it seems entirely inexcusable. An occupation may be the means of promoting health and longevity, or it may certainly result in disease and early death. What a pity that in order to sustain life so many poor mortals must engage in pursuits that inevitably bring their life to a pre- mature close! Out-of-door occupations, even if laborious, are not usually unhealthful; farmers, mechanics, teamsters, sailors, if they observe ordinary precautions, are wont to enjoy rugged health. On the other hand, those who work indoors are more susceptible to disease; hence factory-hands, tradesmen, even professional people, unless their indoor life is compensated by sufficient out-of- door exercise, are deficient in physical endurance. Muscular exercise, an abundance of fresh air and sleep, and simple food seem to be the principal factors in determining physical well-being. For those whose life must be passed indoors to a large degree, it is therefore desirable that physical exercise should be constantly had. It may consist in walking, riding, rowing, athletic games, gymnasium exercise, or a variety of other useful measures. Unless something of this kind is systematically pursued it will be very difficult to maintain uninterrupted good health. The daily bathing of the entire body is especially useful for indoor workers. The skin disposes of much of the waste material of the body. Those who are constantly engaged in out-of-door work usually find that the skin readily responds to the task which is imposed upon it, and the general activity of the organism also encourages easy performance of function of the other excretory organs, the lungs, kidneys, and intestines. The indoor worker is often deprived of this constant stimulus, and the daily bath will be of assistance in keeping the skin in condition to perform its necessary work. Its temperature must be largely a matter of choice. The indiscriminate use of cold baths is neither wise nor satisfactory. Amusements.-Amusements aside from physical exercise are not to be neglected; music, the drama (when it is clean and in- structive, which unfortunately is not always the case), interesting or amusing lectures, various indoor games, and many other forms of wholesome recreation are useful adjuncts, in the consideration of the means for the promoting of health. Vacations.-Occasional vacations have a most important sani- SANITATION AND HYGIENE 123 tary value. No one who has followed the development of the move- ment for giving brief periods of rest during the summer, whether by the sea-shore, at the mountains, or in the country, to our tired and sick men, women, and children of the city, our brethren and sisters, especially to the poor and those whose homes are not very bright or cheerful, can fail to realize what this means even from a physical standpoint. If employers and capitalists were to look at this matter only from an economic point of view, divesting it of its sentimental side if they chose, they would find that they would realize large returns for all investments which they might make in country homes and vacations for their employees. An occasional change of scene, a brief respite from work, and an opportunity to develop acquaintance with the beautiful things in this beautiful world in which we happen to be staying for the present, is a tonic which I would like to prescribe for every tired worker in whatever field. Habit-Forming Drugs.-It is a curious fact that so many sub- stances which primarily may be used for the relief of diseased con- ditions have been perverted in their action through the weakness of human nature and, instead of becoming helpful and beneficial, have become injurious. We are constantly dealing with substances of this character, and it is very important that we should be ever mind- ful that they are double-edge tools and so avoid using them, except when they are properly and consistently called for. The legitimate use of these substances is for the relief of pain or distress of some kind or another, or to produce sleep, and to this extent they are a great boon to mankind and add much to human happiness and comfort and the prolongation of life. When they were in the hands of doctors only, their power for injury was quite limited. Those who required them took them with faith in those who administered them, and the responsibility rested with the doctors as to when and how they should be given. Of course, some doctors were careless in the way they gave such medi- cines and encouraged their use when good judgment should have taught them better, but I do not believe that a very large per- centage of the medical profession ever was guilty of that kind of practice. With the development of modern chemistry, the increase of population, and the comparative ease with which habit-producing drugs could be obtained, a large number of people have acquired 124 HOW TO KEEP WELL easily, and sometimes insensibly, the habit of taking them unneces- sarily on their own responsibility; and thus has arisen that class of diseased individuals, usually with weak and flabby wills, whom we call drug habitues, or people who have the drug habit. The makers of these habit-producing preparations, by their com- mercial keenness and the seductiveness of their advertising, have encouraged human weakness and greatly aided in recruiting the army of drug victims. I am aware that there is legislation which restricts the sale of some of these drugs. I am also aware that there are very many conscientious pharmacists who will not break the laws nor dispense the drugs except as the laws provide; but there are always others who will take their chances in evading the laws, and there is always illicit and irregular dealing which it is very difficult for the authorities to control. Alcohol in its various forms is the best example of a habit-pro- ducing drug, useful in many ways externally and internally, which has been thus perverted; and though we have a very rigorous prohi- bition law it is constantly evaded. Opium with its various derivatives-morphine, heroin, codein, etc.-is almost as much abused as alcohol, and yet for the relief of pain or cough it is incomparable. It has well nigh ruined some of the great nations of the world. It is a more deadly poison than alcohol, and its sale is subject to most stringent regulations; but with all its dangers, with all the victims of its habitual use, it is one of the few substances for relieving pain for which there can be no efficient substitute, at least so far as present knowledge goes. Cocaine comes next on the list of dangerous habit-producing drugs. Introduced less than fifty years ago to produce anesthesia in operations on the eye, it has a value in surgery that is enormous, though it has several substitutes which are equally effective and less dangerous. The intoxication it produces is as seductive as that of opium or alcohol, but it has a smaller army of victims, and the re- strictions upon its sale have been more or less effective. Cannabis indica or Indian hemp, the Oriental hashish, is a drug comparatively little known in this country, its principal use being to relieve cough, which it often does very effectively. It is danger- ous as a habit-forming drug and in the East has many victims. The so-called coal-tar derivatives are enormously used, and often quite legitimately, for the relief of pain, especially pain in the head, muscles, and joints. As a consequence they often are taken un- SANITATION AND HYGIENE 125 necessarily and with deleterious results. They are known as heart depressants, and when taken in large doses by those who have weak or diseased hearts the consequences may be serious. All the drugs mentioned belong to the group known as the nar- cotics. Another class of the habit-forming drugs are the hyp- notics, which are taken to produce sleep. Chloral is the most important member of this group. Though it often works bene- ficially, it is very seductive; one is tempted to take larger and larger doses, and sometimes quite unexpectedly the limit is reached and with it the termination of life. Other hypnotics which are widely used, but should always be used with caution, are sulphonal, trional, veronal, and paraldehyde. There are many others. I have only touched the borders of this subject. What I would like to insist upon is the danger element in using all such drugs as I have referred to; not only the danger of forming a pernicious and will-destroying habit, but the danger even to life itself. Alcoholism.-I have seen many instances when alcohol has been of the greatest possible service, but it is abused to such an extent that I should be glad to see it abolished as a beverage, for there is no doubt that something could be found which would fill its place and do less harm. Alcoholism means the result of the excessive internal use of alcohol. It does not matter in what form it may have been used. Alcoholism may be produced by hard cider or beer or wine, as well as by whisky or gin or rum, if only one takes enough of it. Of course it is produced more slowly as a rule when the liquor used has a small percentage of alcohol than when it is large. The effects are more disastrous from the heavy, unrefined alcohols than from those which are lighter and purer. Methyl alcohol, or wood-alco- hol, is an exception, being lighter than the ethyl alcohols from which alcohol beverages are obtained, and far more poisonous. Alcohol, being a poison, may cause fatal results either from a single dose or from long-continued use. When continually used its effects upon the organs and tissues are progressively destructive. It is eliminated from the body by the skin, the lungs, and the kid- neys; but when taken persistently a portion of it is not eliminated, and this is the portion whose action is destructive. Alcoholism may be acute or chronic, the poisoning in acute cases having effects that are immediate and attended with more or 126 HOW TO KEEP WELL less excitement, while chronic alcoholism produces chronic diseases, with progressive changes in the organs and tissues. Acute alcoholism is drunkenness, which not only has its par- ticular set of symptoms but often gives rise to or excites other conditions, which may be serious or even fatal. Drunkenness, that is, acute poisoning from alcohol, may be the direct exciting cause of an epileptic fit or some other form of convulsion, an at- tack of hysteria or of delirium tremens or of hemorrhage into the brain. There are distinct stages in alcoholism. In the first there is excitement and exhilaration, but usually a loss of keenness in mental control. This is followed by a stage of incoherence, when the speech becomes thick and the gait uncertain and staggering. The centers in the spinal cord which control motion and those in the brain controlling the senses are more or less paralyzed; the sur- face of the body is warm, and there is often profuse sweating. The third stage is that of unconsciousness and insensibility, lasting from six to twelve hours, with more or less paralysis, loud breathing, and sometimes apoplexy, collapse, and death. The danger of this con- dition may be realized from the fact that the brain, the lungs, the heart, the kidneys, and the digestive organs are all in a state of acute congestion, and if the arteries are weak they may not be able to stand the pressure. Drunkenness is often followed by headache, general depression, stomach disturbances, and trembling. It is usually well to give one who is recovering from it a mild cathartic, some form of ammonia, and external heat or a hot enema if there is need of stimulation, with very little food except milk. It would be well if one dose of poisoning of this kind would satisfy those who experience it. In chronic alcoholism there may be disturbances in any or all of the organs; notoriously the liver and the digestive apparatus become diseased; constipation alternates with diarrhea; there is more or less constant trembling, tenderness, and numbness; the heart-sounds become indistinct; there is insomnia; the mind often becomes diseased; and there may be more or less profound paraly- sis. One of the worst effects of chronic alcoholism is the effect it has upon offspring, the children of alcoholic parents inheriting a handicap which in multitudes of cases blasts their entire lives. The treatment of alcoholism as a disease, whether at home, in a hospital, or in a sanitarium, has many good results and many fail- SANITATION AND HYGIENE 127 ures. One of the greatest difficulties met is the paralysis of the will, which prevents efficient cooperation with the physician. Alcoholism is one of the diseases in which treatment by drugs is often of great value, but this is frequently overrated by those who supply it and may not accomplish what is expected or prom- ised. Sanitarium treatment is also frequently of great benefit, but much depends not only upon the disposition of the patient but upon his surroundings, and especially upon the intelligence and good judgment of his physician. The Tobacco Habit.-Tobacco is a poison; that is, the plant con- tains a principle called nicotine to the extent of one to eight per cent, which is fatal to life in certain doses. It also contains nico- tianin, or tobacco camphor, which gives the aroma or flavor so much enjoyed by those who use the plant; also certain oxidation products which intensify the action of nicotine. It has a medicinal value. It will produce vomiting or purging, and it sometimes was used in this country by the early practitioners for such purposes; also as an enema and as a poultice, for our fore- bears in medicine did not have as many resources as we have and frequently used stiff medicines which sometimes produced effects more intense than they desired. Sometimes, incidentally, the nico- tine killed the patient. Tobacco is in constant use over the entire civilized world, and over much of that which remains uncivilized, for smoking, chewing, or snuffing, the last-mentioned habit being far less in vogue now than formerly. In almost all cases in which tobacco is used experimentally or habitually the secretions of the glands of the mouth are increased, the saliva becomes abundant, and if it is swallowed distress in the stomach or even more urgent symptoms may result. Those who use tobacco habitually frequently suffer with chronic inflammation of the nose and throat, indigestion, loss of appetite, heart weak- ness and irregularity of action, headache, deafness, blindness, etc. Those who use it should know that these results are possible, with even more serious ones as the brain and spinal cord and their as- sociated nerves become implicated. I have personally known several doctors of eminence who have suffered with cancer of the tonsil or larynx which seemed attributable to tobacco smoking. Young men who smoke cigarettes immoderately often succumb to fatal nicotine poisoning of the heart or nervous system. I be- 128 HOW TO KEEP WELL lieve the smoking habit which so many women are acquiring is a very pernicious one, for women generally are more sensitive to tobacco poisoning than men. I am not a fanatic on the subject. I have used tobacco moder- ately for a great many years, sometimes, I must admit, to my disadvantage. Smoking is a pleasant habit, but one should not be blind to its dangers. Those who are manifestly poisoned by to- bacco and cannot accustom themselves to its use without harmful or unpleasant symptoms are foolish to the point of imbecility to continue it. Much was said during the World War of the value of the ciga- rette to the soldier in enabling him to bear hardship and suffering. That was because it was the universal fashion at that time and the prevailing belief. A cigarette of something else would have done just as well. As a rule, it is much easier to abandon the tobacco habit than the alcohol habit. Both are bad enough. I think phy- sicians should be particularly urgent to dissuade young boys from using tobacco. If you must smoke, wait until you have reached maturity and have become less susceptible to tobacco poisoning. When one is acutely poisoned by tobacco he should lie in the horizontal position; stimulants should be given, aromatic spirits of ammonia, for instance; the clothing should be loosened, especially around the throat; heat should be applied to the feet, and cold to the head. If vomiting has not taken place it should be encouraged by giving the victim a pint or a quart of warm water in which one or two spoonfuls of mustard have been dissolved. When the stomach has been relieved of its contents, the patient usually will recover promptly unless a large quantity of nicotine has been absorbed. Diet.-Equal in importance with almost any of the questions which have been discussed in connection with personal hygiene is that of diet. The question for civilized man not only, is, How much shall I eat? but, What shall I eat? and physiology and chemistry have been giving very exhaustive answers during many years of investigation. We are not considering the man who eats every- thing within his reach which is eatable or which he assumes is eatable, but the one who has a certain amount of intelligence and who realizes that some articles of diet may be more useful than others. SANITATION AND HYGIENE 129 Various Influences Which May Modify the Diet.-It seems hardly necessary to say that infants and young children are not provided with organs to digest the same food or the same quantity of food as adults; and when they are fed from the common family table, as is often the case among the poor and ignorant, it is not strange that only the fittest survive. It would be startling if the facts were known as to the thousands of children who are annually killed by improper food. Food for the young is, therefore, not necessarily appropriate for the mature, and vice versa. The fundamental object of food is the production of heat and vital force, and it is quite analogous to the production of heat and force in an engine by means of fuel. Food is not required to the same extent in summer as in winter. In a cold climate the activi- ties of the body are greater than in a warm one; more heat is re- quired and is developed; and hence more food is necessary. It is also necessary to select for cold weather those varieties of food which have great heat-producing capacity and which would be quite inappropriate for warm weather. Hence diet must be modi- fied by climate as well as by age. The work which one must do should modify the diet; the lumberman, the sailor, the miner require different food and more of it than the shopkeeper, the clerk, the teacher, or the lawyer. Both the quantity and the quality of the food must also be regu- lated by the physical condition in a given case. A robust person requires more food than a sick one and he can eat without fear or harm or indigestion many forms of food which the stomach of the sick person would be unable to digest or would reject promptly. Benefits of a Mixed Diet.-Many series of physiological experi- ments have been made, both upon man and animals, to determine the most useful substances which may be employed as food; and it has been definitely determined in the case of a large number of substances just how much can be expected in the way of useful results when they are used for food. We learned in the chapter on physiology that the stomach digests only albuminoid substances (lean meat, eggs, milk, and certain portions of the cereals), and that the intestines aided by the liver and pancreas digest only the hydrocarbons (oils, fats, butter, potatoes, rice, and the greater portion of many of the vegetables), and that therefore while it might be possible for a person to live upon food which was digested only by the stomach, 130 HOW TO KEEP WELL or only by the intestines, at least for some time, it would be, to say the least, an unfair distribution of work to impose all upon the stomach or all upon the intestines. The obvious conclusion would be that a diet should be a mixed one, that is, one composed of both albuminoids and hydrocarbons; and this conclusion is fully borne out as the result of physiological experiments. That is to say, a mixed diet, meat, eggs, milk, and vegetables of different kinds, is not only the most rational but the one which is best adapted to secure health and the best results in the direction of physical and mental work. Utility of Tea, Coffee, and Their Substitutes.-The value of tea and coffee, so far as their active principle (theine, caffeine), is concerned, is alike for each, since the molecular construction of each is the same. Tea contains tannic acid, which gives it its astringent property and explains the constipation which is so common with those who take much of it, especially if it is taken in very strong or concentrated infusion. Tea is a leaf; coffee is a berry or fruit, and the latter contains more starch, which is an essential product of all growing plants, than does the former. The value of tea and coffee is due largely to the heat of the water with which they are usually taken in the form of an in- fusion. The starch value, that is the nutritive value, is very small; but the influence of the active principle (theine, caffeine) as a stimulant to the heart and the nervous system is very great. When one is cold and wet, or weary with severe exertion, a cup of hot tea or coffee with its generous warmth and its whipping on of exhausted nerve-centers banishes bad feelings for the time and re- vives drooping energies. It is not usually desirable to give such substances to children. The depression which comes from fatigue and exposure is quickly rallied from if only they can be warmed and dried and the surface of the body actively rubbed for a few minutes. The use of tea and coffee by children, unless in a very dilute form, overstimulates the sensitive nervous system and will comparatively seldom be found necessary. Preparation of Food.-Not only the palatability but to a large degree the usefulness of food depends upon the care which is exer- cised in its preparation. Certain kinds of food require no preparation but are palatable and nutritious as provided by bountiful nature. Many of the fruits SANITATION AND HYGIENE 131 and not a few vegetables may be included in this category. Other vegetables, cereals, etc., must be ground, baked, boiled, fried, or otherwise subjected to the action of heat before they become suita- ble or attractive for food. This operation in which the action of heat is invoked, which we call cooking, is a most important one. It develops certain odors or flavors which are agreeable both to the sense of smell and that of taste, making the food more palatable and in many cases more digestible. It coagulates albuminous material, and with some sub- stances it produces chemical changes which promote their nutritive value. Of particular importance is it that animal tissue should be sub- mitted to heat before it is used as food. Certain very troublesome parasites are found in the muscles of animals (for example, trichinae in swine), and the habit of eating this tissue uncooked has led to countless cases of disease, every one of which could have been avoided had the meat always been cooked. Oysters and clams are also not infrequently the bearers of disease-germs and poisons, and the friend who places them in tempting array before us may little realize the danger to which he is exposing us, or possibly the dis- aster which he unwittingly invokes. Condiments and relishes are often useful in giving piquancy to the taste of food and often assist digestion by their stimulation of the gastric mucous membrane. The effect of salt, pepper, mus- tard, cloves, allspice, etc., is too well known to require comment. Gravies and sauces in which fat and grease form the principal ele- ment are not usually to be commended; if the digestive function is weak they will usually add an unnecessary burden to it. Care of Teeth and Mouth; Selection of Nutritious Food.-The best way to treat disease is to avoid those habits and methods and substances which produce it. Equally pithy and equally true is somebody's remark that to cure a certain disease in a certain family he should have been allowed to go backward and begin with the grandparents. That is, we are now realizing the importance of pre- ventive medicine. In this important science, which concerns every- body, we should know something of the nutritive value of the ma- terials from which we select our diet; we should also determine by experiment those substances which are helpful to us and those which are harmful. The care of the teeth and mouth in this connection is not to be 132 HOW TO KEEP WELL neglected. Sores in the mouth must be cleansed with frequent washings of weak solutions of boric acid (teaspoonful in a glass of water), carbolic acid (one part to one hundred of water) or bi- carbonate of soda (teaspoonful in a glass of water). The teeth should be brushed with a stiff brush night and morn- ing with or without the use of a dentifrice, of which many excellent varieties are now obtainable. Food should not be allowed to collect between the teeth, a quill toothpick being used to remove it. The dentist should be visited sufficiently often to keep decayed teeth under control and to secure the removal of those which are beyond repair. One can scarcely realize the harm to the digestive appara- tus from decayed teeth and sores in the mouth. Decayed teeth are the cause of infections in great variety, and in the mucous membrane of the mouth there are more kinds of germs and more of them than in any other part of the body. Deposits of decomposed and decaying food in and between the teeth make the finest kind of culture medium for such germs. The legitimate results are offensive breath, neuralgia, suppuration of the teeth, gums and other tissues of the mouth, and other wretched dis- orders. Food cannot be properly masticated by diseased and broken teeth; the sense of taste becomes impaired; and infectious material is carried with the food into the stomach. Indigestion follows, and almost anything may result as a consequence. A Suitably Balanced Diet.-A well-balanced diet means proper proportions of proteid, carbohydrates, fats, and mineral salts. The proteid substances include meat, eggs, fish, and a portion of the con- stituents of cereals. The carbohydrates are starch and sugar, the first of these be- ing converted into the second, both in plants and animals, before it is finally used as nutriment. The carbohydrates, therefore, include all vegetables, for the product of every form of plant life is starch. The fats may be animal, vegetable, or mineral. Animal fat differs in quantity in different animals. Vegetable fat, like olive-oil and peanut-oil, is a product of nuts and seeds. Mineral fat, like petro- leum, is something for which the chemistry of the body has no great affinity; it passes through the body with very little change and acts mainly as a lubricant and as a stimulant to the intestinal muscle. The mineral salts have no food-value but are very essential to the processes and tissues of the body. We require common salt SANITATION AND HYGIENE 133 or the chloride of sodium. We also require the mineral salts and the vitamins in the husks of grain, which are so often foolishly destroyed. Proteids are the tissue-builders, our bodies being com- posed largely of proteid material; and as this is constantly being wasted and worn out we renew it from the proteids we take in and absorb. The carbohydrates and fats supply us with heat and energy, enabling the body in health to maintain an even temperature, and fat is stored up under the skin in varying quantities as a reserve for the supply of heat. In sickness, for example, it is called upon and used up, and we become thin in consequence. The mineral salts go to the blood and to the tissues and are indispensable to their normal condition. The simplest form of diet for an adult in good health working in the open air would be approximately fourteen ounces of lean meat, seventeen ounces of bread, three ounces of butter, and three pints of water a day, this amount giving the proper proportion of proteid, starch, fat, and mineral salts. The water and bread we may consider as constants; there is nothing which is cheaper, nothing more essential, and we can live on bread and water if the bread is good, of whole wheat, rye, or oats, and the water is good. We could live on such a diet a long time without starving and do hard work. It would not be a pleasant diet, but a great many people get nothing else. Except for those whose work is severe, meat once a day is sufficient. The albumen, the proteid, we need for the blood and the tissues we can obtain from cheese, milk, fish, and cereals at less cost than from beef, veal, mutton, and chicken, and usually with greater benefit. Frequent use of white beans is most desirable, as those of us who were brought up in New England will never forget. Of the es- sential elements they contain about 56 per cent of starch, 26 of albu- men, and 3 of fat. Potatoes contain only 30 per cent of starch and 3 of albumen, while the remainder is mostly water. Rice, on the other hand, which is far cheaper than potatoes and is the staple article of diet of the majority of the inhabitants of the globe, con- tains nearly 89 per cent of starch and 8 of albumen. Surely there are no healthier or finer people than the Scotch, who live largely on oatmeal, with its 61 per cent of starch and 24 of albumen and other nitrogenous material. Spaghetti or macaroni, 134 HOW TO KEEP WELL when cooked with cheese, is one of the most nutritious and eco- nomical of foods. The fruits are luxuries; they are agreeable to the taste, and in many cases help digestion, though in many others their acid can- not be tolerated. Milk is the perfect food and is the most eco- nomical that can be placed before adults as well as children. Masticate Your Food.-This means chew it and chew it thor- oughly none the less, whether you have few teeth, bad teeth, or no teeth at all, using only soft food when the teeth are poor and wanting. That we are provided with teeth is a sure indication that the chewing habit was foreordained. Solid food given to a baby may make him sick or even kill him; he has not yet reached the stage when chewing is required. When he gets his first teeth, they are there for business, but they are fragile and temporary and not intended for hard and firm substances. Teeth are not all of the same kind; some are for tearing and cutting, others for grinding and triturating, which teaches that chewing consists of two distinct acts. Mothers ought to teach their children that their teeth were not made for hard candies, hard fruit, and hard food in general, and that food should not be swallowed until, by biting and grinding, it has been reduced to a soft pulp. But why spend so much time and trouble in preparing food for the stomach instead of bolting it whole, which is easier and takes less time? In a grist-mill the grain is shoveled into the hopper, then carried to the mill-stones and crushed and finally turned out as meal. Food in the mouth undergoes a somewhat similar process, being bitten off, chewed, rolled about by the tongue, and permeated by the saliva. Moistening by the saliva is just as important as thorough chewing, and when the mouth is parched and there is no saliva and the food is very dry it is difficult or almost impossible to swallow it. But the chief reason why the food should be both thoroughly chewed and moistened is because digestion begins in the mouth, the saliva containing a ferment which begins the digestion of the starchy foods with which it may be brought into contact. Well- masticated food, then, is a soft, moist, pulpy mass in which diges- tion has already begun in those parts of it which consist of vegeta- bles, cereals, bread, and fruit. If food is to be absorbed and assimi- lated it must be liquefied by digestion, and the digestive ferments in the stomach and intestine may be unequal to this task unless it has SANITATION AND HYGIENE 135 first been thoroughly softened and moistened. In that case it may pass out of the body in much the same condition as when it entered the mouth, being of no use, therefore, for the purpose of nutrition. A child or an adult who bolts his food may consequently be poorly nourished, though he may eat a great deal and is perhaps astonished that he remains so thin and weak. Such a person is apt to have cramps in his stomach and bowels because of decomposi- tion and fermentation with formation of gas; his tongue is coated, his breath offensive, and ten chances to one he is constipated. It therefore pays to masticate the food thoroughly and to teach children very early in life the great importance of doing so. The School.-In the brief remarks which will be offered in re- gard to the school, from the hygienic standpoint, reference is made particularly to those institutions and those buildings, whether pub- lic or private, in which so large a portion of the time of our children and youth is passed. They will also be not inappropriate to the lecture- and recitation-rooms of our colleges and higher institu- tions of learning, though any mischief which might be associated with the former is mitigated in the latter by the fact that the time which is spent continuously in the latter is usually much less than that which is spent in the former. Necessary Hygienic Conditions for the School-Room.-The ordinary school-room-say, in the average city public school, where the majority of our children spend a large portion of the early period of their lives-is intended to accommodate fifty or more children for three hours in the morning and two or more hours in the afternoon. These children breathe rapidly, that is, require a large volume of oxygen, are more sensitive to disease than at any other portion of their lives, are undergoing physical changes with great rapidity, are exposed to injury to vision-that sense which will be more important to them than any other in the forthcoming struggle to get their living-and are most susceptible to impres- sions for good or evil upon their moral natures. All this is external to the specific business which the school-teacher has in hand in his relations with them, namely, the training of their minds, upon which subject I do not propose to encroach. What should the children demand of the state, that they may receive no damage while the state is preparing them for citizen- ship? Undoubtedly the first requirement should be an abundance of fresh air sufficiently cool in summer and sufficiently warm in 136 HOW TO KEEP WELL winter (65° to 700 F.). The walls of the school-room, therefore, should be higher than in rooms in an ordinary dwelling where the number of occupants is relatively smaller than in a school-room; that is, from ten to fourteen feet when the pupils, number forty, fifty, or more. Each child should have if possible a single desk and seat with sufficient space on either side for passage to and fro; and there must be sufficient passage-room in the rear of the rows of desks, and also in front of them, and ample desk-room for the teacher. If ten to fifteen square feet be allowed for each pupil, a room containing fifty pupils should contain seven hundred to seven hundred and fifty square feet of space; that is, its surface dimen- sions should be twenty-five by thirty or thereabouts. With a height of fourteen feet, the cubic contents of such a room would be ten thousand five hundred feet, and this would give an air space of 210 cubic feet for each pupil. This is considered insufficient by some writers on hygiene; it is more than is allowed in many schools whether urban or rural. If the allowance is much smaller than this, depend upon it the health of the children will suffer, the conditions of ventilation being such as ordinarily obtain. The air-capacity of a child's lungs is less than that of an adult, but he breathes half as fast again; hence he would require nearly as much air to keep his blood supplied with oxygen as an adult. The average requirement of an adult for each respiration is twenty cubic inches. If twenty respirations were taken per minute, this being a fair average, four hundred cubic inches of air per minute would be required for an individual, or twenty thousand cubic inches for fifty. At this rate the room which contains ten thousand five hundred cubic feet of space would theoretically have air enough to supply fifty people nearly fifteen hours. But assuming that the air in the room is stagnant and receives no additional pure air, it is being constantly mixed with carbonic acid and organic matter which is often very offensive and both of which are exhaled with every expiration. This, being diffused into the room and having no outlet, or an insufficient outlet, must be breathed over again and again, and the blood is forced to receive again that which it had discarded and which now acts as a poison. The headache, the pallor of countenance, and the languor of which so many school-children complain are usually traceable to this vitiated air-supply. SANITATION AND HYGIENE 137 Therefore, the air of a room in which human beings are gath- ered must be put in motion, a constant supply of fresh air must be provided by windows and ventilators, and also a draft for the removal of that which has been corrupted with foul gases. In large buildings such as are our large schools, it is poor economy to ventilate the rooms by windows alone. They either give too much air or too little, and the drafts which they cause are certain to bring colds to those who are exposed to them, if they bring nothing of a more serious nature. The ventilation of a school-building is as important as any feature in its construction, and it is poor economy to save in such a matter when the health if not the life of so many is connected with it. Light.-A school-room which is not well lighted or properly lighted is totally unfit for the purpose. We must conclude that the enormous number of near-sighted children who are compelled to wear spectacles at a very early age have to a greater or less extent a grievance against the school authorities and that the weakening of a most important sense is an injury which in very many cases is entirely avoidable. The question is not, how high the windows are, nor how many; it is not altogether, from what direction the light comes. Robbed of all its complications the question is, Is there sufficient light to illuminate the room; is it reflected from the book the child is study- ing and not shining in his face; and is the type of the book suf- ficiently large so that there need be no straining of the accommo- dation, but such a use of the eyes as would render the pupil unconscious that the eyes are being used? This is the whole matter in a nutshell, and there is very little doubt that if this plan were constantly carried out by teachers and school authorities there would be fewer near-sighted children, fewer who would bring a reproach upon somebody by going about in spectacles. Cleanliness.-This is another essential requirement of a school- room. It is better that it should have no carpet, that its walls have curves instead of angles, that wills, floors, and ceilings be swept and dusted, scrubbed if necessary daily, and also that after the school day is over the room be flushed for an hour or more with fresh air. In view of all that has been written in the foregoing para- graphs, the reason for this care will be apparent, and when we realize what prolific bearers of disease children may be we are dere- 138 HOW TO KEEP WELL lict if we neglect any possible means of preventing them from carry- ing disease by way of the school-room. Health of School-Children and Inspection.-It is only within recent years that it has dawned upon the public mind that our schools are the most favorable locations for the propagation of disease. Children are, of all individuals, most susceptible to the attacks of infectious disease, and the possibility of communicating contagious and infectious diseases by personal contact is so much more thoroughly understood than formerly, and so many diseases are now known to be thus communicable, that there is little excuse for the extension of any disease whatsoever by this medium. This means exclusion from the school of all suspected children, disin- fection of the school-room in which a suspected child has been attending, and closing the school if necessary until the unfavora- ble influences which surround it have been brought under control. The carrying out of these precautions is becoming more easy as the custom of daily medical inspection of the children is adopted. The inspecting doctor and nurses cooperate with the teachers, and all of them cooperate with the community for the welfare of all. This is another evidence of the increasing importance which at- taches to preventive medicine. Recesses.-It is not fair to confine a healthy growing child to a school-room and a desk as a polypus is confined to its stalk. Like a wild bird in a cage he will rebel and break out if he can. This is only the "nature of the beast," and if he occasionally "plays hooky" you ought not to be too severe with him. It would be well if every school-child could have a few minutes to move about and shake himself every hour, but as school authori- ties do not seem to think this wise, he should be turned out after not more than two hours and encouraged to enjoy himself by run- ning, shouting, playing for at least fifteen minutes. During this time the school-room should be thoroughly aired, and when he goes back to his study or recitation it will be with his youthful vigor renewed. All this implies that every school should have a playground. A school which is without it is to that extent defective. It need not be beautiful; children are not exacting; only let there be the ground underneath, the sky overhead, and space enough to move about, and give the muscles a chance to work off the confined energy which has been accumulating in the school-room. SANITATION AND HYGIENE 139 Moral Influences at School.-A word upon this subject is not foreign to the matter which we have been considering. Children are no less sensitive to moral than to physical influences, and the one often reacts upon the other. A bad boy or girl, bad in any sense, can usually contaminate half the children in the community. A teacher who is without princi- ple and does not command respect cannot compensate for this defect by superior scholarship or great gifts in imparting know- ledge. If character is not built up, or at least a good beginning made during the years of pupilage, the deficiency may persist through life. Is it not, therefore, self-evident that parents should know what influences are thrown around their children by their teachers and their schoolmates, and if these influences are bad or doubtful will they be willing to submit to them with all the consequences which may result? Bacteriology.-Many people are doubtless unaware of the mean- ing of this term, or of the important bearing which it has upon our health and even our life. Bacteriology is the science which has to do with bacteria, and bacteria are the minute vegetable organisms which swarm within the body, in the soil, in the air, in fact in almost every part of the world where there is animal or vegetable life. This science has been almost created and developed within the last fifty years, and it has been built up and a vast amount of useful knowledge acquired by the patient labor of many earnest workers in various parts of the world, the very name of many of whom is scarcely known beyond the walls of their own laboratories, or at any rate beyond the company of their fellow-workers. Relation of Bacteriology to Health.-It has been ascertained by careful investigation that very many of the diseases which attack men and animals are due to the development within the body of germs or bacteria which have a particular life history, a particular form or shape, and yield characteristic products or poisons which cause the different diseases with all their varied phenomena. Not all diseases have thus completely been analyzed; but very many have been, among them being pneumonia, malarial fever, tubercu- losis, childbed fever, diphtheria, infantile spinal paralysis, influenza, hydrophobia, and others. The most familiar example of the influence of bacteria in produc- ing disease and at the same time preventing a more serious disease 140 HOW TO KEEP WELL is seen in what we commonly call vaccination, the discovery of the immortal Jenner a century ago and the forerunner of the existing science of bacteriology. The phenomena of vaccination explain the principle upon which inoculation for other diseases is made. The vast scope and usefulness of such a system of treatment almost transcends the power of the imagination, and we have probably not begun to realize, or only to a slight degree, the enormous benefit which will come to the human race when this system has been more perfectly developed. Various Means of Infection.-The various problems relating to disease have been greatly simplified by the knowledge that, in so many cases, it is due to a particular form of organism, and also that in many varieties the organism can be identified or labeled. The organism having been identified in a given case, of course the determination of the kind of disease becomes almost a matter of certainty. "Almost," we say, because it is sometimes very diffi- cult to catch the organism whether in the blood, the secretions, or the discharges of the patient. Furthermore, the matter is more difficult, because many forms of bacteria may be found in the specimen which is examined; that is, there may be what is known as a mixed infection. Also, many of the bacteria which are in various parts of the body are at times entirely harmless, while at other times, under influence of certain conditions, they are changed in their nature and become harmful and injurious. The subject is, therefore, one which will demand much more investigation, analysis, and arrangement before its per- fect fruition will be attained. These germs of disease when liberated from one individual are carried to others in various ways. In many cases they are taken into the stomach with water or milk in which they have found a temporary residence; with others they are floating in the air and are inhaled and taken into the lungs; in others they are carried directly from one person to another through an opening in the skin as in vaccination. In all cases they reach the blood, develop by a process which is more or less like fermentation, and produce the particular disease with which they are identified. Vaccination.-Vaccination properly means the production of vaccinia or cowpox in an individual by injecting into his tissues be- low the skin prepared lymph or serum which has been removed from a vesicle or blister on the udder of a cow or calf suffering with SANITATION AND HYGIENE 141 this disease. Cowpox is the means by which immunity is gained from smallpox and is directly transmissible from animal to man. The use of this material, properly cleansed and sterilized, has en- tirely supplanted the use of crusts or scabs from the skin of those who have been vaccinated, and it has thus eliminated the danger of transferring disease from the one who furnished the scab or crust to the one who was to make use of it. Vaccination is now used in a broader sense and implies the use of the attenuated virus of any disease to produce immunity from that disease in the normal or severe form. Vesicles in cowpox are the small cysts or blisters containing a more or less clear fluid, which seems to hold the germ of the disease. This fluid changes to pus, as its final stage, before the formation of the scab or crust which, when it falls off, leaves the pock-mark or pit. It is desirable to remove this fluid before sup- purative changes take place. For this purpose the blister may be pricked or incised and the fluid secured in tubes, on bits of wood, bone, or ivory, or in any other effective way. It is then properly sterilized and prepared for market. It comes to the doctor for prac- tical use in different forms, but whether in dry or in fluid form it is supposed to contain the essential germs with which human be- ings are to be inoculated. The operation consists partly in cleansing with soap and water, and additionally with antiseptic substances if desired (for instance, with iodine or alcohol), a portion of the skin one inch or more in diameter. The arm is usually selected for convenience. The outer layers of cells of skin are scraped away with any kind of an instru- ment that has a cutting or scraping edge, this operation exposing the absorbing surface of the skin which is immediately beneath its outer or horny layer. Upon this raw surface the prepared vaccine is carefully and thoroughly rubbed. It is absorbed by the lymph vessels which have been opened by the scraping operation, and ultimately reaches the blood-current, in which incubation takes place. If the operation has been successful, the vaccination wound be- comes red, swollen, and somewhat painful in three or four days. A vesicle forms at the site of vaccination and a scab appears in due time, which falls off when the underlying wound is healed. The vaccination wound must be protected from rubbing by the clothing; otherwise the vaccine material may be rubbed off. 142 HOW TO KEEP WELL During the period in which vaccinia or cowpox is in progress the vaccinated person may feel weak and ill and have something of an accession of fever. Because these symptoms are wanting it does not imply that the vaccination has not "taken," nor does it necessarily mean that something is wrong with the vaccine. If there is no reaction at all, either local or constitutional, the opera- tion has been a failure and should be repeated and repeated yet again if necessary. After a successful vaccination a person is im- mune to smallpox for five or ten years or even longer, after which time revaccination should be performed, and it should be repeated later in life if there is any possibility of exposure to smallpox. Infants and children are most susceptible to the influence of vaccine virus, and the susceptibility to this and to smallpox as well diminishes as the years progress. In those countries in which inoculation with vaccine virus is compulsory and is systematically performed by government officials smallpox has been obliterated. Vaccines.-A vaccine is properly a substance obtained from a cow or a calf. A vaccine virus is a poison obtained by drawing fluid from the vesicles or blisters upon the skin, especially the skin of the udder of the cow or calf which is suffering from vaccinia or cowpox, the purpose being to inject this substance which contains the germs peculiar to cowpox into the circulation of a human be- ing, and by thus producing cowpox in that individual to immunize him to smallpox. The term now has a broader meaning, for it comprehends the principle that by introducing into the body substances with a known and measurable power of producing disease, we can procure, for a longer or briefer period, immunity to that disease, having produced the disease in question in the individual in the mild or attenuated form. A vaccine as now understood by those who practise bacteriology means a preparation composed of a great number of living, attenu- ated bacteria, or a smaller number of very virulent ones, or their products. Such preparations when offered for sale and practical use are usually in liquid form, activity of the bacteria having been restrained by heat and the use of suitable antiseptics. There are many diseases which are now treated or prevented by vaccines, the latter being introduced into the body through the mouth, or by hypodermic injection into the skin or the muscles, or by direct injection into the circulation through a vein. SANITATION AND HYGIENE 143 The present theory of vaccination presumes the presence within the blood of substances known as phagocytes, antibodies, or anti- gens which are antagonistic to disease-germs which have found their way into the circulating blood. They attract some disease- germs and repel others. Those which they attract they envelop and absorb-hence the name phagocytes-and thus limit or destroy their power to produce disease. The vaccine which may be introduced into the circulation stimu- lates the healthy tissues to form new antibodies or phagocytes, and thus still further limits the power of deleterious germs to produce their harmful results. There are various kinds of vaccines and they have varying degrees of utility. In some cases of disease they appear to work very well. The vaccine of typhoid fever, for in- stance, has now been so thoroughly tested that it is considered entirely reliable as a means of prevention and treatment. Other varieties have not given results that were uniform or dependable. It is evident, however, that we have a valuable principle in vac- cines which will be more and more perfected as experience in- creases. Serums.-The blood while circulating is composed of two parts, the plasma and the corpuscles, or the red and white blood-cells. After it has escaped or has been drawn from the blood-vessels the fibrin elements it contains quickly cause the formation of a clot. Soon after the clot has formed it contracts and in contraction squeezes out a fluid which is called serum. This serum consists of water, inorganic salts, albumens, and extractives, and it is this substance, obtained both from man and animals which plays an important part in the treatment of various diseases. Take, for example, the serum which is used for the treatment of diphtheria which is known as diphtheria antitoxin; that is, a substance used to counteract the poison or toxin of diphtheria. This serum is obtained from the blood of a horse. The horse being susceptible to diphtheria, germs of diphtheria combined with a suitable liquid are injected into a horse which has been selected for the purpose; the disease is produced and runs its course, less vio- lently than it would in a child. After a sufficient length of time diphtheria germs are again injected, and diphtheria again results but in a milder form than before. After this process has been re- peated a sufficient number of times the germs fail to produce any diphtheria reaction; that is, the horse is immune to diphtheria. 144 HOW TO KEEP WELL Blood is then drawn from one of the veins of his neck in quantity such as he can easily spare; it is allowed to clot, and the serum which is squeezed out of it, after suitable preparation, is placed upon the market as diphtheria antitoxin to be injected into human beings who have diphtheria, or are threatened with it, as a preven- tive or a curative agent. Diphtheria antitoxin is the first serum, or one of the first serums, which were used in the treatment of disease, and it has led to great elaboration of the method of serum treatment. Not only has the blood of the horse been requisitioned for thi-s beneficent purpose, but also that of the rabbit, sheep, goat, and probably other animals. The serum of the rabbit and the sheep in itself, without any kind of treatment or experimentation, has been found to be an excellent means of arresting hemorrhage and in cases even of the disease known as hemophilia, in which the blood lacks the necessary ele- ments which cause a clot to form. This is a most valuable dis- covery, for those who have this disease-bleeders they are called- are in danger of bleeding to death from even a very slight injury, because all the ordinary measures that are used to arrest hemor- rhage are of no avail. Besides these conditions which have been mentioned, serums are used for the treatment of cerebrospinal meningitis, pneumonia, measles, childbed fever, scarlet fever, erysipelas, rheumatism, and various other conditions, and there is no reason to think the limit of their usefulness has been reached. There are so many diseases in which the condition of the blood has undergone change, and in which the problem seems to be to find and introduce into the blood-current a substance which will counteract this change, that the prospect of future usefulness of serum treatment seems very attractive. Of course, it is always of the greatest importance to know that a given serum has been prepared by a perfectly reliable manu- facturing chemist; the method of preparation is costly and can only be accomplished by those who are well informed and expert in laboratory work. Substances of this kind also deteriorate in a very short time, and it is always important to know when the sub- stance was issued from the laboratory and for how long a period it is guaranteed to be effective. This information is usually printed upon the container of the serum and should be observed and noted in every case. SANITATION AND HYGIENE 145 Disinfection.-If the statements in the preceding chapter are true, this section upon hygiene would not be complete without some reference to the various methods of disposing of the germs of disease which have been liberated in the atmosphere or absorbed by water, or which have settled upon the walls of houses or upon articles of furniture, clothing, etc. Many of these germs are exceedingly tenacious of life; they may remain inactive a long time even though they do not develop and grow. Some of them (called anaerobic bacteria) will live even in a medium which is without air; but the most of them, it is believed, require air like other forms of life. Some of them bear a temperature below the freezing-point without discomfort and are often found in ice; none of them will endure a temperature above the boiling-point for any length of time. Most of them will suc- cumb to powerful chemicals like sulphur, chlorine, mercury, and formaline. Disinfection of Water and Food.-Food which is thoroughly baked or boiled is not a source of trouble from disease-germs, but such food does not interfere with disease-germs which are already in the digestive apparatus, and their disposal can hardly be under- taken until they have manifested their presence by some disturb- ance in the individual affected. Raw food is always taken with risk; it may be disinfected with chemicals, but this is usually inconvenient. It may be thoroughly disinfected with heat; that is, by cooking. Water which is boiled or distilled is free from germs; so also is artificial ice which is made from distilled water. Five or ten drops of dilute hydrochloric acid in a glass of water will sterilize it sufficiently, and the acidulous taste of the water will not be objectionable to most people. Milk is so important an article of food and so often a source of disease from the bacteria which it contains that a few words concerning its disinfection or sterilization are demanded. Pro- longed boiling of milk destroys its germs, but it also coagulates its casein and makes it more difficult to digest. There are several excellent forms of apparatus on the market (Soxhlet, Seibert, and others) for sterilizing milk, when used as food for infants, which may be adopted with safety. Pasteurization of milk con- sists in subjecting it to heat from 158° to 1700 F. for half an hour or longer and then rapidly cooling it to 540 F. or less. This will 146 HOW TO KEEP WELL destroy or render inactive the bacteria which it may contain but will not coagulate the casein. Disinfection of Clothing, Books, and Small Articles.-Such articles require disinfection when they have been exposed for any length of time to an atmosphere in which there has been con- tagious or infectious disease. Those who as nurses, doctors, or assistants have attended the sick with the eruptive diseases, measles, scarlet fever, smallpox, whooping-cough, diphtheria, or even tuberculosis and typhoid fever, also childbed (puerperal) fever, and, in general, any form of sore or injury which is accompanied by blood-poisoning, should wear special clothing for that purpose which should be worn nowhere else, at least not until it has been boiled, washed, and ironed. Books and various small articles in the sick-room which have been exposed to infectious disease may be baked at a temperature equal to the boiling-point of water, but as this is not always easy and involves the risk of destroying that which is put in the oven for the purpose, the better way may be to subject the infected material to the action of chemical vapors. All the efficient chemical disinfectants are irrespirable in the state of vapor, and hence the disinfection must be effected in a closed room which is unoccupied at that time. Chlorine is a valuable disinfectant but it also removes the colors of substances which it attacks. Formaline has been found very effective as a disinfecting agent and does not injure or decolor- ize substances. There are various lamps on the market which are used for liberating this gas from wood-alcohol. There are also metallic boxes, not very expensive, in which a large number of articles can be placed and then disinfected with formaline vapor. Disinfection of the Body.-Those who attend the sick, not less than the sick themselves, should disinfect themselves after ex- posure. Alcohol is one of the best disinfectants, and the daily sponge-bath for the entire body of one who has infectious disease is both agreeable and useful. If the skin peels or scales the sponge- bath should be followed by inunction with fresh (that is, not rancid, this being important) cocoa-nut oil, which will not only soften the skin but prevent the loosening and flying of scales. For those who attend the sick the daily bath should be a cus- SANITATION AND HYGIENE 147 tom. If the disease is infectious, an antiseptic soap (formaline, mercury, or even plain Castile) should be freely used, and es- pecially upon the hair, the hands, and the nails. The latter should be kept closely pared, rigorously clean, and a stiff brush used frequently in the spaces around the nails. Dirty hands, finger-nails and instruments are responsible for much of the disease which ought never to occur. Disinfection of Rooms, Furniture, Carpets, Etc.-A room which has been occupied by a person with an infectious disease should in no instance be used again until everything in it, and, better still, everything in the house, has been disinfected. In most of our cities the board of health will attend to such matters, but in villages and in the country it must be done by individuals. Carpets and curtains and also all bed-coverings and mattresses must be steamed for an hour or longer until every inch of surface has been thoroughly permeated. Inexpensive articles of furniture, especially when old and dilapidated, also straw beds, old coverings, etc., should be destroyed by fire. Walls, ceilings, and floors may then be scrubbed, if they will admit of such treatment, with hot bichloride of mercury solution (one of mercury to one thousand of water). Windows and doors must then be closed and formaline vapor liberated into the room for an hour. This method is preferable to burning sulphur in the room; it is more effective and the odor less persistent. The .room should remain closed for twenty-four hours; it may then be opened and aired and used again with safety. The proper rule to follow in these days, when we know the terrible possibilities from the spreading of infectious disease, is to take all necessary precautions which are available, resting rea- sonably assured that if we do the disease cannot be extended through fault of ours. There is little excuse for ignorance in such matters; in fact, ignorance becomes a crime, for it need not exist. Sleep Sleep that knits up the r avail'd si eave of care, The death of each day's life, sore labour's bath, Balm of hurt minds, great nature's second course, Chief nourisher in life's feast. Consideration of this subject includes not only normal sleep, such as comes to those who are in every way in good physical 148 HOW TO KEEP WELL condition, but the various digressions and aberrations from the normal that result from injury or disease, occupation or bad habits or the influence of poison. It is difficult to define sleep with exactness. Many have tried it, but I have failed to see a definition which is entirely inclusive and comprehensive. The reason of this may be that the cause of sleep is not the same for all persons, nor the same for one person all the time. At any rate, sleep that is real sleep is unconsciousness. It is not necessarily profound, for light sleepers waken with the slightest disturbance, sometimes from the mere presence of another person near them. On the other hand, sleep is often so deep and stupe- fying that it resembles the unconsciousness of coma when the brain is paralyzed by injury or disease. Unconsciousness exists in normal sleep, and the brain is inactive; the nutrient forces of the body go on, even if at lesser speed than in waking and working hours. The heart and lungs particularly are required to keep on without pause or respite; but the digestive, the urinary, and the other essential apparatus are doing only moderate work, are on half-time, as it were. Inasmuch as we know that anemia of the brain will cause un- consciousness, it seems to me that this must be the principal factor in producing sleep; and since the influence of many poisons -not only drugs, but other substances which may circulate in the blood-is seen in the drowsiness, stupor, lethargy, and uncon- sciousness which follow their use, it is fair to presume that the waste substances of the body, especially the urea, the poisonous matter absorbed from the intestines and bladder, and the material generated by the excessive work of muscular tissue of various kinds which we call fatigue, are all contributing factors in pro- ducing sleep. The entire muscular system is quiescent; this is vividly demon- strated in the disease known as paralysis agitans, or shaking palsy, in which certain muscles are constantly in action during the waking hours, but during sleep they are at rest. Rest for the muscles is essential to life. The human machine does not differ from any other in this respect. If it is worked continuously it soon wears out. Many people who say they are poor sleepers do not appear to suffer severely from this fact, for they lie quietly in bed for a sufficient number of hours and learn to be passive and to SANITATION AND HYGIENE 149 free themselves from brain activity, even though they may not enjoy the great boon of peaceful, continuous sleep hour after hour. That the brain is anemic during sleep is at least suggested by the loss of color in the face, which occurs in many, though not in all people, as the heart slows down and the blood tends to accumulate on the venous side of the circulation. The object of sleep is recuperation, renewal, renovation. Who, unfurled beneath thy drowsy wing a triple hour, But renovates and lives? It is the relaxation of the tension of muscles, the rest of brain and nerve cells, like the yielding of a rubber band before renewed stretching, or the interval of rest in an electrical battery to store up strength and energy. It has often seemed to me more important than food. Some people have gone three or four weeks without food. Very few could go three or four weeks without sleep; most of us are not of much use if we pass forty-eight hours without it. I have read of but one case in which it was stated with apparent truthfulness that a certain man never slept; and as he was in a hospital, watched day and night, and seemed not at all the worse for his vigil, it may have been true-but it is extremely against nature. Nature has arranged that the requirement of sleep should vary for different persons and at different periods of life. An infant sleeps almost continuously. For infants and growing children many hours of sleep are indispensable to healthy development. In mature life one third of the twenty-four hours passed in sleep satisfies the requirements of most people, women frequently getting along with fewer hours than men. In old age there are many who say they are satisfied if they can sleep four or five hours, but in my experience this rule is by no means general, and I believe there are many who return to the conditions of childhood and sleep the larger portion of the time. The influence of sleep in conserving vital force is well illus- trated in the case of hibernating animals, who furnish sufficient fuel from their own tissues to keep their machinery in operation several months. The custom in tropical countries of sleeping after the midday meal is a good one and might well be followed in temperate 150 HOW TO KEEP WELL climates, especially during the summer months. Night seems to be better adapted for sleeping than the day, partly on account of the darkness, principally because of the force of habit. The insane, the neurotic, and the neurasthenic, patients with acute diseases, and brain-workers often suffer from loss of sleep; and the period of life when sleep is most likely to be irregular is between thirty and fifty. People can usually adapt themselves to sleeping at any time; and indeed there are many ways in which compensation takes place when it becomes necessary to change the customary scheme for performing natural functions; but I think it is a hopeless task to attempt to improve upon the methods of nature and that violations of natural conditions must be paid for in some way. The season of the year has more or less to do with sleeping in many instances, some sleeping better in summer than in winter, while with others the reverse is the case. Atmosphere and atmospheric pressure have a very distinct influence upon sleeping in many cases, those who are accustomed to sleep at the sea-level finding great difficulty in sleeping at the diminished pressure of two or three thousand feet. On the other hand, people with pulmonary diseases who cannot sleep well at the sea-level are often greatly relieved by removing to a moderate elevation. Sleep not only may be insufficient-insomnia, we are accus- tomed to call it-but it may have irregular forms and phenomena, including dreams, nightmare, terrors, somnambulism, trance, epi- lepsy, lethargy, hypnotism, sleep due to poisons, and the African sleeping sickness. When one dreams the sleep is usually light, and one often awakens at the end of the dream. The more intense and vivid the dream, the more likely will it be to awaken the sleeper. It implies a certain amount of brain-action; it does not necessarily imply a vigorous brain. Children's dreams are often exceedingly intense, and when fearful and with nightmare we call them night-terrors. Nightmare at any age is often the result of disease of the heart or liver, or of overeating, or poor digestion, hard work being re- quired of organs which should be quiescent. Irregularities in sleep often seem to be inherited, particularly in those whose parents have had a bad nervous system. Lying on the back disturbs sleep in many cases, and the same is true if the bed is too low, or if the bed-clothing is too heavy or too light. SANITATION AND HYGIENE 151 Drowsiness or lethargy often makes it impossible for one to remain awake, particularly if one tries to concentrate attention in church, in the theatre, or in any public gathering where the air is poor and the lights are brilliant. The inclination is often over- powering and one may even fall asleep standing or at work in any kind of employment. Such people may sleep many hours at a time. Sometimes the condition is due to disease, and some- times it is merely an individual peculiarity. In somnambulism there are sleep and unconsciousness; the walking and other actions are automatic and without volition or brain activity, unless possibly of the sub-conscious brain; but it is such a bad and dangerous habit, whether in the young or the old, that it ought to be brought under control. Hypnotism, trance, and mesmerism are forms of induced sleep, particularly by suggestion, and often with those whose wills are weak. There are occasions when it seems to me they may be of service, but they are edged tools and should not be used indis- criminately. Bathing.-It is not strange that water, which, with the excep- tion of air, is the most abundant and plentiful thing we know of, should have the most powerful influence upon every form of life. Indeed it is quite as essential to life as air, and unless it is sup- plied to living things in sufficient quantity they inevitably wither and die. It is as essential to the outside of the body as to the inside, for we should never think of outside and inside as existing by and for themselves, but only as parts of one composite, com- plete organism. The influence of water upon disease, or rather upon the wel- fare of the body, has been observed for thousands of years, and we do not have to look very far into human history to see what importance men have always attributed to it. In fact public and private baths and the internal use of medicated waters may be regarded as among the earliest contributions in the building up of a science of health. They indicate a process of deduction from observed facts which at first were probably purely accidental, but the reasoning was sound and logical and has remained valid and cogent to the present day. The cultivated nations of two or three thousand years ago laid even more stress upon the value of water as a means to health than we do, and hence the mag- nificent baths, both public and private, which they constructed 152 HOW TO KEEP WELL and the encouragement which was given to high and low, slave and free, to the most lavish use of water not only as a luxury and a means of self-indulgence but as a direct aid to health and well-being. The science of treating disease by means of water, whether out- wardly or inwardly, is known as hydrotherapy, and there seem to be very few diseases which may not be helped by it when in- telligently used, though it is very far from being a cure-all. Mineral springs are natural sources of water in which are dis- solved mineral substances of one kind or another. Water being the universal solvent, its contact with the various strata of rocks of which the earth's crust is composed has given us these various substances in solution; hence the lime, the chloride of sodium, the magnesium, the sulphur, and other mineral waters which are found in the vicinity of these different rocks. The solution of seaweeds and other vegetable substances has supplied additional medical material to that obtained from the rocks. The waters thus impregnated have been studied in their influence upon disease and thus have arisen the various health- resorts of different countries. To mention Carlsbad is to suggest the treatment of diseases of the kidneys and other organs with its waters and its hygienic regimen. To mention Harrogate or Epsom or Bath is to suggest the treatment by their waters of disease of the intestines or stomach, or of gout from high living or overfeeding; and so of Vichy, Ems, Wiesbaden, and a host of other places which are of importance principally because they are resorted to by those who are sick, or who think they are sick, and drink or bathe in their waters. The mental factor of the treatment at mineral springs is, of course, a very important one. One person visits them who is not really sick but thinks he is; another has some kind of disease and goes there with the expectation of being cured. Both will prob- ably be benefited if they follow the rules and have faith in their doctor, so great is the influence of the mind over the body.4 But there is one mineral water that is more important than all the others because of the vastness of its volume, the enormous area it covers, and the multitudes to whom it is available-the *The State of New York maintains baths at Saratoga which have been used advantageously in the treatment of heart, kidney, and other organic diseases. SANITATION AND HYGIENE 153 ocean. It is not an agreeable water to drink, Its chief mineral constituent is chloride of sodium or common salt, but it may also have other substances in solution, according to the nature of the rocks and the vegetation in a given locality. The value of sea-bathing is unquestionable; in fact, nobody who has ever taken a sea-bath, especially on a hot day, if the water were not too cold and his physical condition were not un- suitable for reaction, would think of questioning it. It is one of the most precious assets of this country that it has thousands of miles of sea-coast both on its Atlantic and its Pacific sides, which the public can use freely as a vast bathing-resort. Bathing to be of any value, whether sea-bathing or any other, must be followed by good reaction. This means that the effect of the water, the substances dissolved in it, and the temperature of water and air must be stimulating but not overstimulating or paralyzing to the nerves of the skin. This stimulus if of proper character is conveyed inwardly to the heart and other organs, and they respond or react by increased activity of function: the heart contracts more vigorously and sends the blood in increased volume to all parts of the body; there is a glow and redness of the skin and a feeling of refreshment and invigoration in every portion of the body. If the reaction is not good there is a feeling of depres- sion and weakness and indisputable evidence that the bath has not been suitable; there is something wrong about its temperature or the substances it contains in solution. A cold bath should have a temperature of 400 to 75°, a warm bath of 750 to ioo°, a hot bath of ioo° to 1200. A vapor Russian bath has a temperature of ioo° to 1400 ; a hot-air or Turkish bath has a temperature of uo° to 1800 or even higher. Extremes of temperature in bathing should be avoided by those who are not robust, for when baths are taken incautiously the re- sults may be disastrous. It is, therefore, most important in using baths of any kind, sea-baths or any other, to know something about the probable reaction that will follow. They are potent influences for good when used discreetly, but it must not be for- gotten that when used unwisely they are equally potent for harm. Exercise.-What do we understand by the term "exercise"? The use or work of tissues which were not meant to be inactive. Exercise implies life. A dead human being or a dead animal can- not exercise, because the activating force by which exercise be- 154 HOW TO KEEP WELL comes possible has vanished. Nothing that is inanimate can exercise. We do not expect anything in that line from sticks and stones. They can be instruments or aids or media for exercise, but they are unchanged by it, the change being in the agent by whom they are used. Exercise means the performance of a function with which an animal or a plant is endowed by nature. If the function is per- formed easily and naturally, the individual thrives; otherwise he does not. When people talk about exercise, unless there is special refer- ence to something else, one naturally thinks of the use of the muscles, but this is a small part of the body's functions. The exercise of the digestive apparatus means the digestion of the food and the consequent nutrition of the body. The exercise of the brain means thought and will and all the manifestations of the intellect. The exercise of the muscles means motion. The body is so constructed that if any portion of it lies idle any length of time that portion will wither and die. Cut off the circulation of blood in your finger by tying a string tightly around the base of it, and in a very short time it will become dark and lose its feeling. Shortly afterward it will become impossible to move it: it will become black and gangrenous, and very soon afterward it will become dead and will have to be removed. Cut off the nerve-supply to your finger, and you will be unable to move it; if a pin is stuck into it you will be unconscious of it; pretty soon it will shrivel and become helpless. The blood must not only circulate in your finger and the nerve force be unim- paired, but you must use the finger if you wish to retain its life and its health. What applies to the finger applies to the body as a whole. If you wish muscular strength you must exercise the muscles. If you wish good nutrition you must keep your digestive apparatus in proper working order by supplying it with appropriate food, neither overtaxing nor starving it. It is the same with the mind. If you want it to grow it must be fed and worked and trained, and with all this will come broader views of life, greater powers of service, greater excuse for being on the earth and for being one of the company of travellers who are making the journey of life. Rest.-The importance of rest as a physical influence is very SANITATION AND HYGIENE 155 often undervalued. Everything that is susceptible of wearing out -and I know of nothing, animate or inanimate, that is not thus susceptible-requires occasional periods of rest to give it its greatest efficiency. If an automobile is run continuously, even though it is kept clean and well oiled, its effective life will not be as long as one that is used intermittently and with less expenditure of force. How much more is this true of the human machine, more complicated and more susceptible of jars and strains and breakdowns than the best automobile ever constructed! None of the organs of the body are planned for uninterrupted work. The digestive function is carried on at intervals; the stomach and liver and the entire glandular apparatus must have opportunity to renew their secretions, and if they are subjected to unlimited pressure they soon give out. The brain cannot work continuously. If it is forced for more than a few hours, diminished and inferior output is the result. The entire body yields to ex- haustion after a hard day's work and imperatively demands food and sleep, and when these necessities have been supplied to a sufficient degree it resumes its customary activity and efficiency. The underlying principle is thus clearly demonstrated that periodical rest is a requirement which cannot be denied except at great cost. Those whose task is to watch the ill and injured are constantly impressed with this supreme fact. Medicines and bath- ing and nursing have their place, but they cannot supersede the importance of rest in restoring suspended and diminished vitality. It always has seemed to me that those who endeavor to make a mathematical problem out of the period of convalescence and re- cuperation-so many days for recovery from this kind of illness, so many days for recovery from this operation-were ignoring the plainest teaching of physiology. I am therefore an unqualified believer in the physiological value of vacations and do not appreciate the position of those who boast that they never take them and do not see the use of them. The diminishing of the working-man's week from six days to five and a half is in the interest of health and happiness, provided, of course, that the extra time is used rationally and sensibly. The vacation period for working-people should be established by law, but it should be longer for those who work hard and are tired out and are undernourished than for those whose work is easy and whose burden is light. But it must not be forgotten that too much 156 HOW TO KEEP WELL leisure and idleness and play are as undesirable as too little and often get men and women into mischief. It is an economic point of great importance that our local and general governments are providing parks and camps and play- grounds for the benefit and welfare of the people, young and old. They are almost as important as schools; indeed, they often are means of great educational value. One of the few hopeful signs of these turbulent times in which we are living is the desire, the eagerness, of great masses of the people to get away from the noises, the odors, the intolerable rush and bustle of the city into the country where the air is pure and the quarreling and the wrangling and the grubbing for money are for the moment forgotten. PART II THE BODY IN DISEASE 157 CHAPTER IV DISEASE What do we mean by this term? It is a word that is in everybody's mouth, though more at certain definite times than at others; and it is almost sure to be used by most human beings at one time or another during their earthly pilgrimage. One way of reaching a definition is by consideration of its antithesis, health. Health is the state or condition when one feels well, when one is well, when the functions are all doing their work as they were intended to do, and when the tissues are all sound and un- broken. In a word, health is like a well-oiled and equipped piece of machinery which works smoothly and without friction or jar, accomplishing what is expected of it. When anything goes wrong with the machinery, when some evil-disposed person puts sand in the bearings or throws a monkey- wrench into some essential portion, instead of harmony and serenity of action there is at once confusion and chaos; the machine is no longer capable of doing work; it stops. So is it with the body when health leaves and disease steps in: the running is irregular and ineffective; the organs do not do their duty; the tissues are injured and broken, perhaps destroyed; the body as a working unit is out of gear; perhaps it is out of commission. "Disease" is a very comprehensive term; it comprises the entire range of abnormal and unusual physical conditions, from the most insignificant disturbance to the disorder or injury which embraces in its grasp every atom of substance in the whole body. It comprehends an enormous number of well-recognized condi- tions, and each year is adding to their number. It would take many volumes to arrange and classify and describe them so that they would be available to the public at large, and the task would 159 160 HOW TO KEEP WELL be a futile one because hundreds of these conditions are mere curiosities of pathology which many a skilled and experienced doctor may never have met in actual practice. There are enough left, however, which are seen sufficiently often, and with the characteristics of which it is well for most people to be somewhat acquainted, or at least to be able to recognize the more common of them if they are confronted by them. Inflammation.-There are many types of disease; in the ma- jority of them when the disease is fairly established there occurs an interesting process which outlines, to a certain extent, its his- tory. That process is called inflammation, and because it is such a common accompaniment of disease it is very desirable to know something about it. The ancient writers on medical topics, whose opportunities for study were far inferior to ours, and whose deductions from their observations, while often excellent in their way, were certainly less comprehensive than are now made in the light of much greater information and knowledge, these ancient writers, I say, recognized the ever-recurring phenomena which were present in inflammatory conditions and laid down as a criterion for deter- mining the presence of inflammation four essential factors: heat, redness, swelling, and pain. This was well enough as far as it went and certainly applies to many inflammations upon the surface of the body where these factors can be seen and felt. It is not so applicable to the chronic processes of inflammation which progress slowly, painlessly, and often without redness, swelling, or elevation of temperature, (though they may have started from acute inflammation) ; and it may not apply in some of the bacterial inflammations, which include a large number of those concerning which we have ac- curate information. That all inflammations have a bacterial origin is at least questionable, some pathologists affirming that this is the case and others denying it. What seem to be the principal factors in inflammation are the blood-vessels and the blood. When an injury or insult of any kind or description is received in any area of the body, large or small, the veins and capillaries of that region at once resent it; the white and then the red blood corpuscles work their way through what may be called the pores of the vessels, and then *he fluid contents of the same blood-vessels follow. These col- DISEASE 161 lect in the tissues around the blood-vessels, and thus an inflamma- tion is begun. This may subside in a few days, or it may last indefinitely. It may subside without formation of pus, or pus may form, the result being an abscess. The abscess may contain pus alone, or it may also contain blood. It seems quite clear that in some inflammations, whether produced by chemical, thermal, or mechanical means, the influence and association of bacteria can be excluded. We must not forget that an injury as the cause of inflammation means a hurt or disturbance of any kind and that it may occur in any part of the body, outside or in. Upon the kind and degree of inflammation in any inflammatory disease to which the body may become a victim, plus the resistance which the body may be able to offer, depend the weal or woe of the individual who is thus afflicted. Pain.-Few of us get very far on the journey of life without being overtaken by a very grim and disagreeable sort of traveler whose name is Pain, and he persists in inflicting his presence and companionship upon us, at longer or shorter intervals, as long as the journey lasts. Some people have an idea that the time is coming when pain will be abolished, but that is as impossible as that there will ever be an end to automobile accidents. No automobile can be constructed that is fool-proof, and as long as there are sensory nerves there will be pain. An infant experiences pain almost as soon as he experiences hunger, and that is very early in his career. How do we know? What is the reaction when a young mother penetrates her baby's clothing and unintentionally pricks the baby with a safety-pin? A cry, and this cry stops almost as soon as the safety-pin is re- moved. Repeat the experiment any number of times, and the re- action will always be the same. Hence we are sure that the prick of a safety-pin hurts the baby if he is a normal baby and that he experiences pain. When the baby gets older and is able to talk he tells you it hurts when he has pain of any character in any portion of his body, and similar testimony may be evoked, at any period of life, from the majority of people, male and female. Of course some are less sensitive and demonstrative than others in their response to pain and may be quite conscious of it though making no complaint or outcry. I have known Christian Scientists 162 HOW TO KEEP WELL who were sufferers from disease and injury which would be con- sidered painful and distressing by the average individual but who denied that they had any consciousness of pain. I hope they were speaking the truth. During the World War we were frequently told of soldiers who when injured in battle were able, with little or no assistance, to go to the rear and then have their wounds attended to, which is ordinarily a painful procedure, without anesthesia and without a whimper or complaint. Many people, Indians, martyrs, and others, are reported to have borne exquisite torture without a murmur, but I see no reason to doubt that the sense of pain was present, though under control. It must be so, for the very existence of the sense of feeling means the ability to report to consciousness that impressions, light or heavy, wet or dry, cold or hot, pleasurable or painful, have been received by the nerve-endings in the skin and transmitted to the brain. There are some portions of the body that are more responsive to painful impressions than others: the tip of the tongue and the ends of the fingers are much more sensitive and so more re- sponsive to pain than the skin upon the back. There also seem to be some pains that are harder to bear than others; that which is produced by facial neuralgia or by the dentist when he discovers the nerve of your tooth with his instruments of torture is more intolerable than pain in the stomach or intestines or in any other part of the body. But if there is pain there may also be relief from pain; the narcotic drugs have a divine influence in this respect. Would that they might be limited exclusively to this! After Warren, at the Massachusetts General Hospital, had painlessly dissected out a tumor from the man whom Morton had anesthetized with ether, he was warranted in saying to those who witnessed the operation, "Gentlemen this is no humbug"; for it meant the abolition of pain in surgical operations; and now, even with local anesthesia, many serious and even prolonged operations are done while the patient is fully conscious and without the experience of pain or unusual shock. What, then, is pain? It is an expression of the sense of feeling which responds to the perception of physical or spiritual discom- fort ; physical when the impressions received by the nerve-endings are of a violent or unpleasant character, spiritual when similar DISEASE 163 impressions but of intangible and immaterial character, and either from without or within, are directly perceived by the brain and the mind. Or to put it in less metaphysical terms and as I once heard it defined by a most able and learned judge with many years of judicial experience, "Pain is something that hurts." Emotions.-We are very apt to underestimate and undervalue the bearing which is exerted by the emotions upon the bodily wel- fare. By the emotions we understand certain distinct products of consciousness, which are mental phenomena or attributes, or sense perceptions, and which we label respectively fear, joy, reverence, hate, love, shame, grief, etc. These phenomena or sensations are excited in the greatest variety of ways by stimuli within the body or outside the body, near or remote. Their effects vary with the particular kind of emotion, with the temperament of the individual acted upon, with his degree of sensitiveness, and his physical condition at the time the emotion is experienced. Thus grief which at one time would overpower and overwhelm and convulse a given individual might with another condition of health or surroundings produce only a slight impression. An experience which would excite an emotion of intense hate in one individual might cause only indifference in another. That which would produce the keenest joy, the highest exaltation in one-for instance, the perfect performance by a well- trained and well-conducted orchestra of a symphony of Beethoven -might easily be as incomprehensible and unmeaning as a hymn in Sanskrit to another by his side, though the same sound-waves were conveyed to the auditory apparatus of each in precisely the same way. The recipient of these various emotions and impressions is prin- cipally the nervous system, both the cerebrospinal and the sympa- thetic divisions; and these nerves have the most positive influence upon nutrition and vital activity. Suppose one is suddenly con- fronted with a great sorrow: the desire for food disappears, and if it were taken it would be only imperfectly digested, if at all. An un- tried, inexperienced soldier goes into battle: he loses control of his bowels and bladder, and fear will compel him to run away, if he can, though he may be a patriot and thoroughly in sympathy with the cause in which he is enlisted. A hysterical woman, and there are thousands of them, imagines she is seriously sick, and though she may previously have manifested all the domestic virtues, she now 164 HOW TO KEEP WELL throws them to the winds, becomes entirely self-centered, and causes the greatest amount of inconvenience and discomfort to her family and friends by her irrational, emotional outbreaks; all she seems to care for is to gratify her exaggerated self-consciousness. It is often stated that people do not die of grief and sorrow. That is not so. The loss of a beloved child or an adored husband or wife may not only so influence the nutrition of the brain that insanity may ensue, or it may so affect the nutrition in general that death will speedily be the direct and logical result. Particu- larly is this the case when the blow strikes one who is already suffering with a serious organic disease, heart-disease, for example. Death of a loved one or sudden unexpected bad news of any kind may affect such persons like a stroke of lightning, and the weakened heart may give out at once. Examples of this are familiar enough to all of us, not only in fiction but in real life. The influence of the emotion, anger or hatred upon vitality is also perfectly well known. How many stout, full-blooded, red- faced men and women, particularly men, with diseased and dis- tended arteries, have "burst a blood-vessel," as the saying goes, when provoked or annoyed beyond endurance, perhaps even by trifles, and have succumbed quickly to a stroke of apoplexy? All this teaches us the importance and the value of self-control and of the paramount obligation so to rear and bring up children that emotion may be curbed and controlled. The obstacles in the way of those whose inherited tendencies to emotional outbreaks are highly developed are almost insuperable; but as there is no royal road to knowledge, so, and even more so, is the only road to equipoise and self-control through hard and self-denying and per- sistent effort. CHAPTER V INHERITED DISEASE Disease may come to us in two ways: we may be born with it, or we may acquire it after birth, and most diseases are of the latter variety. The diseases with which some people are afflicted from the moment of birth are inherited diseases. The list of these diseases is not a long one, but they are a bad lot, some of them be- ing fatal even before birth, others at birth or soon after, while others serve as a continual handicap and in one way and another may make life a grievous burden and cut it off prematurely. There is one disease upon the inheritance of which there can be no possible question, and that is syphilis. In many couples in which one or both members are syphilitic impregnation does not occur. It would be well if it were so in all cases, but it is not. In many cases in which impregnation occurs the child dies during some period of its prenatal development and when delivered often shows the marks upon the skin or some other portion of its body of the disease of which it was the victim; or it may be born with a syphilitic eruption, covering all or a portion of the skin; or the disease may not appear until later in life, different organs or senses being affected or the nervous system seriously attacked. Heredi- tary blindness, deafness, and a great multitude of serious ills of all kinds may be due to this terrible disease. Tuberculosis is an inherited or inheritable disease, though in most cases the inheritance is only a tendency and frequently is overcome or outgrown. The offspring of parents in advanced tu- berculosis may be dead at birth or succumb soon afterward, directly or indirectly the victims of this disease. There are various diseased conditions which are due to faults of development but which, unless remedied by medical or surgical art, remain as permanent evidence of some inherited taint or stigma. 165 166 HOW TO KEEP WELL Many children who have a family history of alcoholism are af- flicted in this way. Some of the conditions which are suggested by faulty inheritance but which cannot always be proved are harelip, tongue-tie, birth-marks, club-foot, hydrocephalus or water in the head, and many others. Many children are born with a directly inherited tendency to epilepsy, chorea, convulsions, and other diseases which are associ- ated with a defective nervous system, while still others inherit certain peculiarities of manner or of structure which may have been handed down through several generations. Alcoholism is a peculiar disease in the way in which its effects are transmitted: the children of an alcoholic parent or of alcoholic parents may have all sorts of disorders, particularly of the nervous system, mild or severe, or they may be entirely free from inherited blemish, while the follow- ing generation may get all the benefit of the sins of their grand- parents. There are many diseases which, with reference to heredity, may be called border-line diseases; it is difficult to know just how to classify them. Mendel and his followers have done much in investigating the laws which relate to heredity, but there are many problems which are still unsolved; and that applies particularly to heredity as it relates to disease. Birth-Marks.-These common and disfiguring blemishes con- sist in areas or patches of discoloration, or small tumors, often of a permanent character, upon or beneath the skin in various portions of the body. Sometimes they do not appear until a few days after birth, be- ginning with a small patch or blot which looks like flea-bites, and spreading until they occupy a very large surface. When on the face and head they may have been caused by the pressure and bruising of the instrument which was used in assisting the head into the world; such an origin is distinctly a traumatic one, that is, an origin from a wound. In the great majority of cases they are due to defective or im- perfect development of certain blood-vessels upon the skin; and these blood-vessels, after birth, coalesce and form a kind of tumor which is known as an angioma, the birth-mark itself being also called a naevus. The discolored skin may be on a level with the surrounding skin, or it may be more or less elevated, or it may have scattered over it more or fewer wart-like growths or tumors. The INHERITED DISEASE 167 color of the birth-mark varies in the intensity of its usual appear- ance. Sometimes it is dark red, commonly known as a port-wine stain, or it may be a deep purple, a flaming red, or a delicate pink. It may swell and throb under the influence of emotion, and it may become dark and almost black when distended with venous blood. The most common location for birth-marks is the face, but they may also appear upon any other portion of the body. In certain families there is a tendency to this kind of marking. I am acquainted with one family in which each of the four children has a mark of considerable size on the arm or leg. A tumor of this kind may appear on a new-born baby and soon afterward disap- pear, the blood-vessels undergoing shrinking and atrophy, or it may remain permanently in a stationary condition, or, as already stated, it may extend and cover a large portion of the body. In- jury to a birth-mark may cause profuse bleeding, for it is a kind of reservoir for a very considerable quantity of blood. It may become inflamed and gangrenous, or it may be the seat of erysipelas; there- fore it is by no means a simple or harmless condition. When on the face, it is a source of great annoyance on account of the disfigurement it causes. I have seen a face, otherwise very beautiful, covered on one side with this kind of a mark. When it is very large, and when it is small and inconspicuous, giving no trouble, it is not worth while to meddle with it. When it is of moderate size and troublesome it may be destroyed by ice, by compression, or by acids, but best by the thermo or electric cautery, a portion of the vessels being destroyed at a time, in successive sittings, until all have been disposed of. Harelip.-This deformity, deriving its name from the cleft or fissure in the lip, which resembles the natural condition existing in the lip of the hare, signifies that the union which normally takes place prior to birth between the middle section of the lip and the upper jaw has been more or less defective, leaving a gap or fissure in the middle, on one side, or on both sides. This want of union may involve not only the lip, but the nose, the portion of the upper jaw in which the front teeth are inserted, and even the roof of the mouth, or hard palate. The extent of the fissure varies from a slight indentation to a deep gap involving the entire height of the lip. A slight fissure is merely a deformity and a blemish upon the face, though a constant annoyance through life, if not remedied by a successful operation. 168 HOW TO KEEP WELL An extensive fissure is a menace to life and probably causes death in not a few of the cases which fail to receive good surgical treatment. This is particularly the case where the fissure involves the palate, for breathing is thereby rendered very difficult, and nursing in the natural manner is impossible. When nursing is at- tempted the child chokes, has great difficulty in either drawing or swallowing its nourishment, and may be strangled in the attempt. The complicated cases in which there are several deformities may even include fissure of the cheek or eyelid. When harelip is un- complicated, it is usually on the left side of the upper lip. The deformity is by no means an uncommon one, but its cause is not always easy to trace. Of course, it implies lack of strength and vigor in the baby during the months before birth, in which it is developing. A weak, delicate mother burdened by care, sorrow, or unduly severe toil during the months of her pregnancy may give birth to such a child. Or the child may be the offspring of a parent who has been dissolute or the victim of constitutional disease, or of parents who may have been too closely related in temperament and tissues. In some of the cases the parents are apparently sound and healthy, and it may be unwarrantable to attribute the deformity to any defects on their part. The successful treatment of such children is one of the great triumphs of surgery. Such treatment has become entirely possible in many of the cases, especially since the introduction of anesthesia and antiseptics. It is often a problem, however, which taxes the ingenuity and skill of the surgeon to the utmost. A very important question is the time when an operation would be proper and desirable. In general terms, it may be said that the earlier the operation is done, assuming that it is done skilfully, the more satisfactory will be the result for the patient. The great object is not only to close the gap which nature has failed to close, but to leave the slightest possible reminder, the most inconspicous scar upon the skin. Other important considerations are the extent of the operation required and the physical condition of the baby. If the deformity is a simple fissure which can be remedied with a few strokes of the scissors and two or three quickly passed ligatures, it may be done almost any time after birth, within a few days or a few weeks, whenever the conditions seem favorable. If the child is feeble and delicate, it will usually be preferable to improve his condition before operating. Injured tissues heal bet- INHERITED DISEASE 169 ter and more quickly at any period of life when they have good recuperative power than when the reverse is the case. If the deformity is extensive, it will usually be preferable to de- fer the operation until the child has acquired strength enough to withstand the strain and shock which such an operation would en- tail, and it may be necessary to wait until the second or third year before it will be considered advisable. If a child is puny, poorly nourished, and the victim of inherited disease, he will not be a good subject for the operation either early or late in his childhood. He may succumb to the strain imposed upon him by the operation, or, if he survives, the wound may heal so imperfectly that the resulting scar will be a source of mortifica- tion throughout life. It is very important to select a surgeon who is skilful and ex- perienced in such work. It is therefore urgently advised that those who must submit their children to this kind of surgical treatment ascertain, first of all, whether the surgeon who may be selected is competent for this particular variety of plastic surgery. Left-Handedness.-Benjamin Franklin, among the many curi- ous and interesting things for which he is responsible, wrote "A Petition of the Left Hand," in which a plea was made for the greater use and cultivation of that member as a means of increasing one's force and capacity; and Charles Reade, in "The Coming Man," enlarged upon the injury that mankind was inflicting upon itself by continuous use of the right hand. One interesting anatomical fact which may explain the prefer- ence for the right hand in most of those motions which call for skill and delicacy is that these motions derive their influence from the left hemisphere of the brain, whose fibers cross from the left side to the right and so pass down the right side of the spinal cord, while the right hemisphere is the origin of those fibers which cross over to the left side and so into the left half of the spinal cord and seem rather to be concerned with the nutrition of the body. Anatomists have guessed that because the greater volume of blood is carried to the right side of the body, therefore it predomi- nates over the left, or that because there is a swifter flow of blood to the left half of the brain than to the right, therefore the nerves which control motion of the right side predominate over those which control motion on the left side, and so on, and so on. This only tells us what we knew before, that right-handedness predomi- 170 HOW TO KEEP WELL nates greatly over left-handedness, and does not explain it. As a matter of fact, about nine per cent of all people are said to be left- handed. It is, of course, a congenital or inherited condition and probably indicates some peculiarity in fetal development which the embryologists and anatomists have not yet discovered and ex- plained. I have never observed that it involved a morbid condition of any portion of the body or that it gave any particular inconvenience to one who had it; it simply means transposition of the usual tendency of the motions of the hand. Does it mean inefficiency on the part of the individual who has it? I do not see why it should, for it simply means a reversal of position, and one who has had careful training ought to make at least as great proficiency in the method which is natural to him as if the same training were directed to that which is unnatural. Indeed, he ought to do better by following out the natural tendency, and this is the advice which I would give to those who have asked me whether a child who is left-handed should be taught to be right-handed and to disregard the left. There is an advantage in being able to use both hands. A sur- geon often finds two hands none too many for various things he is called upon to do, and I know from experience how advantageous it is to be able to use both hands with facility in the performance of surgical operations; but all the surgeons I have ever known, or at any rate, almost all of them, have been right-handed, and while they might be able to use both hands, the finest and most delicate work was done with that which would do it the most naturally. I should think the same would be true with one who was born left-handed and had cultivated the use of the right. The question has been asked whether mental development would be affected by teaching a child who was left-handed to use his right in preference. I suppose much depends upon the disposi- tion of the child and the way the instruction is given. If the teacher is patient and kind I do not see how his instruction can harm the child, even if he be timid and nervous, and even if the admonitions to give preference to the right hand be frequently repeated. The object of such teaching should not be to break down the child's will, but to show him the advantage, if advantage there be, in the use of the right hand in preference to the left, or, perhaps better, in the ability to use either hand with as nearly equal facility as possible. CHAPTER VI INFECTION AND INFECTIOUS DISEASE An infectious disease is one which is produced by the presence and activity of very simple forms of animal or vegetable life, pro- tozoa in the former and bacteria in the latter. Some of these organ- isms are too small to be seen even with a microscope of the highest power. They require heat, moisture, and nutriment for their de- velopment, and they or the poisons they produce cause disease, each germ producing the disease of its kind, the pneumonia germ pro- ducing pneumonia, the typhoid germ typhoid, the influenza germ influenza, etc. Sometimes a disease is developed from more than one kind of germ, and then we have a mixed infection; thus in pneumonia there is in the blood or expectorated sputum the distinctive germ, the pneumococcus, but there are several other kinds in addition, or there may be the pneumococcus alone. In some infectious diseases, especially those of the mixed type, we sometimes find a germ which by its presence adds to the seriousness of the disease. Thus in pneumonia and many other diseases we are apt to find a germ called the streptococcus, while in diseases of the intestines and other ab- dominal organs we are pretty sure to find the colon bacillus, what- ever other varieties may be there. These germs are reproduced and multiplied in the body under favoring conditions, in the blood and the secretions and juices; or they may be grown outside the body, in glass tubes for example. As an example that is well known, a mass of dough is permeated and raised by the growth and multiplication of yeast bacteria which have been placed in it and find conditions favoring their growth. Bacteria and bacilli are everywhere, in the ground, in the air, on food and clothing, on the walls of rooms, on dishes, and especially on the hands of human beings. They can be inhaled and conveyed 171 172 HOW TO KEEP WELL to us on food and drink. In the mouth and nose many varieties are constantly present, some harmless and others only waiting suitable conditions to cause disease. A child may have diphtheria germs in his mouth or nose for months without getting the disease because the conditions are not favorable, but should they become favorable the germs would de- velop and disease follow. During the time they are latent and harmless to the child who is carrying them they may escape and at- tach themselves to a susceptible child, and he will almost immedi- ately have an attack of diphtheria; this has often happened. Bacteria cause disease by their presence or by their poisonous products. Suppose, for instance, that disease-producing bacteria were carried on the fingers of a doctor to a cut on the hand of a patient he was attending; they would find in the blood and raw tis- sues a good medium for their development and multiplication. They ferment like the yeast in the dough and irritate the tissues; and inflammation with the formation of pus follows. Perhaps they are absorbed by the lymphatic vessels, and then there will be inflammation and pain in the arm; or they may be carried beyond the lymphatics into the blood-stream, and then the whole body will show the effect of blood-poisoning. This is the way disease is car- ried from one part of the body to another. Take rheumatism, for example, assuming it to be an infectious disease; the germs, being taken into the mouth, nose, or stomach, find their way into the blood-current and become arrested in one or more of the joints. Then they multiply, and the joints are in- flamed; then some of them are taken into the veins and carried to the heart, where they multiply on the valves or the lining mem- brane of the heart and produce the heart complications of rheuma- tism. The meaning of all this is that we must keep the body in such good condition that it will offer successful resistance to the great army of disease-germs. As a good machinist keeps his machine in order by constantly watching and caring for it, so if we would keep off disease we must have proper food, exercise, sleep, recrea- tion, clothing, everything which will make the physical parts work smoothly. The skin must be guarded by suitable bathing and scrubbing so that it may better assist in eliminating poisons from the body. The bowels must be kept in good working order, for they are as important to the health of an individual as sewers to a INFECTION AND INFECTIOUS DISEASE 173 city. The habit of deep breathing must be formed to flood the blood with oxygen and get rid of poisonous carbon compounds. If it is true that germs are so omnipresent and malevolent, so abundant in the mouth and nose, and so prone to migrate from this locality as a base to those parts of the body which are most vul- nerable, they should be destroyed before they have a chance to multiply and move on. That is, the daily toilet of the nose and mouth with atomizers, sprays, and mouth-washes is as important as the use of the tooth- brush, or more so. This will prevent much of the sickness which is so common in the mouth, nose, and throat. Menthol, eucalyptol, thymol, lysol, boric acid, carbolic acid, salicy- lic acid, are all valuable antiseptics and should be used freely as occasion may arise. Children should be taught the disinfection of the nose and mouth from their earliest years, and this will tend not only to prevent disease but to prolong life. Bacteria in Milk.-If you were asked what article of food was of greatest importance to human beings, you would unquestionably answer, "milk." Milk is practically the only food most of us get during the first year or so of our life. The principal reason why the mortality during the first few months, especially in the cities, is greater than at any period except that of extreme old age, is be- cause the food supply of that period is often unsuitable. Infant mortality statistics furnish a fairly reliable index of the quality of the public milk supply. At the present time the infant mortality in cities is commendably low; in New York it is not more than ten or eleven per thousand of inhabitants, which means that the milk supply is commendably good. This is of particular advantage to the poor, who are compelled to buy the milk which costs the least. All the elements which are necessary to sustain life are present in milk, but frequently there are other things, too. If a cow has improper food her milk may be poisonous. If the milker has dirty hands, if the milk-pail or can is foul, if the cow's udder is filthy with manure or is diseased, the milk will suffer; and if the cow has tuberculosis or some other disease from which cows suffer, the germs which cause the disease may be present in the milk. Or the air of the cow's stable may be loaded with impurities which easily get into the milk and thus make it an imperfect article of food from the start. The further the milk goes and the more hands it passes through, 174 HOW TO KEEP WELL the worse it may become, so that when it reaches the consumer, who may be a baby or a sick person, it may be, and often is, a pretty poor food substance. The impurities in it which can be seen can be strained out, but the more dangerous substances cannot be seen. Chief of these are the germs or bacteria which can be dis- covered only by microscopic examination. If a few hundreds of them were placed in milk at a proper temperature they would in- crease to countless millions in a few hours. Milk contains many varieties of bacteria, some harmless, others very harmful. Some varieties will decompose it; some will make it sour or bitter or change its color or make it thick and ropy; and some will generate disease in the body when it has been used as food. A healthy cow's milk has few if any harmful bacteria while within the animal, but it has harmless ones, of which the lactic acid bacillus is an example. As soon as milk is drawn unless treated with care and cleanliness it is attacked by dif- ferent kinds of bacteria, beginning at the cow's udder. Bacteria grow rapidly in milk that is fresh and warm, but they grow slowly if it is rapidly cooled; hence the colder it is kept on the way to the consumer the less will it be injured by them. Bacteria are destroyed by pasteurization, which consists in heating the milk to 158° to 1700 F. for thirty minutes. This will destroy germs of tuberculosis, cholera, typhoid, scarlet fever, and diphtheria without materially changing the taste of the milk. If the milk be boiled the germs will all be killed, but the milk may also become so changed that to some it would be more or less indigesti- ble. The bacillus of tuberculosis may be in the milk of a tuberculous cow when it is drawn, or it may get into it by way of the atmo- sphere or the cow's udder, and the scarlet fever bacillus may get into it in the same way. The typhoid fever bacillus may come from the water which the cow drinks, from the hands of the milker, or from the manure of the stable, the same being true of the bacilli of cholera and diarrhea, of the common bacillus of the intestine, and of the different varieties of streptococcus. All or any of these may or may not grow abundantly in milk before it is used as food according to the temperature, exposure, etc. When they once get into the body they find conditions favorable for growth, particu- larly in infants and sick people whose resisting power is low. They are absorbed from the stomach or intestine, are carried INFECTION AND INFECTIOUS DISEASE 175 along by the blood-current, and in due time produce the diseases of which they are characteristic. The most common bacteria thus taken into the body are the streptococci and the common bacilli of the intestine. The former cause boils, abscesses, blood-poisoning, and other serious and fatal diseases; the latter may be harmless, though if they undergo change they grow harmful. The lactic acid bacilli by which milk is soured are not only not harmful but they may be beneficial by destroying harmful bacteria with which they come in contact in the intestine. Infection from the Colon Bacillus.-The colon bacillus is a germ which has several varieties and is always present in one or more of these varieties in some portion of the large intestine. Some of these varieties are more virulent than others. The one which is of most common occurrence is called the com- mon bacillus of the colon (B. coli communis). It is not always harmful, for if it were everybody would have more or less severe intestinal disease at all times. It causes disease when it is associ- ated with other disease-producing germs, and in individuals with poor resisting power or those who are weakened by other diseases, or who are under the influence of suitable conditions of heat, mois- ture, etc. Some of the varieties are also much more readily de- stroyed by vaccines and other means of treatment than are others. Many of the diseases in the abdomen, chest, and pelvis are caused by infection from this bacillus, and more than half the diseases of the urinary organs are due to this cause. Though the germ is a native of the large intestine, it is often found in other organs during health, in connection with childbirth, or in operations upon the organs of the abdomen or pelvis. In diseases in which the mucous membrane is involved bacilli are present in greater or less abundance in the urine, and are persistent and difficult to get rid of. In some cases they disappear and return, the process being kept up for weeks and months, thus making it difficult to know when one is entirely rid of them. This can easily be understood when we consider that bacteria are plants which grow with amazing rapidity on any tissue surface under favoring conditions of heat, light, and moisture. One of the means now frequently used in treating disease pro- duced by the colon bacillus consists in an injection obtained by cultivating bacilli removed from a sick person, so that the bacilli become not only producers of disease but the means by which it 176 HOW TO KEEP WELL may be cured. A preparation derived from this form of culture is known as an autogenous vaccine. The cultivation of bacteria and the treatment of disease with preparations made therefrom is an intricate process and is the basis of the new science of bacterial therapy. Tuberculosis.-This is the universal scourge of men and ani- mals, attacking all kinds of tissues, present in fifty to seventy per cent of the human race, the fatal "white plague" of all countries and climates; but it is frequently curable, even spontaneously. It appears in families for successive generations until the families are wiped out or the disease is conquered by lapse of time and the admixture of tough and resisting stock. Neither age nor sex is spared by it. It may be prevalent like an epidemic in a com- munity, and a few years later it may have almost disappeared. One seventh to one tenth of all deaths are from this cause, and a majority of invalids are sick with this disease. It is distinctly an infectious disease, being due to a particular kind of germ; it is also more or less contagious when, in a given case, it is very virulent or the person exposed to it has poor re- sisting power. The germ which causes it is called the tubercle bacillus and was accurately described in 1882 by Robert Koch. It is emitted from the body in expectorated sputum and in discharges from the bowels and bladder and from tuberculous sores. It be- comes attached to walls and floors; gets into water, milk, and other fluids; it is in the tissues of animals used for food; and floats in the atmosphere of unsanitary houses, shops, factories, and all other places where men or animals are present. It is destroyed when exposed for a sufficient length of time to the sunlight. If this were not so, the number of its victims would be even greater than at present. It may enter the body by the air-passages, the stomach, or a sore or cut in the skin. Tuberculous milk and imperfectly cooked meat are believed to be responsible for many cases of the disease, especially among children, the intestines, the tonsils, and the glands of the throat and neck being often attacked. The majority of those who have tuberculosis probably derive it by inhalation of the germ through the mouth or nose. From the mucous mem- brane on which it is deposited it passes into the small blood- vessels or small lymphatics and finally gets into the general blood-current. INFECTION AND INFECTIOUS DISEASE 177 The lungs are the organs most frequently attacked, manifestly because the blood is constantly passing through these organs to be purified. Other tissues and organs deficient in resisting power, or attacked by tubercle bacilli of especial virulence, are the mem- branes lining the organs of the chest and abdomen and those of the brain and joints. The bones, especially in children, the skin, the glands in various parts of the body, the kidneys, bladder, intestines, and liver are very often the seat of the disease. The bacilli grow and multiply in the various tissues in which they are deposited and also produce poisons which irritate or stir up the cells with which they come in contact, causing inflamma- tion and a great increase in the number of cells. The tendency of many of these cells is to form clumps or masses, resembling seeds, grayish in color and embedded in or attached to the tissues. They lead to the formation of ulcers or abscesses and frequently show no tendency to heal and get well. One of the best instances of their abundance and rapid growth and the irritation they produce is the disease known as tubercular peritonitis, in which the abdominal cavity is sometimes hugely distended with the fluid derived from the blood-vessels through their influence, the peritoneum itself being covered with millions of the seed-like bodies. After a time they disintegrate, becoming soft, cheese-like, and yellowish in color. They may disappear, they may become hard like lime, or they may cause ulceration with corrosion of the surrounding tissue. Hemorrhage results when they corrode through blood-vessels, and this often occurs in the lungs. The pus and blood and disintegrated tissue are expectorated, the consequence being a cavity or hole in the lungs, which under favoring conditions will contract and leave only a scar. Mani- festly the larger the cavity the greater the destruction of the lung- tissue and therefore the smaller the residue for breathing pur- poses. A person thus afflicted evidently must breathe more rapidly than one who has normal lungs in order to get air enough to aerate his blood properly. The virulence of tuberculosis depends upon the type or strain of the bacillus in a given case and the defensive power of the tissues it has invaded. Sometimes it remains latent or dormant and may never give rise to active symptoms. The disease has many varieties and symptoms, and it may appear, subside, and 178 HOW TO KEEP WELL reappear. It may be very acute and rapid, lasting but a few weeks and almost inevitably fatal; or it may become chronic with many symptoms, perhaps resulting fatally, but under favorable conditions being recovered from; or it may be prolonged through many years, gradually forming new and hard connective tissue, sapping the strength very slowly and sometimes yielding to disease in some other form. These three types may be regarded as a comprehensive classification for ordinary purposes. The first or acute type of tuberculosis is most frequently seen in children and young adults. It is characterized by the rapid and abundant development of tubercles in all parts of the body or in one or two organs. It usually begins in the lungs or in a group of lymphatic glands and spreads with great rapidity, run- ning its entire course in from six to eight weeks. One form of this variety is often mistaken for typhoid fever, having symptoms very suggestive of that disease. In another form the symptoms are limited chiefly to the lungs, while in a third, which is confined almost exclusively to young children, the membranes of the brain are chiefly involved. The last-mentioned form has very severe and trying symptoms, and the end comes quickly. The second or chronic type of tuberculosis is the one which is so familiar a picture in almost every part of the globe. It is propagated not only by germs from human beings but by those from cattle and other animals. Scarcely any of the tissues of the body are unsusceptible of attack, but it will be possible at this time to discuss only the familiar and well-known form, in which the lungs are conspicuously the victim. Anybody may be selected as the object of attack, but the pref- erence is for those whose bodies are weak or who have inherited a tendency to disease, those who are at the beginning of maturity or the end of child-bearing, those who have just given birth to a child or who are nursing one, those who are weakened by ex- posure, grief, worry, shame, or some other emotion, those whose surroundings are bad or unhygienic, the dissipated and the suf- ferers from all kinds of excess. There is no rule about the appearance of symptoms, but some of these which are well known are frequent and severe colds, cough and expectoration, chills, fever, rapid pulse and sweating, indi- gestion of all varieties, weakness and emaciation, hoarse or metallic INFECTION AND INFECTIOUS DISEASE 179 voice, anemia and bleeding-especially from the lungs-and ex- hausting diarrhea. The tuberculous are frequently very irritable, their eyes brilliant, their finger-ends bulbous, and their nails curved. They are flat-chested, and their breathing is shallow and distressing. Symptoms come and go; the patient gets better or worse according as his treatment is suitable or unsuitable; and, after months or perhaps years, there is no more rallying, and he sinks down and dies. In determining a diagnosis an X-ray picture is of value if enough of the lung has become consolidated by the disease to throw a good shadow. Examination of the sputum is always of great importance, the presence of bacilli proving the presence of tuberculosis, though their absence does not prove its absence. Various tests in the skin, the eye, etc., are used for determining the disease, and many other diseases may be mistaken for this one. The better the patient's general condition, surroundings, habits, food, and medical treatment, the better his chances of get- ting well; hence those who are well-to-do and have comforts and luxuries have a better chance than the poor. When a patient is improving, his cough, sputum, and sweats diminish, his sores heal, his appetite and weight increase, he sleeps better and feels better generally. The object of treatment, therefore, is to increase the strength and vigor and give the bacilli no chance to increase and multiply. A suitable change of climate and surroundings is often desirable; fresh air and sunlight are imperative; and there should be abundance of sleep and rest, mild exercise, deep breathing, and as much good food as the digestive apparatus can manage. The clothing should be of silk or wool, adapted to the weather; the daily bath must not be omitted; and common sense should rule in all things. Such symptoms as sweating, cough, fever, and bleeding must be considered and treated. Drugs often used are cod-liver oil, creosote, iodine, arsenic, lime, ichthyol, camphor, digitalis, and quinine. It goes without saying that in many cases drugs are superfluous. It is important to remember that the disease is contagious; hence sputum should be destroyed; one should cough only into a destructible handker- chief; kissing and caressing should be omitted; and the food utensils should be kept clean and disinfected. The third type of tuberculosis needs only brief notice. The 180 HOW TO KEEP WELL resisting power of those who have this form is considerable, but not enough entirely to destroy the disease and its effects. Their tissues do not show the same tendency to break down as do the tissues of those who suffer from other varieties, nor are they entirely normal. Progress in such cases, therefore, is very slow- perhaps lasting many years; sometimes the disease being entirely recovered from, or finally causing the patients to succumb. This is especially the case in the aged, and it is the aged who are the principal sufferers from this form of tuberculosis. CHAPTER VII NUTRITIONAL DISORDERS Atrophy.-The picture which arises before the mind at the mention of the word "atrophy" is of something withered or shrunken or weakened, unable to do its normal work, lacking the appearance of health, something that has had its day and is worn out. A child who has suffered with infantile spinal paralysis drags its little leg and foot helplessly along, and if you examine it you will find it is thin and shapeless, its muscles unable to give him much assistance in locomotion and showing that something very important and very serious has happened to it. That something is atrophy, and in this particular case it has made the child a cripple for life. This atrophy of the muscles of the child's leg and foot is the consequence of disease; but there is another kind of atrophy which comes simply because the work of the part or organ is completed and there is no further use for it, like the stalk of the plant which dries up after the season's work is over, and this is called physiological atrophy. There is in the upper part of the chest an organ or gland called the thymus gland or sweetbread. Just what its work is we do not clearly know, but it is one of those ductless glands which, as endocrinology has recently taught us, play an important part in development and nutrition, and its work is completed by the fourteenth year or earlier. From that time on it shrivels up, and before very long, unless it has become diseased, there is scarcely a trace of it. So, too, in the wonderful reproductive organs of the woman; when the child-bearing period is ended and there is no further use for them they shrink and wither, and in old age you can merely 181 182 HOW TO KEEP WELL find the rudiments of them. Atrophy implies a want of nourish- ment, especially as derived from the blood and the nerves, and so we find in atrophied organs and tissues that they have less blood in them than in the normal state; they are smaller, firmer, drier, and less elastic. A single organ or tissue may undergo atrophy or it may affect the entire body, as it does in extreme old age, when the machine is worn out. Defective development is not necessarily atrophy. A child may come into the world with certain parts poorly developed or deformed, or he can fail to develop after birth in a normal way and may appear dwarfed and stunted. That is not atrophy; it is merely imperfect development. Atrophy which is the result of disease is accompanied by emaciation and wasting; there is degeneration both in structure and function of the organs and tissues which have undergone this change. Atrophy may be produced by pressure, particularly if it be long continued. The tight lacing which some foolish women in- dulge in has been known to produce atrophy of the liver. The pressure of strings and straps and garters may produce atrophy of the tissues which they compress; so also with the pressure of tumors. Inaction or want of use is a frequent cause of atrophy. If a muscle is not used, the biceps of the arm, for example, it becomes weak and flabby; if a gland ceases to produce its natural secretion it atrophies. Excessive loss of any secretions or discharges from the body means atrophy and body waste, for it implies excessive drafts upon the blood and nerves. This is true whether there is loss of blood directly, as in repeated hemorrhages, or prolonged sup- puration, or chronic diarrhea, or the loss of albumen and sugar from the blood through the kidneys. Fat is the tissue which is first called upon in the process of atrophy, for it covers the entire body and is the reserve which is most invoked in time of distress. Atrophy of fat is followed by atrophy of muscle, and this by atrophy of nerve-tissue. Even the bones may undergo a form of atrophy and become unusually brittle when they are deprived, to any considerable degree, of the lime salts which are vital to them. It is possible for some organs and tissues to be restored if the blood and nerve-currents can again be made to course through them. NUTRITIONAL DISORDERS 183 Convalescence.-Convalescence means getting well and is ap- plied to that period of an illness when the severe and dangerous symptoms have disappeared but when the sick person is still un- able to attend to his ordinary duties. Convalescence is a relative term, and it may be of long or short duration. It depends partly upon the severity of the sickness or injury and partly upon the recuperative powers of the sick person. Of course it is perfectly well known that some sicknesses and injuries are much more prostrating than others and require a longer period of convalescence. Some individuals, too, are less sensitive to sickness and injury than others and rally more quickly. Medical writers are accustomed to consider illnesses as acute or chronic according to the usual period of time they occupy and the severity of their symptoms, though the latter is not always a determining factor. Typhoid fever is an acute disease and is of rather long duration, four or five weeks. Pneumonia is also an acute disease but runs its course, in uncomplicated cases, in one or two weeks. A chronic disease, on the other hand, may last for months or years; it may be recovered from and the person be entirely well again, so far as that disease is concerned, or it may last indefinitely with periods of apparent recovery and relapses, eventually over- whelming the patient. Bright's disease of the kidneys is a well- known example of chronic disease. In all these diseases, acute or chronic, when they are not fatal there comes a time when it may be said that the material which causes the disease has worn itself out. The surgical diseases, as they are usually considered, are those in which some kind of operative interference is expected or desirable, but it is sometimes difficult to differentiate them from the medical diseases; indeed, the two varieties frequently overlap. These diseases are also acute or chronic so far as the element of time is concerned, or they may be both acute and chronic. For instance, a person may suffer for months or years with gall-stones, a chronic disease if ever there was one. At length an operation is performed for their removal, and we immediately have the chronic disease converted into an acute one. When a disease like typhoid fever or pneumonia has worn itself out, or a surgical disease has been subjected to operative treatment and has outridden the period of shock, depression, and 184 HOW TO KEEP WELL inflammation which so often follows, the stage of convalescence or getting well immediately ensues; and this as already stated, may be long or short, mild of severe, with complications or with- out them. It is a very important period, and I have often felt that it may require as much wisdom to conduct a person safely through it as it does to manage the disease which preceded it. It is a period when the elemental requirement of rest must be insisted upon, for nature is struggling to bring the patient back to normal condi- tions, and every unusual effort or strain, every error of diet, every omission of sleep, is simply a means of thwarting and combating nature's efforts. The fault in many of our hospitals-inevitable, I know, be- cause of the imperious necessity of treating the greatest number of sick people in the shortest possible time within rigidly fixed accommodations-is in putting people out before they are able to go to work, frequently before they are well able to stand on their feet. The movement to create a large number of convalescent hospitals for the care of the sick and injured is, therefore, a most important one economically and philanthropically and ought to be carefully considered by those who have money to give away and desire to place it where it will do the most good. Some of our hospitals have too much money and are too luxuri- ous. If the money that is devoted to fancy work and frills in many of them were used to develop places of rest and recuperation for those who need the extra few weeks of careful attention after they have been dismissed from the hospital wards, such money would assuredly be of much more practical benefit than it is now. There are institutions like the Burke Foundation which are doing splendid work in caring for convalescents. The only fault I am finding is that there are not enough of them, and I am pleading for more. Debility.-Many a person who consults a doctor is told, after the doctor has questioned him, looked at his tongue, felt his pulse, and sized him up generally, "You have nothing serious the matter with you; you are only suffering from debility." Now, what is debility? Suppose you were the one to whom this verdict was given. You are perfectly aware that you are not well, if you had been you would not have paid your money to visit the doctor. Very few persons seem to enjoy that privilege, although NUTRITIONAL DISORDERS 185 they often get more for the investment than for many in which people indulge very freely. It is a comfort to you to be told that you have no serious ail- ment, nothing that is likely to kill you; but that doesn't take you very far. If you have no disease with a name to it what is the matter with you? The doctor tells you that you have debility; that means weakness-debilitas, a good Latin term that has been in use a thousand years, and, like charity, covers a multitude of sins. There is debility of the young and debility of the aged, debility before recovering one's strength from illness or injury, and debility from fear, grief, or any kind of physical or mental disturbance. But that is not your case. Strange how complicated a little thing like this can become! You lack strength for your work; you are not interested in what is going on; you do not enjoy your food; perhaps you are con- stipated ; you do not sleep well; you are easily irritated; and everything seems out of joint. I may not be able to tell you what has caused this. Perhaps it is too close attention to your business or your household cares. Perhaps you have been indoors when you could have been out- doors, bathing in the sunlight, walking abroad, and seeing and admiring the curious and beautiful things in this interesting world. Perhaps you have dissipated, indulged in vices, gambled, wronged somebody, committed crime. No wonder you are weak if this is the case. Nature is inexorable, and you cannot fool her. She will get even with you sooner or later, for this is the law of compensation. Well, I suppose you will say, admitting that you are telling me the truth: "What am I to do? You are a physician, have observed the weaknesses and ailments of men, women, and chil- dren for many years, and ought to be able to give some kind of a prescription." Yes; that is true, and experience has taught me that if you really desire to get over any kind of an ailment you must first find out what causes it. If you find it, you have taken one long step toward removing it. In some cases it cannot be removed. Those are the incurable cases. But in the majority of cases it can. If the cause is a moral one, try and be a better man or woman than you have been, to your shame. The world never needed real religion as it needs it to-day, and I don't care whether you 186 HOW TO KEEP WELL call me a preacher or not. I'm not ashamed to state the fact. If your weakness is caused by too extensive drafts on your physical strength, you must stop them some way or other. If you say you are unable, by and by you will be compelled to. If the doctor is correct in telling you there is no serious disease now, he may not give you that opinion a month hence. It will cost less now than if you wait until your physical reserves are exhausted. I would like to see a great army of those who are weak and do not exactly know what ails them get out of the crowded city, go where they can cross the road without fear of being run over, to the woods, to the mountains, to the seashore, and stay there as long as they can. Many would add years to their lives and greatly to their usefulness if they would find some occupation in the country which would detain them permanently. Obesity.-Obesity simply means too much fat. Now, fat is a necessity to the body, both for ornament and for practical utility. It is the filling for cavities otherwise unseemly and unprotected, like the armpit, the space between the lungs, or the space behind the knee-joint. It is also a protection to important structures, veins, nerves, and lymphatics in these several locations. Then it gives curves and graceful outline to the body when not too abundant; for instance, on the abdomen, the breasts and the limbs. It is also a great protection to the delicate machinery within the body, because it is an admirable non-conductor of heat and cold; and since fat is distributed in a layer of varying thickness on the under surface of the skin over the entire body, the temperature of the body remains constant at 98.4° F. during health, no matter whether the temperature of the air be high or low. It is only when this material is present in large, unwieldly masses in particular locations, or all over the body as a whole that it becomes unen- durable, a disadvantage, and an injury. Normally it represents about one twentieth of the weight of the body. Fat is one of the reserve substances which are called in service in time of emergency. Because of this utilization, bears, woodchucks, and other animals which sleep all winter are lean and ill favored when they awake in the spring. A person who has an illness lasting many weeks and is unable to take or assimilate much food during this period is weak and emaciated at its end, his reserve of fat having been used up. Fat belongs to the class of substances known as hydrocarbons. NUTRITIONAL DISORDERS 187 It is derived not only from the animal and vegetable oils which are used for food but from transformed starch and sugar and also from certain proteins. Fat taken into the body in the form of fatty or oily food is emulsified in the small intestine, absorbed, and transferred to the blood after passing through the lymphatic system. As the blood passes through the lungs some of the fat which it contains is de- composed and disappears; the remainder continues in the circula- tion until it is deposited as an addition to previous accumulations in various parts of the body. Fat also may infiltrate or permeate organs and tissues and weaken or injure them. The heart may have so much fat in its structure that an increase in its pressure, whether sudden or gradual, may be followed by fatal rupture. An excess of fat may affect the entire body, muscles and organs becoming disorganized, and the layer which is usually connected with the under surface of the skin greatly increased, or the excess may be limited to certain portions of the body. Tumors composed entirely of fat and sometimes of large size are very common on the back and may appear on any portion of the body. A not unusual occurrence is an enormous deposit of fat in the breasts. The most common illustration of localized excess fat is the deposit upon the abdomen, which occurs in both men and women as they approach old age. Even those who have previously been thin and scrawny frequently fill out with fat and improve in appearance thereby at this period. Many persons become fat as a matter of inheritance or tendency, some in childhood and youth, others in middle life, and nothing that they do or refrain from doing appears to have any particular relation to it; they are members of families in which obesity is a characteristic. Disease of certain organs will cause obesity. Thus it will re- sult from insufficient activity of the thyroid gland or from too much activity of the adrenal gland, and it often results from the removal of the ovaries in women or the analogous organs in men. An attack of fever or a hemorrhage may be very prostrating at the time, but when the body reacts and the conditions become favorable again an accumulation of fat may be the consequence. Obesity comes often to the lazy and inactive, to those who lead sedentary lives, and to those who work in lead, arsenic, or phos- 188 HOW TO KEEP WELL phorus. It comes to those who are heavy eaters, especially if they eat starches, sugar, and fat, including peas, beans, potatoes, animal and vegetable oils in abundance. It is a very common occurrence with those who drink quantities of wine or beer, and, as is well known, such excesses bring other undesirable consequences, also. Obesity is disturbing not only from the discomfort caused by excessive and unnecessary weight; but the fat person is unable to do severe or prolonged work, he has difficulty in breathing on account of his bad heart-action, his lungs are subject to conges- tion, and when in this condition fluid may escape into the lung- tissue, forming what is known as edema. His liver also may be- come congested and enlarged; he is very apt to suffer with obstinate constipation; and he offers very poor resistance when exposed to infection. Very fat women are incapable of bearing children. Very little in the way of medicine is indicated for this condition. It is to be treated by diet and exercise. Not too rigid a diet may be followed in any case, for the strength must be maintained, and weakened organs like the liver and heart may not bear unusual strain or de- nial. In general the starchy foods, especially beans and potatoes, must be omitted or cut down. Milk in moderation, especially, fer- mented or skimmed milk, may usually be taken. Lean meats, especially raw, scraped beef, are allowable. Exercise should begin with walking or golf and deep breathing, the length and duration of the walk being gradually increased, but never exceeding the strength. Massage and light gymnastics are desirable in most cases. Daily baths should be cold or warm, ac- cording to the power of reaction. Frequent small meals are better than large infrequent ones, but there should be no gormandizing and no midnight suppers. Surgical removal of excessive layers of fat, especially on the abdomen, has been advocated by some surgeons, but such cases as I have seen have not impressed me with the value of this method of treatment. Scurvy.-In the days when sailors made voyages lasting one, two, or three years, on which they were fed largely on salted food, with no vegetables at all or scarcely any, one of the ailments almost sure to visit every ship was scurvy. The same disease was common in armies, prisons, poorhouses, and other institutions where indi- NUTRITIONAL DISORDERS 189 viduals were fed at public expense on food which was supposed to go the furthest and cost the least. Those who had this disease became very anemic, prostrated in mind and body, suffered with hemorrhages in various parts of the body, had soft and spongy gums which bled easily, and hardness and pain in the muscles, especially those of the legs. The blood of those who have scurvy is thin and dark, is deficient in red cor- puscles, and clots very easily; and the important internal organs undergo fatty degenerative changes. The disease begins with pallor of the skin and great muscular weakness and emaciation. Then there are pains like those of rheumatism in the joints and muscles, difficulty in breathing and constipation, though the appetite may be good. After a while small hemorrhages into the skin take place and larger ones into the loose tissue under the knees, in the armpits, and under the eyes. Then the gums swell, become soft, and perhaps bleed; the teeth become loose, and may drop out; and the breath becomes terribly offensive. The weakness and exhaustion may be so great that death will result from the profound condition of malnutrition. This may occur after weeks or months of suffering, the end being hastened when the appetite fails, and the bowels be- come loose and the evacuations offensive. For a long time there was uncertainty as to the cause of this disease, but it was at length determined that it was purely a pre- ventable disease, and was caused by absence from the diet of citric acid and potassium salts, which are furnished by fruits and fresh vegetables. Laws were passed compelling ships to furnish their crews with vegetables and compelling public institutions to give them to their inmates, and when these beneficent laws became effective the disease died a natural death. The knowledge which has been gained about the cause of this disease has been of great value not only to the groups of indi- viduals referred to but to all who must carry large quantities of provisions with them in journeying to places and climates where the question of obtaining an adequate supply of suitable food is pre- dominant. The abundance and excellent quality of canned vegeta- bles at the present time have assured success to many undertakings and expeditions which heretofore might have failed solely because of an improper food supply. CHAPTER VIII DISEASES OF INFANCY AND CHILDHOOD Infancy and childhood present problems in disease which are quite different from those which occur in diseases of the same character in adult life. It is therefore desirable to consider some of these diseases from both points of view even at the risk of appearing repetitious. Care of the Newly Born Infant Asphyxia or Failure to Breathe.-This may present either of two aspects. In the first the head is blue and turgid, the face is puffed and swollen, the lips livid; the possibility of resuscitation in such a case is good. In the other case the surface is pale and shrunken and the limbs relaxed; this is far more serious. The throat should first be cleared of mucus by the finger covered by a thin strip of linen; and then one or two slaps upon the back or a sprinkling of cold water will often be sufficient to induce breathing. If this fails, the application of alcohol to the chest may prove efficacious. This failing, dipping the child alternately from warm to cold water a few times may be tried. If the child should still fail to breathe, artificial respiration, as described elsewhere for drowning, must be employed. It is of importance that the vital heat should be maintained, and the child should be wrapped in a hot blanket or be placed in a warm bath. When he is born the eyes should be carefully cleansed with a saturated solution of boric acid. This will prevent the danger- ous inflammation of the eyes which sometimes occurs during the first days of life. It must not be forgotten that an infant at birth is chilled at the slightest exposure; hence great care must be used in giving 190 DISEASES OF INFANCY AND CHILDHOOD 191 the bath. The white substance on the surface of the body is soluble in oil. After anointing every portion of the body, es- pecially the folds and creases, the oil should be wiped away with a soft towel, a little warm water and soap being also used. On the following day a more thorough bath may be given. A large soft swelling is frequently found on the side of the baby's head. This results from pressure during birth and usually disappears in a few days. It should, under no circumstances, be pricked or interfered with. The baby's breasts sometimes become red, swollen, and painful, but serious trouble from this source is rare. Nothing should be used upon the breasts but warm camphorated oil gently applied. Harsh rubbing and pressure may cause serious and last- ing injury. Jaundice occurs in most babies the first week. It usually subsides spontaneously and need cause no apprehension. A red, blotchy rash sometimes occurs at this early stage and is known as "red gum." During the first days of life the infant should be offered, several times daily, in a spoon, as much warm water as it will drink. The Hygiene of Infancy The Nursery.-Every infant should, if possible, have a nursery where it can be kept apart from the family. The temperature should be maintained between 68° F. and 700 F., never over 720 F. At night it should not fall below 65° F. the first year. The baby should have a separate bed. Throughout childhood, in fact, each child should have a bed of its own if possible. Bathing.-The bath is the most essential item in the hygiene of infancy. When the tub is first used, the period of immersion should be short. The nurse should take the child upon her lap and sponge and soap it with care. It may then be dipped into the water more for rinsing than for actual bathing. The duration of the immersion may be increased until the whole bath is given in the tub. A healthy child should be bathed daily until it is at least two years old. The bath should be given midway between the morn- ing meals. In hot weather, the child may also be sponged in the evening. Cold baths should never be given to an infant, and all attempts at "hardening" should be strictly avoided. A cold bath accom- plishes good only when it is followed by good reaction. Little 192 HOW TO KEEP WELL children are very susceptible to cold, and reaction may be slow and imperfect. If such baths are frequently repeated the child will become irritable and cease to thrive. Too hot baths should be avoided with equal care. The temperature should always be taken with the thermometer. The following table shows the prop- er temperature of the bath for various periods during the first two years: At birth ioo°F. During first month 98° F. One to six months 96° F. Six to twelve months 90°F. One to two years 86°F. The best grade of white Castile soap is the most suitable for the baby's use. Talc is the best powder for the skin, but lyco- podium, rice-powder, magnesia, and starch are almost equally good. If the child shows a tendency to chafe, a powder may be used consisting of two drams of subnitrate of bismuth and one ounce of powdered starch. If the child is afraid of the bath, it is unnecessary cruelty to insist upon plunging it into the water. Such fear, if once acquired, is difficult to overcome. The best way of giving the bath in such cases is to place a wet sheet over the tub and gradually lower the baby and sheet into the water. The scalp should be washed daily until the child is six months old. After that the frequent applica- tion of soap and water renders the hair brittle, and hence is not advisable. The details of the infant's bath are important. The nurse should have a rubber apron for her own protection. An excellent device consists of two large pieces of flannel buttoned or sewed to the waist-band like an apron. The lower one may be used to hold the baby and the upper one to cover it while the towels are being used. Weighing.-By no other means can we obtain such valuable information regarding the general health of the child as by the record of its weight. During the first three days there is in- variably a loss in weight, which is not usually regained until the middle of the second week. If the original weight is not regained DISEASES OF INFANCY AND CHILDHOOD 193 by the beginning of the third week, the condition of the child and its diet should be investigated. During the first five or six months, a child who is not gaining four ounces a week should be an object of particular attention. As a rule the original weight is doubled at five months and trebled at fifteen months. The weight at one year is doubled at seven years, and this weight is again doubled at fourteen years. The average weight of the infant at birth is seven pounds and four ounces for girls, and seven pounds and eleven ounces for boys. Every infant should be weighed every week during the first year, and once in two weeks thereafter. Airing.-The importance of fresh air can hardly be overesti- mated. The appetite is better and the child is brighter and happier for its daily airing. In summer a baby may be taken out when a week old; in the fall and spring it should be three or four weeks old. In winter, in the Northern States, it is rarely advisable to take the baby out until it is two months old. It is not best to take a child under three months into the open air when the tem- perature is much below the freezing-point. The chief indications for omitting the daily airing are extreme cold, dampness, and strong wind. While the importance of the daily airing is very great, the exercise of judgment is necessary, and it is wise to err on the side of caution. The use of the baby-carriage is advisable, for the child can then be well protected and its feet kept warm. There is no ob- jection whatever to a child's sleeping in its carriage in the open air. The only argument against it is a liability to perspire with the possibility of catching cold when it is brought into the house. Hours of Sleep.-Very few children sleep too much. A young infant should sleep at least twenty hours a day. It should never be wakened from sleep except for its feedings during the day, but it is advisable to waken it at regular intervals for that purpose. It will soon form the habit of waking, of taking its nourishment, and dropping to sleep again. After five months the baby should not be wakened at night even for feeding, but should sleep from ten in the evening until the early morning. If possible the daily nap should be continued until the child is five years old. Restlessness at night results chiefly from three causes: de- ranged digestion because of improper feeding or overfeeding at night; excitement caused frequently by boisterous play just before 194 HOW TO KEEP WELL retiring; excessive weariness, usually by reason of overexertion at play and the lack of a nap during the day. Medicines to in- duce sleep should be given only upon the prescription of a physician. If children do not get the necessary amount of rest, they will certainly become nervous, fretful, and difficult to manage. Growth and Development The average length of a child at birth is 20 1-2 inches. About eight inches are gained during the first year. The temperature at birth is ioo° F. but soon falls to 98° F. The pulse is about 130 and may be increased twenty or thirty beats by crying. Even in health the pulse is often irregular and is of little value as a symptom. The respirations are about forty-four and fall to thirty by the end of the first year. The eyes are almost invariably of a greenish or bluish-gray color, and no opinion can be formed at birth as to what their permanent color will be. The pupils are large and sensitive to light. The fontanel, the membranous throbbing portion on the top of the head, is usually closed at eighteen months. If persistent after two years it indicates some abnormal condition, probably rickets. A child usually holds its head up when three months old, sits up at seven months, stands with assistance at eleven or twelve months, and runs alone at thirteen or fifteen months. Most chil- dren learn single words at one year and short sentences at two years. These statements are only approximate and are subject to numerous exceptions, which may not indicate disease. Dentition.-The temporary or milk-teeth are twenty in number. The time of their development is extremely variable, as they appear in normal children at various ages. It is not un- common for the first teeth to appear in the fourth month, but in some cases they are delayed until the ninth month without apparent cause. Delayed dentition results from rickets more com- monly than from any other cause. Peculiarities in dentition are frequently hereditary. The permanent teeth appear far more regularly than do the temporary teeth. When a child is well, is developing regularly, and does not show signs of rickets, irreg- ularity in the appearance of the teeth should cause no anxiety. The following tables are approximate only and represent aver- DISEASES OF INFANCY AND CHILDHOOD 195 ages. The average child at one year will have six teeth, at eighteen months twelve teeth, at two years sixteen teeth. Time of Appearance of the Temporary Teeth Two lower central incisors 6 to 8 months Four upper incisors 8 to 12 Two lower lateral incisors and four first molars. ... 12 to 15 " Four canines 18 to 22 Four posterior molars 24 to 32 Time of Appearance of the Permanent Teeth First molars 6 years Incisors 7 to 8 Bicuspids 9 to io Canines 12 to 14 Second molars I2toi5 Third molars 17 to 25 Clothing Great improvement has been made in recent years in the clothing of infants. Tight bands and waists are relics of bar- barism and are being superseded by more rational methods of dressing. One of the best outfits consists of a band, shirt, slip, dress, napkin, and stockings. The clothes should hang loosely from the shoulder. The band is important, for the child is far less liable to colic and indigestion if the abdomen is protected by a layer of soft flannel. It should be four inches wide without a hem, long enough to go once and a half around the body, and fastened in front with small pins. Its object is protection, and it should never be drawn tightly. The knit wool bands now to be obtained everywhere are in many respects more desirable. The shirt is of flannel, is cut high in the neck, has long sleeves, and opens in front. The slip is also made of flannel, heavy or light according to the season. It is cut high in the neck without waist or sleeves and is open in front and about twenty-five inches long, this being sufficient to cover the feet without being burden- some. The dress is muslin and may be made according to the taste of the mother. The napkins are usually too thick and bulging. They should be made of soft cotton cloth. They should be cut one yard long 196 HOW TO KEEP WELL and one half yard wide, and folded once so as to make two thick- nesses, being, when ready for use, eighteen inches square. Rubber napkins and shields are objectionable from their ten- dency to overheat the skin. They are only admissible for short periods, as when traveling. The stockings should be long enough to fasten to the napkin and should always be kept on the feet. Patterns for making rational infant's outfits may be obtained from most of the pattern companies. They differ somewhat in details, but one should be selected which dispenses with bands, opens in front, and adequately protects the neck and arms. The night-garment for a baby should be a long flannel slip with a gathering-string at the bottom. The little one thus has freedom of movement but is unable to kick itself uncovered, and at the same time can be easily reached and cared for. For older children nothing is better than the combination sleeping suit with feet, now in such universal use. An infant should be covered with a blanket when carried from room to room, but this should be removed in the nursery. For children with little hair or those who take cold easily a light flannel cap may be worn during cold weather. Children who perspire easily also take cold easily, and the cap with some light protection to the back of the neck when perspiring will sometimes check the tendency completely. Infant Feeding Maternal Nursing.-Every mother should nurse her child if it is possible, and it would be more often possible if certain simple rules were observed. Many a child is taken from the breast because the milk is supposed to disagree with it, when the trouble is due entirely to improper methods of management. Breast nursing requires as much attendance to details as does artificial feeding. Of these, regularity is most important, but after the appearance of the milk the baby should be fed every two hours and twice at night. Continuous night nursing is certain to produce indigestion and colic. The habit of nursing every time the baby cries will produce the same result. The stomach requires two hours to complete digestion, and if nursing is permitted at shorter intervals there is a gradual accumulation of partially digested milk. Sour stomach, indigestion, and pain are almost certain to follow. DISEASES OF INFANCY AND CHILDHOOD 197 After the third month the intervals of nursing should be gradually extended to three hours, but should not be made longer than that during the first year. After the fourth month no baby should be nursed at night, between late evening and early morning. The baby will thrive better and will receive sufficient nourishment. Twenty minutes are sufficient for each nursing. If a longer time is required it is probable that the milk supply is not adequate, or that the flow is not free. If the baby drops to sleep it should be wakened and made to finish and should be allowed to have nothing until its next nursing, even if it cries. The nipples should be washed and carefully dried after each nursing. If the milk is abundant, one breast will prove sufficient for a single nursing, but in many cases both will be needed. The diet of the mother affects the milk but little unless it causes actual indigestion on her part. The extremely limited diet adopted by some mothers is neither necessary nor desirable. The diet should be generous and not too restricted, and at the same time digestible and plain. She should not take malt liquors nor alcohol in any form unless advised by her physician. They in- crease the quantity rather than the quality of the milk and some- times cause eczema in the nursling. The mother's mental con- dition is far more important to the baby than is her diet. Sudden attacks of temper, fright, grief, worry, and nervousness cause in- digestion and sometimes convulsions. If the child sleeps well after nursing, or is comfortable and quiet when awake, if it grows properly, has a good color, and gains steadily in weight, the milk is undoubtedly adequate. If the bowels are irregular and evacuations contain undigested food, if there is colic and the child cries frequently, the milk is not agreeing with it. If, in addition to these symptoms, the child re- mains at the breast a long time or takes it for a moment only and drops it in disgust and fails to gain in weight, the inference is strong that the supply is inadequate. The occurrence of menstruation is by no means necessarily an indication for weaning the child. In many cases it seems to have no effect at all upon the baby. In others the baby becomes ill and restless. Weaning is to be advised only when these bad spells are repeated and the baby is made ill. The occurrence of pregnancy is always an indication for weaning, but it should not be done with undue haste. 198 HOW TO KEEP WELL Although maternal nursing is to be advised in every possible case, there are conditions in which it is not advisable, of which the following are the most important: when serious complications have occurred before or during confinement, such as kidney dis- ease, puerperal fever, convulsions or profuse hemorrhage; when the mother has tuberculosis; when she suffers from epilepsy or grave nervous disorders; when she is particularly frail, delicate, and nervous. Mixed Feeding.-Very few mothers can nurse their children successfully for more than one year. It is wise to begin artificial feeding once or twice a day at about eight months. The child is thus gradually accustomed to artificial food. When the breast- milk begins to fail, it is wise to begin the use of artificial food, at the same time continuing the breast feeding as far as possible. Such a plan of mixed feeding is far better than to wean the child outright. Cow's milk should be the substitute food adopted. The formula should be that proper for a child several months younger than the patient. The strength should then be gradually increased. This is an important rule and will do much to prevent the indigestion common at the weaning period. A child accustomed to breast- milk digests with difficulty the curd of cow's milk. The stomach must be trained to its new work. The child may perhaps lose weight for a short time, but this is of small moment compared to the loss which is certain to follow acute indigestion. Wet-Nursing.-As the art of artificial feeding has advanced, wet nursing has diminished. In rare instances a wet-nurse seems de- sirable or even necessary. This most frequently occurs when the digestion has been demoralized by bad feeding or prolonged ill- ness. The many drawbacks, however, usually more than counter- balance the advantages of a wet-nurse. It is not necessary that the child of the nurse should be the age of the one to be nursed. For a child of six weeks the milk may be between one and five months old; under six weeks, the dif- ference should not be so great. It is desirable that the nurse should have fed her own child for a sufficient period to demonstrate her capacity as a nurse. She should never be employed without ex- amination by a physician. Artificial Feeding.-The number of mothers who cannot or will not nurse their children is certainly increasing; so much so, in DISEASES OF INFANCY AND CHILDHOOD 199 fact, that the subject of artificial feeding has become one of the most important in pediatrics. Numerous substitutes for nursing have been proposed, but may be grouped into three general classes: infant foods, condensed milk, cow's milk. The subject has been studied by some of the most competent medical men of this and other countries. While there are dif- ferences of opinion as to minor details, all are unanimous in the most important conclusions which have been formulated by Dr. Holt as follows: (i) An infant's food should contain the same constituents as breast-milk. (2) They should be present in about the same proportions. (3) They should resemble those of breast- milk, not only in chemical composition, but also in their action with the digestive fluids. (4) The addition to the food of young infants of substances not present in breast-milk is unnecessary and may be harmful. (5) Cow's milk may be made to fulfil these requirements more nearly than any other food. Taking breast-milk, therefore, as the standard of the infant's food, we must consider its constituents. It consists of five ele- ments : fat, 4 per cent; sugar, 7 per cent; albuminoids (casein) 1.50 per cent; mineral matter, 20 per cent; water, 87.30 per cent. In general terms fat is the heat-producer of the body, sugar the fat-producer, curd the tissue-builder. Each is important, and neither can be omitted without detriment to the child. Infant-Foods.-These foods are more or less deficient in fat and overcharged with sugars, while most of them contain free starch, a foreign element which the stomach of the infant cannot digest. Moreover, the albuminous matter in many instances is vegetable, not animal, and therefore does not act satisfactorily under the digestive fluids. Rickets, scurvy, and marasmus are the diseases most frequently seen among the infants fed exclus- ively upon these foods. They are useful to tide over illness when milk is not desirable, but their long-continued and exclusive use is not to be advised. Childhood is a period of foundation-laying, and the future must be considered, as well as the present. The food should be selected, therefore, with reference not only to the present but also to its power to build a strong and sturdy con- stitution. Condensed Milk is a very inadequate food. If we know that a food contains but one eighth the amount of fat and one third the amount of albuminoids found in normal breast-milk, we can reach 200 HOW TO KEEP WELL but one conclusion regarding it, that it is not suitable for con- tinuous use. Yet these are the proportions of one-in-twelve dilu- tion of condensed milk. If made twice that strength, the solution contains but one fourth the proper amount of fat, but at the same time an excess of sugar. Few infants will digest condensed milk in a one-in-six dilution. As the result of taking a large amount of sugar, condensed milk babies often become fat, but owing to the small proportions of fat in the food they also become rachitic. Cow's Milki-Cow's milk contains about four per cent of fat, casein, and sugar. Therefore while it contains the same propor- tion of fat as does breast-milk, the casein is double and the sugar one half. Hence, cow's milk must be modified. To effect this it must be diluted to reduce the casein, but this also reduces the fat and the sugar; hence, fat and sugar must be added. Fat is ob- tained by adding cream. Granulated sugar may be used, but sugar of milk is to be preferred. Sugar is an important part of the food and is not added to sweeten it. No one food will be found that will suit every case. The rational plan is the adapt- ing of the food to each infant. This is what is meant by modified or adapted milk. The formulas given in the following pages must be regarded simply as guides to the strength of food that will probably be adapted to each age. Each one must be changed as indicated by the symptoms of the child to whom it is given. The following directions for making up the food should be carefully studied. By top-milk is meant the upper portion of a quart of milk after it has stood at least four hours. It should be dipped off with a spoon and not poured off. The milk should stand in a pitcher or bottle. For the first three formulas, eight ounces should be taken from a quart; for the fourth and fifth formulas, ten ounces. Even if this is not all required, the full amount should be taken, as a smaller amount would contain too much fat. The portion not used may be returned to the bottle. If more than three amounts are required, two quarts of milk should be used, or otherwise the top-milk will not contain suf- ficient fat. The lime-water is necessary to render the cow's milk, which is naturally acid, slightly alkaline like breast-milk. If cane- sugar is used, one third less should be taken than the amount given for milk sugar. DISEASES OF INFANCY AND CHILDHOOD 201 All the food should be prepared at one time. The number of bottles should be decided upon, and also the amount necessary for each feeding, thus giving the total amount for the day. The whole amount when prepared should be divided into the requisite number of bottles and each bottle corked with a piece of absorbent cotton. Contamination is thus avoided, for the bottles are only opened as they are used. All measurements of liquid should be made in ounces, for which a graduated feeding-bottle serves every purpose. Tables Showing the Quantity of Each Ingredient Necessary to Make the Food for Different Ages Third Day to Two Weeks Ounces to Be Made 16 20 24 Top-milk .... 2%. . . . .... 3 .... .... 4 ounces Water 12%. . . . ....15%.... ....18% " Lime-water .. . , I .... .... 1%.... Milk sugar .... 2 .... .... 2%.... .... 3 tablespoonfuls Two Weeks to Seven Weeks Ounces to Be Made 24 28 32 Top-milk 5 •••• .... 6 .... .... 7 ounces Water 17%.... .... 20%.... ....23 Lime-water . . . 1%.... .... 1^2.... .... 2 Milk sugar ..... 3 •••• .... 3/2.... .... 4 tablespoonfuls Seven Weeks to Eleven Weeks Ounces to Be Made 28 32 36 Top-milk 7 •••• .... 8 .... 9 ounces Water 19% • • • • .... 22 ... 25 Lime-water .... 1%.... .... 2 ... 2 " Milk sugar 3 •••• .... 4 ... 4% tablespoonfuls HOW TO KEEP WELL 202 Three Months to Six Months Ounces to Be Made 28 36 42 Top-milk n%.... ....14 .... ....17 ounces Water 15 •••• .... 20 .... ••..23 Lime-water .... 1%.... .... 2 .... . . . . 2 Milk sugar .... 3%---- .... 4%.... .... 5% tablespoonfuls Six Months to Eleven Months Ounces to Be Made 36 42 48 Top-milk 18 .... ....21 .... ....24 ounces Water 16 .... ....19 .... 22 Lime-water ... 2 .... .... 2 .... .... 2 Milk sugar .... 4% • • • • .... .... 6% tablespoonfuls When it is desired to increase the fat, it may be done by taking more than the specified amount from the top of the quart; for each extra ounce, by taking more milk, reduces the strength of the cream. Conversely, the fat may be increased by taking less from the top of the quart, the cream being thus more concentrated. Simply taking a greater quantity of the top-milk of the prescribed strength would increase the casein as well as the fat. It is not wise to attempt to meet every single symptom by a change of food. If a child has colic without other symptoms, the casein should be diminished. If there is colic with frequent thin, green movements, the sugar should also be diminished. If the child throws up masses of food and sour water, the fat should be diminished and perhaps the casein. Large curds are more often due to fat than to casein. If there is constipation, the fat may be slightly increased. If the child fails to gain in weight but other- wise seems to be doing well, the amount of the food should be increased. The care of the bottles and nipples is very important. The bottles should be round, with the ounces marked upon the sides. They should have wide necks but no angles or corners. Com- plicated bottles are to be avoided, as it is impossible to keep them clean. Straight nipples should be selected which will slip over the DISEASES OF INFANCY AND CHILDHOOD 203 neck of the bottle. The hole should be only large enough to allow the milk to drop rapidly when the bottle is turned. Nursing- Table Giving Rules for Feeding During the First Year (The day feedings include those of 6 a.m. and io p.m.) Age Intervals hours Feedings in 24 hours Night Feedings Average amount at each feeding x week 2 xo 1 1 oz. 2 weeks 2 10 1 2 " I month 2 9 1 2X " 2 months 2% 8 1 3 " 3 months 2% 7 1 4 " 4 months 3 7 0 5 " 6 months 3 6 0 6 " 9 months 3 6 0 7 " 12 months 3 5 0 9 " bottles with tubes are abominations, for they cannot be kept clean. Before using the bottles they should be thoroughly washed with soap and water and scrubbed with a brush, and should then be immersed in boiling water for ten minutes. The nipples should be washed in cold water after each feeding and should be kept in a weak solution of borax during the intervals. The baby should not be allowed to drink more than twenty minutes for each feeding and should keep awake until finished. Young infants should be held in the arms during feeding and should never be left alone to alternately sleep and nurse until the bottle is empty. Pasteurized Milk.-As the subject of bacteriology developed it was found that the boiling temperature (2120 F.) killed all germs. Hence, sterilizing by boiling was devised. Experience taught, however, that this temperature produced changes in the milk, and further experiments showed that Pasteurizing by raising the temperature to 1550 F. was sufficient to kill the germs found in milk. Pasteurized milk will keep three or four days. If it is desired to preserve milk for some time, as for an ocean voyage, sterilizing should be adopted. Spach's method of Pasteurizing is as follows: "Place the bottles upright in a tin pail Fill the pail with cold water to the level of the milk in the bottle. Suspend a thermometer in the water. Place the pail on the stove and heat until the thermometer regis- 204 HOW TO KEEP WELL ters 1700 F. Remove and cover with four layers of boiled canton flannel for twenty minutes. Put in ice chest or cool place." A very important detail is that the milk should cool rapidly after sterilizing by allowing cold water to flow into the receptacle containing the bottles. It should be fully understood that steriliz- ing is designed to accomplish but one object, viz., the killing of germs. It does not render the milk more digestible, and does not in the slightest remove the necessity for careful modification. Feeding after First Year.-Milk should form the basis of the diet during the first year and an important element throughout childhood. Five meals are required during the second year. From the twelfth to the eighteenth month, four of these should consist of mixture containing five ounces of milk, one ounce of cream, two ounces of water, and two ounces of thick gruel made of oatmeal, barley, or wheat flour. The fifth meal, that taken in the middle of the day, should consist twice a week of six ounces of chicken or mutton broth, three to four ounces of beef-juice three times a week, and a soft-boiled egg twice a week. After these have been taken, four or five ounces of the milk mixture should be given. Between eighteen months and two years, the milk should be given plain. The first and last feeding may consist of plain milk alone. For the second meal a cereal may be given, at first made thin and strained. Cereals should always receive thorough and prolonged cooking and should be eaten without sugar. From six to eight ounces of milk should be taken with this meal, a part of which should be eaten with the cereal. To alternate with the cereal, a soft-boiled egg may be eaten with a little bread and a glass of milk, or plain bread and milk may be sufficient. The meal in the middle of the day should be the dinner or heartiest meal. It may consist of the pulp of rare cooked steak, chop, or roast beef, of which a tablespoonful may be given, together with milk and a little bread. On alternate days mutton or chicken broth may be given with rice in it, together with a little bread and butter, or a plain rice pudding; or three or four ounces of beef-juice may be used with bread crumbed into it. Later, a baked potato may be given at this meal, moistened with beef- juice, dish-gravy, or cream. During the third year no better diet could be adopted than that outlined by Griffith as follows: Breakfast: (1) A small portion of beefsteak, with oatmeal, DISEASES OF INFANCY AND CHILDHOOD 205 hominy grits, wheaten grits, corn-meal, or other cereal porridge with plenty of milk. (2) A soft-boiled egg, bread and butter, and a glass of milk. Second meal: (1) A glass of milk with bread and butter or with a soda or other biscuit. (2) Bread and milk. (3) Chicken broth. Dinner: Roasted fowl, mutton, or beef cut fine; mashed roast potato with butter or dish-gravy over it; bread and butter. As dessert, tapioca, sago, or rice pudding, junket, or some of the fruits mentioned. Supper: (1) Bread and butter. (2) Milk with soda or other biscuit, or with bread and butter. Digestive Disorders Acute Indigestion.-This is usually marked by vomiting, pain, and fever. When undigested food has remained so long in the stomach as to have caused inflammation, chronic indigestion follows the acute attack. It is due to improper food, overloading of the stomach, food that has fermented or decomposed. Aid vomiting until the stomach is entirely emptied of food. Give as much warm water from the bottle as the child will take, which will either clear the stomach of curd and fermented food, or aid in quieting it if it be simply irritable. Reduce the diet to barley- water or broth. If the symptoms are severe, withhold all food for the time. Return to the usual food gradually. For persistent vom- iting no simple measure is so effective as hot water in as large quan- tities as the child will take. Chronic Indigestion.-Vomiting is the most common symptom. The tongue is coated, the breath bad, the sleep disturbed, the temper irritable. The child fails to gain in weight and becomes un- naturally pale. The bowels may be alternately relaxed and con- stipated. The cause is improper feeding or the giving of too much food. Treatment consists chiefly in correcting the diet. Medicine is of no avail unless food is adapted to the needs of the child. Colic.-The feet are cold and pain occurs in paroxysms marked by a loud, violent cry with drawing up of the legs. The cry of hunger is more continuous, and there is no evidence of pain. In colic the paroxysm is relieved by the expulsion of gas. Colic usually results from distention of the bowels by gas. It is most common between the second and sixth month. It may occur with- 206 HOW TO KEEP WELL out flatulence as the result of exposure of the feet or abdomen. It usually results from too much casein in the milk. There is a strong temptation to nurse the baby suffering from colic, but this only adds to the trouble. Relief may be obtained with simple warm water, and peppermint relieves some babies promptly. In many cases pain is in the lower bowels, and nothing gives such prompt relief as a small injection of warm water. This, together with heat applied to the abdomen, is commonly the most effective treatment. A few teaspoonfuls of water are sufficient. If not effective, a half-teaspoonful of glycerin may be added; but large injections should not be used for this purpose, neither should brandy, gin, paregoric, or soothing-syrup be used. The curative treatment consists in regulating the diet. The casein should be the first reduced, and, this not being effectual, the sugar should be reduced. Constipation should also be overcome. Vomiting.-Vomiting is not a disease but a symptom of numer- ous diseases. An enumeration of the causes will serve as a guide to the treatment. It may result from acute indigestion, chronic indigestion, overloading of the stomach, nervous diseases, and re- flex irritation. It also occurs in the first stage of scarlet fever and other acute fevers. Constipation.-Constipation is one of the most troublesome dis- orders of childhood. The local trouble is frequently the only symp- tom, but in many cases there are colic, disturbed sleep, and irrita- bility. Improper diet, irregular habits, and rickets are among the most frequent causes. Two errors are common in the treatment of chronic constipa- tion. The first is reliance on a single measure or a single drug. No one of these is alone sufficient, if the case be obstinate. The second error is the attempt to cure a continuous and persistent condition by intermittent and spasmodic treatment. No matter how good the treatment, it is sure to fail unless persisted in. The cure of con- stipation is to be effected through diet, exercise, massage, and habits of regularity; only temporary relief may be obtained from drugs. The diet of infants should be changed by increasing the fat and reducing the curd. This requires judgment, for beyond a cer- tain limit the fat will cause stomach indigestion. A teaspoonful of olive-oil once or twice a day is sometimes effective. In bottle-fed infants oatmeal water may be used in place of plain water. The giving of water is effective in some cases in which the movements DISEASES OF INFANCY AND CHILDHOOD 207 are inclined to be hard and dry. It should be an item in the treat- ment of all cases. In older children fresh fruit in season should be given freely. Baked apples, stewed prunes, and orange-juice may be given during the second year. Orange-juice may be given to all infants and is far better than medicine. Regularity is of vital importance. A convenient hour should be selected and an attempt made to secure a movement every day even if it repeatedly fails. Massage of the abdomen daily is an effective and important measure. This consists not simply in rubbing the surface but in gently kneading the abdomen and in grasping the abdominal wall with the hand and causing it to move upon the bowels underneath. For palliative purposes suppositories should be tried first. They may be made of soap, gluten, or glycerin. The latter, however, should not be frequently repeated. Injections are next in impor- tance. One or two teaspoonfuls of cool water are sometimes all that is needed to start the action of the bowels. In urgent cases a teaspoonful of glycerin and water may be used. Large injections should not be given repeatedly; medicine is the last resort. Castor- oil should never be used in chronic constipation. Milk of magnesia is the safest and simplest medicine for an infant. A teaspoonful may be added to a bottle of milk once or twice a day. Aromatic cascara is one of the most effective drugs for older children. Equal parts of syrup of rhubarb and syrup of senna may also be em- ployed. The dose of either of these must be determined by the needs of the child, and when found it should be slowly reduced. If thus used the medicine may be a helpful addition to the treat- ment. Diarrhea.-Simple diarrhea is rarely severe and passes away upon removal of the cause. Overfeeding, indigestible food, swal- lowing of foreign bodies, overdoses of cathartic drugs, and acute indigestion may produce it. After a dose of syrup of rhubarb to clear the bowel of offending matter, reduced diet and a few small doses of paregoric will usually effect a cure. Infective Diarrhea.-This is usually known as summer diarrhea and is the most common form seen in children. It presents two types. In the first the onset is gradual, and looseness of the bowels is the first symptom. There may be five to ten movements a day. Thin and frequently green, they soon contain mucus. More or less fever is present. The case may run a mild course and terminate in 208 HOW TO KEEP WELL recovery. It may become progressively worse and run into inflam- matory diarrhea. It may, however, develop suddenly into the most grave and serious type. The disease may continue for a few days or many weeks and is variable in symptoms and course. In the second type the onset is sudden and is marked by fever, vomiting, and numerous loose green movements. At first the move- ments may be large and watery and contain blood, but later they become green or brown and contain mucus. Vomiting is some- times persistent. The number of movements is not always a guide to the seriousness of the disease, for some of the worst cases have a high temperature and but few movements. The disease may sub- side and recovery gradually follow, or the symptoms become less severe but drag along for days and weeks. In less favorable cases the child succumbs within a few days. In strong children, under favorable surroundings, and with judicious treatment, recovery usually takes place. Improper feeding, chronic indigestion, and excessively hot and moist weather of summer are causes. The immediate cause is germs, which are usually taken into the stomach with the food. This form of diarrhea prevails in summer chiefly because the hot weather favors the development of bacteria in milk. Breast-fed babies almost never have this form of diarrhea. Study of the causes shows the importance of keeping babies in good surroundings and in good health, and the digestion in as perfect order as possible. Indigestion in hot weather should receive prompt attention. The most important preventive measure is the exclusion of germs from the food. This is accomplished by Pasteurizing it. The milk should come from a clean and well-managed dairy. When the at- tack begins milk should be at once withdrawn. Although so valuable a food in health, when fermenting diarrhea begins it will add fuel to the flame. Mothers sometimes object to this, but to an adult one would not think of giving beefsteak in dysentery and typhoid fever, although they are excellent articles of diet in health. In place of milk, broths, rice-water, barley-water, or egg-water (made by beating up the white of an egg in a pint of water) may be used, or even one of the infant-foods made with water alone. Return to the milk should be gradual, and its effect should be care- fully watched. At the outset it is wise to give warm water freely to wash the stomach, and also a large injection of warm boiled water. DISEASES OF INFANCY AND CHILDHOOD 209 At the outset of such an attack there is no medicine so effective as castor-oil, a teaspoonful being the usual dose at one year. This should be followed by subnitrate of bismuth in doses of at least ten grains every two hours, at the age of one year. Occasional small doses of paregoric are permissible if there is pain or the movements are excessive. Medical advice should be obtained at the earliest possible moment. A change of air will often accomplish more than medicine, the sea-shore being especially advantageous. Inflammatory Diarrhea.-This is usually an advanced stage of infective diarrhea and is known by physicians as entero-colitis. Diarrhea, pain, and fever are constant symptoms. The child loses flesh and strength, and nervous symptoms are not uncommon. Cholera Infantum.-This term is sometimes incorrectly applied to all forms of summer diarrhea. It should be given only to a disease marked by large, very frequent watery movements, accom- panied by persistent vomiting and very high fever; in other words, to a disease simulating cholera. The child loses flesh with great rapidity and may succumb within two days. True cholera in- fantum is rare. It requires stimulants and treatment to check the vomiting and watery movements. Dysentery.-In young children dysentery is a severe form of inflammatory diarrhea, in which the disease is located chiefly in the large bowel. It is most common in late summer and is character- ized by frequent, small, painful movements, consisting wholly or in part of mucus and blood. Straining and pain are present after the movements, a symptom known as tenesmus. Irrigation of the bowel is especially indicated, and paregoric may be used more freely than in any other form of diarrhea. Diseases of the Mouth, Throat, and Lungs Thrush.-Thrush usually begins upon the tongue or inside of the cheek as small white flakes which may be mistaken for coagu- lated milk. There may be but few spots, or the whole mouth may be covered. There is usually dryness and some soreness, but rarely sufficient to prevent nursing. Slight diarrhea is common, but the thrush itself does not go below the mouth. The disease is due to the formation of a fungus. It is conveyed by nipples or other arti- cles which enter the child's mouth. The spores of the fungus may come directly from another case or through the air. It is most com- mon during the first three months and is rarely dangerous outside 210 HOW TO KEEP WELL of hospitals. Exercise absolute cleanliness in every detail in the baby's care and feeding. The best wash consists of borax and bicarbonate of soda, five grains of each to an ounce of water. Borax and honey should not be used. The wash should be used carefully after nursing. Harsh removal irritates and does harm. In addition to this, a saturated solution of boracic acid should be used two or three times a day. Ulcerated Mouth.-Ulcerated mouth consists in the formation on the tongue and lips of little round ulcers varying from one or two to a dozen or more. They sometimes run together to form large patches. They are exceedingly troublesome and prevent the child from eating. The disease runs its course in about a week and cannot be much shortened by treatment. Relief may be afforded by a mild wash like Dobell's solution. Powdered burnt alum hastens healing when it is delayed. Spasmodic Croup.-False croup is rare before the sixth month and after the fifth year, but may occur at any time during child- hood. The symptoms to the inexperienced are very alarming. The child may have been perfectly well, or there may have been slight hoarseness or cold in the head. He suddenly wakes early in the night with a loud metallic cough. Breathing is difficult, the child often struggling for breath, being terrified at its own condition. The voice is hoarse but not lost. There is little or no fever. After a few hours the attack subsides, and on the following morning the child seems well. The next night a milder attack occurs and still another on the third night. This typical course is not, however, the rule in damp climates like that of New York. The night attacks occur as described, but recovery during the day is not so complete. The child has a cough, more or less troublesome, and the attack runs into bronchitis, which continues for a week or longer. Heredity is an active cause. Some children have a predispo- sition to croup; others under the same conditions never have an attack. The chief exciting causes are indigestion and exposure to cold. Prevention consists in relieving indigestion and constipation, in the removal of adenoids and enlarged tonsils, in giving tonics, and, particularly, daily cold sponging about the neck and chest. The at- tack is to be treated by syrup of ipecac given in twenty-drop doses every fifteen minutes until the child vomits or is relieved, after DISEASES OF INFANCY AND CHILDHOOD 211 which one full dose of paregoric may be given (fifteen drops at one year). This may be followed by Brown mixture (one half teaspoonful or one half tablet every three hours for. a child of one year), the dose being doubled at about seven o'clock every evening. A large sponge squeezed out of hot water may be placed over the front of the throat, or a flaxseed poultice. The croup-kettle is a useful aid. For this purpose a tent should be made by spreading a sheet over the crib if it has a high top and foot. If not, the sheet can be raised in tent shape by means of sticks or broom-handles tied to the head and foot. Into this tent the pipe of a croup-kettle should be introduced, and the steam allowed to pass for fifteen or twenty minutes. In the use of poultices and steam the child should be scrupulously protected against cold. Bronchitis.-Next to indigestion and diarrhea, "cold on the chest" is the most common acute disease of young children. It may be mild with little or no fever; in severe forms the fever may rise to 102° F. The cough may be loose with free secretion of mucus, or short, dry, and teasing in character. It may become so paroxysmal as to suggest whooping-cough. The usual duration is between one and two weeks. Except in very weak and very young infants, it is never fatal unless pneumonia supervenes. Causes are wetting the feet, exposure to cold, insufficient cloth- ing. It is a symptom in measles, grippe, and several other diseases. Prevention is similar to that required for croup. Children subject to bronchitis should take cod-liver oil for one or two weeks out of every month during the cold weather. Young children with bronchitis should be kept in bed during the acute stage. They may wear a flannel jacket and sit up in bed with toys and books, but the disease will be much shorter if they are kept from active exercise. Poultices are not advisable, but a mustard paste (one part of mustard to six of flour) may be used two to four times a day, for a few minutes, just long enough to redden the skin. In milder cases the chest should be thoroughly rubbed two or three times a day with hot camphorated oil. In the early stages, the tent and croup-kettle are an admirable means of treatment, as in croup, every three to six hours. A tablet containing one one-hundredth grain each of antimony and ipecac may be used every two hours for a child of two years, or, if the cough is very harassing, a tab- let representing one teaspoonful of Brown mixture. Pneumonia.-There are two varieties of pneumonia, broncho- 212 HOW TO KEEP WELL pneumonia and lobar pneumonia. The first is the common form seen in children under two years. The second is rare before the third year but. is the common type after the fourth. Lobar pneu- monia is far less fatal in children than in adults. It usually pursues a short and sharp course, terminating generally within a week. Bronchopneumonia pursues a course varying from ten to twenty days or longer. It terminates gradually and not suddenly like lobar pneumonia. The onset may be abrupt but is often gradual. In ordinary cases the symptoms are quite characteristic. There is fever (usually above 1020 F.) and persistent cough with evidence of pain. The breathing is known as expiratory; that is, the expiration is prolonged and exaggerated and is accompanied by a slight sound, often by a slight moan. When the child is quiet this expiratory moan may be absent, but it appears when he is dis- turbed. The nostrils dilate with each breath. The child is com- monly more patient and less irritable than in the digestive diseases and rarely cries loudly. There is thirst, but the appetite is usually completely lost. Although bacteria are the exciting cause of pneumonia, expo- sure to cold is a potent predisposing cause. It often results from bronchitis and is a common complication of measles, whooping- cough, diphtheria, grippe, and inflammatory diarrhea. Treatment is similar to that of bronchitis except that the mustard pastes and croup-kettle may be more freely used, as they are of far greater efficacy than drugs. It is of importance that the nourishment be maintained as completely as possible, but it is a grave error to over- load the stomach with milk in the early stages simply because the child takes it freely on account of thirst. Treatment should always be in the hands of a physician. Pleurisy.-Pleurisy is not uncommon in young children but is always secondary to pneumonia. It is accompanied with fluid in the chest much more commonly than in adults, and the fluid is apt to be purulent. If it is merely serum, there is a possibility of its absorption through medical treatment. If it is pus, it will never absorb. If it is allowed to remain, the child will die of hectic fever and exhaustion; it can be removed only by an operation. In either case the condition is a grave one, but operation offers the only hope of recovery. Diphtheria.-It is impossible to depict diphtheria by a single description, for few diseases show such extremes of mildness and DISEASES OF INFANCY AND CHILDHOOD 213 malignancy. It is a disease of the fall and winter months and is most apt to occur where the sanitary conditions are not good. The following symptoms are those most commonly seen: the onset is mild and often uncertain; there may be slight fever and soreness of the throat, prostration, and weakness. Upon one tonsil, rarely upon both, a membrane appears and increases in size. It may be thick or thin and is of a gray or brownish color, surrounded by a zone of red inflammation. The membrane may not extend beyond the tonsil, or it may gradually involve the whole back of the throat and soft palate. It may extend upward into the nose or downward into the larynx. It is possible to have diphtheria without the false membrane, the tissues being red and swollen and the bacilli being present. The glands of the neck are usually enlarged, and, when the nose is involved, they increase rapidly in size. The membrane sometimes begins in the nose, and there may be a watery, acrid discharge which inflames the lip. If far back, the disease is obscure until the membrane appears in the back of the throat. There is frequently an offensive odor to the breath. The child is prostrated, rapidly becomes anemic and sallow, and may die either from steadily increasing prostration or rapid weaken- ing of the heart. Sudden death sometimes occurs. In favorable cases the symptoms gradually subside, and the membranes slowly disappear. Duration ranges from a few days to two or three weeks. Many people carry the germs of this disease in their throats and are not susceptible to it though they may transmit it to others. The onset is sometimes sudden, with fever, vomiting, sore throat, and prostration. As a rule, the more acute the onset and the higher the fever during the first day, the less serious is the case, these symptoms belonging to tonsilitis rather than to diphtheria. In malignant cases the onset is intense, and the child is soon over- whelmed. Other cases are so mild that diphtheria is never sus- pected until an examination of the throat is made. No doubtful throat case should be neglected. Within recent years it has been found very useful to give injec- tions consisting of antitoxin and diphtheria toxin obtained directly from a diphtheria case. Thousands of children have been immu- nized in this way, and the hope is that diphtheria may be van- quished by this treatment. Diphtheria is due to a germ known as the Klebs-Loeffler bacil- 214 HOW TO KEEP WELL lus, after the men who discovered it. It lives in the diphtheritic membrane, where it generates a virulent poison, which is absorbed into the system. It is spread by direct contagion and also through clothes, like scarlet fever. It may occur at any age but is most common between one and five years, and rare after ten years. In young babies it is usually fatal. Enlarged tonsils and adenoids, by forming a favorable field for the growth of the germs, are predis- posing causes. The period of incubation is from a few hours to two or three days. It is contagious from the first symptoms until the germs have disappeared from the throat, which does not happen for many days or even weeks after the membrane has gone. The efficiency of the antitoxin treatment has been demonstrated all over the world by such overwhelming evidence that it is not an exaggeration to say that to omit it is to tamper with life. It should be administered promptly and in full doses. Early use is of the greatest importance, for it is many times more effective if given on the first or second day than when its use is delayed. The fears entertained by many as to the bad effects from antitoxin are groundless. Before its preparation was as perfect as at present, some bad symptoms were caused by it. A rash sometimes follows, but it is not serious. Harsh and excessive local treatment is no longer employed; it does harm. Mild antiseptic washes are em- ployed, and stimulants are given if required. The child should be kept absolutely quiet in bed, in severe cases not even being allowed to raise the head. The same precaution as to prevention and isola- tion should be taken as in scarlet fever. Small doses of antitoxin given to the well are certainly effective in preventing the disease and do no harm. The toxin-antitoxin immunization treatment already mentioned is likely to supersede antitoxin alone both for prevention and as a means of cure. The Schick test is gradually being used throughout the civilized world, to determine whether a child is naturally immune to diphtheria. It consists in the in- jection of a minute quantity of diphtheria toxin into the skin of the forearm. If the child is not naturally immune a small elevated white spot will appear at the site of the injection; it will become red and swollen within twenty-four hours, and in forty-eight hours it will be a mere brownish spot. False Diphtheria.-The term "diphtheria" was formerly applied to all membranous diseases of the throat. The distinction is now made between true diphtheria, caused by the Klebs-Loeffler bacil- DISEASES OF INFANCY AND CHILDHOOD 215 lus, and false diphtheria caused by other less active germs. It is often impossible to distinguish these two forms by appearance alone. Until the question is settled by bacteriological examina- tion, careful physicians treat all cases as if they were the true disease. The most important difference between the two is the fact that the mortality of true diphtheria is at least five or six times greater than that of false. Membranous Croup.-Membranous croup is an inflammation of the larynx marked by the formation of a false membrane. It is dangerous chiefly because of the obstruction it causes to the breath- ing. The larynx is in the narrowest part of the respiratory pass- ages, so narrow, in fact, that but slight obstruction proves fatal. Hence, a membrane, which would cause no obstruction on the tonsil, becomes serious in the larynx. In between eighty and ninety per cent of cases the membrane is due to diphtheria. The disease usually begins insidiously. The progress is slow as compared with false croup but is continuous and relentless. The voice is hoarse and at length is completely lost. Difficulty in breathing steadily increases, and without treatment the child dies of strangu- lation. The breathing acquires a peculiar sound known as stridor. The nostrils become dilated, the chest sinks in at every breath, and the skin becomes more and more blue. The disease is one of the most fatal in childhood, the death-rate, when untreated, being about ninety-five per cent. The duration in infants is thirty-six to forty- eight hours; in older children from two or three days to a week. Intubation and antitoxin have produced extraordinary results. Antitoxin alone prevents the necessity of operation in a large num- ber of cases. By the best methods of treatment before antitoxin, about thirty cases in a hundred were saved; now about eighty cases are saved when the treatment is begun with reasonable promptness. Intubation has completely superseded tracheotomy. By the latter, an opening was cut through the throat into the trachea and a tube was inserted. By intubation, the tube is inserted through the mouth, no wound being made. The tube can be removed at any time; the operation does not require an anesthetic and is accompa- nied with very few dangers. As croup is usually diphtheritic, isolation should be enforced as in diphtheria. Scarlet Fever.-Scarlet fever is a contagious disease, typical cases of which begin suddenly with strawberry tongue, vomiting, and fever; within twenty-four hours a rash appears on the neck and 216 HOW TO KEEP WELL rapidly spreads over the body, continuing for about six days, when it terminates in desquamation or peeling, which lasts for three weeks or longer. The rash consists of minute points of bright scarlet color, closely grouped on a slightly reddened skin. They run together, in places, forming bright scarlet patches. Peeling begins at first in fine branny scales, which soon become larger, and in some cases the skin peels off in long strips. The fever is usually high. Sore throat is an early and serious symptom and is often membranous. Membranes which appear in the early days of the disease indicate false diphtheria; those that appear late indicate true diphtheria. The complications are many and grave. The ears frequently discharge, and deafness is not a very uncommon result. Enlarge- ment of the glands of the neck is common. The heart may give way; bronchopneumonia may develop in the lungs, and meningitis in the membranes of the brain or spinal cord. The joints some- times become red and tender as in rheumatism. The kidney is often involved, most commonly during the third or fourth week. The kidney complication may pass away completely or run into chronic Bright's disease. Scarlet fever may be so mild as to be overlooked or so malignant as to be rapidly fatal. It is most common between the fifth and eighth years, and though the streptococcus is the germ most frequently found the specific or real germ has not yet been discovered. Few other diseases are so readily transmitted by clothes, bed- ding, books, toys, and other articles. The period of incubation is between two and four days. It is contagious from the first symp- toms until all peeling and discharges from the ears have stopped, a period rarely less than forty days. Prevention is very effective, the most important measure being absolute isolation, which should not be for less than forty days. Uncomplicated cases usually recover, for death results chiefly from the complications. Protection from exposure is important in order to prevent kidney complications. One attack of this disease usually immunes a person for life. A dose of castor-oil should occasionally be given and simple fluid food, especially milk. Good nursing, with two baths daily, are of su- preme importance. It is claimed for the Dick test, by which cultures of hemolytic streptococci are injected within the skin, that it bears a specific relation to immunity in scarlet fever. DISEASES OF INFANCY AND CHILDHOOD 217 Measles.-Measles is a contagious disease, more common in warm than in cold weather, which usually begins with feverishness, cold in the head, running of the eyes, and dry cough, followed on the fourth day by a rash which appears first on the sides of the face and neck and slowly spreads over the body, appearing last on the hands. The rash continues for about five days, when it fades away and is followed by a bran-like peeling, which is usually com- pleted within a week. The rash consists of small rounded spots or slightly elevated papules, with reddened skin between. In some locations the spots run together. There is considerable swelling of the face, and the spots are blotchy, so that the appearance of the child is much changed. In malignant cases the spots are dark in color and form "black measles." The fever is not, as a rule, as high as in scarlet fever. The child is frequently drowsy and stupid, but occasionally very restless. The bowels are frequently loose, a troublesome diarrhea being not uncommon. The cough is hard and metallic and constitutes one of the most troublesome symptoms. Among the complications pneumonia is the most common. Tuber- culosis is the most serious sequel. Death rarely occurs in uncom- plicated measles in children over four years of age; under that age it is often fatal. It may be conveyed by clothes, by discharges from the mouth and nose, and probably by the scales from the eruption, but less readily than scarlet fever. The average period of incubation is twelve days, the extreme being eighteen to twenty days. It is contagious from the first symptoms of cold in the head until peel- ing has ceased, a period of about twenty-eight days. In uncom- plicated cases but little medicinal treatment is required. The cough can be but slightly relieved during the earlier stages. After the rash has appeared, the whole surface of the body should be anointed daily with oil, which does much to relieve the irritability of the skin and to prevent spreading of the disease. The serum treatment of measles is used with increasing frequency and success. German Measles.-German measles is a distinct contagious disease and not simply a mild form of measles or scarlet fever. In many cases there are no symptoms until the rash appears; in others there is mild fever and nausea. There is no cold in the head and little or no cough. The rash consists of spots larger than those of scarlet fever and smaller than those of measles. It comes out 218 HOW TO KEEP WELL rapidly over the whole body. In some cases the rash is fine and simulates that of scarlet fever. In others it is coarser than usual and so much like measles that the diagnosis is difficult. It lasts from two to four or five days and is followed by very little desqua- mation. Its period of incubation is eight to sixteen days. It re- quires rest in bed, anointing with oil, and some simple medication for the fever, such as sweet spirits of niter. Mumps.-Mumps is characterized by painful swelling of the parotid gland, which may extend to all the other salivary glands, usually occurring in the fall or spring. This swelling is triangular in shape, the upper angle being in front of the ear, another at the side of the jaw, and the third behind the ear. One or both sides may be involved, one usually preceding the other by a few days. In swellings of the glands of the neck the enlargement does not extend so high upon the face. In mumps, the lobe of the ear is lifted outward. Usually the saliva is diminished and the mouth is dry and parched. The disease continues about a week on each side. An occasional and very peculiar complication is inflammation of the breasts and ovaries in girls and of the testicles in boys. Contagiousness begins even before the swelling and may con- tinue a week after its disappearance. The period of incubation is variable, commonly sixteen to twenty-one days. Little treatment is required in ordinary cases. Warm camphorated oil is the best local application; daily baths should be given, and the bowels should be opened daily with castor-oil. Only fluid food is permissi- ble. The mouth should be swabbed out frequently with boric acid solution, and gargling with menthol or eucalyptol solution should be practised if possible. Chicken-Pox.-Chicken-pox is characterized by slight fever and the eruption of small vesicles. Each vesicle rests on normal or slightly reddened skin and looks as if a drop of hot water had raised a round blister. The vesicles slowly dry and form scabs which fall off. They come in successive crops, so that some are drying while others are beginning to form, thus differing from smallpox, in which the vesicles are all found in the same period of development. The rash appears over the whole body, particularly on the back and shoulders. The period of incubation is fourteen to sixteen days. Little treatment is required, except to keep the child quiet, and protect the eruption, particularly on the face, where a pit is some- times left if the vesicles are broken. DISEASES OF INFANCY AND CHILDHOOD 219 Smallpox Vaccination.-Every child should be vaccinated before the sixth month. The best time is during the third or fourth month if the child is healthy, for then the fever and other symptoms are milder than at any later period. Vaccination should be again performed during later childhood. The importance of revaccina- tion has been taught by experience. With improved methods of obtaining the lymph, accidents and complications are rare. Blood diseases are never conveyed when reliable bovine lymph is used. Glycerin lymph in sealed tubes is now regarded as the best. Varioloid.-We do not hear very much about this disease nowa- days, because smallpox, or variola, is itself of rather rare occur- rence, and varioloid is really smallpox in a mild form. Its name indicates that it resembles variola. It is in reality the same disease, produced by the same cause, and giving the same results upon the skin, though in a form that is not excessively disfiguring. It im- plies that the person infected has been exposed to the germ of smallpox but that his resisting powers were strong enough to pre- vent a flagrant and virulent development of the disease. It some- times occurs in those who have been more or less recently vacci- nated but have not obtained complete immunity by the vaccination, and it may also occur in those whose immunity has almost run out. Its symptoms are all of a mild character; the victim is not nearly so ill at the outset of the disease as in smallpox of the highly de- veloped form, and the preliminary eruption, instead of being in separate points, is rather a diffused redness or rash over the greater part of the body. Then comes the eruption with the raised spots or papules, and this is distributed far less generally over the body than is the case in well-marked smallpox. The eruption then pro- ceeds to the formation of cysts or vesicles, but the fluid they con- tain is clear and does not, as a rule, undergo change to pus. After a few days the vesicles dry up and leave a far less conspicuous pit or pock-mark than the severer form, and the patient may be out again long before it would have been prudent to relax the quaran- tine of real smallpox. At no time is the patient greatly depressed or exhausted by the disease; complications are rare, and when pres- ent are not of a severe or dangerous type; and altogether the patient experiences no great amount of inconvenience from the disease, except from the quarantine, which should be as rigid during the period of the disease as if the exposure were to the severe type. The 220 HOW TO KEEP WELL immunity gained by an attack of varioloid is probably the same as from an attack of variola; as a rule one does not have either form of the disease more than once. Nursing and diet are the principal considerations in the treatment of this disease, and it is never safe to treat it slightingly because it is proverbially so mild in its course. Whooping-Cough.-Whooping-cough is a contagious disease caused by a particular variety of bacillus with catarrh of the mucous membranes and a peculiar paroxysmal cough, most common in the spring and fall and in children from four to twelve. It begins with a catarrhal stage, lasting about ten days, during which the symp- toms are those of a cold. The second or spasmodic stage lasts four weeks or more. The disease increases for about two weeks, re- maining stationary for two weeks or longer, and gradually subsides. The paroxysms vary from eight or ten to forty or fifty daily. Vom- iting is frequent, and occasionally every paroxysm is a struggle for breath. In some cases an enormous quantity of mucus is secreted; in others the quantity is small. Sometimes the whoop may be heard but a few times during the course of the disease. The most com- mon and serious complication is bronchopneumonia, but there may also be indigestion, diarrhea, convulsions, and hemorrhages. It is due to direct or indirect contagion, and the period of incubation is one to two weeks. Much can be done to relieve the severity of the cough. A change of air is often valuable, sea-air being particularly effective. The child should be in the open as much as possible. The sleeping- room should be aired thoroughly and not occupied by the child during the day. Inhalations are of considerable value, creosote being the most valuable it is best used by being vaporized in a croup-kettle or on boiling water. Much may be done by drugs to modify the disease, but they are all of a character to require a physician's prescription. The recent use of vaccines in treating this disease has been found satisfactory and efficacious. Malarial Fever.-Malaria is not uncommon in children but pre- sents numerous peculiarities. A chill never occurs under three or four years, though the child may become pinched and blue and ap- parently cold. Sweating is also less common than in adults and sometimes occurs several hours after the fever. The paroxysm usually occurs every day and is irregular in its hours of occur- rence. The child is irritable and during the fever is frequently DISEASES OF INFANCY AND CHILDHOOD 221 drowsy and heavy. An "ague cake" or enlarged spleen is frequently seen as an accompaniment of the disease. The germ of malaria is the same as in the adult and proceeds from the bite of the anopheles mosquito. Quinine is the only remedy to be relied upon. It is best given in syrup of yerba santa, three times a day in the case of a young child. At three years, each dose may range from one to three grains. Rheumatism.-It was formerly supposed that rheumatism was rare in children. This error resulted from the fact that the symp- toms varied so much that it was often overlooked. The joint symp- toms are very mild. A little fever and redness of a single joint may be all that is seen. The child may be lame for a few days or com- plain of tenderness about one of the lower joints. In rare cases a marked attack of inflammatory rheumatism occurs. Mild attacks, however, deserve careful attention, on account of the danger of heart inflammation, which is much greater in children than in adults. The mildest attacks are sometimes complicated by endo- carditis (inflammation of the lining membrane of the heart). St. Vitus's dance is a frequent accompaniment of rheumatism and also tonsilitis. "Growing pains" are almost invariably rheumatic. Heredity is a very potent causative factor. Exciting causes are the same as in the adult. Even in the mildest cases the child should be kept absolutely in bed, for nothing else will do so much to prevent heart complica- tions. Rheumatic children should wear flannels the year round but should not be over-clothed. They should receive tonics like iron and cod-liver oil during cold weather. The attack requires the doc- tor's care. He should be asked to lay down special rules for the continuous management of each case. Heart-Disease.-The symptoms in children are usually obscure and such as might arise from numerous other causes. In many cases there are no symptoms. The diagnosis is only to be made by exami- nation of the heart. In the vast majority of cases rheumatism is the cause. In rare cases it results from scarlet fever, erysipelas, and other infectious diseases. When there are active symptoms the treatment must be prescribed by the doctor. When none are pres- ent it is wrong to give medicine except tonics. Children with val- vular disease should have free exercise in the open air but should be guarded against violent exercise and overstraining. The mere fact that the doctor finds a "murmur" does not mean necessarily 222 HOW TO KEEP WELL that the child has an active disease requiring treatment. The in- jured valve is the result of previous diseases, and nothing can be done except to prevent a fresh attack of rheumatism and conse- quently more injury to the valve. Hence the reason that heart- disease in many cases does not require treatment. The heart fre- quently accommodates itself to the condition, and the patient lives a long life and never has any symptoms. When this is not the case and symptoms arise, treatment is required. Nutritional Diseases Rickets.-This is a chronic disease of nutrition. While the most important symptoms are found in the bones, it is not alone a bone disease; for the muscles, nerves, and organs are seriously affected. The most common early symptoms are sweating of the head, rest- lessness at night, constipation, delayed and defective dentition, and beading of the ribs. The last of these symptoms appears as a row of small prominences extending in a curved line up and down each side of the chest where the bone and cartilage of the ribs join, Later, deformities appear, because of the softening of the bones. The head is large and square; the chest in extreme cases shows two furrows, one running up and down, the other around the body; and the child is chicken- or pigeon-breasted. The spine is usually curved, the curve being large and rounded and not sharp like that of Pott's disease. The legs are either knock-kneed or bow-legged, and in extreme cases they are otherwise deformed. The bones of the arm may also be bent. An early and important symptom is increase in the size of the wrist- and ankle-joint. The mucous membranes are subject to catarrh. The child is usually nervous and irritable. If untreated, the disease continues for many months. The deformities, if not too extreme, mostly disappear in later life; if extreme, they remain. While rarely fatal, rickets renders any acute disease which the child may contract more serious. Too little fat in the food and too much starch are the chief causes. Lack of sunlight and unhygienic surroundings also contribute. Treat- ment is indicated by the causes. Among medicines cod-liver oil is the remedy par excellence. Improved diet and cod-liver oil will check the severest cases. A change of residence to the mountains or sea-shore will often work wonders. Scurvy.-Although unrecognized in America until a few years ago, scurvy has come to be a not uncommon disease among infants. DISEASES OF INFANCY AND CHILDHOOD 223 It occurs in well-to-do families and not in tenement regions or among the poor. It is often mistaken for rheumatism, rickets, or paralysis. It is marked by pain on motion, swelling of the ex- tremities, bleeding or spongy gums, and frequently by paralysis of one or more limbs and black and blue spots on the body. The pain is intense and often occurs before the swelling, which is usually between the joints and not around them, as in rheumatism. The skin is glossy and tense but rarely red. Around the teeth, the gums become inflamed and purple and often bleed. When un- treated, scurvy is very fatal. When properly treated recovery is prompt. Lack of fresh food is the main cause. Many of the cases are those which have been fed on proprietary foods and on condensed milk. Diseases of the Skin Eczema of the Scalp in Infants.-It may happen to any kind of a baby, to one who is plump and apparently in good condition, as well as to the puny, half-starved little infant whose energy is all used up in constant crying and moaning. One of the great authorities on children's diseases says it comes to those who have a tendency to congestive or catarrhal troubles, to those who are called scrofulous, and to those who suffer from rickets, indigestion, anemia, and vari- ous kinds of fevers. This disease may occur at any period of infancy, before or after weaning, and the pain and soreness which so often accompany teething doubtless aggravate it in many cases. There are many causes for it; probably there is a germ in some cases, but I do not know of any specific or particular germ which can always be found. It is often connected with the parasitic disease known as the itch, and with vermin of various kinds. Filthiness and want of care of the nose, the ears, and the eyes, and the irritating saliva of a dirty mouth, may be connected with its origin. Constipation and indigestion are often associated with it, and exposure to the sun's rays or to the heat of a badly ventilated room may produce it. One of the commonest causes that I know of is indigestion. It is first a collection of red points called papules, and in a few days these points contain fluid. In a few days more this fluid may get thick and purulent, the points run together, and soon we have a series of crusts or scabs, or perhaps a crusty sheet covering the en- tire scalp. The itching is usually night and day. Perhaps with the 224 HOW TO KEEP WELL constant tendency to scratch and rub the scalp, the nails and fingers will carry infectious material to other portions of the body, and this may be the beginning of trouble in the eyes, nose, mouth, and ears and of sores in different parts of the body. The eruption in- terferes with the growth of the hair, and more or less of the hair may fall out. The constant irritation, with other conditions which may be associated with the eruption, may wear the baby out, for the endurance and resisting power of babies are usually very limit- ed. Cut the baby's nails to prevent injurious scratching, and also cut the hair, wash out its rectum daily, and make a thin muslin cap or bonnet to cover and protect his head and face. Use no water, hot or cold, on the scalp; use drying-powder freely-boric acid, zinc, or starch. When the scabs begin to loosen, remove them and then keep the scalp covered with a suitable astringent ointment. The ointment must be removed and reapplied daily. Fresh food should be given. Medicine has no effect whatever. The child will die unless the food is changed. Fresh, unsterilized milk, beef-juice, and a little orange-juice daily will promptly cure the worst cases. Eczema.-This is the most frequent skin-disease of young chil- dren. In infants it is due to irritation of clothing, strong soaps, cold damp winds, etc. Digestive disturbance is a more common cause than in adults. It appears upon the face most commonly, where it is easily improved, but cured with difficulty. Diet is of especial importance in infants. The fat should be reduced, and con- stipation carefully treated. It is never dangerous to cure eczema. The local treatment is similar to that of adults. Prickly Heat.-This consists of bright, red papules closely set. The summit of most of them consists of tiny vesicles. They appear suddenly, chiefly where perspiration occurs freely, and itch severely. Powders like stearate of zinc or talcum are usually the best local treatment, but sometimes more ease is obtained from a weak solu- tion of vinegar and water or of carbolic acid and water. Cathartics should be freely given. Teething.-Teething was formerly believed to be the cause of most of the ailments of infancy. The ills attributed to it, however, have steadily diminished, as knowledge of the diseases of children has increased. More than half the children cut their teeth without any symptoms, but it cannot be denied that in some cases the symp- toms are marked. It is unsafe to attribute any illness to teething without a search for other causes. When trouble does occur, the DISEASES OF INFANCY AND CHILDHOOD 225 strength of the food should be reduced, and the symptoms should receive their appropriate treatment. Lancing the gum is rarely necessary or advisable. Rubbing the teeth through with a hard body is never to be done. All soothing-syrups and opiates should be avoided. Nervous Diseases St. Vitus's Dance.-This disease consists of involuntary and ir- regular movements of many muscles or groups of muscles of the body. They are not under control of the will and are usually made worse by efforts to control them. They are rarely present during sleep and are increased by excitement, fatigue, or embarrassment. They commonly begin in the muscles of the hands and face, so that children are sometimes punished for dropping things and making grimaces. The mental condition, as a rule, undergoes change. Re- current attacks are sometimes foreseen by the mother by the irri- tability of the child and a change in its disposition. The tongue is often thick and the speech indistinct. The disease runs a variable course, which is rarely less than six weeks, and is liable to recur, frequently at the same season of the year. St. Vitus's dance is closely associated with rheumatism and may occur before, during, or after a rheumatic attack. It may, however, be caused by fright, excitement, and overwork at school. Some families seem predis- posed to it. It occurs most frequently between seven and fourteen years, and is twice as frequent in girls as in boys. The mildest case should receive prompt treatment, but not necessarily by drugs. The child, no matter how slight the move- ments may be, should be taken from school at once. He should be removed from all excitement, and all reference to his condition should be studiously avoided. Above all things he should be re- moved from the possibility of ridicule and should not be punished for any act resulting from weakness or from his movements. In severe cases absolute rest in bed should be insisted upon. As the disease improves the child may be allowed to be up for two or three hours, the daily period being gradually lengthened. The diet must also be regulated very closely. "Milk and rest," says Dr. Sachs, "will do more for most cases than any other two measures." The most effective medical treatment involves the use of one or two quite potent drugs, which should be prescribed for each case by the doctor. 226 HOW TO KEEP WELL Night-Terrors.-This is a term usually applied to two different conditions. The first is most common and is of the nature of night- mare. The child awakes frightened and excited; the mind is clear, and he recognizes those about him, but it may be some time before he is sufficiently calm to sleep again. In the second the child is usually found sitting up in bed, terrified. The fright is frequently associated with a red color or with some animal. The child does not recognize those about him nor realize where he is and may go to sleep without fully waking. He may not remember the attack the following day. A large amount of pale urine is frequently passed. Attacks of the first class are usually due to indigestion or partial asphyxia resulting from adenoids. They are comparatively common. The second class is quite rare and is more serious. Re- move the cause when possible. Give light diet in the evening; avoid excitement and over-fatigue. The child should not be com- pelled to sleep far away from older people. Opiates should never be given, the moderate use of bromides in persistent cases being all that is admissible. Convulsions.-The symptoms of convulsions are too evident and common to require description. The only question to be settled is their nature. In young children they are usually the re- sult of digestive disturbance and may not be immediately serious. Convulsions may, however, be due to epilepsy, brain-disease, kid- ney-disease, or the first stage of some infectious fever. They often occur in the children of the insane, the imbecile, the epileptic, and the hysterical, and also in those who have had a syphilitic, tuber- culous, or alcholic family history. It is always safe to unload the stomach and bowels. As soon as the child's condition will permit, a teaspoonful of syrup of ipecac may be given and an injection of warm soap and water. During the convulsion cold, should be ap- plied to the head and heat to the body, the child being kept as quiet as possible. The time-honored warm bath has many objections. In the excitement many children have been scalded, and the injury is often so great as to counteract the good result. The mustard- pack is better than the bath. It is made by wrapping the child for ten or fifteen minutes in a towel saturated with mustard solu- tion (level tablespoonful of mustard to a quart of warm water). A low diet should be prescribeed and freedom from excitement maintained. The doctor may be asked to leave special directions and medicine for each case in the event of recurrence. DISEASES OF INFANCY AND CHILDHOOD 227 Meningitis.-Meningitis may be acute or chronic. When acute it may occur in epidemics or independently. It is commonly known as cerebrospinal meningitis. Meningitis may also occur in the course of acute infectious diseases. Usually, after a day or two of general discomfort, the attack begins with convulsions, violent headache, and high fever. The pain extends into the back of the neck and down the spine, the head is drawn backward, the back is rigid, the abdomen is normal or retracted, and there is obstinate constipation. There is frequently delirium, which may be active, but there is often stupor and finally unconsciousness. In some cases spots occur upon the face and body, which have given the disease the name of spotted fever. The case terminates in one of three ways: the patient becomes unconscious, the muscles relax, and death follows; the patient may pass into a typhoid condition, in which death finally follows, frequently from a complicating pneumonia; or there may be recovery. Death occurs in acute cases in from three to ten days; in prolonged cases, in from one to two weeks or more. In cases which recover the symptoms subside gradually; convalescence is tedious and is marked by relapses. The disease may last from one to three months or longer. Deaf- ness, blindness, local paralysis, or impaired mind sometimes fol- lows. Chronic meningitis is due to tuberculosis. The onset is in- sidious, and few diseases are more difficult of diagnosis in the first stages. For many days there may be indefinite symptoms which suddenly give evidence of certain disease. The first distinctive symptom is frequently a convulsion. The disease continues from one to four weeks and is always fatal. Meningitis is due to bac- teria, though it sometimes seems to follow a blow or injury. Treat- ment can be only palliative; and that which is adapted to convul- sions should be followed until the doctor can be summoned. Infantile Spinal Paralysis.-The germ is anaerobic; that is, it grows without contact with oxygen. It is so infinitesimally minute that even microscopes of very high power do not detect it. That is of less importance than the fact that the germ has been isolated from other germs, and Noguchi has succeeded in growing it, so that in large colonies it can be seen and studied. Flexner has ex- perimented extensively with pure cultures of the germ upon monkeys and has reproduced in them the disease which is ap- parently identical with that which attacks human beings. He has 228 HOW TO KEEP WELL also obtained pure cultures of the germ from the nasal discharge of children who had the disease and with these has also reproduced it in monkeys. So much is settled. The next thing will be to find a serum or vaccine which will immunize those who may be exposed to the disease or who have come down with it. In due time this will probably be done. The germ is present in the secretion of the nose. Certain indi- viduals, especially adults, are carriers of it, immune themselves, like carriers of typhoid or diphtheria, but distributers to those who are not immune, especially children under ten. It may be trans- ferred by the hands, by handkerchiefs, or otherwise to the nasal mucous membrane of those who are sensitive. In some way or other it gets into the lymph or blood and is finally localized or de- posited in the cells of the anterior portion of the gray matter of the spinal cord. Developing there, it produces the disease of which the chief symptoms are paralysis of the muscles of the extremities. Arms and legs may be involved, both legs, one leg, or only one muscle or group of muscles. There may be no symp- toms until paralysis appears, or there may be the chill, fever, con- vulsions, etc., which usher in other infectious diseases. It may progress very rapidly. Health authorities insist upon at least six weeks of quarantine. That is also the reason why it is best that children should not gather in crowds at picnics or motion-picture shows, for there may be carriers or those who already have the disease and haven't shown any symptoms as yet. When a child is attacked with this disease he must at once be isolated. There is no medicine which will have any effect upon its course. Nevertheless I do not believe there is any harm in giving such tonics as iron, quinine, strychnia, or arsenic. Pain may be absent, it may be mild, it may be severe; and it is right to ease the pain as far as possible with sedatives, with heat, perhaps even with gentle massage. The two main things in treatment are simple food, especially hot or cold milk, and rest. Keep the patient absolutely quiet, if possible, and give the spinal cells a chance to recuperate. Some cases are mild and give very little trouble; some are severe and result in more or less extensive paraly- sis. Some of the paralyzed muscles will regain their vitality, and some will remain permanently helpless. This is a disease of warm weather; it will not be over until cold weather comes; consequently DISEASES OF INFANCY AND CHILDHOOD 229 parents must be very watchful all summer. Bathe the children fre- quently, keep them as clean as possible, keep their bowels open, keep them away from crowds, and put them to bed early. Nature at once begins her reparative work in these cases after the acute febrile symptoms have subsided and the paralysis has ceased to extend. One muscle after another regains its power, and then improvement ceases, certain muscles, especially in one of the lower extremities, remaining helpless; the foot turned outward, and dragged after the other in walking, is a familiar sight. The muscles which have been paralyzed, being deprived of nerve- force, shrink and wither and may continue comparatively helpless through life. These chronic invalids are often benefited by what is called tonic treatment, which includes such drugs as iron, quinine, and strychnia. A fat like cod-liver oil is also helpful, and an abun- dance of plain, simple food like bread, butter, and milk. They are also benefited by an out-of-door life and should be encouraged to stay out of doors and play as many hours daily as possible when the sun is shining. They should sleep many hours remembering that sleep is often more useful than food. Both galvanic and faradic electricity will be found helpful in stimulating and exercising the flabby muscles, but they must be used with proper intelligence and not in the haphazard way in which they are so often used by amateurs. Massage is another useful means of treatment for these weak and semiparalyzed children, but this also must be given properly, mere rubbing alone not being the only requirement. The ortho- pedic treatment with braces and splints and other apparatus is al- most indispensable in putting these patients on their feet, and for- tunate is a community that has a good orthopedic surgeon, or, better still, a good orthopedic hospital. We must not forget the surgical treatment whereby a muscle that is not paralyzed may often be so transplanted as to do work formerly done by a paralyzed muscle for which it acts as substitute. Headache.-Except as a result of brain-disease, headache is not very common in young children. In older children, it may be due to the following causes; (i) Eye-strain, a common cause in school- children. (2) Indigestion, acute or chronic, particularly with con- stipation. (3) Anemia and malnutrition, common in children of frail constitution who are overcrowded in school or improperly fed. (4) Kidney-disease, accompanied by other symptoms. (5) Gout 230 HOW TO KEEP WELL and rheumatism, not common but sometimes occurring in children inheriting a tendency to those diseases. (6) Nervous headaches may occur in children of high-strung nervous temperament. Neur- algia is not common in children except as the result of decayed teeth. Treatment is of little avail unless the cause can be removed. Hydrocephalus.-"Water on the brain" is marked by gradual but enormous increase in the size of the head. In young children it is often surprising how few symptoms may accompany great en- largement. The head is full and rounded, thus differing from the square enlargement of rickets. The eyes are bulging and turned downward in a characteristic manner. The development of the child is usually retarded, and the mental development suffers. Re- covery is rare, the child seldom living beyond seven years. When recovery occurs, the head does not usually become smaller. It is due frequently to small tumors at the base of the brain or to local meningitis, which has compressed the blood vessels. It is, in rare cases, due to syphilis. Treatment is unsatisfactory. It is most apt to be successful when syphilis is the cause and when this disease is treated by modern methods. Peritonitis.-Peritonitis is not common during early childhood, but when it does occur it is very serious. In younger children it is obscure and uncertain. Tubercular peritonitis is a chronic disease, which occurs usually in children suffering from tuberculosis. It is characterized by great distension of the abdomen with fluid. Marasmus.-Marasmus means wasting or emaciation, but that is a condition which is present with many diseases and is not dis- tinctive of any one in particular. If it is more closely identified with one disease than with another, I should say it probably would be tuberculosis. Perhaps there is nothing which gives to sufferers with this disease the appearance which stamps it as peculiar in the mind of the average person more than emaciation. The term "marasmus" was also used extensively, at one time, to indicate the emaciation which comes in young children as the result of intestinal diseases like diarrhea and cholera morbus and tuberculosis of the glands of the abdomen. The marasmus of nursing infants who were underfed and undernourished by the maternal source of food is another variety of this condition, which was often referred to in the days before mothers were instructed by public health boards and district nurses in regard to the care and nurture of their offspring. DISEASES OF INFANCY AND CHILDHOOD 231 Scrofula.-Forty or fifty years ago it would have been difficult to find a person of average intelligence in this country who did not have an idea of what was meant by the term "scrofula." Nowa- days the term is so seldom used that the average person is ignorant of its meaning, showing that words, like fashions, prevail, become obsolete, and are forgotten. Fifty years ago scrofula was thought to be a real disease like mumps or chicken-pox, and the scrofulous person, old or young, had a thick, swollen neck with running sores. As now recognized, scrofula is an irregular collection of symp- toms, without any definite disease history. When we speak of scrofulous glands nowadays we usually mean tuberculosis in the lymph-glands of the neck. When we speak of scrofuloderma we mean various kinds of skin eruption of tubercular origin. Scrofu- lous blood used to be regarded as impure blood causing acne and other eruptions and was the excuse for giving sulphur and molasses, senna, stillingia, sarsaparilla, and other remedies supposed to be re- quired for an annual spring cleaning. It may be said that scrofula stands for tissues and organs which easily get out of order and get well slowly. Sores on a scrofulous child heal slowly, run indefinitely, and, when healed, are followed by others in the vicinity. Scrofulous children have weak mucous membranes, catarrh of the nose, mouth, and ears, adenoids, and enlarged tonsils. The glands of the neck and elsewhere are large and often the seat of running sores. Such people resist disease badly and are always catching diseases, that have the possibility of being caught. A scrofulous child is almost sure to have had parents or grandparents who had the same trouble, or else tuberculosis or syphilis, and if a child with this tendency lives amid bad hygienic surroundings he will, almost to a certainty, develop scrofula. Good food, plenty of sleep, out-of-door life, a daily bath, a well- ventilated home and school, these are the best means for fighting scrofula. Three drugs have been found effective in treating scrofula -iodine, cod-liver oil, and iron-and they should be given not only in a form in which they can be readily assimilated, but in one that will make them acceptable to the sensitiveness of children. Syphilis.-Syphilis may be acquired by children, but it is usually hereditary. The symptoms in the latter case are so often obscure and misleading, and the subject is so complex and difficult, that an attempt at description might lead the reader into error. The 232 HOW TO KEEP WELL treatment, moreover, is beyond the capacity of any mother or nurse. Leucorrhea.-Leucorrhea may occur in infants and is not un- common between the third and ninth years. In many cases it is gonorrheal in nature and results from infection, either direct or through towels or clothes. This is more common than was form- erly believed. The disease may, however, be a simple catarrh in debilitated children or those who are not kept clean. In such cases cod-liver oil, iron, and tonics are indicated. Local treatment consists in irrigation of the parts with a solution of boric acid (tablespoonful to a pint of water), or a solution of carbolic acid (teaspoonful to a pint), two or four times daily. The doctor should be consulted, for the disease should be cured as quickly as possible. He may find it necessary to give more radical treatment. Diseases of the Kidneys.-Diseases of the kidneys in young chil- dren are not common except as secondary to acute disease. When they do occur they present the symptoms appearing in the adult. Scarlet fever and diphtheria are the diseases most frequently com- plicated by kidney trouble. It may prove rapidly fatal; it may disappear completely. It may subside to be followed by chronic kid- ney disease in later years. When it develops the child should be under the doctor's care, and caution should be observed long after the last symptoms have disappeared. Phimosis.-A long and narrow foreskin is natural to male babies. If adherent or excessively narrow it may cause nervous symptoms, but in the past the number and importance of those symptoms have certainly been overestimated. Still, it is a very im- portant matter, and every boy baby should be examined by the doctor. If not extreme the difficulty may be overcome by stretch- ing and other mild means. If extreme, circumcision should be per- formed. The teaching that every boy should be circumcised is a gross exaggeration. It is an equal exaggeration to say that it is never required. CHAPTER IX DISEASES OF THE SKIN Why Are There So Many Kinds of Diseases of the Skin?-We must in the first place find out something about the normal skin which is to be found on every slightest particle of the body. De- stroy the least bit of it, and nature immediately goes to work to repair the damage. Sometimes the work is imperfectly done, and we get unsightly and perhaps painful scars as a result. To prevent these scars, which may even become dangerous to life, the doctor often applies to the injured surface little grafts of skin taken from other places, and even from the bodies of other persons. If they take root, as they usually do when the work is properly done, they spread out and fill up the wound just as a plant spreads out in the soil. If you take off the skin, or even the greater portion of it, the person who is skinned will die. In the tropics the skin is the only covering which the body requires, and it is all that the natives in many tropical countries have or desire. In cold climates the hair, which is a part of the skin, grows long and thick and keeps out the cold; this is the clothing of the fur-bearing animals. The skin is an excellent non-conductor of heat and cold. What- ever the outside temperature may be, the temperature of the in- side of the body of human beings, when in health and at rest, is always about 98.4° F. So the skin is not only essential to life, but it protects the machinery within the body by which the daily and hourly work of life is done and is thus a great aid to health. Furthermore it is one of the roads by which the wastes and poisons which are formed within the body are got out of it, and in this work it helps the action of the lungs, the kidneys, and the intestines. If you covered the entire skin with a thick and air-tight coat of varnish, the person so covered would die, just as 233 234 HOW TO KEEP WELL surely as if you tied a rope around his neck; for with such a covering the body could not be properly ventilated, and the other organs would not be able to dispose of all the poisons which it contains. In winter the skin has less work to do than in sum- mer, the extra work being thrown on the kidneys. In summer the conditions are exactly reversed. In order to keep well, there- fore, the skin must do its work properly, and because it does not always do this it becomes diseased. You should know something also about the structure or make- up of the skin. It has two layers: a soft inner one, from which leather is made, and which always contains more or less fat; and a hard and horny outer one, which contains the coloring-matter, black, brown, red, by which different races of men are distin- guished, and which is always wearing out and coming off. Within the skin there are nerves, veins, arteries, lymphatics, muscles, hair- follicles, sebaceous glands, sweat-glands, and nails. You should know something about the sweat-glands of the body because through them the perspiration and the waste and poisonous materials which it contains are carried out of it. They consist of very tiny tubes coiled up in the inner layer of the skin and extending upward to the surrounding surface. They are very close together, and there are as many as two million four hundred thousand of them on the entire body. They are constantly at work sending out moisture, which appears in the form of pers- piration or sweat when you are hot, when you exercise, and in certain kinds of disease. About two pints of fluid per day are taken out of the body in this way, and the quantity is greater than this in hot weather and during hard work or severe exercise. Acne.-There are half a dozen or more varieties of this erup- tion, all of them called acne, and all of them diseases of the sebaceous glands. There is one variety in which there is an oily or greasy condition of the scalp, which extends also to the fore- head and face; another in which there is dandruff and loss of hair, with crusts and scales on the nose and cheeks; another in which there are hard and horny masses on the face, this being the form which occurs in the aged. Then there is a form which comes on the face of children, in which there is usually only a small number of soft lumps containing a cheesy material, the lumps being easily removed and leaving no scar. The wens or tumors on the face and scalp of grown people belong to this class of diseases, and DISEASES OF THE SKIN 235 they can only be removed by making an opening in the skin and removing the sac or tumor which is underneath. The most com- mon form is that which is so repugnant to young people and in which the nose, face, and forehead are covered with black points or spots which are commonly known as blackheads. With this is often associated, though not always by any means, a disagree- able eruption in which there are pimples or small tumors on the face and forehead, and sometimes also on the back, shoulders, and chest. These pimples often become inflamed and sometimes get very hard and painful. They may also break and continue to dis- charge for quite a long time, and when they heal they often leave an angry scar. The face is often disfigured by them for months and years. It is not always easy or possible to say what is at the bottom of these eruptions. They sometimes come when no fault can be found with the manner of life or the habits of the individual, but in very many cases they are connected with indigestion, constipation, with dis- turbances of the monthly sickness in women, and with improper habits of one kind or another. Improper diet has a great deal to do with acne, and it is particularly desirable that those who suffer with it should avoid pastries and sweets, cheese, nuts, fried greasy food, hot and half-baked bread, and all forms of alcohol. Exercise is a matter of great importance in this disease, and it tends to equalize the distribution of the blood-current. When the circula- tion in the face is normal there will be diminished tendency to acne, for in such cases the sebaceous glands will usually do their work properly. Bathing is an essential matter, both in preventing and curing this disease, and warm baths are preferable. Upon the face and scalp it is often helpful to use very hot applications and to continue them until the skin is red and moist. The diet should be simple but very nutritious, milk, eggs, cereals, fresh vegetables, and a minimum of meat or fish being used. Those foods which tend to constipate must be avoided and a suitable laxative must be taken systematically if constipation is habitual. Albinismus.-Whiteness of the skin extending over the whole or portions of the body is known as albinismus and is not a very common condition in this portion of the world. It has nothing to do with the peculiar whiteness of leprosy, which used to be very prevalent in the East and is mentioned very frequently in the Bible. Normally the skin is everywhere provided with pigment 236 HOW TO KEEP WELL or coloring-matter, and this is one of the means by which dif- ferent races are distinguished as black, red, brown, yellow, or white. In albinos this coloring-matter is absent; and if, when their skin is observed at a single angle of light, it appears red, it is simply due to the redness of the blood in the veins near the surface. The hair is an appendage of the skin and normally con- tains coloring-matter which makes it appear black, yellow, or brown; but as there is no pigment in the hair of albinos it is perfectly white and often of a silky texture. Another peculiarity is in regard to the iris or curtain of the eye, which is ordinarily blue, brown, or black, according to the quantity and variety of the pigment. In albinos the iris is red; not from pigment, but from the color of the blood in the numerous fine blood-vessels it contains. When the iris of albinos is viewed from the side, how- ever, it is blue. Their vision is poor, and the light is avoided, which shows the importance of the iris to the sense of sight. The eyes of albinos also are constantly in motion from side to side, this motion being known as nystagmus. It is an inherited condition, though not in all cases, often af- fecting all members of a family. Sometimes it follows syphilis. In the acquired cases only certain portions of the body may be white, the track of certain nerves being followed, round or oval patches of whiteness making their appearance, certain hairs or locks of hair becoming white; but the whiteness may extend to the entire skin. Alopecia.-Alopecia may be partial or complete, and it may occur at any period of life from infancy to old age. Many indi- viduals enter life with complete alopecia, and in the cases of some it remains complete to the end of the chapter. If the matrix of the hair, the portion from which development takes place, dies or is destroyed, the baldness will be permanent. That which is dead cannot be restored by any kind of treatment. Baldness may also be due to disease or injury or want of activity in the hair- follicles. Those who have defective hair-follicles and a scanty growth of hair often have also defective nails or teeth, for those are developed from the same original portion of the body from which the hairs develop. When alopecia is premature, that is, when it occurs in early life, it may be the consequence of fevers or of some disease of the sebaceous glands which furnish the hairs with lubricating material. Alopecia in the aged is a feature in the DISEASES OF THE SKIN 237 degenerative process which sooner or later attacks all portions of the body and indicates that the machinery is wearing out. One very common cause of this condition, especially in young men, is the habit of wearing a closely fitting hat the greater part of the day. This interferes with the circulation of the scalp, causes overheating, and loosens the attachments of the hairs. Alopecia sometimes is in spots or patches, which may remain distinct or may coalesce and form one large area of baldness. When these patches are round and sharply outlined, they often are one of the indications of syphilis and are usually not susceptible of cure. When one has alopecia, it is better to consult a skilled and well-informed dermatologist. The scalp should be kept thoroughly clean by frequent washing with hot water and soap, the alcoholic solution or tincture of green soap being very useful. Frequent rubbing with a clean stiff brush also is useful for cleanliness and for stirring up the circulation in the scalp. Frequent cutting of the hair is stimulating and may encourage a healthy and vigorous growth. Some of the substances which are useful for application to the hair and scalp are bay-rum, capsicum, sulphur, cantharides, mustard, resorcin, and salicylic acid. Other agencies which also are useful in many cases are electricity, massage, and light. Blis- tering of the scalp and singeing the hair may also be helpful. It is scarcely necessary to say that when parasites are present in the hair they are not only a source of annoyance and mortification but their removal is demanded on account of the injury they may do to the hair and scalp. Baldness.-The hair is one of the elements of the skin; it is abundant in some places, in others scanty or altogether absent. Normally it is abundant on the scalp, scanty on the back, and absent on the palms of the hands and the soles of the feet. The scalp has exactly the same construction as any other portion of the skin, except that the hairs are closer together than elsewhere on the body and usually grow to a greater length. Each hair is embedded in a cavity or socket which is known as a hair-follicle, which is provided with blood-vessels and nerves and has at its base a tiny structure which furnishes the material which causes the hair to grow. This material constantly pushes the shaft of the hair upward to its outlet at the surface of the skin. On either side of the hair-follicle are attached the sebaceous glands, which supply the oily or greasy material by which the hair is 238 HOW TO KEEP WELL kept soft and moist. If there is a deficiency in this lubricating material, the hair becomes dry and brittle and is easily broken off. Baldness cannot always be prevented; for instance, it may follow erysipelas, typhoid fever, scarlet fever, or some other serious illness in which the hair has been killed by the poison or germ of the disease. Very often baldness appears to be an in- herited or family characteristic in one generation after another and resists all attempts to prevent it. But it is often due to causes which are entirely preventable. Some of these are over- heating the scalp and thus overcharging the blood-supply, wear- ing too tight a hat and thus interfering with the blood-supply, accumulation of dirt or want of cleanliness in other respects, worry, indigestion, and many other things. What should be done when the hair begins to fall out? If the cause lies in the sebaceous glands, it means neglect and want of attention. In other words, the treatment for such cases is simple, rigid cleanli- ness, washing or shampooing the scalp frequently with soap and hot water, using alcohol or bay-rum if necessary to dissolve the oily material, abstaining from pomades and ointments, and ap- plying the same rules of common sense that you would to a similar trouble on any other part of the skin. Barber's Itch.-It is probably acquired very frequently with the barber's art, the parasite being conveyed by the razor, the brush, or other implements which the barber uses. The same parasite causes this disease not only upon the hair of the beard, which is affected in shaving, but the skin upon any portion of the body, and even the nails. It begins as a small red point, which gradually enlarges in circular form, the center retaining more or less the natural color of the skin, while the red border or ring gradually becomes covered with a scaly formation. It may or may not give rise to an annoying itch, but as it progresses the inflamma- tion becomes deep-seated and troublesome, the hair-follicles be- coming involved, the hairs broken and destroyed, and the discharge more or less abundant and troublesome. The more numerous the rings, the greater the extent of the eruption, the greater the annoyance, the disfigurement, and the mortification. Those who have it very often experience not only the mortification but shame on its account. This is entirely unjustifiable, for if there is any parasitic, contagious disease that is acquired innocently it is this. DISEASES OF THE SKIN 239 Its nature is such, however, that those who have it ought not to patronize a public barber shop. The disease is quite amenable to treatment if the treatment is careful, thorough, and intelligent. Strict cleanliness is the first imperative essential, the skin being cleansed daily with carbolic soap and hot water. Loose and diseased hairs must be removed and each ring in the eruption, together with the adjoining skin, painted daily with a parasiticide lotion or anointed with a parasiticide ointment. Iodine, sulphur, tar, and carbolic acid are frequently used in treating the disease, and if good results are not obtained with one, another and another must be tried until the efficient one is found. The disease may last several weeks or even months, and eventually the hairs which were lost may again grow out. Boils and Carbuncles Boils.-A boil or furuncle is a painful, inflammatory swelling of the skin which develops around a hair-follicle. There may be a single one, or several may develop in the same area or in different areas at about the same time, or they may come in successive crops. The swelling is not necessarily limited to one-hair follicle; and as many follicles as may be included in the inflammation, so many openings will there be when the boil is ripe and dis- charges. They often come at the close of winter or in the early spring when one is run down, after being confined all winter in the house, and are the sign for the spring-cleaning medicines which so many people seem to think they require. They are due directly to the attack upon the skin of germs which cause inflam- mation with suppuration. Such germs are on the skin more or less of the time, particularly if one is not scrupulous in scrubbing and cleaning the skin; but though they may be harmless most of the time they produce inflammation with all its accompaniments when they meet an individual who has poor resisting power and whose skin is especially deficient in that respect. Aside from this generally deficient resisting power; they are attributable to improper diet, especially to the use of greasy food, half-baked bread, rich pies, pastries, and gravies. They may be associated also with nervous irritation, overwork, con- stipation, or local irritation or friction of the skin. A tight or ill-fitting collar, impairing the circulation of the neck or constantly rubbing the skin, may be responsible for a boil or a series of them. 240 HOW TO KEEP WELL If the cause is a general lack of tone, one must overcome it by simple food, especially milk, eggs, and cereals, abundance of sleep, as much out-of-door exercise as possible, and perhaps the use of a good mineral tonic of iron, mercury, arsenic, or sulphur or a vegetable tonic of quinine, strychnia, or some other vegetable bitter. Many methods are available for the treatment of this ailment, the most fashionable one at the present time being the injection of suitable vaccines. One may also apply mineral acids or other caustics to destroy the infected skin. I have had satis- factory results from the application of pure carbolic acid, being careful to prevent it from destroying the skin surrounding that which is inflamed. Carbuncles.-A carbuncle is first cousin to a boil, and while it is sometimes difficult to say which is which, there are points of distinction which may be worth noting. A carbuncle is an in- flammation which is more deeply seated than a boil; it covers more surface; it does not always present a swelling so much elevated above the surface of the body as a boil; and it may be accompanied by a diffuse, intense redness, which sometimes is very suggestive of erysipelas. When it discharges, it discharges from many openings and is accompanied by extensive death and sloughing of the skin. Its constitutional effects are very profound and prostrating. It begins with a chill followed by fever; there are intense tenderness and throbbing pain at the seat of the dis- ease; and the adjacent lymphatic vessels and glands become red, swollen, and tender. It is not infrequently one of the accompani- ments of diabetes, which is true also of boils. The depression and constitutional disturbance are so profound that it not infre- quently results fatally. It is due to infection with a specific germ, the bacillus anthracis. It occurs in both the young and the old, and may be located upon the back, the abdomen, the scalp, or the lip. In the last-mentioned location it is a serious and often fatal disease in the young. When it occurs in the aged it is fatal in almost any location. It is also a very bad complication in those who are suffering with diabetes, Bright's disease, or tuberculosis. In treating this disease the great thing is to sustain the strength. It is better to remain in bed, even if one prefers to sit up. It is a disease which preeminently demands an abundance of nourishing food, particularly rich milk, port wine, and good tonics like quinine, organic iron, and strychnia. It is well to apply to the DISEASES OF THE SKIN 241 diseased surface pure carbolic acid and to inject it into the swelling. Or it may be frequently dressed with a one-to-five-hundred solu- tion of bichloride of mercury. It is often desirable to make several incisions into the swelling to relieve tension and also to facilitate drainage. Vaccines are being used more and more in treating this disease, and with favorable results, it is reported. Chapped Hands and Lips.-Like chilblains, it may be called a cold-weather disease. Occasionally it occurs in warm weather, particularly in children and old people, but as a rule those who have suffered with it during the winter get relief when warm weather comes. It is because the face, lips, and hands are ex- posed to the cold that they suffer more than the parts that are covered. Those who go about insufficiently clothed will suffer chapping of the exposed parts. In the present fashion of exposing the neck, chest, and legs many women imagine that they are har- dening themselves to the weather. Not a few of them will find that they cannot harden and toughen themselves in that way. They will develop not only a hard, horny, and unattractive skin, but they will also become easy victims to influenza, bronchitis, tonsilitis, and pneumonia. Chapping means not only hardness and dryness of the skin but exfoliation of small portions, especially on the lips, and cracks and fissures upon the lips and the ends of the fingers. Eczema is a disease of many varieties; chapping might even be classified as one of them. The loosening of the skin upon the lips constantly tempts one to pick it off. This is especially the case with children. The result frequently is the formation of painful sores. The thing to be remembered is that if the skin is protected from the cold, and nerves and blood allowed to per- form their functions properly, there will be comparatively little trouble from chapping. Consequently the skin of those who are susceptible to this ailment should be constantly covered with a bland, non-conducting substance, which will protect them more or less effectively from the air. Cold cream is extensively used for this purpose. When it is made of fresh cocoanut-oil, without the addition of irritating substances, it frequently gives great relief. Lanolin, the fat obtained from sheep's wool, when carefully pre- pared is also very useful as an application. Ointments made from lard should be avoided. They are very apt to become rancid and are then very irritating to the skin. Water must be used sparingly 242 HOW TO KEEP WELL upon chapped skin, especially when there are cracks and fissures, and it should not be used cold but warm and even hot. Cyanosis.-Occasionally one sees people whose lips are blue instead of red, or with a blue color upon the entire surface of the body, or upon a patch of skin somewhere on the body and commonly known as a birth-mark. All these are examples of what is known as cyanosis. The ailment may be a very serious matter. The blood as it comes to the lungs, loaded with impurities and especially with carbonic dioxide, is blue or purple; but when it leaves the lungs and goes back to the heart on its return journey and mission of health over the body it is red because of the oxygen it has absorbed. When one is influenced by sudden fear or almost any strong emotion the blood-vessels, especially those near the surface, are squeezed or constricted, the blood being forced out of them; and the skin becomes pale, sometimes even ghastly white. When one is influenced by emotion of another kind, shame or bashfulness, for example, the blood-vessels near the surface are partially paralyzed; they relax and dilate, the blood rushing in in an unusual volume, and the entire surface becoming bright red. Cyanosis of another kind in new-born babies, the so-called "blue babies," is due to an anatomical deficiency. In the development of the heart, prior to birth, there is an open duct or canal leading from its right to its left lower chamber. This canal or duct normally becomes permanently closed at the time of birth, but in some cases it does not close, and in such cases when the heart contracts in order to send its charge of blood out into the arteries of the body a portion of the charge is forced into the open duct between the two chambers and back into the lungs. The con- sequence is the lungs are constantly over-filled or congested, there is constant tendency to cough and hemorrhage, there is great difficulty in breathing, and the skin is persistently of a purple color. Cyanosis occurs when a person has a convulsion, and it is very startling to see the skin become suddenly purple, then almost black, and to realize that, unless the spasm can be loosened and air permitted to enter the lungs, death will be but a matter of a very few minutes or even seconds. Cyanosis is also a prominent feature in those who are drowning or drowned, in those who are hanged, in those who are suffering with pneu- monia, and, in fact, with almost any kind of disorder in which air cannot get into the lungs. There is but one remedy for it, and DISEASES OF THE SKIN 243 that is to remove the obstruction which prevents the free ingress of air, and to do it as promptly and as effectively as possible. Dandruff.-In the dry form of dandruff, which is practically limited to the face and scalp, there is a constant shower of dry white or yellow fine scales, particularly from the scalp. It is increased whenever the hair is brushed or rubbed. The scalp is sometimes dry and pale and sometimes red, the hair being usually dry and brittle, with a tendency to break or split. Dandruff of the face is seldom as abundant as that of the scalp; it is apt to be more plentiful from the eyebrows than from the hair or the beard. The crusted variety is less common than the dry and is in the form of thick crusts or lumps; it is not an unusual condition in babies who are artificially fed, producing what is commonly known as eczema of the scalp, or milk crust. It is not limited to the face and scalp but may be found upon other hairy surfaces of the body. In dandruff of the oily form there is a greasy condition which may involve almost any portions of the skin which are provided with sebaceous glands; it is an excessively annoying condition, the skin being not only very oily, but giving out an offensive odor. The hair and the scalp are not only greasy, but the hair may become matted and difficult to manage, and soon becomes oily again after thoroughly washing and drying. It is asserted that this condition is due to the influence of bacteria; probably it is in some cases. At any rate, its treatment with vaccines is now quite prevalent, and it is said to have been help- ful in some cases, though this is by no means the general verdict. The object of treatment is, of course, to dry up the secretion and limit the activity of the sebaceous glands. One of the most im- portant measures of treatment consists in keeping the bowels freely open, for it will be found almost universally that those who have this ailment, particularly among the young, are constipated. The skin must be kept as clean as possible by daily hot baths, with plenty of sulphur soap or the tincture of green soap. Alcohol or strong bay-rum should be applied freely with a sponge and thoroughly rubbed in. The diet must be very simple, as free as possible from fats and oils; and out-of-door exercises, particu- larly in pleasant weather, must be encouraged or even insisted upon. Dermatitis.-Dermatitis in its simplest significance is inflam- mation of the skin. Perhaps the simplest and most easily under- 244 HOW TO KEEP WELL stood form of dermatitis is sunburn. Almost everybody knows that when he has been exposed to the direct rays of the sun a sufficient length of time, especially in the spring, he experiences on the exposed skin an uncomfortable heat, redness, pain, and swelling. If he has been exposed to poison ivy or oak he also has these uncomfortable manifestations, together with an itching eruption which may spread over a large portion of the body. This is true dermatitis, the skin having been infected or attacked by harmful influences from without. Or suppose one has eaten shell- fish which is none too fresh, or tomatoes or strawberries which are not thoroughly ripe, again he has those general symptoms of skin inflammation plus an eruption over his body, plus the most intolerable itching. This is a dermatitis which is called urticaria or hives and means that the skin is endeavoring to assist the in- testines in disposing of poisonous matter which was in the sub- stances taken into the mouth. It is a dermatitis which comes from internal influences. Dermatitis in another form may be in- duced by scratching the skin with nails which are not clean, and which contain germs of disease with which the skin is inoculated or vaccinated; or some kind of poisonous drug or metal is taken internally; or the skin is exposed to it externally, as in certain occupations. Some of these forms of dermatitis require particular forms of treatment. That which will heal and cure one may make another worse, and treatment may be required for a long time and call for a high degree of skill and intelligence, although they may all be primarily inflammations of the skin; that is, dermatitis. In those cases which are comparatively simple, like sunburn, rest, cold applications, and removal from the exciting cause are all that is necessary; nature will do the rest. When the exciting cause is something which is in the stomach or bowels, this must be eliminated with a suitable cathartic, the irritation of the skin being relieved by a sponging of the body with a cold solution of bicarbonate of soda or lime-water, or some other soothing bath. Castor-oil is one of the best cathartics in such a case. Eczema.-Eczema is the most common and one of the most troublesome of all the diseases which attack the skin. It is one of those conditions in which the skin is crying out because of bad treatment, and animals suffer from it as well as human beings. It is what is known as a constitutional disease, though it is often DISEASES OF THE SKIN 245 influenced by local causes, as when two opposed surfaces of the skin chafe each other in walking, or the skin is irritated in work- ing in metals or in working in great heat or intense cold. It is common at every period of life, from infancy to old age, alike in males and females. It is not due to infectious causes or malaria; it is rarely inherited or influenced by diet, and may be due more or less to external irritants; but there is no cause which is an unvarying one in all people who suffer from it. As a consti- tutional disease it implies more or less weakness or debility. It usually means that there is something wrong in the behavior of the nerves, or of the nutritive condition of the body, or of the way the body takes up or assimilates the food which is given to it; and some dermatologists think that in the majority of cases the last-mentioned fault is present. It is also what is called an inflammatory disease. The majority of eczemas are of the chronic variety. The symptom which is most common is burning or itching, and this is sometimes severe enough almost to drive one crazy. It may be worse at night, when the heat of the body is retained by the bed-clothing. Scratching cannot be prevented, and the more one scratches the worse the eruption will become. Another symptom which is less common is a watery, rather sticky discharge. In some of the cases the skin becomes thick and hard, and in places where it is bent or folded it will crack, these cracks healing very slowly and being very sore and painful. An eczem- atous skin may be merely a reddened surface from beginning to end, and dry or moist, scaly or crusty, or by and by it may develop a crop of papules or pimples. If this continues or it is not well treated the papules may develop into vesicles or blisters containing fluid, and these may run together or coalesce, forming large blisters and perhaps covering a large area. The fluid may become infected and changed to pus, and finally we may have a larger or smaller sore or ulcer, which may discharge for an in- definite period. Eczemas of the hands, arms, palms, legs, feet, and soles are very common, often very rebellious, and may take either of the forms which have been mentioned. Treatment of this disease is often very difficult, even for those who are expert. The first requisite in treatment is to find the cause and, if possible, remove it, whether it be an unsuitable occupation, unhealthy surroundings, improper diet, or unsettled nervous system. Moisture and air should be removed from the 246 HOW TO KEEP WELL diseased surface, as far as possible, in the majority of cases; that is, an eczematous skin must not be washed and scrubbed, and it must be protected by suitable ointments or dusting-powders or bandages. The bowels must be kept freely open with castor-oil or cascara or salts. When the eruption has healed over, hot or cold or carbolic acid baths may be useful. Foods which irritate the skin and tend to cause eruptions, like acid fruits, shell-fish, tomatoes, etc., must be omitted, and also alcohol and tobacco. If the skin is moist, dusting-powder of talc, dry wheat flour, bis- muth, or zinc may be used, and they will often allay the intense itching. Soothing ointments are often useful in many cases, es- pecially those which contain tar, zinc, or lead. This is a disease in which tonic medicines are very often required, especially iron, quinine, strychnia, arsenic, and cod-liver oil. Exercise must be carefully regulated, and sleep must be abundant. Erysipelas.-The germ chiefly responsible for this disease is of the variety which is known as streptococcus. It is the lymphatic vessels chiefly which are attacked and inflamed in erysipelas, and along which the disease extends with great rapidity and often with great virulence. In addition to the mucous membrane of the air-passages, which is the location where the disease most frequently originates, it may begin on the skin of any portion of the body. In the air-passages it extends in the majority of cases to the nose; it may involve the face, the skin becoming swollen, intensely red, and painful. If it attacks the eyes it will usually cause blindness. It sometimes attacks the tongue and the ton- sils or the larynx, or extends into the ears or to the membranes of the brain, causing meningitis. Sometimes it extends to the lungs, and pneumonia is the result. Occasionally the skin of the joints is the part attacked, the inflammation penetrating the tis- sues to the lining membrane of the joint, causing great swelling and pain, and even destroying the joint structure. Old people are very susceptible to this disease, especially upon the skin of the legs, and it may persist in this location for many weeks. New-born babies, if in filthy and unhygienic surround- ings, may be attacked soon after birth at the unhealed navel, and the disease may extend inward to the peritoneal cavity and prove fatal in a very short time. It may develop in an operation wound in any portion of the body; but this, because of the precautions of modern surgery, is rare and almost inexcusable. A mere DISEASES OF THE SKIN 247 scratch is sufficient to start the inflammation, and the practice of picking the nose or scratching the legs is the explanation in many cases. Vaccination wounds of infants and children occa- sionally form the starting-point of this disease, but that is now unusual because of the care with which vaccine material is pre- pared. Erysipelas, except in very mild cases, begins with a chill; then follow intense fever, thirst, coated tongue, nausea and vomit- ing, and more or less prostration. Pneumonia may develop, the lining membrane of the heart become inflamed, the heart condition become serious, and the patient wild with delirium. The skin becomes red, tense, hot, and painful. If the disease extends in- ward the tissues become hard and thickened, and there may be extensive suppuration and even gangrene and destruction of the skin and underlying tissues. If recovery results the skin may re- main thick and hard a long time, and there may be a long suc- cession of painful boils. The kidneys not infrequently are involved, the urine showing albumin and casts, and evidences of disturbances more or less profound may continue many weeks. The disease lasts from a few hours to three or four weeks. The principal objects of treatment are to prevent the spreading of the disease and to keep up the strength by simple food, especially milk, by keeping the skin clean and moist by suitable baths, by keeping the bowels open, and by getting plenty of sleep. The local treatment calls for antiseptics, and of these mercury, carbolic acid, ichthyol, absolute alcohol, and red rays of light are most approved. Erythema.-The blushings and flushings which come with bashfulness or emotion of various kinds, or the digestion of a heavy meal, or which come spontaneously with women who are undergoing the changes peculiar to approaching age, are all good illustrations of erythema. Heat external to the individual is a great producer of erythema. We see it in sunburn after exposure to the sun's rays. It is one of the constant accompaniments of certain occupations; cooks and stokers always suffer from it. It is seen in those who imbibe alcohol to excess, either upon the nose, the entire face, or the entire body, and it comes alike to those who drink beer, wine, or whisky, provided they drink enough. Cold also will produce it, for it paralyzes the myriads of small vessels at the surface of the skin and allows the blood to rush in in unusual volume. There are not a few herbs and drugs which 248 HOW TO KEEP WELL will cause erythema, some when used in moderation and some when used immoderately. In poisoning from belladonna, the skin is flushed; also in poisoning from ivy or cantharides, or after the use of sulphur or mustard upon the skin. Redness follows the use of coal-tar preparations and arsenic. Everybody knows the effect of a tight band upon any portion of the body: it is not only pain and discomfort but redness of the surface. A tight collar will produce this effect very promptly. Erythema is often the mark of inflammation of the skin, as in eczema, psoriasis, and hives. It is very common in new-born babes as the result of carelessness and want of cleanliness. An ordinary term is "chafing." When bad nutrition is added to this ailment there may be a crop of ugly and distressing sores as a consequence. Those who stand or sit at their work for hours at a time have erythema where the pressure is applied, and it dis- appears when the pressure is removed. Redness follows the bite of insects and the pricking of thorns and nettles, and there is a bright circle of redness around a vaccination sore and sores of other kinds. In certain diseases redness is one of the characteristic and distinguishing symptoms. We look for it in diphtheria, measles, scarlet fever, cholera, and Bright's disease. For the ordinary erythema it is necessary to keep the bowels freely open, eat only the simplest food and not too much of that, and keep the skin covered with an ointment of boric acid or zinc, or dusted with the bland soft powder of stearate of zinc. Excessive Growth of Hair.-It may be a family peculiarity. Father or mother may have been endowed by nature with abun- dance of hair, and the children may have reaped the benefit of it. Or it may follow a fit of sickness, or childbirth, or worry, or ner- vous strain. It is not uncommon in insane women, and it may be the result of stimulation of the skin by blisters or strong liniments. An attack of neuralgia is sometimes followed by a growth of hair along the course of a painful nerve. Some of the patent cosmetics and face applications which contain animal or vegetable fat ad- vertise as one of the inducements to make people use them that they do not cause the hair to grow. In many women it is impossible to say what the cause may be; the hair is there, and they are un- pleasantly reminded of it whenever they look in the mirror. The worst of it is, the older they grow the more conspicuous this blemish becomes; it is an unending source of trouble to a woman DISEASES OF THE SKIN 249 who is particular about her appearance, as all women ought to be, and she is very apt to devote much time, thought, and money, if she has it; in trying to get rid of the blemish. The removal of hairs from the face is a very ancient custom; it is called depilation, and the means of doing it are called depilatories. Pitch or resin plasters are sometimes applied to hairs and pulled off after they are firmly attached. This is a painful and unneces- sarily cruel method; besides, it may not be successful. Pumice- stone rubbed against the hairs for a long period is sometimes recommended and may destroy more or fewer of them, but it may also set up an inflammation of the skin and should be used cau- tiously. Continued use of peroxide of hydrogen is also recom- mended by good authorities, but one must be sure that the prepara- tion is free from impurities which would irritate the skin. Then there are depilatories of vegetable and mineral substances, some of which will destroy the hair but will also destroy the skin and leave disfiguring scars. It is not best to use these except under direc- tion of an expert dermatologist. The X-ray has also been used, but one must remember that X-ray burns are sometimes very serious matters. Experienced dermatologists are very cautious about recommending this powerful agent. Finally there is the method of electrolysis, or destroying the hair with the galvanic current, and then pulling out the stump with a forceps. When this is done skilfully it is very successful and gives very little pain, the chief objections being that it is a very slow process, as only one hair can be destroyed at a time. Hair Peculiarities.-The influence of bacteria and parasites causing loss or disease of the hair is now well recognized. Ex- cessive growth is one of the hair peculiarities, and there is scarcely a circus or freak show which does not have specimens in which the face and body are thickly covered with hair like that on dogs and others animals. With this excessive growth usually go defects in the teeth, the developmental force being expended on the hair; for both hair and teeth are elements of the same development layer in the fetus. The hair may be absent from the entire body, or only from spots and patches on account of absence or rudimentary condition of the hair-follicles. When these follicles are rudimen- tary the hairs are wanting in certain parts of the body, and wher- ever present they are thin and imperfect. Loss of hair accom- panies many diseases, especially those in which the skin is 250 HOW TO KEEP WELL particularly concerned, like smallpox, scarlet fever, measles, and typhoid fever. Another peculiarity is that on certain parts of the body, the eyebrows, for example, the hair may be plentiful in old age while on the scalp and other parts it may fall out. Young people frequently lose their hair in consequence of a scaly disease of the sebaceous glands known as seborrhea. This may affect the scalp or the hairy portions of the entire body, the falling hairs being short and pointed or split and fissured; and if replaced at all the new hairs may be fine and silky like those on a new-born baby. Color changes in the hair are of great importance; the hair absorbs pigment readily, so that those who work in copper may acquire a green color of their hair, and those who work in indigo get hair that is blue. Disease of the nerves is particularly a cause for loss of pigment in the hair, changing it to gray or white; such a change is sometimes due to air-bubbles in the hair. In these cases the papilla or root of the hair loses its power to reproduce pigment or coloring matter, and the hair remains permanently white. There is the best of evidence that a change from dark hair to white may take place within a few hours from worry, overwork, or nervous or mental disease. It is possible for hair to become gray and eventually resume its color, but this is not a very common occurrence. Stains may be used to change the color of the hair, like peroxide of hydrogen or walnut-juice. The change from gray to black is best produced by a suitable solution of nitrate of silver, and it is said to do no harm. A greasy or scaly scalp may be washed with good sulphur soap. Freckles.-These small brown lentil-shaped accumulations of pigment are perfectly harmless, but they are very annoying to everybody who has them. There may be only a few of them scat- tered over the face, or the face and hands, or they may be thickly distributed over any portion of the body. They may be perfectly flat, or they may be slightly elevated above the surface. Most frequently they are on the face, the back of the hands, and the arms, for these are the parts that are uncovered and exposed to the light. In color they are a yellowish brown, and they are simply masses of pigment cells on the external layer of the skin. In most people they are present only in summer. In some cases, however, they are present summer and winter. They appear in light people rather than in dark, but I have seen them in those who are dark. DISEASES OF THE SKIN 251 Those whose hair is red are often visited also with freckles. They come early in life in children of either sex and may disappear with maturity. They may be produced either by the chemical rays of the sun or by the arc-light or X-rays. As they are limited to the external layer of the skin they may be scraped off if only a few of them are present. Or the skin may be painted with a weak dilution of acetic acid or of corrosive subli- mate. A mixture of glycerin, alcohol, and Cologne water is occa- sionally used with good effect, but it is not deemed advisable to recommend any of these measures very heartily, particularly for the reason that those who suffer most from freckles and are most dis- turbed by them are boys and girls who should be guided by their family physician in undertaking the use of any such substances as have been suggested. Hives.-This troublesome skin-disease, also known as urticaria and nettle-rash, consists mainly in an eruption of hard, slightly raised blotches or wheals, round or oval in shape, white, pink, or bright red in color, with a white spot in the center, and there may be four or five hundred of them scattered over the entire body. They occur singly or in groups, sometimes coalescing, and rang- ing in size from a small pea or bean to a silver dollar. There may also be an eruption in the mouth or the throat, with swelling of the tongue, and the patient may be in danger of choking to death. Occasionally there will be nausea, vomiting of blood, and asthmatic symptoms, but I do not think such severe conditions are very com- mon. Sometimes the wheals contain serum or blood and, instead of being red or white, may be yellow and last a long time, or they may come and go at short intervals. This eruption must be dis- tinguished from that produced by the bites of fleas, bedbugs, and mosquitos, which it may resemble. It may be preceded by head- ache, coated tongue, distress in the stomach, and slight rise in temperature; or, if the exciting cause is severe, it may even be pre- ceded by high fever, congestion of the brain, and delirium. It is a very trying condition, producing the most intense itching, burn- ing, and pricking, and is greatly aggravated by scratching. It lasts a few hours or days, but may return at intervals, and it may be- come chronic and last for months. It may occur at any period of life but is very common in childhood among those who are weak and poorly nourished. It is an expression of the sympathy which exists between the skin and the digestive apparatus, so that if the 252 HOW TO KEEP WELL stomach or intestines is the seat of any considerable disturbance an eruption of hives is always one of the possible consequences. There are many exciting causes; that which is probably the most common is indigestible or decomposing food. The list of such foods is a long one, and includes crabs, lobsters, shrimps, oysters, clams-in fact, fish of any kind, especially if it is not fresh; cheese, milk, sausage, honey, pork, veal, strawberries, raspberries, cu- cumbers, and mushrooms. Any variety of intestinal parasite may cause it, particularly in nervous and sensitive children. Another very common cause is the poisonous influence sometimes exerted by drugs, including quinine, copaiba, the salicylates, iodide of potash, morphine, turpentine, chloral, arsenic, etc. It may also be caused by the injection of the preventive antitoxins; for instance, the antitoxin of diphtheria. It may also be an accompaniment of Bright's disease, malaria, rheumatism, whooping-cough, asthma, some of the fevers, and some of the nervous diseases. The treat- ment consists in removing the cause when this is removable. This is easily done when it is due to putrefying and indigestible food, the stomach being emptied as quickly as possible by an emetic-mus- tard-water for instance-or the intestines by a laxative like castor- oil, Epsom salts, or some kind of intestinal antiseptic. A hot bath containing an alkali, like bicarbonate of soda, must also be taken, the entire body being carefully and repeatedly sponged over. Ichthyosis.-This peculiar disease, which receives its name from the scale-like formation of the outer or epithelial layer of the skin, is due to an inherited predisposition of the skin, in any given case, to form cells in excess. They may seem almost like a coat of mail and are shed in great quantities upon the slightest friction -for instance, when one is in bed at night-like the scales of dan- druff which are shed from the scalp in eczema. The skin is wrinkled, harsh, and dry, but in the less well-developed cases it is only its furrows and folds that are thickened and scaly. The scales are of a dark green color, owing to an excess of pigment they contain, and are more than a little suggestive of the scales of a fish or a snake. When the disease is well developed the slightest motion causes a rattling and clattering, which attract attention and mortify the patient. In addition to the furrows and folds of the skin this disease may be distributed upon the joints and the ex- terior surface of the body, and it may even involve the entire body, though the palms, the soles, and the face are not often attacked. It DISEASES OF THE SKIN 253 may be inherited by either males or females and is said to be aggravated by hard physical labor. As might be expected, motion on the part of those who have this disease is restricted and painful, and troublesome fissures form at the folds of the skin, which do not heal readily. About the only thing that can be done is to re- move the scales where they are in great excess by warm baths, or by causing free perspiration, or by the use of soft soap or the tincture of green soap. It is also desirable to keep the skin as flexible as possible by carefully rubbing it with bland ointments, like cosmoline or lanoline or cold cream. The internal use of medicines, thus far, has not been found of any value. Impetigo.-This is essentially a skin-disease of children but not infrequently occurs in adults. It is seen with great frequency in schools and institutions devoted to children. Among infants it is not uncommon, especially during the intense heat of summer, when they apparently are suffering with prickly heat and boils. In adults it is sometimes traceable to barbers' shops, especially those in which cleanliness is not rigidly observed. The eruption occurs chiefly on the face, neck, and hands and is in the form of vesicles or blisters, varying in size from a pinhead to a pea. There may be a moderate degree of fever if the blisters are in great number and appear suddenly. The fluid they contain is at first clear and watery, but within one or two days it becomes purulent. Then a scab forms, which soon dries and falls off, leaving a red stain upon the skin. This disappears in a short time, leaving the skin un- blemished. This disease is very contagious, being transferred directly from one child to another by contact, or it may be transferred upon wearing-apparel and articles in household use. It also may be trans- ferred from one part of the body to another, and children are especially prone to carry it from the face to the fingers, where it causes the common inflammation around the nails which is vulgarly known as a run-around. It is a germ-disease but probably has no distinct specific germ as its cause. Often it comes in children who have purulent discharge from the nose, eyes, and ears, and in those who have vermin in the scalp. It is much more common in the children of the poor and neglected than in those of the well-to-do. Indeed, it may almost be considered a mark of poor nutrition, bad sanitation, and very defective hygienic conditions. This disease may get well of itself in the course of ten days or two weeks, or it 254 HOW TO KEEP WELL may run on for weeks and weeks. Cleanliness and care will soon produce complete cure. Leprosy.-There is a definite bacillus by which this is caused; that is, it is an infectious disease and it is very contagious or "catching," though with proper precautions it may be avoided like other contagious diseases. It is a very chronic disease, may last an indefinite period, seldom kills directly, and, until the recent method of treatment with chaulmoogra oil, was said to be incura- ble. There are two distinct varieties of the disease. One attacks the skin, and the other certain nerves and tissues around them. There are also mixed varieties, intermediate between these two. There is a long period of development after one has been infected with the bacilli, say, through some break in the skin, lasting per- haps a year or two, and with such symptoms as loss of appetite, dyspepsia, fatigue after slight exertion, drowsiness, dizziness, sweating, profuse nosebleed, and an intermitting fever. Then comes an eruption of red, itching spots, particularly on the face and extremities, soon followed by small lumps or nodes rising above the skin, spreading and coalescing during the succeeding months and years. These lumps eventually soften, becoming dark, ulcerating sores, which discharge freely, are quite insensitive, and after a long time may become scarred over. The face, forehead, eyebrows, knees, elbow-joints, hands, and fingers are most often at- tacked, but any part of the body may suffer. The mucous mem- brane of the mouth, nose, and eyes is also attacked, the nose be- coming ulcerated and sunken, the larynx destroyed, and blindness produced. The face and hands become enlarged, disfigured, and unpleasant to look upon, and the glands in the face, neck, and groin are greatly enlarged. If the person is well cared for and removed to a healthful locality the symptoms may appear to be arrested. In the form in which the nerves are attacked there is a long preliminary period in which there is great sensitiveness of the entire skin, pain in the arms and ankles, which is increased by pressure, and inflamma- tion in the tissue around the nerves, which eventually undergo atrophy and loss of function. Boils and blisters appear on the skin, the skin loses its color, and there is paralysis of certain muscles, especially of the hands and feet, so that they resemble the claws of birds. At length the hands and feet may die and drop off from the body. Pain and tingling over the entire surface DISEASES OF THE SKIN 255 gives way after some months to absolute loss of sensation, and there is fever with each new development of the disease, as in the first-mentioned variety. Lichen Planus.-It consists of small yellowish groups of erup- tive points, flat and somewhat elevated above the surface; in some cases their color is not different from that of the skin which sur- rounds them. After a short time they grow larger, deep red or violet in color, and there may be a minute depression on the top of each point or papule. Still later the eruption may become some- what scaly and the papules coalesce and form red or violet patches. These papules, as the separate points of eruption are called, pene- trate to an appreciable distance below the surface of the skin, and if a small portion of the skin is pinched between the thumb and forefinger the papule between the fingers may be rolled about, giving the sensation of a shot or some similar hard round sub- stance. The eruption of lichen planus may come on any portion of the body. Very commonly it occurs on the knees and itches in- tolerably. It may last months or even years and may extend until the entire surface of the body is covered. After one crop of papules has spent its course, it disappears and leaves depressions in the skin, which are gradually obliterated. Around these depressions new papules may form, like a ring, and when the entire body be- comes covered by such an eruption, the skin gets thickened, mo- tion may become difficult, cracks in the skin occur at the joints, and the nails become thick, brittle, uneven, and brown in color. This disease may occur at any time between the ages of twenty and fifty, and occasionally it occurs in young children. It is some- times mistaken for eczema, though eczema is redder in color, and its changes into a vesicular, pustular, or scaly form occur more rapidly than the changes in lichen planus. It is also sometimes mistaken for psoriasis, though the abundant scaliness of that disease and its predilection for joints should usually prevent such a mistake. Lichen planus is one of the numerous skin-diseases in which the use of a suitable form of arsenic is frequently followed by good results. Lupus Erythematosus.-It chooses those whose circulation is poor and attacks those parts in which the circulation is poorer than elsewhere. More often it is on the face than elsewhere, beginning on the bridge of the nose and extending symmetrically to either side of the face. Less frequently it attacks the lobule of the ear, 256 HOW TO KEEP WELL the forehead, the back of the hands, or the feet. It begins as a red spot and as it spreads becomes scaly, but with a well-defined margin. It chooses for its location the skin surrounding a sebace- ous gland, and as it spreads other glands are involved. It does not extend far below the surface and is not especially painful but is very disfiguring and annoying. As the spreading continues the various parts coalesce into one unsightly area. After spreading to a certain extent it becomes stationary, the surface becomes dry, and a persistent scar forms. If the sebaceous glands are connected with hair-follicles, as on the scalp and parts of the face, both the glands and the follicles are destroyed, and the portion attacked becomes permanently bald. It is sometimes mistaken for eczema or hives and does not extend over large areas of the body, as is usually the case with hives. The active process may disappear after the scar has formed and reappear an indefinte number of times in other places, keeping up this troublesome procedure for years. It may be of tubercular origin, but it is not always possible to trace it to such a cause. Sometimes it seems to be excited by extremes of heat or cold, especially the latter, and when on the feet may be sug- gestive of chilblains. The ordinary zinc oxide ointment is a good application for it, or the surface may be painted with collodion or with tincture of iodine. Salicylic acid ointment and carbonic acid snow also are used in some cases with advantage. The Diseases of the Nails.-The nails are an appendage of the skin and form a matrix or root at the base of the nail bed or plate. As to color, the nails normally are a delicate pink-that is, over the nail bed-but they may be yellow, brown, or grayish white, according to the condition of the underlying tissue. They fre- quently have longitudinal lines or ridges, and sometimes they con- tain white spots or patches. The nails on either the fingers or the toes may be defective or absent as the result of faulty development or injury. Some of the nails in a given individual when diseased show deformity or defect more than others, and when the matrix is destroyed or degenerated the nail may disappear or becomes merely rudimentary and the nail bed be practically converted into ordinary skin. The growth of the nails is suspended in fevers and other acute diseases and also in chronic wasting diseases like tuber- culosis; while in some of the nervous diseases, rheumatism, and diseases of the bones, in the aged and in those who are careless and neglectful in their habits, they may become very thick. Cold DISEASES OF THE SKIN 257 affects the vitality of the nails, and certain occupations are deleteri- ous to them, this being especially the case with workers in acid. They are also affected unfavorably, like other tissues of the body, by the parasite of scabies, or itch, by sand-fleas, and by certain other kinds of flies. Fungi on one portion of the body may be transferred to the nails and make them brittle and furrowed. Diseased nails upon the fingers frequently impair the sense of touch, preventing good handiwork, and everybody knows the dis- astrous effect upon walking of disease of the nails of the toes. The nails may be renewed after their loss from certain skin-diseases like psoriasis and eczema, but if the matrix becomes degenerated or destroyed the loss is irreparable. One of the most common and troublesome diseases of the nails is the inflammation known as paronychia. It may involve the nails of the fingers or the toes, but is most common upon the large toe in the form commonly known as ingrowing nail, spreading laterally into the skin, causing great pain, and frequently lasting for months. It may result in loss of the toe, or even of the foot, and it is possible for the result to be fatal. The most common cause of this painful trouble is ill- fitting shoes, shoes that are too short, shoes that have pointed toes and high heels. The body in such cases is improperly balanced, too much weight is thrown upon the forward part of the foot, and this, with the constant squeezing and pressing, makes conditions that are most favorable for inflammation. An intelligent and well- equipped chiropodist-and many chiropodists are well equipped- should be able to treat many of the cases of nail-diseases involving the toes, but when there is infection and constitutional involvement my preference would always be for a skilful surgeon. Offensive Odors from the Skin.-This condition proceeds from a disturbed state of affairs in the sweat-glands and in the sebaceous glands, which are distributed over the area of the skin, particularly wherever there is any trace of hair. Some have supposed that it implied want of cleanliness in all of its victims. I do not think that is so necessarily, but I am equally positive that there are many people, black and white, who, if their bathing facilities were greater and were more comprehensively and generously used, would not be annoyed or annoy others as they do from this cause. That this offensive odor is more annoying in warm than in cold weather is familiar enough to everybody. Why is this? Probably because perspiration is more abundant in warm than in cold weather, and 258 HOW TO KEEP WELL decomposition takes place more rapidly in summer than in winter. The cause, then, is probably to be found in decomposed secretions; and, in addition to the normal product of the sweat and sebaceous glands, there may be a substance which is prepared with them in the chemical laboratory of these glands which intensifies the dis- agreeable odor. This odor proceeds not alone from the skin but from the clothing, especially stockings and shoes, which have ab- sorbed the secretion, and in which the decomposing process has occurred. There are some people who would not give out this bad odor if they bathed oftener, say, once or twice a day, using soap freely and warm water. There are others who would be less an- noyed and annoying if they changed their clothes oftener, especially those which are in contact with the skin, but I am prepared to be- lieve that there are yet others who smell badly in spite of all the care in bathing and wearing clean clothing which they can exer- cise. These must have some sort of chemical antidote to the offensive substance which emanates from their bodies, and there are many which are available. Plentiful use of tar soap or sulphur soap is recommended. Dusting-powders should be used freely on the portions of the body which give most offence, particularly the armpits and the feet. These may consist of talc, chalk, stear- ate of zinc, subnitrate of bismuth, or salicylate of soda. A solu- tion of permanganate of potash painted upon the body with a swab of absorbent cotton is one of the best deodorants. It stains the skin a mahogany color, but the stain is not permanent, and it may be applied night and morning if necessary. A solution of bichloride of mercury, I to 2000, often has been used by soldiers when on duty, and it has been particularly valuable in deodorizing and pro- tecting the skin of the feet. Formaldehyde is also an excellent deodorant, a thirty-five per cent solution of this substance being combined with an equal portion of distilled water. This may be applied with a brush or sponge or swab of absorbent cotton, the skin being thoroughly dried before the clothing is put on. Pellagra.-This disease is always present in certain parts of Italy, Spain, France, Poland, and Algeria, especially among those who are poor and undernourished and those whose food consists largely of sour bread made from sour or diseased grain. It seems to be inherited in some cases, especially in badly kept and unsani- tary homes. It is more often in females than in males, rarely occurs before the fifteenth year, and increases in frequency to the fifty- DISEASES OF THE SKIN 259 first year. The older the person the more is it likely that he will succumb to it. Negroes are more susceptible to it than whites. There are three groups of symptoms in this disease relating to (i) the skin, (2) the digestive apparatus, (3) the nervous system; and the following are the special characteristics: (1) The skin be- comes very red, especially those parts that are exposed to heat and light. Finally the skin peels off in layers, like an onion, and there are painful cracks on the back of the hands and feet. (2) There is indigestion; the lips, tongue, and inside of the cheeks get sore and the gums red and soft. The mouth is constantly filled with saliva, the stomach feels hot, and there is obstinate diarrhea. (3) There are dizziness, heat along the spine, trembling and partial paralysis stupidity and disturbance of sight and hearing. These symptoms appear in the spring, though sometimes in the summer. Then they disappear during the winter, but only to reappear the following spring. Eventually they become persistent and result fatally in many cases. Medication does not seem to be of much value. Good hygiene in the home, good food, especially milk, baths, and general improvement of the nutrition, are the essentials of treat- ment. Pemphigus.-This disease is characterized particularly by large blebs or blisters, some of which may become as large as a small egg, appearing on various parts of the body. The acute form, which occurs almost exclusively in adults, is due to a microbe of animal origin received into the blood through an injury of the skin. The injury may be a mere scratch and is often acquired by those who handle hides and skins, especially butchers, tanners, and workers in furs. The injury may be forgotten, for the disease may be several months developing, when suddenly the victim has severe chills and evidence of profound poisoning, the eruption breaks out, and in a few days it may result fatally. In the chronic form the blisters come in successive crops, each crop lasting from three to ten days, accompanied with fever. It may persist for months. The fluid in the blisters is first a clear serum; then it becomes purulent and may be followed by hemorrhages and even by gan- grene of the skin. In this form the mucous membrane of the mouth, stomach, nose, and even the eyes may become involved, as well as the skin on the top of the foot; and the nails and hair may be lost. The kidneys also may be involved, and the general health impaired. In some cases there are remissions, but there is ultimate recovery, 260 HOW TO KEEP WELL In another form the blisters are present in the armpits, the mouth, etc., and are followed by fungous ulcerating growths with severe symptoms, possibly in connection with the brain, the spinal cord, and the sympathetic nerves. These cases are sometimes contagious and may result fatally. The chronic form of pemphigus not in- frequently occurs in pregnant women, in young children, and in new-born infants on the palms of the hands and the soles of the feet particularly when it is associated with syphilis. It also is some- times one of the accompaniments of alcoholism, and may be due to that as a cause. The itching and pain associated with this disease may produce troublesome insomnia, and the general nutri- tion is sure to suffer. The attempt must be made to improve the nutrition, arsenic and other tonics being given; the skin must be covered with soothing antiseptic powders, and the contents of the blisters must be carefully withdrawn as soon as possible to mini- mize the extent of their absorption. Pityriasis Rosea.-This disease of the skin, as described by Weyl, may announce itself with moderate fever, after which small red patches covered with silvery gray scales, moderately elevated above the skin, sometimes causing annoying itching and sometimes not, appear upon the throat and chest. These patches spread con- centrically in a few days, the central part of each patch becoming yellowish and fading to the normal color of the skin as the border is reached. The eruption may spread over the entire body, in- cluding the scalp, though the face is usually spared. It occurs in childhood or early adult life and may be caused by external irritants of various kinds. Very minute spores have been found in the eruption by various authors investigating the disease, but whether they are the definite cause of the disease does not seem to be clearly decided. There is not very much to be said in the way of treatment. The bowels must be kept freely open, and daily warm baths may be taken, with the addition of bland, unirritating soaps. The eruption should be kept covered with a fine astringent dusting-powder like the stearate of zinc. Such a dusting-powder is also useful in allaying the itching of the disease. Poison Ivy.-Poison ivy or poison oak or poison sumac, as it is variously called, may be either a vine or a shrub. As a vine it runs along the ground or over rocks and fences just as the common ivy or Virginia creeper does, or it may climb and cover the trunks and branches of trees, attaching itself firmly by rootlets at short DISEASES OF THE SKIN 261 intervals. As a bush or shrub it is three or four feet high. The stems are tough, and spotted brownish gray in color. The leaves are shaped like a spear-head, arranged on the stem in groups of three, and are smooth, shining, and light gray in color. There are clusters of greenish-white flowers in early summer and small bluish-white berries in early autumn. The leaves in the autumn turn yellow, orange, and violet and are often gathered for their beauty and pressed, usually with bad results to those who handle them. The fresh leaves and stems yield a milky, resinous, yellow juice which is quite volatile and acrid and was formerly used to a moderate degree as a medicine. This and the volatile odor from the flowers form the poisonous element. The plant grows almost everywhere in Canada and the United States, and children, especi- ally those who have a light complexion, are very sensitive to its influence. Some persons are poisoned while riding or walking where it is growing, especially when it is in bloom, while others are not affected by any amount of exposure to it. The poison is easily transferred from one person to another, and its effects be- come noticeable within a few hours, or at most a day or two. The eruption upon the skin is not the only bad result, for there is frequently intense irritation of the stomach and decided prostra- tion. The eruption begins with little red points, raised from the skin and itching fiercely. Scratching inflames them, blisters are formed, and the eruption spreads rapidly. The poison is usually carried by the fingers to the face, and in some cases to every portion of the body. Sometimes the face becomes greatly swollen and the eyelids closed. Finally crusts and scabs are formed, and in about two weeks the disease is over, but it may be repeated at every fresh exposure. Those who are very sensitive cannot help being poisoned if they go where the ivy is, and when wandering through the woods and fields or riding over the country roads it is not always possible to keep away from it. It usually begins on the hands, wrists, or face. As soon as the itching and redness announce themselves, the hands and face should be frequently bathed with a weak solution of carbolic acid, or a solution of boric acid, a tablespoonful to the pint or with alcohol, but not with wood-alcohol. The skin must be kept covered with vaseline or zinc ointment, and this may check the spreading of the eruption, though usually it will not. As the erup- tion spreads the affected parts must be kept covered with pieces of gauze moistened with alcohol or lime-water or with a weak solu- 262 HOW TO KEEP WELL tion of the acetate of lead. If this plan is followed up vigorously it will at least do much to relieve the pain and itching, and it may shorten the course of the disease. At the same time the bowels must be kept freely open with suitable doses of Epsom salts or castor-oil. It need hardly be said that the quieter one keeps the better, and the easier will it be to bear the disease. In many cases it will be better for the patient to remain in a darkened room, especially if the eyes have been attacked. Prurigo.-It consists of small, red, slightly elevated points or papules as large as the head of a pin, or larger, on the back of the legs; or on arms, body, or forehead. This eruption is accompanied with intolerable itching, and the constant scratching causes thick- ening, drying, and hardening of the skin, with scratch-marks and scabs. The intensity of the itching is suggestive of that which is present with hives, but hives almost always is traceable to some error in diet. When the inflammation is considerable, the lypmhatic glands in the vicinity of the eruption may be enlarged and inflamed also. The disease is very rebellious to treatment. It is not very often seen in this country, except as it is imported. Poor immi- grants from central Europe bring it to us, especially in cases in which they have suffered from poor food and bad hygiene. It has been suggested that it may bear a relation to tuberculosis. This does not seem unreasonable, in view of the class of people whom it selects. It also resembles one of the forms of eczema. The pur- pose of treatment should be to improve the general condition by good food and sanitary habits, to relieve the itching, and to remove the eruption if possible. Sulphur ointment, alkaline baths, and suitable cathartics are means of treatment recommended by dermatologists. Pruritus.-This annoying and very prevalent condition of itch- ing, known technically as pruritus, may exist by itself, with no rash or eruption upon the skin, or it may be a form of eczema or a symptom of a great number of diseases. It involves not only a limited area but may involve the skin surface of the entire body. It is of course, a disturbance or irritation of the nerve-endings, which are everywhere present in the skin, and when only a limited area causes trouble it must mean that the exciting cause is not sufficiently violent to cause more extensive disturbance. It is particularly common in the aged, in women rather than in men, and is worse at night when the body is warmly covered in bed, and DISEASES OF THE SKIN 263 in cold weather rather than in warm. Few people, whether old or young, can resist the temptation to scratch and rub the skin in the presence of intolerable itching, but such scratching may do great injury, especially when poisonous germs are transferred from the finger-nails to the skin, as is very often the case. The inflammation and disease which are produced in this way may be very much worse than the original condition. The cold weather variety of this disease often begins in the autumn, lasts until the following summer, and may be repeated year after year. Itching is the principal symptom in multitudes of cases of eczema, and it is also prominent in malarial poisoning, ivy poison, hives, psoriasis, infection from lice, scabies, and ring- worm, and in the eruptive diseases like measles and scarlet fever. It is always important to distinguish between itching which con- stitutes the disease pruritus and itching which is merely the symp- tom of some other disease. The cure in such cases will consist in abstaining from that which produces the misery, and in general from foods which cause the overheating, including fats, spices, and alcohol in every form. In addition to abstaining from the known causes which provoke this condition, treatment which has served me well consists in free purgation with castor-oil, Epsom salts, or compound cathartic pills, and sponging the entire body, frequently if need be, with a hot solution of bicarbonate of soda. Ointments containing tar or zinc or menthol may also he used. Psoriasis.-Why such a name was ever given to this disease I do not know. Psoriasis comes from a Greek word which means the itch, and while troublesome itching is one of its symptoms it has no other relation to the contagious skin-disease of that name, which is due to the presence and activity of a very busy little in- sect or parasite. It is not contagious, and what causes it is not clearly known. It is not due to any particular kind of food, nor to friction or irritation, which are the causes of so many of the diseases of the skin. A person may have it and be in perfect health, to all appearances, but of course there must be some fault in the digestion, or in the blood, or in the glands of the skin, or it would not occur. Children may have it, and so may adults, but it seldom comes to those who have passed middle life. It usually lasts many years. It may apparently be cured and come back again and again. It comes on the elbows, the front of the lower limbs, the scalp, 264 HOW TO KEEP WELL and the sides of the body, and sometimes on the back of the hands and feet, and the face, not all at once and, perhaps in more than one place. These are the parts that are the most frequently attacked, but it may come in other places. In appearance it consists of round red patches of skin covered with shiny scales or crusts. These crusts peel off or scrape off very easily, but there will be bleeding if you remove more than the outside layer, and the bleeding may be rather profuse. Mothers who remove this crust from the scalps of their children for the sake of cleanliness are often surprised at the pain and bleeding which follow. The annoyance from the disease is mainly from the itching, but the thicker the crusts the less troublesome will be the itching. Like other itching diseases, it is apt to be worse at night after one has gone to bed. The shedding of the scales is also troublesome, and so is the constant soiling of the clothing from the scales or from the medicines which are used to relieve the disease. The itching is often greatly relieved by an alkaline bath, if possible, or otherwise by a sponge-bath. Either boric acid or bicarbonate of soda may be used in the bath. Sea-baths are unusually refreshing to sufferers from this disease, and a carbonic acid bath is a positive luxury. In all skin-diseases and certainly in psoriasis diet is a matter of greatest moment. If you want the skin to be free and clear from eruptions you must eat simple, easily digested food. Of equal importance is it to keep the bowels freely open, by proper food if possible, but otherwise by the systematic use of such laxatives as are found to suit each individual case by the convincing test of experience. Purpura.-The eruption, when occurring independently, may develop within a few hours, or it may be several days. The spots are reddish or purple, sometimes in blotches or patches, and some- times as small as fleabites. They are more abundant on the lower limbs than elsewhere and may present no symptoms except slight soreness or itching. In some cases there is no annoyance at all except the disfigurement. The condition may last a week or two, or there may be several crops of eruption during months or years. The severe form of the disease in which the hemorrhage is exten- sive is serious but is comparatively rare and need not be con- sidered here. Purpura is said to be due to a poison which acts upon the blood and the walls of the blood-vessels. This may be a germ from the various infectious diseases, or a drug like iodine or arsenic, or an antitoxin acting as a poison within the body. In the simple DISEASES OF THE SKIN 265 form of the disease recovery is the rule; but the reverse is the case in the severe forms, for the hemorrhages are not merely into the skin but into the mucous membrane and organs of the body; and one dies from loss of blood just as truly as if the blood were poured out from the body. Rest, simple diet, and the use of a good astringent like iron or ergot are useful. It is desirable to administer something which will change the condition of the blood, causing it to clot or coagulate more readily; and a solution of chlor- ide of lime is much used for this purpose. Ringworm.-This common parasitic disease of the skin is known by various other names, but perhaps the name "ring- worm" expresses it as well as anything else. It begins as a small red spot, scaly in the center like a patch of eczema, more or less round, and enlarges rapidly. It contains small vesicles or blisters, and these usually form a more or less well-defined ring. In other cases there is only scaliness without the blisters, and in yet others there are vesicles or blisters as large as a nickel, especially on the faces of children. Within a few days, instead of one circle or ring there may be many, either from many sources of infection or by the spreading of the original patch; and when there is union of the rings, figures of various kinds are formed. A common location is the scalp, but in this location the ring formation is not always clearly indicated. On the scalp or any other hairy surface the disease makes the hair dry and brittle; it loses its glossiness; and dark hair may become light with the loss of its pigment. Unfortu- nately when the hair breaks off the diseased root remains, and occasionally the inflammation becomes a suppurating one, with pus and crusts for its products. Ringworm is accompanied by itch- ing but not by fever except in some of the severest cases. When it is on the face it is often called barber's itch and may take a severe inflammatory form, causing much pain and even the formation of numerous abscesses. The disease is due to a fungus known as tri- cophyton, and it is frequently most obstinate in its persistence, especially when it attacks the scalp or the face. When there is ringworm of the body, soap and water frequently and freely used may be all that is necessary. Diseased hairs on the face or scalp must be pulled out and the surface frequently scrubbed or sponged with a very strong antiseptic solution. A solution of mercury may be more effective than anything else, but it is always best when possible to get the opinion of a competent dermatologist in a case 266 HOW TO KEEP WELL of ringworm. Ringworm is always very contagious, and those who have it should be very particular about contact with others. Scabies.-It is extremely contagious-by contact with one who has it, from clothing, and from bed-coverings. Hence it is desirable to be on one's guard for it whenever and wherever it may appear. Like most contagious diseases it is accompanied with inflammation of the skin and very annoying itching, which is worse at night when one is in bed. There are cases in which itching is not present, but they are not numerous. The eruption in a majority of cases is between the fingers and on the anterior or palmar surface of the wrists and elbows. It is not strictly limited to these locations and is often present in the armpits, groin, legs, feet, and other portions of the body. The eruption in its typical form consists of small blisters or vesicles, and an irritating substance is thrown out from the body of the parasite which intensifies the desire to scratch the skin. This tends to increase the eruption, which may become pustular and present the appearance of urticaria (hives) or eczema, with a quantity of crusts or scabs. Thickening of the nails and loss of hair may result when the matrix of the nails or the hair- follicles are involved. Both male and female itch-mites or acari are to be found in this disease, the females being the larger and more numerous. The male acari live under the scales of the outer layer of the skin. The female burrows deeply into this outer layer, her course being indicated by a distinct scratch-mark. In this burrow she lives and lays from six to thirty eggs, the duration of her life being two to three months. A few days after laying her eggs she dies; then the eggs mature; the larvae come to the surface and be- come sexually active; the females are impregnated, burrow, lay their eggs, and die like their predecessors-thus carrying out the round of life. Sulphur is a deadly poison to this parasite and may be used as an ointment, a soap, or in a vapor-bath. A single thor- ough sulphur-bath is usually curative, but if not it may be repeated as often as necessary. Other substances which are used to destroy the parasite are tincture of benzoin, beta-naphthol, tobacco, soap, and menthol. Scleroderma.-This rather uncommon disease has as its dis- tinguishing feature a hardness of the skin and its underlying tis- sues, which may appear in spots, may extend over a considerable portion of the surface of the body, or may be limited to the terminal portion of one or more fingers. When it appears in spots or patches, DISEASES OF THE SKIN 267 they are few in number, slightly raised from the surface, oval or round, light brown in the center and light blue at the border. They may come on the neck, chest, abdomen, arms, or thighs. They may be irritable and itching but seldom are painful. Where the fingers are attacked the skin becomes atrophied and dead; there is an abscess around the nail, leading to its destruction; the fingers have a hooked appearance and the skin becomes hard, con- tracted, immovable, and bluish. If the disease spreads it may in- volve only the face and upper portions of the body, or it may ex- tend over its entire surface. In such cases it progresses rapidly and is accompanied by chills, itching, pain, and stiffness in the muscles and joints, the skin becoming cold, white, hard, and life- less. The fingers and toes become hooked and stiff, and the skin seems fastened to the bones. It is a disease of the nerves which are supplied to the blood-vessels in the portions of the body which may be affected, occurring especially in thdse whose nervous sys- tem is sensitive and in sufferers from rheumatism. It may follow exposure of various kinds, strains and shocks, injuries, etc., as well as rheumatism. A certain percentage of its victims recover under judicious treatment, particularly among the young. The disease calls for an abundance of nourishing food, especially milk and cod- liver oil, and also systematic bathing, massage, good hygienic sur- roundings, and plenty of sleep. Sebaceous Cyst or Wen.-What is meant by a sebaceous cyst? A cyst is a sac or bag which may hold fluid or semifluid or even moderately solid contents. Scattered over the skin, especially wherever there is hair, there are sebaceous glands. At the base of each hair there is one and sometimes two. These glands furnish sebaceous matter, which is greasy or oily and is intended to lubri- cate or soften the hair. Without it the hair would be dry and brittle and would break off and die. The absence of sebaceous mat- ter, or sebaceous glands, which are living and active, is one of the causes of baldness. On the other hand, if there is too much se- baceous matter, we have the disease known as seborrhea, which also may be a cause of baldness. In some cases the duct or mouth of one or more sebaceous glands becomes stopped up. The secre- tion continues to form, but it cannot get out, and so by and by we have an accumulation which projects above the new surface of the skin, forming a new growth or tumor. This tumor may be as small as a grain of rice, or it may be as large, in extreme cases, 268 HOW TO KEEP WELL as an orange; and when it thus appears upon the surface of the body we have a sebaceous cyst or wen. These cysts or wens are not uncommon on the faces of aged people, and sometimes undergo malignant degeneration and become cancers, pursuing a slow but destructive and ultimately fatal course. There is only one way that I know of to treat these tumors successfully, and that is to make an incision over them through the skin, laying bare the cyst wall, then peeling or shelling out the cyst, cleansing the cavity, and closing the wound. It is of no use simply to open the cyst and let out the contents, for in a short time it will fill again and be as bad as before, or it will remain open and become an ugly and ulcerating sore. Neither is it of any use to put corrosive plasters upon it, for that is a slow, painful, and inef- fective procedure. The operation can easily be done under local anesthesia, without pain, and in a very short period of time. The only precautions necessary are that the skin be carefully cleansed before the incision is made and that the tumor be not broken in pulling it out. Seborrhea.-This is a disease of the sebaceous or oil glands, which are distributed over most of the skin to provide the hairs with material to keep them soft and moist. When too much of this material is provided-that is, more than is required for the purpose mentioned-the condition is one of disease and is called seborrhea. This material may be oily, greasy, and semi-fluid, or solid and scaly. It may be present in excess at any time of life. It may be present on any portion of the body except the palms of the hands and the soles of the feet, which are unprovided with se- baceous glands. The new-born infant is covered with a layer of this material. Nurses or attendants who are ignorant or meddle- some try to scrape or scrub it off and frequently scrub off the sensi- tive skin of the baby with it. If it receives only rational and com- mon-sense treatment it will dry up and come away in a few days, leaving the skin soft and beautiful. Most negroes are subject to seborrhea over all or a great portion of the body. As a characteris- tic of other races it occurs only occasionally and over limited portions of the body. It is of exceedingly common occurrence on the scalp in the form of dandruff, and on the scalp of infants it often appears in the form of thick, brownish, greasy crusts. In any form, whether solid or semifluid, it is very apt to be disastrous to the growth of hair, frequently making it greasy, filthy, matted, DISEASES OF THE SKIN 269 and tangled. It is often noticed in adults in the form of yellow or white scales, greasy or dry, like snowflakes, and continually falling on and soiling the clothing. More or less of the hair usually falls out in such cases, and the scalp becomes irritable and itchy. On the face, particularly on the nose and cheeks, it may be an accompani- ment of acne, the secretion, as on the scalp, being dry in some cases and moist in others. The underlying skin in these cases is very red and sensitive and bleeds easily. Suitable preparations of iron and arsenic are given to those who have this disease, while exter- nally one may use certain astringents like tannic acid, oxide of zinc, and tincture of green soap. Shingles.-It occurs in children and young adults and very often in the aged, with whom it is sometimes very troublesome, persist- ing for months or for years. The preliminary fever lasts three or four days, and the pain which follows it may be either dull, or sharp and severe. After the eruption appears the pain may subside, but it may return at intervals for a long time. It is usually more severe in the aged than in children, is worse at night, and interferes with sleep. The eruption is in the form of groups of vesicles or blisters as large as a pea or bean, from three or four to as many as twenty in a group, the surrounding skin being discolored, sensitive, in- tensely hot, and puffy. The blisters come in successive crops in ordinary cases for a period of five or six weeks, inflammation pro- gressing to suppuration and discharge, and healing with scarring which may be troublesome. This eruption is a disease by itself, or it may be a symptom of injury or of important nerve-disease, or it may follow exposure to drafts of cold air or mental or physical ex- haustion from overwork or fatigue. It may appear so frequently in a given locality at a given time as to constitute an epidemic, which also favors the theory of its infectious origin. The fluid within the vesicles at first is clear and watery, but as inflammation progresses it becomes discolored, bloody, and purulent, the vesicles eventually breaking and discharging. The eruption may be on any portion of the body but is most frequently on the abdomen, face, chest, and arms. When it is on the chest it follows the course of the nerve, between two adjacent ribs. If it is on one side of the face it may cause paralysis of that side. Should it attack the eye it is likely to destroy it. It is sometimes confounded with such skin-diseases as erysipelas, chicken-pox, and psoriasis. It may occur at any season of the year but is most common 270 HOW TO KEEP WELL during cold weather. Normally there is but one attack, which runs from three to six weeks; it may end more quickly, or it may be prolonged for months and years, particularly in the old and feeble. The relief of pain is the most important consideration in the treat- ment of this disease. It is important for the patient to remain in bed and to be as free as possible from fretting and worrying. The bowels must be kept open and free with castor-oil or salts, this being the most effective procedure for disposing of the infectious material. The diet should be simple but sufficient to maintain nutrition, milk, soups, eggs, fruits, and cereals being allowed, but very little meat. The eruption must be carefully dressed from day to day without breaking the vesicles, gauze moistened with alcohol or suitable sedative antiseptic lotion being applied. Sties.-The sty is painful and suppurates, but after a few days the swelling and hardness disappear. Sties are often present in connection with a weak and debilitated condition and may be associated with eczema or boils. They often come in crops of a dozen or more, one after another or perhaps several at once. Their treatment is usually simple enough, the first thing to be done being to empty the bowels freely and keep them open with castor-oil or salts or some form of antiseptic cathartic, remembering always the reciprocal relations between the skin and the intestines. A good tonic like cod-liver oil or an approved mixture of iron, quin- ine, and strychnia will also be beneficial. The tumor itself must be dressed antiseptically as a boil would be dressed; and it is not usually wise for the patient to try to do this himself, for it is a matter requiring delicacy of manipulation on account of the proxim- ity of the eye. If the eyelids are glued together they must not be separated forcibly, but a stream of hot boric acid solution should be permitted to trickle upon them from a suitable tube or from absorbent cotten moistened with the solution, and this should be done as often as morning and evening. The sty may be dressed with any suitable antiseptic ointment, carbolized zinc ointment serving the purpose very well; or an antiseptic powder like bismuth or stearate of zinc may be dusted upon it. The ointments seem to be preferable and more likely to prevent adhesion of the lids. It is particularly necessary to protect the eye by scrupulous cleanli- ness after the sty has commenced to discharge to prevent autoin- fection. There are cases in which the pain and tension are so great that an incision will be required for relief. Of course this DISEASES OF THE SKIN 271 can be done only by one who is skilful and accustomed to delicate manipulations. It may be done painlessly under local anesthesia. Sunburn.-If the sun's rays are concentrated in one spot by a glass or lens, burning takes place very quickly, as most people are aware who have seen a burning-glass used in starting a fire. The tougher and harder the skin the more resistance it offers to the sun's rays, a light skin being more susceptible to sunburn than a dark skin. A moist skin also offers more resistance to the sun's rays than a dry one. When a sensitive skin is subjected to a temperature of ioo° F. the first evidence of burning will appear, the skin becoming red and in a short time smarting and becoming pain- ful. Should the temperature reach 1500 F., burning will be severe in character, blisters will be raised upon the skin, and a greater degree of inflammation excited. It is possible for the sun's rays to be so intense in their thermic effect on very sensitive skins that they will be seriously burned, more or less of the external tissue being destroyed. These, then, are the three degrees of sunburn which are pos- sible, and they represent as many degrees of intensity of inflamma- tion. In the first variety, if the exposure of the skin is not con- tinued, the inflammation subsides in two or three days and, apart from the peeling of thin strips of its outer layer, leaves no trace upon the surface except a certain amount of redness and staining in skins that are sensitive; and this, too, soon passes away entirely. In the variety in which there are vesicles or blisters, the inflamma- tion is more intense, there is consequently more pain and soreness than in the simpler form, and the discomfort lasts longer. If the blisters are not broken, the fluid within them is gradually absorbed, the burned surface is covered with new cells in a few days, and when the dead outer skin is removed a healed surface will be found beneath it. This will also be bright red in appearance, but the redness will gradually fade away, and, except for more or less contraction of the skin where the burn has been severe, all traces of it will soon vanish. In the third variety the skin is more or less cooked and charred, and its vitality in the burned area destroyed. Nature at once strives to repair this injury also, an inflammation is excited beneath the destroyed tissue, and as the injured space is filled in by cells which are constantly pushing up from below, the burned and dead tissue is pushed out of the way and is removed 272 HOW TO KEEP WELL by the one who dresses the wound in a mass of slough, the entire gap finally closing in. The first variety of sunburn requires little or no attention. One should avoid exposure for a few days and apply cold cloths or ice to the injured surface if it is troublesome. In the second variety the blisters must not be broken, sunlight should be avoided, and cold, moist applications should be used freely, or a suitable solu- tion of sugar of lead. The third variety is more serious and requires careful daily attention. A very good dressing during the active period of inflammation is a mixture of olive-oil and lime- water, and after the slough has come away there should be daily cleansing and dressing until healing has taken place. Sycosis.-This very common disease of the hair-follicles con- sists of an inflammation and swelling of one or more follicles, with the development of a smaller or larger pimple, which suppur- ates and may terminate in one or more abscesses of very considera- ble size. It occurs on any portion of the face where there is a growth of hair, and also in the nostrils, in the eyebrows and eye- lashes, the armpits, and elsewhere. It is painful, particularly when it occurs on the lips and the entrance to the nose, and as a number of the lumps or tumors may form in succession and during a long period of time, the sufferers frequently imagine that they are vic- tims of a crop of boils. These inflammatory swellings frequently run together, especially on the face, forming a large mass, which may be covered with a dirty offensive crust; and in rare cases the eruption may extend over the entire face and scalp. The hairs in these suppurating crusts are loose in their follicles and when de- tached from the crusts can easily be removed. If the crusts are removed a fiery red granulating surface will be exposed beneath them which will bleed profusely. This condition of affairs may last a long time. Sometimes it is made worse by shaving, and sometimes shaving seems to be a benefit. Of course shaving under such conditions is not an easy undertaking. When healing occurs, as it does after a longer or shorter period, which some- times is extended to years, there is scaling of the surface varying in extent and disfigurement with the intensity and obstinacy of the inflammation. The cause of this disease does not seem to be clearly determined. We would naturally expect it to be a germ-disease, and in all probability germs have something to do with it. The irritation of DISEASES OF THE SKIN 273 the skin by a discharge from the nose, the irritation of cold and wind, and certainly, in some instances, the irritation of shaving will bring it about. If it is possible the beard should be removed, and as soon as the disease has established itself. It is much easier to treat it, and it can be treated more effectively when it is possible to make the necessary applications directly to the skin and not through an overlying mass of hair. The hairs must be re- moved as they become loose, and the skin kept as clean and as free from discharges as possible. A sulphur paste may be applied daily to the eruption, but it must be removed each day with the accumulated discharge, very carefully, after first cleaning and softening the skin with hot water. Vitiligo.-The disease is usually present in middle life, though it may occur-indeed, it is said it most frequently begins-be- tween the ages of ten and thirty. It has been noticed as one of the sequences of acute disease of various kinds, particularly typhoid fever, and it has been observed to begin in the vicinity of scars. A bad condition of the nutrition of the skin may therefore be re- garded as one of its basic features. The first noticeable evidences of it are small, round, white spots upon the skin. These spots gradually enlarge and lose their regularity of outline, becoming oval and then quite irregular as contiguous spots coalesce and run together. These patches may enlarge very slowly though con- tinuously until nearly the entire surface of the body may be in- cluded. A peculiarity of the disease is that the white patches progress symmetrically over corresponding areas on the two halves of the body, showing that there is an identity in the anatomical conditions of the skin in this disease in the two halves of the body, which gives equal opportunities for development in each half of any morbid process. Another peculiarity is that in the vicinity of each white patch there is an accumulation of brown pigment cells, as if they were being pushed forward and piled up as the white or atro- phic patches increase. This gives the appearance of small islands of brown skin in a large field of white, and it is particularly notice- able on the face, hands, and feet. Another peculiarity consists in the presence of white hairs, single or in small bunches, on one or both sides of the scalp, with or without the white patches on the skin. It has no perceptible bearing upon the health. Those who have it are as well as other people in other respects. It is some- times mistaken for albinism, but that is an entirely different 274 HOW TO KEEP WELL disease; and it may also be mistaken for leprosy. The disease is a permanent one. Nothing has as yet been tried that will cure it. Warts.-A wart is an accumulation ol the cells of the outer or horny layer of the skin, together with an increase of the growth of the little cones or papillae which are just under the horny layer. These cells are formed in heaps, making small tumors, more or less elevated above the surface and ranging in size from a pinhead to that of a pea, or bean. Sometimes they are in clumps or crops, but more frequently each wart is by itself. Sometimes the sur- face is smooth and sometimes it is cracked, and very often it is discolored from neglect and dirt. They usually appear on the hands, but true warts may also be on the face. In the aged they sometimes appear on the face or on the neck and on the back, and in very considerable numbers. They are more irregular in outline than when they occur in the young, are usually of a dark brown color, and are important because they sometimes degenerate and become cancerous. It is said that warts are most common in those who use their hands at hard labor, but this point does not seem to me well taken, for they are often very abundant on the hands of little children who have done no work at all. Why they come it is often impossible to say, and in many cases there is no evidence that there has been mechanical irritation of the skin of any kind. They may disappear spontaneously, or they may require removal. Like corns, they are much more sensitive and much more readily removed in some cases than in others. I have always found it possible to remove them by freshening the surface with a knife or sterilized file and then applying either lunar caustic or nitric acid. Of course, this will usually cause smarting and pain. It takes about ten days for the wart to be entirely destroyed, after which it can be picked off like a scab from a sore that has healed. CHAPTER X PARASITIC DISEASES Hook-Worm Disease.-This disease occurs in many countries of the world, but has been particularly prevalent in this hemis- phere in the Southern States along the Atlantic coast and in Mexico. The parasite prevalent in this country is said to differ from that which is found in other countries, and the following remarks will apply only to the American variety. The male worm is a little more than a quarter of an inch long, and the female a little less than half an inch. There are hook-like teeth with which the parasite is provided. The eggs of the female are laid in the intestinal canal of the patient or host, are passed from the body with the intestinal discharges, and are hatched in the soil under favoring conditions of heat and moisture. After a com- plicated period of development the worms become active and readily attach themselves to the skin of human beings, es- pecially in those who go barefooted. Burrowing into the skin, they get into the blood-current and are carried to all portions of the body. They finally reach the intestine and there complete another generation of existence. The symptoms they produce are severe or mild, according to the number of the parasites and the resistance offered to them, these symptoms being due to loss of blood and to the influence of the poison proceeding from the parasites. Hence, they cause ulcerations of the intestines, with resulting anemia and loss of blood. Those who have suffered this infection have indigestion, difficulty in breathing, headache, pain in the abdomen, and constipation. The growth of children thus infected is retarded, their nutrition is impaired, and their mental condition may be weak. An inflammation and an eruption of the skin caused by the entrance of the parasite are marked symptoms, being accompanied with itching, swelling, and suppura- 275 276 HOW TO KEEP WELL tion. Diarrhea, cough, and sore throat are also common symptoms. The tongue of the victim is always coated, the breath offensive; the heart is weak; there are constant pains and aches; and the patient has an abnormal craving for things which are dirty and filthy. Cleanliness, suitable food, baths, and good sanitary sur- roundings are the principal measures of treatment. The care of the skin is one of the chief things to be considered, while every possible means must be taken to destroy the parasites and their eggs. Roundworms.-Roundworms are among the very common varieties of intestinal parasites. They are usually less trouble- some and annoying than the tapeworms that annoy adults or the threadworms which are so irritating to children, but they are bad enough in any event. The two sexes of these worms are distinct. The female lays a large number of eggs throughout the intestinal canal, which develop into living worms without passing through any intermediate stage. These eggs, when swallowed with food or water, mature in the intestine in ten or twelve weeks. The worms are present alike in children and in adults, not usually, however, in very large numbers; and their favorite habitat seems to be the neighborhood of the lower end of the bowel. If they are few and poorly developed, they may not cause any noteworthy symptoms. If they are abundant and active they may cause intestinal pain and diarrhea, and in chil- dren they may excite convulsions. Other symptoms which are especially common with children are nausea and vomiting, irri- tability, indigestion, offensive breath, coated tongue, loss of ap- petite, picking of nose, disturbed sleep, grinding of the teeth, and other manifestations with which many a mother is familiar. It is thought that certain nervous diseases in children, for instance, St. Vitus's dance, are attributable to the irritation of worms, and this seems probable. When a child or an adult has a combination of these symptoms, it is always well to make careful examinations of the bowel movements until these worms are discovered or their presence can be reasonably excluded. Before attempting to drive them out, it is well to omit the food, with the exception of an occasional glass of milk, for a day or two, or even to take a mild cathartic like Epsom salts or castor-oil. The substance most ef- fective for the removal of roundworms is santonin, but it is a powerful drug and should be taken only under the direction of PARASITIC DISEASES 277 the family physician. Other substances which also are effective are senna, chenopodium, and naphthalin. A single dose is not always sufficient; it is, therefore, necessary to keep a careful watch of the evacuations. When there is little but mucus and fluid, it is undesirable to continue the medication. Tapeworms.-The tapeworm is an intestinal parasite deriving its nourishment partly from the nutrient fluids in which it is bathed and partly from the tissues to which it is attached. Tapeworms resemble a strip of tape, being composed of white, oblong seg- ments, averaging about an inch in length. They also are charac- terized by a small head followed by a thread-like neck. The head is provided on its lower surface with suckers and rows of booklets, and by these they anchor themselves to the intestinal mucous membrane. The head, or the head and its nearest segments, form the vital part of the parasite; and unless these are detached and ex- pelled he will reproduce himself and become just as troublesome and ugly as before, within three or four months. The segments are shed from time to time and pass off with the intestinal evacuations, sometimes single and sometimes in strings or bands which may be several feet long. The most common form of taenia (T. solium) is from seven to ten feet long, and when mature it has from 200 to 450 oblong segments. His head is about as large as the head of a good- sized pin, and his neck about one half an inch long. The segments which are near the head contain each both male and female organs of generation, and from these are produced en'ormous numbers of fecundated eggs. These eggs passed from the human being are next taken up by the hog. Development goes on in the hog's stomach or intestine, a minute head growing out of a minute cyst. In this larval condition the cyst passes into the blood and may be deposited in the brain, the eye, the liver, the muscles, the skin, and elsewhere. Its most common location is in the muscles, and pork which contains these cysts is known as measly pork. Another variety of taenia (T. mediocanellata) is developed within the cow, becomes encysted in her muscles, including the muscle of the heart, and, when the beef is eaten raw by human beings, becomes a tapeworm in the intestine. The taenia (T. cucumerina) which infests the intestine of dogs and cats is sel- dom present in human beings. Of the other family of tapeworms, the bothriocephali, which are common in man, there is but one 278 HOW TO KEEP WELL variety (Bothriocephalus latus) which has been observed. This is a very large worm from sixteen to thirty feet long and con- taining from three to four thousand segments. Its intermediate hosts are sometimes the dog or the cat, but more frequently fish such as pike or perch. These different forms of parasite may attack men or women at any age but are not very common among children. In some cases there are no apparent symptoms, and the victim is unaware of the presence of the parasite. But in many of the cases symp- toms are very marked, depending largely upon the endurance and the resisting power of the individual. Perhaps the most common symptom is anemia, which may be of moderate degree or very intense, showing that the red corpuscles and the hemo- globin of the blood have been involved. There also may be defective nutrition, the patient becoming thin and emaciated. Very often the nervous system is attacked, and the patient suffers with convulsions or St. Vitus's dance, dizziness, neuralgia, ringing in the ears, or nervous disease in some other form. The digestive apparatus is frequently disturbed; sometimes the appetite fails; sometimes it is voracious, constipation alternates with diarrhea; and there may be intestinal colic with nausea and vomiting. Itch- ing in various portions of the body is a common symptom. Avoid- ance of raw or imperfectly cooked food, and of water which is in the least suspicious, is the only way to protect one from these parasites. A diagnosis of their presence can always be made if their eggs are found in the evacuations of the intestine. When one is sure that he is suffering from tapeworm he should prepare for its expulsion by a few days of comparative fasting, doses of castor-oil at night, and an enema of cold water in the morning, preceded by a saline cathartic like Epsom salts or phosphate of soda. This may be all that is required; but if not, one should take, under proper directions, one or another of the well-recognized vermifuges, or taenicides, as they are called. The list of these is not a long one and includes male fern, pomegranate root, pumpkin- seeds, quassia, croton-oil, oil of turpentine, and a few others. Most of these are powerful poisons, and it is very important that they should not be taken except as directed by one who is familiar with their action. Threadworms.-It is a small, round, white worm found in the large intestine and in the lower portion of the small intestine, PARASITIC DISEASES 279 choosing by preference the lower end of the large intestine or rectum for its residence. It has also been found in the stomach and even in the mouth, probably reaching the latter with vomited contents of the stomach. It is a very lively and active parasite and frequently crawls from the rectum to the adjacent skin, some- times being found upon the child's clothing. The female lays a large number of eggs, and these must be swallowed by man or animal in order to develop within his intestine. Within two weeks after the eggs reach the intestine they are developed into full- grown worms, which are not easily destroyed, and then in the majority of cases they migrate toward the rectum. There the mature females lay their eggs, which in some cases are passed out of the body and in others remain and are developed into a new colony of worms, this process continuing indefinitely, unless the victim is fortunate enough to have them expelled and exter- minated. The eggs are taken into the body with food or water or by infected hands. There is no difficulty in detecting either the worms or the eggs, and the symptom which is ever present and prominent is intense itching, which is more troublesome at night when one is warm and in bed, being also very disturbing to sleep. Other symptoms are irritability and fretfulness, burning pain, restlessness, dis- turbance of the function of the bowels and bladder, loss of appe- tite, and anemia. In sensitive children it is not unusual for St. Vitus's dance and convulsions to be caused by the parasites. Their complete expulsion is often a very difficult task, since they breed so rapidly and find so many places for concealment in the folds of the mucous membrane of the rectum. Cleanliness is of course, insistent, and after each movement of the bowels a child who is thus infected should be carefully sponged with a i to 10,000 solu- tion of bichloride of mercury. No uncooked food should be allowed to the child; his nails should be kept short; and his fingers must frequently be moistened with an infusion of quassia. Castor- oil or senna, and Epsom salts, may be given at night, but not in excessive doses. Every morning, or every other morning for two or three weeks if necessary, an enema should be given through a rubber tube or catheter which has been carefully introduced four or five inches into the bowel. A pint of warm water or soap and water or boric acid solution may first be used to cleanse the rectum, this being followed by half a pint of 1 to 10,000 of bichlor- 280 HOW TO KEEP WELL ide of mercury. Another excellent enema is an infusion of quassia, two ounces of quassia chips being boiled in a pint of water. Other enemas frequently used are solutions of carbolic acid, turpentine, vinegar, sulphur, etc. Trichinosis.-This disease is caused by an intestinal parasite which is found in the rat, dog, cat, hog, and human being, and has two phases of development, one in the intestine, the other in the muscles and fat. When in the intestine it is a white, hair-like worm, the female one inch long, the male one half inch. In the muscle it is one third of an inch long coiled up in a capsule of lime salts. When the muscle of a hog containing trichinae is eaten by a human being or an animal the capsules are softened in the stomach and the worms liberated. They pass into the intes- tine, the two series mature in three or four days, and the female during an existence of four to eight weeks has several broods of embryo worms, which pass from the intestine into the blood- current and are eventually deposited and encapsulated in the muscles. Here they cause more or less inflammation but may be retained for years. The muscles of the diaphragm and abdomen are involved, and also those of the neck, larynx, head, eyes, and limbs. This disease is common in Europe among those who eat pork raw or only slightly cooked. If the parasites are numerous they cause chills, fever, muscular soreness, difficulty in chewing, talking, swallowing, and breathing. Present also are weariness, loss of appetite, pain in the abdomen, vomiting, and diarrhea or constipation. Also there are sweating, itching, boils and emacia- tion, and possibly bronchitis, pleurisy, pneumonia, or kidney dis- ease. The disease may be mistaken for rheumatism, chorea, or typhoid fever. The treatment includes the use of mercury, tur- pentine, hot baths, strychnia, massage, and electricity. It is easy to avoid the disease by omitting pork from the diet or eating it only when thoroughly cooked. Vermin upon the Body.-Of the parasites in human beings there are more than fifty varieties, some living on the surface of the body and others in the intestines, muscles, eyes, liver, and elsewhere. About three quarters of the human parasites are found on the skin or in the intestines. Lice live and propagate in the hairy portions of the skin. They are particularly numerous on the hair of the scalp, but also are found on the eyebrows, eye- lashes, beard, and armpit. On the scalp they usually prefer the PARASITIC DISEASES 281 hair on the back of the head. One variety of lice has its home in the seams of the clothing but migrates to the skin when hungry. The eggs (or nits) of lice attach themselves to the hairs, and it is very difficult to dislodge them. They are small white globular bodies, sometimes near the root of the hair, though they may be at any point along the shaft. In neglected cases they are in the midst of dirty, matted hair mingled with pus, scabs, and other evidences of inflammation. The sexes of lice are distinct, and there are separate varieties for particular portions of the body. They fasten themselves to the skin by booklets, and when one of them is feeding he thrusts his nose into the skin and withdraws blood like the mosquito. The female lays from fifty to sixty eggs, which are glued to the hair by a very tenacious secretion from her body; the fully formed young crawl out of theii* shells in six days, and in twenty days they are capable of reproduction. The activities of these parasites cause itching and scratching and result in inflammation and sup- puration. The purulent discharge accounts for matting of the hair and the general filthy condition in neglected cases. The in- flammation may have the appearance of eczema, and there may be swelling and soreness in the neighboring glands, particularly in the armpit, groin, or neck. The parasites and their eggs also must be destroyed to rid one of the nuisance. A soap or lotion con- taining sulphur, tobacco, or mercury thoroughly used will kill the vermin, or one may use a prolonged sulphur vapor-bath. Efficient also when thoroughly used is crude petroleum or kero- sene, alone or mixed with sweet-oil or balsame of Peru to diminish the unpleasant odor. An infusion of the flowers of larkspur or the fluid extract of its seeds also will destroy the vermin; and if it does not it is probably because the preparation is a poor one or is not rubbed in thoroughly. The work is only half done unless the eggs are destroyed, and for this purpose one may use strong preparations of soda, borax, vinegar, and alcohol. CHAPTER XI DISEASES OF JOINTS AND TENDONS Since affection of the joints and malformation of the bony system occur most frequently in childhood, it is most desirable that all children should be examined frequently by their parents, or, still better, by the family physician, in order to detect at once any deviation from the normal. This is all the more important from the fact that very often a chronic, serious disease of a joint is insidious in its onset and becomes firmly seated without causing much complaint on the part of the child. Head and Neck.-The head should be perfectly balanced, in- clining neither to one side nor the other, and perfectly movable. It should be possible to bend the head forward, so that the chin can rest upon the chest, or backward so that an object held directly perpendicular above the body can be seen. Rotation should be so free in all directions that the chin may be brought around to a line very nearly parallel with either shoulder. A fixed position of the head away from the perpendicular, or a restriction of the various movements, indicates something abnormal. Body or Trunk.-The spinal column presents normally three curves forward and backward. When looked at from behind there is a hollow or concavity at the neck; a projection or convexity in the middle portion where the ribs are attached, known as the dorsal portion; and again a concavity in the lower or lumbar portion. These curves should be smooth, rounded, and regular. There should be no deviation to either side, and a plumb-line dropped from the middle of the base of the skull should lie over all the projecting spines and fall into the fold between the buttocks. The sides of the chest should be rounded and symmetrical, the shoulder-blades on the same horizontal line, projecting an equal 282 DISEASES OF JOINTS AND TENDONS 283 distance, and the shoulders level. The chest should be quite flat in front with very little prominence of the breast bone. The lower ribs normally move considerably with each act of respiration. The normal spinal column possesses, as we have noted, a consid- erable range of motion at the neck; in the middle or dorsal area, motion is very limited, while in the lower or lumbar portion motion again becomes quite free, though not to the same degree as in the neck. This question of normal motion is very important in the consideration of disease of the spinal column. Arms, Legs, and Feet.-The arms should be of equal length and size in corresponding portions, though not infrequently the right is somewhat larger from greater use. The same general proposi- tion holds true for the lower extremities, but it is not at all un- common to find one leg from one fourth to one half an inch shorter than the other in an otherwise perfectly formed individual; and the difference may never be noticed until some occasion arises to cause measurements to be taken; If the legs are straight, the knees, the thickest part of the calves, and the bony pro- jections at the inside of the ankles can be made to touch each other. The inner border of the foot should be a straight line extend- ing out to the end of the great toe and should have in the middle a well-defined hollow, where the individual stands, the points of contact with the floor being the ball and heel. The smaller toes should be straight, fully extended, separated by an appreciable space, and the second toe slightly longer than the great toe. The feet should be planted firmly in walking, slightly turned out, and the weight of the body borne upon the ball, outer border and the heel. Shoulder-Joint.-The shoulder-joint has the greatest range of motion of any in the body, and when it and the muscles controlling it are in normal condition the arm can be voluntarily rotated upon its own axis, carried in front of the body (flexed), behind (ex- tended), across (adducted), out from (abducted), or raised per- pendicularly above the shoulder. Elbow-Jdint.-Motion of the elbow-joint proper is confined to bending the forearm upon the arm or straightening it out. But just below the elbow-joint there is a peculiar joint which allows the larger bone of the forearm to be partially rotated upon the smaller, and enables one to turn the hand at will. 284 HOW TO KEEP WELL Wrist-Joint.-At the wrist we find only flexion and extension. This is also true of the smaller joints of the hand and fingers, except the thumb, which has quite an extensive range of motion. Hip-Joint.-Next to the shoulder, the hip-joint possesses the greatest range of motion, and flexion, extension, adduction, ab- duction, rotation, and circumduction, or a combination of all the foregoing, are normally quite free, though not to the same degree as at the shoulder. Knee- and Ankle-Jdints.-Here we find motion limited to flexion and extension except that when the foot is completely extended; then it is possible to slightly adduct and abduct. There is very little voluntary motion in the numerous small joints of the foot, and in the toes the motion is limited to flexion and extension. Ankle-Joint Disease.-In chronic tubercular disease at the ankle- joint the first symptom is usually a slight swelling or puffiness on one side or the other just below the sharp points which form the lower ends of the leg-bones. The surface of this swelling has a doughy feel, but there is no heat nor tenderness. There is also a slight limp, and the child walks upon the toes, when walking is necessary; but his inclination is to keep very quiet. Any attempt to move the foot causes pain and muscular spasm. Oc- casionally the joints in the arch of the foot are involved, and the symptoms are very much like those in the ankle-joint disease, but the swelling and pain are in the foot instead of the ankle. Motion at the ankle-joint is free, but any attempt to move the forward part of the foot is met with pain, resistance, and spasm. Ankylosis.-Ankylosis is a term which always refers to a joint or joints. It means that there is stiffness or rigidity of a joint. That rigidity may be partial or complete. Ankylosis of the joints of the hands and arms is sufficiently common; ankylosis of the jaw is less common but extremely inconvenient. A perfectly rigid joint may not be painful; one which is partially rigid is painful whenever motion is attempted, and usually the more extensive the motion the greater the pain. The pain may be taken as an indication that the structures of the joint are not wholly de- stroyed. A single joint may be the seat of ankylosis, or several, or even most of the joints of the body, in which latter case the sufferer is quite helpless. We often hear the expression "ossifica- tion of the joints," or bony union of the joints. This means that the opposing bones in the joint have grown together, sometimes DISEASES OF JOINTS AND TENDONS 285 by real bony union and sometimes simply as the result of inflam- mation. Ankylosis, therefore, is of two kinds-bony or hard, and fibrous or soft. There is absolute immobility in the one, partial mobility in the other. The structure of a joint is very interesting and curious; for instance, the knee-joint. In this joint the thigh-bone and the shin-bone come together, also the outer bone of the leg to a slight degree. The ends of these bones are covered with cartilage or gristle; strong ligaments are in front, behind, inside, and outside, covering in the bones. Other ligaments and cartilages are within this inclosure, holding the bones in true position and enabling their ends to work smoothly over each other. Lining this in- closure or cavity is a thin membrane which secretes the synovial fluid. This fluid lubricates these structures and thus prevents friction whenever they are in motion. Suppose this joint is in- jured, bruised, cut, or punctured. Suppose dirt or germs of any kind of irritating material are conveyed to the wound and perhaps to the joint. The result would be an infectious inflammation. Or an inflammation might follow tuberculosis, or a venereal disease, or a fever, or rheumatism. If the inflammation were mild and properly treated it might get entirely well after a sufficient length of time, and the joint might be as sound and as useful as ever. Or the inflammation might be long and tedious, and its product might be one or more firm, tough, fibrous membranes or adhesions at- taching themselves to the structures within the joint, impairing their motion and causing the fibrous ankylosis heretofore men- tioned. Or the inflammation might cause destruction of the tissues within the joint, the lubricating membrane, the ligaments, and the cartilages. Then the ends of the bones would be denuded; they would no longer move smoothly over each other; and, as healing progressed, they would grow together and we would have an immovable bony ankylosis. In the cases in which membranes are formed in the joint they often can be stretched by suitable exercise, or by the aid of machines, which impose a fixed degree of motion upon the joint. Electricity, baths, and a certain amount of medication may be given, so that the bad condition may be ameliorated and even a good degree of recovery obtained. Arthritis.-An epidemic of influenza is likely to be followed by a large crop of cases of arthritis. Two of the most common forms of arthritis are associated with gout and rheumatism and may 286 HOW TO KEEP WELL involve a single joint or a great number of them. The knees, ankles, fingers, and toes are more often attacked than other joints. When the arthritis is persistent, involving all or many of the joints, making them rigid and distorting and deforming the en- tire body, it is known as arthritis deformans and renders the patient as helpless as if paralyzed. Arthritis when acute is accom- panied with high fever and great pain, swelling and tender- ness in and around the joint. A very good example of this is what is commonly known as inflammatory rheumatism in the knee- joint. If this continues very long the joint becomes stiff and useless, and by and by there may be withering and atrophy of the muscles in its vicinity from lack of use and also from im- pairment of their nutrition. If an attempt is made to move the joint a grating sound will be elicited as the dried ends of the bones rub against each other. At length there may be complete de- struction of the joint, the ends of the bones and the cartilages being dead and the lining membrane dry and useless. The disin- tegration may proceed to such an extent that the limb below the joint will be helpless and useless, and it may be preferable or even imperative to amputate it. The treatment of arthritis is often very discouraging, and when it becomes chronic its victims frequently travel about from one doctor or sanatorium to another, seeking relief and finding very little, hopelessly searching for somebody who can stay the ravages of the disease and relieve them of their pain and deformity. Only general rules can be laid down for the treatment of this disease. Rest is, of course, an absolute necessity; rest in bed in the majority of cases. The ends of the bones in the joint are sometimes separated with traction by suitable weights, and this will often give a certain measure of relief. If there is fluid in the joint it can be withdrawn, thus relieving tension. Sometimes its place in the joint may be taken by a suitable fluid, which is injected in the hope of effecting healing action. The best that can be expected in bad cases is healing with a perfectly stiff and useless joint. Careful diet and suitable exercise, passive and active, par- ticularly in a sanatorium, are desirable; massage, electricity, and suitable baths are also indicated. Some cases are benefited by suitable rays of light, either plain solar light or certain separated rays from red to violet and beyond. Extreme heat or baking has often been found helpful, and a great variety of measures may DISEASES OF JOINTS AND TENDONS 287 be tried if one has the patience and the money to experiment with them. Cold Abscesses.-Such abscesses are very frequent complica- tions of chronic tubercular joint-diseases wherever situated. They generally develop slowly without pain, heat, or redness, and differ from ordinary abscesses in that they contain, not pus, but a thin fluid containing broken-down tissues, which, if it has not been exposed to the air, is usually harmless, as it contains no disease- germs. Such abscesses should not be disturbed unless they cause pain from pressure, interfere with the treatment which is being carried out, or show the usual symptoms of inflammation, pain, heat, tenderness, and fever. The reasons why they should not be opened early are: first, they frequently disappear spontaneously; secondly, simply opening them exposes them to the air and to infection; thirdly, such an operation does not remove all the tubercular tissue, and scraping the lining membrane of the abscess frequently causes the bacilli to enter the blood-current and pro- duce tubercular disease in the lungs or brain. Congenital Dislocation of the Hip.-By this term is meant a condition existing at birth, in which the deep socket in which the round head of the thigh-bone revolves is absent or only par- tially formed, so that the thigh-bone slips up upon the pelvis or haunch. This condition is rarely discovered until the child begins to walk, for the hips do not present any unusual appearance. If the dislocation involves only one limb, as soon as the child begins to walk a lump will be noticed. This is caused by the upward slipping of the head of the thigh when the weight is borne upon the limb. At first the lump is very small, but the act of walking stretches the ligaments and allows the head of the bone to slip farther up. This is followed by shortening, and the limp becomes more noticeable. There is no pain; an examination will show that the joint motions are nearly normal; and there is no muscular spasm. There is also no deformity or wasting of the limb. If the pelvis is firmly held with one hand and the limb drawn forward, the shortening can usually be overcome, while the head of the thigh-bone can be felt to move up and down. If both hips are affected it will be noted in the standing position that both hips are very prominent; the lower inward curve of the spine is exag- gerated and forms what is known as lordosis. The gait is a peculiar, waddling one and when once seen can never be mis- 288 HOW TO KEEP WELL taken. Without treatment, these cases, whether of the single or double variety, grow worse; the shortening increases, and the limp or waddling gait becomes more marked. In some cases the reduction of the dislocation can be brought about by manipula- tions, the bone being kept in place by a plaster-of-Paris dressing; in other cases it is necessary to operate, the soft parts which prevent the reduction being divided and the joint being opened to form a new socket. Contraction of the Tendons in the Palm of the Hand.-It con- sists in an increase of the dense, firm tissue in the palm of the hand, known as the fascia, and forms hard lumps or masses along the sides of the tendons which cross the palm, are attached to the bones of the fingers, and control their motions. As these lumps increase in size and hardness they cause contraction and incurving of the fingers, so that they may eventually become like bird's claws. This incurving is permanent, and the more it progresses the less power has the sufferer over the normal movements of the hand; at length the hand becomes incapacitated for all its finer movements. The disease is not attended with pain and usually occurs in those who are subject to rheumatism or gout, or whose occupation causes more or less constant pressure within the palm. It does not usually develop until about middle life, and its prog- ress is very slow but very sure. In the course of five or ten years it will have crippled the hand effectually. It usually comes on but one hand, sometimes the right and sometimes the left, and occasionally both hands are attacked. All the tendons are not attacked at once, the disease usually beginning with the tendon which goes to the ring-finger and extending to those on either side. The tendons of the index-finger and thumb usually are spared. Massage, radium, and electricity are often used to try to arrest the progress of this disease; and ointments containing salicylic acid are frequently rubbed into the hardened tissues, or a solution of this substance is injected hypodermically. Other cases are treated surgically, the hardened tissue being removed as thoroughly as possible, and the hand fastened to a suitable brace or splint until complete healing has occurred. The great trouble with all these procedures is that the benefit gained by them is not usually permanent, for the tissue is prone to return again, however care- fully and skilfully the treatment may have been conducted. Of course, if nothing is done, the result is sure to be the incapacitating DISEASES OF JOINTS AND TENDONS 289 of the hand, while if persistent efforts are made to check or re- tard the disease there may be fairly good use of the hand for a long time, and some may be so fortunate as to obtain a cure. Disease of the Shoulder, Elbow, and Wrist Joints.-The joints of the upper extremity are rarely affected with chronic disease compared with those of the lower. This is probably due to the facts that the circulation of the blood in these joints is very active, they have no weight to sustain, and they are less exposed to injury. They are usually observed in young adult males and generally follow injuries. Their earliest symptoms are swelling, pain, and tenderness, with a decided restriction of motion in all directions, which is followed by wasting of the muscles in both arm and forearm. It is sometimes quite difficult to decide whether these joints are affected with true chronic tubercular disease or are disabled from rheumatism or severe injury which has left them painful and tender. The indications for treatment are abso- lute rest and protection from motion. Gout.-It is not only the disease of the rich man and the high liver; the poor man may have it also, particularly if he has drunk heavily of beer, is weak and emaciated, and has suffered from exposure to cold weather. Abundance of alcohol will cause it, especially the rich, heavy wines, but not the strong alcohols, gin, whisky, and brandy; so also will abundance of rich food, easy and luxurious living, and neglect of exercise and of everything which makes the body strong and vigorous. It is a constitutional disease, inherited in many families, coming in acute attacks, and becoming chronic through indefinite periods. It practically con- sists in an excess of uric acid and urates in the blood and tissues, showing preference to the joints, and to the joints of the feet in particular. In many cases there are deposits of lime salts in the joints, and sometimes also in the skin of the ear and other parts of the body. The disease usually begins between the ages of thirty and forty, more often in males than in females, after a debauch of any kind or after overwork, workers in lead being particularly susceptible to it. It is more prevalent in cold than in warm countries. As might be expected, attacks are preceded by indigestion, constipa- tion, hemorrhoids, dullness, pain in the muscles, irritability, chilli- ness, and neuralgia. The appetite may be good; but the tongue is coated, the urine scanty; there are thirst, nausea, and vomiting, 290 HOW TO KEEP WELL and there is pain which is suggestive of rheumatism. The great toe-joints are the ones first attacked, and this is followed by at- tacks on other joints in the feet or hands or elsewhere, the dis- ease being thus marked as gout and not rheumatism. The pain in the joints is excruciating, lasts for hours, subsides slowly, and leaves the joints stiffened, swollen, red, tender, and often with lime-deposits in them which cripple the patients permanently. Sometimes the attacks progress slowly and gradually and without intense pain, in the spring, in the fall, or irregularly, the average duration being a week or ten days. Not only are the joints affected, but the same intense pain may be experienced in the kidneys and bladder, while the symptoms in the nervous system may be headache, dizziness, and neuralgia. Other symptoms which are noteworthy are irregular heart-action, difficulty in breathing, and the skin eruptions of acne and eczema; as might be expected, diabetes is not infrequently a complication. The treatment of gout is frequently the treatment of habits and family peculiarities; individual power of resistance has much to do with the success of treatment, and gouty subjects are readily susceptible to other diseases. Meats and alcohol must be omitted from the diet of the gouty, and they must be content with plain food, especially vegetables, bread, milk, cheese, and fruits. Almost always it is desirable to drink freely of distilled or suitable alkaline waters, to remain out of doors as much as possible, and to get as many hours of sleep daily as circumstances will permit. Strap- ping the inflamed joint with rubber plaster will often ease the pain; cathartics must be freely used; heat, light, and electricity when intelligently employed are valuable assistants; and there is one drug, colchicum, which is related to gout almost as quinine is related to malaria. Hammer-toe.-This consists in contraction of the soft tissues beneath the toe so that it is bent at the second joint and cannot be straightened. The affected toe rises above its fellows, and the rubbing of the shoe against the toe causes thickening of the skin and sometimes painful inflammation. It begins as a slight bending, but gradually the contraction increases until the joint is dislocated. It is usually noticed in young adults from sixteen to twenty and may interfere seriously with walking. The second and third toes are most often involved, and the trouble may be on one foot or both. The cause is unknown, but it is important DISEASES OF JOINTS AND TENDONS 291 to recognize the condition early, for by stretching the tissues and wearing a sole to which the offending toe or toes can be strapped and kept straight, a cure can be readily effected. In long-continued cases or those in which dislocation has occurred, an operation for thoroughly dividing the contracting tissue will be necessary. Hip-Joint Disease.-The immediate cause may be an injury which did not seem serious at the time but from which complete recovery failed to take place. One of the first noticeable symptoms is a limp or stiffness early in the morning which wears off later 'in the day. By and by the limp may disappear and return later in a severe form with eversion of the leg and foot, pain in the great toe and knee, flattening of the buttock, and spasm of the muscles of the calf, together with those which control the motion of the hip-joint. Atrophy or withering of the leg and thigh muscles soon follows from impairment of nutrition, and the patient is observed to bear his weight on the sound leg. If an abscess is forming in the joint, the slightest jarring of the body will produce intense pain. By this time the child will be so sick that an investigation will be demanded. Placed upon a bed or table, he will involuntarily incline his pelvis toward the diseased side, and when the examining doctor raises the leg on that side it will cause spasm of the muscles around the joint and arching of the spine, while the very slightest motion of the joint will be very painful. The inflamma- tion may begin in the bony portions of the joint or in the lining membrane, the tubercle bacilli causing it being in the blood cir- culating in the joint. During the acute part of the inflammation the child has rapid pulse and high fever, just as in inflammation from any other cause. The results in this disease depend upon the intelligence with which it is treated, the amount of destruction of joint tissue, and the reserve and recuperative force of the patient. A perfect result may often be obtained in cases which are not of tubercular origin; and in the tubercular cases the results are frequently good, and the shortening of the leg not excessive, if the patient is seen early in the disease by a competent orthopedic surgeon and is made to wear a well-fitting brace for a sufficiently long period. The dis- ease may be over in two years, or it may last five or six. An abscess does not form in all cases, but when it does it may dis- charge for an indefinite period in spite of good treatment. The objects of treatment are to give rest to the joint and improve the 292 HOW TO KEEP WELL patient's general condition. In doing the former it may be neces- sary to keep him in bed a long time with his leg on an inclined plane and a sufficiently heavy weight attached to the foot to keep the ends of the bones apart. Not all abscesses of the joint need be opened, and it is believed that more harm is sometimes done by opening the joint for the prolonged drainage of an abscess than by leaving it alone. Housemaid's Knee.-This unpleasant condition received its name from its very common occurrence among the maids in Eng- land. I suppose it is equally common among maids elsewhere if they are accustomed to devote much time to scrubbing and other useful labor while on their knees. Doubtless the name will become obsolete soon. The more correct name for this disease is "burs- itis," which means inflammation of a bursa. A bursa is a sac or cushion containing fluid placed between a tendon and a bone, or a tendon and the skin, that the tendon may play smoothly and without friction as it contracts and lengthens. Sometimes bursae are accidental or adventitious, being formed, in the economy of nature, to relieve pressure upon some portion of the body which may be prominent or exposed. But in other cases they constitute a customary part of an individual's structure. At the front of the knee-joint is a movable, rather flat, and irregularly formed bone known as the patella or knee-cap. It is of great importance in the motions of the leg; and if it is broken or displaced, movement of the knee-joint, especially in walking, becomes difficult, painful, and often impossible. Between the bone and the skin-covering the knee is placed the protecting bursa, and as the tendon of the great muscle at the front of the thigh moves over the knee-cap it is kept moist and in good working order by the fluid in the bursa lying over it between it and the skin. An injury to this bursa or constant irritation from the opera- tion of scrubbing or other tasks requiring the knee position pro- duces inflammation. There is then an increase in the quantity of fluid in the bursa, a swelling which may become as large as an orange, great pain when the knee is bent or when attempts are made to bend it, and inability to walk. The condition may be acute and last only a few days, or it may become chronic and last for weeks and months. It is especially likely to become chronic when it is one of the accompaniments of such diseases as rheu- matism, gout, and syphilis. It is, therefore, very important, when DISEASES OF JOINTS AND TENDONS 293 a trouble of this kind appears, to give up work and sit or lie with the limb at rest and elevated. The joint may be wrapped with cold cloths, and in simple cases the swelling may subside in a few days. If it does not subside it may be necessary to have the fluid withdrawn and for the patient to continue at rest, watch- ing the progress of the disease with great care. If suppuration takes place the condition becomes one which should be treated only by a skilful and experienced surgeon. After the disease has been cured, the knee-joint will be stiff and will require massage and graduated exercise before it resumes its customary mobility. Knee-Joint Disease: White Swelling.-Tubercular disease at the knee begins in two ways. If the large capsule about the joint is attacked at the outset, the first thing which is usually noticed is swelling, which has come on gradually without pain. There is no heat or redness, but on the contrary the joint has a white, smooth, shiny appearance. There is no tenderness, but a doughy feeling. Motion in the joint is nearly normal, and there will be only slight pain and limp following fatigue. If, on the other hand, the disease begins either in the lower end of the thigh-bone or the upper end of the leg-bone the symptoms are very different. The outline of the joint is not changed, but pain is usually present quite early, accompanied by a limp, which is most marked after rest. Motion in the joint is greatly restricted, and generally the leg is slightly bent upon the thigh and held in that position by a spasm of the muscles, so that it is impossible to straighten it. Complete bending at the joint is also impossible from the same cause. In both hip and knee-joint disease wasting of the muscles of both thigh and calf takes place quite early even though the limb is used, careful measurements showing that the affected side is somewhat smaller than the other. The results in chronic knee- joint disease of either variety are usually better than in spinal or hip-disease, if treatment is begun early; and complete restoration of motion is frequently obtained. In the treatment two indica- tions are to be met; viz., to prevent motion at the joint and to take off all weight and pressure. Lateral Curvature of the Spine.-It occurs more frequently in girls than in boys and is generally discovered about the age of twelve to fourteen, when closely fitting dresses begin to be worn. The deformity, however, starts much earlier in life and in some cases has been discovered immediately after birth. The true cause 294 HOW TO KEEP WELL is not definitely known, but it is probably an inequality of growth of the two sides of the body. A certain form of curvature may be produced by a short leg on one side or by standing and sitting in bad positions, but this is not true of lateral curvature and is easily corrected as soon as the cause is removed. The deformity is slow in its development, insidious and progressive unless checked early by proper treatment. The main curve in this deformity is gen- erally in the middle region of the spine, with its convexity to the right, and a second or compensatory curve to the left in the lower region; but occasionally the curves are reversed. In addition to the curvature and rotation of the spine, the ribs project on the side of the convexity, the shoulder is elevated, and the hip on that side ap- pears higher than the other. The front of the chest is also somewhat deformed, and if the breasts have developed the one on the convex side of the curve is smaller than the other. There is no pain or tenderness as in Pott's disease, but muscular weakness is generally present, and the patient tires easily. In the beginning the spine is flexible, and it is possible nearly to correct the de- formity by manipulation and pressure; but later the position becomes fixed and the spine rigid. In the variety of lateral curvature produced by a shortened leg or by faulty position in sitting or standing, the spine is always flexible, and there is no deformity of the ribs or difference in the size of the breasts. Restoring the length of the leg by means of a shoe with a cork sole, and exercise to strengthen the muscles, soon correct the deformity. Pott's Disease.-Tuberculosis of the spinal vertebrae was very carefully studied and described one hundred and fifty years ago by the distinguished English surgeon Percival Pott and is now commonly known as Pott's disease. It begins in the softer part of the main body of a vertebra, spreading slowly, involving the car- tilage between it and the adjacent vertebra, and may extend to other contiguous vertebrae until they become honeycombed and rotten, collapse, and produce a projecting hump-usually on the back of the spine, but occasionally at the side. Any portion of the spine from top to bottom may be attacked. A larger or smaller abscess or accumulation of pus results from this disease, which may be sterile and comparatively harmless or may be in- fectious and contain tubercle or other bacilli. If the abscess is large and presses upon the spinal cord, it may cause more or less DISEASES OF JOINTS AND TENDONS 295 extensive paralysis. If it is in the upper part of the spine, it may press upon the windpipe or the lungs, and when it comes to a head it may break and discharge through the windpipe and bronchial tubes, perhaps causing pleurisy or pneumonia and choking or nearly strangling the patient in his efforts to expec- torate the pus. If the abscess is in the lower part of the spine it may press upon the bladder or rectum or some other portion of the intestine, perforating and discharging through one of these channels; or it may burrow through the muscles at the sides of the pelvis called the psoas muscles. It is a disease which occurs principally among children and may be caused by injury or in connection with some other form of disease. It is often fatal, but not always, especially if the care and treatment are good and include the various mechanical sup- ports which have been devised by American and other orthopedists. The symptoms include pain, spasm in the muscles, fever, and inability to lie down without adequate support. If the vertebrae opposite the stomach are involved the condition may be mistaken for indigestion; if the pain is lower down it may suggest colic or appendicitis. Children with this disease are apt to walk on their toes, or support themselves with chairs, or try in other ways to guard against jarring the spine; and they may hold their head between their hands to prevent painful motion. If an abscess breaks or is opened the wound must be most carefully dressed and drained. But these technical details belong to the skilled doctor, who should always, when possible, be one who is familiar with orthopedic practice. Rheumatism.-The cause of the muscular and the joint rheum- atism is probably the same; that is, there are infectious or para- sitic germs which in all probability are responsible for it, though there are plenty of other causes which are contributory. The acute form of the disease, which is also known as rheumatic fever or inflammatory rheumatism, attacks any of the joints and their surrounding structures, but particularly the hands, the feet, the knees, the elbows, and the shoulders. It often involves also the membrane which covers the heart and the membrane which lines the inside of the heart, the latter disease being known as pericardi- tis and endocarditis, and this is particularly the case with rheum- atism in children and young people; so that this not only is a very painful disease, but it may be dangerous. The ear may be 296 HOW TO KEEP WELL very painful before the joints are attacked, and in hard-working men and women it often attacks the muscles of the arms and then one after another of the joints of the fingers and toes. It is often associated with nervous diseases and with tonsilitis, scarlet fever, Bright's disease, and diseases of the breathing apparatus. Before the joints get painful and swollen the patient may feel badly for two or three days; then follow chills and fever, rapid pulse and breathing, and the other symptoms which go with fever. There is often perspiration and the eruption of little blisters or little vesicles on the skin, and finally the joint or joints become red, swollen, hot, and painful, and the patient is not only in great pain but is really very sick. It has been thought that uric acid in the blood and tissues was a cause of rheumatism, and it is not improb- able that this substance has great influence in producing or prolong- ing it, but it is also probable that the germs which are found in the blood and the fluid from the joints of rheumatic sufferers are the principal cause. The chronic form of rheumatism or rheumatoid arthritis must begin, of course, as an acute disease, but it may not show the same picture which is seen in inflammatory rheumatism. It is apt to have less fever, less swelling, less heart-trouble, and even less pain, and may progress very slowly until the joints become stiff and helpless. It also attacks older people than the acute disease, especially those between forty and fifty, is common among women, and is often connected with grippe and diseases of the breathing and digestive organs. The joints are at first soft and eventually hard and stiff; the fingers are first attacked, then the elbow, shoulder, knee and hip; fluid accumulates in them, and the slightest motion causes intense pain. The joints are swollen, the hands and knees deformed, and the skin glossy and bluish in color; the muscles near the joints become withered and thin. Like acute rheumatism, it is probably due to the influence of germs; it is hastened by hard work and exposure to cold and dampness, and, like the acute disease, it may appear in successive generations of the same family. In any of these forms of disease it is very important to lead a simple, regular life, avoiding excesses in eating and drinking, avoiding alcohol, getting plenty of sleep, avoiding worry and strains of all kinds, and keeping the bowels open. There is one medicine that has much the same influence on rheumatism that DISEASES OF JOINTS AND TENDONS 297 quinine has on malarial fever, and that is salicylic acid. Because it is a powerful antiseptic it strengthens the view that rheuma- tism is a germ-disease. Its great disadvantage is that it is very prone to upset the stomach before it has accomplished its work. Other means of treatment are blisters and cupping of the joints, dry heat, stimulating liniments, electricity, and judicious massage. Many sufferers from rheumatism are cured by courses of baths and other treatment at hot springs, especially sulphur springs. There are several such springs in Virginia; at Sharon Springs, New York; Mount Clemens, Michigan; Hot Springs, Arkansas; and elsewhere; and just as good results can be obtained there as at the famous springs in Europe. Synovitis.-The membrane which forms the lining of all the joints in the body is called the synovial membrane, because it secretes a peculiar fluid called synovia. When this membrane becomes inflamed, from any cause whatsoever-and such an oc- currence is exceedingly common-the disease is called synovitis. This inflammation is particularly common in the knee-joint and is popularly known as water on the knee, the membrane becoming thick and swollen, while the synovia or synovial fluid, instead of being bland and watery, becomes bloody or purulent. Syno- vitis is most often due to the action of infectious germs, especially such as are brought to the joint by the blood-current; but they may also be introduced from without in connection with injuries of any kind. It is frequently a sequel of pneumonia, typhoid fever, appendicitis, and other infectious diseases, the germs of these diseases being carried to the joint by the blood or the lymph. When the inflammation is acute and severe the joint becomes swollen and hot; it is red and painful and, of course, out of com- mission. The interior of the joint is distended with the fluid which has accumulated. In the milder forms of the disease the symptoms are all less severe than in the acute form. The disease may be- come chronic and persistent, with a permanently swollen and use- less joint and with constant dull and annoying pain. This disease can frequently be traced to injuries, strains, or bruises, and to exposure to cold and wet, and is a not infrequent accompaniment of rheumatism and gout. Treatment, to be effective, should be begun in the earlier stages of the disease and followed up most carefully. Purging with Epsom or Rochelle salts or some other mineral salt must be 298 HOW TO KEEP WELL vigorously carried out, and this will often be the means of re- lieving pain and producing sleep. The inflamed joint must be kept at perfect rest, and if it is of the knee or foot, the limb should be elevated, the joint immobilized, and all pressure upon it removed. Many applications may be made for soothing the joint or acting as counter-irritants-including iodine, chloroform liniment, mustard, etc.-and the joint may be cupped, leeched or blistered, or burned with the actual cautery. Cold and heat may be used, and also the X-ray and the ultra-violet ray; and when the inflammation has subsided judicious massage may be given. CHAPTER XII DISEASES OF THE FEET The Care of the Feet.-Nobody will deny the tremendous im- portance to the general welfare of the body of sound, well-de- veloped feet. Nevertheless there is no part of the body which is more neglected than these long-suffering, useful members. No por- tion of the body is so habitually cramped, squeezed, confined, and placed out of all natural relations as the feet; and for what pur- pose? It is hard to say which is the more ridiculous, a young man with pinching shoes coming to a point at the toes and raised like stilts upon their slender heels, or a young woman with such con- ditions even more exaggerated, fore and aft, mincing and hobbling along and apparently possessed with the impression that something is admirable in this grotesque display. The foot of a child that never has been confined by shoes that are too tight, too short, and too high in the heel (and children, especially little children, resent shoes like these, that hurt them), is often an object of great beauty. The feet of the Greeks and Romans were shapely, for natural beauty was ardently cultivated by them; their clothing was loose and graceful, and nothing more than a sandal confined the foot. The Indian of former days had no heels on his moccasins; his muscles were unrestricted by them; he walked and ran with toes turned inward, and is said to have excelled in both forms of exer- cise, though his feet were flat. Flat feet, therefore, are not neces- sarily to be deplored, provided the bones and ligaments and muscles of the feet are well and properly developed. With many of the present modes of footwear for men and women, especially the young, the bulk of the weight of the body does not rest upon the ball of the foot, but the center of gravity is unduly advanced, undue weight and pressure thus crowding upon the toes. The conse- quences are manifest in deformed and limping and suffering vic- 299 300 HOW TO KEEP WELL tims. Corns and callosities logically follow the squeezing of the feet; bunions result from the shortening process. To this list of ills must be added ingrowing nails, abscesses, and other inflam- matory and painful conditions. Arching feet unfit most men for the ordinary duties of life. An army of men with ill-fitting shoes might easily be defeated by an inferior adversary with sound and well-conditioned feet. Not only should the shoes and stockings be suitable in size and form and texture, but the feet should be bathed and rubbed often, especially after the day's work is done; the nails should be kept properly pared, and at least the same intelligent care given which one would not think of withholding from the feet of a valuable animal. Bunions.-These outgrowths are troublesome and deforming. They consist in an enlargement of the bursa or sac which covers the joint formed by the lowermost segment or phalanx of the large toe and the head of the contiguous bone on the top of the foot. This is their most common location, but they occasionally are associated with other joints of the foot. They occur more fre- quently in women than in men. They are usually caused by wear- ing shoes that are too short and particularly by shoes which are pointed and in which the great toe cannot possibly follow a straight line with the rest of the foot. The toe is displaced inwardly; the bursa at its joint becomes irritated and inflamed; and a deformity is gradually produced which is very unsightly and frequently the seat of much pain. Not infrequently the inflammation becomes suppurative, and an abscess is formed which demands careful surgi- cal treatment. If correctly shaped shoes are worn soon after the trouble begins, the swelling may subside, but it is doubtful whether the toe will ever resume its normal position and relations without surgical treatment. When the deformity is excessive it often be- comes necessary to perform a surgical operation upon the joint, reforming it, removing the excess of bone, and bringing the bones into proper relations. If an operation is not required, great com- fort may frequently be obtained by the use of felt bunion-plasters, which protect the foot from the pressure of the shoe. Applications to the irritated joint may also be made of iodine, ichthyol, or any good anodyne liniment. If inflammation and suppuration take place, the products of suppuration must be removed as speedily as possible. If they are allowed to remain, the result may be the destruction of the joint and serious injury to the foot. DISEASES OF THE FEET 301 Callosities.-Almost everybody who reaches middle life has one or more of these collections of hard, horny cells. They occur almost entirely upon the hands and the feet, particularly upon the palms and soles. They are not the same as corns, for while corns are collections of hard, horny cells, they include in addition the endings of one or more peripheral nerves, which makes them exquisitely sensitive and often very painful. The corn is also fre- quently more highly organized than the callosity and when it is cut may bleed furiously. A callosity consists of an accumulation of hardened cells of the outer or horny layer of the skin, thick and flat, or rounded, and gray or yellowish brown in color. When the skin first begins to thicken there is no apparent change in its ap- pearance; but by and by, if the exciting cause is continued long enough, a kind of lump is formed more or less elevated above the surrounding skin. The adjacent lines and folds of the skin may remain unchanged, or if the lump becomes very considerable in size the lines may be obliterated. The callosity may be so located that it will interfere with the ordinary use of the hand affected, and this is particularly the case when it is in the palm of the hand and pulls the fingers over so that they can no longer be used to advantage. The skin in these cases is brittle and breaks easily if force is used to bend the parts or to produce motion, and painful cracks and fissures may result. Injuries of this kind are some- times followed by severe inflammation and abscesses, which may result in the sloughing out of the hard, horny mass, producing a cure at the expense of more or less suffering. Callosities are caused by pressure and friction upon one particular spot which is kept up continuously or intermittently. Those who use their hands in hard labor are almost certain to get them, and so we look for them and usually find them in the palms of farmers, day-laborers, shoemakers, blacksmiths, carpenters; in fact, in any case where tools are in more or less constant use. They also occur in the soles of the feet of those who stand or walk a great deal, particularly when the shoes are ill-fitting, stiff, and hard, and the feet are sensi- tive. Ordinary callosities do not require any particular treatment. If you remove the cause the tissues will gradually soften and the callosity will vanish. If they are very hard and troublesome, it is well to remove them, softening them with dry or moist heat, and then paring them away as a blacksmith pares away the excessive growth on a horde's hoof. Or they may be removed with a poultice 302 HOW TO KEEP WELL of green soap or an application of caustic potash or carbonic acid snow. A solution of ten or twenty per cent of salicylic acid in alcohol is also said to be effectual. Of course, the cause which originally produced this condition must be removed; otherwise a recurrence may be expected. Chilblains.-Chilblains and frost-bites are, of course, one and the same thing; that is, they are the product of cold weather, par- ticularly prolonged, persistent cold weather. They are not due to cold alone; furthermore they do not attack the feet alone, and may be quite as troublesome upon the hands as upon the feet. The condition is one of inflammation of the skin and is accompanied with redness, heat, swelling, and pain, the four elements which make up the old idea of inflammation. If the case is a bad one it will result in the formation of blisters, and if these are broken they will terminate in painful sores, which may last a long time, be very difficult to heal, and completely disable the patient. If the skin is sensitive and thin and perspires freely, chilblains will be more likely to occur than if it is thick and dry. That is why women and children are victims oftener than men. Those who constantly complain of cold hands and feet-that is, who have a poor circulation-are very susceptible to them; and hence they are often present in the aged, in invalids, and in those whose nutrition is poor from any cause whatsoever. They are also of frequent oc- currence in the great army of sufferers from rheumatic and gouty disease in the bones, joints, and muscles. The important question, of course, is how to avoid them. Those who go about thinly clad, as so many do at the present time, are constantly inviting these troubles and others which are even more serious. Those who for fashion's sake persist in wearing low shoes and slippers and thin stockings, and whose lower extremi- ties are entirely too insufficiently protected, should not complain if their only penalty is a severe and painful attack of chilblains; they ought to expect it, and they are inviting punishment of a much severer character. The first thing that should be done, there- fore, to avoid chilblains is to wear warm, loose clothing, that the circulation in the skin may be entirely unimpeded. If the hands and feet are always cold, woolen gloves and stockings-not neces- sarily thick ones-should be worn as long as the cold weather lasts, and it is especially necessary to keep the feet warm at night, with the aid of a hot-water bag or an electric pad. A household which is DISEASES OF THE FEET 303 unprovided with one or more of these useful articles can never be regarded as completely furnished. The question of shoes is an all-important one in the matter of chilblains, and it is one of which most people, particularly women, are very inconsiderate. Shoes should never be tight enough to interfere with the circula- tion and should allow for a certain amount of swelling, which is very apt to occur, especially in those whose occupation compels them to stand most of the day. The soles must be thick enough to protect the feet, not only from dampness but from cold. It is supreme folly to wear wet shoes if there is any possibility of chang- ing them for dry ones. They should be high enough, not only to support the ankles, but to protect them from the wet and cold. Rubbing the feet with snow has been recommended. This will sometimes remove the heat and swelling but cannot be advised for indiscriminate use. A warm foot-bath at night followed by a rub with cold cream will often be found very soothing, the feet being dried, but not rubbed, with a soft towel. Rest is most important as a means of treatment, the feet being elevated upon a chair or other support. Club-Foot.-Club-foot is a term applied to four primary deform- ities of the foot: (i) The heel is drawn up and the patient walks on the ball of the foot or toes. This is known as Talipes equinus. (2) The toes are elevated, and the patient walks on the heel. This is known as Talipes calcaneus. (3) The foot is twisted so that the sole looks inward, and the patient walks on the outer border. This is known as Talipes varus. (4) The foot is twisted outward, and the weight is borne on the inner border of the foot. This is known as Talipes valgus. We may also have combinations of these forms. If the heel is drawn up and the heel twisted inward, it would be called Equino varus. A combination of Varieties 1 and 3 would be Equino valgus; of 2 and 4, Calcaneo valgus, etc. Club-foot may be inherited or acquired, i.e., may exist at birth or may develop in what has been hitherto a normal foot through accident, paralysis of some of the muscles, faulty position in standing or walking, etc. Inherited club-foot is exceedingly com- mon and is almost always of the Equino-varus variety. The gener- ally accepted theory is that it is produced by a faulty position of the child in the womb. The deformity may be slight, consisting only of a moderate drawing up of the heel and twisting of the foot, which may be replaced to a nearly normal position with little 304 HOW TO KEEP WELL effort; or the foot may be so twisted that its inner border rests upon the leg, while it may be so rigidly held that it is impossible to change its position except very slightly. Between these two ex- tremes there are various degrees of deformity. In any case, whatever the deformity may be, treatment should be begun at once, on the day of birth if possible. The prevalent idea that treatment should be postponed until the child is several weeks or months old is erroneous, for delay causes increased con- traction of the muscles and ligaments and produces changes in the bones of the foot, so that correction of the deformity becomes more difficult. It is very important that the foot should be straight or nearly so and good motion at the ankle established before the child begins to walk. The sole will then rest flatly upon the ground, and the force of gravity will aid in effecting a cure. If the case is taken in hand early, a perfect cure can be obtained without an operation in almost every case. This means daily and persistent work on the part of the mother or nurse, under the direction of a skilful surgeon. In mild cases, without contraction or rigidity, re- placement of the foot and holding it in position by some simple apparatus, together with manipulations and rubbing, will produce a good result. In the more rigid and complicated cases, braces will be necessary together with stretching. A few very obstinate cases and those which have been neglected will require operation. The acquired forms of club-foot are nearly all due to the con- traction of tendons and muscles following paralysis, and most frequently to that variety which is known as infantile paralysis. Others may follow sprains of the ankle as a result of too long confinement of the foot in one position; others are due to fractures and injuries near the joint which are not properly treated. Corns.-There are those who speak slightingly of corns and of those who treat them. Such people are lacking in experience, in wisdom, and in common sense. No one who has felt the agoniz- ing pain and the dejection, loss of courage, and loss of animation which come in connection with a really active, thoroughly busi- nesslike corn will have aught save respect for their possibilities for evil, nor aught save respect and gratitude for the skilful chiropo- dist who disposes of them. Chiropody, be it known, is a progres- sive art; it means not only the removal of corns, but the oversight of the medical and surgical conditions of the feet, and no man or DISEASES OF THE FEET 305 woman is a good chiropodist unless he or she has acquired practi- cal as well as theoretical knowledge of the anatomy, the physiology, and the pathology of the feet. What is a corn? It is a callosity or hardening of the epidermis or outer layer of the skin, and something more-the latter being a cone or core of hardened cells in the center of the callosity ex- tending downward to the inner layers of the skin, or the true skin. The outer layer of the corn is not sensitive; the inner layer is as acutely sensitive as almost any portion of the body. Corns are usually, if not always, the result of pressure, particularly against a bony prominence; and they are very often so located as to press upon the projecting heads of the bony joints on the upper surface of the toes or upon the heads of what are known as the metatarsal bones on the sole of the foot. The point of greatest pressure, and consequently of greatest sensitiveness, is at the site of the cone or core; and this pressure, added to the external pressure from stock- ings and shoes, may produce excruciating pain. Corns may be upon the upper surface of the toes, upon the sole of the foot-especially the ball-and between the toes. They are hard or soft according to the degrees of moisture of the foot, being of the soft variety between the toes and in cases in which the feet perspire profusely. Ill-fitting shoes are the usual cause of this disturbance, particu- larly those which are too tight and too narrow from the ball to the extremity of the toes. The presence of corns, especially those that are active and progressive, makes walking difficult or impos- sible, and makes even the pressure of easy shoes and stockings intolerable. Rings of felt, fitted over corns and secured to the skin by suita- ble adhesive material, enable one to wear a shoe of respectable proportions with comfort. There are also numerous preparations of caustic substances available which will destroy the connection between the corn and the underlying skin and permit one to scrape or pick it off without difficulty. A fairly sharp knife, when cau- tiously used, will separate the hardened tissue of the corn from the soft and sensitive tissue beneath. A good chiropodist will remove corns skilfully and without pain; but they will return, particularly if the former conditions of pressure remain. There is a certain amount of danger in so simple an operation as removing corns; therefore it is important that one should always be sure that the knife employed for that purpose is sterile. 306 HOW TO KEEP WELL Flat Foot.-Flat foot simply means dropping of the arch of the foot, the entire sole being on one line, causing disproportion be- tween the strength of the foot and the use or work required of it. The muscles of the legs having become weakened by disease or poor nutrition, more strain is placed upon the ligaments of the foot and leg. The latter, becoming stretched, fail to give the ac- customed support to those bones of the foot which bear the body weight in standing or walking and become flattened out. There is often an inherited tendency to this condition on account of faulty development and relationship of the bones to each other. If this does not result in flat foot in childhood it is likely to in the adult, especially if the individuals are poorly nourished, or have some disease affecting the muscles and ligaments, like rheumatism, or are obliged to stand all day at their work with little chance to exercise these tissues. The strain upon the muscles and ligaments in the unnatural position of the foot causes pain, weakness, and general inefficiency in work. The foot loses its flexibility, is really or ap- parently longer, is very apt to sweat profusely, and is painful in the heel and soft tissues when pressure is made over the bones and liga- ments. The flat foot is often the seat of callus, soft corns, fissures, and eczema, and there may be a varicose ulcer at the ankle. If the general health is impaired in those who have flat feet, it must be improved; improvement in the tone of the tissues may be of great help. An insole or a plate suitably constructed may be placed in the shoe; or a particular form of shoe adapted to the given deformity may be constructed, raising the heel and sole on the inner side and tending to throw the weight of the body to the outer side of the foot. In children where the bone and the soft parts are still flexible, the foot and ankle are by some orthopedists strapped into proper position with strips of rubber plaster, which may be worn several weeks at a time. It is self-evident that one who has flat feet should rest them as much as possible, and it is often very comfortable to raise them above the center of support of the body, in so-called American fashion. The following scheme of exercise has also been recommended by a prominent orthopedic surgeon: Daily massage, with such manipulation of the foot as will throw the broken arch back to its normal position. Morning and evening the fore part of the foot should be grasped with one hand and rotated from the outer to the inner side, while with the other hand pressure is brought upon the foot below and in front DISEASES OF THE FEET 307 of the ankle, to press the arch upward, this being repeated many times. Also the foot is to be moved backward and forward to make it more flexible. To strengthen the muscles one should stand on the toes and raise the heels from the floor many times daily, and should walk on the outer edge of the feet with the toes turned in. Trench-Feet.-During the life in the trenches in the Great War there was nothing from which soldiers suffered in greater numbers than what for convenience was called trench-feet. It was said to be an infectious condition, produced by the action of fungi or bacteria; and even before the war, French observers had reported it among the African native troops. It appeared among them as a form of blood-poisoning with fungi or bacteria in the blood, which, when isolated and injected into animals, produced blood-poisoning of a similar nature. The result of standing in cold water in the trenches for long periods was that the organisms derived from the ground, even such virulent ones as those of tetanus or lockjaw, were absorbed by the tissues; and more or less extensive blood- poisoning followed. Some writers regarded the condition as a kind of neuritis, which affected not only the feet but the arms and legs, sensation below the knees being dull and benumbed. The scientific explanation given was that the water in the trenches caused the body to lose heat; there was effusion of salts from the body and infusion of water into the skin. Soldiers in the trenches are not the only ones who suffer with this ailment, for it occurs also among fisherman, hunters, and workers in various industries who stand in water more or less continuously. Soldiers and others who are similarly exposed should protect the feet with applications of salted lard, oil of wintergreen, or camphorated oil; they should wear rubber boots if possible, loosening their puttees, which con- tract when wet; and they should rest as much as possible with their feet elevated. Predisposing conditions of trench-feet are fatigue, accumulation of blood in the veins, and edema, or the passage of fluid into the tissues under the skin. An extreme result of this condition may be gangrene of the tissues. It may be treated by rest for two or three weeks in the horizontal position with very little covering on the feet, no walking, and gentle massage. There should also be a daily foot-bath, the feet being painted with form- aldehyde and the inside of the stockings sprinkled with oxide of zinc powder. The condition is prone to recur, especially to those whose feet perspire freely. CHAPTER XIII MUSCLE TROUBLES Cramps in the Muscles.-Almost everybody suffers from pain- ful cramps of the muscles at one time or another. They may come to any of the muscles and at any time, night or day. They are simply muscular contractions caused by nerve irritation and are not at all under the influence of the will. Not all cramps or muscular contractions are painful, however, and they may occur entirely apart from knowledge or sensation. Such are the reflex cramps or spasms from which anybody may suffer, and the twitchings and even extensive motions of the body which occur during sleep, especially in children. The most extensive form of muscular cramps of the painful variety is that which occurs in tetanus or lockjaw, in which groups of muscles are strained and cramped with great violence and with great suffering to the patient. In such diseases as St. Vitus's dance and epilepsy there is also extensive cramping and contraction of the muscles, the cramps of St. Vitus's dance being sometimes painful and always annoying. The cramps and contraction of epilepsy occur while the individual is uncon- scious and therefore are not painful, though there is usually a sense of great weakness in the muscles when consciousness returns, be- cause of the severe work done by the muscles in the progress of the fit; for muscular contraction, whether voluntary or involuntary, means work, and work when violent or prolonged is always fol- lowed by weakness or exhaustion of the muscles used. Cramps often occur in children in connection with intestinal worms, the irritation causing it being applied to the nerves in the intestines and then reflected to the muscles in which the pain is experienced. A very common form of cramps is that which comes from overuse of the muscles, making their contraction difficult, especially when it is called for in an unusual manner, as in swimming, lifting heavy 308 MUSCLE TROUBLES 309 burdens, or riding a bicycle or a horse; or the cramps may be caused by a blow, a fall, squeezing or twisting. It is not infre- quently associated with rheumatism or some other disease in which the muscles or joints are implicated. In all these forms of cramps rest is the matter of first importance. Other measures which are often used are heat, light, electricity, massage, hot or cold applica- tions or compresses, mustard, etc. The Very Common Backache Known as Lumbago.-It really means pain in the lower or lumbar region of the back and seems to be seated in the muscles. You may call it a neuralgia if you like, just as every painful trouble is in reality a neuralgia; or you may call it muscular rheumatism, as many do, though it is unlikely that it is an infectious disease, like the rheumatism which attacks and stiffens the joints. But whatever its cause, it is a very un- pleasant thing to have. It is one of the signs of approaching age and feebleness, for I never knew of a case in a person who had not reached middle life; and the older one gets, the more susceptible to it he becomes. There does not seem to be any way of outgrowing it, as there is with some aches and pains. It may go away for a few weeks or months, but it invariably comes back, no matter how carefully you may try to get rid of it. It is far less prevalent in summer than in any other season, and it is not invariably trouble- some in the clear, cold days of winter; but at all other seasons, particularly in the early spring and fall, it is an ever-present enemy, causing unlimited misery. It has seemed to me from a rather care- ful study of it in my own person that the most important influence in causing it is the atmosphere. When the air is heavy, the baro- metric pressure low, the atmosphere nearly saturated with mois- ture, and the wind south, southeast, or northeast, an attack of lumbago may be expected by those who are susceptible to it, no matter what precautions they may take to keep it off. It begins with stiffness in the muscles on one or both sides of the back, and this rapidly becomes more and more annoying, more and more painful. When you get down to a chair or the bed it seems as if you could never get up, and when you get up it is some seconds or minutes before you are sufficiently limbered up to be able to move with ordinary comfort or freedom from pain. After being around a few hours during the day, your back is so painful and all motion so difficult that it seems as if you could never again get down to a chair or get into bed. Not infrequently there is involuntary cramp 310 HOW TO KEEP WELL or spasm of small portions of the muscles which is extremely pain- ful. Usually it is possible to get into a position in which the pain is only moderately acute, but sometimes a change in position seems only to start up a new kind of pain. Other causes of lumbago are exposure to cold and wet, violent exercise of the muscles, intense emotion, etc. It is made worse by constipation, overwork, improper eating and drinking, and loss of sleep. An attack may last a few days or several weeks, varying in severity with the weather and the kind of treatment it gets. It is frequently mistaken for disease of the kidney or spine or other organic ailments which seem to be located in the back. Heat is perhaps the best and most soothing remedy for it. We should have a hot-water bag at the feet and another at the back. It is often helpful to cover the back with flannel and go over it rapidly with a hot flat-iron. Blistering, cup- ping, massage, and electricity, when skilfully applied, are all useful. It is well to avoid the use of drugs as far as possible, with the ex- ception of laxatives to keep the bowels freely open. The clothing must always be sufficient to keep the surface of the body warm. Muscle-Strain and Rupture.-First, let us recognize a difference between a sprain and a strain. A sprain is an injury to the tendons or ligaments in the vicinity of a joint. A strain means a stretching of a tendon or the muscle to which it is attached and which hold it in its proper place. A strain may be so severe that the tendon or the muscle will break. This is not by any means an insignificant acci- dent, for it sometimes means the permanent weakness or lameness of the portion of the body controlled by the muscle or tendon. Thus, if the large tendon above the heel is snapped and retracts an inch or two, it may prevent the free movement of the foot upward and downward forever after. Permanent lameness is almost sure to happen when a ruptured tendon at the knee is not properly re- paired. Accidents of this kind are usually the result of sudden and violent effort, as in jumping or dancing or lifting a heavy weight, when unusual force is applied to the part which is injured. Or if the muscle or tendon is weak or degenerated by age or disease, it may result from a slight exhibition of force. When such an accident occurs there is at once the conscious- ness that something is broken; perhaps one can almost hear the snap as the fibers which make up the muscle or tendon give way. Immediately there is a sensation of pain, and it is usually a sharp, cutting pain, to which most people react with a cry of distress or MUSCLE TROUBLES 311 with words which are not polite or suitable for printing, when they are inclined to the use of such language. If a tendon has been torn from its place of attachment, it retracts; and if a muscle or a por- tion of a muscle has been torn, the divided fragments retract, and a depression will mark the place where the injury occurred and the part will be very sensitive to the touch. Blood-vessels will be broken, and more or less blood will ooze into the tissues, producing swelling and discoloration of the skin. As soon as these accidents have occurred, nature at once goes to work to repair the damage; inflammation is set up in the injured tissue, and a sticky, glue-like material is released from the blood- vessel to fasten this injured tissue in its new position. If the in- terval between the two ends of the divided tissue is not too great, this material serves to splice them together, and after a long time and suitable exercise the injured muscle or tendon may do good service again; but if the interval is large, each end will be fastened to its new position and normal motion in the muscle and in the part of the body it controls will be lost. These injuries demand, first of all, absolute rest, so that nature may have every possible chance to repair them, and to that end the position of the body must be favorable to the union of the divided fragments. In some cases the body or a portion of it may be extended; in others it must be flexed or bent, the injured portion being supported by splints or bandages. At the proper time suitable massage must be used to prevent stiffness. Antiseptic surgery is now so proficient and safe that it is often possible to cut down to the injured parts and suture the divided tissues in their normal position. Sprains.-Many people who have had or who have been told that they had a sprain would be puzzled to define what a sprain really is. The first idea in connection with the term is that it ap- plies only to joints, and some joints are much more frequently sprained than others. The ankle- and knee-joints are great suf- ferers from this accident, the wrist and elbow less frequently, and the hip and shoulder less frequently still. A sprain may be an injury to one or all the structures in a joint, but most frequently it is a tearing, stretching, or twisting of one or more of the ligaments by which the joint is kept firmly in position and enabled to do its important part in the work of motion. A sprained ankle is one of the commonest forms of this injury; it seems almost as if every- body had suffered from it at one time or another. It very often 312 HOW TO KEEP WELL happens from slipping or bending or straining the ankle, particu- larly when this is done suddenly or unexpectedly. What happens when such an accident occurs? First, there is excruciating pain, because nerves are bruised or torn and ligaments lacerated. Then there is inability to walk, because the injury to the ligaments has displaced the bones from their normal relations. Neighboring tendons and muscles are also torn or strained; the lining membrane of the joint may be bruised or otherwise injured; cartilages may be displaced; and in some cases pieces of bone are chipped off. Add to this the fact that there is almost always injury to the blood-vessels with hemorrhage into the joint and the sur- rounding tissues, and we have an accident which is by no means simple and never trivial. It is no wonder that such accidents fre- quently lay a person up for weeks and months, and it is even possible that one may be injured permanently, irremediably there- by, an injury of this kind being in many cases worse than a frac- ture. The pain of this accident is not infrequently accompanied with nausea and faintness, and the joint and surrounding tissues swell and continue to swell perhaps for twenty-four hours or longer. Not only are the structures proper of the joint injured in a sprain, but the bones may be broken or dislocated, or they may be badly bruised, and the skin and muscles may be badly injured. A joint which has been thus injured demands complete rest, measures for subduing the inflammation which follows the injury, measures for the relief of pain, and such treatment as will restore the joint to usefulness at the earliest practicable moment. Thomsen's Disease.-This peculiar disease is a form of inherited trouble in which stiffness of the muscles, coming often at most in- convenient seasons, interferes with voluntary movements. It seems almost to be related to epilepsy and, indeed, may possibly be so related, for it sometimes occurs in those who are subject to that disease. It also may come with the form of neuralgia known as migraine and with certain forms of mental disturbance. It is pretty well marked as a hereditary disease and has been observed in as many as five successive generations. In this disease there are contractions of certain muscles, when one attempts to make cer- tain motions, and rigidity and stiffness which slowly relax. Such an attack may come unexpectedly, as when one trips and falls and finds himself helpless to move until some minutes afterward, when relaxation and ability to move return slowly. Spasms of this kind MUSCLE TROUBLES 313 may happen repeatedly, following each other at rather short inter- vals. The first attempt to move after such an attack may be un- successful; a second may have better results; and by degrees the stiffness disappears, and one is able to go about again. Not all the muscles of the body are involved in such an attack, those which are most affected being the muscles of the upper and lower extremities. In addition to these the muscles of the head and neck may be rigidly contracted, and more or fewer of the muscles of the body. The muscles of the eyes and those of the tongue may also be con- tracted, and sometimes the muscles by which swallowing is ef- fected. There is no pain connected with this muscular contraction, as there is in some other forms of muscle-spasm, and the condition becomes worse if one is fatigued or excited. Rest and warmth tend to relax the spasm and bring relief. The condition is one which continually recurs throughout life without much change for the better as old age comes on. It is thought that this may be one of the bad consequences of consanguineous marriage. Wryneck.-This painful contraction or shortening of the muscles of one side of the neck results in drawing the head and neck to the side of the contracted or shortened muscles, the head being also drawn down more or less. It is most frequently an inherited trouble, the long muscle which passes diagonally down either side of the neck being shorter on one side, when the child is born, than on the other. Of course, after birth the development of the muscle on either side progresses at the same rate, without reference to the defect at birth. Consequently, when the muscles have reached their full growth at maturity the individual has a well-marked deformity. This condition may also be acquired in childhood or at a later period by injury to the muscle referred to, on one side or the other; and it may be the result of cold, rheumatism and disease of the glands or some other structure of the neck. It may also result from burns that cause excessive scarring and contraction of the skin of the neck, or from paralysis of one or more muscles on one side of the neck, or even from defects of vision, with straining of the eyes. A peculiar thing about this trouble is that it seems, in some families, to be inherited; and there may be several cases of it in a single family in a single generation. I said it was painful. In some of the cases there is a spasm of the muscles on one side or the other, perhaps with painful twitching on account of disease in the nerves in this portion of the body. It is very important to know what to 314 HOW TO KEEP WELL do for these painful experiences, and it is not always absolutely essential that a doctor be called. Heat applications or massage may be used to relieve the spasm; and, in case the trouble is associated with rheumatism, the preparation of salicylic acid, which may be used to cure the rheumatism, will probably relieve the pain in the neck also. Some cases will demand that the shortened muscles and associated tissues be cut and the neck stretched on the same side to correspond to the uninjured side. Other cases are satis* factorily treated by supports or splints or plaster casts such as ma; r be provided by a skilful orthopedic surgeon. CHAPTER XIV DISEASES OF THE BONES Bow Legs.-This is especially common among negro and Italian children whose nutriment has been deficient or improper in charac- ter. By improper nutriment reference is made particularly to those who suffer with rickets, their food, whether from the maternal source or otherwise, being deficient in those salts, especially the salts of lime, which give stiffness and firmness to the leg-bones as supports for the body. The period at which it is most frequently acquired is from the first to the sixth year. The deformity is not limited to children, it is not infrequent in adults, particularly in those who spend much of their time on horseback. It also may occur in adults as a result of disease of the bones. I have seen pronounced cases of it in circus-riders, and it is self-evident that those who are in the habit of riding large horses are more subject to it than those who ride small ones, particularly those who ride bareback. The curve of the leg is usually inward, though in some cases it may be from front to back. Occasionally there is a com- pound curve in both directions, the knees are widely separated, and the feet are pigeon-toed. It may involve thigh-bones and leg-bones below the knees. Such deformities were formerly hopeless, and the bow-legged individuals were deformed for life when the bowing was extreme; but under modern methods of treatment by ortho- pedic surgery they are amenable to great improvement and even cure. Of course, the earlier the treatment is undertaken, while the bones are more or less flexible, the better the chances for radical cure. When the deformity is due to bad dietetic and hygienic conditions, these must be completely reformed. Cod-liver oil and lime salts are usually indicated, as well as an assimilable prepara- tion of iron. Straightening of the bones of children can frequently be brought about by the use of suitable braces, or plaster casts, and 315 316 HOW TO KEEP WELL it may be necessary to wear these for many months. Some ortho- pedic surgeons recommend that during this period the child should spend most of his time in bed, but of course for a young and grow- ing child this is a plan which is not without danger and disadvan- tage. A warning which must be sounded when bandages are used in treating this deformity is that at no point should they be so tight as to interfere with the circulation. Surgical methods are also in vogue in the treatment of bow legs, the bones being cut and properly shaped in some cases and broken in others. Instruments are available by which the breaking can be done with great ac- curacy. Knock-Knee.-In its minor degrees and when the legs are cov- ered with clothing it may give no trouble at all and may not be noticeable to the ordinary observer. In knock-knee the bones of the leg are not in the same line or plane with those of the thighs, be- ing inclined outward from the knee-joints. The feet are conse- quently wider apart than in the normal condition, and the knees closer together. In extreme knock-knee the inner surfaces of the knee are in contact with each other, and walking is difficult on account of continual interference. This condition is most notice- able when the limbs are extended; that is, when one is standing or walking. When the legs are flexed or bent as in sitting, there may be little or no trouble and no particular cause for mortification. Should attention be called to a knock-kneed person while sitting, a lump or projection might be observed at the end of the thigh- bone. In addition to the displacement of the bones there may be a relaxed condition of the ligaments of the knee-joints, especially on their inner aspect. This condition may be due to faulty condi- tion of the bones during fetal life and become apparent at birth, like the various forms of club-foot. Or it may be due to poor nutrition during childhood, when the bones are having their most active growth; to diseases like rickets, which are the result of improper feeding and consequent bad nutrition; or it may be the result of deformities or other troubles in the feet which conduce to improper use of the bones of the legs in walking, etc. In the later years of childhood and youth it may proceed from curvature of the spine or flat-foot, with faulty methods of walking. It may also be asso- ciated with injuries and with certain forms of paralysis. It is not improbable that knock-knee may be a sequel in more or fewer cases of those who were victims in the epidemic of infantile spinal paraly- DISEASES OF THE BONES 317 sis a few years ago. When knock-knee is developing in a child, at- tention may be called to it by his peculiarities in walking, as he stumbles or falls frequently and has an awkward, waddling gait. The deformity may not be very great, but it gradually gets worse as the child progresses; and as soon as the condition is observed he should be referred to an orthopedic surgeon for treatment. In some cases a suitable form of brace will remedy the deformity; in others an operation upon the bones will be necessary. It is, of course, imperative that the child's nutrition should be carefully considered, suitable food being given and tonics like iron and cod- liver oil administered when required. With improvements in the general condition there will also be improvement in the condition of the bones. Osteomalacia.-This curious disease consists in a softening of the bones, with more or less deformity, on account of their inability to sustain the pressure which is normally required of them. It is said to occur most frequently in pregnant and nursing women and hence means deficiency of the lime salts, which give firmness and rigidity to the bones, but it may also occur in children and rarely in men. It is easy to understand how a nursing woman, especially if her nutrition is poor, may yield to the vital substances which support her infant a larger proportion of the lime in her bones than she can readily spare. Fortunately the disease is not a common one. It begins with pain and weakness in the muscles and inability to stand for a very long time or do the ordinary work to which one is accustomed. It is quite likely to be mistaken for rheumatism, or for some obscure disease of the spine or the spinal cord. The bones of the spine or of the pelvis or haunch are most often at- tacked, but it may also attack the bones of the legs. The person who suffers from it actually diminishes in height and is compelled to walk with a kind of waddling gait and with more or less diffi- culty. Sometimes the efforts at motion cause fracture of the bones; and unless effectual treatment is given, the patient may die from exhaustion or from some acute disease which is induced by the osteomalacia. The identification of the disease becomes possible as it develops, from the pain in the bones, the presence of lime salts in the urine, and the peculiar deformities which gradually appear. Phosphorus and cod-liver oil are reported to have been used suc- cessfully in treating this disease, and, of course, other means must also be used to improve nutrition. If it occurs in a nursing woman 318 HOW TO KEEP WELL it may be necessary for her to wean her baby. A woman who has had this disease should not become a mother again, and in some instances it has been found that a cure could only be effected by removal of the ovaries. Osteomyelitis.-This stands for a disease which is by no means uncommon, particularly in children and young adults. It means literally inflammation of the bone-marrow; but by usage it is an acute inflammation which affects not only the marrow of the bone but the soft or spongy tissues as well, leaving the hard dense tissue uninvolved. It is an infectious disease and not infrequently is the consequence of fracture of the bones or of tuberculosis. It may cause the death of the entire bone, or only a portion of it, and it may be complicated by extension to the nearest joint. The bones most frequently attacked are those of the thigh, the leg, and the spinal column. It is usually associated with poor nutrition of the bone, owing to interference with its blood-supply. In addition to its connection with fractures and infectious elements, it may be caused by intense cold, by injuries of various kinds, and by overexertion. It begins, as inflammation so frequently be- gins, with a more or less severe chill. Then follows pain in the bone, with redness and swelling of the overlying tissues, and a feeling of fluctuation in the tissues, if suppuration has occurred. This inflammation may subside in a few days and the bone, to all appearance, get entirely well; or an abscess may form and the vital membrane covering the bone, called periosteum, become involved with it. In such cases the consequences may be serious, for septi- cemia or pyemia-that is, more or less extensive blood-poisoning- may follow. The result sometimes may be fatal. If the individual survives, more or less of the bone is almost certain to perish, and there will be a suppurating sore from the skin to the dead bone which will continue to discharge until the dead bone is separated from the living and removed from the body. As soon, therefore, as it is evident that the bone is dead and is removable, an opening of sufficient size must be made, and this piece of dead bone be taken away. The tissues, then being properly cleaned and dressed, will be in a favorable condition for healing. By means of an X-ray exposure it is possible to detect with accuracy the presence of dead bone, and its removal may thereby be greatly facilitated. Periostitis.-The membrane which covers bone in any portion of the body is called periosteum, and from this membrane the bone DISEASES OF THE BONES 319 has its principal source of development. It is, therefore, essential to the life of the bone, and should a portion of it die, the portion of bone which is contiguous would die also, unless it received nour- ishment from healthy periosteum in its vicinity. When this mem- brane becomes inflamed, as is frequently the case, the diseased condition is known as periostitis. One of the most common causes of inflammation of this characater is injury or violence of any kind to the bones of any portion of the body. Such an injury is followed by the usual signs of inflammation, pain, redness, swelling, and heat. Blood or pus usually accumulates between the periosteum and the bone; and the swelling thus formed may be very hard, or it may be more or less compressible and indicate the presence of fluid. The pain in these swellings is often excruciating, as in the case of a felon upon the finger, which is a form of periostitis. The condi- tion becomes more extensive and more painful when, in addition to injury, the inflammation is due to infectious germs. When the in- flammation extends over a large area of periosteum the suffering from pain and from the absorption of poisons may be so severe as to cause great prostration and exhaustion or even death. When the inflammation involves the periosteum covering the bones of the upper and lower extremities it may extend to the neighboring joints and corrode and destroy more or less of the underlying bone. While the disease is most commonly the result of injury, supplemented by the influence of infectious germs, it may be due to the influence of the latter alone and appear as a complication or sequel in such diseases as typhoid or scarlet fever, smallpox or measles. In such cases it is obviously a disease which more fre- quently attacks the young than those of mature life. Periostitis is also a frequent accompaniment of syphilis and tuberculosis, and in such cases those who are mature or in middle life are chiefly its victims. There are two plain principles which should always be considered in the treatment of diseases like periostitis, one being that the nearer the affected parts can be brought to absolute rest the less will be the pain and suffering, and the other that the ten- sion of the inflamed tissues should be relieved at the earliest pos- sible moment and the accumulated fluid released. The wound thus made must be kept open and thoroughly drained and irrigated until nature has closed it from the bottom by the process of granulation. CHAPTER XV DISEASES OF THE BLOOD-VESSELS Aneurism.-An aneurism is a dilated or expanded portion of an artery forming a tumor with a wall of varying thickness. It may have one or more openings or communications with the arterial tube; it may form a connection with an adjacent vein; or it may gradually fill up and become solid, in which case nature effects a spontaneous cure. Unfortunately this does not occur very often. The arteries which are most frequently the seat of aneurism are those of large size; but some of the smaller ones, particularly those in the brain and the lungs, may also be attacked. Arteries which come directly from the heart or its vicinity are frequently its vic- tims; and because it is almost impossible to subject them to mechanical treatment, disease of this kind is almost hopeless when they are involved. Aneurisms are produced by disease or injury, or by increase in the blood-pressure or diminution in the arterial resistance or both combined. The disease is one of mature life, particularly between the ages of thirty and fifty, when the hardest work is usually done. It is much more common in men than in women, notably in those whose work is severe and subject to strains, like porters, draymen, soldiers, and all who bear heavy burdens. It is also not uncommon in those who suffer from rheum- atism, gout, syphilis, alcoholism, diseases of the heart and kid- neys, and in poisoning from metals, especially lead. When an aneurism is on a main artery of an arm or leg it may interfere with the pulse beyond it. By its pressure it may have a corrosive action, destroying nerves, communicating with an adjacent vein, and cor- roding the spinal column or the skin. It may come suddenly from a strain or injury or gradually as the result of disease. It is usually accompanied with pain, which is sharp in some cases, dull and 320 DISEASES OF THE BLOOD-VESSELS 321 boring in others, the pain when the largest arteries are involved be- ing in the abdomen or in the region of the heart, and radiating to the neck shoulder, back, and arm. There may also be difficulty in breathing and difficulty in eating. A purring sound or murmur is usually heard over the tumor, and the patient is often aware of a continuous throbbing and pulsation. The rupture of an aneurism is a very serious accident and is accompanied with sharp pain and violent hemorrhage. Inflamma- tion and abscess sometimes occur in the tissues adjacent to it, and their influence upon its progress is bad. It is treated by medicinal or surgical measures or both. Tying or ligating the artery at the proper point will often cure the disease, especially if it is due to injury and the remainder of the artery is strong and sound. Some aneurisms have been cured by the use of drugs, which cause ab- sorption of their contents, or by those which modify the heart- action; others by long-continued pressure with the fingers; and a few by the introduction of fine wire into the tumor, or by various other measures. One who has an aneurism should lead a very quiet life, free from excitement; he should rest as much as pos- sible and live on a very restricted diet. A good surgeon should be consulted at the earliest possible moment, and his advice should be implicitly followed. Angioma.-There are many varieties of this kind of tumor, the simplest form consisting of blood which has been effused from ruptured blood-vessels into the tissues. This blood is converted into a clot or mass and by and by becomes more or less organized, being encapsulated or surrounded by a rudimentary sac or capsule. Another variety is a collection of minute vessels forming a stain or blemish on the skin, or the vessels may be large enough to be distinct and conspicuous. Such are the birth-marks, port-wine marks, nevi, etc., which are very common and perfectly familiar to everybody. When a tumor contains a multitude of spaces which dilate when filled with blood and retract when the blood is squeezed out of them, like the spaces of a sponge, it is known as a cavernous angioma or an erectile tumor. Such tumors usually occur on the skin, especially on the face and scalp, and are purple or blue in color and of different sizes; under excitement or emotion they swell, like the comb of a cock, and become very prominent. They are of frequent occurrence in children and may get larger and very troublesome as a child increases in age and development. Another 322 HOW TO KEEP WELL form of vascular tumor is made up of dilated arteries or veins or both, very much resembling a group of worms. When consisting mostly of arteries it pulsates constantly, occurring most frequently on the scalp and face, but sometimes on the upper or lower extremi- ties. It is usually the outgrowth or extension of a simple birth- mark or nevus and is a rather dangerous development on account of the liability of the blood-vessels to break and bleed very pro- fusely, sometimes even seriously. Occasionally these tumors are present in the organs of the body, most frequently the liver, rarely in the spleen or the alimentary canal. The treatment is a very interesting consideration. If they are within the body they are less amenable to surgical treatment than when in the skin, though they have been successfully attacked in numerous instances when within. There are many methods of treating them from without, and no one method is adaptable to all cases. In some instances, especially in infants and very young children, graduated compression may permanently destroy or con- trol the superfluous blood-vessels. Other cases, especially when the tumor is small and inconspicuous, are successfully treated with caustics like nitric acid, chloride of zinc, the actual cautery, or carbonic acid snow. Injections of boiling water and of alcohol have been successfully used in some cases, and electrolysis, or radium or the X-ray in others. In cases in which there are many vessels of considerable size and covering a large area, the best and most expeditious plan of treatment is the purely surgical one, the vessels, or a sufficient number of them, being ligated, or the entire tumor being dissected out and the wound carefully closed. Apoplexy.-This disease, called apoplexy or cerebral hemor- rhage in medical language, is ordinarily known as paralysis, or a stroke of paralysis. It is one of the most serious of the acute diseases. It comes at any period of life: the new-born baby is not infrequently its victim in his efforts to come into the world; chil- dren have it rarely; adults approaching middle life have it rather more frequently; and it comes most frequently of all to the aged. Babies often recover from it within a few days after birth if the attack has not been severe, but sometimes it leaves a palsied arm or leg, which must be carried through life. Children seldom re- cover from it completely. The best results happen to those who are attacked by it in middle life, especially when the attack is a mild DISEASES OF THE BLOOD-VESSELS 323 one. In old age entire recovery is almost impossible, and death often results quickly. The essential feature is hemorrhage into or upon some portion of the brain. When an apoplexy or rupture of one or more blood-vessels in or upon the brain occurs, the out- flow of blood is governed by the size of the vessel, which is usually an artery, and by the amount of resistance it meets. If the vessel is on the surface of the brain the bleeding is abundant, perhaps enough to produce death in a few hours, not so much from its quantity as from its pressure upon and destruction of vital parts. If the vessel is within the brain, the blood escapes more slowly; it pushes aside and breaks up the tissue which gets in its way; and it may continue to flow for days before it is stopped by death or some other cause. If it should amount to as much as four or five tablespoonfuls it would be serious. The greater the outflow of blood the more serious the case and the more quickly it is fatal. Sometimes there is nothing to indicate that such an accident is going to happen; sometimes, on the other hand, it is preceded by high blood-pressure, headache, nosebleed, dizziness, flushing or pallor of the face, or a sense of fullness in the head. Sometimes there are floating bodies before the eyes, or ringing in the ears, rest- less sleep, thickness of speech, dullness of the intellect, a slow or intermittent pulse, and very often constipation. As the hemor- rhage continues the severity of the headache increases; yawning and sighing may follow; and after certain nerve-centers have been compressed by the flowing blood there will be profuse vomiting, perhaps profuse perspiration, and then unconsciousness accom- panied by loud snoring. The unconsciousness may last a few hours or several days, gradually disappear, and end in death. There may be twitching of one or more of the limbs, or there may be very marked convulsions. If the conditions are favorable, the blood which has flowed upon or within the brain becomes clotted, a clot seals the opening in the vessel, and repair begins, the clot shrinking while the pres- sure upon the brain is gradually reduced. Many serious symptoms may result from this pressure. The nerve-cells or fibers which have been broken or destroyed by it cannot be restored, and the parts of the body which are under their control will be damaged perma- nently. Sometimes the clot presses upon the centers which control speech; then the patient has what is called aphasia and is unable 324 HOW TO KEEP WELL to speak distinctly or to say what he desires to say. Almost always there is paralysis of the arm and leg on the side of the body op- posite to the hemorrhage, the only portions that can be moved vol- untarily being the fingers and toes. Not only is the power of motion in the limbs lost, but feeling or sensation may be lost also, and sight and hearing, taste and smell may be more or less im- paired. A very important symptom which must be carefully watched is difficulty in swallowing, on account of the paralysis of the muscles of the throat. The kidneys are frequently diseased in connection with apo- plexy and may have an influence in producing it. When the con- ditions are favorable the bad symptoms gradually clear up; the sense of feeling usually returns first, and then by degrees the power of motion. In many cases, particularly in the aged, complete power of motion is never regained. Control over the power of speech is frequently obtained, but certain words may remain difficult of enunciation. In unfavorable cases the paralysis continues, the patient becomes bedridden, the extremities swell, the mind becomes weak, and death results from exhaustion, from some complicating disease, or from another hemorrhage. Some individuals and some families are predisposed to apoplexy, especially those with bad ar- teries and bad kidneys. When this tendency exists it is favored by overexertion, straining, profound emotion of any kind, coughing, injuries, or anything which increases blood-pressure. Those who have diseased arteries and have had one attack must lead a very simple, temperate life, sleep as much as possible, avoid excitemnt, indigestion, constipation, and getting chilled; in a word, they must do everything in their power to keep down blood-pressure. Treatment by certain drugs and by surgical measures is now much more hopeful than formerly, and those who have had apoplexy frequently live comfortably for years after the first attack. Arteriosclerosis.-Intimately connected with the subject of blood-pressure is that of arteriosclerosis, for it is in this latter con- dition that the blood-pressure is increased in consequence of the sclerosis or hardening of the arteries. It is important to notice that together with this condition of hardening there is also frequently a condition of softening. The outer coat of the artery is that which becomes hardened, and the inner one may at the same time become softened, or, as it is technically termed, atheromatous. The outer DISEASES OF THE BLOOD-VESSELS 325 coat is hardened by an increased growth of the tissue which holds the cells together, the connective tissue, or by the absorption of salts of lime, both of which increase the rigidity and stiffness of the vessel and diminish its elasticity. Arteries which are the seat of arteriosclerosis are, therefore, soft on the inside (that is, in many cases) and inelastic on the outside, and when any unusual strain comes they break or tear, and serious or even fatal hemorrhage may follow. A small portion of the arteries in the body may be thus diseased, or the disease may involve the entire arterial system. Sometimes the arteries of the extremities, especially of the toes, are extensively involved, so extensively that the communication between them and the capillaries of the foot is cut off, and the foot becomes gangrenous and dead for want of proper nourishment. This occasionally takes place in the aged, and it becomes necessary to remove the foot in order to save life. Very frequently the ar- teries of the brain are the seat of this disease, and because they are very fragile they often break, and cerebral hemorrhage or apoplexy is the result. Another occurrence which is less common, resulting from this disease, is aneurism. When there is arterio- sclerosis, the relations of the arteries with the other blood-vessels, the capillaries, and the veins are disturbed, the tissues cannot get the nourishment to which they are accustomed, and so one of the prominent characteristics of the disease is disturbance of the nu- trition ; and this will manifest itself by fatigue, headache, nervous- ness, loss of hearing and trouble with the vision, difficulty in breathing, nosebleed, swelling of the legs, palpitation, and inability to use alcohol or tobacco, even in cases in which they have been used for years. With these symptoms frequently come irritability, failure of the mental powers, asthma, disease of the kidneys and eyes, and in- crease of blood-pressure. These changes may come simply as the result of growing old and of all the degenerative conditions which are the penalty of getting old, but do not misunderstand me as say- ing that such symptoms are essential to all who grow old. Some of the chief causes of this disease are prolonged and severe strains, from work, from emotion, from worry, or from excesses of various kinds. Those who are the victims of infectious disease, of poison- ings of various kinds, of sexual and alcoholic excesses can reason- ably count on having arteriosclerosis if they live long enough. The great thing is to endeavor to keep off the disease by a temper- 326 HOW TO KEEP WELL ate and simple life, by avoidance of stimulants and of too much meat, by the proper use of baths, and by suitable exercise every day. There are numerous drugs which can modify the symptoms of this disease and perhaps stay its progress. The patent medi- cines which are advertised for this disease ought not to be tampered with. Most people who suffer with it are incapable of interpret- ing their symptoms, or of prescribing for them if they recognize them. Blood-Pressure.-It simply means the degree of force which the blood-current in the arteries exerts against their wall under the influence of the contractile force of the heart muscle. This force is measured by the height of a column of mercury in a capillary tube. Any artery in the system can be used for determining this pressure, if the system is in good working order; but an artery of moderate size is better than one which is very large or very small. It is also better to take an artery which is near the surface and which is easily got at. That is why the artery in the wrist, which is called the radial artery, is used for the purpose. Changes in the structure of the arteries may begin at any time, but after middle life there are certain changes which are pretty sure to take place and which in a certain sense are characteristic of mature life and old age. It is therefore a reasonable as well as a very common say- ing that a person is as old as his arteries. In some people the arteries during old age absorb or take up salts of lime from the blood and retain it permanently, so that they may become almost as rigid as pipe-stems and will snap if extra pressure is put upon them. The arteries may also be softened by disease, and in some diseases that is one of the characteristic symptoms. Of course, when any one of these conditions which I have mentioned takes place in the arteries, rupture or breaking is liable to occur at any time; and if it occurs in one of the important parts of the body like the brain, where it occurs very frequently as in apoplexy, the result will be disastrous and usually fatal. There are many varieties of instruments for determining blood- pressure, but they are reducible to two forms; in one it is deter- mined by the height to which a column of mercury is raised in a capillary tube, and in the other by the registrating of an indicator upon a circular dial-plate acted upon by pressure upon a spring. As springs vary in their resisting power from time to time, the mercury instrument is more accurate and reliable. The blood- DISEASES OF THE BLOOD-VESSELS 327 pressure is usually represented by a certain number. That means the pressure which is indicated when the ventricle of the heart contracts and sends out its blood-stream. This is the maximum pressure, but there is also a minimum, and a differential or pulse- pressure which need not be explained at this time. Congestion.-The blood is conveyed to all parts of the body along certain channels or tubes which are more or less flexible and vary greatly in size. These constitute what is known as the vascular system-arteries, capillaries, and veins. The current starts from the heart, passes through the arterial portion of the system; irrigates the tissues of the body through the fine, hair-like, invisible capillaries; and then is gathered up for its return journey to the heart through the veins. It goes to the lungs to be purified and then starts again in its journey over the body, keeping up this cycle day in and day out, year in and year out, as long as life continues. But suppose something happens to a person; perhaps he gets very angry, his face gets red or even purple, and blood- vessels stand out conspicuously where they were not seen before. That means that the impulse of anger has stimulated the heart, which acts like a force-pump, and the blood-current is hurled with increased velocity over the body, particularly to the skin, and the skin becomes red and hot, in other words, congested, until the im- pression of anger passes away and the person cools off and becomes quiet again. Or suppose one has been exposed to cold or fatigue, or has drunk a great quantity of whisky or dissipated in some other way. In this case the heart becomes feeble and is unable to do its pumping with its usual force; then the current of blood from the lungs to the heart slows down, the blood accumulates in the lungs, and the breathing becomes difficult and rapid. Perhaps the con- gestion in this case may be relieved by a hemorrhage from the lungs, or pneumonia may quickly follow with all the chances and dangers which accompany that disease. Any portion of the body, any organ of the body, may suffer from congestion. Probably the lungs are most frequent victims, because a considerable portion of all the blood of the body is constantly in them to be relieved of its carbonic acid and to absorb from the air the life-sustaining oxygen. The liver suffers next in frequency to the lungs from congestion, for it is the largest organ in the body, and a stream of blood is constantly pouring into it through the great portal vein which has been gathered from the blood-vessels of the intestines. 328 HOW TO KEEP WELL The brain often suffers from congestion, and if it is extensive and the blood-vessels have poor resisting power, one or more of them may break, and we have the condition of apoplexy or stroke, which is always a very serious matter. Endarteritis.-It is a disease which very often leads to fatal consequences; indeed when it is once fairly established there is usually little doubt as to what the final result will be. It is a slowly progressing, inflammatory process which attacks the inner of the three coats or layers of which an artery is composed. Athero- matous disease is another term by which it is also known. In rare instances it progresses rapidly, taking the form of an acute disease, as when an embolus or plug of clotted blood is transported from one of the valves of the heart, or one of the large arteries, to a small artery where it blocks up the current, causing irritation of the lining membrane, and, because of the sensitiveness and poor resisting power of the patient, quickly results in ulceration, rup- ture of the artery, and serious or even fatal hemorrhage. In the majority of cases, however, the progress of the disease is slow and chronic but very sure. There are certain diseases which predis- pose to the development of this disturbance in the arteries. Of such diseases alcoholism and specific constitutional disease are the principal ones, others being gout, rheumatism, lead-poisoning, kid- ney-disease, etc. It occurs oftener in men than in women, seldom before the age of forty, and very often after the age of fifty. Over- straining of an artery or arteries seems to be the directly exciting cause, or one of them, at any rate. First there is a thickening of the inner coat of the artery or arteries in various spots or patches; then the accumulation of cells in these patches undergoes fatty de- generation; and as these degenerated cells are washed along by the blood-current, a number of small ulcers or sores appears. Then the blood-current may work its way in those various small open- ings, separating or pulling apart the layers of the arteries from each other, and forming swellings or tumors known as aneurisms, which are liable to break at any time, with more or less severe hemorrhage. Sometimes projecting points or spicules develop in these sores, projecting into the tube of the artery and interfering with the blood-current. Clots may form, and the tube of the artery may be so plugged that the blood-current can no longer flow through it. Then, of course, the tissues formerly supplied by this artery or arteries are deprived of their nourishment and gradu- DISEASES OF THE BLOOD-VESSELS 329 ally wither and die. That is what sometimes occurs in the feet of aged people, from this cause, and one or both of them may have to be removed. In some cases this softening process is followed by deposits of lime in the arteries, and they become hard and brittle like bone or pipe-stems. The great central artery of the body, the aorta, which is at- tached directly to the heart, is frequently a victim, and so are the valves of the heart itself. Material from either of these localities may be washed off by the blood-current and carried along to smaller and smaller arteries. Not infrequently they may lodge in the small and delicate arteries of the brain and cut off the circula- tion in them, leading sometimes to softening of the brain, as its nourishment is cut off, or to rupture and hemorrhage with all the appearance of stroke. When the arteries of the heart are attacked by this disease, the muscular structure of that organ may become softened, as its nutrition becomes impaired; and sooner or later there may be hemorrhages into the sac which surrounds and in- closes the heart, known as the pericardium. From every point of view, therefore, endarteritis is a very undesirable disease and a very bad one to be afflicted with. Gangrene.-Gangrene is simply death and decomposition of the soft tissues, and according as it occurs in different ways and with different appearances, it is moist, dry, white, senile, diphtheritic, diabetic, etc. Gangrene may be due to injury or to disease. The result is the same in either case, death of the tissues. Suppose a person has a boil or a carbuncle. After a few days of severe pain the skin becomes dark, pus pours out from various openings, and gradually the swelling shrinks, there is an offensive odor, and there are shreds and lumps of dead and decayed substance which gradually are separated from the healthy tissues beneath. This process is gangrene of the skin and the structures which it con- tains. Or imagine a very old person with arteries that are hard as pipe-stems. Some day the person will complain of cold and pain and numbness in his feet, and a little later he will notice that the skin of one of his toes is black, there may be moisture on the skin, and presently there is an offensive odor, feeling is lost in the toes, and we have an example of moist and senile gangrene. These toes, and perhaps the foot, must come off, for they are of no further use; indeed, poisons from the dead tissues may be absorbed which will injure or destroy the rest of the body. 330 HOW TO KEEP WELL Again, a portion of the body-a leg or an arm-is crushed in an accident. The doctor does what he can to save the limb, but the blood-vessels and nerves and lymphatics which supply life and nutrition are injured beyond repair, and in a few days there is only a mass of dark, offensive, decomposed skin and muscle, ligaments and tendons. This, too, is a picture of moist gangrene, and the dead tissues must be removed to save those which are living. On a winter's day with the mercury away below zero, a man's fingers are frozen; they are white and without feeling. You rub them, ap- ply cold to them, and do all you can to restore warmth and color, but in vain. They remain white and dead, and because they are useless they, too, must be removed. This is an example of dry, white gangrene. A limb may be compressed for an hour or two by a heavy weight, a drug, like ergot, may be taken in large quantities for several days in succession, a person may fall upon a hot stove, or a caustic metal like chloride of zinc may be applied to the skin. In all these cases we shall have gangrene of the tissues as a re- sult. Similar consequences follow in bad cases of gout and rheuma- tism, and in cases of long-continued debauchery and licentious- ness, Bright's disease, exhausting fevers, diabetes, and diphtheria. Poorly nourished, unhealthy children sometimes have a gangrenous condition of the tissues of the mouth which is very apt to result fatally. Before the blessed era of antisepsis the public hospitals almost everywhere had terrible experiences with what is called hospital-gangrene. It was due to bad care, ignorance of bacteri- ology, dirt, and filth. In diseases of the heart and arteries, known as endocarditis and endarteritis, small clots sometimes form and are propelled into vessels which are too small to permit their further passage. The clot forms a plug called an embolus in such a vessel, and it cuts off the arterial blood-supply to the tissues formerly fed by this vessel. These tissues gradually deprived of nourishment gradually wither and dry up, or may undergo the moist process of gangrene. This is a process common to many diseases. Then we have a con- dition of septicemia, or blood-poisoning, with chills, suppuration, diarrhea, and frequently death. Gangrene always will exist, but its terrors and the scope of its course are infinitely less than they were fifty years ago, before Pasteur and Lister taught us the tre- mendous significance of germ life in the history of disease. DISEASES OF THE BLOOD-VESSELS 331 Nosebleed.-It is one of the commonest occurrences among children; it is rather less common in old age when the blood- vessels are so often diseased; and it is least common in mature and middle life when all the tissues are at their best. Injury is said to be the most prolific cause of nosebleed, a statement of which I am rather doubtful. This we know, however, that blows upon the nose are among the most numerous of accidents, and in these days of boxing and prize-fighting and athletics in general, a bloody nose is of such frequent occurrence that it may not receive the attention and care which it deserves. Even violent blowing of the nose and removal of scabs and crusts which form on the mucous membrane often excite bleeding, while it frequently follows such accidents as fractures of the skull and operations of various kinds upon the nose and throat. This chronic congestion of the nasal mucous membrane is a marked feature in the aged in connection with diseases of the heart, lungs, blood-vessels, liver, and kidneys. It may also be caused in certain cases by the action of certain drugs, such as quinine, phosphorus, and salicylic acid, and by extremes of heat and cold and very low air-pressure. When one ascends from the sea-level to a very high altitude, nosebleed is one of the things he must look out for. Finally, it may be due to certain changes in the blood itself, or to obstruction in some portion of the circulation, or to lowered resistance in the tissues. In the majority of cases nosebleed is to be attacked directly. The simplest form of treatment is that by which hemorrhage in any location may often be arrested, namely by pressure. If the nostrils are sufficiently compressed for a sufficient length of time that may be all that will be required. A plug of cotton-wool thor- oughly moistened with a solution of adrenalin or cocaine and intro- duced high up into the nostril will often check even a troublesome bleeding, and so will powdered alum or tannin insufflated into the nostril with a powder-blower. Solutions of zinc, copper, and silver and the actual cautery are powerful in arresting hemorrhage but require skill and judgment in their use. Other substances which are often used are collodion, gelatin, bismuth, peroxide of hydrogen, and vinegar. If the nostrils are packed with cotton or gauze one must not pack them too tightly nor leave the packing in too long, particularly in the aged. If the hemorrhage is not readily arrested both the patient and the attendant are apt to get excited and lose 332 HOW TO KEEP WELL self-control; therefore before that point is reached it is always wise to call in a physician. Edema.-In the cases in which fluid causes the swelling or edema in the tissues and cavities of the body, we have, in so far as the question is understood by pathologists, either changes in the condition of the blood or overfilling of the blood-vessels from some cause. This overfilling means increase in the pressure within the vessels, and, as the walls of the vessels are to a certain extent porous, the less dense portion of the blood, that is, the serum, is forced or squeezed through these walls, following the line of least resistance, and lodges in or between the tissues, causing them to swell and increase in density or hardness, according to the quan- tity and density of the effused fluid. Those in which it most fre- quently occurs, and in which it is confidently expected, are diseases of the heart and kidneys. In certain stages of chronic Bright's disease it is almost certain to be present in the ankles and legs and under the eyes. In advanced diseases of the heart it may be present in any portion of the body where the tissues are loose and pressure from behind forces the fluid into them. Such cases are some- times described as water-logged, and compression of the skin al- most anywhere will produce a pit or depression which will remain until the pressure from behind fills it up again. This condition of edema is also observable in those who are very anemic, whose blood-pressure is low, and in whom the blood seems to stagnate in the veins. In diabetes edema frequently occurs and adds to the seriousness of the situation. It may occur as one of the symptoms of hardening of the arteries or arteriosclerosis, in neuralgia and neuritis, and in other forms of disease of the nervous system. In the annoying disease of the skin so frequently resulting from in- digestion, and known as urticaria or hives, edema may be present and add a complication which may suggest involvement of the kidneys. If the tissues are very tense the fluid is sometimes withdrawn by means of a needle and aspiration. In dropsy within the ab- dominal cavity large quantities of fluid may be thus removed. This is only a palliative measure, giving relief for a season. If the edema exists to only a moderate extent, the tension in the tissues frequently may be lessened by the use of cathartics, a suf- ficient quantity of fluid being removed by way of the intestines. Rest, with elevation of the limbs, may also bring a measure of DISEASES OF THE BLOOD-VESSELS 333 relief when the swelling in the lower extremities is troublesome. Sweating, hot baths, and various drugs to strengthen the action of the heart and kidneys are also employed. The condition is al- ways one which calls for the help of a doctor. It is not wise to neglect it, even though the discomfort it causes may not be great. Phlebitis.-Phlebitis means inflammation of a vein or veins. Sometimes one vein is involved and sometimes several. The disease may occur in any portion of the body, but the veins of the lower extremities are the ones concerned in a great majority of cases. It may be due to a variety of causes. I suppose there are those who would insist that it is always associated with infection and infec- tious germs. It is very often associated with injury to a vein- an injury during childbirth, an injury during a surgical operation, a cut or a bruise, an injury to veins already enlarged or varicose and already diseased or very susceptible to disease. Such is the condition of the veins when one or more of them contain clots which may extend and ramify over a considerable portion of a limb, or when they are already thickened and narrowed in connection with rheumatism, gout, specific constitutional disease, anemia, certain infectious fevers, tuberculosis, and cancer. A fatal issue will occur if the end of a clot becomes detached and is borne by the circulation to the heart or lungs, death in such cases occurring suddenly and without warning. It is difficult and often impossible to determine an inflammation of veins that are deeply seated. When the inflammation extends from them, as it often does, to the superficial veins, or when it originates in the veins near the surface, these vessels become tender, swollen, knotted, and hard; they may stand out prominently from the skin, and may, from a certain point where the blood-cur- rent is manifestly interrupted to the next vein in which the cur- rent continues, become plainly visible until the infiltration of the skin and underlying tissues with the fluid which is a product of the inflammation obliterates them, and the entire affected limb be- comes enlarged, hard, and glossy. The limb is tender or even pain- ful, the joints are stiff, and the limb is out of commission. The inflammation may announce itself, as infectious and septic condi- tions frequently do, by a more or less severe chill followed by fever. If the patient be not already in bed he must go to bed at once. In any event the disease, unless it is of an extremely mild type, 334 HOW TO KEEP WELL progresses rapidly, and the utmost care, with good nursing, is imperative to restrict and restrain the symptoms when this is possi- ble. Only simple and easily digested food, like milk, soup, and cereals, may be given. The bowels must be kept freely open, for this is the principal avenue by which the poisons developed by the disease may be eliminated. The limb must be elevated five or six inches from the surface of the bed and must be covered with cloths or loosely wound bandages moist with sedative lotions. Leeches are sometimes used to draw off the fluid in the tissues and so re- duce the tension. If abscess occurs, incision and drainage must be resorted to. Not until days or weeks after the acute symptoms have subsided will it be prudent to massage the limb, and even then it must be done with great gentleness, lest a portion of a clot be detached. Raynaud's Disease.-This is a disease in which there are func- tional changes in the blood-vessels, but, so far as has as yet been discovered, there is no organic change in them. It affects the fingers and toes principally but not exclusively, for other portions of the body may be implicated. The vessels are contracted, with resulting pallor and apparent deadness of the skin; and this condi- tion may be followed by their dilatation, with a purple and then a red color of the skin. It often leads to loss of vitality and even to death of the tissues. In Raynaud's disease the symptoms are similar to those in frost-bite and are due to the action of nerves which are supplied to the blood-vessels called the vaso-motor nerves. In the one case these nerves are stimulated, causing con- striction or squeezing of the vessels and exclusion of the current of blood; in the other they are paralyzed, the vessels dilate, the current of blood flows in again, and the color returns to the skin. Women have it more frequently than men. It occurs usually be- tween the ages of ten and thirty, and it has sometimes been noted as a family characteristic, several members of one family havinr what are commonly known as dead fingers. Besides the fingers, especially the middle finger of the left hand, the toes, the ears, and the nose may be implicated. The attacks may be mild or severe and may occur eight or ten times a day. They may be brought on by fright or emotion of any kind, especially in high-strung women; and they are favored by cold and dampness. A finger that is cold and apparently dead may remain that way for an hour or more, then change to blue and then to red. If the disturbance DISEASES OF THE BLOOD-VESSELS 335 to the circulation is prolonged, death of the tissues will result; in the less severe cases there will be blisters and slight destruction of the skin; in the more severe ones there will be gangrene of the ears, the nose, the fingers, or the toes. As in the case of frost-bite, there may be serious complications, especially if it should happen that there is disease in the blood- vessels, as in arteriosclerosis and some other diseases. These may take the form of dizziness, disturbance in the vision, depression, fainting, epilepsy, albuminuria, etc. This disease is not unknown in connection with such diseases as diabetes, malaria, pneumonia, and typhoid fever. When an attack comes on, the proper course is to relieve the pain and try to restore the circulation as soon as possible. The affected parts should be carefully massaged; the galvanic current may be used; baths to stimulate the circulation of the skin, like the carbonic acid baths, may be taken; and the general regimen should have as its object the building up of the system and the nervous system in particular. Thromboangiitis.-When an artery or a vein is tied, the current of blood which was flowing through it is, of course, cut off. The blood-current is dammed back, the vessel becoming dilated in the process and making a new channel for itself in the nearest availa- ble blood-vessel which is not obstructed. But in an obstructed blood-vessel something else happens. There is in the blood a substance called fibrin, by means of which the blood coagulates or clots. When the blood is flowing freely there is no occasion for the fibrin to produce a clot; but when the current is slowed up for any cause, or the wall of the blood-vessel becomes roughened in any way, or the blood is exposed to the air, the fibrin comes to the front and clots or coagulates the portion of blood which has been disturbed by any of the conditions mentioned. The clot thus formed in a blood-vessel extends back to the blood-vessel along which the blood-current makes its new channel, and sometimes even farther than this. This newly formed clot is called a thrombus, and the surgical disease produced by it is called thrombosis. Now, there may have been disease-germs in the blood from which the clot was formed, or in the innermost of the three layers or walls of which the blood-vessels are composed. These germs set up in- flammation in the blood-clot, or in the wall of the blood-vessel, or both, resulting in the formation of pus, which may be putrid and of foul odor, one or more abscesses being the consequence. Usually 336 HOW TO KEEP WELL the tissue around the blood-vessel is also inflamed; in fact, the inflammation may begin in this tissue and extend to the blood- vessel, and this condition is called thromboangiitis. There are fever and discomfort in this disease, but what is worse, the blood- current often washes off the end of a thrombus, this being called an embolus, and carries it to the liver, the lungs, spleen, or kidneys, where it becomes lodged, and, being infected, sets up inflammation leading to abscess in those important organs. Thrombosis.-A blood-clot may form in a vein after any kind of an injury to it, and it will extend in both directions, being in- creased by deposits of fibrin, which are taken out of the blood as it flows along when the wall of the vein is roughened by any cause whatsoever. A clot may be formed by pressure upon a vessel, causing slowing of the current and development from the blood of the fibrin which is the essential element in producing a clot. Should a blood-vessel become dilated and the current retarded, it might lead to the formation of a clot; a clot might also form when the current is habitually slow, as in aged people. After the operation of bleeding or venesection which used to be performed for every con- ceivable ailment, a clot always formed in the large vein at the bend of the elbow, which was opened for this purpose; and it is re- markable that so comparatively few serious cases of blood-poison- ing followed this operation, in view of the careless way in which it was usually done. If inflammation does not follow the formation of a thrombus and there is no infection, the blood-vessel in which it is located is necessarily withdrawn from the circulation, the clot becomes hard and, with the vessel which incloses it, becomes firm and organized tissue, its work as a part of the system of blood- vessels being ended. While this change is going on, the tissues around the obstructed vessel are infiltrated and hard, and it may be several weeks before they resume their soft and natural condi- tion. In other cases the clot in the vessel softens, disintegrates, and is liquefied, and after a time the blood may course through the vessel as before. In yet other cases, when infection has taken place, the vessel and the surrounding tissues become inflamed, an abscess forms, and this may cause disturbance of a more or less serious nature. Varicose Veins.-Varicose veins are simply enlarged, dilated, and perhaps thickened veins. They may appear on any part of the body, but occur most frequently on the lower extremities, DISEASES OF THE BLOOD-VESSELS 337 where phlebitis is usually found. They are present either in superficial veins or in deep ones; if in those which are deep, they are not always easy to discover. A number of small veins in a group or bunch may be varicose, or there may be only a single one extending, perhaps, along almost the entire length of the leg. This will be a dilated, knotted, bluish cord, sometimes hard and sometimes soft. In some cases it may extend to the lower part of the abdomen, crossing it and ramifying in distinct blue lines. This is especially the case when the circulation of the veins is im- peded by pressure; for example, by the pressure of an abdominal tumor, or by a developing child in the later months of pregnancy. As a partial safeguard, there are valves in the veins at short inter- vals to prevent a back-flow and damming of the blood in the lower extremities. The tendency of the column of blood to fall back is very great in those who have hearts with poor pumping capacity, or who must stand all day at their work, or whose tissues are weak- ened by disease, flabby, and capable of offering little support to the vein wall. This in time causes the dilated condition, while the knotted condition marks the attempt of the valves to resist the backward flow. The circulation may even leave these veins, making new channels for itself, the veins becoming hard and thick and found empty when opened. In other cases the blood-pressure of the struggling blood-current in the lower part of the limbs causes fluid to pass out of the veins and into the surrounding tissues, making them thick and hard; and a slight injury or even constant pressure upon the weakened skin will break it, a sore or ulcer be- ing formed, which may heal slowly or with difficulty or not at all. Eruptions of eczema or other skin-diseases also may appear in the skin adjacent to the ulcer and increase the difficulty of the situation. It is not very unusual that the breaking down of the tissues is accompanied with more or less profuse hemorrhage, which can usually be controlled by simple pressure. Those who suffer with varicose veins become fatigued easily, and the pain and aching in their tissues prevent them from doing active and continuous work. The condition seldom occurs in children, but is very common in clerks, bookkeepers, house- servants, and any who stand hour after hour at their work and get very little active exercise from their leg-muscles. Women suffer from it more frequently than men-especially those whose circula- tion is obstructed by tight garters or who must lift heavy burdens 338 HOW TO KEEP WELL in connection with their work. Obstructed circulation in connect tion with diseases of the heart, lungs, and kidneys-in fact, with disease of any of the internal organs-may be followed by varicose veins. There is nothing better for treatment that I have found than a rubber bandage two or two and a half inches wide, carefully wound, but not too tightly, from toes to knee or even higher if necessary. This can be worn without inconvenience and with great comfort during the day. It should be removed and cleansed with an anti- septic solution at night, and in the morning applied again. If the veins are much enlarged and constantly painful, it will be wise to rest a week or two, lying on a couch during the day, if desired, but always having the foot elevated six inches or more above the level of the body. When the pain and swelling have subsided, the bandage may be used and ordinary duties resumed. Should actual inflammation occur, the condition must not be trifled with, the patient must remain in bed with foot elevated, soothing antiseptic lotions must be constantly used over the inflamed area, and, should suppuration occur, the abscess thus caused must be freely opened. In some very troublesome cases the veins have been tied and portions or even all of them removed. CHAPTER XVI DISEASES OF THE BLOOD Anemia.-Anemia means deficiency of blood. When a person has lost a quart or more of blood by a hemorrhage from the lungs, or an injury, or a severe surgical operation, or in child- birth, that person becomes anemic; that is, he or she hasn't as much blood as he or she requires for good health. When a man cuts his throat, or there is a rupture of a blood-vessel in his brain, or a dilated artery called an aneurism breaks, there is so great a loss of blood that he dies, for blood is essential to life. It used to be thought that because the blood carried humors and diseases over the body it was a good plan to draw off some of it occasionally, and bleeding was the fashionable practice for almost every kind of ailment. Sometimes it worked well and people were relieved by it, but very often it was mischievous, and a person who had been bled several times in the course of a disease became so anemic that he was practically or even actually killed by the doctor's method of treatment. A person who has plenty of blood may be anemic if the blood is of poor quality. In such cases the blood lacks the proper quantity of coloring material called hemoglobin, which contains iron and oxygen. Iron and oxygen are therefore essential to the body and to the blood. A person who is anemic is pale, not for a few moments only, as in fright or sudden emotion, but all the time; the face, the lips, the entire skin are colorless like those of the dead. Or the skin may be of a greenish-white appearance, as is frequently the case in poorly developed and poorly nourished young girls or in those who are suffering from tuberculosis or cancer or malaria or lead-poisoning. When there is anemia there is almost always loss of appetite, loss of strength, loss of weight, and poor nutrition. Those who are anemic often have buzzing in the ears, dizziness, faintness, and shortness of 339 340 HOW TO KEEP WELL breath. All of this means not only that the blood is insufficient, poor, wanting in substances which build up the body, but that the heart, by whose action the blood is kept in motion, is unable to do proper work, that the kidneys cannot perform their task, that the lungs do not contract vigorously enough to supply the blood with the proper amount of oxygen, and consequently that the brain is unable to respond to the usual demands which result in thought. An anemic person under any circumstances is, there- fore, more or less disqualified from doing work; in many cases he is entirely helpless. What medicines can he take to build him up? I'll tell you what I think an anemic person chiefly needs: rest, sleep, fresh air, and simple food. These will give him oxygen, stimulate his appetite, and furnish his blood with those elements which it lacks; then his organs will work properly, and in the majority of cases he will get well. There are medicines which sometimes can be used to advantage, chief among them being iron. There are hun- dreds of preparations of iron on the market, and most of them are almost as useful as a solution of rusty nails. Iron, in order to be appropriated by the blood, must be in a colloidal or organic form, and there are a few good preparations of this kind of iron. Strych- nia and quinine are also useful, particularly when the anemia is due to malarial or other poisoning. If the anemia is due to a germ or a poison of some kind it is quite proper to use a medicine which will kill the germ or be an antidote to the poison. Some medicines, like cod-liver oil, have a food value, and they may be taken to the limit of toleration by the stomach. The emphasis in treating anemia must be laid upon such medicines as milk, eggs, cereals, and roast beef. Blood-Poisoning and Its Treatment.-Blood-poisoning implies that infectious germs or bacteria have been introduced into the blood-current and have produced unpleasant or serious symptoms which in a general way we call poisoning. Three grades or classes of blood-poisoning are now recognized. In the first germs are received through a break in the skin, whether this be a prick or a bruise, a cut or a gash. They find favorable conditions and within a few hours or days produce inflammation with pain, heat, redness, and swelling at the seat of the injury. Under proper treatment this inflammation is arrested or it is of a mild type and soon over; or a few germs get into the lymph and blood-currents DISEASES OF THE BLOOD 341 and are destroyed by the defensive organisms or phagocytes which are in the blood. The blood has been poisoned, but to so slight an extent that it has made little impression on the patient's general condition; perhaps no more impression than is made by a boil, a sty, or a pimple. But in another case the injury may be precisely the same as in the first instance, but the germs are of a more virulent type, and the patient is weak and deficient in resisting power. The conditions at the seat of the injury may or may not be more intense than in the first; but more germs get into the blood, and they have better opportunities to grow. The patient complains of headache, chilliness, nausea, and pains throughout the body; his skin is hot and dry; the inflammation extends up his arm, which becomes red and swollen; the glands in the armpit become in- flamed, and may suppurate; the heart becomes disturbed; its action is weak and irregular; and there is a general weakness and pros- tration. The patient is obliged to take to his bed and may be very weak and sick for weeks, after which he will slowly recover; or he may be unable to stand the pain and exhaustion of the disease and die from the prostrating effects of the poisons or from some complication like pneumonia or peritonitis, which has developed out of the blood-poisoning. In the third form the germs are most virulent, so virulent that no matter what the resisting power of the patient, they will be too strong for him. He is quickly prostrated; his wound sup- purates profusely; abscesses form in glands in many parts of the body; and pus circulates in the blood. This extreme form of blood-poisoning is known as pyemia and is almost always fatal, no matter how careful the treatment. The principles of treatment in these different grades of poisoning are the same and consist in conserving and supporting the strength with an abundance of nutritious food, in skilful nursing, in doing everything which will encourage rest and sleep, and in the proper use of antiseptics to kill the germs or to prevent, as far as may be, their entrance into the blood-current. Iodine is one of the most useful antiseptics for application to the skin. For the treatment of wounds, pre- parations of mercury, salicylic, boric, and carbolic acids are used. The secretions of a wound must not be retained but must have the freest exit. During the late war infectious wounds were treated with the greatest success by the very free use of the Dakin- 342 HOW TO KEEP WELL Carrel solution of hypochlorite of soda, plus a small percentage of boric acid. Caisson Disease.-It is only within the past thirty or forty years that the symptoms attending work under high atmospheric pressure have been studied and formulated under the name of caisson disease. Divers, miners, and workers in tunnels under water and in mountains are subjected to this unusual pressure, which is sometimes as much as three or four atmospheres, and which gives rise to conditions which may prove serious or fatal. It may not be generally known that in working in a place in which the air-pressure is unusual the workman first enters a lock in which the air-pressure is gradually raised and then proceeds to the tunnel or caisson in which he does his work under the in- creased pressure. When his work is done he again enters the lock where the air-pressure is gradually reduced and, after a sufficient period of decompression, returns to the ordinary atmos- phere. If the person doing this work is young and vigorous his experience during the first month is one of exhilaration, his ap- petite increases, his hair grows rapidly, and his muscular strength and endurance increase. His pulse continues normal, and his breathing is normal but shallow. The excess of oxygen which he has inhaled causes increased lung-capacity, but his abdominal wall falls in on account of the increased pressure. While he is undergoing decompression he has pain in the ears, deafness, and dizziness and his voice has a metallic ring. The white cells of his blood increase in number, and the coloring-matter or hemoglobin diminishes, causing pallor of the skin. After a month of such labor he becomes depressed and experiences loss of appetite, anemia, emaciation, and indifference to his surroundings. He may also suffer from defective vision, ringing in the ears, and mental confusion. He has pains in his muscles and joints commonly called "bends" and perhaps loses control of his bladder and rectum. His pulse becomes rapid; he perspires profusely and has pain in his abdomen and numbness or paralysis in his limbs. Hemor- rhages within his spinal column result in paralysis of motion and sensation in his muscles, and he may also have nosebleed, faint- ness, convulsions, pain in the back and extremities, and loss of speech. This results from forcing too much oxygen and nitrogen into the blood and tissues, the air-globules in the blood-vessels acting as plugs to the blood-current and producing hemorrhage DISEASES OF THE BLOOD 343 into the tissues. These results usually happen during decom- pression, especially if it is done too rapidly. It is, therefore, all- important that the lock-tender should not reduce the air-pressure more than one pound in four to nine minutes. If these bad symp- toms occur the patient must be returned to the lock and recom- pressed, and this with heat and massage will in most cases relieve the pain and paralysis. After a person has had one attack of this kind he should get another kind of a job. Hemophilia.-The disease is one which affects the composition of the blood itself. It means that the blood is deficient in fibrin, which is a substance that is inactive while the blood is circulating in the blood-vessels, but active when it escapes from these vessels to the external world or to one of the cavities of the body. It is through the agency of fibrin that escaped blood coagulates or clots, and a clot sealing an opening in a ruptured blood-vessel is nature's measure for arresting the bleeding. It is a principle that always must be remembered that blood is a vital substance; loss of a sufficient quantity of it must inevitably mean loss of life; and nature's plan is to conserve it to the greatest possible extent by means of fibrin and the clot which it produces. One who has hemophilia or is a hemophiliac has no such safeguard, or has it only to a slight degree. When bleeding takes place in such a person it continues indefinitely, possibly until death has occurred, and at- tempts to stop it are often disappointing and futile. People are born with it, and it is very difficult or impossible to get rid of it. Hemophilia is more common in women and girls than in men and boys and may be acquired by habits and occupations which conduce to the thinning of the blood. Sometimes there are families which are predisposed to this disease, and it recurs in their members generation after generation. Infants frequently suffer with it, even the newly born, and may bleed to exhaustion from the nose, mouth, or rectum, or into the tissues and cavities of the body. Children may show their predisposition to this disease by bleeding profusely after an attack of scarlet fever or chicken-pox, after vaccination, the extraction of a tooth, or a pinch or scratch. Hemorrhage in bleeders may be external or internal and is particu- larly prone to affect the mucous membranes, occurring often with- out any justifiable cause. It may also occur into the joints and cavities of the body or into the bowel, the bladder, or the brain. It may not occur until after a surgical operation. In fact, the vic- 344 HOW TO KEEP WELL tim may be unaware that he has such a trouble, and it may be dis- covered only as the surgeon finds the difficulty of checking it al- most insuperable. It is revealed in many cases for the first time at the end of childbirth, when it may come in an appalling volume which not infrequently ends life in a very few minutes. One who is aware that he has such a weakness should always be cautious about exposing himself to blows, bruises, or even vio- lent exercise. It is not well for bleeders to marry, if they are aware of their weakness, for they may transmit it to their children. Preparations of lime have been much in vogue in recent years in the treatment of bleeding sickness. Substances which are in com- mon use for the arrest of bleeding are ergot, adrenalin, thyroid extract, cotton-root, and various preparations of iron. It is said that the most effective substance is blood serum from the human being, the horse, or the rabbit. The simplest way to stop bleeding when it is at the surface of the body is by pressure-pressure with the finger or any convenient instrument. The trouble usually is that people are so much excited when they see blood flowing that they lose self-control and do not apply pressure where it would have the best mechanical advantage. Leucemia.-The paleness of the blood in leucemia is due to the fact that the white blood-cells, which have a normal relation to the red cells as one to five hundred, may be as numerous as one to ten, or even one to one. Not only are the white cells greatly increased in number, but the red cells are greatly diminished, and the hemoglobin, which is the oxygen- and iron-bearing constituent of the red cells, is reduced fifty per cent. Furthermore the bone- marrow undergoes degenerative changes; the spleen becomes enormously enlarged, and so do the lymphatic glands; and as these are supposed to have more or less to do with the formation of white blood-cells, their diseased condition may bear a direct relation to the great increase in the number of these cells. In the chronic form, which is the more common one, it usually occurs between the ages of twenty and fifty and lasts from one to five years. Its diag- nosis can only be made with positiveness by a careful examination of the blood, because there are other diseases which have many symptoms in common with those of leucemia. Unfortunately the disease may be fully developed when attention is first called to it, perhaps by pain and swelling in the region of the spleen, or by tenderness of the bones upon pressure. Or there may be a profuse DISEASES OF THE BLOOD 345 nosebleed or a hemorrhage in some other portion of the body. Fur- ther investigation probably would show that the patient had been ailing and half sick for months, had had poor appetite, became fatigued after the least exertion, and had been steadily losing weight. After a few weeks or months the pallor of his skin becomes very no- ticeable, he frequently is dizzy, and he has troublesome headaches, great difficulty in breathing, and swelling of the feet and ankles. Sometimes his urine contains albumen, and sometimes it does not. He constantly has several degrees of fever and occasionally has hemorrhages from the mucous membranes or even into the brain, which may be alarming and serious. Then there are peculiar sen- sations. Sometimes the skin is unusually sensitive; sometimes it is without feeling; it is numb at one time and burning at another. There are dullness of vision, deafness, ringing in the ears, melan- cholia, or delirium, and if a hemorrhage into the brain occurs there may be complete paralysis. Not only is the spleen greatly enlarged, but the liver also, and both may be very painful on pressure. The enlargement of these organs causes displacement of the heart, and a valvular murmur may be heard. Gradually the lymphatic glands become enlarged, and in one form of the disease this is one of the earliest symptoms. In this form there is also intense itching of the skin, and there may be all kinds of skin-eruptions. When the disease is acute and runs its course to a fatal end in a few days, pain, weakness and hemorrhages are its first indications. The pulse in such cases is rapid and feeble; the temperature is high, until just before death, when it suddenly drops, and there is great difficulty in getting air enough into the lungs. The cause of this strange disease is not known. It probably is infectious and may be due to certain undiscovered bacteria. Some cases have improved under arsenic, benzol, and X-ray, but such improvement has been tem- porary, and the patient ultimately has succumbed to the disease, when not carried off by some complicating disturbance. Pernicious Anemia.-Ordinary anemia is often only temporary, and with good care and treatment it disappears in a few weeks or months. But when the pallor is excessive, the prostration extreme, and the degeneration of the blood overpowering, we have a condi- tion called pernicious anemia, which, though it may continue through months or even years, is very serious and in the majority of cases fatal. This condition may come on suddenly, as in new- born infants or in pregnant or puerperal women, or it may come 346 HOW TO KEEP WELL on gradually until it is past relief. The pallor of the face and body becomes extreme, though it sometimes deepens into a lemon yellow, which is striking in appearance. With this discoloration are great weakness, heart palpitations, difficulty in breathing, frequent sigh- ing, slowness of speech, rapid pulse, and fever. There are heart- murmurs, caused by the condition of the blood; swelling of the ankles; the face; and the lungs; dropsy of the body; and hemor- rhages of the retina. The appetite may be good and the weight and nutrition may be maintained, but there will be trouble in the stom- ach and intestines, nausea, vomiting, diarrhea, pale and dirty tongue and gums, tenderness over the stomach, and tenderness over the bones. Frequently there will be dizziness upon slight exertion, sometimes sleeplessness and sometimes drowsiness, but always great weakness and faintness with even moderate effort and exer- tion. Delirium and incessant headache and irritability are present in some cases, neuralgia and numbness in others. The blood is pale, and when drawn it does not clot easily if at all; the red corpuscles are disfigured, imperfect, and greatly diminished in number. Per- haps there may not be more than one tenth of the normal number. This pernicious condition is due to a great variety of causes, to poisons of various kinds, especially mineral poisons, to severe hemorrhages, to profound emotions, to infections of the mouth and intestines, etc. The disease may last, as stated above, through many months, with periods of improvement, but the blood remains defective, deficient in hemoglobin, iron, potassium, and fat, and excessive in water and chlorine. It is most common in males be- tween the ages of twenty and forty. Those who have this disease should remain in bed, have massage, practise light gymnastics, and have their diet carefully regulated. Arsenic is one of the few drugs which has a certain amount of control over it, and salvarsan and neosalvarsan have been used for it with a moderate degree of success. Transfusion of blood also is one of the recent measures of treatment found efficacious. Tonics.-A tonic is something which gives tone and strength to the body, reinvigorating relaxed and inert tissues, reanimating the functions which may have become defective and inefficient, put- ting vitality into the blood and nerves; in short, bringing an organ- ism, which was below par in one way or another, back to normal conditions. The human body assimilates to itself substances that are animal, vegetable, or mineral in character, for it normally is DISEASES OF THE BLOOD 347 composed of all these elements; hence it uses as tonics appropriate substances of all these classes. Certain vegetables have been found very useful for this purpose. Among them are nux vomica and its active principle, strychnia; quassia, gentian, cinchona, and quinine, the active principle of cinchona. Alcohol is a very useful member of this group of remedies, and, partly because of its solvent proper- ties, is often combined with them. Another valuable substance de- rived from the mineral world as a tonic is arsenic, which in suitable doses stimulates the appetite, improves the digestion, and increases the body force generally. Another important effect produced by tonics acting through the digestive system is the antiseptic action upon the substances in the stomach and intestine, fermentation and putrefaction being prevented, and the formation of harmful poisons arrested. Cod-liver oil is a tonic of animal origin used to an enor- mous extent, being emulsified in the intestine and then absorbed and distributed to the tissues, not only increasing weight and improv- ing nutrition, but adding to the body necessary substances like iodine, bromine, and phosphorus. Iron is a tonic of the mineral class which is used extensively and is often extremely beneficial. Those forms of iron are most efficient which are colloidal in character; that is, similar to the iron which is organic in animals and vegetables. Most important tonics are the minerals-mercury, arsenic, phosphorus, iodine, etc. These act more or less through the blood, changing its character and frequently destroying noxious germs which it contains. Ar- senic and mercury are the great medicines in the treatment of syphilis, while phosphorus often has a most beneficial action on diseases of the nervous system. A particular class of vegetable tonics seems to h?ve a more or less direct action upon the heart, and when we realize that diseases of the heart are among the most fatal of all ailments their importance cannot be overestimated. The member of this group which is supereminent is digitalis. It may be regarded as one of the most valuable drugs in the entire pharmaco- poeia. CHAPTER XVII DISEASES OF THE NERVOUS SYSTEM Bell's Palsy or Facial Paralysis.-Facial paralysis is the com- monest form of paralysis experienced by human beings. It is also called Bell's palsy or Bell's paralysis. It means that the muscles of one or both sides of the face which are controlled by the branches of the motor nerve of the face are unable to move, and this results in a great many uncomfortable symptoms. All or a portion of one side of the face, or both sides, may be paralyzed. The paralysis may be more or less complete, and it may last a few hours, a few weeks, or a lifetime. It can come from many causes; probably that which causes it most frequently is exposure to cold, which means that it is more common in cold than in warm weather. It is often due to injury, to blows on the face, to bullet- and stab-wounds, and to fracture of the bones on the side of the face. It is sometimes caused by the pressure of a blood-clot within the skull after a surgical operation on the face or ear, or an injury. In new-born babies it is not uncommon if a severe forceps operation has been necessary in the birth of the child. It often follows disease of the parotid glands (the ones which are inflamed in mumps) and of other glands, disease of the internal ear, diphtheria, and smallpox, and it may be caused by the pressure of bony and other tumors within the skull. It is the paralysis which often accompanies rheumatism and is sometimes called rheumatic paralysis. It occurs most often between the ages of twenty and forty, with about equal frequency in men and women. It may come sud- denly or gradually. If one has been exposed to a strong wind for hours in a long automobile trip he may wake up next morning with this disease affecting the whole side of his face, or it may paralyze the parts supplied by one part of the nerve and gradually extend to others. It may be preceded by pain in the face and ear, noises 348 DISEASES OF THE NERVOUS SYSTEM 349 in the head, deafness, and more or less loss of taste. If only one side is paralyzed, that portion will be smooth, the wrinkles dis- appearing, while the other side looks natural. Motion on the paralyzed side is out of the question; you cannot close the eye, the tears roll constantly over the face, the nostril falls instead of expanding in inspiration, the mouth is drawn to the unparalyzed side, the cheek puffs out in speech, which is indistinct, and the saliva dribbles from the mouth. This condition is not without danger, for the muscles of swallowing are often paralyzed on one side, and the food may cause choking in attempts to swal- low. In some cases the hearing is abnormally acute, and in others there is complete deafness on one side. There is also loss of taste in a greater or lesser portion of the tongue, especially for things which are acid, sweet, or salt; there is diminished sense of smell and dryness of the nostril. The sense of feeling in the face may be unimpaired, or the nerve which controls it may share in the trouble which has paralyzed the motor nerve, and feeling may be abolished. When both sides of the face are paralyzed the danger of the situation is increased, and it is constantly necessary to be on guard against suffocation. In new-born infants the par- alysis may pass off in a few hours or a few days. One of the most important means of treating this disease is the electric current, either the faradic or galvanic or both as may be deemed proper, and also careful massage given as a substitute for the inaction which has been imposed upon both the muscles and the nerves. It is also necessary to be careful about the diet on account of inability properly to masticate and swallow the food. Beriberi.-This tropical disease obtained its name in Ceylon, where it long has been prevalent. In Eastern countries, at any rate, it is said to result from the excessive use of polished rice; that is, rice which in the process of milling has been deprived of its husk. It is a form of the disease which is known in this country by the name of multiple neuritis. Besides great weak- ness, it is marked by general pains, soreness and weakness of the muscles, gradual loss of muscular power and the sense of touch, and shriveling and shrinking of the muscular tissue. With these symptoms are those which are usual in conditions of disordered nutrition-headache, coated tongue, loss of appetite, fever, and bowel disorder. Two forms are described, the wet and the dry. 350 HOW TO KEEP WELL In the wet form there is swelling in the lower extremities, which gradually extends to the entire body; the breathing is labored, and the heart-action weak. It may begin with a chill, as is so often the case with fevers; there is great prostration, and death from exhaustion may result in a few days. Or the swelling may subside, the heart-action improve, and muscular paralysis follow; and this also may gradually improve, and recovery may slowly take place. In the dry variety there is less swelling of the tissues and less disturbance in the heart-action, but there is more nerve- disorder and pain, the latter often sharp and tingling, with pro- gressive evidence of a disordered condition of the skin. The sense of touch becomes defective, the muscles fail to contract properly, there are frequent and painful cramps and spasms of the muscles, the muscles gradually become shriveled and paralyzed, and the joints fail to perform their proper function. With these cases there are also fever and disordered condition of the stomach. This condition may last for weeks or months, with more or less improvement in some cases and death in others. It appears in camps, hospitals, and almshouses, and on shipboard. Not infrequently it is brought to this country. In addition to the theory of polished rice as the apparent cause of the disease in tropical countries, it is necessary to add that it may also be caused by insufficient or unsuitable food of other kinds, by ex- posure to dampness and cold, by unhygienic and unsanitary conditions of living, by alcohol, syphilis, and malaria, and by metallic poisoning. The disease calls for proper regulation of the diet, for use of the unpolished rice or rice bran in cases in which rice is the principal article of food, and for improvement in the sanitary surroundings and in the habits of living in cases in which the habits have been bad. Under favorable conditions of treat- ment many of those who suffer with this disease will recover wholly or in part. It will be recalled that the husk in rice and other cereals contains the vitamins which are so essential to nutrition. Epilepsy.-In an epileptic attack there are convulsions-that is, involuntary contractions of all or a portion of the muscles of the body-with partial or complete unconsciousness. These at- tacks come on suddenly, usually at irregular intervals, with or without warning, and last from a few seconds to a minute or two. When the patient comes to his senses he is usually exhausted, for the muscular contractions are equivalent to hard muscular DISEASES OF THE NERVOUS SYSTEM 351 labor, and he falls asleep and may sleep for hours. The effect of this disease as it continues is gradually to produce weakness in mind and body; it often terminates in insanity. The disease is as old as civilization and perhaps much older. Sometimes there is a so-called masked epilepsy with neither spasm nor uncon- sciousness, but with sudden happenings in the mind or the muscles, frequently repeated or without warning, and with no recollection of these happenings afterward. There is epilepsy which comes in the morning or the evening, and that which comes only at night. An attack of any of these forms often comes with a warning or aura, and it is most important to heed it, for it often points to the source of the disease. It may be the sensation of a ball rising in the throat, a flash of light, blindness, deafness, a great noise, sudden pain in the extremities, and a great many other sensations. It may last but an instant and it may last longer. In the small disease, petit mal, as the French call it, there may or may not be a warning, and perhaps only a nodding of the head, or a violent explosion of speech, or a contraction of a par- ticular group of muscles. This form may ultimately develop into the large disease, or grand mal, which very often has the warning. There is a cry, a scream, unconsciousness, a fall, stiffness of the whole body, and then contraction of one group of muscles after another. The patient snores violently, becomes a livid pale or dark blue and has frothy or bloody saliva at the lips, and there may be want of control of the contents of the bowel and bladder. The tongue often gets between the teeth and may be badly bit- ten; hence a stick or a cork should be placed between the jaws before they are tightly closed. The disease usually begins early in life, especially in female children of nervous, hysterical parents. It may result from such diseases as meningitis and scarlet and typhoid fever, from sunstroke, from scars in various parts of the body, and especially from the irritation of depressed bone in the skull, pressing upon the brain and its membranes. It may also result from certain trying occupations, from bad teeth, from eye- strain, and from disease of the nose and ears. In many and per- haps all of the cases there is a diseased condition of the gray matter of the brain and brain anemia. Death may occur as the result of a fit, from injury during the fit, or from exposure leading to bronchitis or pneumonia. 352 HOW TO KEEP WELL The longer the disease lasts the more difficult will it be to cure it; a convulsion habit becomes established. Treatment must be considered from various points of view. Drugs are often given, especially the bromides, which stupefy the patient and arrest the spasms but only substitute one disease for another. Rattlesnake venom was thought to be curative, but the latest accounts are unfavorable. Certain French pharmaceutical preparations have claimed great efficiency; I cannot say whether they are well founded. In a moderate number of cases an operation on the skull and brain has been successful, especially when the brain and its membranes were the seat of irritation. The most successful treat- ment is the colony or village plan, in which a business is made of treating this disease alone. Those who are subject to epilepsy must eat the plainest food, not too much of it, and not too much meat. Two meals daily will usually suffice. Indigestion and constipation with the development of intestinal poisons must be avoided at any cost. It is not usually desirable for epileptics to be under treatment and attending to business at the same time. Headache.-It may involve the entire head or half of it, the top, back, or forehead, or it may be limited to a single point, and it may be accompanied by a gush of tears. It also gives us the greatest variety of pains, slight, severe, dull, sharp, darting, paroxysmal, continuous. It may last for a few minutes, or it may continue for days; and very often it is periodical, coming at the same time each week or month and gradually wearing itself out. Very often it is symptomatic, many diseases having this as one of their most conspicuous features. In fevers it is present more or less continuously, and with less or greater intensity; in meningitis it is agonizing; in typhoid fever it is stupefying; in Bright's disease it may be dull and continuous; in malaria it may be severe and head-splitting or throbbing. The scalp may be so tender that touching it seems like burning it with a hot iron; then, there may be great intolerance of light and other disturbances of vision and great sensitiveness to sounds, while the taste and smell may be unusually acute or perverted in some way. Heredity has not a little to do with it. In women and children it is also greatly influenced by hysteria. There may be a bilious headache due to congestion, and there are many other kinds. Frequently it is the result of excess in eating or drinking, following a debauch un- DISEASES OF THE NERVOUS SYSTEM 353 failingly in many individuals, while in other cases it is due to want of food. It may be caused by tumors and other diseased con- ditions within the brain, in which case there is frequently conges- tion, with redness of the face and eyes. If there is a nervous headache, the pain will be sharp and darting. Any of the varie- ties may be the consequences of overwork, fatigue, want of sleep, worry, intense emotion, or eye-strain. Some people get nervous headache from looking at moving pictures; and it may be accom- panied with nausea and vomiting. Congestion headache may also be due to exposure to the sun, to lightning, bad ventilation, etc., while the opposite condition, or anemia, will cause headache of another type. Poisons of many kinds will produce headache, and it may be associated with malaria, rheumatism, constipation, and ptomaines, and may arise from decomposed food and from drugs and minerals of many kinds. Atmospheric pressure may also cause headache, too much being the cause in one case and too little in another. To relieve headache it is always desirable to remove the cause when possible, and while this often means the judicious use of drugs, it does not mean the free and unlimited use of the headache powders and tablets with which the market has been flooded for years. Beware of the dangers lurking in these drugs. If the trouble is due to an overloaded stomach, or to fermentation or decomposition, a pint of warm mustard-water, hastily drunk, will empty the stomach and give relief. If constipation is the cause of the headache, take castor-oil, or cascara, or Rochelle salts judiciously. When the blood-pressure is too great, as in con- gestion headache, the removal of a few ounces of blood from the arm will frequently stop the pain and perhaps prevent an apoplexy. In periodical headaches, try and find the cause and treat it vigor- ously in the intervals. A grain or two of caffeine with a little camphor is a splendid remedy for nervous headache; and when there is congestion great relief is often possible by soaking the feet in a basin of hot mustard-water. A quiet, dark room is pre- ferable when one has any kind of headache, and if one can get sleep with or without soothing drugs, the headache may be lured away, and one will awake with the pleasant consciousness that it has vanished. Hiccup.-It is caused by a quick contraction of the diaphragm. This contraction produces a sudden motion of the chest and abdo- 354 HOW TO KEEP WELL men, with a peculiar bark or cry in the organ in which vocal sounds are produced called the glottis. The contraction of the diaphragm is produced by the irritation of the important phrenic nerve, which passes down both sides of the neck. There are other important nerves which are also implicated in the procedure. Hiccup may come on suddenly, or it may be preceded by a sort of warning that something is going to happen. The spasm of the diaphragm may be so violent as to cause vigorous muscular action in various parts of the body, and if the attack is prolonged it may produce great fatigue. The separate noises or sounds of hiccup may come at very short intervals, as many as sixty or seventy a minute, or they may be no more than eight or ten, and some- times they correspond with the contractions of the heart. They may continue day and night without interruption or stop at night or when the patient is fatigued. They are often accompanied with inability to talk, sometimes with pain and sleeplessness, difficulty in breathing and swallowing, and sometimes with discoloration of the skin because of interference with the circulation. The attack may last a few minutes, or it may continue for days and weeks. Some people are victims of the hiccup habit. In others an attack may be produced by tobacco, as by swallowing tobacco-juice, by too much alcohol-a man who is drunk often has hiccup-by great loss of blood, by fluids that are too hot or too cold, or by food that is imperfectly masticated. Hiccup may also be an ac- companiment of cancer, or of disease of the lungs, liver, stomach, intestines, or other organs. It is not uncommon in infants who are habitually overfed and in children who have worms, and it has been known to appear among large numbers of people in a community at the same time as a kind of epidemic, as hysteria on a large scale. The thing to do is to find its cause, if possible, and relieve that; for example, to give an emetic of a pint of warm mustard-water if it comes from abuse of the stomach. Sugges- tion is of value in the hysterical cases; and in nervous diseases drawing the tongue backward and forward a number of times may give relief. One of the surest means of relief consists in pressure or friction of the neck from top to bottom and back again along the course of the phrenic nerve on either side. Hydrophobia.-The bite of a rabid animal produces this dis- ease, and it takes three to eight weeks or even much longer for DISEASES OF THE NERVOUS SYSTEM 355 it to develop. It is an acute infectious disease caused by a par- ticular microbe, the germ being communicated by the animal to the bitten tissue. It may be communicated by cats, dogs, wolves, cattle, horses, swine, and skunks. Of those who are bitten by dogs only ten to twenty per cent develop the disease. If a dog is bitten by a rabid dog his symptoms begin in a few days. He is irritable but dull and drowsy if left to himself. He will snap, grab at dirt and sticks, growl and foam at the mouth. Soon his hind legs become paralyzed, and the rest of his body by degrees. If he bites a person, the skin being broken, the disease is likely to follow. Toward the end of the incubation period the bitten per- son becomes nervous, irritable, wakeful, and depressed. He has headache and fever, and soon his muscles become rigid, and swal- lowing becomes difficult. He becomes more and more sensitive, has spasms in the mouth and throat, and has great fear in drink- ing because of the pain it causes; hence the name "hydrophobia." Then the mind becomes unsettled, saliva drips constantly from the mouth, and gradually the patient becomes paralyzed and un- conscious and dies. One of the great triumphs of Pasteur was the conquest of this disease; by the use of timely inoculation nobody need die, at the present time, from it. Intercostal Neuralgia.-The intercostal nerves run along the lower border of the ribs on each side of the body and emerge at the surface at three points on the front, side, and back; it is at those three points that pain is felt when one has intercostal neu- ralgia; that is, neuralgic pain between the ribs. Of course it need not be equally severe at all points, and it is very likely to be sharper and more troublesome at one point than the others, that point being especially the one in front. A neuralgia differs from neuritis, in which the nerve is inflamed, and in which there are redness, heat, pain, and swelling along its track. In a neuralgia there are pain and tenderness along the track of the nerve, and there must be some molecular change in its substance, but what it is has never clearly been found out and demonstrated. Intercostal neuralgia is more common in women than in men; and, next to facial neuralgia, it is the most common neuralgia there is. It is thought it may be due to the pressure of the fat in the breasts, and it is sometimes called mammary neuralgia; but it is more likely to be due, as it seems to me, to the pressure of the garments, particu- larly the corsets, and to exposure to cold and dampness, which 356 HOW TO KEEP WELL cause neuralgia in so many forms. It may attack one nerve or several, and it is usually on only one side of the body. Irritating and stimulating liniments may be rubbed over the chest in treating this disease; galvanism will often relieve its pain; and blistering, baking, or even the use of a hot-water bag may be found acceptable. It is always desirable, when suffering from such an ailment, to keep as quiet as possible, and it may be conducive to speedy recovery to remain in bed a few days. Locomotor Ataxia.-Everybody knows or should know that the contractions of the muscles of the body by which motion is produced are controlled by the nerves which proceed from the spinal cord. These nerves sprout, as it were, in pairs, from oppo- site sides of the spinal cord, and are distributed to the portions of the body which are near them, their branches ever growing smaller as they approach their distribution in the body. Each of these nerves has two roots in the spinal cord. The one which is posterior controls the nerve branches along which impressions travel which are received upon the skin, while the one which is anterior controls the impressions which come from the brain, down the nerve-strands of the spinal cord, and then out upon the spinal nerve to the muscle or muscles which it supplies. This causes the muscle to contract, and the contraction is translated into motion. In loco- motor ataxia there is progressive hardening of the posterior roots of more or fewer of the spinal nerves, of the posterior strands of nerve-fibers in the spinal cord, and of the ends of the affected spinal nerves as they are distributed in the skin. The nerves are no longer good conductors of impressions. The consequence of this condi- tion is ataxia; that is, want of harmony between your will or in- tention to make certain movements and the way in which the move- ments are made. This disease is called locomotor ataxia because the want of harmony in the motions occurs chiefly in those muscles by which walking or locomotion is produced. Besides this trouble there is absence of feeling in some areas of the skin, and terrible pain or neuralgia in others; there is great pain in some of the organs like the stomach, and there is gradual wasting of certain muscles and nerves. The disease begins insidiously and progresses very slowly. Sometimes the first sign is numbness or tingling in the feet; sometimes it is sharp pains in the legs, and one gets fa- tigued from ordinary exercise. In the eyes the pupils are con- tracted and unequal, there is double vision, or there may be squint- DISEASES OF THE NERVOUS SYSTEM 357 ing, and the optic nerve may shrivel away with resulting blindness. There may be want of control of the bladder and rectum and there may be great pain in the rectum. There is more or less loss of the sense of touch, the sense of heat and cold, and the ability to esti- mate the weight of objects. Often there is vomiting, with intense pain in the stomach, difficulty in breathing, palpitation, and de- structive changes in the skin, hair, nails and teeth; the joints en- large, and the bones break easily, and there is a sense of constric- tion, of numbness, around the waist, chest, or throat. The gait is very peculiar, the feet being held widely apart and lifted high in walking, and there is loss of power in the legs. If a patient was asked to stand erect and put his two forefingers on his nose he would sway from side to side, perhaps fall, and be unable to reach his nose with both fingers at the same moment. If his legs are crossed and the tendon immediately under the knee-cap is tapped with closed fingers, the leg remains still instead of flying up as it would in health, and this is one of the most positive signs of the disease. It is thought that this disease may be inherited, but there are probably few who get it in this way. It comes very often from constitutional infection, from excesses of various kinds, from worry, and from exposure to cold and wet. It is most frequently observed in men between twenty-five and forty-five, and it may last as long as twenty or thirty years. Medicines are not of much use in treating it except to relieve the pain. Rest in bed is impor- ant, with freedom from worry, frequent baths, especially hot baths, simple diet, massage, and suitable cathartics. Migraine.-This form of headache is better known as bilious, sick, or neuralgic headache. It is called migraine or hemicrania because in many cases it is limited to one side or one half of the head. It is a severe form of paroxysmal headache, seldom coming on suddenly, usually preceded for several hours or even a day or two by dullness and drowsiness and sometimes by despondency and general discomfort. As the discomfort progresses the patient suffers indistinctness of vision, spots of sensitiveness on the head and face, loss of voice or imperfect power over speech, and more or less mental confusion. Then the head begins to ache in the temple, the eye, or the back portion of one side, gradually spread- ing and increasing in intensity until one entire side is included, or even both sides. The pain becomes more severe and may be throbbing and violent, accompanied with dizziness, made worse 358 HOW TO KEEP WELL by the light or by the slightest sound, by motion, or by the least mental effort. Not infrequently it is accompanied with nausea and vomiting, bitter acrid bile being thrown up. Sometimes vomit- ing gives relief, and sometimes it exaggerates the pain and throb- bing. The face may be flushed or it may be pale, the pulse slow but strong, the desire for food lost, the patient being very misera- ble and greatly prostrated. Sufferers from this kind of headache usually suffer also from chronic constipation. An attack may last a few hours or a day or two. It is very common in women, occur- ring periodically from young womanhood till the end of the child- bearing period. It is not unusual in children, and in any case, old or young, is frequently precipitated by some fault in the diet or by the influence of poisons generated in the intestines from retained and decomposed food material. When the headache reaches its climax the patient may fall asleep, or is induced to sleep by the influence of drugs which may be given to him, often sleeping several hours and awakening with the headache vanished; hence the great object in this disease is to produce sleep. When migraine occurs in little children it is quite suggestive of meningitis, which therefore should always be remembered when children complain of headache. The tendency to it is often due to certain well-marked causes, like persistent constipation, eye-strain, or some other eye disturb- ance; or it may be due to overwork in school or in business, to worry or want of exercise. General rules to be observed by a sufferer from migraine are: Simple and rather spare diet, especially when an attack is expected; daily hot or cold bath, according to the reaction in individual cases; avoidance of constipation by occa- sional use of salts or castor-oil or cascara, or of mercury if there is tenderness of the liver or vomiting of bile. Five or ten grains of quinine before an expected attack may mitigate or prevent it. During an attack ice may be applied to the head or a blister may be produced by mustard at the nape of the neck. Relief can often be obtained by the use of caffeine, camphor, phenacetin, etc. Multiple Sclerosis.-It is characterized by well-marked symp- toms, among which is trembling or tremor. This occurs with any kind of muscular effort and stops when the effort is completed. Another symptom is slow, measured, indistinct speech; and a third is violent oscillation of the eyeballs from side to side. Other symp- DISEASES OF THE NERVOUS SYSTEM 359 toms are impairment of vision from partial withering of the optic nerve, headache, pain in the eyeballs, dizziness, vomiting, flashes of light, apoplexy with rigid spasm of the muscles, and partial paralysis, which may be recovered from or may become complete and permanent. There may be also unusual activity of what are known as the reflexes, in distinction from what is known as the paralysis of these reflexes, which is seen in certain other chronic nervous diseases and various kinds of disturbance of the sensibility. The patches or plaques which seem to be the cause of this disease are found in different portions of the brain and spinal cord, and cause pain or paralysis of those portions of the body which are controlled by them; for example, the lower extremities, or the muscles which control the action of the bladder and intestine. The disease may progress until melancholia or imbecility has resulted. Multiple sclerosis may come suddenly or gradually; it may exist alone, or it may be associated with scarlet fever, syphilis, or small- pox. Not infrequently it is an occupational disease, caused by overwork or injury, and particularly by poisoning from lead, mer- cury, or copper. It may result also from exposure to cold and wet, from dissipation of various kinds, and from malarial poisoning. It is a disease of early life, especially from the twentieth to the fortieth year; but it sometimes occurs in young children. There may be remissions and apparent recovery from it, but when a case is steadily progressive the outlook is bad and the con- dition may be hopeless. If the exciting cause is removable, as in some of the cases of metallic poisoning, or poisoning from alcohol, or malaria, there may be improvement. Various powerful drugs are used by the neurologists for the relief of the more distressing symptoms and often with considerable success. Relief is often ob- tained also by systematic treatment with baths, electricity, massage, and exercise. Nervousness.-This term is used far less frequently by doctors than by laymen, for doctors realize how vague and inexact it is. But it is dear to the heart of those who are nervous, and few of them would wish to substitute any other term. Doctors are more familiar with this condition under the terms nervous excitement, neurasthenia, hysteria, and hypochondria. Nervous excitement expresses it best of all, for the other terms mean nervous excite- ment plus something more. For the nervousness which comes from disease there is no cure except as we cure the disease which causes 360 HOW TO KEEP WELL it, nor can it be prevented except by preventing its exciting cause. Not infrequently it is an indication of insanity, and shows that mind and body are in need of suitable remedies. This may consist of pro- per hygienic measures or a different kind of food, or certain medi- cines which may heal existing injuries or at least give nature a chance to do her work. For nervousness which is unassociated with disease the great remedy is the training of the will, the determina- tion not to give way and to carry on the struggle until either death or victory results. Nervousness comes to all ages and both sexes, but it is far more common in women and children than in men. It is far less common in women who have to do daily work, care for their households, or earn their daily bread than among those who have been brought up in luxury and idleness, or spend their time in frivolity or in tasks that are useless and unprofitable. The frequency with which it occurs in children shows how much they are indebted alike to bad inheritance for mental and nervous instability and to improper education, especially to the want of inculcation of self-restraint. Many times I have found such attacks relieved by a single five- grain pill of old-fashioned asafetida. Nobody that I have ever seen has ever contracted a love for this useful but not pleasant-smelling drug, nor have I ever known of an overdose being taken. Useful, too, are the infusions of catnip, pennyroyal, chamomile, and other herb teas which are mild and soothing and were once so much in vogue. Neuralgia.-The facial nerve suffers most frequently from neu- ralgia; less frequently the sciatic nerve, which passes down the back of the thigh and leg, the intercostal nerves, which pass be- tween the ribs, etc. Neuralgia is not only a condition which is peculiar to a particular nerve; it may be symptomatic of some dis- tinct disease. Thus we may have a neuralgia associated with gout or rheumatism, or poisoning from minerals, or malaria or diabetes, or excessive use of tobacco, and many other causes by which nerve tone is diminished. It is often a reflex disturbance from disease of the eyes, teeth, or one of more of the intestinal organs. The essential characteristic of neuralgia is pain; not always of the same character, for while we usually think of a neuralgic pain as stab- bing or darting, it may also be dull and aching or burning and tingling, or gouging and boring, or associated with a feeling like that of crawling insects. It is not always steady and continuous; DISEASES OF THE NERVOUS SYSTEM 361 it may be intermittent and paroxysmal and varying from time to time in its severity. It may last for a few minutes or for hours, and continue for short intervals for days, months, or years. The pain of facial neuralgia and of sciatica is sometimes so atrocious that it takes away reason and self-control, and suicide has often come when the sufferer could stand it no longer. It is usually most in- tense at the surface, but there may be soreness and tenderness throughout the entire course of the nerve. An attack may come suddenly and without warning, or it may be preceded by soreness and stiffness of the skin and the muscles, with acute pain at certain points. In some cases the pain comes periodically, perhaps in con- nection with malarial attacks, and seems to be a feature essential to them. Pain is not the only symptom in neuralgia. It may be accompanied by a feeling of coldness, or an eruption along the track of the nerve, or by twitching of the muscles, or by nausea and vomiting; and the hair may fall out or turn gray after a severe attack. An attack may be precipitated without any apparent cause, or it may follow an intense impression of any kind like grief, fright, great joy, a strong draft of air, fatigue, severe cold, etc. It is much more common in cold and damp weather than in weather that is clear, warm, and dry. Nervous, neurasthenic, hysterical, high- strung people are more subject to it than those of phlegmatic temperament. The treatment of neuralgia depends very considerably upon the cause of the disease. If one lives in a malarial, damp, intensely cold climate, or one which is unhealthy in other respects and is the cause of neuralgia, a change to a location which is more salubri- ous may be all that is necessary. It is astonishing how greatly the change to a warm, sunny, dry climate may benefit one who is worn out with the pain of neuralgia. Dietetic treatment also is very important, especially for those who have abused their digestive apparatus by excesses in food and drink, or even by using food not adapted to their use. In the severe forms of neuralgia surgical operations are often curative. Thus the sciatic nerve is sometimes exposed and forcibly stretched; a portion of the facial nerve, or even the ganglion in the skull from which it proceeds, may be removed; or alcohol may be injected into it; or the painful surface may be blistered or cauterized, rubbed with stimulating liniments or exposed to the influence of X-rays, light-rays, and galvanism. There are also many drugs which are of the greatest value in 362 HOW TO KEEP WELL relieving the pain of neuralgia, including the coal-tar preparations, iron, arsenic, strychnia, phosphorus, quinine, and aconite. Neurasthenia.-It is essentially a nervous exhaustion, and it is believed that it signifies diminished oxygen-carrying power of the blood, so that the nerves and other tissues cannot receive from the blood the stimulus they require in order to do their best work. In addition to the nervous exhaustion there is general physical exhaustion. One who has this trouble is always tired and is al- ways fearful that something is going to happen; the slightest effort fatigues him and gives him a headache or makes him dizzy; he has backache continually; and he is unable to concentrate his mind for any length of time. Frequently he looks well, though he may be pale, wear an expression of anxiety, and occasionally have fits of trembling which he is unable to control. He loses weight, becomes irritable and forgetful, has points of tenderness along his spine, is troubled with insomnia, or, if he sleeps, has annoying dreams. Other symptoms are possible in myriads; the skin is sensitive or tingles, or he has flashes of heat and the extremities are constantly cold; the heart is weak and irregular and palpitates unpleasantly, while the arteries throb; the sight is imperfect, the pupils dilate, the ears ring, and there is offensive taste or smell. The digestive organs share in the general misery, the symptoms being nervous indigestion, acidity, belching, want of appetite, con- stipation, pain in the stomach or intestines. If it is apparent that there is falling of the stomach or kidney, this may be looked upon as one of the causes of the trouble, and the same is true of the diges- tive disorders. This multiplicity of symptoms may be due to an inherited weak nervous system, to rheumatism or gout, to worry or grief, to intense desire to get rich, to sexual or alcoholic excesses, and sometimes to the intense heat and moisture of summer, or to autointoxication. Sensitive people who undergo surgical opera- tions, even very slight ones, may have a long convalescence with more or fewer of the symptoms of neurasthenia, this being a more frequent occurrence with women than with men. Neurasthenia may also be regarded as one of the occupational diseases; for in- stance, for those who work in lead and suffer lead-poisoning. It is much more common with those who work indoors than with those who work outdoors and might be called a favorite disease with people of an extremely sensitive nature, like poets, musicians, artists, and students, especially if they are overworked or greatly DISEASES OF THE NERVOUS SYSTEM 363 worried. Very little medicine is required for this disease, except suitable cathartics like castor-oil or cascara for constipation, and reliable vegetable or mineral tonics. One should take daily exer- cise in deep breathing to increase the oxygen of the blood. Walk- ing or other helpful exercise or occupation is very desirable, but not to the point of fatigue. Neuritis.-A single nerve may be involved as in the diseases known as tic douloureux and Bell's palsy, or many nerves or groups of nerves may be implicated, giving us a simple neuritis in one case and a multiple neuritis in the other. So, too, the inflammation and the destruction of nerve-tissue may be slight or extensive, and the disease last a few days or many months or years. The princi- pal symptom is pain, which may be unbearable or may become un- bearable. It may come in a steady ache, or it may come in a suc- cession of stabs and darts, especially when the weather changes, or one becomes excited or deeply moved, or suffers from acute indi- gestion. Besides the swelling of the skin, the skin may become glossy or shiny, and there may be sweating along the track of the nerve, or a crop of vesicles or blisters. The joints sometimes become swollen, and fluid accumulates in them; and perhaps they may become permanently stiffened. If the nerves are extensively injured the muscles shrivel and wither, for nerve vitality is as im- portant for the tissues as a suitable supply of good blood. Because of the disturbance to the nerve-system in general in this disease, people who have it often get hysterical or excited or even crazy. The skin is the organ of sensation or touch, and besides the pain which this disease brings there may also be in it a sensation of tingling or burning, or a feeling of ants or bugs crawling over it. In the form of the disease known as multiple neuritis, where many nerves are involved, there may not only be withering of the muscles, but there may be twitching, and the fingers and toes may be bent over or contractured, and resemble the claws of birds. The nails may fall off; the hair becomes gray; and many other symptoms called trophic symptoms show that the nutrition of the tissues is suffering as a result of disease of the nerves. In multiple neuritis such causes as bacteria, blood-poisoning, or anemia are often effi- cient. It may develop slowly or rapidly and may begin with a chill and fever, like other infectious diseases. It may paralyze important muscles like those of speech, swallowing, and respira- tion, and be quickly fatal, or it may be long-drawn-out and result 364 HOW TO KEEP WELL fatally from exhaustion or pneumonia or tuberculosis. It is verj pitiable when it is prolonged through years of suffering, creeping steadily onward to hopeless paralysis and helplessness. The treatment of simple neuritis involves a great variety of agencies. Of external measures, rest is always important, and the changes may be rung on such measures as moist and dry heat, cold, massage, irritants and blisters, electricity, light, etc. Drug treat- ment is often beneficial when judiciously given, a great number of drugs being available and helpful. Relief to constipation is one of the most important things to be insisted upon, and cathartics must be changed as their efficiency diminishes. It is very important that nourishing food should be taken in as great abundance as possible, and it is equally important to avoid indigestion. Sleep is so apt to be irregular and broken in this disease that suitable hypnotics may become imperative. Paranoia.-This is a variety of the mental disease known as dementia precox and of great importance because it includes from twenty to thirty per cent of all diseases of the mind. It occurs in the young or those who have not reached middle life; it does not usually occur before twenty-five. It develops suddenly but may be stationary for many years. It takes those who are eccentric and predisposed to mental disease by inheritance or occupation. It begins with suspicion, self-consciousness, self-satisfaction, and often with fear of some impending accident; then follow hallucinations, confusions, delusions, and worry. It is better for those who have the disease to be in a sanitarium or public institution, for it gives all concerned a feeling of protection; but it does not arrest the disease nor remove the hallucinations. The disease goes on steadily to its final termination though it may last many years. Paresis.-The name "paresis" or "general paresis" is often heard; less frequently do you hear of paralysis of the insane, pro- gressive general paralysis, and paralytic dementia, which mean the same. It is a disease of the active period of life, from thirty to fifty, more common in men than in women. It is based upon in- fectious constitutional disease, and if it follows its ordinary course, that is, if the patient is not carried off by some other disease like pneumonia or Bright's disease, it will invariably end fatally. In some cases it occurs in early life, from fifteen to twenty-five in those who have inherited the disease which is its foundation, and these also are fatal. Causes which may contribute to its develop- DISEASES OF THE NERVOUS SYSTEM 365 ment are worry, nervous strain, overwork, exhaustion from severe illness like typhoid fever, injuries of various kinds, excessive use of alcohol, and wickedness and vice. It is one of the very best examples of the reward which follows a sinful life. In the begin- ning the patient is usually unaware that anything is the matter with him; he gets tired easily; sometimes his face is pale, and some- times it is flushed; he becomes forgetful, is inaccurate in his work, sleeps poorly, cannot fix his attention, and has ringing in his ears, specks before his eyes, and pains in his head. It is very much like neurasthenia, but it is not neurasthenia. By and by his mind be- comes weaker; he gets easily confused, and often acts as if he were intoxicated. As the disease progresses he gets careless about his person and clothing, is indecent, lies, and steals. When the disease is well developed, that is, in a year or two from the beginning, he may have an attack of apoplexy, or occasional attacks of epilepsy, his hand trembles and his tongue is unsteady, the lines of his face are smoothed out, he sways when standing, and his walking is awkward. His speech is thick, his ideas disconnected; he has aphasia; that is, he is unable to frame the proper words for what ideas he may have; and his hearing, smell, and taste are blunted. One of the most important groups of symptoms relates to the eyes: the pupils are of different size; the power of accommodation and the sensitiveness to light are lost; and there is gradual dimness of vision, which may end in blindness. Before these severe symptoms happen he may get better, and for an interval of weeks or even months he may appear to be getting well, but these appearances are deceptive, and by and by the bad symptoms return. His mind fails; he has delusions and hallucinations, becomes boastful and has fits of excitement. Finally his strength gives out, and he is obliged to take to his bed. His skin shows the effect of poor nutrition; he has bed-sores and eruptions of various kinds, and contractions of the arms and legs. In this weakened condition he may be at- tacked by la grippe, or pneumonia, or Bright's disease, or diarrhea; and may die from any one of them. The disease may last from one to ten or more years, and the best that can be done is to try to make the patient as comfortable as possible. He should give up his occupation as soon as the dis- ease is fastened upon him, avoid excitement, sleep as much as possible, and eat only the simplest food. If his digestion and assimilation are carefully attended to, his bowels kept open, and 366 HOW TO KEEP WELL his skin kept in good condition, he may live in comparative comfort for a long period. Progressive Muscular Atrophy.-The disease consists in pro- gressive wasting of the voluntary muscles-that is, those which are under the influence of the will-generally during a period of months or years. Muscles or groups of muscles are attacked con- secutively; and hence the name "wasting palsy," by which it is also called, is entirely appropriate. One of the most marked features in connection with its causation is the influence which heredity exerts upon it. It has often been observed in families in which intermarriage has been carried on for several generations, and it has not been unusual for several cases to occur in the same family. Males are more often subject to it than females; occasionally it occurs during childhood, but young adults are most frequently its victims, and it has seldom been observed in those who have passed middle age. Not infrequently it has been a consequence of acute, exhausting fevers. It usually begins in the muscles in one of the upper extremities, particularly in those muscles which are between the bones of the right hand. The group of muscles may be at- tacked and those which are adjacent to them spared, and when the hands have been thus invaded they are strongly suggestive of the claws of birds. The muscles of the shoulders and abdomen may also be attacked, perhaps unequally on the two sides of the body, and also the muscles which control respiration, either directly or in- directly. Muscular power diminishes as the muscles continue to waste until there is at length complete helplessness, such a result being seldom deferred longer than five years. Sometimes there are involuntary muscular contractions in the disease which are very painful, but in other respects pain is not usually a characteristic. The affected parts are, however, usually cold, numb, pale, and sub- ject to disagreeable tingling sensations; and sometimes there are profuse sweating, swelling of the joints, and fever. This disease is not inevitably fatal, the wasting process being sometimes arrested, particularly if it has been caused by overwork and the overwork has been abandoned. Relief is not infrequently obtained by ju- dicious treatment with gymnastics, baths, massage, electricity, good food, and suitable tonic drugs. Sciatica.-Those who suffer from poor nutrition, from rheuma- tism and gout, from digestive disorders, and in fact from any- thing which lowers the general tone and the general powers of DISEASES OF THE NERVOUS SYSTEM 367 resistance are subject to sciatica. Its direct causes may be ex- posure to cold and dampness, injuries of one kind or another, overstrain from muscular exertion, and various other provoca- tions. The pain may begin as a more or less severe ache either at the lower portion of the back or the upper part of the thigh; the muscles are stiff, and there is a feeling of decided weakness in that portion of the body. This pain gradually becomes more intense and extends down the thigh and leg, the entire limb hurting excruciatingly on the slightest motion and being sensitive to the slightest pressure. There may also be contraction of the muscles of the leg and thigh, bending the knee and drawing the foot some distance from the ground. The pain may be dull, or it may be sharp or burning, and it may be accompanied by sensa- tions of tingling or crawling or even with complete absence of feeling in certain areas. Another feature which very often attends inflammation of nerves in any portion of the body is swelling of the limb and a crop of blisters such as is usually seen in the disease known as shingles. This disease is a very persistent one, lasting for weeks, months and sometimes years. Sciatica is not an unusual accompaniment of disease of the bones of the pelvis or of hip-joint disease, particularly in the aged; and it has been observed as an accompaniment of the pregnant condition. The first requirement is complete rest in bed; a splint on the leg is often deemed advisable, or it may be placed upon an in- clined plane at an angle which will relieve all tension upon the diseased tissues. Heat is one of the most valuable means of treat- ment and is often very soothing to the pain; even baking the limb at a temperature of 200 ° F. or more has its advocates and is said to be frequently beneficial. Hot baths are also useful, as well as electricity, massage, blistering, and cupping; in extreme cases the nerve may be cut down upon and stretched. Shaking Palsy.-It is a disease of advanced life, rarely attack- ing young people; and men are more often its victims than women. It may begin in various muscles, in one or several of the limbs, abruptly and suddenly; or it may come slowly and progress very gradually for two or three years, being sometimes preceded by a period of sleeplessness, irritability, and weakness. It is brought on by anxiety, worry, exposure to cold and wet, injury involving important nerves, infectious fevers; it is often associated with 368 HOW TO KEEP WELL rheumatism, and it seems sometimes to be inherited. It is essen- tially a condition of trembling or tremor, and it often comes after an experience of great emotion. Frequently it first attacks the foot, the hand, or the thumb, perhaps only slightly, disappearing and then reappearing. The fingers are more often attacked than anything else, all of them moving tremblingly at once, while the thumb oscillates toward them, the entire movement suggesting the holding and moving of a pen. This motion is not necessarily continuous; it is provoked by excitement or emotion, and it may continue while other muscles are at rest. During sleep the trem- bling ceases. After a time it may extend to the arms, the legs, the feet, and the head; and after the disease has fully developed it is almost incessant during the waking hours. It resembles the disease which comes from poisoning with lead, tobacco, opium, coffee, cocaine, arsenic, etc. The intensity of the trembling is aggravated by excitement, by cold, and by severe muscular effort of any kind. Gradually the muscles weaken, and motion becomes labored and difficult. There is often a sense of intense heat which may be followed by profuse perspiration. Sooner or later many of the muscles of the body become rigid, the attitude is changed, the head and body are inclined forward, the control of the joints is lost, and when walking is attempted the center of gravity seems to be changing and the unhappy patient moves forward as rapidly as possible to keep from falling. This period of rigidity begins with painful cramps; the head and eyes become fixed, and the features expressionless. As the dis- ease progresses the thighs become bent toward the body and the hands more or less distorted and deformed. At length the patient finds voluntary motion almost impossible; he becomes helplessly fastened to a chair and later becomes bedridden. The skin becomes glossy from the impaired nutrition; the body becomes swollen; and there may be diarrhea, loss of control of the bladder, and sores at the end of the spine which refuse to heal. Helpless paralysis with withering and wasting of the muscles may come at length; the memory fails; the intellect weakens. A curious fact is that shortly before death the trembling may cease, the patient remain- ing helpless. Sufferers from this disease often find comfort in frequent hot baths, and it would be quite desirable in many cases to spend most of the time at hot springs, where good care and attention can be obtained DISEASES OF THE NERVOUS SYSTEM 369 Softening of the Brain.-The brain requires an abundant supply of blood. The greater its blood-supply, the greater the intellectual activity of the individual. Conversely, the more limited its blood- supply, the feebler the intellectual capacity of the individual. This means that the brain is furnished with a vast number of blood- vessels, large and small. When the course of the blood-current from arteries to capillaries and from capillaries to veins into and out of the brain is cut off or impeded or obstructed, the nutrition of the brain is to that extent impaired; and if this continues long enough and is sufficiently extensive fatty degeneration and then liquefaction of the brain substance takes place. This is the pic- ture in softening of the brain. Sometimes a small clot called an embolus is formed in the heart or one of the large arteries. This is carried along the blood-current and finally reaches one of the arteries in the brain. It is too large to go any further and forms a plug in this artery beyond which the blood-stream can- not go. Or, from one cause or another, a clot forms in one of the veins of the brain. It may extend in a string-like mass to the neighboring veins. This is called a thrombus and prevents the blood-current from following its channel. In both cases the region of brain formerly nourished by the blood in these arteries and veins is now deprived of its blood-supply, and from this time and this source degeneration of the brain begins. Or the blood-supply may be cut off by the pressure of a tumor within the brain or by a severe injury. It also may come in connection with such diseases as syphilis, Bright's disease, rheumatism, chorea, or scarlet fever, or from sunstroke, intense cold, prolonged mental excitation or emotion, or excesses in alcohol and other irregular- ities of living. One of the commonest causes is the degenerative changes which so often come in old age, though softening is not limited to any period or condition of life. Men suffer from these degenerative changes far oftener than women, and those who have highly developed brains more often than those who are less highly organized. When softening begins there is a suspicion of apoplexy or stroke; the patient complains of dizziness and headache; then come unconsciousness and paralysis, usually on the right side. But the paralysis is usually more transient than in apoplexy, and the patient regains the use of his muscles, only to lose it in sub- sequent attacks. These attacks also are accompanied by vomiting 370 HOW TO KEEP WELL and delirium and persistent aphasia or loss of speech, with rest- lessness, depression, and constant drowsiness. The movements of one who has softening of the brain are slow; he is irritable, stupid, forgetful, and ill-mannered. Disease of the lungs, heart, or kidneys may intervene and carry him off. New symptoms are constantly developing, making a bad condition more trying and hopeless. The only thing that can be done is to try to make the patient as comfortable as possible by good food, massage, cheerful surroundings, and intelligent hygienic measures. Relative comfort sometimes can be obtained when good care and nursing are available. Stammering.-Stammering is the imperfect articulation of vowel or consonant sounds on account of malformation of the organs of speech or imperfect innervation of the muscles con- cerned in the formation of articulate speech. It has nothing to do with the joining of sounds, but signifies inability to use them properly even when used alone. Stammering is frequently a mat- ter of habit, particularly in young people whose surroundings have been unfavorable; or it may follow an injury. A distinction must always be made between stammering and stuttering, the latter being characterized by attacks of spasm, especially in at- tempts to pronounce the explosive sounds b, d, g, k, p, and t. Unless stammering is precipitated by an injury or by disease it may begin in very early life, perhaps as soon as attempts are made to talk; and, if correct teaching is not available, the stam- mering habit will be quickly formed. It is greatly influenced by surroundings, by fear, fatigue, and any kind of emotion. It is particularly a matter of mortification to young men and women and is as conspicuous when youth is merging into maturity as at any period of life. The treatment is a matter of education, and, if the organs of speech are defective, it will usually be impossible to educate one to produce normal sounds; harelip, for instance, would offer effectual resistance to normal sounds. The same is true of the stammering which accompanies such nervous diseases as St. Vitus's dance, multiple sclerosis, and apoplexy when the muscles controlling speech have been paralyzed. But in the case of children or young people who have no serious dis- ease a good instructor will often succeed in overcoming the speech defect if both stammerer and teacher are patient and willing to make persistent effort. DISEASES OF THE NERVOUS SYSTEM 371 Stuttering.-Stuttering is by no means the same as stammer- ing, being a spasm of the muscles which control respiration, phonation, and articulation in attempts to utter articulate sounds. With it there is spasmodic closure of the air-passages, especially in efforts to pronounce the explosive consonants or even the open sounds. Stuttering attacks vary in intensity: when stutterers are calm and by themselves or with relatives and friends they may be entirely free from their trouble, and likewise in whispering and singing; but when they are with strangers or excited, or fatigued under emotion of any kind their trouble appears, and the greater the excitement the greater the difficulty which is experienced. This trouble, unlike stammering, is never due to organic disease, rarely is it due to carelessness; and it is worse when attention is called to it. At one time it was thought to be due to convulsive movements of the muscles of the tongue, lips, and other parts of the respiratory apparatus; and about the middle of the last century there was a notion, particularly in Germany, that it was due to a malformation of the tongue. Straightway it began to be fashionable among stutterers to have a portion of the tongue removed, and not until many operations had been performed, some of which resulted fatally, was this foolish practice abandoned. Stuttering is often very amusing to those who witness it, but seldom to those who experience it. Attempts to overcome the spasm causing the stuttering often intensify it; and at length the patient gives up trying, or the center in his brain by which the mauer is controlled resumes its function. The intensity of the stuttering spasm is also increased by fatigue, by shock, or by excitement of any kind; and men are sufferers more often than women. It usually begins in childhood but may come in mature life to those who have used their organs of speech with too great freedom, like singers and public speakers. Heredity also seems to play an important part in this trouble, and even when one is apparently cured, relapse and recurrence are frequently noted. Tic Douloureux.-This French term means painful spasm; it is a form of facial neuralgia, which in other words, is a painful condition of the facial nerve. It is not a neuritis or inflammation of the nerve, but just a condition of acute pain, caused, probably by some disturbance in the molecular condition of the nerve. Neuralgia may attack any one of the subordinate branches of the facial nerve. It is facial neuralgia irrespective of the portion which 372 HOW TO KEEP WELL is the seat of the pain, but if the pain is intense, paroxysmal, and accompanied with spasm of the muscles of the face, it is called tic douloureux. The upper branch of the nerve is the one most fre- quently attacked, the pain being in the eyeball and the region of the eyebrow. Sometimes the pain will spread from one branch to the others, the face, eyeball, and teeth being all literally "on the jump" at once. Excruciating pain may also be present on the side of the tongue. The pain comes and goes; it may last steadily for weeks, or for a day or two, and then disappear for a while, or it may be present constantly. It is sometimes so severe and persistent that the patient becomes insane, and it is not un- usual for a sufferer to commit suicide in his desperation. It is sometimes traceable to bad teeth, particularly in the young. Ex- posure to dampness and drafts may bring it on, as well as in- juries, malarial poisoning, poisoning in some of the occupational diseases, etc. With regard to treatment I do not know of any patent med- icine that will do it any good, though there are plenty of them which advertise that they can cure it. Powerful drugs have always been used in treating it, by regular and irregular practi- tioners, some of which are effective and some quite successful in fastening drug habits upon the patients. In recent years there has been more or less success in injecting osmic acid solution into the substance of the nerve through the opening in the skull. It is said that permanent cure has been obtained by this means. More recently alcohol of seventy to ninety per cent strength, sometimes with the addition of five per cent of carbolic acid, has been injected, and hundreds of cases are now on record. The advantage of this method is that it can be repeated as often as necessary. Galvanism is another means of relieving the pain, but its effects are, of course, evanescent. In obstinate cases the trunk of the nerve or a portion of it is removed, the skull being opened for that purpose. A few gifted surgeons have obtained most brilliant results in this field, and I know of nothing more gratifying and satisfying than the power by such means to remove the torture and agony from which these poor people suffer. Vertigo.-It is a sensation of swimming or giddiness in the head, surrounding objects apparently vibrating or rotating, while there is staggering and uncertainty in the motions of the body. It carries with it a defective relation between the contractions DISEASES OF THE NERVOUS SYSTEM 373 of the muscles by which motion is accomplished and the different objects by which the body is surrounded. It is a prominent symp- tom in connection with the diseases of the cerebellum or small brain, the organism which controls the movements by which we are able to maintain the erect position. It is also a constant fea- ture in what is known as Meniere's disease, which is an affection of the internal ear or labyrinth, very unpleasant and very serious. There is vertigo when certain muscles which move the eyes are paralyzed, the eyes being thereby more or less displaced and their relations to each other more or less disturbed. This is particularly the case in such movements as occur in the rotation of the head. Vertigo is also frequently an accompaniment of dyspepsia, con- gestion of the brain, and anemia. When it is present with disease of the labyrinth, or Meniere's disease, it is accompanied by deaf- ness and noises in the head. It may also be associated with ac- cumulations of wax in the ears, and it may be produced by the passage of a galvanic current through the ears. With it are frequently associated weakness of the pulse, irregular breathing, faintness, and vomiting. It may last but for a second, or it may be prolonged for many minutes. I have sometimes found that relief to vertigo could be obtained by inhaling smelling-salts or drinking a cup of strong coffee. Writer's Cramp.-This is a form of paralysis which has long been recognized in England among those who use the muscles of the hand constantly in writing under the name of scrivener's palsy. Only recently has attention been paid to it in this country, but, with the great multitude of men and women who are being occu- pied as bookkeepers, stenographers, and typewriters, it is becom- ing comparatively common and will be of still greater frequency in the future. Not only does it occur as the result of continuous work in the occupations mentioned, but also among milkers, teleg- raphers, players on the violin, and piano; in fact, it is likely to affect anybody, man or woman, who employs the muscles of the fingers and hands continuously in work which is delicate and in which skilful manipulation is necessary. A rather singular fact is that it is inheritable. It is not only caused by overuse of the muscles but also by exposure to cold, injury to the muscles and nerves, or diseases of the nerves, extending to the nerves of the hands. It begins with great fatigue in the muscles after their prolonged use; and by and by there are spasmodic movements in 374 HOW TO KEEP WELL one or more of them, making writing difficult and more or less illegible. The thumb and forefinger in some cases are forcibly and involuntarily extended, the pen slipping away from the finger, entirely out of control; and in others the spasm is of the opposite or flexor muscles, the pen being squeezed in a firm grip, while the muscles do not respond to the efforts and direction of the will. In some cases there are tremors of the hand and arm, which have more or less pain, and the writing is illegible, while in another class of cases there are great fatigue and weakness of the hand and arm almost to the point of paralysis when writing is attempted, though it may not be present at other times. Not only is writing interfered with, but there is also impairment of other movements which require fine action of the muscles of the hand. Other symptoms are weariness, tingling pain, and some- times numbness in the muscles extending to the shoulders and back; and in addition there may be more or less spasm of the muscles of the eyes, stammering, and spasm of the face or throat. The disease may last through life, unless the occupation is changed, whereupon it may subside spontaneously. But it does not appear to have any influence upon the general health. It is desirable to change the occupation if possible, when the disease is apparent, for the constant attempt to use the affected muscles makes the spasm or paralysis worse. It is said that a particular form of pen or penholder may be used with a certain amount of satisfaction by those who have writer's cramp, es- pecially if they write very slowly. Galvanism, massage, and certain forms of gymnastics are also used as means of treatment. CHAPTER XVIII ABNORMAL MENTAL CONDITIONS Amnesia.-Loss of memory of any kind is amnesia. There is a form of amnesia which is entirely distinct from disease; anybody who has a poor memory, who is unable to recall past events or experiences with ordinary facility, is amnesic. Some people have memory for peculiar kinds of events, though their memory for other events may be normal or even acute. The memory of the aged usually is defective, except in certain directions, but this is because the apparatus which controls memory is wearing out. They may not remember events which happened a day, a month, or a year ago, though they may remember with distinctness and clearness the events of their early life. Growing children, if they are progressing normally, seldom have amnesia. They usually can recall with readiness and promptness the greater portion of the experiences of the brief period during which memory has been fairly established. Dull children often have difficulty in recalling the lessons they have studied at school, but this is because the subject studied was not entirely comprehended, or because the functioning of their minds is imperfect for that kind of work. They may be perfectly well physically and at least equal to the average of the type of minds of which they are representatives. But greater numbers of people are amnesic as the result of injury or disease. A man receives a blow on the head, or his skull is fractured, or his brain is penetrated or is subjected to great shaking or concussion. This man may immediately lose all memory of the past, either temporarily or permanently. If the brain is not greatly injured it may recuperate. Gradually or suddenly the man finds himself able to recall the past, and his memory for past events may henceforth be as good as ever. There are many forms of disease in which memory is tem- porarily and sometimes permanently lost. Of course, this is true 375 376 HOW TO KEEP WELL of some of the forms of insanity, the mind and all its faculties, in- cluding the memory, being more or less of a blank. Idiots and imbeciles have little power of memory; whatever life and activity they have being limited to the present. They are oblivious of the past. The amnesia which comes in many of the cases of hemorrhage into the brain, or apoplexy, is a not uncommon occur- rence. Frequently it is associated with inability to use language freely and properly, and is called amnesic aphasia, the sufferer having a very limited vocabulary of words and inability to re- member those which it is desired to teach him. There are innumerable cases in which the memory has been strengthened by suitable exercises carefully and persistently car- ried out. Recalling the events of each day at its close, memoriz- ing passages of scripture, verses of poetry, important events in history, and a thousand other things which will readily suggest themselves, may be tried if one is really in earnest in desiring to strengthen the memory. Aphasia.-Aphasia means disturbance of an injurious character in the interior portion of the left half of the brain, or in the arteries which supply that portion of the brain, which disturbance impairs the power of speech or abolishes it altogether. It may mean loss of the power of language or of memory or of both. In the first case the power of articulation is lost or perverted; in the second the memory of words is lost or perverted. In either case, speech is slow and more or less inarticulate, ideas are incoherent, and there is more or less inability to express thought by speech, ges- ture, or writing. There is loss of memory for words, loss of power to express ideas by written signs or by gestures, loss of the proper use of language. Aphasia as thus defined is also entirely different from the imperfect speech, or speechlessness, of deaf- mutes, of those who have difficulty or disease with the muscles of the throat and mouth or with the larynx, or from the incoher- ent speech of idiots and imbeciles. In aphasia, which is due to disease of the brain, there is sus- pension of speech, misuse or forgetfulness of words, loss of memory of suitable words, and a very limited vocabulary, limited perhaps to half a dozen or a dozen words. Such words as are used are mispronounced or badly articulated, and words and thoughts cannot be coordinated. At the same time the mind may be normal or even keen for business, amusements, and other things requir- ABNORMAL MENTAL CONDITIONS 377 ing mental activity. A single word by one who is aphasic may indicate an attempt to express an entire sentence. He may re- peat it over and over and get very angry because you do not comprehend what he desires to tell you. In one form of this condition the patient can write fairly well, especially if he is aided or prompted by suggestions; in another the writing is scrawly and unintelligible; and in another the control both of writing and speech are almost or quite abolished. Aphasia may be transient and recovered from as the pressure upon the brain which may be the cause of the trouble is relieved, or it may be progressive and permanent, ending in insanity and death. It may be the result of anemia, rheumatism, hemorrhage from various sources but especially hemorrhage into the brain, syphilis, inflammation or softening of the brain, diabetes, Bright's disease, fevers of many varieties, etc. It may come to old or young, male or female, with or without paralysis; and if the paralysis improves the aphasia may improve also. Improvement in children and young people is not unusual; in the aged improvement and recovery seldom occur. It is most frequently caused by injuries and diseases of the brain, and when- ever the brain is seriously diseased recovery does not occur. Re- covery with ordinary use of language may take place spontaneously or after a longer or shorter course of instruction in the use of words. One frequently has to begin at the beginning like a child. With the aphasia there may also be other intellectual troubles and weaknesses, or, as already stated, the mind may be unusually acute in certain directions. Autosuggestion.-Autosuggestion means suggestion to one's own individuality. Every leader of men from time immemorial suggests things to himself, making possible the apparently im- possible, and stimulates autosuggestion in others. It is by no means limited to matters of health and disease, but applies to the whole universe, animate and inanimate. M. Coue in his lecture upon autosuggestion differentiates the imagination from the will and makes it superior to the will. If it is associated with the will at all it is as one of its phases or subdivisions. I suppose it is what the psychologists of a generation or more ago labeled the fantasy. I do not see how it is possible for the imagination to work, or at any rate to work efficiently, except through the will. The mere statement, "Every day, in every way, I am getting better 378 HOW TO KEEP WELL and better," amounts to nothing in itself and might be said by an idiot with absolutely no perception of its meaning and no pos- sibility of any consequences so far as he was concerned. It is only when the desire that something be accomplished is impressed upon the formula that it has a chance of accomplishing anything, and that is an exercise of the will. M. Coue also tells us that by autosuggestion we can accom- plish anything that is reasonable or within reason; but what does he mean by reasonable? Is it to cure fibroid tumors, or cancer, or heal broken bones, or remove congenital defects and deform- ities, which he believes possible by autosuggestion? I should think not. All these things if and when apparently accomplished by means of autosuggestion are beyond reason, extra rationem, for they are not accomplished by adherence to the laws of therapeutics as they are at present understood. We have gone beyond the domain of reason and have invaded the domain of faith. I am not saying that these things may not be accomplished, are not accomplished; but it does not seem to me they are accomplished by such means as self-suggestion, but by invocation of some kind of power from without, and I do not know of a better term than faith for the medium through which this power acts. Fur- thermore it is of the greatest importance to differentiate those who have imaginary or pseudo-diseases from those who have actual organic disease. Autosuggestion is the instrument which is largely used, not only in these irregular forms of therapeutics, but in numerous religious or semireligious cults; and I am quite willing to admit that it ha§ resulted, in many instances, in great benefit to those who have adopted it. Delusions.-A delusion is a belief, more or less fixed, that something is a fact which is not. A delusion is not necessarily ^n evidence of insanity. If a person has a belief or an idea the unreality and untruth of which can be shown to him, and he accepts the evidence and follows the reasoning, he is not insane- at least in so far as this particular delusion goes-but if his belief exists and originates only in his imagination, and he cannot be reasoned out of it, even by the most convincing evidence, his is an insane delusion. If a person affirms and believes that a cer- tain stream runs uphill when it is palpably evident that it runs downhill, his mind is not sound; he is insane. So there are delusions of the sane and others of the insane. ABNORMAL MENTAL CONDITIONS 379 The delusion of an insane man are unlimited in number and variety. They may induce him to dispose of his property, not merely by error of judgment as to its value, but by the conviction that an earthquake, a flood, or some other upheaval of nature is going to destroy it. They may have reference to his family and induce him to hate and ill-treat those whom he has every reason to treat with kindness and consideration. They may even incite him to do violence to his best friend or to those who are doing everything in their power to help him. Delusions in the insane may produce the most violent changes in the habits, morals, behavior, and conduct in general; or they may affect only certain actions and habits, while in other respects the conduct may be irreproachable. The victim of delusions may not express his disordered feelings in words; he may be absorbed in his own contemplation or show his delusion by peculiarities and eccentricities in dress or even by his facial appearance. He may be very quiet and melancholy, or excitable, restless, and exhilarated. Delusions of a religious character are not at all uncommon in those whose lives have been religious in their tendencies. De- lusions may be so subtle that their victims may deceive judge, jury, and doctors when the physicians are called to testify in court. Their reasoning may be apparently flawless, with, perhaps, a few exceptions when the examiner happens to be shrewd enough to draw them out. It is even stated by writers on insanity that the victim of delusions may have periods when there is complete mental lucidity. It is not always easy to differentiate between delusions, illu- sions, and hallucinations. An illusion is a deceit or imposture upon the senses. A juggler's trick is an illusion, for it endeavors to make something appear real to the eye and the mind which is not so. If beliefs in particular illusions affecting any of the senses are insistent and persistent, they may be evidences of in- sanity. A hallucination is a perverted or false idea and may be identical with a delusion. Hallucinations frequently result from bodily or mental disease, real or imaginary. A man may have a disease in certain organs, and he may have the hallucination that the organs are filled with insects or other animals. Some insane persons have hallucinations of voices speaking to them, or think, perhaps, that their identity is changed. 380 HOW TO KEEP WELL Dementia Precox.-The term includes several types of disease, in all of which there is a tendency to mental deterioration, all appearing during the first thirty years of life. There are three principal types which are distinguished by the alienists, all of which have certain symptoms in common: in all there is mental deterioration; in the first two there is a certain percentage of recoveries, either partial or complete; and in the third or para- noid form, there is no recovery, and there is the homicidal impulse, which makes it dangerous for those who have it to be at liberty. These different types of disease develop usually between the ages of fifteen and thirty; they may last many years and may result in complete helplessness long before they are terminated by death. It is very interesting to note that they include about twenty-five per cent of all the cases that are admitted to hospitals for the insane. Mental impairment is the significant character- istic of the disease, and it varies all the way from slight mental disturbance to idiocy. Perhaps it will first become apparent by mental disquietude, by restlessness, by frequent changes in one's position or job, by incapacity for mental effort. As in many other forms of mental or nervous disease, there are periods of improvement, which are followed by relapse and return of bad symptoms. Defective power of attention is one of the most common symptoms. The patient is aware of his surroundings; his consciousness is clear except in moments of excitement, depression, or stupor; but he has hallucin- ations and delusions. In the early stages of the disease his memory is fairly good, but he remembers things that happened long ago better than those which happened yesterday or last year; finally his memory fails altogether. He loses his power of judg- ment from the very beginning of the disease. He also loses his moral sense and his sense of affection and is subject to fits of anxiety, depression, and excitement. He is indifferent to emotion, loses his normal activity of will, and sometimes, especially in the paranoid form, has impulses which lead to violence in his conduct toward himself or others. His physical state is marked by certain morbid conditions, but these are not so distinctive as the mental disturbances. He usually suffers from indigestion and constipation; his hands are persist- ently cold; and he loses weight. His skin is sallow, his face may be covered with the eruption of acne, his pupils are dilated, he ABNORMAL MENTAL CONDITIONS 381 suffers with headache, rapid heart-action, flushings, and sweatings, and his general physical condition is one of low vitality. It is not unusual for such cases to be associated with some form of tuber- culosis. There are many causes for this disease; frequently it is connected with a bad family history, a history of alcoholism or of specific constitutional disease or of some form of mental disease. Again, it may be due to great physical or mental shock or strain, to autointoxication, to worry, or to some disturbance in the functions of the ductless glands like the spleen or the thyroid. Those who suffer from this disease are incapacitated for work. They may not require to be shut up in a hospital for the insane, but they do require watching and attention and are frequently benefited by being in a sanitarium. They should have pleasant surroundings, if possible lead an outdoor life, have an abundance of simple, nutritious food, sleep as much of the time as possible, and take frequent prolonged warm baths. Dreams.-Dreams are the product of sleep. Sleep, when it is complete, means unconsciousness with anemia of the brain; when it is partial a portion of the brain has a greater or less supply of blood, mainly venous blood rather than arterial and this portion manifests its activity in the phenomena of dreams. Unconscious- ness means the inhibition of the customary power of the senses. In the subconscious state one or more of the senses may have varying degrees of ability to respond to stimulus. If the stimulus is not considerable we may not be able to recall the picture pro- duced by it in our dream. Reflex muscular action is not abolished except in the deepest sleep, perhaps not even then, for it is of spinal origin, not cerebral. It is quite probable that the character of dreams is influenced by the quantity and the quality of the blood which reaches the thought-centers in the brain during sleep. Time and space in dreams are not abolished, but decidedly disarranged. Events move fast or slow, logically or illogically, coherently or incoherently. A person of analytical mind is apt to have a well-arranged dream; a criminal will dream of crime, a miser of gaining or losing money, a sensualist of sensuality. The hallucinations which come to the insane during sleep as well as during waking hours are further evidence that dreams are not necessarily associations or representations, and the same is true of the delirium of the fever-stricken. Dreams which come 382 HOW TO KEEP WELL when one is awake, so-called day-dreams or reveries, should not be placed in the same category with those which occur during sleep, for one who has them is not unconscious. An important fact which must not be overlooked in the consideration of this subject is that during sleep a large portion of the body, particularly that which is controlled by the cerebrospinal nervous system, the brain and spinal cord and their nerves, is entirely at rest, recuper- ating, gathering strength, undergoing reconstruction, while that which is governed by the vegetative or sympathetic nervous sys- tem is still more or less active. Sleep under any conditions means diminished activity, rest, reconstruction of tissue, and little if any responsibility. Nightmare or dreams that are terrifying in which the victim feels that he is paralyzed as to speech and motion very often have a basis in physical disease and sometimes in a perplexed and disturbed mind, as in the case of Lady Macbeth. Somnambulism is a form of dreaming and a very important one, for as in the case of Lady Macbeth, most accurately depicted by Shakspere, a somnambulist may have not only power over motion, but also over speech, touch, hearing, smell, and sight. That the psyche is not entirely unconscious in this condition is quite evident from the fact that certain acts are sometimes thus per- formed with even greater accuracy than if one were awake. The effective leadership of men in battle is a form of hypnotism or something analogous to it. Clairvoyance is another form of dreaming allied to hypnotism, self-imposed or imposed by others. It is often a means of experience which is quite inexplicable by any known laws; and it is not all humbug, by any means, not- withstanding the objections of its many opponents. To the phy- sician the dreams which come to patients subjected to general anesthesia are always interesting and suggestive. They occur prior to unconsciousness and prior to complete abolition of sensi- bility. Although dreams, taking them as a whole, occur at various stages of impaired consciousness, it is a question whether a dreamer is absolved from responsibility for acts done in the subconscious state which are interpreted under the category of dream phenom- ena. Hallucinations.-A hallucination is a mental or physical ex- perience the constituents of which are entirely fictitious. They do not exist, except in the imagination of the subject. An illusion is a mental picture which really exists, has some basis in fact, but is ABNORMAL MENTAL CONDITIONS 383 wrongly interpreted; it is magnified, minimized, or mentally twist- ed by the subject. A hallucination, however, may presume things either within or without the individual. One may insist that voices are heard within his head or some other part of his body, or he may hear those voices near or remote, outside himself. Both are figments of the imagination. Hallucinations are classified ac- cording to the sense which may be imposed upon or called into action by them; they also vary in character with the period of life in which they occur. A child has hallucinations which are en- tirely different from those of an adult. The commonest hallucin- ations probably are those of hearing. Hallucinations of hearing are the most common deceptions of the insane, but they also may come to thosewho are perfectly sound and rational. Voices are heard commanding one to do certain things, anything, even the commis- sion of crime. The insane man is positive that the voice is real, and he cannot be dissuaded from this belief. The sane man, on the contrary, differentiates that which is reasonable from that which is unreasonable, and rejects the latter. Peculiarities of this form of hallucination are that they may be unilateral, that is, heard in only one ear, or they may be experienced by deaf-mutes who never have heard at all. Hallucinations of sight are next in frequency and occur alike in the sane and the insane. They often are due to the influence of suggestion or hypnotism, or, perhaps, to some manifestation of the subconscious. Another variety of hallucinations involves the sense of feeling. One may have a feeling of pain when there is no cause for it, or an absence of pain when it should be present; or one may imagine that he has superhuman muscular power, or that he is absolutely without power, and it may be impossible to convince him to the contrary. The sense of smell is less frequently the seat of hallucinations. One may imagine the most delicious odors or those which are obnoxious and repulsive. The latter are more common than the former and are not infrequent with the insane or with those who have disease of the brain related to the center which controls the sense of smell. Whenever the brain is imperfectly supplied with blood from any cause, even in natural sleep, hallucinations are possible; and this frequently is the explanation of dreams, which are closely re- lated to hallucinations. Hallucinations in children are extremely common, often being associated with the irritation of intestinal 384 HOW TO KEEP WELL worms or some other irritant. Hallucinations in the aged also are of frequent occurrence and may be agreeable or disagreeable, mild or violent. Hebephrenia.-It is a variety of dementia precox, that form of insanity most common in adolescence and early maturity. It progresses gradually in people who are predisposed to insanity and is usually fully developed before the twenty-fifth year, somewhat earlier than other varieties of dementia precox. It is particularly apt to occur as youth merges into maturity. It often has for its basis a bad family history-alcoholism, syphilis, disease of the brain or spinal cord, anything, in fact, in the nervous system which may be passed along by parents to offspring. It is slow in developing; for a long time those who are destined to be its victims suffer with headache, insomnia, palpitation of the heart, inability to concen- trate the mind, though their mental development may be fairly good. They are shy, moody, and constantly examining and ques- tioning their state of mind. They have few physical symptoms of disease, those which are prominent and frequently present being poor circulation, coated tongue, obstinate constipation, and cold and clammy hands and feet. As the disease progresses they become restless, depressed, irri- table, indifferent to their surroundings, and frequently perverted in their moral nature. After months and perhaps years they have hallucinations and delusions; their personal habits become objec- tionable ; and at length the mind gives way and a condition more or less like idiocy supervenes. Sometimes there are intensified symp- toms, and again there may be remissions, when there is an apparent return to health; but this is prone to be followed by relapse and, it may be, by complete helplessness. In less than ten per cent of the cases is there a complete return to health. There often is a relation between these cases and sexual problems, and they demon- strate the tremendous importance of grounding a person in the fundamental principles of physiology and hygiene. They do not require much in the way of medicine except such as may be neces- sary to keep the bowels freely open. Castor-oil has a very happy effect upon them, as a rule. A daily warm bath, followed by a brisk and vigorous rub is useful; also walking, riding, and exposure to the direct rays of the sun. It is desirable that they have some occupation in which they should be encouraged to take interest to the limit of their ability. ABNORMAL MENTAL CONDITIONS 385 Hypnotism.-It has been defined as interference with or sus- pension of free will and judgment, with readiness to heed sugges- tion on the part of others. It may even be a form of autosuggestion, as autohypnotism. Even animals may be hypnotized, especially birds. This is the secret of the power of the cat and the snake over birds. Hypnotism has power for evil as well as good and is most effective with those who are fatigued, distressed, disappointed, overpowered by misfortune, depressed, hopeless; in a word, in any mental condition in which a weak will is disposed to yield to a stronger. It may be of great benefit when the stronger will is benevolent and imposes useful impressions upon the weaker. It is harmful when the stronger will is base, designing, malicious, and imparts impressions which are evil. It is adapted particularly, like all the methods of mind cure, to nervous and mental troubles in which there is no real structural disease of nervous tissue but rather a disorder of function, to the neurasthenias, hysterias, hypo- chondrias, and their attendant debilities and exhaustions compre- hended in the term "psychasthenia." But it also has been used by scientific persons of eminence for the relief of pain in rheumatism, neuralgia, and parturition, for producing sleep in the insane, and for anesthesia in surgical operations. The hypnotic state is intermediate between waking and sleep- ing, will usually permit past experiences to be recalled, and will yield unhesitatingly in susceptible subjects to suggestion, the hypnotized person submitting unqualifiedly to the will and desire of the hypnotizer. The method of procedure in hypnotizing is as follows: The subject is told to fix his eyes on a certain object, often a very bright object. The operator then makes passes at him, strokes him, and suggests aloud that he is about to sleep, that he will sleep, that he is sleeping. If the subject is impressionable, he quickly becomes semiconscious and does, or tries to do, whatever he is asked to do, however unreasonable or awkward it may be. He may become rigid or cataleptic, or there may be very little change in his appearance. In such demonstrations as I have seen I have thought there was humbug and pretense by some of the performers, but I have no doubt that a real hypnotic, semiconscious, suggestible state is entirely possible and practicable. When hypnotism has been genuine and has continued as long as the operator desires, he arouses the subject by a suitable suggestion by blowing in his face, stroking him, etc., and complete consciousness promptly re- 386 HOW TO KEEP WELL turns, with or without one's customary physical and mental equili- brium. Mesmer was one of the first to use hypnotism, which he called animal magnetism 'or mesmerism. Hypochondria.-Hypochondria or hypochondriasis is essentially a disease of the mind, a psychosis, without involvement, struc- turally, of the brain or nervous system; or it may be a real disease involving nervous tissue in addition to the mental dis- order. It is in the abdomen that the thought of hypochondriacs often seemed to be concentrated, and upon the right side particu- larly; that is, in the region of the liver; and it was from the liver with its black bile that all fantastic thoughts and imaginings were supposed to proceed. Hypochondriacs have a morbid tendency to study and analyze their physical condition, and they are constantly tormenting other people with the narration of their symptoms and their ailments. Their symptoms may or may not give them anxiety; they interest them superlatively. Of course, if there is a real foundation of disease in their symptoms, and there sometimes is, they may so exaggerate the situation that even their physician may fail to realize its importance and attribute all to a diseased imagination. Some of the symptoms which are complained of are pain in different localities, numbness, pricking sensations, cramps, twitching, ringing in the ears, palpitation of the heart, and great weakess. These people are intensely egotistic and self-centered, are all the time examining themselves, and are fond of reading medical writings which they cannot begin to understand and of talking about disease in all its varieties. Many of them are in constant dread of such serious diseases as apoplexy, cancer, Bright's disease, diabetes, etc.; and their symptoms may either remain constant or vary from time to time. They go from one doctor to another, try- ing all kinds of remedies and perhaps get temporary relief as they try the medicine of a new doctor; for it is the peculiarity of many of the sick, and the pseudo-sick, that they go to each new doctor with a certain amount of hope and confidence, especially if he is persua- sive and voluble and self-confident. Too much sympathy is not usually desirable for such people; they should be encouraged to be self-reliant; they should be di- verted by rational amusements, by occupation out of doors when possible, by travel, bathing, wholesome food, abundance of sleep, and the frequent use of castor-oil. Most medicines may be safely ABNORMAL MENTAL CONDITIONS 387 and properly eliminated in the treatment of this disease, but castor- oil should be retained as a kind of sheet-anchor. Hysteria.-One of its curious features is its contagiousness, a hysterical woman or girl imitating the peculiarities and disease symptoms of one who is really sick, though having none of the fundamental disease conditions of the one she is imitating. It is not limited to any particular period of life but occurs most fre- quently in girls on the verge of womanhood and young women who have not reached middle life. Frequently a girl or young woman who becomes hysterical remains hysterical to the end of her days. It is a condition which is very often the product of sugges- tion; it is the mimic of disease par excellence. Symptoms may be apparent in any portion of the body; in the skin, for instance, there may be acute pain or entire absence of feeling, and any por- tion of the surface may be sensitive to the slightest touch, or acutely painful, according to the statements of the patient, without provo- cation of any kind. Not only may the skin be acutely painful or free from all sensation, but the same may be true of the mucous membrane of the mouth, tongue, lips, and gums, and also of the teeth- and the joints. Hysterical people often pretend to be paralyzed and profess to be unable to move hand or foot, or they may have the contractures of the fingers and toes which occur with certain forms of paralysis, but their muscles remain in good condition and show that they are faking. Interesting, too, are the imitations by the hysterical of blindness, deafness, and loss of smell and taste. There are myriads of imitations relating to the organs of the body and their functions, including vomiting, especially vomiting of blood, loss of voice, cough, refusal of food, rapid action of the heart, rapid breathing, etc. A hysterical woman may have attacks of violent blushing or of pallor, one following the other, and accompanied with the discharge of a large quantity of colorless urine, or by scantiness of urine, but such attacks may be involuntary and not made up. Great emotion may be shown by a hysterical girl or woman; she laughs or cries easily and immoderately; she has great depression or exaltation; she may even have delirium or convulsions but does not lose con- sciousness as genuine sufferers do. Again she may hear voices and commune with spirits, or be profoundly drowsy or sleep for pro- longed periods. 388 HOW TO KEEP WELL Illusions.-An illusion has been defined by an eminent writer on diseases of the mind and nervous system as an erroneous percep- tion of external objects and relations, and cites as a very good example a mirage in the desert where a lake with its appropriate surroundings appears to be seen. Illusions happen to most of us rather frequently. If our minds are strong and well trained we are not much influenced by them. On the other hand, if our minds are weak the constant repetition of the illusory phenomena may sooner or later overcome us, and we become unable to place the proper estimate upon events which happen to us; and the result may be the unbalancing of the mind with its power of judgment and discrimination. Illusions may come to the insane, for comparatively few peo- ple are insane or unbalanced on all subjects. An insane person may even be able to detect an illusion; if he understands the science of optics he may not be deceived by the mirage of the desert; but mental disease is very often steadily progressive, and one who is thus affected may end by losing entire control of his reasoning powers on all subjects. An illusion is an optical deception; the sense of vision tells us, in the mirage, we are looking at a lake; the judgment, the power of discrimination, the faculty of reason- ing corrects this error and tells us it is not a lake but something else. An illusion may also be a delusion, but a delusion is more comprehensive of the two ideas. One may believe absolutely that a thing exists which exists only in his individual imagination. Melancholia.-The chief characteristic of melancholia is pro- found mental depression; the countenance is downcast and gloomy, the vision is darkened, and the outlook is hopeless. The patient has hallucinations and delusions and fear in regard to the future. Very often he is stupid and inattentive, and it is difficult or impossible to rouse him. Over everything hangs the black cloud of despair; he cries and laments and sometimes commits acts of violence. He has no desire for food and takes it only because he is compelled to, is obstinately constipated, and imagines there is obstruction or decomposition in his bowels. His suspicions in regard to the latter are not infrequently correct. The food he takes does not digest properly; his tongue is heavily coated, and his breath offensive. His nutrition is bad, his brain anemic; in fact, he is poisoned by products of decomposition absorbed from the intestines. After a while this patient gets careless in his manners and habits and loses ABNORMAL MENTAL CONDITIONS 389 weight, and his skin becomes dry and is dark in color from an excess of blood in the venous part of the circulation. The basis of all this trouble is frequently a bad line of ancestors. They were weakened by bad habits or disease, and their descend- ants to the third and fourth generations are affected. A bad tendency or strain is thus produced, and the habits or manner of life or unfavorable surroundings or wasting disease of the patient bring on the cerebral anemia, which is the principal feature in the development of the disease. But one need not be discouraged, for with good care it is said that seventy-five to eighty per cent of such cases may get well. This means that they must have an abundance of good food, careful nursing, suitable medicine, plenty of sleep and sunlight, and cheer- ful surroundings. They will do better and be more likely to re- cover if treated in a sanitarium than if treated at home. But this depends upon the quality of the sanitarium. Nostalgia.-It is not, properly speaking, a disease, and yet it is often one of the products of disease. For instance, it often is asso- ciated with malarial poisoning, and it may even cause sufficient distress and disturbance to intensify existing disease and lead to fatal consequences. I can even imagine that its effect upon mind and body may be sufficiently profound to excite real disease. It consists in an intense longing for home and its surroundings, and of course implies absence from them. One could not be homesick if he were at home. The mind of the homesick is filled with fore- bodings, with gloom, and with melancholy which amounts to dis- tress and even pain. It does not imply that the homesick person is unusually sensi- tive or has a highly developed nervous system, although that also may be the case. On the other hand, it may occur in individuals who ordinarily are phlegmatic and undisturbed by external con- ditions. It commonly occurs in those who are devoted to their home, their country, and their family and are absent from them from compulsion or otherwise. Anybody may suffer from it whether old or young. Young children who are separated from their parents often suffer acutely; so also do old men and women who have become deeply attached to the familiar sights and sur- roundings of the home in which they have lived many years and are permanently removed from them. With the latter it is a serious condition and may lead to insanity or suicide. It is a very common 390 HOW TO KEEP WELL affection in armies. Those who have lived in a mountainous country and are removed to one that is flat suffer greatly in this way. Those who are confined in prisons, especially when unoccu- pied, and perhaps troubled with regret and remorse, are homesick oftener than they are willing to admit; and those who are in hospb tals, especially hospitals for the insane, when they reach the stage of convalescence long for their homes with intense longing. It is not always easy to relieve homesickness; sometimes it is not possible, unless one can be restored to his home again, or unless there is a definite prospect of such an event. The effective treatment of homesickness is therefore home, not medicine or stupefying drugs. But when this is not possible, the best substi- tute is diversion, active occupation, interest in the welfare of others. Psychoanalysis.-The relation of the subconscious to mental and physical health briefly discussed. In order to discuss the subject of psychoanalysis, even in the most cursory manner, certain definitions must be kept clearly in mind, for they are fundamental and indispensable to its considera- tion. The psyche is that part of an individual which is concerned with his mental processes; that is, with his thought, or thinking. It is operated through the two nervous systems, the cerebrospinal and the sympathetic or vegetative, but probably to a much greater degree by the former than by the latter. Its functioning presup- poses consciousness for its ordinary work, but it is susceptible of a certain amount of activity when consciousness is suspended, as in sleep, dreams, hypnotism, and various abnormal conditions of the nervous system. Now, modern psychology says there is a region of semicon- sciousness, a subliminal or border-land consciousness, in which, without the aid of an active state of the cerebrospinal and sympa- thetic nervous systems as ordinarily manifested, the psyche may perform some of its most wonderful and impressive tasks. Most remarkable of all is the insistence of those psychologists who tell us that out of the reservoir of unconsciousness, provided the essen- tial organs or media of the body are in good working order, pro- ceed the influences upon which the psyche depends for more or less of its most important work. Psychasthenia, or psychopathy, im- plies that the psyche is unable to perform its tasks with their usual or normal results. Psychasthenia is very often, but not always, ABNORMAL MENTAL CONDITIONS 391 identical with neurasthenia. A neurasthenic may have a remark- ably good psyche, but his two nervous systems may be so deranged and disturbed that he is physically unfit for the ordinary duties of life. ; Psychoanalysis is a "calling to account" of the operations of the psyche. It means a looking inward, an examination and cross- questioning of the activities of the psyche, the finding out of the why and the wherefore of this or that line of thought. It is not concerned with the results of the thought but with its activating cause. It may be a self-analysis, subjective, or it may be objective^ as is the case when the analysis is made by a physician. Psychotherapy includes all means which may be used in the treatment of psychic ailments. There are many psychic ailments, however, which are removed temporarily or permanently by psy- choanalysis. You bare your whole nature to the psychoanalyst: your fears, hopes, anxieties, and everything which has been pulling you down, weakening not only your mind, but your body. If he is the right kind of psychoanalyst or psychiatrist he sees to the bottom of your trouble, or makes you think he does, and suggests a remedy at which you grasp and, following it out, are benefited. This is undoubtedly the explanation of the successful results of Christian Science, mental healing, hypnotism, and many other pro- cedures which are being extensively practised at the present time for the healing of human woes. A very important phase of psychoanalysis at the present time consists in the reference of physical ills, which is made by Freud and his followers, to a sexual basis. It is true that in great numbers of the animals the sexual impulse dominates all others. But it would be a most amazing and unwarranted deduction that this con- dition should exist universally after large numbers of the human race had cultivated mental discipline for ages and ages. The object of psychoanalysis therefore is, by means of all the instrumentalities of psychotherapy, whether physical or psychical to put the psychasthenic individual on the right course, encourage him to be self-reliant, chase away his gloom and his forebodings, and persuade him that his case is not so desperate nor so hopeless as he has believed. Even in the incurable maladies there is an opportunity for betterment by this kind of a gospel, and it is quite possible to exercise it without straining the truth or departing from the path of rectitude and integrity. 392 HOW TO KEEP WELL Self-Consciousness.-It is more common for boys to have these experiences when in the presence of girls or those toward whom they are expected to show a certain amount of deference than for girls under corresponding conditions, but girls are not exempt from them. This restraint and this blushing and stammering are a source of great annoyance to these individuals. There are doubtless some cases in which there is a basis of disease, either inherited or acquired. Some people who have a weak or defective nervous system, whose parents or grandparents were defective in some way, whose home or school training has been bad, or who have been victims of the vices and indiscretions of youth-all of these are purely pathological cases which need the attention of doctors and perhaps medicines. But the vast majority of those who suffer in this way-and the number of the victims is certainly a very large one-are simply suffering from an excess, or an exaggeration, of self-consciousness. In other words, the con- dition is not physical, but psychical, with certain physical mani- festations. These physical manifestations are brought about through the agency of the nervous system, which, of course, is more highly developed and more sensitive in some individuals than in others. Why the feeling of restraint should occur I cannot explain for the majority of cases, except by a guess that it is due to con- ditions analogous to positive and negative electrical affinity. It is easy enough to comprehend it when the individual has a sense of fear or remorse or shame, but not when there is no occasion for these feelings, and when furthermore the individual exciting the sense of restraint has only feelings of benevolence or love toward the sufferer. The explanation of blushing is as follows: The walls of the arteries of the body are provided with minute nerves called vaso- motor nerves, which by their action regulate the caliber of these vessels and determine whether a large or a small volume of blood shall flow through them. If an impulse of one character is sent to these nerves from the brain they close down on the vessels, or on more or fewer of them, shutting off or diminishing the current of blood; while if an impulse of a contrary character is sent they loosen up on the vessels, their caliber is enlarged, and a torrent of blood rushes in, extending, before the tide reaches its limit, to the myriads of minute vessels at the surface of the body. Fear, re- morse, and some other emotions would cause the first of these ABNORMAL MENTAL CONDITIONS 393 reactions, and pallor at the surface would be apparent; joy or exaggerated self-consciousness would cause the second, and redness or blushing would be the result. Stammering in such cases as we are considering would be the result of an impulse from the brain to the organs and tissues which control speech, producing in them more or less of a paralysis. Sometimes, if we know the cause of a trouble or ailment, we are at least on the road to its cure; we have made a start in the right direction. Senile Dementia.-The tragedy of growing old! How often we see it in men who have been strong, vigorous, hard workers, men who have accomplished much in life, decaying from the top like a tree that has been tall, beautiful, and fruitful. It is more common with women than with men, and is a pitiful picture. It is often called a second childhood, but that is an inapt term, for the simplic- ity of childhood always has the hope and promise of future develop- ment and usefulness. Senile dementia never has it. It is the twi- light before the sunset that has no to-morrow's rising. It seldom comes before the sixtieth year and frequently begins much later in life. It sometimes has spurts of improvement, but they soon pass off. It means a persistent weakness of the brain and its functions from wearing out. It is often the concluding period of alcoholism or syphilis, and it comes to those who have suffered long with gout, rheumatism, excessive strain-physical or mental or both. It is the legitimate consequence of prolonged worry and anxiety, of struggle against hard luck, and of neglect to cultivate the virtue of self-control. Many of those who have been fast livers, whose habits have been loose and licentious, may expect senile dementia as the final chapter of their history, if they live long enough. In the harmless cases there may be a constant desire to sleep. Those affected sleep while they sit at the table or read the paper, or in the midst of a conversation. They are always drowsy, and it is impossible to stir them up. Others sleep badly and at intervals; they have unpleasant dreams; they are afraid of being alone and of the darkness; and they have a very bad propensity for getting up in the night, prowling around, and perhaps injuring themselves by falls and bruises. Not infrequently they have slight shocks or strokes, from which they may recover more or less completely un- less the hemorrhage into the brain is profuse, in which case they pass more or less quickly into unconsciousness and death. In other cases temporary improvement is soon followed by helplessness. 394 HOW TO KEEP WELL They become bedridden, and because the circulation in the skin is sluggish they develop ugly bed-sores on the back and become a great care to those who attend them. Senile dementia frequently begins with loss of memory. One forgets where articles were placed. Not only does the intellect become weak and childish, but the moral nature may degenerate: and become very unlovely, while the physical powers gradually fail. Walking becomes slovenly. One who previously has been neat and orderly becomes offensive in habits. For recent events the mind may be a blank but for those of early life it may be keen. Statements are repeated again and again and stories retold, to the distraction of friends Senile dements often become obstinate and vain. Men boast of their power and capacity and cannot be con- vinced of their incapacity for the duties to which they have been accustomed. Speech is halting and inarticulate, and ideas are con- fused and incoherent. In a majority of the cases there is obstinate constipation, and the poisoning which accompanies this condition is responsible for many of the bad symptoms. Alcoholic stimulants wisely given are often very beneficial in these distressing cases. Good nursing, bathing, and gentle atten- tions may greatly mitigate the situation. CHAPTER XIX CONCERNING SLEEP Insomnia.-I shall be very frank at the outset and say that of sure cures for insomnia I know of none. Certainly, since sleep is so important, so refreshing, and so essential, there ought to be some way of alluring it when it persistently evades us. Of the drugs which have been offered as remedies there is certainly no lack, and it is confusing to choose among them. Most of them are poison- ous and dangerous to life, and they are often ineffective even when given under the direction of a watchful physician. The insomnia of disease is very different from that which is due to other causes. A healthy child is never troubled for want of sleep; it comes easily and naturally, as a physiological act encour- aged by fatigue, and sometimes disturbed by errors of diet or by emotional causes. Real sleeplessness and a healthy child are in- congruous terms. During sleep he is collecting energy for the work which is necessary to his growth and development. But if a child is suffering from disease or injury he will be unable to sleep because he is suffering from pain, fever, delirium, or some other discomfort. A grown person, under similar conditions, is sleepless in the same way as the child. In both cases there are physical disturbances which are not under the control of the will and which must be counteracted by suitable physical agencies. In such cases it is quite proper that powerful remedies, perhaps poisonous ones, should be used to bridge over the diseased condi- tion ; but they are justified only by the emergency of the situation, the requirement being that the one who gives them should give them intelligently and watchfully. Now, insomnia from causes other than disease or injury is a very different matter, such causes being worry, grief, overwork, business cares, and a thousand other things. These things have 395 396 HOW TO KEEP WELL not been dismissed at the bedroom door, but have been carried to bed, often unavoidably, I grant; and the mind keeps turning them over, jumping from one to another, and never letting go until ex- haustion brings with it a longer or shorter period of sleep, or until the return of the day demands a return to the day's work. There are those who will tell you that if you relax and lie perfectly passive you will get over your sleepless and restless con- dition, forgetful that even this may require more or less mental effort and end in making you more wakeful and disturbed than ever. Sometimes drowsiness and sleep may be obtained by taking a warm bath, by reading an amusing book for an hour, or by drinking a glass of warm milk. The use of the faradic current just before going to bed has often been found helpful but is not infallible. Counting one hundred and repeating it, or saying the multiplication table, or continued repetition of some simple phrase, are other expedients which may be tried. The best success which I have had in this line consists in the repetition of a series of words sug- gestive of sleep, like hypnotism, balmy sleep, hypnosis, etc., re- peated as mechanically as possible. Many sufferers from insomnia find relief by a change of surroundings, by going to a different room, or a different house, taking an ocean voyage, or going into the country, especially to some place which is free from disturbing noises. Still if there is no irremediable disease in the case and no other cause which is incapable of removal, one need not get discouraged. Many times it has happened that the troublesome condition finally wears itself out; certainly if one expedient fails there is no reason why another may not be tried, and at length the right one may be found. Sleeping-Sickness.-The real sleeping-sickness, or trypano- somiasis, is not seen outside of Africa unless brought from that country. It is produced by a parasite in the blood called trypano- soma, a minute protozoon three times the size of a red blood cor- puscle, present in the blood of'certain African animals. These ani- mals are bitten by the tsetse-fly, an insect which is not found in this country and which lives principally in bushes and grass along the banks of certain African streams. The bite, like that of the mosquito, is accompanied by the sucking of a portion of the ani- mal's blood containing trypanosomes. When the fly bites a human victim he transfers more or fewer CONCERNING SLEEP 397 of the parasites to his victim, and these parasites are promptly absorbed into his blood. Within the blood circulation incubation takes place rapidly in whites, slowly in negroes, the parasites eventually finding their way into the fluids of the brain and spinal cord and into the lymphatic glands. Thus the sleeping-sickness is produced as malarial fever is produced by the anopheles. The first symptom to be noted is fever, which, however, is not accom- panied by chill and sweating, as in malaria, lasting two to four hours. Then comes a period of subnormal temperature, followed by swelling of the lymphatic glands on the back of the neck, and then by swelling of the glands over the entire body. With this swelling comes the formation of small vesicles or blisters, and the fluid within them contains parasite trypanosomes. These blisters also occur upon the skin of the chest, which is very sensitive to pressure, while more deeply within the tissues there is severe pain. About this time also there is edema, or swelling about the eyes, the face, the ankles, and even the entire body. A few weeks later, after the parasites have passed into the brain and spinal cord, the nervous symptoms become apparent: dullness, inattention, drowsi- ness, irritability, fits of anger or weeping, and general loss of self- control. These symptoms may be followed by shaking and twitch- ing of the muscles, epileptic attacks, even insanity and spinal trouble of some kind or other. The dullness and drowsiness finally pass into an almost continuous sleep, from which the patient can be roused at first, particularly if he feels the need of food; but after a time it becomes impossible to rouse him, sleep deepens into the unconsciousness of coma, and this is soon followed by death. This disease, unlike malaria, is not influenced by quinine, but if it is attacked in its early stages it may sometimes be treated successfully with preparations of arsenic, strychnia, mercury, and antimony. Somnambulism.-Somnambulism means sleep-walking or walk- ing while asleep; but writers upon this subject give it a much more comprehensive meaning, for they also include talking, writing, and motions requiring the use of many muscles which are necessary in walking, singing, playing on instruments, and many other acts that ordinarily require precision and training. Somnambulism is a state of partial unconsciousness, like dreaming; indeed, it is a kind of dreaming. When one is in deep asleep, there is complete unconsciousness; 398 HOW TO KEEP WELL all the brain-cells are completely inactive; there is absobutely no knowledge of what is going on, no sensation, and only such mo- tions as are reflex and involuntary. The will being out of commis- sion, there can be none of these motions which are initiated and instigated by the will, commonly called voluntary motions. In dreaming, and therefore in somnambulism, some of the brain-cells become functionally active, while the others remain inert. It may be certain cells which have been trained for particular work, and a stimulus comes to them, stirring them to activity, as the opening of certain stops in an organ produces particular effects. Such a stimulus may be an intense impression which has come from the performance of an important duty, fatigue, or some experience of an unusual or startling character. Some writers find the stimulus in disease of the body or mind, which works upon the brain-cells concerned in any given act of somnambulism as a ferment like yeast works in and through a mass of dough. It is to be noted, and it seems to me very remarkable, that the motions and actions in the somnambulistic state frequently are per- formed with an accuracy which would not be manifested by the same individuals if they were awake. This has been attributed to the fact that the attention of the somnambulist is entirely concen- trated upon the act he is doing. One of the most interesting and most peculiar phenomena of the somnambulistic state is the vision or prescience which sometimes attends it. While those who are in this state may and doubtless do say many things that are not so, they have also been known to say many things which have proved true, and it would be well if some way could be discovered of differentiating the true voices from the false ones and utilizing the messages which are given. The ordinary sleep-walker rises from his bed, proceeds deliberately to the performance of a certain task, as if prearranged, and returns to his bed. He may have no knowledge of the act the following day, or it may have left on the mind the more or less vivid impression of a dream. The nervous system of the somnambulist is in a condition of unstable equilibrium, probably more so than even in sound sleep, for a portion of the sensorium is awake. One should, therefore, be exceedingly careful about awakening a somnambulist whether a child or an adult, in a rude or sudden manner. It has been said that those who are subject to this condition express thereby a morbid predisposition which is more or less akin to chorea, epilepsy, CONCERNING SLEEP 399 and hysteria. This is probably true, and hence somnambulists, whether children or adults, should be regarded as subjects of ner- vous disease and great care taken to prevent its continuance and extension. Twilight Sleep.-The use of scopolamine and morphia in obstet- rics and in surgery is not new. It is often resorted to here as a preliminary to anesthesia in surgical operations, and its results are good in calming the fears of nervous patients, in facilitating the taking of the anesthetic, in obviating the vomiting after the opera- tion, and in producing quiet and restful sleep for several hours. I believe it is not without a certain amount of danger. It is strange, if its use in obstetrics is so invaluable, that it should not have been appreciated and employed at Vienna, Berlin, Munich, Prague, and other great obstetrical centres. American obstetricians are as intelligent and as skillful as any, and it is a litle strange also, if this method has the merit it is supposed to have, that it has not been quite generally adopted by them. We have painless childbirth under spinal anesthesia, and many have abandoned it, and ought to, in my opinion, because it is dan- gerous. If there can be any improvement over anesthesia with chloroform in obstetrics, or with ether in rare cases in which chloroform is undesirable, I have failed in a good many years of obstetric practice to learn it. And this is true whether the labor be or be not an instrumental one. I am willing to admit that scopolamine and morphia are often useful in allaying the apprehension of timid and nervous women who are approaching parturition with dread and anxiety, and that it eases the pain of their labor, but it is of no value in the intervals between pains. In that respect chloroform is its superior, for it is given only as it is required. CHAPTER XX DISEASES OF GLANDS Endocrinology.-The ductless glands have no tube through which their secretions can be discharged, and yet these secretions are manufactured and properly utilized in this most complex of mechanisms which we call the animal body. How is it done? They are absorbed by the blood-vessels of the glands and conveyed by the blood-current to the portion or organ of the body which it is their job to activate or influence. Most of the ductless glands are small and insignificant in ap- pearance. Only one of them, in its normal condition, is of consider- able size, this being the spleen, the principal function of which seems to be the formation of white blood-cells. The other princi- pal ductless glands, so far as they are known and have been studied, are the thyroid, the parathyroids, the thymus, the adrenals or suprarenals, and the pituitary gland or hypophysis. There is also a small collection of cells in the pancreas called the islands of Langerhans, which acts like a ductless gland and, although so very minute, is of vast importance, for it has an influence upon the changes which take place in the digestion and assimilation of the starches and fats of the food, and when it becomes diseased it causes diabetes. The functions of these glands having been ascertained by care- ful study and experimentation, it became the work of endocrinology to use extracts obtained from the corresponding glands of freshly killed animals (sheep and cattle) in the treatment of the disorders arising from disturbances in these functions. So far as the influence of the parathyroids is understood, their secretion seems to influence the distribution of calcium or lime within the body. This is ex- ceedingly important, for lime constitutes the greater part of the bones. Disease of the parathyroids is also believed to have an in- 400 DISEASES OF GLANDS 401 fluence in producing the destructive disease known as tetany in infants. Extracts prepared from the thyroid and parathyroid have been found more or less serviceable in treating the various diseases which are influenced by the presence or absence of the secretions of these glands. Even more wonderful is the action of the secretions of the min- ute pituitary gland, that which is derived from the posterior portion being the part which is physiologically active, so far as is known. When the anterior portion of the pituitary gland is diseased in children it produces an ailment known as gigantism, different por- tions of the body being enormously enlarged. When this diseased condition occurs in adult life, it produces the peculiar disorder known as acromegaly. Acromegaly.-This condition was described and named by Pierre Marie in 1885, its distinguishing feature being increased size of the hands and feet and of the bones of the nose, the cheek, and the lower jaw. There is also in well-marked cases an outward curvature of the upper portion of the spine, which gives a hump to the back and changes the dimensions of back and chest. Both men and women may have this disfigurement, though it is more common in women. It usually begins between the ages of eighteen and twenty-five and may continue four or five years, or it may last as many as thirty years. It ends in fatal exhaustion unless it is cut short by some acute disease or some accident within the brain. It begins with thickening of the ends of the fingers and toes, and gradually the whole hand and foot are enlarged. This enlarge- ment does not mean increase in the muscles and increased strength, but rather increase in the connective tissues which bind the muscles together. It diminishes strength. Finally the hands become large and clumsy, the forearms remaining nearly unchanged. The toes become enormous, and the feet like the paws of an animal. The legs are enlarged to the knees, but not to the same extent as the feet. The face is elongated, the lower jaw projecting, and the forehead being narrow and receding, though the brows are enlarged. The eyes protrude and are small and expressionless, and one or both of them may squint. The nose is flat and broad, the lips and tongue enormous, the ears protuberant, and the entire facial ap- pearance repulsive. The skin of the face may be a brownish yel- low and have warty growths distributed over it, while the hair is coarse and stiff. Thickening of the vocal chords gives the voice a 402 HOW TO KEEP WELL deep, metallic character. The projection of the spine may cause a more or less extensive deformity. In some cases the knee, wrist, and elbow joints are enlarged and crackle painfully when moved. The heart may be enlarged and its action irregular, and there may be varicose veins in various parts of the body. As the condition develops the patient becomes sensitive to cold and may complain of neuralgia or rheumatism. This condition is caused by an en- largement or a tumor of a structure on the under surface of the brain called the hypophysis or the pituitary gland. It weighs nor- mally seven or eight grains, is connected at one end with the base of the brain, and is seated on one of the inner bones of the skull. Suitable medicines are given to relieve pain and sleeplessness, but no medicine has yet been discovered which has any influence on the tumor. Treatment by surgical measures is one of the most difficult problems that have ever been undertaken, but it has been undertaken successfully by perhaps half a dozen men, and they are supreme masters of their art. The investigation of this subject has brought out at least one important fact, and that is that an extract of the pituitary gland may have great value as a medicinal agent. Of course, the gland from animals is used. This has been given to sufferers with acromegaly without good results, so far as I am aware; but it is said to have very positive influence in arrest- ing hemorrhage and in facilitating childbirth. Addison's Disease.-It was described by Addison as a disease of the suprarenal capsules, the chief pecularity in its outward ap- pearance being a bronze color of the skin. He thought it was due to insufficient activity of these organs or to some trouble in por- tions of the neighboring structures of the sympathetic nervous system called the semilunar ganglia, which are parts of the im- portant organism known as the solar plexus or abdominal brain. Little was known about the suprarenal capsules at that time except that they were two small glands without ducts or outlets, one of which rested upon the top of each kidney. Shortly after this the celebrated French physiologist, Brown- Sequard, investigated them and found that they manufactured a very important secretion, and that when they became diseased other important ductless glands, like the thyroid and the spleen, also were involved. Addison's disease seemed to him such a very im- portant one in its symptoms and its results that he thought it might involve the entire sympathetic nervous system, which presides over DISEASES OF GLANDS 403 the nutrition of the body. Other investigators believed they dis- covered that the sympathetic nerves, acting upon the suprarenal capsules, controlled the deposit of pigment or color cells upon the skin and other parts of the body; and if this is so it would account for the peculiar bronze pigment which is distributed over the skin in Addison's disease and makes the victim look like a mulatto. About the first noticeable symptom is great weakness and pros- tration. The slightest effort causes great fatigue; even eating and breathing are burdensome. Following the weakness brownish spots appear on the mucous membrane and then on the skin. These spots may remain distinct or they may run together and give the skin the bronzed appearance characteristic of the disease. With the weakness may be also great difficulty in breathing, coughing, expectoration, subnormal temperature, vomiting, and diarrhea, the diarrhea alternating with constipation. The vomiting, consisting principally of mucus, may begin early in the morning and be re- peated frequently through the day. The blood-pressure becomes very low; there are pains in the back and the abdomen; the kid- neys cease to excrete a normal quantity of fluid; blood-poisoning becomes evident; the patient becomes wasted, thin, and paralyzed, and at length dies of exhaustion. All this may occur within a few weeks, and death may come suddenly without a warning; or, if there be good resisting power, the case may be prolonged, and tem- porary or permanent improvement may take place. Addison's disease is one of those in which treatment by means of animal extracts was suggested when its nature became known. Aside from careful nursing and suitable diet, I know of nothing more likely to be of service in this disease than a suitable prepara- tion of the animal gland, begun early, given in suitable doses, and continued for a sufficient period. Adenoids.-Where are adenoids? The mucous membrane which lines the throat and nose normally contains what is called lymphoid tissue; that is, tissue which resembles lymph-glands and tubes. When this is increased in spots or in groups of spots and forms masses or lumps which project into the nostrils or into the cavity of the throat, these masses are called adenoids, which means some- thing that resembles glands. They may be as large as a pea or larger, or they may even be in bunches like small grapes. The larger they are the more they obstruct the air-passage in the nose and throat, so that one who has them, instead of breathing through 404 HOW TO KEEP WELL the nose, which is the proper way, must breathe through the mouth. The consequence is that the mucous membrane is constantly dry, and every facility is present for taking in dust and germs of dis- ease, while development is hindered in many ways. Anybody can have adenoids, from an infant nursing at its mother's breast to an old man or woman of three score and ten, but they are most common and troublesome in children from eight to twelve. In children they are soft and succulent, absorb poisons readily, and furnish a splendid bed for culture and development of disease-germs. In mature or old people they are harder, and bac- teria cannot grow on them so well. A nursing baby with adenoids cannot breathe while nursing and has to stop frequently to catch his breath, so that it often happens he does not get air enough. From this it happens that his blood is not properly aerated, and perhaps in addition he does not get food enough, so that his digestion suffers, his sleep is disturbed, and his entire nutrition becomes affected. An older child with adenoids also cannot breathe properly while eating. His food is not thor- oughly masticated, and he, too, will have imperfect digestion and poor nutrition. He breathes through his mouth waking and sleep- ing; he snores, has bad dreams, and cannot control his bladder. He very often has a nasal catarrh, the discharge running down in part upon his lips and in part into his throat and stomach. Pretty soon he loses his appetite, and anybody can see he is a very unhealthy child. Together with the adenoids there often comes enlargement of the tonsils and the uvula, the little cone-shaped body which hangs in the middle of the palate, the entire opening to the throat being apparently blocked up. Children who are thus afflicted often have a dull and expressionless countenance; their complexion is bad, their upper lip is retracted, the septum of their nose is deflected, and the glands in the neck may be enlarged. Stammering some- times comes from this cause; the voice is thick and lacking in resonance, and the intellect often seems to suffer. Children who have adenoids are very frequently victims of croup, hiccups, St. Vitus's dance, nosebleed, earache, and headache; they are constant sufferers from colds, and they often are deaf and have weak eyes. There is no excuse nowadays for parents, however poor, to withhold proper treatment from their children. There is scarcely a town of any size where there is not a dispensary or hospital in which such treatment may be received if it is needed. The earlier DISEASES OF GLANDS 405 it is given the better for the child, and in the class of cases which has been under consideration it will consist first in the removal of the adenoids, with the tonsils, too, if necessary, the use of suitable tonic remedies, and the administration at the home of properly prepared and easily digested food. Adrenals and Adrenalin.-The adrenals or suprarenal capsules are small bodies or glands, one on the top of each kidney, and be- long to the series of ductless glands. These glands are very small, and yet their secretion, called adrenalin, or epinephrin, like that of the thyroid, the pituitary, and the spleen, is exceedingly important and powerful. These glands are the seat of important diseases, particularly according as their secretion is increased, diminished, or cut off altogether; but they are as yet obscure and little understood. The extract obtained from the adrenals, that is, adrenalin or epinephrin, acquired a very important position as a medicinal agent and is coming more and more into use as its value and scope be- come known and appreciated. If it is applied to the skin or mucous membrane the surface becomes blanched because its blood-vessels have contracted and the blood is squeezed out of them. Hence it is used on the nasal mucous membrane and the conjunctiva of the eve when it is desired to dry up their secretion, and upon any por- tion of the skin which is broken and bleeding to arrest the bleeding. In either of these locations it may be applied in powder or in solu- tion, both preparations being made from the dried glands freshly ob- tained from killed animals. It is also used internally, both by mouth and by hypodermic injection, but its use is not unattended with danger, and serious results have been reported from this method of use. Viewed from the standpoint of safety, its greatest value at present seems to be in cases in which there is hemorrhage and in which it can be applied at or near the site of the hemorrhage. The field in which it can be so used is not a small one. Take, for in- stance, the many cases of cancer in which bleeding is troublesome; adrenalin may be applied on cotton directly to the source of the trouble. In profuse nosebleed or bleeding from the throat or larynx it may also be applied with great satisfaction. In hemorrhoids, which may be very troublesome on account of hemorrhage, it may be used by local application or in the form of suppositories. Neu- ralgias of the surface and numerous forms of skin-disease are also benefited by local applications of adrenalin, pain and congestion 406 HOW TO KEEP WELL being greatly relieved as the blood is squeezed out of the turgid blood-vessels. Bubonic Plague.-It is the most deadly of all acute diseases, eighty per cent of the cases being fatal. Its undoubted cause is a bacillus which is incubated in the intestines of bedbugs and fleas, especially the latter. The fleas attack dogs, monkeys, squirrels, rats, and other animals, especially rats, and transfer the bacilli to them. They may also be transferred to the dirt and dust of houses and streets and may be acquired by human beings through the injured skin of the feet, hands, and legs, a very slight abrasion being suffi- cient to admit them into the lymphatic vessels, from which they are transferred to the circulating blood. They may also be floating in the air, be inhaled through the mouth or nose, pass into the lungs, and then get into the blood-vessels. There are really two forms of the disease, the bubonic, which is characterized by lumps or bubos in the glands of the groin, thigh, armpit, and neck, and in the tonsils. This form comprises eighty per cent of all cases. The other twenty per cent, or nearly that number, comprise the pneumonic form, which attacks the lungs in the most virulent type of pneumonia, without bubos on the skin, and with symptoms of overwhelming poisoning in the stomach, intestines, kidneys, and brain. A relatively small number of cases show only internal evidence of poisoning in the blood, the lymphatic system, and the cellular tissue beneath the skin. After one has been infected either by the bite of a flea, by inhal- ing the bacilli, or by acquiring them through the feet or hands, there is a period of incubation in the blood of two to seven days. Then there is a sudden chill and great fever, dizziness, headache, delirium, and complete prostration. The pulse and breathing be- come very rapid, the face and eyes congested, and the tongue swol- len and coated; and constipation is followed by diarrhea. The kidneys fail to act, and the bubos promptly appear in the glands above mentioned. There may also be hemorrhages into the skin and the mucous membrane of the nose and lungs. Unconsciousness and death may come in a few hours or be deferred for three or four days. If the fifth day is reached and the patient not utterly ex- hausted, there is a chance that he may rally and get well. The pneumonic form begins like influenza with chill, pain in the side, cough, bloody expectoration, fever, delirium, and spots of consolidation in the lungs or bronchopneumonia. There is com- DISEASES OF GLANDS 407 plete prostration and usually a fatal result in one to four days. There is also this difference between the two varieties of the disease. The pneumonic form does not occur as an epidemic in hot countries and is most virulent in cold weather; the bubonic form occurs in hot countries and always between April and December. A serum has been prepared for this disease which is sometimes efficient and it is very useful as a preventive. Cold applications, cold drinks, and nutritious fluid food, with careful nursing and opening of the bubos at the proper time, are suitable measures of treatment. Cleanliness, plenty of light and air, isolation of the sick, and disinfection of clothing, bedding, and everything connected with the sick-room are rational precautions. Of course, all possible efforts must be used to get rid of rats, fleas, and bedbugs. Diseases of the Salivary Glands.-The salivary glands are a very important element of the structures of the mouth. There are three pairs, one under each ear, one under each side of the lower jaw, and one under each side of the lower aspect of the tongue, or there may be but one under the tongue. The material which they secrete or manufacture is called saliva. It is composed almost entirely of water, but also contains a small quantity of a ferment called ptyalin, which has a weak digestive action upon starchy foods taken into the mouth, converting a small portion of them into sugar, as the beginning of the digestive process. The saliva to a certain extent dissolves the food as it undergoes mastication preliminary to its being swallowed. It also keeps the mucous membrane of the mouth moist and soft, facilitating the use of the tongue and the act of articulation. It always is called for by the presence of food in the mouth. Sometimes the mere smell of food, or the talk of food, or even the thought of it "makes the mouth water"; that is, excites the flow of the saliva. It is therefore a very essential secretion, and when it is cut off or dried up from any cause whatso- ever the dryness of the mouth which follows it is not only extremely uncomfortable but may have a bad effect upon digestion and indirectly upon the general welfare of the body. In disease of these glands the tongue is red, cracked, and dry; the inside of the cheeks and the palate is also dry; and the mucous membrance of the mouth is pale and shining. It is accom- panied by arrest of the secretion of tears and of the ordinary dis- charge of mucus from the nose. Not only are these uncomfortable conditions present, but the entire skin may be dry. and the teeth, 408 HOW TO KEEP WELL which developmentally are a part of the same structure as the skin, are defective and easily broken. The act of swallowing in such cases is extremely difficult, and one can easily imagine a disturbed general condition, with loss of weight and other important symp- toms as logical consequences. About the only drug which appears to have any influence upon it is pilocarpin, which acts as a direct stimulant to the secreting power of the salivary glands. Much more frequently are these glands subject to excessive secretion producing the condition known as ptyalism. In such cases the flow is continuous, sometimes watery, and sometimes thick with mucus. This condition may be produced by unusual nervous impressions, or by the smell or sight or thought of food, especially when one is very hungry. It is very frequently present in children who are teething, in women who are pregnant, and in diseases of the stomach. It may occur as the re- sult of poisoning with mercury, with iodine, with copper, and with pilocarpin as mentioned above. Ptyalism or salivation from mercury formerly was an extremely common result of the injudicious administration of this substance in malaria, syphilis, and other diseases. It frequently happened that the teeth were permanently loosened or lost as a result of such treatment. It is desirable in treating salivation to improve the general condition by an abundance of good food, to use an astringent mouth-wash and gargle like chlorate of potash or alum, and to apply a mild galvanic current. The salivary glands and their ducts may be the seat of stones which form within them and necessarily arrest the flow of saliva. These glands are also the seat of tumors, either fluid or solid, some of which are benign and may be removed, while others are malig- nant and irremovable. Diseases of the Sweat-Glands.-There is a fluid from the sweat- glands which has a peculiar and even a very offensive odor; and sometimes, instead of being colorless like ordinary perspiration, it is blue or yellow or red, though such variegated colors are not very common. Normally the sweat-glands are always busy, always on the job; and their average output is about two pints per day. Ordinarily this is not noticed, as it is quickly evaporated, and so it is well called insensible perspiration. When we work hard or get excited or frightened, or when the weather is hot, the sweat gathers in drops or trickles off the skin in little rivulets. DISEASES OF GLANDS 409 Now, if the sweat glands get diseased, the back of the neck, the palms, the soles, or some other portion of the body may al- ways be moist, or in other cases they may be uncomfortably dry. The fluid of the sweat-glands is taken out of the blood, and as there is more blood in the skin when we exercise than when we are quiet the sweat-glands are busier than usual at such times, and consequently there is more perspiration. Again, when the tissues are all relaxed, as they are during sleep and in certain di- seases, the sweat-glands are relaxed also, and there is nothing to hinder the perspiration from coming out. If the skin is dry, on the other hand, there is either too little blood in the skin, or the glands are closed up as a flower is closed at night, or they are in bad working order in some other way. Sometimes when the sweat is formed but cannot get out little blisters are formed all over the skin, which is then not only dry but may be very sensitive. I can only say that we are less likely to have these troubles if we lead regular and simple lives, eat proper food, avoid constipa- tion, and are constantly careful to keep the skin clean. In how many ways it is true that cleanliness is next to godliness! Absolute cleanliness is of the first importance; the removal not only of dirt, but of wet garments, dried perspiration, and dead bits of skin. The same rule of cleanliness must be applied that is used in the treat- ment of wounds. Hot water and a good astringent soap plentifully used will cure many of the cases of profuse sweating. Some dry powders are useful, and some are not. The best powder that I know of is boracic (boric) acid. It is antiseptic and slightly as- tringent, but like all others it may cake upon the skin and irritate. It must be removed after it has been on a few hours, and a fresh supply put on. For very dry feet or hands, soaking in hot water for fifteen or twenty minutes will improve the circulation and make the skin red and moist. Sometimes the result will be better if a little mustard is added to the water. Enlarged Glands in the Neck.-These glands are a part of the lymphatic system and are normally dense and firm in structure, serving as a kind of filter for the materials which must be separated from the lymph-stream on its way to join the blood-current. It is not strange that bacteria which may be retained in them in the course of this filtering process should cause disease. The lymphatic glands on either side of the neck are very numerous, and a single one of them may become diseased and enlarged, or an entire chain 410 HOW TO KEEP WELL of them on either side or on both sides. They may resemble a string of beads, or they may become distinct masses or tumors. There may be no very great degree of swelling at the surface, but the enlargement of individuals or groups of glands may extend deeply into the tissues of the neck. The enlargement may begin in childhood and progress slowly until adult life, and then it may gradually subside. This is particu- larly the case when the person affected has good care and treat- ment and leads a normal life. In other cases there g.re acute at- tacks of inflammation, and the inflamed gland or glands suppurate and undergo the history common to abscesses in other portions of the body. When the inflammation subsides the swollen gland may remain inactive, and perhaps little harm may be done unless inflammation is reexcited by some disturbing cause. In many cases the abscess breaks through the skin and discharges its contents; but instead of healing promptly, as other abscesses often do, it may continue to discharge and remain an open sore for an indefinite period. This disease is very often associated with disease of the tonsils, and bacteria are often directly transferred from the tonsils to the lymphatic glands in the neck, with subsequent disease in these glands. When children suffer from enlarged and troublesome ton- sils it is very important to examine the neck and see if there are not also enlarged lymphatic glands. The removal of diseased tonsils will sometimes be followed by disappearance of swollen glands in the neck. It can be laid down as a rule that enlarged glands in the neck, particularly in children, mean poor nutrition, and that in such cases there is an urgent call for an abundance of simple food, especially milk, out-of-door life, sleep, cod-liver oil, and iodine. A child who is thus diseased should be taken out of school, removed to the country, and encouraged to play out of doors in the sunshine as much as possible. A child with discharging glands-that is, with running sores in the neck-should have such sores dressed and cleansed daily, as well as have attention given to his diet and habits. Exophthalmic Goiter.-Certain features of the disease are well marked in all, or nearly all, cases. These are protrusion of the eye- balls (exophthalmos), very rapid heart-action, trembling of the muscles in different portions of the body, and what is called vaso- DISEASES OF GLANDS 411 motor disturbance, which means irregular action of the nerves supplied to the blood-vessels, causing flushing of the skin, sweat- ing, chilliness, and copious flow of colorless urine. It is also pretty well established that the disease is due to a disturbed condition of the blood, resulting from a change of some kind in the secretion of the thyroid gland or from an excessive quantity of the same. The thyroid gland itself is not always enlarged in this disease, but both surgeons and physicians agree that it is not in a normal con- dition, and it may be soft and tender. Together with the symptoms mentioned, there often exist men- tal dullness or irritability, loss of strength, vomiting, and jaundice. The nervous system is perturbed in both its nutrition and its func- tion, this being evidenced by the excitability, restlessness, depres- sion, or insanity of the patients. Not infrequently they suffer also with epilepsy before or after the appearance of the goiter, and with paralysis which is not the result of hemorrhage into the brain. The appetite and thirst are excessive, and the voice is often high- pitched and sharp. The rapid action of the heart is often very troublesome, attacks often coming without any perceptible cause, frequently in the night, and with a pulse running as high as 200. With it there may be flushings of the skin, palpitations and violent pulsation of the large arteries, painful and swollen joints, albumen and sugar in the urine. Also all kinds of skin disturbance are possible, including loss of hair; the spleen and lymphatic glands are enlarged, the bones frequently become very soft, and there may be a great loss of weight. Organic iodine is one of the constituents of the secretion of the thyroid gland, and it is said exophthalmic goiter may be pro- duced both in man and animals by the use of this substance; also by the use of thyroid extract, which is now so extensively em- ployed as a medicinal substance. It is also claimed that it may be due to autointoxication resulting from the absorption of poisons from the intestine. Inherited influence has more or less to do in causing it; so also have tuberculosis and rheumatism, and it is possible that an attack may be precipitated by fright, anxiety, grief, or intense emotion of any kind. The outcome of this disease varies greatly; that is one of the reasons why it is still obscure and unresolved. Some cases get well in a few weeks or months almost without any care or atten- 412 HOW TO KEEP WELL tion; others linger along for months and years; and others are malignant from the start and rapidly fatal. Medical treatment is appropriate at one time in one group of cases, and surgical in another. Goiter.-The thyroid gland is a very important and even an in- dispensable part of the body, for it takes out of the blood the iodine which has been removed from the food and prepares a substance called thyroidin, which seems to be necessary for the welfare of the body. When there is too much of this secretion the gland swells up and the body is oversupplied with iodine and poisoned by it. This becomes the more easy because the thyroid gland has no duct or outlet, and its secretion is raken up and distributed by the blood-current. When this poisoning occurs we not only have the tumor on the neck but also bulging of the eyes, rapid action of the heart, trembling, and numerous other well-marked symptoms which make up what is known as Graves's or Basedow's disease. Sometimes the tumor is associated with general weakness, tuberculosis, skin disorders, and other conditions which show a disturbed condition of the nutrition of the body; and, as the disease progresses, the tumor and different organs of the body undergo important changes. Apart from the contents of drinking-water, which may or may not be the cause of this trouble in the places where it is very common or endemic, it is said to have been traced to physical or mental strain, to nervous diseases, and even to tonsi- litis, appendicitis, gall-stones, and numerous other diseased con- ditions. It has been observed in successive generations of the same family, though I do not see any good reason for this unless the successive generations were subjected to the same influence. I do not find it mentioned as a germ-disease, and since iodine is a powerful antiseptic it is unlikely to be attributed to such a cause. The great importance of the thyroid gland is manifest from the fact that when it is removed from young animals they become de- formed and stunted and do not reach a condition of normal ma- turity. It can be treated medically or surgically, and good results have been obtained by both methods. The serum, which is prepared after Beebe's method, by injecting solutions of human thyroid tissue into sheep and subsequently removing the serum from the blood of the animals, has been used DISEASES OF GLANDS 413 in several thousand cases with very good results, so far as the bad symptoms were concerned, though the tumor has not entirely dis- appeared. A few cases have been reported as entirely cured by sheep's serum or other medical means, and many cases have shown great improvement. When surgical measures are decided upon various procedures are possible; the entire gland is now seldom removed, the re- moval of a portion of it having been found preferable and produc- tive of much better results. If a portion of the gland is left it is possible it may enlarge again. The X-ray has been used in treat- ing this disease, and it may relieve some of the symptoms without helping others. It is thought that its beneficial action, on the whole, is still in doubt. Hodgkin's Disease.-It is a spurious form of a much more com- mon disease which involves the white blood-cells and consists of chronic inflammation, and of enlargement of the lymphatic glands in the neck, groin, armpit, and chest, and also occasionally in other parts of the body. There may also be enlargement of the liver, spleen, and kidneys from the same cause which produces the glandular enlargement. The cause is supposed to be some kind of infectious germ taken by mouth and carried to the lymphatic tis- sues. Tubercle bacilli are sometimes found in these glands, but they are not supposed to be the cause of the disease. It occurs chiefly among young adults. The glands in the neck are first affected. The disease may last six months, and it may last several years, but eventually it is fatal. Some symptoms are due to pres- sure. Pain is due to pressure of the enlarged glands upon im- portant nerves in the neck, armpit, or groin. The windpipe may be pushed aside by the enlarged glands, causing difficult breathing and loss of voice, and the nose may be obstructed by the same cause. The glands by their pressure on the blood-vessels may in- terfere with the circulation and cause swelling and destruction of tissue unless the pressure can be removed. Hemorrhages may take place into the skin and elsewhere, making the skin pale, sallow, or bronzed, and these hemorrhages may mislead one as to the true nature of the disease. Poisonous effects are apparent in fever, rapid pulse, anemia, sweating, emaciation, and great weakness. Pressure on the bronchial tubes may cause pneumonia, abscess, or hemorrhage from the lungs. The heart-action may be rapid, and there may be valvular trouble with murmurs. The liver is en- 414 HOW TO KEEP WELL larged, and its circulation and secretion disturbed; and this results in dropsy, jaundice, and constipation, alternating with diarrhea. Digestion is deranged, the mouth and tongue are sore, and there may be difficulty in swallowing; also there may be dizziness, head- ache, and sleeplessness. The object of treatment is to sustain the strength by means of nutritious food and sleep. Arsenic is said to be the most useful of the minerals used in treatment. Surgical measures will some- times relieve pressure, but they are not always possible or feasible. Lymphangitis.-The term means an inflammation of the lym- phatics, or lymph-vessels, which are distributed over the entire body, superficially, immediately under the surface of the skin, and deeply in all the underlying tissues and organs. Some of the lymph-vessels are so small that they are not ordinarily visible to the naked eye. As they progress over the body they are interrupted at short intervals by lymph-glands, through which the fluid or lymph must pass and undergo a filtration. If this fluid contains poisonous substances, as it always does in lymphangitis, these substances may be retained in the glands and cause inflammation or lymphadenitis in them. It is therefore al- most impossible to have an inflammation of the lymph-vessels or canals without a coexisting inflammation of the lymph-glands. In the lymph-vessels is a watery, colorless, or milky fluid, which is absorbed from the surrounding tissues and from the intestines. It consists normally of water, waste and worn-out tissues in solution, and emulsified fat which has been absorbed from the intestines. It, therefore, has a nutrient value. The entire lymph-current, through its two trunk vessels on either side of the body, empties into two great veins, one on either side of the neck, and is projected from them directly into the heart. If, therefore, this current contains poisonous elements, bacteria, or parasites, which it has absorbed either at the surface of the body or from the intestines, it is easy to see what damage may be done, as the blood containing these substances circulates over the body and contaminates and injures it. It will be easy to understand it as derived from a wound or injury of the skin. Bacteria, being ab- sorbed through such an opening from the air or from any material which is brought in contact with the wound, develop in the fluid of the lymph-vessels and generate poisons, and these are carried over the body. DISEASES OF GLANDS 415 In a few hours, or at most in a day or two, the patient has a chill, followed by fever and perhaps vomiting and diarrhea. He feels very ill and will be wise if he at once goes to bed. Within a day or two, supposing that the injury were in the hand, the hand and arm become painful, red, and swollen. Fine red lines appear upon the skin, indicating the inflamed lymphatics, which previously were invisible. The glands at the elbow and armpit will become enlarged and painful and in a few days may suppurate and form ab- scesses. Abscesses may also form along the course of the inflamed lymphatic vessels in the arm, while the tissues in the vicinity of these vessels will become hard and painful. The patient may re- main very ill a week or ten days, and then, if he has good reacting power, he will gradually get better. The abscesses must be opened, pain relieved by narcotics, and as much fluid food given as can be disposed of. Laxatives must also be given to help in eliminating the poisons. Nothing is better for this purpose than castor-oil. Complete recovery often is very slow and protracted, and there are few diseases in which good nursing and care count for more than in this. Myxedema.-The thyroid gland in sheep and calves is the part which is known as sweetbread and is a very nutritious and very digestible substance. This gland is a very important part of the body. It makes a secretion or juice called thyro-iodine and is probably the only portion of the body from which iodine is obtained. Whenever the gland undergoes withering or atrophy and fails to supply the body with this necessary juice, particularly necessary for those chemical changes known as processes of metabolism, the disease which is termed myxedema is the result. It is more com- mon in women than in men. It is worse in cold than in warm weather, and if one who is susceptible to it is exposed to cold and dampness it may bring it on or intensify it if it is already present. It is greatly influenced by heredity, and where there is a family history of alcoholism, tuberculosis, cancer, rheumatism, asthma, or nervous disease it is one of the possibilities which may happen. It is one of the diseases which may be brought about or made worse by intense emotion, and its symptoms are sometimes exaggerated after a prolonged course of treatment with certain drugs, notably with the iodide of potash. It may come in early or in middle life and produces great change in the personal appearance. The body 416 HOW TO KEEP WELL becomes enlarged, and the skin dry, rough and firm; the abdomen, the neck, and limbs are thickened, and the hands and feet thickened and flattened. The greatest changes are in the face and head; the scalp is thickened; the face becomes broad and expressionless; the nose is flattened, the mouth enlarged, and the skin yellow. The mucous membrane of the mouth and nose is swollen; the lips and tongue are thick, and so also are palate and uvula. The ears are enlarged; the eyelids droop; there is a discharge from the nose and eyes; and the gums frequently recede, suggesting Riggs' disease, with which it must not be confused. The hair and nails are brittle and the hair falls out. The swelling sometimes disappears and subsequently comes back again, perhaps in some other portion of the body. There are nervous symptoms, also, which when the swelling disap- pears give place to headache or neuralgia, these in their turn dis- appearing when the swelling comes back again. With the symptoms that have been mentioned it is not strange that speech should be difficult and enunciation imperfect, and that the voice should have a nasal tone. The digestive apparatus is out of order; there may be hemorrhages from the bowels and else- where; the appetite is disturbed; and there is more or less obsti- nate constipation. The senses are perverted, particularly those of touch, smell, and taste. The muscles gradually become weak, and there is stumbling and staggering of the gait. The urine is di- minished and may contain sugar. Patients with this disease must be kept warm; they are better in summer than in winter; and they should be treated with pro- longed warm baths every day if possible. There is only one sub- stance in the way of medication that has thus far proved any value, and that is thyroid extract. Pituitary Disease and the Medicinal Use of Extract of the Pituitary Gland.-It is now known that the pituitary gland is one of the ductless glands, like the thyroid, having a very important secretion, which is taken into the blood-current, increasing the contractile power of the heart and arteries, and which probably influences the nutrition of the bones and nerves. The gland consists of two parts, or lobes, and while an extract made from the anterior lobe seems to have no perceptible medicinal effect, an extract made from the posterior lobe will cause a slow- ing of the heart's action and will raise the blood-pressure. As a DISEASES OF GLANDS 417 necessary consequence, it will increase the functional activity of the kidneys and the quantity of urine which is discharged. On the other hand, when the functional activity of the anterior lobe is either excessive or insufficient, it becomes a distanct cause of dis- ease, in the former case causing the peculiar disease known as acromegaly, in the latter causing an excessive accumulation of fat. The extract which is made from pituitary gland is known as pituitrin, and it is extensively advertised, particularly in the medical papers. It has been found to be valuable in the shock which fol- lows severe surgical operations, sustaining the temperature and the contractile power of the muscles, especially what are known as the involuntary muscles, which control the mobility of the organs within the body. It is used as a medicine in acromegaly, severe headache, and heart-failure, and it is also used to control the heart's action when it works with great rapidity. It is frequently used when childbirth has been accompanied by profuse hemorrhage and when there is very sluggish action of the muscle which controls the movement of the intestine. In certain of the acute diseases it has also been found useful, among them being pneumonia, typhoid fever, diphtheria, and influenza. The Prostate Gland and Its Diseases.-This gland is about as large as a good-sized horse-chestnut and resembles one. It has three lobes or divisions, two lateral and a smaller median one, on its lower aspect. In childhood and early life it is inconspicuous and not apt to be troublesome. In mature and middle life it is subject to diseases of various kinds; after the fiftieth or sixtieth year it undergoes enlargement, and in many cases it is the cause of no end of trouble and mischief, even causing death. The acute inflamma- tion of this organ may be associated with inflammation of the blad- der or the urethra and may be an extension of one or the other of these. This is the form which is the more apt to occur in early mature life, but this acute inflammation may persist if the condi- tions are in any way unfavorable and thus in a chronic form may last indefinitely and make life very miserable. Like other inflammations, it will have fever, and if an abscess develops, as it frequently does, there will be chills and more or less evidence of blood-poisoning. There is always sensitiveness in the region of the inflammation and frequently sharp pain. There may be hemorrhage, and this is often a very grave symptom. But the most characteristic symptom is a constant desire to empty the 418 HOW TO KEEP WELL bladder, frequent attempts to do so, and very often inability to do so, even though great effort be made. If there should be inability completely to evacuate the bladder it would mean gradual disten- sion of that organ, great distress, and an urgent demand that relief be obtained. Inflammation of the prostate may be caused by infectious con- ditions of various kinds: it may be associated with constipation and hemorrhoids, and it may be excited by fear, worry, cold, and par- ticularly by the excessive use of alcohol. It is said that it may also be induced by horseback or bicycle riding. When there is en- largement of the prostate gland as one of the changes of approach- ing age there may be nothing to indicate that such a change is going on, or on the other hand even slight enlargement may give much annoyance and trouble. The frequent desire to urinate, especially at night, is always troublesome, and if as the enlargement continues the opening of the urethra or the bladder is encroached upon the difficulty will steadily get worse. Besides the conditions which have been men- tioned this gland may be the seat of tuberculosis, of cancer, and of tumors of various kinds. Some of these diseases are susceptible of relief by heat, by the withdrawal of blood, by the removal of pus when there is an abscess, and by the use of various soothing and antiseptic drugs. When the bladder and urethra are so encroached upon that urination becomes difficult or impossible, relief must be obtained by the use of suitable instruments. When there is persistent hemorrhage or there is likely to be danger to life in other ways, the question of surgical operation must be resolutely faced. The enlarged and diseased prostate is now successfully removed with a fair degree of safety, and there are few operations which offer better inducements for complete restoration to health and useful- ness than this, when it is properly and skilfully performed. Diseases of the Spleen.-The spleen resembles a Lima bean in appearance, lies in the left upper quadrant of the abdominal cavity, weighs normally not much above half a pound, and is of very considerable importance as one of the ductless glands of the body. A gland is an organ which generates or produces a secretion or juice, but if it has no duct or tube to let this juice out the juice must either accumulate or be absorbed into the blood-current and be carried to some other portion of the body where its work DISEASES OF GLANDS 419 is done. The secretion of the spleen, so it is said, is carried to the pancreas and there assists in the formation of trypsin, one of the digestive ferments prepared by the pancreas, and an exceed- ingly important substance. If this is so, it would seem to be war- rantable to classify the spleen with the digestive organs, and this is the more reasonable because during the hours when digestion is going on the spleen is swollen, while when digestion is over it becomes contracted again. It is believed to be one of the sources of supply of the white corpuscles of the blood, and Mayo says its secretion removes bacteria and poisonous substances from the blood and returns worn-out corpuscles to the liver, where they are subjected to further chemical treatment. The activity of the spleen seems to be greatest in the formative years of childhood; in ma- ture life it is less active, though still important; in old age it is quiescent, shrinks in size, and seems to be like some of the other organs which have accomplished their task when old age arrives. In mature life and old age, therefore, it does not seem to be an indispensable organ; it may become so small as to be hardly noticeable, and it may even be removed from the body without serious harm. Besides becoming very small, it may be malformed or dis- placed, sometimes moving about like a floating kidney. It is some- times very much enlarged and may be as soft as a mass of putty. This sometimes occurs to women during the pregnant condition, and it is the usual thing in typhoid fever, malarial poisoning, and injuries of various kinds. It is also enlarged in connection with infection from a variety of sources, from the attack of the hook- worm and various other parasites, from anemia, and from tumors and cysts. It may be the seat of abscess, it may be ruptured by injury, and it is not infrequently the seat of tuberculosis. The symptoms caused by these diseases do not seem to be very clearly defined. If there is much enlargement or displacement of the organ there may be a sense of discomfort, dragging, and backache; and if there is infection there will be symptoms customary with infec- tion. The organ has been removed many times, and this is ap- parently the proper procedure when it is so diseased that it is likely to be a menace to the rest of the body. The Thymus Gland.-The thymus is one of the series of glands which, like the thyroid, the spleen, etc., has no duct or outlet, but has an internal secretion or product which plays an important part 420 HOW TO KEEP WELL in development in early life. It is a gland which attains its full development by the end of the second year, and has usually ful- filled its function by the fourteenth year. By that time it has shrunk and shriveled, unless enlarged by disease, and has become merely rudimentary. It is located at the lower portion of the neck, and when enlarged by disease it may extend downward into the chest. Deformed and undeveloped infants may lack this important structure, or it may be present in a merely rudimentary condition. If this gland is diseased or does not perform its function properly there is serious interference with both the physical and the mental development of the child. Children who are affected with rachitis, or rickets, are supposed to have disease of this gland which has prevented the proper development of the bones. When it is en- larged it may press upon the windpipe and interfere seriously with breathing. Children who suffer from croup and asthma are often the victims of enlargement of the thymus; and by its pressure upon the windpipe it causes the distressing attacks of wheezing and difficulty in breathing which often prove fatal. The symptoms of a child who suffers from this cause are more severe when he is lying down or when the head is thrown back than when sitting up because of the increased pressure upon the windpipe in this position. It is, therefore, rational when a child is seized with croup or asthma at once to raise him to the sitting position as the first measure of relief. Crying or straining in- creases the trouble, and therefore attempts must be made to soothe and quiet the child by all possible means, change in position being one of the most essential and effectual. The pressure of the enlarged thymus may also be a complica- tion when a child is suffering from an infectious disease like diph- theria or whooping-cough or bronchopneumonia. Hemorrhages from this gland sometimes occur in infants and young children as the result of crying and straining and other causes, and these also may be serious in their consequences. This emphasizes the im- portance of preventing constipation in little children, for the straining which accompanies it may induce serious trouble if an enlarged thymus gland is present. The recommendations for treatment do not appear to be very satisfactory. The child must be kept free from excitement, must not be overfed, must reside in a mild climate when this is attain- DISEASES OF GLANDS 421 able, must be shielded from all sources of infection, and should be under the care and observation of one who is experienced in the treatment of disease in children. Thyroid Glands and Thyroidism.-The thyroid gland is a shield- shaped structure at the front of the neck on the upper part of the windpipe. It is one of the series of ductless glands; that is, it has no duct or outlet for its secretion or juice, which, therefore, is absorbed from the cells of the gland directly into the lymphatic vessels. This secretion is one of the most important in the body, especially in its influence on the conversion of food into animal tissues, these changes being known as metabolism. It also in- creases oxidation, and its principal constituent is iodine. The body suffers greatly when this secretion is in excess, and equally so when it is deficient or absent. If the gland is entirely removed, so that there is no longer any secretion, various unpleasant and annoying symptoms may arise, and particularly the disease known as myxedema. An extract made from the thyroid gland is extensively used in the treatment of certain diseases, and forms one of the avail- able resources in the system of treatment known as organotherapy, which consists in the use of preparations obtained from living or dead animals. Thyroid extract is a very powerful remedy. When perfectly fresh and used in suitable doses, it stimulates the vital forces and improves the nutrition, but, like all animal prepara- tions, it is exceedingly sensitive and decomposes very quickly. If used in such a condition it will promptly result in ptomaine poison- ing. Even when perfectly fresh, if used injudiciously, it will pro- duce shortness of breath, vertigo, vomiting, rapid heart-action, and evidences of poisoning. It is extensively used in the treatment of obesity, goiter, and various skin-diseases, of the form of idiocy known as cretinism, and of arteriosclerosis, asthma, epilepsy, etc. There are two forms of disease associated with the secretion of the thyroid gland: hypothyroidea, or hypothyroidism, when the secretion is insufficient; and hyperthyroidea, or hyperthyroidism, when it is excessive. In hypothyroidism the patient constantly has subnormal temperature, is always chilly and tired, is consti- pated, frequently has sick headache, and may also suffer with autointoxication and such skin-diseases as hives and eczema. Chil- dren born of mothers who have suffered from hypothyroidism fre- quently have harelip or rickets; they are very fat, and their mental 422 HOW TO KEEP WELL development is slow and imperfect. In hyperthyroidism, or ex- cessive activity and secretion of the thyroid gland, there may be a development of goiter or exophthalmic goiter; there are changes in the nervous and mental condition, and there is overactivity of the functions of the body in general. CHAPTER XXI DISEASES OF THE EYES The Care of the Eyes.-The eye is a wonderful and delicate machine; a grain of sand will put it out of commission and dis- turb the equilibrium of the entire body, and yet with good care and attention it will usually last as long as the rest of the body. It is true that eye-disease may be inherited and that the eyes may be imperfectly developed at birth, but in the great majority of cases blindness in infants is preventable. The law now wisely insists that the eyes of every infant at birth should be properly cleansed and a suitable antiseptic instilled into them. Very little attention was paid to children's eyes a generation ago, and the children were often punished or scolded for squinting or holding their books near their faces to get sufficient light. Now they are sent to an oculist, who corrects their eye difficulty and gives them suitable glasses for the school or the home. A generation ago little attention was paid to anything which might obstruct or im- pair a child's vision; now such things are corrected, and those who have eye-disease are promptly sent to the proper place for treatment. The problem of safeguarding the eyes and the vision in the industries is often difficult. In the grinders' trade it is almost impossible to prevent a cinder from occasionally striking the eye, and yet it is often difficult to get the grinder to submit to the inconvenience of goggles. In offices and shops many must use their eyes continuously by artificial light, often to their disad- vantage. People are constantly reading with improper glasses or when their vision is so blurred that they can scarcely distinguish words. If the light where you are working is imperfect and your employer will not remedy it, look around for another job. Don't read in the cars when the light is poor and unsteady. 423 424 HOW TO KEEP WELL If your eyes are hot and reading-matter is indistinct, moisten them with cold water and a clean soft cloth, and rest a while before resuming work. Do not force or strain your eyes if you can help it. If straining becomes necessary you have received a peremptory signal to quit. Amblyopia.-This term formerly was used in contrast with the word "amaurosis," which signifies blindness, but the two terms are seldom placed in opposition nowadays. Amblyopia may come from many different causes, the sight becoming blurred, reading becom- ing difficult, and ability to fix or focalize the vision upon objects being greatly disturbed. One of the principal varieties of amblyopia is that which re- sults from the use of poisonous drugs. Chief of these may be mentioned tobacco and wood-alcohol. The amblyopia which re- sults from tobacco may come on gradually or suddenly; it may be an acute attack from overindulgence, or it may become chronic and continuous. Those who smoke cigarettes to excess, especially those who are young and sensitive, are liable to suffer from this ailment, and it not easy to relieve it by any resort to glasses. The wood-alcohol sufferers are common enough nowadays; and dullness of vision ending quickly in blindness, if not in loss of life, is a frequent experience with those who are unwilling to obey the prohibition law. Not only may this trouble come from drinking wood-alcohol but also from drinking raw spirits in abun- dance, or even from inhaling the fumes of alcohol in the pursuit of certain occupations. It may also result from the use of quinine, belladonna, lead, coffee, and various medicines which are in very common use. One's sensitiveness to the action of drugs is, therefore, a matter of importance in prescribing their use, and the possible deleterious effect they may have on the vision should ever be regarded by doctors in making their prescriptions. Amblyopia sometimes is an accompaniment of certain diseases, such as scarlet fever or Bright's disease. In these cases it sometimes is recovered from; in others it is permanent and may result in blindness. Sometimes amblyopia is affected or simulated, this condition being a not uncommon symptom in hysterical women. This sim- ulated trouble was one of the ailments from which recruits suffered during the late war who did not wish to be conscripted, or, having been conscripted, were unwilling to do the tasks assigned. Defects DISEASES OF THE EYES 425 in the structure of the eye may give rise to this trouble. These may be defects of development and present from birth, or they may be acquired at any period of life. The cataract, which is so common in old age, is a familiar instance of acquired amblyopia. Asthenopia.-As the term is used by the oculists, it means in- ability on the part of the eyes to look intently and for a long period upon near objects, though at first they may be seen dis- tinctly, while distant objects may be viewed distinctly for any length of time. There may be with it no external appearance of disease; but reading and sewing, anything which requires close application of vision, may be and is extremely difficult. After the eyes have rested a short time the vision may be good again. This condition usually begins in early life and may last in- definitely and perhaps get worse, and it is to be remedied by the use of suitable convex glasses. It is caused by an inherited weak- ness of the muscles of accommodation-that is, the muscles which adapt the visual apparatus to the objects which are to be looked at; and when there is asthenopia there is difficulty or clashing be- tween the efforts at accommodation and the convergence of the light-rays proceeding from objects seen upon the retina, by which the distinguishing of different objects becomes possible. Some- times the difficulty in accommodation is caused not only by weak- ness of the muscles and consequent straining, but by imperfect light, or by insufficient acuteness of vision from other causes. There are certain symptoms which often go with it and should call for an examination of the eyes, such as pain and sensitiveness in the eyes and elsewhere, headache, dizziness, and indigestion; and these symptoms may appear when the eyes are used too per- sistently, as in reading or sewing, or when one is recovering from illness or injury and is in a condition of general weakness and impaired nutrition. Asthenopia often is cured by using convex glasses with gradu- ally increasing focus, the muscles of accommodation thus undergo- ing a process of training until at length they are able to perform their function properly. When this can be accomplished, the use of glasses will be required no longer. Astigmatism.-Rays of light coming to the eye undergo refrac- tion, or bending, as they pass through its cornea, fluids, and crys- talline lens and strike the sensitive retina. If they converge and strike the retina at one point, or focus, a correct view of the image 426 HOW TO KEEP WELL or object seen may be obtained, and the vision, under favoring conditions, will be normal ; but if they spread out, the image will be an imperfect one, and vision will be impaired, this condition being known as astigmatism. The greater the spreading of the rays, and the less the concentration or focalization, the greater will be the degree of astigmatism, and consequently the more imperfect the vision; therefore, astigmatics who must get their living by sewing, reading, working with the microscope, or with any other instrument which requires accuracy of vision are continually and materially handicapped. Such sufferers, while at their tasks, constantly, strain their eye-muscles in endeavoring to see objects clearly, and the result is slow and unsatisfactory work, in addition to great discomfort. It is not strange that they complain of headache, which becomes the more persistent the more they are compelled to use their eyes. Instead of getting a single image of an object, they may see two or more; and there is, therefore, constant confusion and annoyance, which may excite other ailments, or intensify such as already exist. Astigmatism may be caused by abnormal changes in the density or the curvature of the crystalline lens, in the shape or density of the cornea, or in the character of the fluids in the anterior or pos- terior chamber of the eye; it may, therefore, be present at birth, or it may be acquired as the consequence of injury, disease, or of those physiological changes which are almost certain to take place with the approach of old age. It may also be produced by excesses of various kinds, or even by intense application to certain kinds of work. In addition to the headache and eye-weakness which so commonly accompany astigmatism, there may also be annoying watering of the eyes, twitching of the lids, pain in the eyes, and a constant inclination to avoid strong light. Those who are near- sighted and those who are far-sighted are usually sufferers also from astigmatism. The correction of astigmatism consists in the use of properly adjusted lenses or spectacles. Blepharitis.-This condition may include inflammation of the glands at the border of the eyelids, commonly known as sties, inflammation of the hair-follicles from which the eyelashes are developed, inflammation caused by errors of refraction or by ir- ritation of the conjunctiva, the mucous membrane which forms the covering of the eyes and the lids, or inflammation of the tear- DISEASES OF THE EYES 427 duct, which conducts the tears from the eye to the nose. The disease can come from a variety of causes. There is the ever- present possibility of injury from bacteria and parasites, and the effect of strain from overuse of the eyes, especially if they have been habitually used where the light is artificial and defective or where the daylight is insufficient or improperly directed. The appearance of eyelids which are the seat of blepharitis is characteristic. They are red and swollen at the border, and yel- lowish crusts are constantly forming upon them, which rasp and scrape the eyes and often cause much discomfort. In bad cases the hair-follicles of the lids are destroyed, the hairs forming the eyelashes falling out, and the eyes thereby losing the protection which the eyelashes are designed to give. In addition to this, just as in trachoma, the inflammation of the conjunctival mucous mem- brane is often followed by scarring, which contracts and averts the lids and prevents the tears from running down the tear-duct into the nose. Consequently the tears are constantly dropping over the lids upon the face, the patient has a blear-eyed appearance, and he is annoyed by the constant necessity of using his handker- chief. The crusts upon the eyelids must be softened with warm water and removed daily, once or oftener, with gentleness and care. A good nurse is capable of giving this attention, but it is usually best that the sedative or stimulating applications which may be required for the eyelids be made by a skilled oculist. Cataract.-We need not go into the details of the complicated structure of the eye, but it is essential to state that behind the beau- tiful curtain called the iris, which gives color to the eye, black brown, blue, or gray, is a biconvex lens of soft material, translucent, hard at the center or nucleus, and covered with a fibrous membrane or capsule called the crystalline lens. The rays of light pass through the opening or pupil of the iris and are refracted or bent as they pass through this lens to be spread upon the sensitive retina, sight or vision being the ultimate result. When this lens or its capsule becomes partially or completely opaque as the result of disease or injury, so that the light cannot pass through properly or at all, sight is partly or completely de- stroyed, and the condition affecting the eye is called cataract. It is most frequent in the aged as the result of the degenerative changes which come with old age, but it may exist at any period of 428 HOW TO KEEP WELL life; in fact, one may be born with it and be blind from birth, because of defective development of the lens. Sometimes it follows eye-disease of some other variety, or it may follow or accompany Bright's disease, diabetes, or certain diseases of the skin. It may be due to the influence of certain drugs, like ergot or naphthalin, to the effect of lightning or electricity, or to prolonged heat in such an occupation as that of the glass-blower or the worker in an iron- furnace. Not infrequently it results from blows or other injuries to the eyes, or to the head or temple, or it may follow inflammation and ulceration of the transparent concave disk in the front of the eye called the cornea. Heredity is also an influential factor, some families being more susceptible to it than others. In the young it is generally the result of some disease or injury. There are many kinds, forms, and degrees of cataract; hence the sight is affected differently in different individuals. It pro- gresses rapidly when it follows inflammation or injury of the eye, especially in the young, and very slowly when due to the degenera- tive changes of old age. The symptoms depend upon the extent, character, and density of the opaque portion of the lens, and the vision is affected correspondingly. The opacity may take the form of spots or stripes or rings, and as it develops there may seem to be hazes or cobwebs of veils before the eyes. The more opaque the lens becomes the more obscure the vision, until at length only the sense of light and darkness remains. If there is no consciousness of light or shadow, vision may be regarded as irretrievably lost. When cataract is developing in the aged the change in the shape of the lens may be such that they will be able to distinguish near objects and even to read without glasses, giving them the so-called "second sight." To the ordinary observer there may be nothing in the appearance of the eye to indicate the presence of disease; or, on the other hand, the area of the pupil may be dull gray or glisten- ing white, or black or brown. If there is swelling of the lens as the cataract develops there will be pain in the eyeballs and intolerance of light, and colored glasses will be required. One must wait until the cataract is mature or ripe before at- tempting any operation. This period will be short in the young but long in the aged. There is said to be no way to cure this disease but by operation. Drugs will not do it, and massage may do more harm than good. In very rare cases the disease has disappeared spontaneously, but it is not best to look for such a result. The DISEASES OF THE EYES 429 better the general condition the more probable that the outcome will be favorable, provided always that the operator understands his business. The operation is one of the most delicate in the entire range of surgery. Not only must the operator have skill, but also rare judgment in the selection of the time when the patient should be operated upon and in the care given after the operation. Choroiditis.-The choroid or chorioid is the middle of the three layers which compose the wall of the eyeball and the one in which its blood-vessels are situated, so that it is, from the peculiarities of its structure, very susceptible to inflammation. A small or a large portion of the choroid may be the seat of inflammation; sometimes several small areas or patches may be thus involved. It may have an infectious agent or germ for its cause, and particularly is this the case in connection with the diseases of syphilis and tuberculosis. It may also be the result of excessive use or straining of the eyes, and hence it may be an accompaniment of near sight, far sight, or astigmatism. Exposure to light and heat when they are intense and long-continued will produce choroiditis, especially when they are directed to a particular area of the choroid. The disease announces itself with great disturbance in the vision, severe pain in the eyeball, redness of its visible portion, and swelling of its tissues. Suppuration follows, and finally there is corrosion and opening of the front of the eyeball, from which pus is discharged. Then the pain diminishes, but the sight in most cases is irretrievably gone. The eyeball shrinks and becomes a per- fectly useless member. This is one of the diseases in which bleeding by means of leeches or cups from the skin above the eye may be followed by great relief. If nature does not promptly produce an opening in the eye and liberate the pus which has formed, she must be assisted by the skill of the oculist, and an opening must be made where it will best drain away the products of inflammation. These are cases in which the most rigid aseptic precautions are imperative, and even with such precautions all hope of saving the vision of the eye may be lost. Then nothing will remain but the removal of the eye, which must be done by one who is skilful and intelligent. Color-Blindness.-The sense of color may be exaggerated or defective. By careful training one can discern shades of color which are inappreciable to normal vision. On the other hand, there 430 HOW TO KEEP WELL are many who cannot differentiate and distinguish the primary colors of the solar spectrum. One who cannot differentiate these colors is color-blind, and the less clearly he is able to distinguish them the more is he color-blind. As the number of shades and tones of color is almost infinite and most people can distinguish only a few of them, we realize how nearly color-blind, at least relatively, most people are. Many factors regulate one's sense of color, the chief being, of course, education. A painter, an artist, often has a vivid sense of color. He naturally would as the result of his occupation. If his sense of color could not be trained, he could not become an artist. Workers in dyes also frequently have an acute color-sense as the result of their occupation. There are some people, as everybody knows, who are born color-blind, some of them being aware of it, and others unaware until some kind of a test reveals their defect. More men than women suffer in this way, the relation being as four to one. If one actually has this defect at birth it cannot be corrected or overcome by any amount of training. There are those in whom color-blindness is acquired as the re- sult of disease or injury, and if this proceeds from destructive or degenerative changes in the optic nerve or other important parts of the apparatus which controls vision, they become just as color- blind as if they were born with this defect. There is partial color- blindness when one has a correct sense for certain colors but not for others; or the sense of color may be influenced by the intensity of the light, or the physical condition of the individual, or the con- dition of the atmosphere. Lack of acuteness in differentiating colors is one of the first evidences of disturbance in the functional power of the visual organs. The ability correctly to determine the seven primary colors, most of all the red and the green, is not only a matter of the great- est convenience, but, as modern society is constituted, it is an indis- pensable requisite in many important occupations. There are dan- ger-signals which every person in a post of responsibility on sea or land, not only in the transportation business but in others also, must be able to detect and differentiate without failure or error. The inability to do this has led to accidents which have sometimes been very serious. Hence the necessity that those who hold these positions should have their vision and their color-sense tested at DISEASES OF THE EYES 431 frequent intervals, for a change in visual power and accuracy may have occurred while they were quite unaware of it. Conjunctivitis.-The common form of conjunctivitis, from which almost everybody suffers at some time or other in greater or less severity, is produced in a variety of ways. There is probably bacterial influence at the bottom of it, and to this are always to be added the heat and moisture which are within the eyelid. The excit- ing causes are many, among them changes in the weather, dirt and filth in the air or carried to the eye by the fingers, injuries of all kinds, sand and splinters. Sometimes there is pain in the eye when the trouble begins; sometimes there is a sensation of something in the eye. This diseased condition does not get very far before there are redness and swelling of the lids and more or fewer newly ap- pearing blood-vessels upon the front of the eye. In colds in the head conjunctivitis is almost always an accompaniment. The con- gested condition of the eye is quickly followed by one in which there is copious discharge of tears; and this is followed, in severe cases, by a discharge of pus, which continues a longer or shorter period, as the conditions are favorable or unfavorable, after which improvement begins, the discharge gradually drying up, the vision becoming clearer, and the symptoms tending to recovery. There is probably no way of preventing an occasional attack of conjunctivitis if one lives as civilized people ordinarily do, but it is usually quite possible to protect the eyes from things which might injure them, to be at least as particular in keeping them clean and free from irritation as any other portion of the body, and not to neglect them when they are the seat of even a slight disturbance. When one has conjunctivitis it is well to use the eyes as little as possible, and very often one feels better in a dark room than in the bright sunlight. When the inflammation begins it is always well to apply a solution of boric acid, instilling a few drops into each eye every three or four hours. When the pain and swelling are considerable there is nothing better than cold applications, thin pledgets of gauze being wrung out of ice-water applied to each eye and changed as soon as the heat from the eyes begins to warm them. If the disease should not yield to these simple measures, a good oculist should be consulted without delay. Cross-Eye.-When both eyes do not look toward the same point, or when a certain point is located with one eye while the other looks 432 HOW TO KEEP WELL in another direction, the condition is called cross-eye or squint or strabismus. The eye that is not turned toward the object of vision is called the deviating eye and gives a certain amount of disfigure- ment to the facial appearance. This lack of coordination in the visual power of the eyes means more than a deformity, for proper vision is materially interfered with, and it very often means double vision. The image that is seen is true or false according as it is seen by the correct eye, and in the latter situation the image is referred to as in a direction different from its real direction. The double vision which comes with cross-eye is overcome when the cross-eye is corrected, or it may be overcome at any time by closing the deviating eye. It is possible for one who has cross-eye to dis- regard or become adjusted to the incorrect image, and this is doubt- less done in many instances, especially when the trouble begins in early life. There are many causes for cross-eye, including arrested de- velopment of the power to coordinate the eye-movements, differ- ence in the refractive power of the two eyes, paralysis of one or more of the muscles that turn the eye, or spasm of those muscles, or unequal development in the corresponding muscles of the two eyes. Cross-eye may be external or internal, according as the eye turns outward or inward, or there may be a vertical cross-eye as the eye turns upward. Sometimes the deviation is in one eye and sometimes in the other; one eye may be constantly deviated, or the deviation may be intermittent. In some cases, while there may be a tendency for the eye to deviate, it is overcome by effort of the will and by practice, so that double vision does not occur, as it would without such effort and training. Cross-eye occurring in childhood is sometimes outgrown, the want of coordination being corrected partly by habit and partly by suitable changes in the defective muscles as development pro- gresses. Both in children and adults, if squinting is not excessive it may be cured or at any rate corrected by suitable lenses. Many cases which are not thus curable may be operated upon and the deformity corrected entirely or partially. When it is due to per- manent paralysis of certain muscles, whether in children or adults, it, of course, will remain incurable. Detachment of the Retina.-Consider first what the retina is. It is a very complex membrane forming the inner lining of the eyeball. It is composed mainly of nervous tissue coming off DISEASES OF THE EYES 433 from the optic nerve by which impressions of sight are conveyed to the centers controlling vision and thence to the proper portion of the brain. The optic nerve thus distributes its thousands of nerve-filaments over all portions of the retinal membrane, and by these the impressions of light coming into the eye are taken up and conveyed to the optic nerve. The outer layer of the retina, the pigment layer, as it is called, is attached to those structures of the eye which are called the choroid, the ciliary body, and the iris. The retina is detached when it becomes dislocated or loosened from its normal position. This may be caused by the presence of a tumor or by displace- ment of the choroid, and the latter may be due to a blow on the eye or the head, the result coming at once or by degrees. Those who are near-sighted are rather more susceptible than others to this accident. The retina may also be detached by the formation of scar-tissue with contractions in the semifluid substance called the vitreous body with which the cavity lined by the retina is filled. When this accident occurs there is sudden impairment of sight, which may affect only a portion of the field of vision. Some- times there is an effusion of blood into the lower portion of the retina and the space behind it. This would leave the upper portion of the field of vision undisturbed. The detached portion of retina may float back and forth like a fringe, interfering with those por- tions of the field of vision upon which it may encroach. The accident is a serious one, but recovery sometimes takes place by the unaided efforts of nature, particularly if the detach- ment has resulted from injury. In the great majority of cases it will be impossible to replace the retina permanently and restore the sight. Prolonged rest in bed with pressure-bandages upon the eyes is sometimes said to encourage restoration of the retina to its normal relations, and various operative measures have been devised to accomplish this end. Foreign Bodies in the Eye.-In medical language a foreign body is a substance of any kind which does not belong in or upon the body. When it gets into or upon the body it is foreign to it, does not belong there, and generally must be removed if possible. There are many kinds of foreign bodies which get into the eye, some of them merely adhering lightly to the conjunctiva, and some be- coming embedded deeply in the conjunctiva or the structure be- yond it, and perhaps perforating the globe and getting into its 434 HOW TO KEEP WELL interior. The accident may therefore be a very simple one or it may be very severe, resulting in the destruction of the eye and requiring its removal. Foreign bodies which get into the eye may be composed of all sorts of materials, some of them being more harmful than others. That which offends more frequently than anything else is a speck of hard dust, a cinder, or a particle of sand. We are everywhere exposed to such attacks. They almost always occur when one is in motion, walking, riding, running; and that is why they usually strike the eye with some force. If the foreign body is moving slowly and the individual is at rest or also moving slowly, the impact upon the eye will be with slight force, the foreign body will rest lightly upon the mucous mem- brane, and though the individual is immediately aware of its pres- ence, it may be easily brushed off if correctly located, or it may flow off in the tears which its presence will excite. If, on the other hand, the particle is hard and sharp and strikes the eye for- cibly, it will become embedded and will require skilful action for its removal. Splinters of wood are foreign bodies which often strike the eye with more or less violence. They are released in chopping, in opening boxes, and in many ways in which wood is being worked. If the splinter is very small it may do little harm and be easily removed. If it is large and sharp it may penetrate the eye and destroy the sight. Particles of metal also injure the eye very frequently. Knife-grinders, machinists, and workers in many oc- cupations in which iron, lead, copper, brass, and zinc are thrown off in small particles are constantly suffering from this cause. The serious consequences which so often follow emphasize the neces- sity of protecting the eyes with goggles in all such occupations. Particles of molten metal also get into the eye and frequently do serious damage. Not all these accidents are preventable; many of them are preventable if proper precautions were used by em- ployer and workman. However small the offending body, the tendency of the average individual when he becomes aware of its presence is at once to rub his eye and often with dirty fingers or a dirty handkerchief. This only fixes the body more firmly in the mucous membrane and increases the difficulty of dislodging it. Therefore, don't rub the eye, whatever else you may be inclined to do. If the accident is very recent and you were called upon to give relief, provide DISEASES OF THE EYES 435 yourself with sterilized absorbent cotton and put the sufferer where the light will shine on the injured eye, perhaps directly, perhaps obliquely. Absorb the tears with the cotton, along with any loose dirt or specks which may be present. Grasp the eyelid, upper or lower, or each in succession, with thumb and forefinger, pull it forward, place a small clean lead-pencil under the lid, and turn it over. Then look carefully over the mucous membrane, and if you can locate the speck anywhere on the exposed surface, whether of lid or eye, take a small portion of cotton tightly rolled and brush it gently and deftly over the speck. If it does not easily come away, you have done enough, and it is time to get profes- sional help. Diplopia.-When the rays of light reflected from an object are conveyed to the eyes in normal vision two images are conveyed, for they are seen by two eyes. In normal vision each of these images impinges upon an identical portion of one retina, and an impression of but one object reaches the brain and is so interpreted. But if the reflected image fails to strike the identical portion of each retina, two objects instead of one are seen with more or less distinctness. This is called diplopia, or double vision. According to the conditions of vision the two objects may be seen in the same plane-that is, side by side-or one may be in front of, above, below, or oblique to the other. Anything which changes the normal relative direction of the axes of the eyes will cause double vision. This will occur if one eyeball is temporarily depressed and the other unchanged, or if the axis of one eyeball is permanently changed, as by the pressure of a growing tumor within the eye-socket. It will also occur when the muscles which control the movements of the two eyes do not work in harmony because of inequality in the relative length or power of these muscles. This is what happens in squint or cross- eye. The muscles of the eyes are supplied with nerve-force by one of the special nerves of the head. If this nerve is paralyzed, or some of its branches are paralyzed, we again have the eye- muscles working inharmoniously, and double vision as a con- sequence. There are certain diseases which have double vision as a characteristic symptom. This is true of some of the diseases of the brain and of the debilitating fevers. It is sometimes the case in syphilis, tuberculosis, Bright's disease, diabetes, etc. When it is due to defects in the eye-muscles, it sometimes can 436 HOW TO KEEP WELL be corrected by changing the position of the head, thus accom- modating it to the muscle which is at fault. Or if that process of education is unsatisfactory, it may be possible to cut the offend- ing muscle or to cut the tendon by which it is attached to the globe of the eye and transplant it to a position where its work will be done more efficiently, the repetition of the image being thereby disposed of. Many of the cases of double vision are relieved by the oculists by the use of suitable prisms. Glaucoma.-The essential condition in glaucoma is increase in the tension of the globe of the eye or eyeball. The eye becomes hard on account of the excess of the fluids which are within it, and this condition is very readily recognized by the resistance offered when the eyeball is pressed upon by the tips of the fore- fingers. Under ordinary conditions of pressure by the fluids within the eye, a sufficient quantity of these fluids escapes through chan- nels designed for that purpose to maintain the normal tension and equilibrium. These fluids or secretions are formed and renewed, like all the other secretions of the body, by the proper secreting tissues, and when their natural flow is impeded and they are re- tained, they become a source of harm to the body. An early symptom of this condition is the appearance of colored rings or halos around distant objects when seen at night. The excessive pressure of the fluids within the eye in this con- dition causes the iris, the colored portion of the eye-structure, to be pushed forward, the pupil being enlarged and staring, and not enlarging and diminishing in response to light, as it usually does, while the space between the iris and the cornea, the anterior chamber, becomes shallow and nearly, or quite, abolished. In the extreme cases the sensitiveness to touch which usually be- longs to the cornea is lost. Pain is one of the most constant symptoms of glaucoma and is felt in the brow, the temple, the cheek, or the side of the nose, like a facial neuralgia. In some cases it is persistent; in others it comes in paroxysms; the veins on the white of the eye become enlarged, and the cornea becomes inflamed. This condition may be due to swelling or displacement of the crystalline lens, and it may also result from fatigue, intense emotion, or certains forms of disease. Together with the hard- ness of the eyeball and the pain, there may be dimness of vision or hemorrhage within the eye, and the condition may become malignant or cancerous. With its accompanying pain, it may last DISEASES OF THE EYES 437 a few days or several years, and it may end in impairment of vision or complete blindness. It comes most frequently in the aged, but also to those who are in middle life, and even to children. The treatment is mainly surgical, and consists in relieving the tension by removing a portion of the iris, or even a portion of the eyeball adjoining the iris, allowing the excess of fluid to escape. Hemianopsia.-Hemianopsia means blindness involving less or more than one half of the field of vision, and it may be located in the outer or the inner half of the visual field, in one or both eyes. When it occurs in both eyes the same half may be involved in each eye, or the outer half may be implicated in one and the inner half in the other. If only one eye is affected, and this one on the inner or nasal side, the fact that blindness is present may not be noticed until the normal eye is closed. If both eyes are affected in the same visual area, the blindness will seem to the patient to be due to the defect in that eye in which the large area is involved. In determining the existence of this condition each eye must be tested separately, and if the condition exists the patient will be unable to see objects within the field of defective vision. It is an evidence of suspended function in the half of the retina corresponding to the defective field of vision. Hemianopsia on one side is caused by injuries to the fibers of the corresponding optic nerve at the point within the skull where they meet the fibers of the other optic nerve and then cross the substance of the brain to the other side. Hemianopsia in both eyes is more common than in one eye and may be produced by the pressure of a tumor within the brain at the crossing of the two optic nerves, or it may be due to an injury to some of the nerve-fibers connected with the visual apparatus as they follow their course through the brain. It is often associated with the defect in speech known as aphasia or word-blindness, the injury which has affected the nerve-fibers controlling vision having also affected those which control speech. In general, it may be re- garded as a local symptom of brain-disease. Hypermetropia.-This is a very important condition of de- fective vision and indicates that the parallel rays of light which enter the eye converge and focalize behind the retina instead of upon it. An eyeball in which this condition exists is too short from front to rear, or the condition may be due to the flattening of the cornea or of the crystalline lens from imperfect development or 438 HOW TO KEEP WELL to entire absence of the crystalline lens. The pupil in such cases is also very small and contracted, as the result of constant efforts to accommodate the vision to the unusual and abnormal ana- tomical conditions. When this defect is present in children they are constantly straining the muscles of accommodation in their endeavors to read and are often blamed for stupidity when the fault is not in the mind but in the defective anatomical structure of the eyes. Chil- dren who cannot readily read good-sized type at the proper dis- tance should, therefore, have their eyes examined at rather frequent intervals, and it may also be necessary to change their glasses frequently. After hypermetropia has persisted some time, es- pecially in the aged or in those for whom drugs have been con- stantly used to enlarge the pupil, the ability to accommodate the vision for different distances may be lost, with consequent great imperfection in the vision. Constant effort to adjust the vision in hypermetropia often causes persistent headache, which is some- times in the forehead and sometimes in the back of the head. Those who are hypermetropic also suffer frequently from conjunctivitis, sties, and inflammation of the eyelids. Objects which are visualized must be placed very near the eye, and this condition, beginning in early childhood, when not properly corrected by convex glasses, will bring the eye into the anatomical stage properly belonging to old age years before such changes are normally to be expected. Constant straining may also lead to inflammation of important structures which control vision and consequently make reading and employment of all kinds requiring nearness and accuracy of vision so distasteful and difficult that they may be more or less abandoned. Some observers have remarked the important influence which hypermetropia in the young has upon the speech, and this may affect the entire future development and well-being of those who are thus afflicted. Hypermetropia is present whenever distant vision is unchanged or becomes more distinct by the use of convex glasses. Those who have this trouble should wear convex glasses constantly when there are squinting, headaches, or inflammation of the eye; other- wise they may wear them when the eyes have become weary from close application to the vision of near objects. Inflammation of the Tear-Duct.-The eye is constantly kept moist by a secretion of tears which flow away through a little DISEASES OF THE EYES 439 opening in the nose. When this passage becomes blocked the tears overflow the lids and roll down the cheek even when there are no more tears than usual. If pressure with the finger just below the inner end of the eye causes a backward flow of fluid into the eye, especially if the fluid is yellow, the obstruction of the passage is caused by inflammation of the duct; surgical in- terference is necessary, and if it is not obtained serious results may follow. It is also well to bear in mind that when such an inflammation of the duct is present a slight injury of the cornea may cause a serious ulcer. Iritis.-It is the presence of pigment or coloring-matter in the iris which permits us to describe a person as having brown, blue, black or green eyes. The iris frequently is the seat of inflamma- tion, and the disease is of great importance. Such inflammation often is the result of injury, but more often it is the result of disease, particularly the venereal diseases. Rheumatism, gout, fevers, and anemia also cause it. There is a belief that bacterial influence is at the bottom of iritis, but that this is present in all cases seems to me a strong statement. It is astonishing how much pain can be concentrated in this little area. It is often so severe that sleep is impossible. Not all the cases are painful, however. As in most inflammations, there is redness, changing the color of the iris and extending in a circular zone beyond its limit. The pupil becomes very small and the vision hazy and blurred. The cornea, the transparent disk in front of the eyeball, loses its transparency and has dots or points distributed over it as products of the inflammation. The disease is slow in its progress, lasting for months, and the pain varies in its severity, now increasing and again diminish- ing. Even in cases which apparently have got well, there often are recurrences of the disease, and the unpleasant experiences of the original attack are repeated. In the bad cases blindness fol- lows, the retina may become detached, and the eyeball may shrink and soften. Few eyes that have been the seat of iritis become as good or as useful as they were before the attack. When it is realized that complete blindness may ensue, the importance of careful and skil- ful treatment at the earliest possible moment becomes evident Self-treatment is to be deprecated in all cases except as certain measures are indicated by an experienced oculist. The eyes, of 440 HOW TO KEEP WELL course, must be at rest and protected by dark glasses from sud- den changes of light and from strong light. Nutritious food in abundance must be given, especially in those cases in which anemia has been an influence in producing the disease. There are those who advise bathing the eyes several times daily with very hot water, but others would consider heat as adding fuel to the fire and use cold instead. Removal of blood from the forehead by means of leeches may give relief to pain and hasten the prog- ress of the inflammation. It is astonishing that so much relief may sometimes be obtained by the removal of only so much blood as three or four leeches will withdraw. When iritis is associated with the venereal diseases, especially syphilis, it calls for systematic treatment with those drugs which are now recognized as the proper ones for successful treatment. Surgical measures are frequently required to open up or enlarge the pupil when it has become contracted or even obliterated. Such measures often are attended with great benefit. Myopia, or Near Vision.-In myopia the globe of the eye from front to back is too long-that is, longer than it should be-so that the rays of light which enter the eye converge and focus in front of the retina instead of upon it. This leads to partial closures of the lids or squinting in the effort to obtain a distinct image upon the retina. Besides the lengthening of the eyeball as a cause for myopia, there may also be changes in the curvature of the cornea, the transparent disk at the front of the eye, or in the curvature of the crystalline lens through which the light-rays pass on their way to the retina; or there may be changes in the density of the crystalline lens substance by which the light-rays are refracted. One who has myopia has difficulty in turning the eye in its socket; his eyes are apt to diverge instead of converge; and in many cases the habit of squinting with one eye is contracted. It is possible, of course, for one to be born with enlarged and elon- gated eyeballs and to be myopic from birth, but the defect usually begins in childhood or youth. The child strains his eyes and his vision becomes indistinct, except when objects are brought very near. Distant objects are seen with still greater indistinctness. The face of such a person may become vacant and staring; he may acquire a stoop in his posture from habitual efforts to get a clear view of objects; and he may have difficulty in playing and DISEASES OF THE EYES 441 moving about with his playmates because of indistinctness of vision. Myopic children often complain of headache as the result of constant straining of the eye-muscles in attempts at conver- gence and at bringing the objects of vision to a focus. Myopia may be produced from bad habits of reading, from reading by poor light, in faulty positions, and with constant strain- ing, from bad health, poor constitution, or bad hygiene in the home, and from many other causes. It is progressive, and if uncorrected it will greatly impair the usefulness of the eyes and may even affect the general health. As soon as it is noticed that a child places a book or paper near his face in attempts at reading and is evidently putting unusual strain upon his eye-muscles, the signal is clear that he should be taken to an oculist and fitted with suitable concave lenses. In most cases these should be worn continuously during the day. As the child approaches maturity favorable changes may take place in the structure of the eyes which will permit disuse of glasses, but in the majority of cases when changes in the shape of the eye- ball which are unfavorable to vision have occurred they will be permanent, and the constant use of glasses will be a necessity. Ptosis.-The form of ptosis which almost everybody has seen, and which is pretty sure to excite attention, is one that affects one or both of the upper eyelids. Usually only one of them is thus affected, and, though it may seem a small matter and causes no pain, it makes the one who has it conspicuous, the nerve which controls the muscle that raises the upper lid being inactive, so that however strong the will may be to raise the lid it cannot raise it. Sometimes it is called "drooping eyelid," the lid falling over the eyeball and almost closing the opening between the two lids. Ptosis usually is a form of paralysis. The only way one can see out of the affected eye is by raising the head, and then the vision is impaired and imperfect. The trouble may have existed from birth, either from imperfect development or from an injury received at the time of birth. And it may be the result of an injury at a later period of life. It may even be associated with paralysis of the entire side of the face, the so-called facial paralysis, or with the paralysis which follows "stroke" or apoplexy. It is said that it may also be due to thicken- ing of the lid from inflammation, or to the dragging effort of a tumor of the eyelid, but such cases are of much less frequent 442 HOW TO KEEP WELL occurrence than the others mentioned. Aside from the influence which it exerts upon the vision, the constant covering of the eye- ball, which was meant to be exposed during the waking hours, may have a unfavorable effect upon its nutrition and may perhaps lead to serious consequences. When it is acquired by accident or injury or as the result of certain diseases, it is sometimes treated with powerful drugs and may undergo a considerable degree of improvement. If the nerve supplying the paralyzed muscle has sufficient vitality remaining, it sometimes may be stimulated by the electric current, so that a certain amount of motion in the lid may be regained. There also are some cases susceptible of operative treatment, attachment of the skin of the lid being made to a neighboring muscle which is not paralyzed. The degree of motion of the lid which thus may be obtained, while not perfect, will at least be better than the original deformity and will improve the facial appearance and per- haps relieve the patient of a great deal of disagreeable attention. Retinitis.-When any portion of the retina is the seat of in- flammation we have the condition known as retinitis. One symp- tom is invariably present, and that is impairment of vision, though this may not indicate much as to the course and gravity of the disease. About the first thing the patient notices is cloudiness in the field of vision, the objects which are looked at appearing dis- torted and sometimes seeming to have a quivering motion. Some- times there is partial blindness by day, sometimes by night; and sometimes there is a sensation of flashes of light. The actual condition of affairs can be determined only by the use of the ophthalmoscope. Hemorrhages may occur from any portion of the retina simultaneously or in succession. If the hemorrhage has been profuse, complete absorption may not take place, and per- manent blindness may be the result. Particles of pigment which have been deposited may be detached, and these, floating in the fluid within the globe of the eye, may be the explanation of the particles or specks floating and dancing before the vision, of which people not infrequently complain. The simplest form of retinitis may be due to excessive use of the eyes, or to eye-strain, or to injury or disease of some kind in the eye or in some other portion of the body. If injury has been the cause, there may be suppuration, and the eye may be destroyed and require removal. DISEASES OF THE EYES 443 The disease is also frequently present with Bright's disease or with general disease of the blood-vessels of syphilitic or other origin. When it occurs in pregnant women it is regarded as a very bad symptom and may require the premature termination of the pregnancy. It may also occur with gout, diabetes, and many other diseases; and when it is accompanied by hemorrhage or atrophy of the optic disk it is likely to result in permanent blind- ness. Intense light striking the retina from the sun or an electric arc or a flash of lightning may also cause retinitis, such occurrences being less frequent than other forms of the disease. Treatment of all these cases demands rest, usually in a dark room with proper glasses or shades, building up the general con- dition, if possible, and removal of the cause if that should be re- movable. Trachoma.-This is one of the most important eye-diseases with which we have any dealings. Because it is so very common among the poor in Oriental and certain European countries, the United States Government takes especial pain to see that immi- grants coming to this country are free from it. It is known among doctors as granular conjunctivitis, which means an inflammation of the conjunctival mucous membrane accompanied by the develop- ment of granulations upon and enlargement of the follicles in the conjunctiva. This is followed by contraction and scarring, and often by great injury to the vision, the eyes, and the lids. Among those who have been observed as suffering severely from this disease, and in great numbers, are Jews, Irish, and North American Indians; and it is prone to be especially prevalent where hygienic conditions are bad and where people are huddled to- gether in unsanitary tenement-houses, in military barracks, in asylums, and in poorhouses. It has not been observed very often at high altitudes, not so much on account of the elevation as be- cause such places are usually less densely inhabited, and be- cause the air is purer than in the crowded places nearer the sea-level. The disease is transmitted by means of its secretion or dis- charge and may be carried upon fingers, towels, sponges, or any- thing else with which it has been in contact. The patient may not be aware of it until it has become well developed, when his lids are swollen and painful, the light hurts his eyes, and the tears are flowing constantly. Then the watery discharge becomes puru- 444 HOW TO KEEP WELL lent; and upon the lids, especially at the back part of them, appear granulations like grains of sago. As the weeks and months roll by the conjunctiva becomes thickened, new blood-vessels appear, and the cornea, the transparent disk in the front of the eye, be- comes involved. It may become bloodshot, covered with a film of new blood-vessels; and then little corroding ulcers will form. Vision becomes affected: it may be reduced to a mere perception of light, or the patient may even become blind. As the granula- tions get well the conjunctiva contracts, and as each granulation heals a scar is left, so that in time the mucous membrane of the lids may be changed to thickened scar-tissue. The eyelashes may be turned inward and add to the uncomfortable, scratchy feeling. The normal blood-supply of the lids having been destroyed, they wither or atrophy; and they may be everted or distorted in various ways, producing more or less disfigurement and discomfort. The secretion from the inflamed eye is so contagious that the greatest care is necessary, especially among children, to prevent the rapid extension of the disease. Not only must the patient himself be kept scrupulously clean in every respect, but every- thing which has been in contact with him must be disinfected as rigidly as in a case of smallpox. The care of such a case is es- pecially trying, for it may continue through months and years. Ulcer of the Cornea.-Among children, particularly among the ill nourished, but occasionally among the well nourished, there is not infrequently seen one or more reddish spots on the white of the eye with a little pimple at the center of the inflammation. They are usually close to the cornea and often upon it and are apt to become small ulcers and cause great intolerance to light, thus rendering examination and treatment of the eye difficult. In the majority of cases this disease is due to faulty digestion. The child has been fed with that which is indigestible, and the eye- disease is a protest against the abuse to which the stomach has been subjected. Attention to the general health is imperative; candy, sweetmeats, and tea may properly be forbidden, not only for the time being, but until the child is grown, while tonics and plenty of exercise in the open air should be prescribed. The eyes should never be bandaged, and the child should be prevented from moping in dark corners or burying its face in pillows; the local treat- ment of the eyes must at the same time be under the guidance of an oculist. CHAPTER XXII DISEASES OF THE EARS Structure and Function of the Ear.-The ear is divided into three portions, outer, middle, and inner. The outer consists of the shell-like appendage attached to the side of the head, and of a tube, the external auditory canal, which leads from this append- age to the middle ear, from which it is separated by the drum- membrane. The middle ear, or drum, contains a series of little bones, which extend across it from the drum-membrane to the opening into the inner ear, and is connected directly with the throat by means of a canal called the Eustachian tube. The inner ear, or labyrinth, is situated in the hardest part of the temporal bone and is filled with fluid in which float the ends of the nerve of hearing, which passes thence from the temporal bone through the internal auditory canal to connect the ear with the brain and carry to the latter the impressions of sound. A sound is produced in the following manner: A vibrating body communicates waves to the air immediately about it, which in turn communicate the same motion to other air. Some of these waves enter the outer ear, are directed down upon the drum- membrane, and cause a vibration of this membrane and of the little bones of the middle ear, in turn being communicated to the fluid in the inner ear, where an impression is made on the nerve of hearing, which is transmitted by it to the brain. The hearing apparatus is so delicate that very minute variations in the waves from without the body are recognized as producing different sounds. There is no absolute standard of hearing, yet a standard can be approximated which is of great use in making an estimate of the amount which has probably been lost in a particular case. For this purpose the hearing is tested by means of the voice, the 445 446 HOW TO KEEP WELL watch, and the tuning-fork. The normal hearing is so much in excess of our daily needs that a large amount is almost always lost before a person becomes aware of the slightest degree of deafness. A greater or less reduction in the power of hearing is associated with all affections of the middle and inner ear as well as those of the external canal which interfere with the access of the waves of sound to the drum-membrane. Chronic Catarrhal Otitis.-This is a form of disease of the mid- dle ear in which there is a persistent watery discharge, and it may terminate, though not necessarily, in disease in which there is perforation of the drum-membrane with purulent discharge and more or less destruction of the bony tissue of the middle ear and surrounding structures. Trouble of this kind occurs in adult life rather than in childhood and may be of hereditary origin or the result of bad habits and surroundings. It is frequently an extension of disease in the nose and throat through the Eusta- chian tubes. It may be produced by the irritation of dust; by tobacco, especially when the smoke is inhaled; by alcohol; in fact, by anything which causes congestion of the mucous mem- brane of the upper air-passages. It is accompanied by noises in the head, dizziness, and progressive deafness; it is aggravated by damp weather and frequently comes to those who are of a catarrhal tendency and suffer from cold in the head. The drum-membrane in these cases is not perforated but is thickened and retracted; there may be deposits of wax in the ear, and there is pain, partic- ularly in connection with loud noises. The hearing is made worse by fatigue, mental trouble, and bad health; but deafness is not complete unless the disease extends to the internal ear. When these cases are uncomplicated with other diseases, high-pitched sounds can often be distinguished, and there is more or less conduction of sound through the bones of the head to the nerves of hearing. Deafness.-Deafness may be temporary and removable or pro- gressive and permanent. The freer the canal through which the sound-waves pass, the better the vibration of the drum-membrane upon which the sound-waves impinge, the better and clearer will be the sense of hearing, provided, of course, that the structures of the middle and internal ear are working properly. From in- fancy to old age the cleansing of the ear-canal, preferably with soap and warm water, is as essential as the cleansing of any portion DISEASES OF THE EARS 447 of the body. This is especially important for those whose occupa- tions expose them to accumulations within the ear. The ear-canal is lubricated with a kind of wax called cerumen. Very often this accumulates and forms a hard plug, which fills the canal and attaches itself to the drum-membrane, preventing its vibration and causing deafness. Almost everybody suffers with this at some time or other in his life. An aurist loosens it or dis- solves it with a stream of warm water or with oil and washes out the canal; the drum-membrane vibrates again, and the hear- ing is as good as ever. This is an example of temporary and re- movable deafness. But suppose the drum-membrane is destroyed by injury or disease, or one of the three little bones in the middle ear is injured or becomes unable in any way to do its proper work; or, what is more serious, suppose the delicate structure of the internal ear is impaired in the performance of its function; then we shall have a more serious condition, deafness, which may be partial or complete, and a state of affairs that is irremediable. Deafness frequently comes as the consequence of loud noises, or of constant repetition of noises, the drum-membrane being ruptured or becoming diseased. An injury to the membrane may sometimes be repaired; the opening may close, or if enough of it remains it may grow together again, but it will be an imperfect membrane. Boiler-makers are very subject to deafness as a result of their occupation, and soldiers in action often get ruptured drum- membranes from the noise and concussion of battle. As some children are born blind, so others are born deaf, with a hearing apparatus which is rudimentary or defective. As old age comes on there are few who may not pay the penalty by impairment of the sense of hearing, the machinery wearing out like all other ma- chinery, however excellent its construction. Fortunately in this age in which we are living there are helps for deafness which were unknown a few years ago. Deaf people are no longer dependent upon the unsightly, unsatisfactory tin ear-trumpet. There are schools and classes for teaching and en- tertaining the deaf. A good lip-reader may be almost as much at home in conversation as one whose hearing is normal. Electrical appliances, some of them admirable, are constantly improving the lot of the deaf, and while no mechanical contrivance can possibly take the place of the normal hearing apparatus, it is possible to hope for something even better than we now have and for conse- 448 HOW TO KEEP WELL quent amelioration in the future in the lives of a great number of afflicted people. Inflammation of the External Canal.-Boils in the external canal should be treated by a surgeon. A prolonged treatment is often necessary to stop the succession of one boil after another, es- pecially when they exist in consequence of a run-down condition of the general health. A diffuse inflammation of the walls of the canal is sometimes caused by local irritation, by picking the ear with earspoons, pins, or other instruments, as well as by the instillation of various drops. Never push anything into a child's ear to clean it. A single layer of a handkerchief over the end of the little finger will pass as far into the canal as anything should be allowed to go and can do all the cleansing needed by a healthy ear. If a piece of cloth is twisted into a point and the point then pushed into the ear the child may be hurt, the ear damaged, and no good accom- plished, for the wax obtained in this way was needed to keep the walls of the canal in a normal condition. To cure a diffuse inflam- mation of the walls of the canal is difficult without skilled assist- ance. If the canal is syringed with hot water it will be kept clean and the pain relieved. Mastoiditis.-The mastoid bone is the projecting prominence which may be felt behind each ear. Its interior consists of a number of spaces or cells with thin, bony walls covered with a lining membrane. The interior of the bone is connected with the middle ear, and when that is the seat of inflammation the inflam- mation very often extends to the cells of the mastoid bone. In- flammation of any portion of the mastoid bone is mastoiditis. It may be a simple inflammation which soon subsides under favor- able conditions, or it may be suppurative and extend to the mem- branes of the brain with serious or even fatal consequences. Pus having formed within the cells of the mastoid, it is necessary to let it out, and this requires a very important surgical operation. If the operation is omitted the suppuration focus or abscess may destroy the bone and form an outlet for itself through the skin, but before this can take place it is more probable that the disease will have extended to the brain and its membranes with serious results. Mastoiditis is marked particularly by pain and sensitiveness in and around the ear, and there may also be swelling and discharge. The pain may be so severe as to involve the entire side of the head, and all the tissues around the ear may be red and swollen. DISEASES OF THE EARS 449 It is in cases like this that the great value of removal of a few ounces of blood is frequently apparent, and there is no occasion where leeches may be used to better advantage. When these fail to relieve or it is not deemed advisable to use them, the aurist makes an incision through the skin and down to the bone, or when this is insufficient he opens the bone itself, and perhaps the discharge will soon cease, the wound close up, and the patient get well; but if there is a tuberculous deposit within the ear or the mastoid bone the inflammation and discharge may continue. If this dis- charge were retained within the mastoid bone or the ear there would probably be absorption of infectious material with serious consequences. Meniere's Disease.-Meniere's disease is a very important one. It may result from injury producing a flow of blood or bloody serum in the structures of the internal ear, particularly into the semi-circular canals, or it may come as a consequence of some form of disease, and it has been observed particularly in connection with epidemics of influenza. When it is accompanied by inflamma- tion of the structure of the internal ear there may be death of more or fewer of its bony elements, disturbance of its membrane and nerves, and possibly serious results to the patient. The symptom which is outstanding in this disease is vertigo or dizziness. It is so intense that one loses his equilibrium and his power of control over n ny of his muscles. It may come on at any time, or it may be pre ent only when one changes position from lying down to sitting or standing, or it may come even when one is lying quietly in bed. With this dizziness is a most uncomfortable feeling of nausea with deafness and ringing in the ears, so that going about or attending to one's daily tasks is out of the question. This deplorable condition may last a short time and gradually dis- appear, or it may be permanent and irremediable, depending upon the absorption or non-absorption of the blood or serum which has been effused into the semicircular canals. If absorption takes place promptly hearing may be restored and the patient may get well again. If absorption does not take place and inflammation should follow, the result will be destruc- tion of more or less of the bone and other tissues which are in- volved, the persistence of the deafness, and other bad symptoms. One who has this disease has to learn to balance himself and gradually acquire the proper muscle sense to enable him to keep 450 HOW TO KEEP WELL his equilibrium. His balance is the more impaired if he closes his eyes, or is in the darkness, or changes the grade in walking. Sometimes it is possible to perform a surgical operation which may give partial relief; but the operation is a difficult and uncertain one, and the tissues of the internal ear when reached may be found in such a state of disintegration that little if anything will be gained. Treatment which is recommended and which seems rational for such a condition includes rest in bed, the occasional abstraction of blood from the tissues behind the iexternal ear by means of leeches, and the use of such drugs as quinine and salicylic acid. Middle Ear Disease.-In this disease there is inflammation in that portion of the ear-structure which is immediately behind the drum-membrane, without much pain, but with more or less con- stant discharge, usually of an offensive character, from the external ear. When the discharge is brown or yellow there is usually more or less destruction of the bony substances of the middle ear or of neighboring structures; when it is bloody there is usually a granu- lating condition of the membrane lining the middle ear, or small tumors or polypi may be present. In all cases the drum-membrane has been perforated. When the outflow through the perforated membrane is unob- structed it may continue for years without any great inconvenience, but if the perforation heals and the fluid material is retained, head- ache and pain and perhaps more serious conditions will follow un- til this fluid is released. With the destruction of bone there may also occur the formation of hard, stony masses in the middle ear and the adjoining mastoid bone. The hearing is always impaired, but the impairment is less when the discharge is free and abundant. Troubles of this kind often go on without treatment for years, but there is always more or less danger that serious complications may set in. The disease often begins in early childhood as the result of scarlet fever or some other ailment, or it may be inherited or re- sult from poor food and bad hygienic surroundings. In addition to the destruction of more or less bone underlying the inflamed mucous membrane of the middle ear, there is partial or complete destruction of the chain of little bones which carry sound-vibrations from the drum-membrane to the internal ear. Sometimes these little bones are not destroyed but are stiffened and fused together and thus become a poor medium for conveying sound. Disease of this kind gets better and worse, and is more apt to get partially DISEASES OF THE EARS 451 cured when the dead bone or the hard, stony masses referred to have been removed, but to get a perfect ear with perfect hearing is seldom if ever possible. Noises and Drumming in the Ears.-These noises are of many varieties and degrees and are located in either the external, the middle, or the internal ear. They may be high or low in pitch, rhythmical or irregular, hissing, ringing, roaring, or drumming, and are often so troublesome and incessant as to interfere with sleep, to interrupt thought, to bring on insanity, to make one wish for death or even to commit suicide. A very large proportion of them are located in the external ear and are associated with ac- cumulation of wax with temporary deafness or a catarrhal condi- tion. Moisture being absorbed, the plug of wax is swollen, and it shrinks again as the moisture is evaporated. Air and moisture are thus very important elements in causing the sounds in this loca- tion. They may also result from the moving of insects which some- times crawl into the ears, or from small bodies like peas, beans, or pebbles which may be thrust into them. In the middle ear noises are not uncommon, particularly with children, in connection with the acute diseases like measles, scarlet fever, mumps, and diphtheria. In influenza or grippe such noises also are common, and may be hissing, singing, roaring, buzzing, humming, throbbing, or ringing in character. In those who have diseased tonsils and adenoids such noises are common the disease process starting from the opening of the Eustachian tube in the nose and progressing to the middle ear. As in the noises in the external ear, air and moisture are the elements chiefly concerned in producing them. In the internal ear the sounds are high-pitched and sometimes blowing in character. In the former case they are connected with some condition in the brain or the bones of the nose or the drum- membrane. In the latter case they are associated with certain con- ditions of the circulation and the general condition. In the former case it may be impossible to cure them, but some benefit may be obtained in both cases by improving the general health. Noises in the external ear may be relieved when due to wax or foreign bodies by removing them. CHAPTER XXIII DISEASES OF THE NOSE Anosmia.-Anosmia is due to disease or injury of the nerves which preside over the sense of smell, called the olfactory nerves, or of the mucous membrane of the nasal passages to which these nerves are distributed, or to some other defect or disturbance in the nasal passages. The olfactory nerves have an enormous number of endings in the nasal mucous membrane, and according as more or fewer of these endings are involved so will the sense of smell be more or less blunted. The condition may be inherited, the nerves or the structure of the nose lacking proper development; or it may be acquired from growths or other disease in the nasal passages, or suddenly from severe injury. A crushing blow breaking down the bony structure of the nose and completely obstructing the nasal passages may pro- duce anosmia, and it is not infrequently caused in this way among boxers and prize-fighters. In the aged it sometimes occurs in con- nection with the other evidences of decay at that period of life. It is usually associated with dryness of the nasal mucous mem- brane ; in fact, a moist condition of that membrane is essential to the proper exercise of the sense of smell. In addition to atrophic rhinitis and tumors of the nostrils, it may be associated with vari- ous degrees of nasal catarrh, with hay-fever, with asthma, with the nasal manifestations of syphilis, and with paralysis of the nerves distributed to the face, this paralysis preventing the inhaling process by which odors are detected. Anosmia may be determined by means of certain test odors, especially the aromatic oils, like cloves and cinnamon, or the repul- sive odors like asafetida. Complete anosmia implies inability to detect any odor at all; comparative anosmia implies want of keen- 452 DISEASES OF THE NOSE 453 ness in discriminating odors. The former is incurable unless due to seme cause-for example, a tumor in the nostril-which is re- movable ; the latter may undergo education to a certain degree, like other defective senses. The anosmia may be in one nostril or in both, according as the olfactory nerve on one or both sides is involved. Atrophic Rhinitis.-One of the varieties of inflammation of the nose is atrophic rhinitis. Other names by which it is also known are dry catarrh and ozena. It is usually the outcome of the moist form of nasal catarrh and may either be a disease, in itself in which the mucous membrane of the nose is constantly dry, con- stantly covered with scabs and crusts, and in which the fragile bones within the nose, called the turbinated bones, are atrophied or wasted, or it may show only a dry and shrunken mucous mem- brane and be an evidence or symptom not so much of nasal disease as of some kind of constitutional disease. Besides these there may be loss of smell and catarrh of the middle and sometimes the internal ear, with more or less deafness and possible interference with breathing from enlargement of one of the turbinated bones and the filling of the nostrils with dry crusts. It is not unusual for it to be associated with some serious constitutional disease, like tuberculosis, adding another complica- tion to those which have already made the patient's life miserable. It may involve one or both nostrils; when the nasal septum is de- flected to one side, one nostril may be widely dilated with atrophic rhinitis, and in the other the mucous membrane may be moist and healthy. It may be associated with small tumors, called polypi, upon the turbinated bones; and it may extend downward and involve the mucous membrane of the throat, the larynx, and the windpipe. It is observed at all ages, from early childhood to extreme old age. It is thought by some writers that it may be inherited, for it has been observed in different generations of the same family. Those who smoke and inhale cigarettes and those who use alcohol freely are often sufferers from it. In some respects the disease is an incurable one, and many suffer with it from childhood to old age. When the mucous membrane has been destroyed or replaced by scar-tissue it cannot be made healthy again. The best that can be done is to try to get accustomed to the inconvenience of the situation and relieve, as far as possible, the dryness and the bad 454 HOW TO KEEP WELL odor. Various drugs are used for this purpose, especially prepara- tions of mercury, iodine, iron, and alum. The fragrant antiseptics thymol, eucalyptus, tar, and pine are often used efficiently as a spray in oily preparations which remain a long time upon the mucous membrane and deodorize the offensive smell. Chronic Catarrh.-It happens that there is often faulty con- struction in the complicated mechanism of the nose. Sometimes the bones do not seem to be joined together properly; sometimes an injury deflects one or more bones from their proper position; and very often there are sores or growths on some portion of the mucous membrane, especially the well-known adenoids on the mucous membrane of the posterior nasal passages and the throat. With these mechanical obstructions children become mouth- breathers, the mucous membrane becomes irritated or inflamed, sometimes it becomes thickened, and the result of this inflamma- tion is an increase in the secretion of this very extensive surface of tissue, which, whether it be mucus alone or mucus and pus, constitutes a catarrhal discharge. It may also be caused by bacteria, of which we have abundant evidence in colds in the head and influenza. I suppose the most common cause is the constant influence of a moist atmosphere. The secretion of the mucous membrane would be evaporated, at least to a consider- able extent, if the air were dry and the wind kept in motion, but this is impossible when it is filled with moisture. The total area of mucous membrane in the nasal cavities is enormous. Of course only a portion of it may be the seat of disease; the more it is involved the more abundant will be the catarrhal discharge. Mere swelling of the mucous membrane does not necessarily mean abundant discharge, but when it is combined with other causes it may become profuse. After the mucous membrane has been subjected to repeated attacks of con- gestion, from whatever cause, it becomes thickened, the character of the discharge is changed, and it may become mucopurulent or purulent and very offensive. Alcohol and tobacco are very apt to make catarrhal disease worse, and it is well to refrain from using them. It also tends to become worse if the patient is a sufferer from disease of the heart, lungs, liver, or kidneys. A great deal of surgical work is done on the nose for the relief of chronic catarrh. Some of it is excellent, judicious, and beneficial, but much of it is not, and the DISEASES OF THE NOSE 455 boring and gouging and cauterizing that are so abundantly used leave many patients worse than they were before having it done. It would seem unnecessary to say that if there are obvious mechanical obstructions they should be removed. Simple living, good food, abundance of sleep, plenty of exercise, and the guid- ance of a wise and conservative physician are the best means for relief I know of, if one must remain in a moist climate. Removal to a dry climate with comfortable surroundings will be more likely to produce permanent results than any amount of medication. Cold in the Head.-The symptoms are familiar enough: a paroxysm of sneezing, watery discharge from the eyes and nose, swelling of the nasal mucous membrane, necessity of mouth- breathing, and difficulty in sleeping on account of general discom- fort. This continues two or three days; and then, if there are no complications, the discharge diminishes; it is no longer watery but mucous, the breathing becomes less troublesome, the general condition improves, and after a few days the person is as well as ever. It is not always easy to know how to treat a cold, and I take the liberty of describing the method used by a medical friend, Dr. Beverly Robinson of New York. - When sneezing, chilliness, and cough first appear, give to an adult five to ten grains of salicylate of ammonia and half a grain of caffeine in capsules every two hours for four or five doses. If this does not break up the cold it will probably shorten it and prevent a complicating grippe or bronchitis. If there is fever, add half a grain of phenacetin to each dose, and at bedtime take half a teaspoonful of aromatic spirits of ammonia and the same quantity of spirits of niter in two tablespoonfuls of water. Rub within the nose a small quantity of carbolized vaseline or menthol salve. At bedtime take a hot mustard-water foot-bath, dry the feet care- fully, and wear long woolen stockings in bed. If constipated, take a laxative pill or Seidlitz powder the next morning. If there are cough and expectoration, stop the other medicines, give a teaspoonful of syrup of hypophosphite of ammonium every two hours, and wear for an hour or two at a time an inhaling- mask, inhaling equal parts of beech-wood creosote, spirit of chloro- form, and alcohol. Paint the chest with compound tincture of iodine, and wear an electric pad at night if there is pain in the chest. If the cold is attended with cough, fever, and pain in the chest. 456 HOW TO KEEP WELL the vapor of creosote may be inhaled from a croup-kettle; or, if this odor is objectionable, it may be modified by adding com- pound tincture of benzoin or the oil of pine. The diet should be very moderate, and it may be entirely liquid during the first forty- eight hours. When there is great weakness, a suitable alcoholic stimulant may be given if relief has not been obtained with hot coffee and tea. The most recent advance in treatment consists in the use of chlorine gas and clinics for treating colds by this means have been establish in various places. Deformities of the Nose.-The upturned nose, the nez retrousse is perhaps the least objectionable of all nasal disfigurements; in fact, there are those who doubtless consider it a mark of elegance and distinction. Then there is the aquiline nose, with or without its ornamental beak or tip, which tip may be considered more or less of a deformity, and is common enough in all countries. These are minor deformities which seldom are such an affliction that they impel their owners to seek correction. The major deformities, which often give ugliness and even repulsiveness to the face and cause sorrow, have been the inspiration for the development of the important, ingenious, and even artistic department of surgery known as rhinoplasty. The surgeon who does rhinoplasty chisels away the excess of bone and reforms it along natural and artistic lines. Probably the best results of rhinoplasty are in this class of cases. When these bones are deficient naturally or are the result of disease or injury, we have the flat or saddle-nose. This deformity is very common as the result of syphilis or lupus, or of crushing blows or other injuries. Many prize-fighters and baseball players are sufferers from it. The rhinoplastic surgeon may have a hard task to pro- duce an effective remedy. If he is skilful he will use bone or car- tilage taken from some other portion of the patient's body in mak- ing his repairs. Skin deficits may be remedied by taking flaps from an adjacent portion of the face and not entirely removing them from their original attachment and source of blood-supply until the en- grafted strips have grown firmly in their new location. In repairing the noses of those who have had syphilis the results are not infre- quently disappointing. Some years ago defects of this kind were sometimes treated by injecting paraffin under the skin and then molding the nose into proper shape; but this operation is not an altogether desirable one, for, unless the paraffin is absolutely sterile, DISEASES OF THE NOSE 457 infection may occur and the resulting condition be worse than the original. The nose may also be deformed as the result of blows and in- juries which cause bending or deviation of the septum, or by bony spurs on the septum, such conditions being extremely common and constantly being remedied by throat and nose specialists. Tu- mors in the nose and even objects like beads or beans or other foreign bodies may cause deformity, but these may be readily remedied by good surgeons. Sometimes, as the result of burns or caustics or acids, one or both of the nostrils may be closed or greatly narrowed, so as to interfere with breathing. These acci- dents are usually remediable, although they sometimes are of such a character as to injure or destroy the sense of smell. Diseases of the Nasal Accessory Sinuses.-These sinuses, being more or less connected with the nasal passages, are subject to the same diseases which effect the nasal structure, especially its lining of mucous membrane, the disease being usually but not always an extension of disease in the nasal passages. Thus we may have any or all these sinuses involved in all the grades of influenza or grippe, in acute and chronic rhinitis, in pneumonia, pleurisy, typhoid and other infectious fevers. These sinuses may also become involved in the many cases in which injury of various kinds and degrees is sustained by the nose, especially in childhood, with or without deflection of its inner par- tition or septum, in the many cases in which there are small tumors or polypi in the nose; and in those cases in which the small and fragile bones of the nose, called the turbinated bones, are in- jured or diseased from any cause, but particularly from the re- ception and retention of the germs or bacteria of disease. These germs find most favorable conditions for their growth in the secre- tions and the many recesses of the nasal cavities and account for the enormous frequency of nasal diseases, particularly in moist climates. In the very common disease known as hay-fever, in which the entire nasal mucous membrane is congested and swollen, there is great opportunity for bacterial growth and for extension to the various sinuses. The disease may also be caused by the ex- tension of disease from the teeth, the roots of which very often penetrate the maxillary sinuses and sometimes cause very serious trouble. This is particularly the case with pyorrhea, or Riggs's disease, which is of such frequent occurrence at the present time. 458 HOW TO KEEP WELL The sinuses may also be involved with such serious diseases as tuberculosis, syphilis, and the different forms of malignant disease. The inflammation of the mucous membrane in the various sin- uses usually produces pain and headache; and many of the obscure pains about the nose and head which are so difficult for the patient or the doctor to describe or even locate are attributable to in- fection and inflammations in these sinuses. When the infection is of such a character that pus forms it is often a serious matter if it cannot be located and removed, and its removal may be a matter of considerable difficulty. Cases in which the discharge from the nose is very offensive and the breath offensive also are often due to neglected disease of the sinuses. Such troubles may even be a menace to life and call for the greatest care and good judgment on the part of the surgeon in locating them and yet more in operating upon them. Polypi of the Nose.-These polypi or tumors are merely out- growths from the mucous membrane of the nose, which is not a smooth, flat tissue like the skin on the outside of the body, but is laid down in folds and reduplications as it covers the irregular structures and cavities which form the nasal apparatus. How are the polypi formed? They are probably not real tumors or new growths, like tumors of bone or fat, or like cancers and sarcomas, but mere outgrowths and thickenings of the mucous membrane. One who is subject to nasal catarrh is constantly affected with colds, especially in early life, and that means gradual and permanent thickening of the mucous membrane and predisposition to polypi. Those who are thus afflicted are constantly blowing their nose to clear away obstructions or to facilitate breathing. By and by, the membrane on the end of one of the irregular structures of the nose, one of the turbinated bones, for instance, begins to stretch and lengthen as the result of this constant irritation, and that is the beginning of a polypus. Continued nose- blowing and continued thickening from colds gradually cause en- largement, and perhaps the formation of similar outgrowths, so that in the course of months or years the polypi become well formed as rounded tumors, with longer or shorter pedicles of at- tachment, which move up and down with the efforts at breathing, or perhaps become a simple obstructing mass clogging up one or both nasal passages. A person thus afflicted necessarily becomes a mouth-breather, DISEASES OF THE NOSE 459 he is always in trouble with his nose, constantly requiring the use of the handkerchief, while his mouth is continually dry and uncomfortable. The voices of those who are thus afflicted become nasal and unpleasant in character; cough is often present and trou- blesome ; asthma or difficult breathing is persistent; and there may be painful neuralgia. Hay-fever is both a cause and a consequence of polypi; the shape of the nose may undergo deforming change; and epilepsy, if not caused by them, very often is associated with them. Polpyi sometimes are difficult to locate, and when discovered they often are unsuccessfully treated with astringent sprays and irrigating lotions. The best and most satisfactory method of treat- ment consists in their removal, and a good nose-and-throat surgeon will make quick work of them. CHAPTER XXIV DISEASES OF THE MOUTH Diseases and Hygiene of the Mouth.-The mouth-diseases of adults are not so numerous as those of children, nor are so many people affected by them; but they are often of very grave signifi- cance, and they are frequently fatal in their results. Cancer of the lip, tongue, and tonsils is far from infrequent; sores of the entire mucous membrane of the cavity of the mouth are the characteristic mark of infectious constitutional disease; suppura- tion and bleeding of the gums and loosening of the teeth are present in thousands who are sufferers from pyorrhea or Riggs's disease; and we have but lately been informed of the great numbers of people in middle and advanced life who are victims of poisoning or autointoxication from abscesses of long duration at the roots of their teeth, notwithstanding the tendency of abscesses in general to become sterile or worn out after they have remained unopened for a considerable period of time. Frequently if we know what causes a disease we can treat it successfully, or perhaps prevent it, which is better yet. There are many causes for mouth-diseases; constant irritation of the lip with the stem of a pipe, or of the tonsil with inhaled tobacco- smoke, will in many csises cause cancer; very hot food will burn the mucous membrane and perhaps cause an ulcer; very acid secre- tions of the mouth will sometimes have a similar effect; exposure to the influence of lead, mercury, or phosphorus may produce poisoning, in the effect of which the mucous membrane of the mouth will share. Bad hygiene of the home, poor nutrition, neglect of the teeth, indigestion, and many other causes will produce decay of the teeth and disease of the gums and other tissues of the mouth. It is said that the mouth contains more bacteria and more 460 DISEASES OF THE MOUTH 461 kinds of them than any other portion of the body. There are certain kinds which are harmful and others which are not. In the presence of decayed teeth and decomposed and fermenting food these bac- teria are always waiting to jump in and cause disease. The watery secretion from the nose and throat and the increase of mucus in catarrhal colds furnish splendid media for their multiplication. Thus it is that grippe, tonsilitis, laryngitis, diphtheria, pneumonia, probably foot-and-mouth disease, and many others are caused, the bacteria extending as they multiply and finally causing the particular disease peculiar to the dominant variety. The lesson which I would like to impress is the great importance of the hygiene of the mouth from infancy to old age. Mouth-Breathing.-Why is the nose, rather than the mouth, evidently the avenue designed by nature for the passage of the column of air which moves in and out with each inhalation and ex- halation in the operation of respiration or breathing? Because it is so plainly adapted to the purpose, as means to end. Each nostril is supplied with three small scroll-shaped fragile bones, one above the other, on its outer aspect and above its lower soft and movable portion. Each of these is covered with a thick mucous membrane, each is fixed in the bony structure of the nose at such an angle that there is a perceptible space between the lower and middle and the middle and upper bones. This arrangement provides a large surface of mucous membrane constantly moistened with mucus during health, the inclosed air-space being warmed to the temperature of the body. When air is drawn in through the nose it must pass over this moist mucous membrane and be raised to the same temperature as the body. It is then fit to enter the lungs and give up to the body its content of oxygen. The arrangement of the turbinated bones and also the hairs in the nostrils prevent, to a considerable degree, the passage of sub- stances which would be harmful, though this is not prevented altogether. The entire arrangement is superior to mouth-breath- ing, however, for the later method allows the air to enter the trachea, or windpipe, with no preliminary heating, no preliminary purification, and over a mucous membrane which is not designed for such work. There are many causes of mouth-breathing, some of which are congenital, that is, existent at birth, while others are the result of disease or injury. These causes may be within the nostrils, in the 462 HOW TO KEEP WELL space back of the nostrils, or in the throat. Many infants are born with the septum or division between the two nostrils so de- viated to one side or the other that air cannot get through one or the other side, or there may be sufficient bone destruction in both sides to shut off the air-supply completely. Or the air may be cut off by little tumors or polypi in the upper parts of the nasal cavities. Infants are also very susceptible to colds in the head, which means swelling of the nasal mucous membrane. Infants thus afflicted are often unable to nurse, so that mouth-breathing may have a serious meaning for them. Young children in great numbers are sufferers from adenoids. These may be in the back of the nose, and those who suffer with them are usually mouth-breathers. So also are children who have abscess in the back of the throat or who have croup or diphtheria, the nasal passage being no longer unobstructed. Tumors of the spaces adjoining the nose, called the nasal accessory sinuses, may also encroach upon and occlude the nasal passages. The effect of burns upon the face is sometimes to close the nasal passage. Caustic medicines or caustic chemicals of any sort may also cause nasal obstruction and mouth-breathing. Among those who suffer acutely on ac- count of swelling of the nasal mucous membrane and the necessity of mouth-breathing are the hay-fever victims and to a lesser degree those who are subjects of chronic nasal catarrh, whether children or adults. Such people are always suffering from colds in the head, and this means more or less swelling and obstruction in the nasal mucous membrane. Accidents to the nose, especially in con- nection with athletics, breaking of the nasal bones and obstruction to proper breathing, are becoming more and more common as devo- tion to sports increases. Finally everybody is familiar with the mouth-breathing of those who snore. Sometimes mouth-breathing can be remedied by surgical means and sometimes by medical, but it is obvious enough that in many of the cases what would seem to be a simple though annoying disturbance does not seem to be susceptible of removal and may have serious consequences. Offensive Breath.-It is very distressing to a sensitive man or woman to realize that an offensive odor proceeds from any portion of the body, and offensive breath is about the most distressing of all the offensive odors. Without being repulsive it may be peculiar and indicative of disease. In diabetes there is a sweetish odor of the breath which suggests honey, or apples, or new-mown hay, ac- DISEASES OF THE MOUTH 463 cording to your imagination. In the eye-disease called glaucoma it is said that one of the distinctive signs is peculiar odor of the breath. Everybody knows of the high flavor of the breath which follows the eating of onions, garlic, Limburger cheese, and other substances with a more or less unpleasant odor. All this is apart, however, from the offensive odor which distresses sensitive people who are within the range of its diffusive influence. It may come from diseases or disordered conditions in the mouth, nose, throat, larynx, lungs, stomach, or intestines. In the mouth there is always the possibility not only of decayed teeth but of decomposing food which is lodged in the cavities or between the teeth; and though many sufferers have told me they are particular in the use of the tooth-brush they should remember that these offensive deposits are often quite beyond the reach of the tooth-brush. Decomposition of secretions and offen- sive odor are also very common in the nose, not only in the nostrils, but particularly in the passages at the back of the nose and in the sinuses or chambers accessory to the nose which are often the site of disease and of disease which is very often overlooked. Polypi in the back of the nose are another source of foul smelling odors, and in all these cases the odors are disseminated as air is exhaled through the nostrils. The tongue may be the source from which bad odors emanate when it is covered with a heavy coating of decomposing material. Those who have attended children sick with tonsilitis, diphtheria, membranous croup, or even with some of the fevers are familiar with the offensive breath which accom- panies them; and in all cases the cause is the decomposition of secretions which have accumulated as the result of the disease or of insufficient care and nursing. Metallic poisoning is another frequent cause of bad odor from the mouth, and this happens to those who work in antimony, arsenic, lead, mercury, phosphorus, and sulphur, or to those who have taken an excess of these minerals for medicinal purposes. A most repulsive odor may also be associated with certain forms of bronchitis, or with abscess or gangrene of the lungs, and it may be excited temporarily by anger or fear or any other intense emo- tion. The treatment of this condition is not always as simple as might be expected. For the removable causes it is always best to get the assistance of a sensible and intelligent physician, a special- ist if need be, and one who is willing to take sufficient time to 464 HOW TO KEEP WELL investigate the case and find out where the cause really lies. It goes without saying that the mouth, teeth, and tongue should be kept clean and sanitary whether the breath is offensive or not. Riggs's Disease.-One of the most important, as well as most common, diseases of the teeth is known as Riggs's disease, or pyorrhea of the teeth-sockets. Riggs was an American dentist liv- ing in the last century, who described this disease. It is only within a very few years that people have realized that their usefulness depends very much upon the condition of their teeth, and the skilful dentist is no longer the man who knows how to pull them, but the one who knows how to preserve them. The teeth are firmly set in a bony socket attached to the jaw, which is lined with a firm fibrous membrane covering the root and inti- mately connected with its very existence. Whatever destroys this membrane destroys the life of the tooth. The root is further pro- tected on all sides by the gum, and is exposed to injury and decay if the gum is removed. If the teeth are close together it will be almost impossible to prevent food from lodging between them, and it is sometimes difficult to dislodge it even with a toothpick or with dentists' floss. Material is also frequently deposited near or on the roots of the teeth from the saliva, and this may be combined with particles of retained food and with the worn-out tissue of the mouth. The mouth, too, contains a great variety of bacteria, and its heat and moisture are favorable to their growth and development as well as to the decomposition of the substances which have been retained or deposited. The specific germ of the disease is said to be the amoeba, which is the well-known germ of dysentery. This disease progresses slowly. It is marked by a constant discharge of pus from the teeth-sockets, more or less of which is swallowed, and may be the cause of inflammatory disease of the stomach and intestines; the breath becomes offensive, the mem- brane which covers the roots of the teeth is destroyed; the teeth become loose, die, and fall out; and the gums shrink and recede. Until very recently its treatment has been the despair of the dentists, but there are now several methods of treating it with success, and it need no longer be looked upon as the destroyer of the teeth, and often of the health as well. Barrett reasoned that, inasmuch as the amoeba of dysentery was found in the discharges of pyorrhea, and amoebic dysentery yielded to treatment with DISEASES OF THE MOUTH 465 ipecac and its active principle, emetine, the same treatment ought also to be effective in pyorrhea, or Riggs's disease. He accordingly applied solutions of emetine to the diseased tissues in forty-six cases and reports that the results were uniformly favorable. Sprue.-Its peculiarity consists in the formation of white spots or patches on the mucous membrane of the mouth, which gradu- ally increase in size and spread to the surrounding structures. The disease begins upon the tongue and eventually extends to the lips, cheeks, palate, gums, tonsils, larynx, and throat; in some cases extending even to the intestines. The infectious agent is a fungus which is transferred from the food container to the mucous mem- brane, where it finds favorable conditions for growth. The in- testinal form is classified among the tropical diseases, those who are not natives of the tropics being more susceptible to it than natives. It causes a profuse and troublesome diarrhea, with abundant formation of gas in the intestines, and, besides being very painful, leads to great weakness and emaciation. Ulcers form in the mucous membrane of the mouth and throat, and the same condition is also present on the mucous membrane of the intestine. Unless the disease is effectually treated, it will be marked by recovery and recurrence to an indefinite extent. Those who have returned from the tropics and appear to have recovered are subject to a return of the disease even months after they seem to have got well. There is with it a very marked condition of anemia, and examination of the blood shows serious deterioration of its elements. The Philippines are among the tropical countries where it is very prevalent. Rest in bed is one of the most important means of treatment. The disease calls for the simplest and most nourishing form of diet, particularly pasteurized milk; and it is one of the intestinal diseases in which castor-oil is a sovereign remedy. Support of the abdomen is one of the rational measures of treatment to be commended, and for this purpose a broad, elastic bandage will give more relief than one which is rigid and unyielding. Tonsilitis.-By this term is meant inflammation of the almond- shaped bodies and the tissues around them on either side of the throat or pharynx. The tonsils guard the entrance to the throat but may be exceedingly troublesome, for they are often diseased and may become so large as to interfere with breathing. When 466 HOW TO KEEP WELL thus enlarged they usually contain offensive, infectious material, are frequently inflamed, may be a menace to hearing and to the health in general, and should be removed. But not indiscrimin- ately, any more than the much-abused appendix; for if they cause no trouble I do not believe one has any business to remove them. Acute inflammation of the tonsils-or quinsy sore throat-is troublesome and painful and very common in children and young adults, especially in the winter and early spring. It may be caused by the infectious material in the mouth or tonsils, by tuberculosis in the mouth or the glands of the neck, and in various other ways. It begins with dizziness, stiffness, and soreness of the mouth, with thirst and difficulty in swallowing. It is accompanied by general discomfort, like grippe, with chill, pain, and soreness in the legs and back, headache, and raging fever. Swallowing becomes more and more painful and difficult and the throat more dry; saliva dribbles from the corners of the mouth; the mouth cannot be opened; the speech becomes inarticulate, the tongue coated, the breath offensive; hearing is impaired; and an abscess may form in the neck, throat or ear. When the abscess discharges or is opened there is a feeling of relief, and improvement begins. One form of the disease, called follicular or croupous tonsilitis, may be mistaken for diphtheria, the tonsils being covered with a deposit which looks like the false membrane of the latter disease; but it may be easily scraped away, which is not true of the diphtheritic false membrane. A patient with this disease should have as much nourishing fluid food as he can take, for the disease is an exhausting one. It is better to remain in bed and be isolated from the rest of the family. If an abscess forms it should be opened and freely drained and the surrounding parts kept scrupulously clean. The bowels must be kept open, preferably with an antiseptic like calomel. The entire cavity of the mouth must be frequently rinsed and cleansed with peroxide or some other good mouth-wash, and the tonsils swabbed several times daily with a strong solution of nitrate of silver. CHAPTER XXV DISEASES OF THE TONGUE The mucous membrane which covers the tongue is but a part of that which lines the entire apparatus known as the alimentary canal, and the appearance of the tongue gives the doctor a good hint of the appearance of that canal and of what is going on in the canal from one end to the other. The tongue ordinarily is perfectly movable in all directions, moist from the presence of the saliva, pink in color, and about a quarter of an inch in thickness. From this normal condition there are innumerable variations. Its motion is restricted from tongue-tie; it is immovable in paralysis. It may be clean as a whistle and dry as a bone in fever, dripping with saliva from poisoning by certain drugs, or covered with mucus or pus in certain inflammatory conditions. Instead of its normal pink color, it may be white and pasty, fiery red, or brown, or yellow, or even black; and in each case it gives a hint of the disease which is present. It may be so thick and large that it is impossible to move it, being like a lump of lead in the mouth, or it may be so thin and dried up that it can scarcely play its important part in the mastication of food. It is a very useful organ also in connec- tion with speech, though it is not indispensable. When the tongue is inflamed it is large and swollen and may be the seat of great pain. It may become inflamed as the result of certain diseases or poisons or as the result of injury. An abscess may form upon it or within it, and until the abscess breaks or is opened the pain may be intense, and the victim will be unable to take any kind of nourishment which requires assistance from the tongue. Even swallowing will be difficult and painful, for the root of the tongue is closely associated with the muscles which control the act of swallowing. Those who have been hard drinkers sometimes suffer with this kind of inflammation, and it may be associated with rheumatism and other diseases. 467 468 HOW TO KEEP WELL Frequently the tongue is involved in diseases of the skin. It may be red or cracked or fissured, and it may itch uncomfortably in eczema, or it may have white patches upon it, as in psoriasis and shingles. It may have sores and ulcers upon its sides or tip or its lower or upper surface, and these sores are sometimes very characteristic. The sore made by the constant friction of a pipe is a very dirty one and not infrequently results in cancer. The sore or mucous patch of syphilis is one of the most characteristic indications of that dreadful disease. Tuberculosis also has a distinctive sore or ulcer upon the tongue, and it is needless to say that all these sores add greatly to the discomfort of those who suffer from them. Tumors of the tongue are not at all uncommon. Some of them are harmless, so far as their relation to life is concerned, and some are fatal. In the treatment of diseases of the tongue the first thing to be considered is cleanliness. Like any other organ of the body, the tongue when diseased demands rest. One should not use it in talk- ing, and it should be used as little as possible in eating. Sores upon the tongue call for great judgment in their treatment. Some require strong caustics and others very mild and soothing sub- stances. Tumors should be removed at the earliest possible oppor- tunity. Even cancer, when it receives early and skilful surgical treatment, has a certain percentage of cures. Leucoplacia.-There are several diseases which have these sores on the tongue as one of their symptoms; tuberculosis, syphilis, the so-called canker-sore which comes so often with certain forms of indigestion, sprue, psoriasis, shingles, etc. They all look so much alike that it is often difficult to distinguish one from another. The sores which I refer to are white, roundish, or irregular patches, but slightly elevated above the surface, which appear for a while, then disappear, and then appear again. They may be in all parts of the mouth but are particularly noticeable on the top of the tongue. These sores may be quite painful even when not irritated by acids, salts, etc., but their chief importance consists in the fact that they may be precursors of cancer of the tongue. It is, therefore, very important that they should not be neglected. They are produced by prolonged irritation of one kind and another; the irritation from the constant use of tobacco; clay pipes, particularly when they are rough and dirty; irregular and jagged teeth; ill-fitting teeth-plates; and many other sources of irritation which may be in the mouth. DISEASES OF THE TONGUE 469 The thing to do is to try to get rid of them when they first appear, and remove the cause which has produced them. A strong solution of iodide of potash or of sulphate of copper frequently ap- plied is said to be effective in removing them, as is an ointment of salicylic acid of moderate strength, or an application of X-rays. I have not observed any recommendation of the use of carbonic acid snow but should think it would be worth a trial and do not see how it could do any harm. Tongue-Tie.-Underneath the tongue is a little strip or band of mucotis membrane, beginning at the middle point of its root and running along its under surface, sometimes half its length and sometimes to its very tip, called the frenum, or bridle, which, I sup- pose, is intended to assist in holding the tongue in its position. Ordinarily one would not know there was such a thing unless he happened to look at it in a mirror, for it yields readily to the movements of the tongue in all directions. But if it happens to be a little shorter than it should be, these movements are at once restrained; and if the shortening is considerable, it draws the tongue up and freedom of motion is quite destroyed. A baby with such a deformity cannot nurse properly; it is liable to choke when attempting to swallow, and the defect may interfere with its breathing and its crying. When the teeth ap- pear, the tongue is quite likely to be bitten in efforts at eating, and it is always in the way when one is talking. The defect is, therefore, not so insignificant a matter as it at first would appear. It is true that in tongue-tie of slight degree constant effort usually will stretch the membrane and give more or less relief; but if there is much shortening of the frenum, such relief is not proba- ble, and it remains a permanent handicap, unless overcome by surgi- cal means. If it is not discovered at birth, it certainly should be as soon as the child begins to nurse. When discovered, it should be remedied at once, the band being put on the stretch and nicked in one or two places with the tip of a pair of scissors. The tongue then is pulled forward until all tension is relieved. A few drops of blood may flow, but this almost always can be checked if a small wad of cotton is placed under the tongue and compressed by the tongue itself. If the operation is deferred until after infancy there will be more hemorrhage and a couple of stitches may be necessary to close the wound. CHAPTER XXVI DISEASES OF THE THROAT Diphtheria.-This disease has been quite fully treated in the chapter on Diseases of Infancy and Childhood (Chapter VIII), to which the reader is referred. Influenza, or Grippe.-The essential causative element in grippe, or influenza, whether it be called Russian or, as more recently, Spanish, or simply influenza, which is sufficiently explicit, is known as Pfeiffer's bacillus, Pfeiffer having written an excellent treatise describing the disease. People may be stricken with influenza at their work or elsewhere, the common symptoms being chill, head- ache, and general bad feelings, together with redness of the face, running of the eyes and nose, sore throat, and great prostration. The pulse is slow; the fever runs from 1020 to 1040 F.; there is often a harsh cough, with very little expectoration; and as compli- cations there are frequently bronchitis and bronchopneumonia, the latter often proving quickly fatal. Mild cases last two or three days and are followed by rapid recovery; severe cases may be quickly fatal. In cases in which there is high fever there are blisters or fever-sores upon the lips, but no disturbance of the digestive apparatus. When a person is attacked with this disease he should go to bed at once and send for his physician. If his fever is high his condition is serious and will remain so until the fever abates, and such an abatement may take place very suddenly. The convalescent period is of great importance, for it is during that period that so many people are neglectful and develop fatal pneumonia. Rigid precautions as to coughing, sneezing, and blowing the nose are of great importance, for nobody can tell how many bacilli may thus be liberated to float in the air and be ready for inhalation by any- body that may be passing along. It is very important during the 470 DISEASES OF THE THROAT 471 convalescent period that one's house should be warm and comforta- ble, and this is something more important than saving coal, no mat- ter how expensive that may be. Fresh air, sunlight, open bowels, simple and moderate diet, and a daily warm bath to keep the skin in good working order should be the program for everybody at all times, but especially when influenza is about, and at such a time one should always keep away from crowds and crowded places as much as possible. An epidemic lasts from four to six weeks in a given locality. The treatment of influenza and its complications includes pre- ventive measures as well as those used during and after the dis- ease. In addition to the hygienic measures advised by doctors and boards of health the question of vaccines must be considered. As a tonic there are three drugs which may be used freely in this disease: cod-liver oil, quinine, and strychnia. Remedies that may be liberally used are large doses of bicarbonate of soda, inhalation of a solution of salicylate of ammonia through a simple mask, and free inhalation of oxygen. Ludwig's Angina.-It is infectious; that is, it is due to the at- tacks of germs known as streptococcus and staphylococcus, both of which varieties are very common and often very destructive in their action. The death of the Earl of Carnarvon in Egypt after the notable discovery of the tomb of Tut-ankh-Amen was said to be due to streptococcus infection. The disease begins as a hard, painful swelling in the tissue of the neck around the lower jaw. The inflammation may be mild for several days and then become very severe, even becoming gangren- ous in some cases. The disease is really a rapidly progressing in- flamation of the cellular tissue of the neck, or cellulitis, and may be associated with tonsilitis, with various conditions of the teeth, and with an ulcerated condition of the mouth. The larynx, windpipe, and lungs are rapidly invaded; there is great prostration of the pa- tient; and the difficulty in breathing may be so urgent that tracheo- tomy must be performed to prevent suffocation. Swallowing also is tery difficult and painful; consequently the nutrition is quickly interfered with, only liquid nourishment being permissible, and this with great trouble and annoyance. Intense blood-poisoning is one of the marked features of the disease and adds to its seriousness. Even though tracheotomy be performed and artificial respira- tion and inhalation of oxygen are resorted to, death is the unhappy 472 HOW TO KEEP WELL consequence in many cases, the swollen tissues of the neck so pressing upon the larynx and windpipe that respiration becomes impossible. The formation of abscess in the inflamed cellular tis- sue means that incision must be made to remove the accumulated pus. Even if abscess does not form, the incision into the muscles of the neck by relieving tension upon important structures may be sufficient to turn the scale and prevent a fatal consequence. This incision also may serve to prevent the absorption of poisons and so dinimish the chances of general intoxication. Frequent injections of antistreptococcus serum are a means of treatment; also rectal injections of salt water. Pharyngitis.-The mucous membrane lining the throat and the tissues immediately under it are the parts which become inflamed. Very often the tonsils are inflamed also, for they are included in the space known as the pharynx. An attack may come suddenly, perhaps with a change in the weather. The throat becomes dry, sore, and stiff; there is more or less fever and a general feeling of discomfort and weakness. Anybody may have it, old or young, male or female. Those who have a tendency to catarrhal trouble are more susceptible than others. The glands of the neck become swollen; the voice is husky; there is a constant feeling that there is something in the throat, and a constant inclination to clear the throat and expectorate. This is the acute form of the disease. While cold and dampness seem to be exciting causes, they suc- ceed best when they attack those who are weak and whose resist- ing powers are not good. The influence of bacteria must also be remembered. Those who are subject to rheumatic troubles often are victims of this disease, and also those who injure their throats with very hot drinks or with hard and rough foods, or whose throats are hurt and bruised by bones or other substances which wound the sensi- tive mucous membrane. After the period of dryness in the throat comes a period when the mucus and saliva are increased. This dries up, and after a few days the trouble passes off, and the person is as well as ever; or the disease becomes chronic and lasts until the return of warm and dry weather. The chronic form often is associated with nasal catarrh and with excessive use of the voice. For a long time it used to be known as clergyman's sore throat, and often was accom- panied by a short, hacking cough, sometimes without secretion DISEASES OF THE THROAT 473 and sometimes with an accumulation of thick mucus and a con- stant desire to expel it. Sprays and gargles constantly are called for, with solutions of chlorate of potash, tannin, guaiac, and camphor, and also lozenges of slippery elm or menthol. Applications of nitrate of silver, or its derivative, argyrol, are frequently used, but their employment re- quires skill and judgment, lest injury be done to the surrounding tissues. One who is subject to this disease should, if possible, change his residence to a more salubrious climate; otherwise he will be exposed constantly to recurring attacks. Vincent's Angina.-Vincent's angina, also called diphtheroid angina, or ulcero-membranous angina, is an infectious inflammation of the mucous membrane of the tonsil and throat brought about by the influence of certain spindle-shaped bacilli. The infection is usually what is known as a mixed one, partaking of the charac- teristics of diphtheria, syphilis, tonsilitis, and pharyngitis, or com- mon sore throat. The symptoms are those which attend ordinary sore throat; headache, general discomfort, coated tongue, offensive breath, high temperature, and pain and swelling in the neck, particularly in the salivary glands under the lower jaw. These symptoms, however, are said to be less severe than in the ordinary sore throat, or pharyn- gitis, or angina. There is also a tendency in Vincent's angina to ulceration and the formation of a membrane like that which occurs in diphtheria, so that there may be difficulty in distinguish- ing the disease from real diphtheria. The disease should be treated, like other forms of sore throat, with mercurial cathartics, antiseptic gargles and mouth-washes, spare diet, and rest in bed. If the infection is not a mixed one, with a variety of disease-producing organisms, it will last three or four days, though the mucous membrane of the mouth and throat may remain red and swollen for many days. If a false membrane and ulceration are present, sprays and applications of powerful anti- septics will be required, and, doubtless, in many cases, it will be deemed wise to inject diphtheria antitoxin as a possible safeguard. When the germs which are peculiar to syphilis are found in this disease, it will mean that the treatment indicated for syphilis should be given. One who has this disease should be quarantined until all the symptoms have disappeared. CHAPTER XXVII DISEASES OF THE STOMACH Catarrh of the Stomach.-The formation of mucus is the pre- cise function of the membrane which constitutes the inner coat or lining of the stomach. It is always present in greater or less quantity; and there is more of it during the period of digestion than at other times, for it is mingled with the food for the purpose of softening it and preparing it for the liquefying action of the gastric juice. When it is secreted in great abundance-moreover, when it is tough and stringy-the stomach rebels and endeavors to get rid of it. This then becomes a condition of disease, which is very properly called catarrh of the stomach. There is more of the mucus in some cases and at some times than at others. In some cases there is an abundance of it all the time. People who have chronic catarrh of the nose and throat are very apt to have catarrh of the stomach also, perhaps because so much of the mucus is swallowed, but more likely because the same process which induces constant running from the mucous mem- brane of the nose and throat is at work also in the stomach. But it often comes in those who have no such nose and throat disease, from overeating, from fatigue, from nervous disturbances of vari- ous kinds, or from serious disease, like cancer. It is or was very common in hard drinkers, but fortunately such cases are becom- ing less and less numerous. It may not give rise to any particular symptoms, except an occa- sional attack of vomiting, in which quantities of semifluid, slimy mucus are ejected with the food, or the mucus may be tough and stringy. With it there may be headache, nausea, loss of appetite, and constipation; and the mucus, when vomited, may be mingled with bitter, greenish bile. Attacks of vomiting may occur soon after eating, or they may have no apparent relation to the digestive process. In some cases there is no pain but only discomfort; in 474 DISEASES OF THE STOMACH 475 others, and particularly when cancer is present, there may be acute pain in the region of the stomach, which is relieved when the stomach is emptied. It is not unusual when the mucus is abundant that it should be propelled into the intestines. Those who suffer from this disease, especially in its acute form, should lead as simple a life as possible, avoiding strains of all kinds, eating only plain food, and not too much of that. Many will find that a fluid diet, particularly one in which buttermilk or fermented milk is the chief constituent, will be the most acceptable to them. A glass of hot water slowly drunk before each meal is helpful in many cases. When the trouble is obstinate the stomach should be washed out every day; that is, filled with hot water and then siphoned out. By this means the mucous membrane will be cleaned off, caused to contract, and stimulated to more healthful action. Dyspepsia.-Obviously enough the causes of dyspepsia are in the food itself or in the digestive process. The food may be de- ficient; those who are starving have dyspepsia, whatever else they may have. Dyspepsia of this kind carries off multitudes of infants who do not get the proper kind of food at the breast or elsewhere. They vomit almost incessantly and lose strength and the possibility of recovering strength, and succumb as a logical consequence; cause and effect indubitable. Drunkards lose food and strength by dyspepsia in the form of vomiting induced by the excessive use of alcohol. On the other hand, overfeeding causes dyspepsia, for it distends the stomach and prevents it from furnishing the proper quantity or quality of ferments. The same is true of habitually eating in a hurry, bolting half-masticated food, or eating food that is unappetizingly, unhygienically prepared. Many men get dyspepsia because of their irregular habits of eating: some eat too often and some don't eat often enough, and by and by the stomach gets insulted and strikes; that is, refuses to issue digestive ferments in proper quantity and quality. A great many people get dyspepsia from eating too much pork, or greasy food, or pastry, or condiments; or their food is too hot or too cold, for the digestive process is old-fashioned and works by rule. When dyspepsia results from defective digestive organs there may be either mechanical or chemical fault. The former consists in imperfect mastication, or in defective motility of the stomach, for the muscular tissue of that organ must be able to roll the food around and subject it thoroughly to the penetrative influence of its 476 HOW TO KEEP WELL digestive juices. If there is paralysis or spasm of this muscular tissue the food may accumulate in quantity and undergo decomposi- tion, and gas dilatation and pain may be the result. With defective muscular action is associated defective nerve-action and a train of bad consequences. Now as to the chemical fault. Digestive secretions or ferments are provided by the stomach for the proteids, by the pancreas for the starches and fats, and by the liver for the stimulation of the intestinal muscle and other purposes; and these secretions may be defective in quantity or quality. There may also be too much or too little mucus in the stomach and intestines, and this has an im- portant bearing on the production of certain forms of dyspepsia. The part which the nervous system plays in influencing diges- tion is very striking; a sudden or violent emotion of any kind may entirely arrest digestion, and if frequently enough repeated it will cause an aggravated form of dyspepsia. The same is true of the blood-supply of the digestive organs, which always call for a more abundant flow during the process of digestion; and if that supply is too great, as in chronic congestion of the stomach from disease of various kinds, or too small, from violent emotion, violent exercise, or disease of the digestive organs, especially catarrh of the stomach or excessive acidity, indigestion will be the consequence. Symptoms and Treatment of Dyspepsia.-It is hardly possible to have dyspepsia to any considerable degree without change in the appearance of the tongue. Don't forget to look at the tongue for dyspepsia. As might be expected, the breath is often offensive, and there is a bad taste in the mouth, sometimes bitter, sometimes sweet, sometimes acid. The appetite may be poor, or, on the con- trary, it may be ravenous. There may be pain and distress, and it may be associated with anemia, malaria, gout, cold, emotion, too much alcohol, or the use of certain kinds of food. Pain may also be present in the kidneys or the bladder as an associate symptom, or in the heart, together with palpitation and irregular action. The heart complication is a very important one, for many people who die suddenly are accused of dying of acute indigestion when it is the heart-disease which is the fatal element. Nausea and vomiting are very common symptoms, occurring just after eating or one or two hours later. They may be due to the character of the food, to an excess of mucus, to blood, and in babies to the coagulation of the casein in the milk they have taken. DISEASES OF THE STOMACH 477 Sometimes constipation goes with dyspepsia and sometimes diarrhea, depending largely upon the character of the food. A very common symptom with the acid form of dyspepsia is the gulping or belching of gas which is disagreeable and acid to the taste, and fluid which is so intensely sour that it puts the teeth on edge. Of course, a great many people who have dyspepsia are fearful that they have ulcer of the stomach or even cancer. Both these diseases are extremely common; both are frequently sequels of dyspepsia; but one does not necessarily lead to the other. If one is to be earnest in his desire to be cured, bad habits, how- ever agreeable, must be eliminated and their relation to other com- plicating diseases considered. General hygiene and sanitation must be made a study, as they relate to clothing, bathing, rubbing, and outdoor exercises. If the stomach retains and decomposes food it must be emptied and washed out with plain warm water once a day or less often. Diet is of paramount importance. Eat what you like if it agrees with you; it is not always a virtue to eat certain kinds of food simply because you think you have to. For reasons which have been sufficiently dwelt upon, starches, sugars, and fats must gener- ally be taken sparingly. Green, fresh vegetables, toast, raw oysters, soft-boiled eggs, prunes, baked apples can be eaten by most dyspep- tics. Milk is a stand-by for the majority of dyspeptics, and you will not starve if you take enough of it and nothing else. Some people think they are unable to drink it raw and whole; if you are sure you belong to that class, put a little bicarbonate of soda in it or a small portion of lime-water or Vichy water, or drink butter- milk, or ferment it with lactic acid bacteria and drink it as often as you are thirsty. If the dyspepsia is of the acid character there is no alkali which I have ever found which would neutralize it so well as bicarbonate of soda, used freely and as long as it may be required. I have never known anybody to be injured by it. Above all things, avoid con- stipation; and in most cases you can safely take as your guide, philosopher, and friend suitable doses of castor-oil at rather fre- quent intervals. Elevator Sickness.-All of our modern improvements have some kind of a penalty attached to them. Perhaps this is the counter- poise, for everything that has weight must have something to keep 478 HOW TO KEEP WELL it in equilibrium, or it illustrates the law of antithesis-a thing be- ing recognized as good because something else is not good, that is, bad. Elevators are no exception to this rule. How useful and indispensable they are in modern buildings-especially the high ones! Still, elevators have their bad features-not only break- downs and falls, with crushing accidents, but a very common form of illness which may be of no importance or may be more or less serious. This illness may be due to faulty condition of the elevator, but more often is due to the carelessness or want of skill of the one who runs the elevator. When there are violent jerks and sudden stops, oscillations, swift and sudden drops several stories in length, one is apt to have a sense of faintness or nausea or dizziness, with difficulty in breathing, perhaps. It is like seasickness. The stomach is a very mobile organ and is innervated by the pneumo- gastric nerve, which also supplies the lungs. A shock to this nerve produces faintness, dizziness, nausea, and difficulty in breathing, just as in the experience referred to in the elevator. The sympa- thetic nerves of the stomach are also concerned, in such symptoms as have been mentioned, and these are similar to the sensations pro- duced by diving or jumping from a height, dropping from an aeroplane, or tossing up and down in a boat at sea. There are some to whom this experience is positively harmful. Such are they who suffer from pulmonary tuberculosis, dilated heart, and other forms of serious heart-disease, and also from brain- disease and arteriosclerosis. Such experience as I have mentioned is almost sure to be bad for those who suffer from displacement of the stomach, liver, kidneys, or intestines; and the number of these is not small. It would be safer if all who have these diseases would avoid the swift-moving elevators, unless they are run with greater smoothness and freedom from shock than most of those I have been in. Falling of the Stomach.-The tissue of which the stomach and its ligaments is composed stretches readily, and as it lacks the resil- iency of an elastic substance like rubber, after a number of stretch- ings it may fail to return to its normal boundaries. The stomach of a full-grown adult holds from two to three pints. How greatly, therefore, must it be distended and overtaxed by those who eat and drink to excess! The continued abuse of the stomach in the manner suggested re- DISEASES OF THE STOMACH 479 suits sooner or later in persistent dilatation; it loses its natural shape, constant fermentation and evolution of gas balloon it into a great bag which encroaches upon neighboring organs, and fre- quently give rise to unlimited discomfort for the victim of the con- dition. From dilatation it is frequently but a step to the relaxation of the loose bands by which the stomach is sustained. When these bands begin to give way there is little, if anything, which is availa- ble in their structure to bring them back to their normal state. The more they are pulled, the more they stretch and the less able are they to support properly the overdistended and overweighted stomach. The stomach consequently drops, sometimes horizontally and sometimes at one or the other end. The intestines offer little resistance to this fall; they are soft, yielding tissues, and in the course of time the stomach may continue to distend until it has reached the pelvis. Some of the symptoms from which those who have falling of the stomach suffer are general discomfort, want of ambition for the ordinary tasks of life, constant sense of bloating, constant de- sire to belch gas, constipation, and poor nutrition. The stomach and intestines are unable to do their work properly and malassimi- lation and poor nutrition follow as a matter of course. Gastralgia.-It would be more correct to speak of neuralgia of the stomach, for that is evidently what is meant by those who use this term. Like other forms of neuralgia, it comes and goes in spasms or paroxysms, and in the intervals one is perfectly well, so far as this particular trouble is concerned. It is due to some disturbance in the important nerves which are distributed to the stomach, especially the great nerve, which gives sensitiveness and vitality alike to the stomach and lungs. Excessive heat in the form of burns in any portion of the body may cause it; so also may the use of excessively cold food or drink, like ice-cream or iced drinks. It is sometimes caused by the use of tobacco when one is not accustomed to it, or by eating certain kinds of food. Many people cannot eat clams or crabs or lobsters without an attack of gastralgia, which is usually put down as a case of acute indigestion. Certain kinds of medicine will bring on an attack in some people, and raw spirits, like whisky, rum, or brandy, will cause it in others. Much depends upon the physical condition of a person. One who is in good physical condition to- day might take with impunity that which would bring on an attack 480 HOW TO KEEP WELL of gastralgia to-morrow. Those who have chronic disease of the stomach are more susceptible to gastralgia than those whose stomachs are not diseased. Hence it is one of the customary inci- dents of those who suffer with cancer or ulcer of the stomach, or with some of the forms of dyspepsia. This is probably what the doctors of past generations referred to as stomachache. The pain may be excruciating, being located in the lower por- tion of the chest, shooting to the right and left and often into the back and shoulder. It is sometimes so severe that it can only be relieved, if at all, by the use of powerful narcotics. In the intervals between the spasms one feels perfectly well and comfortable, but repeated attacks take away strength and leave one helpless and prostrated. Heat over the stomach will sometimes ease the suffer- ing, and when the attack is due to indigestion relief may often be obtained by emptying the stomach, a pint of lukewarm mustard- water being swallowed for that purpose. Acute Gastritis.-This disease may come from the greatest variety of causes-from fevers and chronic disease of the heart, lungs, or kidneys, of which it may be an associate or side-issue, im- pairment of the digestive apparatus, diseases of the blood, injuries, poverty of nutrition, overeating, drinking of alcohol, especially when the person is fatigued or depressed, or taking of food or drink that is very hot or very cold, food that is unsuitable from whatever cause, or drugs of various kinds. There is no doubt that indigestible food, stale food, food that develops ptomaines, is the most frequent cause. The attack is usually sudden and unexpected, beginning with a sensation of fullness and discomfort in the stomach, which soon becomes painful. If the accumulating gas is dispersed there is relief for a brief period, after which the pain and swelling become worse than before. Nausea and vomiting, or attempts at vomiting, follow; also headache, fever, chilliness, and thirst. Frequently there is ejection of sour or bitter fluid, palpitation, restlessness, and perhaps cold sweating and prostration. As the attack con- tinues the patient may become jaundiced. If the vomiting con- tinues it will no longer be food that is ejected but a mixture of blood, mucus, and bile. The tongue is coated, and there are fever- sores on the lips; diarrhea is succeeded by constipation; the skin itches frightfully, especially when there is ptomaine-poisoning from stale food. The vomiting may be almost incessant and the DISEASES OF THE STOMACH 481 patient become completely prostrated. This is especially so in the cases of old people and little children. An attack of this disease may be over in twenty-four hours or it may last several days, ac- cording to the physical condition of the patient and the severity of the attack. It may develop into a chronic condition of indiges- tion, particularly if it is neglected or treated injudiciously. The offending substance should be removed from the body as soon as possible. If vomiting is not spontaneous one should drink a pint of lukewarm mustard-water as an emetic or fill the stomach with warm water and siphon it out, taking a good dose of castor- oil after the stomach has been emptied. Heat is essential to sus- tain the vitality and should be applied to the feet and over the stomach, while, if there is fever, cold should be applied to the head. Absolute rest is essential, and so is sleep, if possible. Food must be withheld until the stomach is in condition to retain and digest it, and for several days it must be exclusively fluid in char- acter. Hemorrhage from the Stomach.-This begins with feeling of faintness and sinking at the pit of the stomach, followed by belch- ing up or vomiting of blood, which may be bright red, if the bleed- ing is recent and the gastric juice has not had time to act upon it, or may be very dark red, reddish brown, or black like coffee- grounds if it has been retained in the stomach minutes or hours. Following the vomiting there may be a feeling of exhaustion or prostration. This form of bleeding is distinguished from hemor- rhage from the lungs by the fact that blood is coughed up, not vomited, in the latter condition. It may be due to the perforation of the wall of a blood-vessel in the stomach by an ulcer or cancer, to changes in the walls of blood-vessels that are produced by scurvy or by the poisons associ- ated with malarial or yellow fever, or it may be the consequence of distension of the blood-vessels from impeded circulation in a con- gested liver or spleen. In women the menstrual blood may be discharged in this way. Treatment consists in rest in bed, the internal use of ice, and an ice-bag over the pit of the stomach; also a hot injection of soap- suds into the rectum may be given. All food must be withheld until it is determined that the bleeding has stopped. Indigestion.-Food, like fuel, is of different kinds. There is pro- teid, of which meat, fish, eggs, cheese, and a certain portion of the 482 HOW TO KEEP WELL cereals are examples, and which furnish to the blood the albumen to be distributed to the cells of the different tissues of the body for their nourishment and upkeep. Then there are the hydrocar- bons or heat-producing substances, which include the starch which is in vegetables, the animal and vegetable oils and fats, and the sugar which by chemical change either in plants or in the body is made from starch. Finally there are coloring-materials and mineral substances, the latter being found in the husks of seeds and grains, and in the rocks which, like salt, are dissolved by water and are assimilated or taken up by the tissues of the body with very little change from their original form. When the husk is taken from rice, wheat, and oats the grains are deprived of one of their most valuable constituents, and it is strange that people should be satis- fied with these denatured foods when the requirements of the body are so much better met when they are in the natural form. The proteids are digested in the stomach, the starches and fats in the intestines, especially in the first part of the small intestine. The first cause of indigestion consists in taking in substances which the juices of the digestive organs cannot split up and dis- solve. If you were to eat a handful of dirt it would go through your stomach and intestines as dirt, and as dirt would be expelled from the body, and you would have indigestion from this cause. If you ate great chunks of raw meat and swallowed them without half chewing them you would have a great deal of pain in your stomach and bowels and would expel the meat in softened chunks or in shreds and small pieces. But suppose you chewed the meat to a pulp, and after an hour or more had pain in the stomach, belch- ing of gas and offensive breath, followed by constipation. That would mean indigestion from insufficient gastric juice or gastric juice of poor quality, or from a stomach with deficient muscular power, so that the food was only partially digested, some of it be- ing decomposed while still within it. Or suppose you ate a large quantity of candy, and, after a while, had great pain in your intes- tines, distention with gas, and possibly diarrhea, that would be intestinal indigestion, and would mean that you had put more work on the intestinal juices than they could stand, and that they had struck, the job being too much for them. These may be con- sidered forms or types of indigestion, and it must be evident that in most cases they are preventable, the conditions being, first, simple and easily digested food; second, careful chewing, which of course DISEASES OF THE STOMACH 483 signifies good teeth; third, proper mixture of the different kinds of food-not too much meat, not too much starch or sugar; and, fourth, not too much work with brain or hands while the stomach and intestines are busy. Irrigation of the Stomach.-The irrigation procedure washes out all offensive material, and with it, as a rule, a lot of mucus which has formed and accumulated in the stomach, and gives the organ a new start. Of course the procedure must be repeated every day or two, and it may be for weeks or months, but I know of no simple operation which gives greater relief in a very short time. The apparatus is a long, soft rubber tube, conical and closed at its anterior end, and with one or two eyes or slits at the sides through which the contents of the stomach pass out. Into the posterior or upper end of the tube is fitted a glass funnel which may hold half a pint to a pint. The rubber tube is half an inch in diameter. You often hear about stomach-pumps being used to empty the stomach. If there are real pumps for this purpose I have never seen them, and according to my experience the rubber tube "fills the bill" entirely. As an irrigating-fluid I have never used any- thing but plain water, warm and clean. It may sometimes be de- sirable to use the water quite hot, say ioo° F., but it must never be too hot, for in the first place it would injure the stomach, and in the second place it would coagulate its contents and prevent their passage through the opening in the tube. In some cases a weak solution of alkaline mineral salt may be used, bicarbonate of soda or common salt or Carlsbad salt instead of plain warm water, but the latter has always seemed adequate to me. Not much more than a pint need be used for each irrigation. The patient is protected with a large towel, and upon his knees he holds a basin with his two hands. It may be useful during the insertion of the tube to receive saliva and vomited material, though it will be by no means necessary in all cases. Of course if there are any false teeth or other impedimenta in the mouth they must be removed. The patient sits in a chair with head forward, and the tube, covered at its end with oil, glycerin, or vaseline, is passed gently along the roof of the mouth into the throat. Gagging will probably come at this point, but it must be resisted by will-power and effort made to swallow the tube. When it passes into the esophagus or gullet it is beyond the grip of the swallowing muscles, and from this location will slide 484 HOW TO KEEP WELL easily down into the stomach. Then the glass funnel is fitted into the end of the tube, raised to a vertical position, and the water poured into the funnel. Then the patient bends slightly forward, the funnel is reversed, and by siphon action the contents of the stomach will flow out. The procedure should then be repeated, perhaps several times, until the fluid returns clear. The first dis- charge may be foul-smelling, contain much mucus and some un- digested material, and one will wonder how it could be carried about without causing all sorts of unpleasant sensations. Nervous Indigestion.-Men oftener than women are attacked with this disease, especially business and professional men who have applied themselves too closely to their work, worried a good deal, and taken very little exercise or recreation. They are irrita- ble, always fatigued in body and mind, depressed, and low-spirited. They gradually note their inability to concentrate upon any sub- ject for any length of time; they have throbbing headaches, are unable to sleep, have pains running up and down the spine, flashes of heat and cold, and sweating; they imagine they have pain in the heart; and their pulse is now slow, now rapid, and perhaps irregu- lar. Even after a full meal they may have a feeling of emptiness and gnawing in the stomach, which is due not to the food they have eaten but to their nerves, their emotions, and the condition of their body in general. Curious as it may seem, food which is perfectly good and digestible may give them pain while that which is indi- gestible and unsuitable may fail to do so. Their appetite being capricious, they don't know how to discriminate between the good and the bad. Heartburn, constant inclination to belching, disten- tion of the bowels, dizziness, fear of something that is about to happen, and constipation are their constant enemies. With all these disagreeable symptoms their general condition may be pretty good, and except that some of them have a worried, frightened look, their appearance is not suggestive of severe illness. Such people need encouragement but not too much sympathy. They can often be assured with perfect honesty that the outlook for them is good if the causes which brought on their trouble can be removed and their general condition improved. Improvement may be slow, and perhaps it will take months to get well, especially for those whose nervous system is weak, but they must expect recovery. In not a few cases the trouble is associated with descent or prolapse of the stomach and intestine, and in such cases a suita- DISEASES OF THE STOMACH 485 ble apparatus should be worn to give these displaced organs as much support as possible. Those who can should give up business and take a prolonged rest in the country, or at sea; anything to enable them to get out of doors and in the sunshine. They should eat plenty of good, sim- ple food, sleep a great deal, seek cheerful companionship, and occa- sionally go to a good picture-show. Great benefit may also be de- rived, in many cases, from skilfully applied massage, frequent baths, and a suitable form of electricity, sometimes galvanic and some- times faradic. They must omit from their diet tea, coffee, and alco- hol; in many cases it will be a good plan to have the stomach washed out occasionally; and they must take cascara habitually, if necessary. Simple sedative medicines like valerian, asafetida, or skullcap will do no harm if used in moderation. Seasickness.-The surest way to avoid seasickness, of course, is to remain ashore, but so many are unwilling to do this, and so many more cannot, that it is bound to continue one of those evils which we must endure but endeavor to mitigate. In seasickness one has headache and is dizzy, faint, and nauseated. He usually vomits everything that is in his stomach, and then keeps on retch- ing and straining and endeavoring to vomit more. Some who are seasick are constipated; others have diarrhea. Besides the irritable condition of these organs, one may be depressed, despondent, fear- ful of death, or, when most miserable, fearful that death will not come to bring him relief. The retching and straining may produce apoplexy, or rupture a blood-vessel in the stomach, or shut off the action of the kidneys, or cause dilatation of the heart, and death may occur in all such cases; but fortunately these severe accidents are rare. Most persons in seasickness are not as ill as they think they are, and, though frequently they are weak and prostrated if the attack is of very long duration, recovery is usually very prompt when the shore is reached. Some actually are benefited by the thorough purgation and the respite given to the digestive organs from their customary labor. The primary cause is the motion of a boat in water that is more or less rough, to which the sick person is unac- customed and rebellious. The sensation produced is probably identical with that which some people have in swiftly moving pas- senger elevators, or even in street-cars. Motion of unusual character is imposed upon the movable 486 HOW TO KEEP WELL organs of the abdominal cavity and to a lesser degree upon the organs of the body which are fixed. The nervous equilibrium of the body is disturbed, particularly that of the sympathetic nervous system by which the digestive organs are mainly controlled. As long as this disturbance goes on, digestion does not proceed, and the irritation of the nerves, together with the unusual motion of the organs, induces constant efforts at contraction and expulsion of their contents. The most important question for the sick person is, how can he get relief? He should lie down as soon as he begins to feel un- comfortable, with his head low. He should get as much air as possible, fanning himself or being fanned vigorously. He should be removed from unpleasant sights and smells. He will suffer less if he lies in that part of the boat where there is least motion, that is, near the center. He should take as little food as possible, prefer- ably fluids, a little at a time, but as frequently as his stomach will permit. Some advise only cold fluids, others only those which are hot, and this may be a matter for experimentation. The chances of seasickness are diminished if the stomach and bowels are in good condition when the journey is begun. Of course, the clothing must be loose and easy, though a firm abdominal bandage is said to be helpful in some cases. Hot compresses on the forehead con- tinued for an hour or more are praised by those who have been benefited by them. Ginger-ale or Vichy water often is very accep- table. Drugs without number are or may be used, especially the more powerful drugs. It does not seem to me wise to say much about them. Subacidity of the Stomach.-The stomach digests only what are known as the proteids or albuminoids, but all other kinds of food are projected into its cavity and undergo more or less prepara- tion for their digestion while combined with the proteids. The glands and cells of the stomach secrete or manufacture mucus, which has no digestive power but furnishes moisture and lubrica- tion or slipperiness to the food mass, and organic hydrochloric acid and pepsin, which are the digestive agents. The hydrochloric acid and pepsin may be in excess; they may be deficient; or in rare cases they may be absent altogether. Subacidity occurs oftenest with those who are troubled with some sort of nervous disorder and in those who have neurasthenia or neuritis or neuralgia; for the nerve-supply of the stomach is DISEASES OF THE STOMACH 487 abundant, and it takes very little disturbance of the nervous system at large to cause it to be reflected in or referred to the stomach. There is no inflammation or gastritis in this disease, the chief trou- ble being an usually small supply of gastric juice. This condition may not be present all the time in the course of the disease, how- ever, for at certain periods there may be an excess of acid, and at others no acid at all, as is shown by examination of the contents of the stomach, removed when digestion is presumably at its height. There is another condition connected with subacidity which adds to the importance of the disease, known as atony of the stomach; and that means that the muscular coat of the stomach is more or less paralyzed, so that it does not contract and churn its contents from one end of the organ to the other, which is a very essential part of the digestive process. Now, if subacidity is present only to a moderate degree there may be no symptoms that are very troublesome, but if it persists and becomes extensive it may develop into anemia and may possibly terminate in cancer. Therefore, it is not wise to neglect it. The usual symptoms in a well-marked case are a feeling of dis- comfort and weight and fullness while digestion is going on, and sometimes want of appetite, belching of gas, headache, dizziness, and constipation. It is well to build up the general condition by simple, easily digested food, an occasional glass of hot water before meals, plenty of sleep, out-of-door exercise and sunshine, and freedom from worry and anxiety if possible. Superacidity of the Stomach.-If for any reason more hydro- chloric acid is made than is necessary to combine with the pepsin and digest the proteids, this excess will produce trouble. It may cause more or less discomfort and pain in the stomach; it may cause a feeling of sourness commonly called heartburn or water- brash ; and it may be so irritating that the stomach will vomit some of its contents in the form of sour watery fluid, which sets the teeth on edge and leaves a very bad taste in the mouth, though one usually feels better after spitting it out and belching up the gas which goes with it. There are many kinds of indigestion or dyspepsia; this one is the most common of all, and it has three times as much acid in the gastric juice as is necessary for digestion. It may come at any age, but it comes most often to men in middle life. It may last a few days, or it may persist for months and years and end in 488 HOW TO KEEP WELL ulcer or cancer of the stomach. Inasmuch as the stomach is the most common seat of cancer, everybody ought to try to avoid indi- gestion, and if the latter should come it ought not to be allowed to become chronic. There are many causes for this disagreeable condition, some of which are preventable and some not. It may come from disease of the teeth, mouth, throat, liver, lungs, and heart, and in such cases it frequently cannot be helped. But it is also the result of improper eating, both as to quality and quantity, eating at irregular intervals, overeating when fatigued, imperfect chewing, and insufficient saliva, drinking too much alcohol, whether beer, wine or whisky, or drinking too much fluid of any kind, es- pecially if it is very hot or very cold; and all of these causes are usually preventable. Then it also may come from nervousness, fatigue, exhaustion, and worry. Those who speculate, gamble, or take big chances on anything, and those who are constantly fretting about themselves or others are almost sure to get it. Besides the symptoms mentioned, this form of indigestion is almost always accompanied by constipation, fermentation in the stomach and bowels, coated or red, beefy tongue, headache, and sometimes dizziness and depression. The victim may get pale and emaciated, and he often has a feel- ing of motion and rolling in the stomach. The appetite is some- times good, and if an antacid or alkali is taken when the distress begins prompt relief may be obtained, or it may be obtained by tak- ing food, of course, one cannot be taking food indefinitely. If relief is obtained by taking food it will be pretty certain that there is no ulcer in the stomach, and if cancer were there the pain and the pallor would decide it almost infallibly. Many simple remedies can be used, one of the best being a glass of hot water slowly drunk before each meal, with the addition of half a teaspoonful of bicarbonate of soda in suitable cases. Wash- ing out the stomach occasionally is an excellent means of treat- ment, and people often learn to do this themselves. The bowels and the skin must be closely looked after and as much exercise as possible taken in the open air. Magnesia and bismuth are very good remedies, and certain bromides are useful when there is a nervous element in the case. Even so homely a remedy as chew- ing-gum need not be despised; and one who has tried it for this pur- pose will appreciate the comfort which a cow gets from chewing her cud, for this not only thoroughly masticates half-chewed food, DISEASES OF THE STOMACH 489 but it mixes with it a quantity of saliva and thus helps digest the starchy substances which have been eaten. Ulcer of the Stomach.-There may be a single ulcer, or there may be several; usually there is only one. It may eat through the mucous membrane alone or through the mucous membrane and the muscle. If it eats through the peritoneum it will let the con- tents of the stomach leak out, cause peritonitis, and very often be fatal. Fortunately in most of the cases it does not eat all the way through. Ulcers may be produced in various ways; by severe burns, by infectious disease, either a fever or a chronic disease like tubercu- losis; by disease of the heart or of the blood-vessels; by injury to the wall of the stomach; by general debility and anemia; but most frequently by the corrosive effect of the hydrochloric acid formed in the stomach when there is a condition of superacidity. Sometimes when they get well a scar is formed which twists the stomach out of shape and interferes with its motion and its digestive powers; sometimes they degenerate into cancer, which is a very common disease of the stomach; sometimes they perforate and cause periton- itis; and very frequently they corrode through a blood-vessel and cause more or less severe hemorrhage; finally they may open into the intestine, the stomach then becoming attached to the intestine at that point. Fortunately in many cases they do not do any of these things but get well without leaving any bad results behind them. There are three symptoms which are almost always present in ulcer of the stomach, pain, vomiting, and hemorrhage, pain being almost an unfailing one. It is constant in some cases and inter- mittent in others; it may be worse just after eating or not until an hour or two later. Sometimes it is worse when one stands up, and sometimes when one sits down or bends over. It is often very severe and may be felt at the pit of the stomach or in the middle of the back. Pressure over or upon the stomach will intensify it. Vomiting may occur from half an hour to two hours after eating or drinking, and frequently blood is mingled with the digested food. Blood is the most positive evidence of ulcer of the stomach and is present in at least half of the cases in the material vomited or in the stools. Bleeding may be caused by excitement or by the slightest unusual exertion. Heartburn and constipation are also symptoms, but the appetite may remain unaffected. 490 HOW TO KEEP WELL The most effective way of treating this disease is by rest. The patient must be fed with suitable nutrient injections about once in six hours, the rectum being first carefully washed out with warm but very weak salt water. To relieve the pain cold com- presses may be applied to the pit of the stomach, and they may also be used if hemorrhage has occurred. Pieces of ice may be taken by mouth. If the physician in attendance sees fit he may introduce suitable remedies into the stomach through a stomach-tube, and these may be given to relieve pain or in an attempt to heal the ulcer. Bismuth, alum, and nitrate of silver are sometimes used for this purpose, and the acidity of the stomach may be neutralized by solutions of magnesia or bicarbonate of soda. Surgical operation is sometimes resorted to, especially if the ulcer has perforated and hemorrhage or peritonitis has resulted. CHAPTER XXVIII DISEASES OF THE INTESTINES Appendicitis.-Almost everybody knows that the appendix-or, more correctly, the appendix vermiformis-is a tube hanging from the end of the large intestine or caecum, in the right lower quarter of the abdominal cavity. Like the rest of the intestine, it is made up of peritoneum, muscle, and mucous membrane, and any or all these layers may be the seat of an inflammation, mild and unim- portant, or as severe as a great conflagration and with a rapidly fatal issue. The essential part of the current of digested food material has been absorbed by the time it reaches the end of the small intestine. That which remains to go through the large intestine is mostly waste matter. This portion must pass first into the caecum, and more or less of it gets into the appendix. Sometimes it is shut in, like a rat in a trap, and cannot get out. The fluid portion is ab- sorbed or otherwise disappears, while that which is solid remains; sometimes in the form of small, hard lumps, which have sharp, jagged points and can easily wound the mucous membrane of the appendix. Bird-shot and other solid material which have been taken with the food are found sometimes in the appendix, but grape- seeds are found rarely, if ever; and the stories about them are mythical. There are always bacteria in this portion of the in- testines, and many bacteria of different varieties are conveyed to it from other parts. When the mucous membrane is unprepared to resist their attack appendicitis is the result. This inflammation also may start from the peritoneum, either from that portion which covers the appendix or from some other portion, from which it creeps along like a prairie-fire. This inflam- mation may be mild and marked only by redness and roughness 491 492 HOW TO KEEP WELL of the peritoneum, or it may be purulent, poisonous, and deadly. Nobody could tell in advance how such a process would end. Faults connected with eating are very common causes; either overeating or eating something which has developed ptomaines, something which will not pass through the intestine, or something which remains in the intestines and becomes decomposed. In- juries of various kinds are causes, such as blows upon the abdo- men, crushing injuries, bullet-wounds, stabs, and many others. Appendicitis often develops in connection with diseases like typhoid and scarlet fever, diarrhea, and inflammation of the female genital organs, the poison being carried to the outer or inner surface of the appendix. The symptoms of this disease are many or few. There is no doubt that the most prominent symptom is pain, and pain radiating outwardly and to the right from the navel. But it may be located at some other part of the abdomen; it may even be spread over the whole of it; and in certain cases it may be almost absent. Rigidity of the abdominal muscles often is an important symptom. In the severe cases which are associated with indigestion there are nausea and vomiting, and frequently diarrhea, while, on the other hand, constipation is a symptom in many cases. If the appendix or neigh- bouring intestine has been perforated there may be collapse and cold sweating, the abdomen may be distended, and the pain may be very sharp; or the senses may be blunted and the patient stupid if death be imminent. Many cases are called appendicitis which are not this disease, and it is thought by some that the operation is usually so simple that anybody can do it. If the list of fatal blunders were published people would not place themselves so blithely in the hands of the inexperienced. Colic.-By custom this term began to be used to indicate pains in either the small or the large intestine, particularly the former, and it differentiated them from other intestinal pains by their sharp, shooting, stabbing character. Gradually the use of the term was extended to spasm or pain in the abdomen, which seemed to have no relation to the intestines. There are also lead colic, painter's colic, and copper colic, which mean intestinal cramps caused by poisoning with lead or copper. There are also mucous colic from inflammation of the large intestine, appendicular colic from inflammation of the appendix, and a great many other varie- DISEASES OF THE INTESTINES 493 ties, so that the original meaning of the term no longer applies, un- less possibly in mucous colic, which, so far as it means anything, means painful inflammation of the large intestine. Colic in the stomach or intestines may be caused by indigestible substances, by injuries, by cold, etc. Colic in the kidney or bladder or liver or gall-bladder may be caused by the irritating action of a stone or other hard body which bruises the respective organs and •causes painful contractions of their muscular fibers. Colic in the appendix is due to the inflammatory action which is set up in •this organ by various influences, but especially by bacteria. How may it be treated? If it is due to a stone in the kidney or bladder or liver, have it taken out by a good surgeon as promptly .as possible; if it is due to a hemorrhage, go to its source and stop the bleeding. This means that many of these troubles are surgi- cal and can only be cured by the aid of surgery. But there often are means of alleviation which any intelligent person, be he doctor or layman, has at his command. Heat is one •of the most important of these-at the feet, over the abdomen, at the back, over the heart. Hot drinks also are useful, hot pepper- mint or chamomile tea, even plain hot water. There are cases also in which hot water, fortified by whisky, gin, or brandy, is positively beneficial, and this must not be misinterpreted as an argument in favor of using these alcohols as a beverage. The narcotic drugs, too, are invaluable for the pain of colic, but they should be given only by one who understands their use, for they have the possibility of doing great harm as well as great good. The position of the body is also important, the body being bent forward and the legs drawn up, for thereby the muscles may be relaxed to the utmost extent. Colitis.-Colon bacilli are in or upon the mucous membrane, and, when stirred up or irritated by conditions that are favorable, cause inflammation or colitis; it may be mucous colitis, ulcerative colitis, or various other kinds. There are sores and ulcers of the mucous membrane in the ulcerative variety, which may have been produced by the action of some kind of corrosive poison with or without the assistance of colon bacilli. Together with these sores there are profuse discharges from the bowels, which are very de- bilitating and will produce a fatal result unless they can be stopped. In mucous colitis there is a very obstinate form of inflammation, not always intense, but often very persistent. This disease is par- 494 HOW TO KEEP WELL ticularly common among women, especially those who are dyspep- tic, melancholy, high-strung, and nervous, or those who have long been victims of constipation or of diseases peculiar to their sex. They are often underdeveloped, poorly nourished, and anemic, are disposed to fret and find fault, have offensive breath, dry and coated tongue, obstinate bladder-trouble, pain and swelling in the abdo- men, bleeding piles, and displacement of abdominal organs. Copi- ous diarrhea alternates with constipation, with a dozen or more daily evacuations; there are always shreds and flakes of mucous membrane and quantities of translucent mucus. Sometimes there are entire casts of portions of the large intestine, but these do not include important structures, and they are not accompanied by hemorrhage or prostration. Often there are pain and straining with the discharges, but the general condition does not seem greatly af- fected. The best that can be done in these cases is to improve their disposition, when possible cheer them up, try to make them hopeful, give them plenty of simple, easily digested food, particularly milk and milk soups, insist on out-of-door life with as much rest as pos- sible, and give daily enemata of hot starch-water or some other bland, soothing, and moderately astringent fluid. Constipation.-It is quite as important to keep the intestinal tract free from waste and decomposing material as it is to supply it with the food which is essential to sustain life. Think of it for a moment. Here is a tube thirty feet long, thelast third of it, or the large intestine, which normally is the reservoir for the waste matter, two or three times the caliber of the other two thirds, or the small intestine. Furthermore, the large intestine contains valves and folds which greatly increase its capacity, and the entire intestinal tube is so elastic that it can easily hold gallons of ma- terial. If this material consists of substances which are poisonous you can easily see what the possibility of mischief and injury to the body from it may be. This explains why so many people who deny that they are constipated are yet sufferers from what is known as autointoxication, and why they are often astonished when the in- testines are emptied by artificial means at the volume of material they have been carrying about. If, therefore, one would be free from constipation and its bad effects, it is absolutely necessary to empty the intestines once or oftener every day. The object of cathartic medicines varies. One kind increases the activity of the muscular coat of the intestine, by the contrac- DISEASES OF THE INTESTINES 495 tion of which its contents are propelled along; another causes the blood-vessels to empty their fluids into the intestinal tube; another serves merely as a lubricant to the tube and its contents; another causes an increased flow of bile into the tube, softening and dilut- ing its contents; and another breaks up and disintegrates them. There is, therefore, need of intelligence and discretion in the use of cathartic medicines, for what will fully relieve constipation from one cause may have no effect upon another kind There are many patent medicines which are offered to the public for the relief of constipation; some of them have been advertised over the entire world for many years and have been used so extensively it would be foolish to say they have no value. The cathartics which produce watery movements are the sa- lines: Epsom, Glauber's, and Rochelle salts, Seidlitz powder, and the many varieties of mineral water. Remember that they vary in strength and are adapted to different degrees of constipation. The lubricating cathartics are the oils; mineral, olive, castor. Of all the oils castor-oil is the most effective; in fact, for all-round work it is one of the most useful medicines we have. The most drastic of all cathartics is Croton oil, two or three drops of which are all that can be taken with safety. Of the cathartics which increase the flow of bile calomel is the typical example, and there are several proprietary preparations in this group. Such medicines must al- ways be used with caution. Of those which stimulate the intestinal muscle the name is legion, including cascara, senna, rhubarb, aloes, colocynth, jalap, and many others. In all the proprietaries of this kind of medicines you will find one or more of these substances. Dysentery.-It is a very common disease, occasional cases occur- ring in every community. In some communities it is always pres- ent, while at times it is a wide-spread epidemic. We now know that it may originate from two causes; a bacterium, which is the principal but not the exclusive cause in temperate climates, and a parasitic amoeba, which is its principal cause in the tropics. In this disease the large intestine, particularly at its lower end, is in- flamed and ulcerated, and parts of its mucous membrane may be- come gangrenous and slough away like the membrane which is present in diphtheria. It may extend to the small intestine, but that is not to be expected in the ordinary case; it is essentially a disease of the large intestine. Fever is an accompaniment of this disease; also frequent evacua- 496 HOW TO KEEP WELL tions from the intestine of blood, bloody serum, and mucus. There is great distress, a constant bearing-down sensation, and continu- ous and insistent desire for relief. It is common to all periods of life, not excluding the aged and the very young, and usually selects those cases in which the nutrition of the body is below par. It is a hot-weather disease. Epidemics prevail in the summer and disappear when the weather becomes cold and settled, sometimes recurring for several successive summers. The disease is common, not only when the weather is hot but in periods of drouth and especially in localities with bad hygienic conditions. It may be called an institutional disease and prevails as an epidemic in camps, jails, hospitals, and almshouses. After exposure to either of its causes, particularly in the case of those who are constipated, there is a period of incubation or development for forty-eight hours; then suddenly come loss of appetite, fever, and frequent, painful, and exhausting stools con- taining blood and mucus, the patient being nauseated, perspiring freely, and experiencing great prostration. In sympathy or by ex- tension, the bladder may also become inflamed, and if the patient remains unrelieved he may die within three or four days. Many cases, however, are mild, continuing several weeks, the severity of the symptoms gradually abating. Such patients are jaundiced, and they vomit frequently. The heart-action is rapid and weak and the urine scanty and containing albumen. The abdomen becomes swol- len and tender, hemorrhoids develop and other complications ap- pear, including Bright's disease, pleurisy, and peritonitis. Almost always the joints and muscles are sore, and the liver may be swollen and may become the seat of abscesses. Causes and Treatment of Dysentery.-Those who have used al- cohol to excess are easy victims of dysentery, and, though it may not be fatal, it is apt to recur frequently. The so-called summer diarrhea in infants and small children is in many cases nothing but dysentery. The treatment of dysentery is more successful at the present time than it has been at any period heretofore. Rest is the first requirement, particularly rest in bed, with heat at the feet and cold at the head. If there is persistent vomiting it may be neces- sary to discontinue all food by the mouth and give only nutrient enemata. When the stomach and intestines have become fairly tolerant, fluid food will be required for a long time, especially DISEASES OF THE INTESTINES 497 peptonized milk, to which other fluids may be added, such as barley-water and lime-water. When the disease first announces itself it is well to take a dose of castor-oil to free the intestines of any possible accumula- tion; also one may take bismuth from time to time and injections of starch-water. A mustard-paste over the stomach will be found soothing and comforting. Treatment with horse-serum is now successfully used to a considerable extent and is highly recom- mended. The sovereign remedy is ipecac, and its active principle emetine. The Enema Habit.-The food is in a liquid state, or nearly so, as the current is swept along the small intestine; and the absorbents of the intestine, like an enormous sponge, suck up the portions which are absorbable, and they are carried through the lymph-vessels into the blood-stream and then distributed over the body for purposes of nutrition. There is always a residue which has not been perfectly digested, and this is carried along into the large intestine, which terminates in a distensible pouch called the rectum. The rectum is lined with mucous membrane and abundantly provided with nerves and muscle-fibers. When it is distended to a certain degree, or when the contents are irritating to its nerves, the muscle-fibers contract and expel them from the body, as water might be squeezed by the pressure of the hand from a rubber balloon. If the nerves are not sensitive, or if the muscle-fibers of the rec- tum are weak, the expulsion of the contents is delayed and per- formed imperfectly and with difficulty. This constitutes the con- dition known as constipation, and the longer it continues the more undesirable its consequences. The fluid portion of the rectal con- tents may be more or less absorbed, and the mucous membrane of the rectum may fail to yield sufficient mucus adequately to lubri- cate the remainder. The consequence is a hardened mass which the rectum is unable to dislodge, and its nerves may have become insensitive and incompetent to stimulate the muscle-fibers to con- traction. In a situation like this there must be help from without. Cathartic medicines may be given to stimulate the rectal muscle to contraction, or fluid may be introduced into the rectum to soften its contents or to act like a whip or a spur in making it contract. This fluid may be plain hot or cold water; or soap, turpentine, or 498 HOW TO KEEP WELL drugs of suitable character may be added to it. A pint or quart or even two quarts may thus be slowly and cautiously injected, varying with the requirements of the case, and this injection or enema will usually stimulate muscular contraction and empty the rectum. The occasional use of an enema, therefore, may be of great value, but when used too frequently, when used daily, as is the habit with some, the rectum may refuse to respond, and this is why I have sometimes referred to the habit as a pernicious one. The distensibility of the rectum, like that of any elastic body, is limited and may be exhausted; and when it is thus exhausted and the tissue has become thin and weak, a very slight increase in the volume and pressure of the injected fluid may cause perforation of the rectum, with consequences which are likely to prove serious. It, therefore, seems to me that those who habitually make use of the enema should be advised of the danger which is associated with it and find other methods of relief less enslaving and quite as effective. Enterocolitis.-In the simple, acute form of this disease pain and discharges of a more or less fluid character from the intestine, more or less numerous, are the chief characteristics. Inflammation may even be wanting, the diarrhea being due to a relaxed condition of the nerve-supply of the intestine; or in some cases there may be inflammation without diarrhea. If the inflammation extends to the lower end of the bowel, besides the diarrhea there may be a feel- ing of griping, straining, and contracting. There are many causes for the diarrhea of enterocolitis. Some- times it is due to bacteria, sometimes to undigested and indigesti- ble food, sometimes to anger, fright, intense cold, intense heat, poisons of various kinds, impure water, etc. The discharges may be watery, or they may be thick. In typhoid fever they are very suggestive of pea-soup in their color and consistency. They may be colorless, or they may be black, green, gray, or almost white; and they may contain mucus, blood, bile, undigested food, or even portions of the intestinal mucous membrane. When the contents of the intestine decompose and ferment gas is formed which distends the intestine and causes pain, especially as it moves from one portion of the intestine to another. This pain is often very severe and seems like the cutting or stabbing of a knife. The evacuations may be few in number, or they may be DISEASES OF THE INTESTINES 499 many, and even almost continuous. When they are frequent they are very exhausting, for they mean the rapid withdrawal of fluid from the blood and interference with its circulation. In Asiatic cholera the evacuations are so profuse that one who has it may practically bleed to death in a few hours. Diarrhea becomes still more prostrating when it is combined with vomiting. Enterocolitis may or may not be accompanied by headache and fever, and it is invariably attended by loss of appetite, heavily coated tongue, and great thirst. The fluids of the body have been removed, and water is demanded to replace them. Very often this condition becomes chronic and lasts for months or years. Children are more susceptible to this disease than adults, but they get over it more quickly. Very aged people suffer greatly from it, particularly on account of their feeble resisting power. The question of food is of the very greatest importance in this disease; in some cases it must be entirely suspended for twenty- four or forty-eight hours. When one is first attacked it is well to take a dose of castor-oil at once. This will empty the intestine, flush it out, and perhaps remove the cause. It will often prove the necessary ounce of prevention. Rest, quiet, and sleep are essential; food may consist of boiled milk, gruel, clam-broth, raw oysters, and but very little solid food. Good nursing, careful diet, and rest are the chief measures to be considered in the care of those who suffer from this disease. Fissure.-A fissure is a break or crack in the skin or mucous membrane and may occur on any portion of the surface of the body. But there is one form of fissure which is particularly painful and troublesome. This occurs at the end of the intestine in the mucous membrane covering the muscle which by its contracted condition prevents the escape of the contents of the intestine. The fissure in question occurs more frequently in women than in men, and occasionally in children. It may be superficial, a mere break or crack in the mucous membrane, or it may extend into the underlying tissue and form an ulcer or sore. Its sides may be soft or hard, and it may occasionally be scabbed over, only to break out again when a hard and difficult movement of the bowels occurs. It may be the result of infectious disease, especially syphilis or tuberculosis, ©r of injury to the delicate and supersensitive mucous membrane. It may occur as the consequence of diarrhea, but far oftener as the direct result of constipation. The nerves in this 500 HOW TO KEEP WELL portion of the body are abundant and extremely sensitive. The difficult effort of expelling the hardened and irregular contents of the bowel when one is very constipated rasps and tears the mucous membrane or breaks it and forms a fissure. The condition is made worse if hemorrhoids are present. The effect of abusive treatment on the nerves of this region is like a sting or a slap on the face, and they respond by causing the muscle to which they are supplied to contract spasmodically and violently. Realizing the agony of this experience, the sufferer defers the evacuation of his bowels to the latest possible moment; and his pain, as a consequence, may be worse with each succeeding ex- perience. This often leads to the use of opium and other narcotics, and thus a drug habit is engrafted upon the evils already existing. If the trouble is due to constipation, the constipation must be overcome. The diet must be so regulated that the contents of the bowels will become fluid or semifluid. The most scrupulous cleanli- ness is imperative, and this is one of the few conditions in which a daily laxative enema becomes a relief and a necessity. Sup- positories also are useful, especially in the attempt to relax the spasm of the irritated muscle. Two of the most satisfactory substances for making such suppositories are iodoform and ichthyol. Both are extensively employed. If the fissure does not heal after sufficient trial of medicinal measures, a resort must be made to surgery. Fistula.-Fistula, or abscess of the rectum, is a very common and often a very painful ailment. There are various kinds and degrees of fistula. Its opening may be upon the skin, and from this point it may burrow along the side of the rectum for any distance, half an inch, an inch, three or four inches, or even more. It may or may not perforate the rectum. There may be a single track, or there may be several; the more there are the more complicated and difficult the situation becomes. There is always a discharge from a fistula of pus, of mucus from the rectum, of the intestinal contents, or of gas. There is also more or less pain; sometimes it is very severe and sharp, out of proportion to the apparent extent of the disease. In the days when alcoholism was more common than at present, it was very often one of the penalties that were exacted from hard drinkers. Can It Be Cured Without an Operation?-Yes, in many cases it can. A few years ago a method of treating it with injections of DISEASES OF THE INTESTINES 501 bismuth was devised. It was said many cases were cured by this substance. Other substances, especially caustics of various kinds, have been employed by injection or suppository, sometimes with success and sometimes without. The use of suppositories or local applications to relieve the pain of fistula will not cure it and should not be expected to do so; they do not go to the source of the trouble and are merely palliatives. I always have felt that it was proper to advise those who have consulted me in past years for this disease to accept surgical treatment at once as the shortest, most efficacious, and most logical method. I always have favored the knife, rather than the ligature, the seton, or any other method which is slow, painful, and often more or less unsatisfactory. If the fistula is not a complicated one the knife in the hands of one who understands his business will divide the diseased tissues and begin the process of cure in a shorter time than it takes to describe it. The work may be done either under local or general anesthesia, according to the conditions of the case. The healing of the wound requires a few days. During that time it is desirable that the patient should remain quiet, not necessarily in bed, though in many cases that undoubtedly will be the most favorable plan, and give nature an opportunity to do her part in repairing the damage. Hemorrhoids.-The very small hemorrhoids frequently do not require any treatment. Hemorrhoids may frequently be relieved by suitable ointments; if they are large and inflamed an operation is usually required. So far as hemorrhoids which have been operated upon are concerned, the cure is permanent; you cannot restore that which has been destroyed and removed, but in some cases ad- ditional hemorrhoids may develop. The mucous membrane of the rectum, for obvious reasons, is more resistant than that in the other portions of the intestine, and at its extreme end it is folded over a very elastic ring or sphincter muscle. Where this mucous membrane ends the skin begins. Beneath the mucous membrane of the rectum and extending down and into the sphincter are its blood-vessels. The veins are larger and more numerous than the arteries and are called the hemor- rhoidal veins. It is these veins which are chiefly involved in the disease called hemorrhoids, and the region where the hemorrhoids occur is called the hemorrhoidal or pile-bearing area. In this condition one or more of the hemorrhoidal veins is 502 HOW TO KEEP WELL dilated; its wall may become as thin as tissue-paper and may be just about as easily torn. If for any reason the pressure in this dilated vein is greatly increased it bursts. The pressure may not be sufficient to cause the blood to break through the mucous mem- brane ; and after a certain quantity has flowed through the loose tissue surrounding the vein, a clot is formed, and this plugs the hole in the broken vein and stops the bleeding for the time. The clot may remain there indefinitely, gradually getting smaller and harder, and this is the simplest form of a hemorrhoid or pile. But if the pressure from the flowing blood is sufficient it breaks the mucous membrane, and then the blood flows out from the body. There may be a teaspoonful of it, or a very large quantity sufficient to cause fainting or even death. This is what is known as a bleeding pile. Then again these hemorrhoidal clots may become infected in various ways, and then inflammation occurs in the neighboring tissues, which is very painful and may result in suppuration, leaving, when the inflammation is over, a lot of hard and troublesome tissue remaining, which will give future annoy- ance. Finally, the discharge which may come from the hemor- rhoidal tumors or from the glands in their vicinity is often of a very irritating character and causes intense itching, and the fric- tion from rubbing and scratching may cause large fleshy tumors in the skin and mucous membrane around the end of the rectum. The symptoms are, first and foremost, bleeding, and this may place the disease among those which are dangerous. Inflammation, pain, and absorption of poisons may occur as already noted, and there may be an offensive discharge such as would come from any wound or sore. The treatment may be palliative or curative. Palliative treat- ment consists in the use of astringent and sedative ointments, sitz- baths, applications of ice or cold cloths, and rigid attention to the condition of the bowels. Curative treatment consists in removing the cause of the trouble. This is sometimes possible by the use of ointments and suppositories, but if the hemorrhoids are large, if they bleed, and if there are blood-clots the safest plan is to have them removed. This may be done with knife, scissors, and ligature, by the actual cautery, and by crushing. The operation should be done by one who has not only skill but good judgment. Hernia.-The most common varieties are those in which the intestine forces its way through a small opening at the upper end DISEASES OF THE INTESTINES 503 of the thigh and becomes a femoral hernia, or forces its way through a short passage in the groin called the inguinal canal and becomes an inguinal hernia. This last is more common than all the others put together. It may come on one side or it may come on both sides. At the lower front part of the abdominal cavity on either side is a depression leading to a short passage or canal through which important structures connected with the genital apparatus, both in the male and the female, pass. This is a weak and poorly protected spot in every human being, but much weaker and less capable of resistance in some people than in others. Intestines are directly over this depression on either side, and when the muscles of the abdomen are greatly strained, either suddenly or gradually, it often happens that the intestine which lies near this depression is forced into it. The peritoneum stretches very readily, and when the intestine has once begun to force the peritoneum into the depression and canal it is a comparatively easy matter to keep it up by a succession of strains or pushes from behind until the short canal is passed and the intestine appears as a soft, movable lump protruding from the body. When you lie down this intestine slips back, and it comes out again when you get up or when you make any particular exertion. If from any cause inflammation is set up in the pouch of the stretched peritoneum which the intestine has pushed before it in its travel through the inguinal canal, the intestine may become attached to it and will not slip back, and the situation becomes a dangerous one which at almost any moment may require a serious operation to release the imprisoned intestine. In many cases there is only a moderate amount of discomfort to which little heed is paid; in others there is a disagreeable drag- ging sensation or dull pain; and in yet others inflammation takes place in the sac or pouch which forms the hernia, accompanied not only by very severe pain but by grave danger to life. This inflammation may subside in a few days, or it may develop into peritonitis, which is one of the most serious surgical diseases that can happen. With the peritonitis or even apart from it may occur that most dreaded of accidents in connection with hernia, strangula- tion of the intestine which is imprisoned in the hernial pouch. In the treatment of hernia which has not become strangulated two courses are possible. First, a truss or supporter may be worn 504 HOW TO KEEP WELL which, if properly fitted, closes the opening through which the intestine passes and keeps it where it belongs; second, the hernia may be operated upon, and if the operation is skilfully done it will usually cure the trouble. In children there is no reason that I can think of why the operation should not always be done and practically always result in cure. In adults, especially if the hernia is a large one and has lasted a long time, there will be a considerable percentage of partial or temporary cures. Wearing a truss is uncomfortable and unpleasant at best. The truss is liable to break down, and perhaps at a very inconvenient time, and an instrument which holds a hernia to-day may not do so to-morrow. Intestinal Catarrh.-Its chief features are sharp colicky pains and diarrhea, although the diarrhea is not always a conspicuous symptom. In addition to the griping pain in the bowels, there is a constant desire to relieve oneself which is often quite ineffectual as to results, this symptom being known as tenesmus. There are various causes for this disease: perhaps it results from profound nervous impressions, for instance, that which follows the receipt of very bad news; or it may be due to the violent action of un- suitable or indigestible food; or it may be due to the influence of bacteria, and this is responsible for the great majority of cases. With the bowel symptoms there may also be attacks of vomiting and a moderate degree of fever, the appetite is lost; the tongue is coated and dry; and there is constant complaint of head- ache, thirst, and great weakness. In some of the cases there is a quantity of undigested food in the discharges; other cases are marked by an excessive quantity of mucus, such cases usually indicating that the inflammation has paid special attention to the mucous membrane of the rectum. Beginning as an acute disease, it may last indefinitely and cause great weakness and emaciation. It may have many causes, one of the most prominent being overeating or the eating of improper or indigestible food. It is often caused by the influence of poisons, both vegetable and mineral; painters often suffer with it on account of poisoning by lead. It may also be due to the influence of prolonged heat and moisture, and young children often suffer with it from this cause. Other well-known causes are bad drinking-water, extreme nervous- ness, or excessive secretion of bile. Then, it may be secondary to various infectious diseases, such as typhoid fever, tuberculosis, and DISEASES OF THE INTESTINES 505 dysentery; and it may be an uncomfortable accompaniment of Bright's disease, cancer, and inflammatory diseases of the abdom- inal organs. Medicines which are given to control it are some- times so drastic and violent in their action that they make it worse instead of better. Regulation of the diet is one of the principal measures by which this disease is controlled. It is frequently desirable to begin treatment by the use of a dose of castor-oil, and when you find just what is the nature of the disease you may cautiously give rice, gruels, tea, predigested milk, raw oysters, boiled fish, baked pota- toes, and milk toast. Intestinal Indigestion.-Intestinal indigestion means, of course, that for some reason or other the food-stuffs which are normally digested in the small intestine by the pancreatic juice-that is, the starches and fats-are not so digested. Perhaps there is insuf- ficiency in quality or quantity of the pancreatic juice, and perhaps there may also be some defect as to the quantity or quality of the bile, for, while we do not know exactly the function of the bile in the operation of digestion, we have good reason to believe it aids in breaking up the fats which are taken as foods. The pancreatic juice is alkaline in its reaction, and it neutralizes the acid contents of the stomach which have been projected from the stomach 'into the intestine after the proteid or albuminous portion of the food which has been eaten has been digested by the gastric juice. The pancreatic juice also emulsifies fats, and when it is deficient in quantity or quality there will as a result be an excess of fats, putrefaction of the digested proteid material, fermentation of the starches and fats, and accumulation of fluids, gases, and bacteria in the intestines; in other words, intestinal indigestion. The consequence of this may be painful distention of the bowels with gas, and intestinal catarrh, with offensive watery evacua- tions ; or the watery elements may be absorbed in the large bowel, and the contents become hard, and very troublesome constipation may ensue. The abundant bacteria in the intestine will produce decomposition and cause the development of various poisons, which may be absorbed to a greater or lesser degree. Of course, careful regulation of the diet will be required, and flushing of the digestive tract from one end to the other to give it, if possible, an entirely new start. 506 HOW TO KEEP WELL Intestinal Stasis.-There is an old term which was in use many years ago called stoppage of the bowels, and this comes as near to a plain definition of what is going on when intestinal stasis exists as anything I know of. In this condition the contents of the bowels, for some reason or other, do not pass through. This fact must be remembered, that it is necessary that the unused, undigested, and unabsorbed food material which has gone into the body, together with the waste and worn-out tissue sub- stances which have accumulated in the intestine, be expelled from the body at the earliest possible moment, for otherwise there will be decomposition, the development of poisons, and their absorption into the blood-stream. This means that the intestines must be doing their proper work without interruption all the time, and that when they fail so to function serious consequences may and will occur. Then follow symptoms of blood-poisoning resulting from the absorption of toxic material. There are many symptoms of this character, such as loss of appetite, discoloration of the skin, dark lines under the eyes, headache, impairment of vision, backache, irregular action of the heart, offensive breath, and uncontrollable nervousness. There will almost certainly be distention of the in- testines from gases which have formed, and this will be accom- panied by pain and uncomfortable rolling of fluids and gases within them. Fortunately by the aid of the X-ray we can find out exactly what the obstruction is and where it is located, and an X-ray picture should always be taken in every case of this kind. In some of the cases relief may be obtained by careful massage and kneading of the abdomen, the obstructing material being gradually worked downward to the lower extremity of the intes- tinal tube. In some cases relief may be obtained by judiciously given enemata of warm water, or of warm water and turpentine, or of warm olive-oil or castor-oil. Enemata of Epsom salts may also be given, and these will be effective in some of the cases. The treatment by enemata will be more successful when the ob- struction is in the lower portion of the intestinal tube than when it is higher up. Vaccines are also used with varying degrees of success. The final resort is to surgical operation, with me- chanical relief to the obstruction. Prolapse, or Falling of the Intestine.-The portion of the intes- tine which most frequently descends is the transverse portion of DISEASES OF THE INTESTINES 507 the large intestine or colon, but any portion of the small intestine may also descend, especially if it becomes stretched and dilated from any cause, or the muscles which form the wall of the abdomen become greatly relaxed. I have seen the intestine so dilated and prolapsed that it was only after careful investigation that it was found to be the intestine and not the stomach. Very tight corsets are responsible for many of the cases of this disease; also persistent and severe coughing. There are many symptoms connected with this condition. The one which is most common and most to be expected is an unin- terrupted dragging sensation, simply because the organs are out of place. But with this displacement necessarily comes a disturb- ance in the arteries and veins of the intestine, the blood circulating with difficulty, the blood-vessels being distended and overfilled in some places and with diminished current in others. This neces- sarily leads to discomfort and disturbances of various kinds. The digestion is deranged, particularly when the small intestine is in- volved and the absorption and assimilation of the food are inter- fered with. Those who were constipated before become more con- stipated now, for the intestinal muscle is thrown out of its proper relations, and it may become so relaxed and weak that it is unable to propel the intestinal contents forward and onward as it should. Accumulation of the intestinal contents is almost inevitable, and it is sometimes well nigh impossible to produce their proper elimi- nation. This means also their decomposition, the development and absorption of poisons, and constant feeling of malaise, discom- fort, and exhaustion. Sufferers from this trouble also have no appetite, their tongue is constantly coated and their breath offen- sive, and they constantly complain of cold hands and feet and clammy skin. They become anemic and lose weight, and have dizziness, headache, and troublesome belching and palpitations, difficult breathing, and all sorts of nervous symptoms and whims. The diagnosis of this condition is much more easily made than was possible a few years ago. A properly conducted X-ray examin- ation at once reveals the difficulty and the extent of displace- ment of the various portions of the intestines. Sometimes relief may be obtained by surgery, and there are cases in which surgery should be resorted to, but by no means all of the cases are in this category. Medicines are of little avail except tonics and suitable cathartics. Relief from hard work is essential, 508 HOW TO KEEP WELL but equally essential is well-directed exercise. Massage is im- portant, and also stimulating baths, good food, sunlight, sleep, and cheerful society. Belts and supports for the weakened abdomen often are very useful. It is better if one has this trouble to go to a doctor who will make a careful study of the case and give it his patient attention. Ulcer of the Duodenum.-Only within a few years has this disease been carefully studied and treated. It is said it occurs more frequently than ulcer of the stomach and that it has many times been mistaken for this disease, for gall-stones, and for that most fashionable of all modern diseases, appendicitis. Should it perfor- ate and cause hemorrhage or peritonitis, it is very apt to be fatal before surgical assistance can be rendered. The ulcers come most frequently in men between thirty and fifty, very often in babies dur- ing the first year of life, and not infrequently in poorly nourished anemic girls. The disease may last for years, apparently be over- come, and then come back again; and sometimes the recovery is accompanied by so much scarring and deformity of the duodenum that the process of digestion is seriously interfered with. It has often been noted in connection with arteriosclerosis, which is rather peculiar, as this is regarded as a disease of advanced life. The first indication of it may be the vomiting of blood or the presence of blood in the evacuations from the bowel, and its presence in not a few instances has not been suspected until death has occurred. It seems to have a predilection for those who have a tendency to tuberculosis, but this is due rather to the bad nutrition of those who are thus weakened than to infection from tubercle bacilli. It may also come to those who are subject to fits of emotion or who are overworked or underfed. It is more troublesome in winter than in summer, in damp weather than in clear, dry weather; and it is believed that it is one of the consequences of severe burns. The disease is very apt to occur in people who have sour stomach or acid indigestion, and there is a hunger-pain or gnawing from two to four hours after eating, though in some cases the gnaw- ing comes immediately after. In addition there may be acute pain, sense of distention and oppression in the abdomen, jaundice, chilli- ness, belching, vomiting, sometimes vomiting of blood. Those who have this kind of ulcer are irritable, lose weight, and sleep badly, though they may have a good appetite and may get relief from pain by taking a little food, some bicarbonate of soda, or a suitable DISEASES OF THE INTESTINES 509 sedative drug. They may also be relieved by having the stomach washed out. They may be cured in some cases by suitable diet, rest, and medical treatment, or it may be necessary to undergo a surgical operation. CHAPTER XXIX DISEASES OF THE LUNGS AND AIR APPARATUS Health and Deep Breathing.-Deep breathing means the infla- tion of the highly elastic organs called the lungs with atmospheric air. The purer the air-that is, the freer from substances which do not normally belong to air-the more useful will it be in sup- plying the imperative necessity of all animal life. The air on the top of the mountain where there is nothing but rocks and trees is pure. The air in a crowded city, where there are smokes and smells of all kinds, and multitudes of living creatures constantly exhaling the contents of their air apparatus, is not pure and con- sequently not so suitable for breathing purposes. Fortunately for us the reservoir of air upon which we are con- tinually drawing is inexhaustible. We can have all we want from the moment we announce our entry into the world until our last expiring gasp. Thank God for one thing which human greed and selfishness cannot control! The blood circulates through the lungs and around the body three times in about a minute. Each time it passes from the right side of the heart into the lungs it is dark purple in color and more or less saturated with carbon dioxide and other waste products which it has gathered in its circuit of the body. As you exhale, in the rhythmic operation of breathing, these products incased in watery vapor are cast forth. Exhalation is followed by inhalation, air is drawn into the lungs, and in the wonderful chemical laboratory of the body oxygen is separated from the air, absorbed through the thin walls of the myriads of minute blood-vessels in the lung structure, and drunk up eagerly by the blood-current. Behold! The stream which was dark purple is now bright red and returns from the lungs to the heart refreshed and reanimated for its journey around the body, 510 DISEASES OF THE LUNGS AND AIR APPARATUS 511 carrying with it life and health. Then, there are always bacteria of various kinds in the lungs waiting for favorable conditions to bring them into activity and cause pneumonia and other lung- diseases. I hope I have now made it clear why deep breathing is im- portant, and also why it is that there are so many cases of lung- disease. I will go a step further and say that a great many of these cases of lung-disease are unnecessary and entirely due to carelessness and inattention and the failure to use properly the most excellent breathing machinery with which most of us are provided. Respiration or breathing is automatic; it goes on regularly and rhythmically night and day, just as a clock ticks, and does not stop as long as its nerve and blood and air supply are maintained. It is rapid in infancy and youth, moderate and strong in mature life, and slow and shallow in old age. It is more vigorous in the waking and active hours than during sleep. In old age the lungs sometimes shrivel and atrophy, less blood passes through them, and consequently less oxygen is supplied to the tissues through which the blood passes. Because the lungs of old people are par- ticularly inactive during sleep, it often happens that death comes to them during the sleeping hours. The more blood passes through the lungs with inspiration and expiration, the more vitality will a person have; furthermore, the more the lungs are exercised in inflation and deflation, the more useful they will be. Now, remembering the need for fresh air to replace the residual air, and the need of vigorous exercise to in- crease the capacity of the lungs, it seems to me very advisable for most people, especially those who are on the shady side of life, to set aside a few minutes every day for slow and deep inhalation, and then slow and steady exhalation. Asthma.-One who has had an attack of asthma never forgets it, and when it comes again, as it almost certainly will, he recog- nizes a very unwelcome acquaintance. While the attack lasts, the suffering is worse than that of having a baby; that is, worse than the majority of cases of childbirth. It is worse in hot, humid weather than in weather that is dry and cold. It is one of the most distressing features of hay-fever. Fortunately not all hay-fever patients have it, but I have seen those who suffered horribly with it. 512 HOW TO KEEP WELL There are various forms of it, that which is connected only or chiefly with the air-passages being the most common form; but there is also a form connected with heart-disease and another with kidney-disease, and in the spasms which come with the latter death is often the result. It is also a not uncommon occurrence during pregnancy among those who are subject to it. One of the most characteristic symptoms of those who are subject to asthma is the variety of wheezing sounds which can be heard in the chest. If you put your ear to the chest of any such person you would think you were listening to the movements of an ancient and dilapidated pair of bellows, as air and mucus move in and out of the tubes; and yet the pulse of such a person may be slow though weak, and the temperature very little above or below normal. It is often complicated with tuberculosis, bron- chitis, arteriosclerosis, edema of the lungs, dilatation of the heart, and other serious diseases. In about half the cases there is a hereditary history, and it is often seen in two or three generations of a family; it is also associated with rheumatism, gout, and neu- ralgia. Those who suffer from indigestion and constipation, those who do not breathe deeply, and those who lead a sedentary life may have it. Pressure upon the neck from a goiter, from growths in the larynx, and from enlarged glands may cause it. A great many cases are caused by obstruction in the nose. It is often caused by what is called reflex action from certain skin-diseases such as urticaria, eczema, and psoriasis, and from disease in the eye, nose, digestive, and genito-urinary organs. The dust from various occupations, sand, the pollen of plants, am- monia, sulphur, and phosphorus, when inhaled, will often cause a paroxysm of sneezing, then a swelling of the mucous mem- brane and then an attack of asthma. The remedies for it are as numerous as the causes. The object is to remove the cause, if possible, and then to prevent other at- tacks. The first of these is done by the use of those substances which will relax or loosen the spasm. Most of them are dangerous drugs and should be used only under a doctor's direction or by a doctor. They include chloroform, morphine, belladonna, aspirin, nitroglycerin, adrenalin, cocaine, etc. Many obtain relief by smoking tobacco or cigarettes of stramonium or by inhaling the fumes of burning niter-paper. The preventive measures involve a change of climate, especially DISEASES OF THE LUNGS AND AIR APPARATUS 513 from a moist to a dry, at an elevation of not less than two thousand feet, where the air is pure and free from dust and the irritating pollen of plants. Aviation Sickness.-A very important part of the training of an aviator consists in becoming accustomed to the change in air- pressure which is experienced with every ascent he makes. Avia- tion sickness simply means air-hunger, or inability to get oxygen enough to keep the functions of the body going in a normal man- ner. The symptoms of this disease are, therefore, not limited to those who go up in balloons or aeroplanes but are common to all who ascend to unusual altitudes. Those who climb high moun- tains suffer from the first few experiences in the same way as aviators suffer. In climbing a high mountain like Mont Blanc, it is customary to rest a number of hours when part way up, to get accustomed to the rarer atmosphere; and even then, as I have been told by those who have made the ascent, they have ex- perienced great difficulty in breathing. It is needless to say that aviation or mountain-climbing is entirely prohibitive for those who suffer with diseases of the heart or lungs. The air-pressure at the sea-level is sixteen pounds to the square inch, and as it dimin- ishes rapidly with each additional thousand feet of elevation, a height of several thousand feet necessarily makes a great difference between the pressure on the surface of the body and the pressure within the body. Remembering this, it is easy to understand that the breathing will become more rapid and the sense of internal pressure more noticeable until adjustment to the rarefied air is effected. Above ten thousand feet the breathing is particularly rapid and the pulse quick; also there are one or two degrees of elevation of the body's temperature, besides headache, weariness, and a sense of constriction in the chest. If one goes still higher, there may be dizziness, nausea, weakness in the legs, dilatation of the veins, blueness of the lips and face, and even bleeding from the skin. Higher still, there may be bleeding from the mouth, nose, and ears, intestinal disturbance, and even death. I wonder at the great elevations of fifteen and twenty-five thousand feet, or even more, which have been attained by some aviators. It seems to me there must be very few whose organs would stand the strain. The difference between the internal and the external pressure causes the blood to rush to the surface; hence the lungs contain 514 HOW TO KEEP WELL less of this fluid than normal, it contains a diminished volume of carbonic acid, and the heart works with unusual rapidity in order to try to enable the blood to make the circuit of the body. We occasionally read accounts of aviators carrying oxygen to be usea at great elevations, but there are those who deny its value. If the very rapid breathing permitted its inhalation I do not see why it should not be serviceable. Sajous has suggested that aviators who suffer with aviation sickness be given dried adrenal or pitui- tary substance, which will facilitate the taking up of oxygen by the blood. It is fortunate that when one's organs are sound an adjustment may be acquired in about five days, the bad symp- toms first apparent disappearing. Bronchitis.-Bronchitis means inflammation of the mucous membrane which lines the bronchial tubes. Recall what these tubes are like; imagine, if you please, an inverted tree. The stem of the tree is the trachea or windpipe; the first large branches are the main bronchial tubes. Remember, too, that air can have little trouble getting into the large tubes, and comparatively little getting into those of medium size; but when it reaches the small- est ones there is barely room for it to pass, and if the lining mem- brane which goes from beginning to end of the bronchial tube is swollen by inflammation, the air will pass into the minute tubes with the greatest difficulty or not at all. In those cases in which the air cannot pass, death from suffocation will result. These are the mechanical conditions in bronchitis. In addition to the swell- ing of the mucous membrane in the form of inflammation, there may be extension of the process of the lung-tissue surrounding the tubes, and then we have bronchopneumonia. The disease may last a few days, and one will gradually get better and recover; or it may take a chronic form and last months or years. With many people it is worse in winter than in sum- mer, and they can get relief from their recurrent "winter cold" only by going to a warm climate. Bronchitis is due to the inhalation of some kind of irritant, either by the nose or the mouth. It may consist of dust, gas, or infectious germs, and it must not be forgotten that these germs are always present in varying number and activity in the mouth and nose awaiting favorable conditions of heat, moisture, and diminished resisting power to develop and produce disease. Hence it is that a cold in the head or a sore throat usually precedes an DISEASES OF THE LUNGS AND AIR APPARATUS 515 attack of bronchitis. So also those who live in bad hygienic sur- roundings, those whose habits are bad, and those who are weak- ened from any cause whatsoever are possible candidates for bron- chitis. Acute bronchitis, like most of the infectious fevers, usually begins with a more or less distinct chill, this being soon followed by fever. Other symptoms are loss of appetite, constipation, soreness and aching of the muscles, sneezing, coughing, and rapid breathing. On the second or third day the discharge of mucus from the tubes begins, and when it becomes abundant and free the fever diminishes. When only the larger tubes are involved, there is little trouble in breathing, and there may be little fever; in fact, no great disturbance of any kind. When the disease in- volves the smaller tubes, however, the conditions are much more serious; and when obstruction of the finest tubes occurs in the form of the dreaded capillary bronchitis, the case becomes prac- tically hopeless; many infants and young children meet death in this way. In cases which follow a favorable course the cough gradually becomes looser and less troublesome, the appetite and strength return, and health is restored. In the chronic, persistent, recurrent form of the disease the symptoms may be mild or severe; the cough is troublesome at certain periods, especially in winter, and in the morning after awakening. Such cases are often suggestive of tuberculosis. They may develop into or be associated with tuberculosis and should always be carefully investigated with reference to the presence or absence of that disease. Those who have any disease of the nose and throat should have it properly treated to prevent bron- chitis. The inhalation of medicated vapors or sprays, or even of steam, is soothing to one's cough. Various antiseptics may be used: carbolic and boric acid, eucalyptol and menthol, creosote, and balsam of Peru. Narcotics must be avoided if possible; they are not prescribed as recklessly as they once were. Cough.-Cough is not a simple act. It seems to be a more or less explosive act of expiration or exhalation, repeated perhaps an indefinite number of times, with partial closure of the glottis or vocal apparatus of the larynx, and sometimes, but not always, preceded by a rather deep act of inspiration or inhalation. It usually occurs when one is awake and conscious, but it may 516 HOW TO KEEP WELL occur in sleep and not be violent enough to interrupt the sleep. The mechanism of cough seems to me very interesting: an irritant or stimulus of some sort-for instance, a collection of mucus- comes in contact with one or more of the endings of a branch of the great pneumogastric nerve, let us say, in one of the bronchial tubes. The irritation thus produced is carried along the afferent or incoming portion of the nerve to the center or central station in that part of the brain which is called the medulla oblongata. In the cells of this center it is transformed into an impulse which passes along the efferent or outgoing portion of the nerve to the various muscles which are connected with respiration or breath- ing, causes them to contract, and in so doing produces the ex- plosion which is known as cough. With severe paroxysms of cough there may be violent and even fatal hemorrhage, especially if blood-vessels in the brain are broken; or there may be hemorrhage from the intestines, the bladder, and other organs in the pelvis. Not infrequently a par- oxysm of coughing is followed by vomiting or involuntary empty- ing of the bladder. Cough is easily excited by irritation of the ears, the nose, the throat, the larynx, the base of the tongue, the windpipe, or the bronchial tubes. The substance of the lungs is less sensitive to cough than the bronchial tubes, which are embedded in it, and the same is true of the pleura or covering of the lungs. The cough of pneumonia is less violent than that of bronchitis. The cough in pulmonary tuberculosis is often slight and hacking at the be- ginning of the disease, and much more violent in the later stages, when there is also much bronchitis. Of course it is desirable to check a cough as soon as possible, for it always means loss of strength and vitality, sometimes to a serious degree. When the cause of the cough can be found and removed that will be the key to the situation, but there are many cases in which the disease is apparently running a fatal course and in which the best that can be done is to soothe and modify the cough, thus easing the patient and conserving his strength by day and by night. Narcotics in these extreme cases are entirely justifiable, and they should be as little nauseating and as pala- table as possible. Many drugs are powerful in controlling and regulating cough, including opium, hyoscyamus, atropia, squills, ipecac, the bromides, chloroform, etc. Hot drinks like ginger or DISEASES OF THE LUNGS AND AIR APPARATUS 517 chamomile or flaxseed-tea will frequently quiet a cough, and also inhalations of steam from the evaporation of benzoin and tur- pentine. Many of the proprietary cough mixtures are excellent and effective and may be used according to one's preference and faith in them, backed up by the approval of the family physician. Embolism of the Lungs.-Embolism of the lungs means a con- dition in which there is an embolus. An embolus is a plug usually composed of red or red and white blood-cells, clumps of bacteria and even other substances being sometimes added to it. The blood in the arteries and veins is ordinarily in a fluid condition and in motion. If its motion is arrested, if it is exposed to the air, or if it contains in excess the elements by which clotting or coagulation is produced, a clot may form; and the larger the vessel in which it forms the more will it interfere with the circulation in that part of the body. When it forms in a vital organ like the lungs, the heart, or the brain the interference is so serious that death is almost sure to take place, and it may take place very suddenly. A clot in a blood-vessel of considerable size may be several inches long and when removed looks very much like a worm; such a clot is called a thrombus. Suppose this were in an artery and one end of it became detached and was carried along by the circulation; this detached portion would be called an embolus. This embolus, going from a larger artery to a smaller one, as it flowed along the blood-current would soon be unable to get further and would plug the vessel it had entered. From the current be- hind it new elements would be added, and it would quickly in- crease in size, perhaps becoming as large as a cherry or a walnut. When the embolus is a very small one it may cause only tem- porary disturbance, and it may become dissolved or disintegrated, or the obstructed vessel may be so small that when cut out of the circulation it does no great harm. The harm comes when the blood and blood-vessels are in such a condition that embolism may occur at any time. The larger the vessel that is plugged the more serious the condition. Diseases like rheumatism, and bac- teria and parasites in the blood, predispose the blood to clotting and consequently to embolism. The striking and startling symptom of embolism of the lungs is difficulty in breathing. With it come feeble heart-action, dis- tressing cough, and perhaps expectoration of blood and mucus. 518 HOW TO KEEP WELL The patient should be allowed to inhale ammonia and oxygen, and a hypodermic injection of morphine should always be given to relieve the distress as much as possible. Empyema.-When pleurisy lasts a long time and suppuration takes place in the inflamed pleural membrane, it is called empyema. This disease comes alike to old and young. It is very common among poorly nourished children, whose home surroundings are bad and unhygienic, and in those persons who are underdeveloped and exposed to poverty and want at any period of life. It is often a sequel to acute pleurisy and is very often associated with tuber- culosis. When suppuration begins, the patient usually complains of chill, fever, and sharp pain in the side. As the qus accumulates difficulty in breathing becomes accentuated, and cough, sweats, and emaciation steadily follow. The temperature goes up in the evening and may be two or three degrees lower the next morning; there will be fever as long as the inflammatory process continues, with no means of ridding the body of its poisonous products. There are few diseases for which more has been done by modern surgery than for this. Formerly its death-roll was a very long one, especially among infants and older children. The few cases which got well were those in which the pus either became sterile or in which it burst its way out through the chest wall or through the lung. Now the logical treatment of the disease is the same as that of an abscess in any other part of the body, a free opening being made for the evacuation of the pus, the cavity being irri- gated if necessary, free drainage being provided for, and healing under surgical principles encouraged and insured. Sometimes an incision alone is made at the proper place, and sometimes a portion of one or more ribs is removed to facilitate drainage and healing. Hemorrhage from the Lungs.-In hemorrhage from the lungs the blood may be spit up, or it may enter the air-cells and be absorbed, or it may be organized into new tissue, or it may cause suffocation. The bleeding may occur suddenly or after slight exertion. The patient experiences a salty taste and spits out more or less blood, which may be pure, or frothy, or mixed with mucus. Sometimes a cough precedes the bleeding. The blood may con- tain casts or molds of the bronchial tubes. The bleeding stops spontaneously, as a rule, but may be repeated in a few days. If the hemorrhage has been profuse, there may be an annoying cough, shortness of breath, pallor, and considerable prostration; DISEASES OF THE LUNGS AND AIR APPARATUS 519 and these symptoms may be followed by fever. The quantity may vary from half a teaspoonful to several ounces. It is most frequently the result of tuberculosis, though it may occur in young persons who are apparently in good health. It may be present in pneumonia, bronchitis, heart-disease, chronic fevers, or gout. Sometimes it results, from the opening of a small blood-vessel by ulceration, in abscess or gangrene of the lungs. It may be caused by the presence of cancer. The stemming back of blood in the lungs in chronic heart-disease may break the wall of a blood-vessel in the lung. The patient should go to bed and be kept free from excitement. Ice may be given by the mouth, and an ice-bag may be applied over the breast-bone. The bowels should be moved with a dose of salts. The diet must be light and free from stimulants. The patient's lungs should be carefully examined as early as possible. Laryngitis.-It is sometimes associated with spasm of the larynx or croup, so common and so much dreaded in little chil- dren, or with edema of the larynx, when the tissues under the mucous membrane become swollen, the passage of air to and from the lungs is obstructed or cut off, and the person suffocates or chokes to death unless promptly relieved. It may be a plain, simple inflammation, or it may have an infectious character from its association with some kind of infectious disease. It may be and often is associated with specific constitutional disease, or it may be a feature of tuberculosis and one of the most serious and painful forms of that disease. It may come after a period of strain or after exposure to dust or smoke, even tobacco-smoke or irritant gases or vapors, or drafts of air, especially cold air, after getting wet through, or merely in connection with a change in the weather. It is frequently an extension of a cold in the head or of a catarrhal condition of the nose and throat. At first the throat feels dry and harsh, then there is an ac- cumulation of mucus, which is annoying and causes coughing and expectoration. If the swelling and congestion are considerable there may even be expectoration of blood as well as mucus. Those who have a tendency to rheumatism, or who have aden- oids, or are mouth-breathers from any cause, often suffer from laryngitis, as well as those who use alcohol freely, or spices, or very hot food and drink, or anything which burns or irritates the throat. 520 HOW TO KEEP WELL In treating this disease the first consideration is rest, as it is with any diseased organ. Singers must stop singing; public speakers and street-peddlers must stop shouting. It is best to remain in a warm but well-ventilated room with an even tempera- ture. Cracked ice may be taken by mouth and cold cloths applied to the neck. Inhalation of steam containing an antiseptic like benzoin or guaiac or eucalyptus is often comforting, or the throat may be sprayed and gargled with an antiseptic solution. It is also very important to keep the bowels freely open, just as it is in all inflammatory conditions; and if there are no complications the inflammation will soon pass off, and the individual may be as well as ever he was. Edema of the Larynx.-In edema of the larynx the fluid ef- fused from the blood-vessels infiltrates the muscles connected with the larynx, by whose contraction its motions become possible, and also the vocal chords and the cartilages which are the por- tions of the larynx immediately concerned in its motions. It seems like a very small matter to have these tissues swollen with a few drops of fluid, and yet life itself often hangs on a slender thread like this. This condition may be produced by the inhalation of superheated steam, by burns, by the inhalation of fire, by caustic vapors of various kinds, by boiling hot liquids, by acids like car- bolic or nitric, by injuries to the larynx, and by infectious dis- eases like scarlet fever, smallpox, typhoid, mumps, and tonsilitis. It may also come from exposure to dampness and cold; probably the foolish women who so ridiculously bare their throats and chests in cold weather and wear clothing suitable only for mid- summer little realize the danger they are running of contracting fatal edema of the larynx by such imprudent and silly conduct. When a person is attacked with edema of the larynx he be- comes chilly and hoarse, has difficulty in breathing, and has a con- stant inclination to relieve his throat of an obstructing substance. There are also heat and dryness in the throat and more or less cough. This may continue several hours, getting more and more uncontrollable until unconsciousness and suffocation end the story. Not a moment is to be lost when this condition begins to show itself. The services of one who is accustomed to the examination and treatment of the larynx must be obtained if possible. While waiting for skilled help cracked ice may be given by mouth, cold DISEASES OF THE LUNGS AND AIR APPARATUS 521 compresses applied to the neck, the feet placed in hot mustard- water, and the patient placed in as comfortable a sitting posture as possible. The object to be accomplished is to reduce the swell- ing of the tissues of the larynx by removing the fluid in them by puncture or incision, and this is not an easy thing to do, especially upon a struggling, frightened patient. Edema of the Lungs.-It means that fluid has escaped from the blood-vessels by reason of unusual pressure, into the adjacent tissues or cavity of the body. This fluid is the serum or watery portion of the blood, and it infiltrates the walls of the air-cells of the lungs and the tissues in which they are embedded so that the lungs become water-logged like a sponge which has absorbed water or glue. Thus there is not much room in the lungs for air, and they become heavy and cannot expand and contract normally. It usually occurs in both lungs, beginning at the bottom and grad- ually filling them up so that the air-space is crowded to their upper part or apex. It comes from congestion, which means that the vessels of the lungs have been overloaded with blood and are under pressure. The escaping fluid follows the line of least re- sistance, and much of it gets into the air-cells, which try to throw it off, causing distressing cough and expectoration of frothy, blood- stained, sticky sputum. Congestion is most frequently a com- plication of a disease in which the vessels of the lungs have become paralyzed, free circulation being prevented and the vessel walls made permeable to fluid under pressure, just as water in a bag of cotton cloth may be squeezed or forced through. It is a com- plication in infectious and poisonous diseases such as pneumonia, Bright's disease, anemia, brain-disease, valvular disease of the heart, and disease of the arteries. It may also be a complication of grippe, erysipelas, rheumatism, typhoid fever, gout, and various nervous diseases. Sometimes it begins with a sudden sensation of fear, dryness or tickling in the throat, cough, difficult breathing, painful expector- ation, and great prostration. The skin becomes purple, cold, and moist; there is gurgling in the throat and gasping for breath; the pulse gets weak and rapid; and if the fluid is abundant and the lungs are quickly compressed the patient may perish from suf- focation. Simple measures of relief are to have the patient sit up in a chair or supported with pillows in bed, to give him every chance for air, fan him, raise his hands above his head, and give 522 HOW TO KEEP WELL him oxygen if it can be procured. Morphine in such a case may be life-saving; strong coffee is useful, and so is a hot foot-bath, or a hot-water bag at the feet and another over the heart. Salts of ammonia may be inhaled freely and frequently; the patient should be encouraged to hold on; his fears should be soothed, his heart stimulated, and the pressure upon his lungs relieved. Pleurisy.-Pleurisy means inflammation of the pleura, which is the membrane covering the wall of the chest cavity in which the lungs are located. It involves, entirely or in part, the pleura of one or both lungs. It may exist alone, but more frequently it is as- sociated with pneumonia or some other disease of the lung-tissue; and frequently it is difficult or impossible to distinguish it from the disease with which it is connected. Perhaps in the majority of cases it is followed by the formation of adhesive bands or cords which attach the lung to the chest walls; a constant source of trouble and pain, which may continue for an indefinite period. The disease, particularly when it is primary or independent of other diseases, begins with chilliness, fever, headache, loss of ap- petite, pain in the side, and general discomfort. If it occurs in a child it may begin with vomiting and a convulsion, as children's diseases often begin. Pain is one of its most constant and note- worthy symptoms; it is usually sharp, running from front to back, and is almost always in the side like a stitch or stab, following the course of one or more of the nerves which run between the ribs. The temperature in ordinary cases is not so high as in pneumonia, but it may persist for weeks, particularly if the disease is compli- cated by tuberculosis or some other serious condition. The pain usually compels the patient to lie on the affected side. Simple cases in which there is little or no effusion usually get better in about one week; and in these so-called dry cases the ear, applied to the chest, will constantly note rubbing and crack- ling friction sounds as the pleura of the lung rubs against that of the chest wall. These sounds disappear if effusion becomes abundant and the accumulation of this fluid effusion compresses the lung and causes the chest wall to bulge. The greater the effusion the more the lung is compressed and the greater the dif- ficulty in breathing. Not infrequently this effusion becomes puru- lent, and the condition then is serious and dangerous. When the effusion is considerable, and whether it is serous or purulent, it must be removed. An X-ray picture is often of great value in DISEASES OF THE LUNGS AND AIR APPARATUS 523 determining the nature and extent of the disease. It may be caused by exposure to cold and wet, by fatigue, and as a com- plication of other diseases. The most important element in treatment is quiet rest in bed, the chest being bandaged or strapped to restrict its motion in breathing. Suitable cough-mixtures are given; heat is often ap- plied; blisters and cupping are often used; iodine is painted fre- quently upon the chest; and the bowels are kept freely open. Pneumonia.-Pneumonia is a winter disease identical with lung fever, and one to which the mature and aged are very sus- ceptible. The young are by no means exempt from it; but their powers of resistance are greater, and they succumb far less fre- quently to it than others. Those who are enfeebled by disease or dissipation, particularly alcoholics, are its easy victims. The mortality percentage from pneumonia in winter is high. It is a germ-disease and has one or perhaps several varieties of bacteria as its efficient cause. When the doctors speak of mixed infection they mean that several kinds of germs are found in the material which is coughed up. It usually begins with a hard chill, high fever, severe headache, and soreness and aching of the whole body. The air-cells of the lungs become filled with mucus and other material and are thus thrown out of use. If both lungs are filled up the patient will die for want of air as surely as if a rope were tied around his neck. When only one lung or a por- tion of it is thus filled up there is hope for him, but he has to breathe much faster than usual in order to get sufficient oxygen in his blood. He coughs and expectorates, if he can, in order to get rid of the material in his air-cells and give him more breathing- space, but if it accumulates faster than he can get rid of it the odds will be decidedly against him. His blood is carrying poisons which it cannot get rid of, and its supply of the life-giving oxygen is more or less cut off. This explains the dusky color of the skin which you so often see in pneumonia. When all these handicaps are present the chances of recovery are not great, and they become smaller as the resisting power diminishes. It is better to ward off such a deadly disease altogether than to try to cure it when it has made its attack. Sometimes it will come when there is a sudden drop in the out- side temperature, no matter how carefully one has been living. Sometimes it will follow sudden cooling of the body, as in going 524 HOW TO KEEP WELL out of doors from a warm room without adequate protection. Sometimes, too, it will follow fatigue and exhaustion. Many a physician has thus been attacked after attending a severe and trying case at night. It is most important, as a preventive measure, to form the habit of deep breathing; shallow breathing lessens the resisting power and is a habit which is especially common in aged people. The feet, and in fact the whole body, must be kept dry and warm. Indigestion and constipation must be avoided; the habits in eat- ing and drinking must be simple and regular; and above all things you must get plenty of sleep and not worry. These statements may seem ludicrously self-evident, but simple as they are the ex- perience of many careful observers testifies that it will pay to carry them out. Pulmonary Emphysema.-When more or fewer of the little air-vesicles or balloons at the end of the most minute bronchial tubes burst from the pressure of the air within them, part of the air which passes in and out during breathing escapes into the soft tissues of the lungs. It is difficult or impossible for this air to get out; it presses upon the surrounding air-breathing tissues, and it interferes with the entire mechanism of breathing. This con- dition is known as pulmonary emphysema, or emphysema of the lungs. So soft are these tissues of the lungs and those which are adjacent to them that the escaped air by its own pressure will sometimes push its way through them even as far as the skin and then work up and down, separating the skin from the tissues beneath it, thus forming a kind of balloon, which is more or less compressible and may be made to cause a crackling or creaking sound with the movements of the body. This emphysema of the skin beginning at the neck may extend over large areas of the body. Pulmonary emphysema often comes when great strain is put upon the lungs in the violent efforts of asthma, or hard coughing of bronchitis, pneumonia, pleurisy, or tuberculosis, with the severe straining during choking or strangling, and with the sharp pain of angina pectoris. Sometimes it comes when the lung is prevented from any cause from expanding uniformly in breathing, one por- tion expanding more than another and giving way in the overdis- tended part, as when a portion of the lung is fastened down by the adhesions of pleurisy. DISEASES OF THE LUNGS AND AIR APPARATUS 525 Those who have emphysema suffer also from headache, drowsi- ness, poor appetite, constipation, and indigestion; their shoulders become rounded, their lips thickened, their chest barrel-shaped from their efforts in breathing. This condition may begin in childhood and last indefinitely, or it may begin in old age in connection with asthma or bron- chitis. If it comes in early life, it often means that the individual will become a chronic invalid. It is an ailment from which porters and draymen often suffer, and also those who play upon wind in- struments, miners, grinders, and those who are constantly inhaling dust in their daily tasks. It is possible to recover from it if the injury is not very extensive and the lung-tissues are not too soft. Changes of occupation or of climate often benefit those who have emphysema, and they may be helped also by exercise in breathing in a compressed air cabinet or other suitable breathing exercise, by cupping, blistering, and the judicious use of cathar- tics, and by proper diet. CHAPTER XXX DISEASES OF THE HEART Angina Pectoris.-Angina pectoris means sharp pain in the chest; breast-pang it is sometimes called. The term is given to a group of symptoms rather than to a well-marked disease, though the condition is usually associated with disease of the heart, es- pecially of certain of its arteries by which the heart substance is nourished, or with disease of the great trunk vessel, the aorta, which leads directly out of the heart, or with arteriosclerosis; that is, hardening of the arteries in general. An attack may come suddenly without the slightest warning and with the most agonizing, tearing pain in the region of the breast-bone. With it is a sense of tightening or constriction around the chest, as if one were being screwed up in a vise. The pain radiates into the back, shoulders, and arms, particularly down the left arm. Sometimes it extends to the head, the neck, the trunk, and even into the lower extremities. The patient becomes stiff and motionless, afraid to make the slightest exertion, for the slightest motion increases the agony. He is bathed in cold sweat and is in fear that each breath will be his last. Sometimes the attack comes directly after a hearty meal, especially if food which is not easily digested has been hastily eaten; or it may come after making great physical exertion, or in the midst of intense excite- ment or anger or deep emotion of any kind. Causes which predispose to it are infectious constitutional dis- ease, excessive use of alcohol or tobacco, rheumatism, diabetes, Bright's disease, etc. The pain may be so intense that the sufferer will die in a few seconds or minutes, or it may gradually become less acute and last for hours. Besides the pain there often is a feeling of numbness; and, strange to say, the heart may beat firmly and vigorously, though with increased tension and often 526 DISEASES OF THE HEART 527 with intermittent beats. Strange it is, too, that some attacks have all the symptoms mentioned except the pain, this being es- pecially true during the first few times of attack. When an attack has spent its force there is belching of gas from the stomach, or vomiting, or the bowels move; there is a copious flow of urine, and then the patient gets relief. An attack may be repeated in an hour, or it may be weeks or months before it returns. For those predisposed to this trouble it is very important that the diet be exceedingly simple, as free as possible from fats and starches, and there should be freedom from excitement or strain. These and other preventive measures may avert attacks and some- times actually produce a cure. Another point which laymen should know and consider is that in this condition there is constriction of the arteries during an attack, and that the thing to do is to relax that constriction and dilate the arteries, thus letting the blood circulate freely and relieving the pain. This is done most effectually by drugs which are called nitrites, and particularly by two of them, nitroglycerin and nitrite of amyl. One who is sub- ject to angina pectoris should never go about without tablets of nitroglycerin or capsules of nitrite of amyl. Dilatation of the Heart.-Closely related to hypertrophy of the heart is dilatation of that organ, for the former almost inevitably leads to the latter if the patient holds out long enough. The heart in hypertrophy is increased in size by the enlargement of one or both of its lower chambers, or ventricles; and it becomes dilated because the compensation for its diseased structure here- tofore exerted by hypertrophy, or increase in muscular volume and strength, no longer suffices. This applies to those hearts in which the process of hypertrophy has been going on for months and years. There is another form of dilatation, acute dilatation, which comes on suddenly as the result of an intense strain of some kind and is quickly fatal. As compared with hypertrophy, dilatation is a condition of decided weakness and danger. Its first indication is shortness of breath after the slightest exertion; sleep is disturbed and unsatis- factory, and can only be obtained in a sitting position. There is always more or less discomfort in the region of the heart, and there are palpitation and cough, with frothy expectoration. The circulation of the brain is impaired in this condition; hence one suffers loss of memory, dullness of perception, irritability, with 528 HOW TO KEEP WELL faintness, nausea, vomiting, and constipation. If the dilatation is only moderate there will only be a pallor of the skin; but if it is extensive the skin becomes livid, the lips and nails blue, the extremities cold, the breathing difficult, and the pulse rapid and irregular. The liver becomes enlarged and painful, and there is an accumulation of dropsical fluid in the cavities and loose tissues of the body. If the body is thin it will be possible to detect more or less of the enlarged outline of the heart upon the surface, and the throbbing of the jugular vein in the neck will be plainly visible. It may be brought about by excesses of various kinds, anxiety, anemia, and by severe strain or exertion causing sudden enlarge- ment. It is an ever-present danger in severe and violent athletic work and results from such work oftener than most people think. It is also one of the possible and not infrequent accompaniments of influenza, pneumonia, typhoid fever, and diphtheria. The important thing is to lead a simple life, rest and sleep a great deal, live on simple food, especially milk, but not too much of anything. It is very important to keep the bowels open, with mild laxatives if necessary, while passive exercises in the form of massage will be found both agreeable and desirable. Endocarditis.-This disease is an inflammation of the mem- brane which lines the cavities of the heart and particularly of that portion which covers the valves. An acute attack many come sud- denly without any symptoms that the patient is aware of; or there may be a moderate amount of fever, with more or less irregularity of the pulse, more or less pain in the pit of the stomach, and an occasional attack of vomiting, but nothing to give the patient the impression that he is very sick. When the inflammation is over, it usually leaves behind more or less impairment of a valve or valves; and usually it is the mitral, which is between the upper and lower cavities, on the left side of the heart. As this valve moves back and forth it gives out a blowing sound or murmur. In the severer cases of endocarditis the pulse is rapid and irregular, there are periods of profuse sweating, the spleen becomes enlarged and very tender, and there may be an eruption over the body resembling flea-bites. As a result of this condition pleurisy or pneumonia may de- velop, and plugs or clots may form in the arteries, probably caused by bacteria which have got into the blood current. Those who have this disease may also be jaundiced and are subject to hemor- DISEASES OF THE HEART 529 rhages within different organs of the body, more or less profuse and more or less dangerous. If the disease is of a malignant type it will usually be fatal within a few days; if it is a mild type it may last three or four weeks. Its most unpleasant feature is that it lays the foundation for future valvular disease. It is an infectious disease, but it is not always easy to say how the infectious germs get into the blood. Very frequently it follows rheumatism, tonsilitis, St. Vitus's dance, smallpox, scarlet fever, and various chronic diseases, and it is one of the con- sequences in cases of childbirth in which the conditions have been unfavorable and severe. When the valves become affected they sometimes have warty growths on them, ulcers may form on them, and they may shrink and contract as nature attempts to heal the ulcers. It is one of the diseases in which medicines may be very help- ful, especially the tonics and those which seem to have a more or less direct action on the structure of the heart. Serums and vaccines are now being used to a considerable extent as means of treatment. Fatty Heart.-This is characterized by a localized or general deposit of fat between the sac which contains the heart and the heart muscle. It is frequently due to overindulgence in food and drink. There is always more or less fat deposited on the heart in corpulent persons, who may present insignificant symptoms during the early stages of the disease. The pulse is feeble; there is shortness of breath on exertion; and there may be asthmatic attacks and dizziness. As the deposit of fat increases the sense of distress and oppression in the region of the heart also increases. There may be more or less mental disturbance associated with the defective circulation. The main object in treatment is to re- duce the amount of fat in such patients. This may be done by following the directions given in the article on Obesity. (Chapter VII). Hypertrophy of the Heart.-A heart may become hyper- trophied and the owner of it be entirely unaware that anything is wrong with him, and not a few young men who are devoted to athletics have made such a confession to me. There may be a certain amount of discomfort with throbbing and a sense of heavi- ness, especially when one is lying on his left side, but no pain or anything to excite alarm or direct attention to the heart. In 530 HOW TO KEEP WELL other cases, there may be dizziness, noises in the head, flashes of light, headache, disturbed sleep, and other unpleasant symptoms, and the more persistent they are the more is it likely that hyper- trophy is progressing onward to dilatation. In an ordinary case of heart hypertrophy the pulse is strong, not very rapid, and sometimes irregular or intermittent; and it may be possible to note a bulging on the left side of the chest with each contraction of the heart. There may also be an enlarged and painful con- dition of the liver, and the kidneys will eliminate urine containing albumen and other abnormal substances; it is said this condition is to be expected only in people whose hearts are in a fairly good state and whose general nutrition is good. Not infrequently it is associated with disease of the arteries, either hardening or softening, and it may be associated with Bright's disease, valvular disease, effusion of fluid into the chest from pleurisy, rupture of air-vesicles of the lungs, or emphysema and pneumonia. It may result from the pressure of a tumor upon the heart from excitement or worry, from excesses and dissipa- tion, and as the result of severe strain in occupations or exercise. Those who have this trouble must keep up their nutrition and their general health, give up tobacco, alcohol, and all kinds of dissipation, and live as free as possible from excitement and worry. Their food should be simple and their meals frequent and small. They should exercise moderately out of doors, take a moderately cool bath daily, keep the bowels freely open, and sleep nine or ten hours at night. Suitable medicines are often beneficial in this disease but must be used with the greatest discretion. Myocarditis.-This term means inflammation of the muscle of the heart. It may begin with a fever, chill, pain in the region of the heart, and a rapid pulse, which soon becomes weak and inter- mittent. Dilatation of the heart, with sudden death, may occur, or there may be great difficulty in breathing, great prostration, and discoloration of the skin, showing obstruction in the circula- tion. If the case is not at once fatal, the kidneys will secret only a small quantity of urine containing more or less albumen, and there will be jaundice, nausea, and vomiting, and conspicuous swelling and enlargement of the liver. In the chronic form there may be repeated acute attacks, or a slow process of degeneration of the muscle may go on for years, bringing with it very few note- worthy symptoms until sudden death, followed by an autopsy, DISEASES OF THE HEART 531 shows a heart more or less enlarged, perhaps more or less fatty, but with muscular fibers which are not normal but degenerated in some way. One of the persistent symptoms in chronic myocarditis is dif- ficulty in breathing, particularly after slight exertion, and this is often mistaken for asthma. Sufferers from this form of the dis- ease are also prone to be irritable, melancholy, and hysterical. They may also be troubled with loss of memory, pain in the region of the heart, inability to sleep, dizziness, and poor ability to stand effort of any kind. They may also have an irregular pulse; sometimes there is swelling of the legs and ankles; and, most important of all, there is arteriosclerosis, or hardening of the arteries, especially in those who have passed middle life. In some of the cases of acute myocarditis an abscess or ab- scesses may form anywhere in the muscular tissue of the heart, and such abscesses invariably mean a fatal termination. In other cases there may be recovery, at least for a time, but they signify that the patients must forever afterward submit to the most care- ful regulation of their habits and manner of life, and even this may not exempt them from serious trouble. They must always be most particular to avoid constipation, which, with its attendant straining, is not an infrequent cause of sudden death. Medicines of certain kinds are imperative in this disease. They are known as heart tonics and include strychnia, which is one of the best for general use, camphor, caffeine, alcohol, ammonia, and digitalis. Pericarditis.-The pericardium is the membranous sac which surrounds the heart and in which it is inclosed. It is very often the seat of inflammatory disease, and such disease is called peri- carditis. It is almost always due to infectious germs in the blood and may be a direct and immediate infection or a complication of some other infectious disease. In not a few instances there is an effusion of fluid into the pericardial sac, and the more there is of it the more the heart's action is interfered with and the more pain there is. The greater the effusion the more indistinct also are the heart- sounds; and if the effusion is very great, the outline of the heart may appear as a visible bulging of the chest wall, and its pulsa- tions may be both seen and felt. As long as there is not very much effusion, the heart and its pericardium become partly stuck 532 HOW TO KEEP WELL together; and as the heart moves in its rhythmical contractions a rasping sound, called a friction sound, may easily be heard if the ear is placed over the heart. This is the characteristic sound of pericarditis. The interference with the movements of the heart causes more or less irregularity in the pulse. Together with the pain in the heart there may also be headache, wakefulness, de- pression, vomiting, difficulty in swallowing, swelling in the veins of the neck, and swelling of the ankles. The disease may be a complication of rheumatism, St. Vitus's dance, epilepsy, pleurisy, pneumonia, valvular disease, or Bright's disease. An X-ray picture often will throw much light on the case and perhaps enable the doctor to distinguish it from enlarge- ment of the heart by dilatation or hypertrophy. It may occur in infants, older children, or adults. It is not an infrequent disease in children, particularly as a complication of rheumatism, scarlet fever, smallpox, diphtheria, measles, typhoid fever, pneumonia, tonsilitis, or influenza. In adults it may be the result of the ex- cessive use of alcohol. It occurs more frequently in children than in adults and may last a few days or several weeks. The bowels must be kept freely open and the pain relieved by suitable sedatives, the application of cold or heat, the withdrawal of blood by leeches, and such other measures as the physician may deem desirable. Tachycardia.-Tachycardia means rapid-that is, abnormally rapid-action of the heart. When the high rate of contraction is not continuous but is produced by exciting causes of one kind or another, at different times, and on different occasions, it is parox- ysmal. Great excitement will always produce tachycardia, news of a depressing or exhilarating character, great fatigue, great exertion and strain, and excesses of all kinds. However undesirable a rapid pulse may be-for any machine going at a great rate of speed wears out more quickly than one which goes at a lower rate and with less wear and tear-there are many people whose hearts contract more frequently than would seem to be normal without appearing to suffer from it, at least not for a long time. In all fevers we almost invariably have rapid heart-action; it is a characteristic that everybody looks for and recognizes. In the diseases of the heart itself, as an organ, and also when asso- ciated with diseases of the kidneys, tachycardia is a symptom; DISEASES OF THE HEART 533 sometimes it is constant, sometimes it is spasmodic or paroxysmal. In certain diseases of the nervous system, especially of the brain and spinal cord, in the chronic constitutional diseases, in weak- ness or convalescence which follows any kind of acute disease, the pulse is constantly more rapid than normal. In excesses from alcohol, very often from the use of tea and coffee, and in abuses of a sexual nature we always note that tachycardia is a conspicuous symptom. The paroxysmal form often is associated with depressed nerv- ous conditions, like neurasthenia or hysteria, sometimes with chronic diseases like tuberculosis, and sometimes it results from accidents or injuries. With the rapid heart-action there may be difficulty in breathing caused by the forcing of an unusual quantity of blood through the lungs, or forcing the blood at unusual rapidity. There are several drugs which are given to retard the rapid ac- tion of the heart, chief among which is digitalis; but it is quite unwise to encourage self-medication in matters like this, which may be of very serious import. Rest is all-important when the heart is contracting too rapidly, and usually rest in the horizontal position. Valvular Disease of the Heart.-In the partition which separates the two upper chambers from each other there is, during fetal life, an opening which normally closes at birth. Sometimes, however, it remains open, and death usually results during infancy as a consequence. Those who have this defect are commonly called "blue babies," because the skin is always purple on account of the obstruction which is thus caused to the circulation. This may be called a form of valvular disease for which there is no remedy, and fortunately it does not occur very often. Between each upper and lower chamber is an opening which is closed by a valve; the one on the left side is called the mitral, the one on the right the tricupsid. At the entrance to the pulmo- nary artery and to the aorta are also valves, each called by the name of the artery with which it is connected. These four valves normally fit securely over their respective openings, and it is when they get too large or too small, or the openings become too large or too small, that valvular disease occurs. After the muscle of the two upper chambers contracts and squeezes the blood into the two lower ones the two valves between them close, and if they fit tightly no blood can be forced back. After the two lower 534 HOW TO KEEP WELL chambers have contracted and squeezed the blood into the pul- monary artery and the aorta, the valves of the vessels also close, and no blood will pass backward if these are tight, as they should be. Disease of the valves usually follows inflammation of the lining membrane of the heart, by which also the valves are cov- ered. This inflammation is called endocarditis; and it may be just an ordinary inflammation which will pass away in a few days or weeks, or it may be accompanied by ulceration, followed by the absorption of poisonous material, and be fatal in a short time. These heart-diseases often accompany or follow rheumatism, measles, smallpox, scarlet fever, and other acute, infectious diseases as well as some of the chronic diseases. When the endocarditis extends to the valves they may become swollen. They may be more or less covered with warty growths, or they may have sores and ulcers on them. If the process is a prolonged one, the valves may become hard and fibrous, or they may have deposits of lime upon them. A valve is incompetent when it is too large or too small to fit its opening, and there is obstruction or stenosis when the open- ing is narrowed or thickened or distorted. The sounds which are produced as the heart contracts and the valves close are different from the normal sounds, when there is incompetence or obstruc- tion in the valves or their openings. These abnormal sounds are called murmurs. The method of detecting them is called ausculta- tion, and it is performed either with the bare ear or with an in- strument called a stethoscope. A trained ear detects and differen- tiates the various kinds of murmurs and locates the valve or valves from which they proceed. The commonest forms of valvular disease are those which are connected with the mitral valve, and fortunately they are also the ones which yield most readily to ap- propriate treatment. The rarer forms of valvular disease are the most serious, as a rule, and they are the ones with which sudden death is most likely to occur. CHAPTER XXXI DISEASES OF THE KIDNEYS Abscess of the Kidney.-The symptoms of this disease are pain and tenderness in the kidney, fever and chills followed by sweating, suggesting typhoid fever or malaria, and turbid urine, which is loaded with albumen and pus. There also is great prostra- tion, with dryness of the tongue and skin and feebleness of the pulse. Sometimes it is caused by a stone which has formed in the substance of the kidney. When this stone has become large enough to have any considerable size and weight, it gravitates downward through the ureter and in its passage causes the most agonizing pain in the loin of the affected side and elsewhere. Of course, the urine behind this obstructing stone accumulates, distending the kidney, and is mixed with blood, pus, and mucus. The pain con- tinues until the stone reaches the bladder and then suddenly stops, the sensation of the patient being like a translation from Hades to Paradise. Following the release of the stone there is a gush of pus and urine into the bladder, from which it is quickly discharged. When the bladder becomes involved in this disease the condition usually becomes a serious one. More or less of the urine is retained within the bladder, undergoing ammoniacal decomposition, and poisonous substances are developed. Absorption of these substances means blood-poisoning, with bad results, unless it can be promptly re- lieved. When this disease is discovered it becomes important to find out its cause and remove it as promptly as possible. This may mean the removal of the kidney, and when the kidney is infected with tuberculosis, which is not an unusual occurrence, this is about 535 536 HOW TO KEEP WELL the only way out of the trouble. Besides being caused by infection from the tubercle bacillus, this disease may also be attributed to infection by the colon bacillus, and to poor nutrition, constipa- tion, and exposure to cold, wet, and fatigue. This form of disease is not uncommon in children as a complication of whooping- cough, scarlet fever, diphtheria, smallpox, or typhoid fever. Of course it is not always possible or desirable to remove so important an organ as the kidney the moment the abscess is discovered; and as palliative measures heat at the loins and the feet may be applied, several cupping-glasses or leeches may be used, and an attempt made to flush out the kidneys by drinking an abundance of alkaline waters, flaxseed-tea, barley-water, or even plain water from the tap. Albuminuria.-Albuminuria, or albumen in the urine, is a very important condition, but it does not necessarily indicate serious changes in the kidneys, as has been maintained by some writers. Albumen may be completely dissolved in urine that is clear and form a considerable percentage of its volume. Furthermore, it may be present indirectly in combination with pus or blood or some other albuminoid substance, in which case it will respond as readily to the test for albumen as if it were free and uncombined. It is possible to say that the presence of albumen in the urine is not incompatible with normal health, and some writers assert that it can always be detected, at least in minute quantity, in apparently normal urine. It can usually be found in the urine of almost anybody after a hearty meal, after severe exertion, great excite- ment, or a cold bath. Examination of another specimen from the same person a few hours later may fail to detect its presence. Albumen is normally present in the circulating blood to the ex- tent of fifty parts in one thousand. As the blood passes through the intricate structure of the kidneys the urine is filtered out, and with it may be passed more or less of the albumen it contains. This may be due to some disturbance in the circulating blood, to changes in the cells lining the tubes through which the urine passes, to changes in the walls of the blood-vessels of the kidneys, or to changes in the composition of the blood. When the vessels of the kidneys are gorged with blood after the stimulus of a hearty meal, the pressure is increased and the albumen may pass through, or the same condition may injure the lining cells of the filtering tubes, or these cells may be injured by poisons which have been DISEASES OF THE KIDNEYS 537 taken into the body, or, finally, albumen in excess may be taken with the food and be passed out through the kidneys. Albuminuria is present in such diseases as anemia, jaundice, scurvy, and diabetes, and also in all kinds of fevers, epilepsy, apoplexy, neurasthenia, and goiter; and it is one of the most com- mon abnormal symptoms during pregnancy, especially in its latter months. The presence of a large quantity of albumen in the urine toward the close of pregnancy is always to be considered a symp- tom of gravity and importance. It is a constant symptom in all diseases of the kidneys and is a frequent one in those of the in- testines, stomach, heart, and skin. It is known to have been caused by the action of certain remedies, particularly acids, and it is fre- quently due to the influence of tobacco. Bright's Disease.-This is a very common term for a variety of forms of inflammatory disease of the kidneys. The correct term for kidney inflammation is nephritis; and it may be an acute disease lasting a few weeks, often resulting in complete recovery, or it may be chronic, of different types or varieties, lasting perhaps a year or two, and ending in more or less complete recovery, or lasting twenty or thirty years with ups and downs, relapses and recoveries, and always ultimately fatal, unless the patient is cut off by some other disease before this one has had a chance to finish its work. Acute inflammation of the kidney may happen to anybody, but it is more likely to come in early life; that is, in the form from which people usually recover. It may come to children as the sequel of scarlet fever or some other disease, or it may come to anybody after great strain or exposure. The patient will have fever, pain, and aching in the loins; the urine may be scanty and contain albumen and perhaps blood and other things which are ab- normal to it. But if he lies quietly in bed a week or two, takes little solid food, and drinks plenty of milk and other nourishing fluids, the kidneys gradually resume their usual work, none or very little of their structure is destroyed, and after a while they may be as sound as ever. Not so, however, if the acute develops into the chronic form, or if the latter, without any notice or warning, gradually develops. In this case there is change in the structure of the organs, the filtering apparatus which separates the urine from the blood is slowly destroyed and its place is taken by new, hard connective 538 HOW TO KEEP WELL tissue which cannot do the work of the normal tissue, the im- purities of the blood are not thoroughly removed, and the indi- vidual is slowly poisoned by his own decomposed cells. The disease occurs in the middle and later years of life. De- generative changes may be going on for years not only in the kidneys but in the heart, arteries, liver, and stomach, without the knowledge or suspicion of the patient. He may not feel exactly well, but he may not be sick enough to give up his work or take to his bed or consult a physician; and if he has vices or dissipations he may ignore the warnings which come to him until it is too late. Some of the causes of chronic Bright's disease are hereditary taint of various kinds, malarial or lead poisoning, rheumatism, gout, anxiety, grief, prolonged and severe cold, and excesses in eating and drinking, particularly the immoderate use of fermented or distilled liquors. Attention to the disease may be called by an attack of pneu- monia or of pericarditis, and on examination it may be found that the heart is enlarged and is trying to compensate for the damage that is being done. The vision may become weak and blurred, and examination of the retina may reveal the changes which are char- acteristic of chronic nephritis. Emaciation may take place and also a swelling of the extremities and puffiness of the face, the ar- teries becoming hard, and the blood-pressure reaching 200 or more; the skin is irritable and has a troublesome eruption. Then there are annoying headaches, and some day there is an apoplexy or a convulsion, preceded, perhaps, by nausea and vomiting, difficult breathing and drowsiness. One may recover from such an attack and perhaps remain quite comfortable for a longer or briefer period, with rest and care and proper treatment; but the changes in the kidneys go on, and they become less and less capable of filtering out the poisons from the blood, so that eventually uremia or uremic convulsions occur, from which there is no recovery. People who have this disease should lead a very quiet life and if possible should live in a dry and sunny climate. They should avoid exposure to fatigue and to wet and cold. They may take moderate exercise but must avoid indigestible foods and live largely on milk, fruit and vegetables. By following out such a plan many people live in a very comfortable condition for a long period of years. DISEASES OF THE KIDNEYS 539 Dropsy.-By the term "dropsy" is usually understood an effu- sion of fluid into the tissues or cavities of the body. There is some doubt as to the origin of this fluid. Probably it does not have the same origin in all cases, proceeding now from the small capillaries of the blood circulation, again from the veins, and again from the lymphatics. At any rate, it is pressure or obstruction on one or more of these systems of vessels which causes dropsy. When the tissues are firm the resistance to the outflow from the vessels on the part of the muscles and other firm tissues will be considerable, and then the quantity of dropsical fluid will be rela- tively small, as is the case with the feet, ankles, and face in con- nection with Bright's disease and certain varieties of heart-disease. When the fluid is effused into a cavity, as into the abdominal cavity, for instance, in connection with cirrhosis of the liver, the quantity is sometimes enormous and can be removed only by tapping the abdomen and drawing it off. Dropsy is a feature of many diseases but is always the result of the mechanical obstruction to the free circulation of blood or lymph. It is always a grave symptom, but when it comes in con- nection with diseases of the liver, lungs, heart, kidneys, larynx, or brain it is doubly important and not infrequently means a fatal issue within a brief period. As above remarked, temporary relief is often obtained by withdrawal of the dropsical fluid, sometimes by tapping, sometimes by puncturing the swollen tissues and letting the fluid ooze out, sometimes by fastening a suitable drain- age material in the tissues so that the fluid will run off as fast as it is squeezed out of the vessels. It may also be removed by sweat- ing and purging; but this is an exhausting procedure, particularly to one who is already weakened by disease, and it should be avoided if possible. Movable or Floating Kidney.-The kidney is surrounded by a thick layer of fat, a tissue which is very yielding, and which also varies in quantity in any given locality from time to time. Now, if this enveloping layer should become thin and weak, or if strains of one kind or another were put upon it, the kidney might become loose; and being loose, and therefore mobile, with many of the motions of the body, it would tend to stretch its surrounding fatty capsule more and more, and consequently move more and more from its original location. It might move even as far downward as the pelvis, or it might move very little; but in all these cases it 540 HOW TO KEEP WELL would be outside the abdominal cavity, where the abdominal organs are located. This is commonly called movable kidney in distinction from a floating kidney, which is within the abdominal cavity at birth and swings upon its pedicle of peritoneum. Movable kidney is much more common in women than in men, more often on the right side than on the left. As it is produced and accentuated by strains and injuries, it often follows the severe efforts of childbirth, prolonged constipation, sudden and violent muscular effort, or injuries in the region of the loins. It may be entirely without symptoms. Many people have this condition and are unaware of it until their attention is called to it by a physi- cal examination; or it may produce discomfort or pain severe in character or dull, aching, and dragging, and intensified by exertion. If the kidney is very loose and very freely movable it may possibly be twisted upon its axis; which would be a serious mat- ter, for its pedicle, containing the ureter, renal artery, and renal vein, would be greatly compressed, great pain or colic would ensue, its blood-circulation would be interrupted, the urine could not pass down to the bladder, and the result might be a fatal one. In addition to pain this condition is often associated with constipa- tion, indigestion, dizziness, palpitation, and more or less intense nervousness. In the majority of cases the symptoms may be relieved by a well-fitting abdominal belt. If this does not give relief an opera- tion may be required. Glycosuria.-There is always sugar in the blood, its source being mainly the starchy foods taken into the body which are con- verted into sugar in the small intestine and absorbed through the absorbent vessels of the small intestine into the blood. In the arteries there are normally from one to one and a half parts of sugar to the thousand of blood; in the veins there is less than one part to the thousand; and in the capillaries, which are the dis- tributers of the blood to the ultimate cells of the tissues, there is none. The ordinary chemical tests do not detect sugar in normal urine; when it is present to an amount of five or more parts to the thousand it responds to such tests. The explanation of this is that the tissues of the body use the sugar that is in the blood when it is in normal quantity but are unable to do so when it is abnormal in quantity. In such cases DISEASES OF THE KIDNEYS 541 the blood endeavors to get rid of it, and the principal avenue for getting rid of it is the kidneys. All of the blood in the body passes through the kidneys in a very short space of time, the urine being screened or filtered out in the process. With the urine go also those substances which the blood may have in excess, among them being albumen and sugar. When sugar is thus eliminated, the condition is one of dis- ease, the disease being known as diabetes. In this disease the quan- tity of urine passed per day sometimes amounts to several gallons, and this means intense thirst to replace the loss of water and sugar from the blood and tissues. Of course, such losses, when long con- tinued, must be followed by great weakness and emaciation on the part of the patient. Glycosuria may be transient or persistent. When persistent, it indicates disease of a serious character as above stated; when transient, it may mean merely temporary disturbance. Such a condition may arise from great excitement, profound mental application, prolonged dissipation, the use of certain drugs, or the excessive consumption of sugar; and the sugar will disappear from the urine when the cause which has produced it is removed. Temporary or transient glycosuria may also occur as a sequel or accompaniment of the disturbance produced by certain diseases, such as pneumonia, scarlet fever, mumps, or syphilis, and various inflammatory conditions, such as boils and carbuncles. Glycosuria, sometimes transient and sometimes permanent, also may follow pregnancy, anesthesia from ether or chloroform, inhalation of coal-gas, unusual activity of the thyroid or pituitary gland, and a great variety of other conditions. In any case, diet is a matter of great importance, starches and sugars being used sparingly and skimmed milk or fermented milk as much as possible. It does not seem to me rational to use what is known as a starvation diet for such cases, for the patients' strength already has been depleted by their disease. Out-of-door life is desirable, and also sunshine and abundance of sleep and pleasant company; in other words, one should lead a simple, rational life, as free from stress and excitement as possible. Hematuria.-This is a term which implies the presence of blood in the urine from any cause whatsoever. The first noteworthy change is a dark or smoky color of the urine and a greater density of the fluid than normal. As the quantity of blood increases the 542 HOW TO KEEP WELL urine becomes red or pink in color and sometimes green at the surface. When the quantity is large the appearance becomes more and more that of pure blood, and after the urine has stood a while there is a brownish sediment and sometimes clots or lumps of blood at the bottom of the containing vessel. In any case, the presence of blood may be determined by various well-known tests. It is of more common occurrence in men than in women or children. It may proceed from disease or injury in the kidneys, ureters, bladder, or urethra. Sometimes it is entirely due to disease or injury of the kidneys, sometimes to the slow and painful passage of a stone from the kidney through the ureter, the sensitive tissues of the ureter being wounded as the stone works its way downward. Frequently it is caused by disease or injury of the bladder, and very often it is connected with disease of the urethra, particularly the venereal disease known as gonorrhea. Disease of the prostate gland, whether cancerous or non-cancerous, almost invariably has hema- turia for one of its conspicuous symptoms, and the same is true of tuberculosis of any of the genito-urinary organs. It may be caused by poisonous drugs, such as carbolic acid or arsenic, which have been taken by the mouth and eliminated through the kidneys. Dark, smoky urine is one of the best evidences of poisoning by carbolic acid. It is sometimes caused by the irrita- tion of worms and is a prominent symptom in connection with in- fectious disease, particularly with smallpox and scarlet, typhoid, typhus, yellow, and malarial fevers. People who are known as "bleeders," whose blood does not coagulate readily, and who lose blood freely after the slightest injury, are frequently sufferers from hematuria. The result in a given case of hematuria will depend upon the quantity of blood lost and the nature of the disease which causes the trouble. Various means of treating this condition may be used, among them being rest, the application of cold to the region from which the bleeding comes, and the injection into the bladder of suitable astringents. In recent years it has frequently been found beneficial to inject into the bladder the fresh blood-serum of human beings or from certain animals. Those who are "bleeders" are sometimes benefited by the internal use of certain astringents, and especially by the use of suitable lime-salts. Surgical treatment is also of great value, and this may consist in the removal of a DISEASES OF THE KIDNEYS 543 kidney, or of a diseased prostate gland, or of diseased tissues in the bladder. Indicanuria.-The term implies that indican is present in the urine. Now, indican can always be found in the urine if the test used is sufficiently delicate, and when it is present in considerable quantity it becomes a matter of decided significance. Indican is a dark blue substance resembling indigo. It is always due to putrefactive changes, with fermentation resulting from bacterial action, and more frequently in proteids derived from animal matter like meat, fish and eggs than from vegetable proteids. It is sep- arated from the blood in the kidneys and so becomes a constituent of the urine. When it is absorbed in abundance, its poisonous action is indicated by headache, irritability, insomnia, and other symptoms which show interference with the blood and nerves; and it is thought by some to have an influence in producing arterio- sclerosis and chronic inflammation of the kidneys. It is quite possible that the symptoms mentioned are not due to indican alone, for other poisons are formed with it when decomposition in the intestines takes place, and these are also absorbed into the blood- stream. It is one of the products developed in connection with chronic constipation or obstruction from any cause in the small intestine, or from suppuration, with decomposition of pus, in any portion of the body. Its formation is encouraged in those who eat large quantities of meat or eggs, or who commit errors of diet in any way, in those who do not take sufficient exercise, whose habits are sedentary, whose digestive secretions are insufficient, and who are subject to nervous troubles of various kinds. Indican is also excessive in many of those who suffer from liver-diseases superacidity of the stomach, and ulcer of the stomach and duo- denum. Those who have epilepsy and those who have inflammation of the bladder are also apt to suffer with indicanuria. It is one of the conditions which are benefited by the use of sour milk, fer- mented milk, or anything which stimulates lactic acid fermentation. Pyelitis.-This inflammation may be a simple one, a so-called catarrhal inflammation, the urine containing merely an excess of mucus in addition to its other constituents; or it may be suppura- tive inflammation, pus in considerable quantity being formed and either remaining in the kidney and distending it or passing down to the bladder with the urine. If a stone has formed in one or the other of the kidneys, and 544 HOW TO KEEP WELL has reached the pelvis of that organ, it may block the entrance to the ureter, (the tube which runs from either kidney to the bladder), or it may become jammed and detained in attempting to pass through the ureter. This, of course, would result in the retention of the urine and pus formed in the obstructed kidney and the forma- tion of a tumor which might have large dimensions. In some cases a stone will gradually find its way to the bladder, and then there will be a gush of the detained fluid into the bladder and disappearance of the tumor of the kidney. Pyelitis may involve one kidney or both, and when the latter condition exists the result must usually be rapidly fatal. When pyelitis is present, the bladder is almost certain to be inflamed also, and it is often very difficult to determine where the disease originated. When the disease is caused by a stone, the latter is formed from material derived from the blood, and according as the stone is made of hard material or material which is soft and crumbling will the difficulty and the danger be increased or diminished. The disease may also be due to exposure to cold and wet, to unusual exertion of any kind, tuberculosis, cancer, fevers, the poison of venereal disease, poisonous drugs, and to various kinds of germs and parasites. When urine is retained in the kidneys or bladder from these causes or any other, the poisons it contains are reabsorbed, and symptoms of blood-poisoning with chills, fever, and sweating may be expected, such symptoms frequently misleading to the diagnosis of malaria. Other symptoms are pain in the loin or loins, in the bladder, and perhaps in the thighs. The patient's digestion is disturbed, he has a heavily coated tongue, and he feels very miserable. Fortunately, this is one of the diseases for which modern surgery has done a great deal, and a surgeon should attend pyelitis from the beginning. With the aid of the X-ray and instruments for inspecting the interior of the bladder a precise diagnosis may often be obtained where heretofore it would have been impossible. With a diagnosis clearly made the opportunities for complete relief are often very promising. Stone in the Kidney and in the Bladder.-Stone in the kidney is one of the most painful troubles from which human beings suffer. The case is very exceptional in which a stone larger than the head of a pin is formed in the kidney which does not give rise to agonizing pain either while in the kidney or while working its DISEASES OF THE KIDNEYS 545 way through the long tube called the ureter, which leads to the bladder. Once in the bladder it may be quiescent; it may continue to grow; it may be joined by others, and all together they may more or less fill the bladder and give much or little trouble as the case may be. But a stone may also form within the bladder entirely apart from any association with the kidney. It only needs a small nucleus in the bladder, and the salts of the urine will precipitate themselves around it and gradually build up a larger or smaller mass or lump. Thus may it happen when a large mass of bacteria becomes a nucleus. Those who lead sedentary lives, or have gout or have uric acid in abundance, are prone to the formation of stones, and so are those who live in certain geological formations, just as others have a tendency to the formation of goiter. The material from which these stones or urinary calculi or gravel, as they are variously called, is formed is principally of three kinds, phosphate or oxalate of lime and uric acid, and it is precipitated out of the urine. Some of these stones are fine, some are coarse, some are crumbly and sandy, and some are hard as rock. Some are smooth and some are sharp and jagged, with projections. It is the latter that tear and rend the patient with agony and with loss of blood as they endeavor to force their way from the pelvis or reservoir of the kidney down to the bladder. They vary in size from a grain of sand to a hen's egg- A stone may be free in the bladder, occasionally acting as a plug and preventing the emptying of the bladder; or it may form a cake or crust more or less thick and extensive upon the bladder wall. Pain and hemorrhage are the chief symptoms when the stone is small and is passing from the kidney. If it once reaches the bladder the patient is relieved of his pain in an instant. The pain is repeated if the stone gets into the urethra and the urethra tries to expel it. Sometimes the stone completely blocks the passage in the ureter and sticks fast. Of course, the urine accumulates in the kidney behind it, dilating it and forming a tumor, and perhaps entirely disorganizing the structure of the kidney. The X-ray will almost infallibly determine the presence of stone in one or both kidneys or in the bladder. Besides the pain and the blood and pus and albumen in the urine, the urine becomes alkaline and offensive; there may be absorption and blood-poisoning; there may be nausea, vomiting, 546 HOW TO KEEP WELL painful contractions of the bladder, and possibly convulsions and death. But in these days of splendid surgery such results are far less common than they were a generation and more ago. At the time of a paroxysm of pain from the passage of a stone the only thing I know of which will relieve or mitigate it is a suitable dose of morphine, and it should be given only by a physi- cian. Heat applied to the loins and abdomen and hot drinks by mouth will also assist in giving relief. One who is subject to this disease must live very simply, get plenty of sleep, avoid excitement, and eat nothing that will not digest easily. Even then the attacks will recur in spite of all he can do. Fortunately surgery offers means of relief. A half-century ago a great surgeon in Boston devised an instru- ment which could be passed into the bladder, the stone or stones being seized and crushed, and the fragments then washed out. Of course this method did not entirely supersede the cutting opera- tions, nor have they ever been entirely superseded. Since the dis- covery of the X-ray the stones can be detected at their source in the kidney, and it is now possible to cut directly to the location of the stone and then at once suitably close the wounded organ. CHAPTER XXXII DISEASES OF THE BLADDER Cystitis.-The inflammation, in the majority of cases, involves the mucous membrane of the bladder, but it may extend and in- volve the deeper structures. It may be an acute disease lasting a few weeks and be entirely recovered from; it may be chronic, lasting for years, and perhaps for life; or it may be partly cured and break out again from time to time, undermining the strength and resisting power, and finally wearing out the patient. It may be produced in a great variety of ways. The greater number of cases are due to germ-infection: the germs of grippe, typhoid fever, tuberculosis, and the "social" disease having count- less victims. Exposure to cold is a frequent cause, and con- sequently a greater number of cases are observed in cold than in warm weather. It may be produced by the action of certain drugs; for example, cantharides and alcohol. Children are relatively less subject to the disease than are adults. It is extremely common in middle life, and more frequently in women than in men-if we except the great number of cases in men which are the result of social disease; and in old age it is very common in men in connec- tion with the physiological changes which take place in the genito- urinary organs. In the aged it is often serious and fatal. Cystitis may begin with a chill followed by fever, as is the case with so many inflammatory conditions when due to infection. The pain may be located in the bladder, or it may extend to the tissues below and around it. Pressure upon the abdomen over the bladder also is painful, sometimes intensely so. The discovery of the cystoscope, by which the interior of the bladder can be thoroughly inspected, has marked the greatest advance in the history of this disease; for the accurate knowledge of the condition of an organ is the most important prerequisite to 547 548 HOW TO KEEP WELL its successful treatment. Next to the cystoscopic examination, the most important thing in treating this disease is to make careful examinations, both chemical and microscopical, of the urine from day to day. The bladder must be frequently irrigated with a suit- able antiseptic, and an alkali or an acid must be administered, ac- cording as reaction indicates one or the other. It goes without saying that one who has this disease in its acute form must remain in bed and keep as quiet as possible, rest being one of the most important measures of treatment. Mucilaginous drinks, like flaxseed-tea, are often very soothing, but alcohol in every form must be rigidly excluded. Not many drugs are useful in treating it and it is not wise to attempt self-treatment; there are too many complications to make this safe. Enuresis.-The annoyance which comes from the involuntary passage of urine is often very great; the clothes and the skin are soiled and disagreeably moist; the decomposing urine causes an offensive odor; and the skin may become excoriated and inflamed so that the unhappy victim becomes a nuisance to himself and to everybody who comes in contact with him. It is with children that this trouble most frequently occurs, and it becomes necessary to seek patiently for its cause before attempting to cure it. At the entrance to the bladder there is a circular muscle or sphincter, which, like the spigot to a water-pipe, controls the urinary flow. When this muscle is relaxed, the urinary duct is opened, the muscular coat of the bladder contracts, and the urine is squeezed out. When the sphincter-muscle is contracted the urine is retained within the bladder and accumulates until there is suf- ficient quantity to provoke the relaxation of the sphincter. The muscle referred to may be weak or imperfectly developed, this being often the case with children and the cause of their in- voluntary urinating and bed-wetting. The muscular weakness of the bladder may be a part of general muscular weakness and want of development, as is seen in so many children. Very often the bed-wetting is merely due to fatigue and exhaustion, with the relaxation of all the muscles, including those of the bladder, which occur in deep sleep. In some families there is an inherited tendency to enuresis, the father or the mother being a victim to it and trans- mitting it to the children. Nerve influence in causing it is often seen in such diseases as epilepsy, chorea, and hysteria, from which children so often suffer. DISEASES OF THE BLADDER 549 Deformities and defects of the external genital organs are very often the underlying cause, and when these are corrected the trouble disappears. Children whose muscles are weak and who are anemic and badly nourished must be built up with good food, sunlight, sleep, and out-of-door exercise. This may be all that will be necessary to correct the trouble, or it may be desirable to make use of such drugs as iron, strychnine, ergot, and belladonna, which are often effective, but should be given under a doctor's direction. A child who has a tendency to bed-wetting should avoid drinking for an hour or two before retiring, and before going to bed should have a warm bath, the external genitals being carefully cleansed, but with the least possible interference with them. It is always important that constipation and intestinal worms should be eliminated as a cause of this trouble. As a rule, it is not wise, I think, to punish children who are subjects of bed-wetting, unless it is clearly evident that they are consciously at fault. Judicious and kindly treatment in such cases I believe to be proper. It is always important to distinguish between those cases which are due to carelessness and inattention and bad habits, and those which are purely the result of faulty anatomical conditions and therefore beyond the control of the sufferer. Irritability of the Bladder.-The bladder is a reservoir for the reception of the urine which has flowed into it from the kidneys by way of the ureters, one from each kidney. It is lined throughout with mucous membrane, which is water-tight. When the urine which has flowed into it reaches a certain elevation an impulse to contract is impressed upon the muscular coat or layer which is behind the mucous membrane, and this contracting or squeezing forces the urine out through a canal or duct called the urethra. There usually is an announcement to the brain when it is time to empty the bladder, and the procedure is accomplished with its consent and direction, but not always, for it frequently occurs during the unconsciousness of sleep, in connection with certain diseases of the bladder, and always when the nervous center in spinal cord which controls the action of the valvular muscle at the outlet of the bladder is badly injured, paralyzed, or destroyed. When the bladder fails to perform its function properly, it is an irritable bladder. It is common to all ages, and to women rather more frequently than to men. Children are great sufferers from 550 HOW TO KEEP WELL irritability of the bladder, often in connection with worms, often from superacidity of the urine, and not infrequently when the bladder is deformed or defective. The irritable bladder which causes loss of control of the urine, night and day, in children is common enough and troublesome enough. Alcohol is one of the most potent causes of bladder irritation and is one of the things which must be rigorously avoided if im- provement is to be expected. Tumors of the bladder, whether innocent or malignant, cause constant irritability and until recent years were almost hopelessly inaccessible and inoperable, especially in men. Tuberculosis of the bladder causes the most intense irri- tability and distress, the desire to evacuate it being continuous, though evacuation brings no relief. Men suffer from irritable blad- der in connection with disease of the prostate gland, that disease so common in old men. Irrigation of the bladder with plain or medicated hot water often will suppress a distressing irritability, while soothing medi- cines like infusion of buchu leaves, flaxseed-tea, chamomile tea, and various other available remedies, some of them time-honored, may be employed effectually by internal administration. CHAPTER XXXIII DISEASES OF THE LIVER AND GALL-BLADDER Biliousness.-It suggests a condition in which bile may be cir- culating in the blood, for those who are bilious are in many in- stances jaundiced, and jaundice means that bile pigment has been taken out of the blood-current and deposited in the skin. It cor- responds also to the condition which is sufficiently well known among the laity as sick headache, the dizziness and disturbed vision being followed within half an hour or an hour by a more or less intense headache with want of appetite and possibly nausea and vomiting. It has seemed to me that this condition was often due to disturbance in the bile-secreting function of the liver, but it may also be associated with disease of the kidneys, with chronic Bright's disease especially; for those who have this trouble not infrequently complain with symptoms which are those of biliousness. Bilious- ness is also particularly connected with errors of diet; an attack of indigestion following overeating or the eating of something which has decomposed or fermented in the stomach or intestines will often bring on an attack. It may also be brought on by emotional causes such as fear, worry, anxiety, or profound feeling of any kind. This condition may last many hours, and with many people it occurs periodically, particularly in the spring. When it is due to retention of undigested food, an emetic consisting of a pint of warm mustard-water will promptly empty the stomach and perhaps will promptly drive away the bad symp- toms also. For those who are subject to biliousness, the thing of greatest importance is to live on food of the simplest character and not too much of it. It is also very essential to avoid constipation, and one of the best ways to do this is to take a generous dose of castor-oil every two or three nights during the period when the bilious attacks are wont to come. 551 552 HOW TO KEEP WELL When an attack is accompanied by jaundice, and particularly when there is with it a feeling of soreness in the region of the liver, a suitable quantity of calomel followed by a dose of Epsom salts will frequently be sufficient to relieve the bad symptoms and postpone another attack. Mercury is not a substance which it is desirable to take habitually, but it acts wonderfully well as an occa- sional remedy for certain morbid conditions one of which is bilious- ness. Cirrhosis of the Liver.-In cirrhosis of the liver there may be at first an enlargement of the organ as it becomes inflamed and overfilled with blood, but by and by new fibrous tissue is formed between the cells which compose the chief portion of the liver- tissue. This gradually contracts and squeezes these cells, finally destroying them. Naturally the liver then gets smaller, and if the patient lives long enough it may become contracted down to half or quarter of its natural size. Sometimes improvement takes place and new liver cells grow, especially on its upper convex surface. These take the form of little knobs or enlargements which can sometimes be felt through the abdominal wall and which give to this kind of a liver the name "hobnail liver." The principal object of the cells of the liver is to make bile. This bile is very useful in the digestive process. Exactly what it does I cannot say. This disease may come from various causes, but its principal cause is alcohol, especially whisky, brandy, gin, rum, and other strong alcohols. Another effect of alcohol on the liver is to cause enlargement and fatty degeneration and destruc- tion of the bile-cells. This may be followed by cirrhosis and con- traction after the manner which has already been described. Still another effect of alcohol is to impair the digestive power of the stomach and intestines. From the imperfect digestion of food substances poisonous materials result, and these are carried in the blood-current directly to the liver and cause disturbance which ends in cirrhosis. The disease may progress very slowly, perhaps for years, but it progresses; and the alcohol drinker, who may not have suspected anything of the kind, suddenly wakes up to the knowledge that he has got an incurable disease. When this stage has been reached it is probable not only that the stomach and intestines will have given out, but the feet and legs will begin to swell, and fluid will be poured out from the engorged blood-vessels into the abdomen and other cavities of DISEASES OF THE LIVER AND GALL-BLADDER 553 the body. This fluid may be so abundant that the abdomen must be tapped and the fluid drawn off, and this may have to be re- peated at intervals. The patient is now miserable with nausea and vomiting; his tongue is heavily coated; constipation alternates with diarrhea; and hemorrhoids annoy him constantly. He is jaundiced, and his kidneys excrete only a small quantity of dark urine. After this stage there is very little that can be done to help him, and death is usually but a matter of a few weeks. This is one of the diseases that are usually preventable. When it has become well established there is little that can be done except to try and make the patient as comfortable as possible; alcohol in all forms must be given up, and also spices, coffee, tea, and all excitants. Fatigue and cold must be avoided, the diet limited largely to milk and plain soups; and suitable alkaline mineral waters must be used to keep the bowels open. Massage and suitable baths, especially carbonic acid baths, will often give relief to the circulation and retard the effusion of fluid into the cavities of the body. Sleep must be encouraged by day as well as by night and the patient's surroundings made as cheerful and free from annoyance as the circumstances will permit. Gall-Stones.-The gall-bladder is attached to the lower surface of the liver, a little sausage-shaped sac, holding normally a few tablespoonfuls of bile, and serving as a temporary reservoir for bile which is not in use. In various ways the bile in the gall-blad- der may become thickened, and then it is not difficult for portions of it to become separated and crystallize or solidify, forming gall- stones. These stones may vary in size from a mere grain, like sand, to a well-formed stone as large as a pigeon's egg. The most common variety are made of cholesterin, and are soft and crumb- ling; the harder ones are made of bile salts or carbonate of lime, formed layer after layer in beautiful stratification, and not easily broken. These stones may occupy not only the gall-bladder and its ducts, but the ducts of the liver through which the bile is poured out; hence it becomes imperative, in operating for this cause, to be sure that all the bile-ducts are unobstructed; otherwise the operation may be of no value. Inflammation of the mucous membrane of the gall-bladder, especially when it is of infectious origin, may be the originating cause of gall-stones. Stones may be a long time, perhaps many 554 HOW TO KEEP WELL years, in forming, and they may pass from the gall-bladder into the intestine and thence pass out of the body from time to time, being observed in the stools as sand in larger or smaller particles. When these stones are the size of a pea or larger their passage from the gall-bladder to the intestine is accompanied with excruci- ating pain and constitutes what is known as gall-stone or biliary colic. It is even possible that such an attack may be fatal in its consequences, for it frequently lasts many hours while the stone is progressing against great mechanical difficulties. When it drops from the duct of the gall-bladder into the intestine the sense of re- lief is immediate and complete. An X-ray picture is important in determining the presence of gall-stones, for it is quite possible that symptoms attributed to this cause may be due to a stone in the kidney or the ureter of the right side. Those who suffer from this disease are apt to be troubled with belching, loss of appetite, gas in the stomach and intestine, nausea, vomiting, and constipation. If the ducts of the liver are obstructed this organ may be enlarged and very painful on pressure, and jaundice may also be present. Attacks may be repeated at long or short intervals, and one never can be certain that the entire crop of stones has been disposed of. Unfortunate tendencies of this disease are to degenerate to cancer of the gall-bladder and to im- plicate the neighboring and very important organ called the pan- creas in disease of a similar character. It may also be associated with so serious a condition as ulcer of the stomach or duodenum or with displacement of the stomach or intestine. Those who have gall-stones must be unusually careful about their diet, avoiding fats, peas, beans, raw fruits, pastry, salads, and alcohol in all forms. They should eat as little as possible, sub- sisting principally upon milk in its different forms. There is nothing which will mitigate the pain of an attack like morphine, and when it comes on one should immediately go to bed, and apply heat at the feet and heat over the liver, also drinking hot water very freely. Glycerin and bile salts are often given during or after an attack, and are sometimes beneficial. Olive-oil is also recom- mended, and in several instances I have seen cholesterin stones and sand passed after administering it. Inflammation of the Gall-Bladder.-Inflammation of this little organ is usually due to bacteria. How they get into it is difficult DISEASES OF THE LIVER AND GALL-BLADDER 555 to explain, but there they are, and they attack not only the struc- ture of the gall-bladder but that of its duct or outlet, which joins the duct conveying the bile from the liver and bearing it to its destiny in the small intestine. It is associated with disturbances of diges- tion, nausea, vomiting, and constipation, the evacuations being light in color, sometimes called clay-colored. With it also is usually jaundice, the skin and even the whites of the eyes being bright yellow, and there is often an uncontrollable lethargy or drowsiness, supposed to be due to poisonous effects of bile, which has been re- absorbed into the blood. There often, perhaps usually is, an enlargement of the liver, with gall-bladder inflammation, and soreness and tenderness when pressure is made in the region of that organ. The inflammation may become purulent as the result of bacterial action. In that case the fluid contents of the gall-bladder may increase to a very de- cided degree, distending it far beyond its normal size. When suppurative inflammation thus occurs there may be absorption of the poisonous fluid, and a serious condition for the patient may ensue. Inflammation does not always mean the formation of gall- stones, though the symptoms may be such that a diagnosis of their presence is made with positiveness. With competent use of the X-ray it should be almost impossible to make a mistake of this character at the present time. Gall-bladder disease often is mis- taken for typhoid fever, or for malaria, or for appendicitis, and there probably are plenty of cases in which it coexists with these diseases. When the disease is associated with the formation of large stones and the complete occlusion of the outlet, the absorption of the poisonous material in the bladder may result in insanity, with serious consequences. There are also cases, not a few, in which persistent disease has been followed by cancer of the gall-bladder, or of the liver, or of both. Jaundice.-Jaundice is a group of symptoms, not a disease. In rural districts, where certain sick people are said to be suffering from "yaller janders," attention is thereby called to only one phase, which is common to several diseases, including cancer, malaria, lead, arsenic, or phosphorus poisoning, and Bright's disease, this term, however, giving only a hint of what the disease may be. One of the most common causes is mechanical obstruc- 556 HOW TO KEEP WELL tion in the ducts of the gall-bladder or liver, or both, from the pres- ence of gall-stone. Indeed, it is altogether probable that when all the evidence is boiled down it will be found that mechanical ob- struction within the liver or gall-bladder, or in their immediate vicinity, is in some way responsible for nearly all cases of jaundice. Strictly speaking, the skin in jaundice is not always yellow; it may become green, or olive, and almost black when cancer is the fundamental cause. Yellow is the constant color of the mucous membrane which covers the eye, and also of the sweat, the tears, the milk, and the expectorated mucus if pneumonia is present. The urine is sometimes yellow, but it may also be dark brown or even black. It is important to notice that since in jaundice, particularly if directly and clearly due to obstruction, bile does not enter the in- testine, constipation will alternate with diarrhea, the evacuations being clay-colored and pasty. Other symptoms which are associ- ated with discoloration are loss of appetite, coated tongue, offen- sive breath, indigestion, and slowness of the pulse and of breath- ing. There may also be hemorrhages into the skin, intense itching, boils, headache, irritability, depression, drowsiness, and dizziness. When simply due to removable obstruction, it may last only a few days, or it may be continued through many weeks. When it is found to be due to obstruction from gall-stones or some kind of removable tumor, as determined with or without an X-ray examin- ation, the obstruction must be removed surgically as soon as possible; but it is not generally best to do operations while the jaundice persists, the condition of the blood and of the liver being unfavorable to such operations, or to use an anesthetic. Purging with suitable drugs, like podophyllin, ipecac, and mercury, when properly carried out, is often of great service, but the principal measures of treatment are hot alkaline baths, rest in bed, very simple diet, especially milk, and plenty of sleep. Torpid Liver.-As usually understood, this condition is not a disease but is often associated with disease of the stomach, in- testines, and heart, with which organs the circulation of the liver is intimately connected. In other words, it is likely that in more or fewer of the cases of so-called torpid liver we have a congestion, either active or passive. If the flow of blood to the organ is exces- sive and the outflow obstructed, the organ is overfilled and the congestion is active. If there is valvular disease of the heart and DISEASES OF THE LIVER AND GALL-BLADDER 557 obstruction to the outflow of blood through the veins of the liver, the congestion is then passive. In either case the liver is enlarged, and the individual has a coated tongue, bitter taste in the mouth, poor appetite, flatulence, constipation, jaundice, headache, depression, drowsiness, or in- somnia ; and he is quite apt to be very irritable, even though ordi- narily of a calm and reasonable disposition. This condition may be brought about by prolonged heat, by sedentary habits, or by dys- pepsia from the use of too much or too rich food, or from some other disturbance of the stomach and bowels, or from fever, or malarial poisoning, or the excessive use of alcohol. It is also frequently associated with hemorrhoids, dropsical effusion into the abdomen, asthma, bronchitis, and emphysema of the lungs; and the urine may be high-colored and perhaps scanty. Those who suffer from this trouble are often benefited by com- plete rest, purgation, warm baths, suitable rectal injections, mas- sage, and careful regulation of the diet. Many are benefited also by careful treatment in a sanitarium, and some sanitariums devote particular attention to troubles of this kind. CHAPTER XXXIV DISEASES OF THE PANCREAS The pancreas is a little organ weighing only three or four ounces, lying just under the stomach and stretching across the ab- dominal cavity from the first portion of the small intestine (the duodenum) on the right side to the spleen on the left. In spite of its small size it is one of the vital organs of the body; it cannot be spared, and if all or the greater portion of it were removed death would occur as a result. Although it is so small, it secretes about one and three quarters pints of digestive fluid every day, more than six times its own weight. Its function is to pour its juice or secretion into the first por- tion of the intestine, the duodenum, where it meets the partly di- gested food which has come out of the stomach. It selects the starches and fats from this material, changes the starches into sugar, and emulsifies the fats, preparing them for absorption as they progress along the intestinal tube. It also has some effect upon the albuminous material which has been digested by the juices of the stomach, but this influence is of minor importance. Addi- tional interest has been aroused by this organ within very recent years because it has been found that in the terrible disease known as diabetes if a substance that is obtained from the pancreas of animals, cattle and sheep, for instance, called insulin or iletin, and prepared from certain cells in the pancreas known as the islands of Langerhans, be injected into the circulation of a diabetic it will arrest the disease. This substance must be used continuously for a long time and in connection with proper regulation of the diet. This organ is subject to various forms of disease, the most com- mon of which is inflammation in either an acute or a chronic form. 558 DISEASES OF THE PANCREAS 559 As an acute disease it may or may not be accompanied by hemor- rhage, which may be profuse and serious. It usually comes sud- denly with constant or paroxysmal pains in the stomach, which be- come worse with every movement which may be made. With it there is vomiting of bile, mucus, food, and possibly blood, and swelling and tenderness of the abdomen. I have a suspicion that many of the cases of supposed gall-stones and so-called acute indigestion, and also ulcers of the stomach and duodenum, are acute inflammation of the pancreas. It may be fatal in a few hours or days, or jaundice may develop, and involvement of the liver and gall-bladder may become real. If it is prolonged and becomes chronic there may be a development of peritonitis, and an abscess may form which may rupture into the intestine or the peritoneal cavity. It may be caused by infection from various sources, from the disease of the blood vessels known as purpura, from injury of the abdomen, etc.; and is often associated with mumps, tuber- culosis, alcoholic poisoning, pregnancy, and childbirth. If it becomes chronic it will be subject to recurring attacks, like appendicitis and gall-stone disease; and the worst of it is you can never tell when a fresh attack is due and likely to come on. If the disease is prolonged it may also develop into diabetes or cancer. The dietetic treatment of the chronic cases is important, and the pancreas must be given rest from its active requirements by omit- ting, to a considerable degree, the use of starches and fats in the food. The pancreas is also the seat of solid and fluid tumors; and a tumor may become very large, fill the abdomen, and cause pain and tenderness, vomiting and emaciation. Small stones are also occasionally formed in the large duct which runs through the center of the organ, and they may present all the symptoms which are present with gall-stones. Diabetes.-Diabetes is supposed to be a disease in which the chief symptom is sugar in greater or less quantity in the urine, but there is another variety in which the urine contains no sugar but in which the quantity of urine passed is enormous, amounting sometimes to several quarts or even gallons in a day. This variety will first be considered. It occurs in most cases after middle life but is not at all infrequent in children. It often comes in families in which the nervous system is highly developed and in which there is a tendency to excitability, 560 HOW TO KEEP WELL hysteria, brain-tumors, and other forms of nervous disease. It often follows injuries to the head, and it is sometimes preceded by the variety in which there is sugar in the urine. Other causes which seem to produce it are immoderate use of alcohol, worry, emotion, and various infectious diseases. The first indication that a person has it may be intense thirst and the passage of great quan- tities of urine that is as colorless as rain-water. Then follow indi- gestion, constipation, dryness of the skin, sometimes excessive flow of saliva, headache, slow pulse, dizziness, vomiting, and gradual loss of weight. The second variety of diabetes like the first is characterized by the discharge of large quantities of urine, but this urine has a sweetish odor and a high specific gravity and contains a larger or smaller quantity of sugar. Now, why does sugar in the urine mean a serious and often fatal disease? I have frequently stated that sugar or glucose is the product of the digestion of starchy material in the small intestine under the influence of the ferment or enzyme which comes to it from the pancreas. This is taken to the liver and from the liver is again taken by the blood-current over the body and distributed to the cells where it is decomposed and used for the production of heat and energy. But if the arterial blood which is thus distributing glucose contains more than one or two parts per thousand of that substance, this excess cannot be utilized; it is carried to the kidneys, which eliminate all they can of it, while the remainder continues to circulate with the blood as a poison to the system, and the individual presents the symptoms which constitute diabetes. It may be hereditary and is often present in those who are very fat, in those who have gout, and in those who are high-strung and very nervous. It often follows grippe, typhoid, and other in- fectious diseases, and it may be brought about by worry, grief, and excessive emotion of any kind, and by injuries, especially in- juries to the head. One of the causes which is responsible for a good many cases seems to be persistent rattling or vibration of the body, such as railroad enginemen and other trainmen experience. The constant vibration of automobile riding will also probably pro- duce a large crop of cases. Some of the organs which may be involved in this disease are the liver, the pancreas, the thyroid gland, the suprarenal capsules (small organs which are attached to the kidneys), some of the DISEASES OF THE PANCREAS 561 structures of the brain and nervous system, and probably other organs. The skin becomes very dry; often there is a most annoying itching and eczema; and one crop of painful and troublesome boils follows another. Besides sugar, the urine may contain albumen. The eyesight becomes dim; cataracts may form in one or both eyes; and other serious eye and also ear diseases may occur. The blood- pressure increases; the digestion fails; there are drowsiness, pain, sometimes paralysis, and finally, in many cases, unconsciousness and death. The disease may last a short time or may continue many years. In young people it runs a rapid course and formerly was almost al- ways fatal. In those who have passed middle life it often disappears from time to time, no sugar being found in the urine and the general health becoming good. It is a disease in which diet is of as great im- portance as medicine. While many of the sugars and fats must be discarded, there are others which are useful and can be disposed of advantageously. It is the opinion of good authorities that it is not necessary to exclude all fruits, but that oranges, peaches, apricots, and prunes are usually permissible. Of the fats cod-liver oil and olive-oil are often helpful, and of other foods a moderate quantity of meat, fish, oatmeal, cocoa, milk, cream, and butter may be taken. The Treatment of Diabetes with Extract of Pancreas.-Diabetes is so serious a disease, and so fatal in young subjects, that any method of treatment which promises to cure or ameliorate it is worthy of careful consideration. It was reasonable to suppose that the pancreas, by whose secretions starchy foods are converted into sugar, was at fault; and it seemed also proper to suppose that the nervous system was implicated, inasmuch as artificial irritation or injury of a certain portion of the brain-structure is followed by the presence of sugar in the urine. The greatest stress, however, seems to be laid upon the condition of the pancreas. For many years students of diabetes have been working along the line of regulation of the diet as the best method of treating it, and by this good results have heretofore been obtained. A few years ago a group of investigators in the University of Toronto began experiments with extracts obtained from the pancreas upon dogs in which diabetes had been artificially produced. This work seemed to have lacked success because of the difficulty of eliminat- ing the action of the enzymes or digestive extracts produced by the 562 HOW TO KEEP WELL pancreas in those preparations of which use was made in these experiments. The Toronto experimenters finally succeeded in producing a substance in which the digestive action of the enzymes was effectu- ally eliminated, and the active principle they were seeking was isolated, this principle representing the activity of the islands of Langerhans and being called insulin by them. This substance, be- ing injected into diabetic dogs, caused reduction of the sugar in the blood and in the urine, and permitted the dogs to tolerate a larger quantity of sugar in the blood than they otherwise could. By their final experiments they succeeded in preparing a fairly stable extract from the pancreas of the ox, and injections of this substance prolonged the life of diabetic dogs, which ordinarily lived only fourteen days from the time the disease was produced in them, to seventy days, and also in comparative comfort. The extract thus prepared was further sterilized and purified and then used by subcutaneous injections in a series of seven diabetic patients in the Toronto Hospital. The results were care- fully observed over a definite period, the blood sugar being reduced to its normal level, the sugar in the urine disappearing, and other important symptoms ameliorating. But it was also noted that cer- tain poisonous reactions followed the injections which required careful attention. Though the benefit in these seven cases was temporary, it was believed that further study and experiment would probably yield more perfect results. There are those who deny that it will have any permanent importance. There are others who look with hopefulness to future developments. One of the most distinguished authorities (Joslin) gives as his opinion that "insulin will temporarily lower the sugar in the blood, banish it from the urine, and promote the accumula- tion of glycogen and the removal of fat from the liver." Thousands of diabetics have, up to the present time been benefited by insulin, but it seems necessary to continue its use indefinitely to obtain permanent benefit. CHAPTER XXXV FEVERS The Clinical Thermometer.-A thermometer registers tempera- ture, upon the principle that variations in temperature will cause a given substance to expand and contract with approximate regu- larity. Mercury is commonly used to measure temperature, but so also are metallic springs or strips of sensitive metal, or fluids which are sensitive to air-pressure. A clinical thermometer is usually a glass tube, four or five inches long, perforated from end to end, with its lower end dilated to a bulb and containing mercury, a thread of which ascends the perforated space as the temperature is recorded. The thinner the bulb the more sensitive will it be to heat and the quicker will the mercury expand. A scale at the side of the tube, usually graded from 950 to no° F., records the temperature. A lens front on the thermometer magnifies the thread of mercury and facilitates reading it. A thermometer must be sensitive and accurate; and such an instrument, standardized and tested, which will register tempera- ture in one minute or less, is purchasable almost anywhere. The importance of frequent records of body temperature has been recog- nized about one hundred years, and suitable instruments have been devised for obtaining them. A thermometer must be absolutely clean as well as accurate. It is a good plan to dip the bulb in a solu- tion of boric acid and wipe it carefully before using it. When the thermometer is applied the tip must look upward, not downward, for an accurate record, and it may be placed in the armpit, the mouth, or the rectum. The last of these is by far the most reliable in determining the body temperature but is often inconvenient, par- ticularly in children. The mouth is next in importance for this pur- pose, the bulb being placed under the tongue. After the thermo- meter has been removed and read, the thread of mercury should be shaken down and the instrument always disinfected and dried 563 564 HOW TO KEEP WELL before being put away. The danger of breaking the thin bulb must always be considered in introducing the instrument especially in the rectum, and it must not be inserted forcibly; an antiseptic lubricant on the bulb may facilitate its introduction. The tempera- ture of the body is usually lowest from 7 to 9 a.m. and the highest from 5 to 7 p.m. It is increased by exercise, digestion, prolonged heat, excitement, etc., and diminished by pain, hemorrhage, fright, hysteria, and various emotions. Children have sudden changes in temperature after sweating, convulsions, or the influence of in- fectious germs. A good thing to have in every household, especially where there are children, is a reliable thermometer, and equally is it desirable to know how to use it. Hay-Fever.-The disease is a catarrhal inflammation of the mucous membrane of the eyes, nose, and mouth, and is due particu- larly to the irritating influence of the pollen of various plants. Some people have a sensitive mucous membrane all the year, more sensitive of course in summer, when the air is filled with the odor of flowers, than in winter, when it is pure and cold. But place those very same people in winter in a room in which there are roses or jonquils or narcissuses or tuberoses, and they will weep and sneeze and remain in discomfort hours or days. Others have it chiefly during the season of roses or when the grasses are ripe in the fields or the odor of new-mown hay fills the summer air. Still others are those whose sufferings are just beginning in mid- August and will continue until the vegetation has been destroyed by the frost and the air is again clear and cool. It used to be said that the responsible cause of this ailment was the pollen of the Roman wormwood or ragweed, which lines the country roadside and is scattered through the fields almost everywhere; but the goldenrod, the beautiful wild flower of early fall, was found equally guilty, and now it is known that there are a hundred or more of the grasses, weeds, and flowers of late summer and early fall which can cause it. Additional causes are the dust of the streets and roads, intense heat and moisture, and the physical debility which results from work and worry. Autumnal catarrh is a better name than hay-fever, for hay has comparatively little to do with it. It may appear suddenly on the day and almost on the hour it has appeared for years; or it may be preceded by days of uncomfortable nervousness and ex- citement, with itching and watery discharge from the eyes and FEVERS 565 nose, and an occasional paroxysm of sneezing. When it has fairly started the mucous membrane of the nose swells and there is a discharge from the eyes, nose, and perhaps the throat almost continuously; breathing is difficult, the appetite fails, sleep is dis- turbed, and the sufferer is as miserable and wretched as he can be. By and by the inflammation creeps down the throat to the bronchial tubes; there is a troublesome wheezing cough and attacks of asthma; and it is frequently impossible to sleep at all except in a sitting posture. The inflammation may also extend to the stomach and intestines, and diarrhea may be added to the other miseries. The poor victim is worn out and exhausted before cold weather comes unless he is able to go to the mountains, where the air is pure and the vegetation unirritating, or take an ocean voyage. Relief under these conditions is sure and effective. There are powerful drugs which will mitigate the suffering, but there is also danger in using them, and they must be used only under the direction of a competent physician. Every hay- fever sufferer should have a good atomizer, should be very particu- lar about his diet, should keep his skin active by the daily bath, should sleep all he can, by day as well as night, and, above all things, should keep his bowels freely open. In the atomizer he must use a good antiseptic solution, one containing liquid vaseline being preferable, as this will form a coating which does not dry readily upon the mucous membrane, thus becoming a protection to the sensitive nerve-endings which control the act of sneezing, and checking the watery discharge from the diseased mucous membrane. The eyes, nose, and mouth should be sprayed with the atomizer every hour or two and the mouth and throat should be rinsed and gargled equally often with a solution containing camphor, peppermint, wintergreen, or oil of eucalyptus. Begin this treatment at least a week before the attack is due and follow it up rigorously, as long as the disease lasts. This will modify it materially and is the next best thing to a trip to the Adirondacks, the White Mountains, or some equally salubrious region. Serums prepared from various pollens are now used in treating hay-fever, and frequently with very gratifying results. Malaria and Malarial Medicines.-Malaria is one of the few diseases which afflict large numbers of human beings for which it can be said without qualification that medicine is essential and, furthermore, that there are certain medicines which will cure it. 566 HOW TO KEEP WELL Since 1882, when Laveran discovered the parasite in the red blood corpuscles which causes it, its origin has been definitely known, and since 1898, when it was determined by Ross that it was com- municated to man by the bite of a certain female mosquito, the way in which it is contracted has been known. As Gorgas and his associates drove it from the Panama Canal Zone, where it was more abundant and troublesome than anywhere else on the face of the earth, it may be concluded that it is one of the few terrible disease-pests which are thoroughly understood and can be com- pletely exterminated. The early Spanish settlers of this continent found plenty of malaria here. The Jesuit missionaries in Peru discovered, early in the seventeenth century, that it could be controlled by decoctions made from the bark of an evergreen tree growing on the Andes. The most important alkaloid obtained from it is quinine. There is nothing in the world which will destroy the plasmodium or para- site of malaria like quinine. In some respects it is the most valua- ble drug we possess. There are different kinds of cinchona bark from which quinine is obtained-the pale, the red, the yellow, etc. -and a few years ago tinctures and decoctions of these barks were in general use. Now we hear of little except the alkaloid quinine, which is combined with acids to form salts of varying strength and solubility and with various other substances. This is the sheet-anchor in the treatment of malaria. A few years ago, especially in the Mississippi and Ohio valleys, malaria was extensively treated with mercury, and I have been told by doctors who practised in those localities that it was treated very successfully. Arsenic has long been used in the treatment of malaria, and in the rare cases which for some reason or other cannot be treated with quinine it may give satisfactory results. Other substances which are used with or without quinine in the treatment of malaria are iron, silver, nitroglycerin, opium, strychnia, cocaine, camphor, musk, myrrh, methylene blue, saline waters, etc. They do not destroy the malarial germ as quinine does; they are often very helpful, however, in strengthening the functions which have been impaired by the poison. One of the most valuable combinations in treating this disease, which was a secret remedy for many years, is known as Warburg's tincture. It is composed of thirteen drugs, including quinine, and will often cure the most obstinate chronic cases. FEVERS 567 Many combinations which profess to be mixtures of various kinds of herbs are extensively advertised as cures for malaria. Unless they contain quinine as their principal ingredient their value may be questioned. After all, as quinine is so much cheaper than it formerly was and is universally available, it is better to make use of it than of any of its substitutes except in the cases, which are by no means frequent, in which there is a real antagonism to it and in which the body will not tolerate it. Malarial Poisoning.-Typical malarial poisoning, or malarial fever, is characterized by well-marked chill, fever, and sweat occur- ring every day, every second day, or every third day. There are irregular types occurring at irregular intervals, or with only a dull, unpleasant consciousness of fever if the patient's resisting powers are unusually good or the activity of the poison lacks virulence. Malarial fever is essentially a tropical disease, but it occurs wher- ever there are mosquitos belonging to the Anopheles family, par- ticularly in swamps, forests, lowlands, and other places where physical conditions are favorable for the breeding of mosquitos. Very cold climates and very high altitudes are not suited to its development. The malarial parasite goes through its first stage of develop- ment in the body of the mosquito, and its second in the blood of the human being, destroying the red corpuscles and causing anemia with pigmentation of the skin. It may be found in all the blood-vessels, particularly those which are deeply seated. It appears in several forms, some being more virulent than others. The parasite develops and matures within the red corpuscle, de- stroying it, and when nature throws off new segments they im- mediately attack other red corpuscles. When a mosquito bites a human being already infected with malaria he thrusts his nose into the victim's blood, plasmodia from the blood adhering to his nose. If he bites an uninfected person a short time thereafter he transfers one or more plasmodia to the new victim, in which they at once proceed to develop. The period from the time one is bitten until the appearance of the usual symptoms of malaria is from six to fourteen days. The most common form of malarial fever is the tertian, appear- ing every two days. The chill is preceded by nausea and vomiting, headache, backache, and general discomfort. The entire body shakes, the teeth chatter, the pulse is rapid and irregular, the 568 HOW TO KEEP WELL temperature is high though the skin is cold, and the kidneys are very active. The chill lasts from ten minutes to an hour or longer, and is followed by a sensation of intense heat, headache, rapid pulse, redness of the skin with or without an eruption, possibly delirum and unconsciousness; and it may last from two to six hours. Then comes a period of profuse sweating with fall of temperature, weak- ness, feeble pulse, and possibly restful sleep. In two days this experience is repeated, a new crop of parasites having developed unless active measures have been taken to destroy them. The symptoms in the other forms of malarial fever, except in the latent form sometimes known as dumb ague, are practically the same as in the tertian. Malarial fever may be complicated with neuralgia, apoplexy, insanity, bronchitis, pneumonia, and diseases of the heart, liver, kidneys, and intestines. A very noteworthy symptom is enlarge- ment and softness of the spleen and the liver. Other complications which sometimes occur are pain in the ears, deafness, and impair- ment of the sight. Typhoid Fever.-It consists primarily in inflammation of certain small glands in the small and the large intestine, but from this inflammation a great variety of symptoms proceed, making this one of the most interesting and destructive diseases from which human beings suffer. It is caused by a very well known microbe called Eberth's bacillus and can be communicated to animals by the injection of a suitable culture of this organism. It is also found in the intestines of animals and of human beings who are known as typhoid-carriers and are constantly distributing it, though im- mune to the disease themselves. It is found in water, in milk, in canned meat, oysters, raw vegetables, and other food, in the discharges from the bowels, whether fresh or dried, in the urine and the sputum, in material which is vomited, and in the exhala- tions from the lungs; consequently it may float in the atmosphere. It can be inhaled with the air or with particles of dust upon which it has settled, or it can be taken into the mouth with drinking- water, milk, and other food. Having entered the body and been taken into the blood, it is passed along to the intestinal glands, where it excites inflammation and develops a poison of great virulence. Then follows the great variety of symptoms which make up the disease. Sometimes it is two or three weeks in developing, sometimes only a few days. It FEVERS 569 begins with a tired feeling, loss of appetite, intense headache, especially in the forehead, nausea, and frequently diarrhea. The tongue is coated; the back and body and bones ache unmercifully; often there is nosebleed, and frequently chills, followed by sweat- ing, which may lead to the erroneous diagnosis of malaria. The disease may come at any season but is most common in the fall. It thrives in camps, hospitals, prisons, and other in- stitutions where large numbers of people are gathered and the hygienic conditions are bad. In certain college communities it abounds some years and is nearly absent in others. It can occur at any age from two to fifty, seldom before or after these limits, and with greatest frequency from fifteen to thirty. It has many varieties and degrees, from the mild walking cases to those which are terrific and fatal within a few days. In the first week of the typical form the temperature usually rises one degree daily, the patient becomes light-headed or delirious; there is a peculiar form of diarrhea; the tongue has a dense white coating; the spleen is enlarged and soft; the pulse is rapid and irregular; and there are more or fewer red spots or points scattered over the surface of the abdomen. In the second week the temperature remains high and the pulse rapid and feeble; delirium and prostration, with evidence of pro- found poisoning, continue; the tongue now becomes dry and cracked, and the abdomen swollen from peritonitis. The lungs become congested, and not infrequently there is hemorrhage from the bowels. In the third week the severe symptoms may become more pronounced and death result, or they may begin to show abate- ment. In the fourth week death may come from exhaustion or hemorrhage, or the temperature may drop and the symptoms in general improve. From this point convalescence may be slow or rapid: there may be one or more relapses; there may be a sudden hemorrhage when everything is apparentl yfavorable; or there may be a variety of other happenings. The mind may remain unsteady for a long time; the tongue may be tremulous and the gums may bleed. The bacilli may be found in the stools and urine for many weeks. The treatment involves, necessarily, the isolation of the patient, careful disinfection of all his surroundings, inspection and tests of drinking-water, milk, and other food, and absolute cleanliness. The 570 HOW TO KEEP WELL daily disinfection of the stools is imperative. A milk diet is often the one which alone is practicable for many reasons. Good nursing is of more value than medicines. Treatment with cold water has been as successful as any method yet suggested, but it is not uni- versally applicable, for example, in the very aged, the very young, or those who are profoundly prostrated. Inoculation with immunizing serum has been of great service in preventing the disease or mitigating its violence. Typhus Fever.-It begins like other germ-diseases, the period of incubation or development of the causative germ within the blood lasting from one to two weeks. Then, as in other fevers, there are pain and soreness throughout the body, chill, fever, and great prostration. There may be nosebleed, redness and dryness of the skin, coated tongue, and constipation. The mind, as in other cases of blood-poisoning is dull or acutely delirious, according to the patient's temperament. The patient continues to get worse for about one week, the temperature steadily mounting till it may reach the extreme of 1060 F., while the pulse is proportionately rapid and the breathing shallow and rapid. The distinctive outward appearance is the eruption which covers the entire body with the exception of the face. It consists of dark red spots or points, somewhat like flea-bites, where blood has escaped into the skin, and gives rise to the name by which it was often known in the past, "spotted fever." Patients who have been weakened by starvation, exposure, and suffering die in great numbers from this disease within one week; others, who have more endurance, may linger one or two weeks longer. When conditions are favorable the fever begins to subside at the end of a week or ten days, the bowels begin to move natur- ally, and the eruption fades away. This disease resembles typhoid fever, cerebrospinal meningitis, measles, and some of the forms of blood-poisoning. It is trans- mitted by head and body lice, and it became an important part of the sanitary work of all the armies in the late war to unlice (entlausen') both soldiers and civilians, particularly in the typhus- infected regions of the Balkans, as a means of self-protection. Aside from the spread of this disease by the agency of lice, it is not a particularly contagious disease. Cold baths at short intervals are refreshing in treating the fever and in preventing the great waste of vitality from the exces- FEVERS 571 sive loss of heat. Fluid food, comfortable surroundings, good nursing, and a minimum of drugs are the most approved measures of treatment. Yellow Fever.-Yellow fever, or "Yellow Jack," formerly so much dreaded in tropical countries and particularly in West Africa, the West Indies, and Central and South America, is now one of the conquests of the medical science of the nineteenth century. Havana, once one of the cities within the tropics worst plagued by this fever, is now free from the pest, thanks to the idea-original and insistent with Finlay, one of the physicians of the last century -that the mosquito was responsible for its spread. After a short period of incubation following a bite by an infected mosquito, the disease begins with headache, chills, fever, nausea, and general all-gone feeling. The eyes are bloodshot and suffused with tears; the cheeks are a dusky yellow; and there are profuse sweating and obstinate constipation. As the disease progresses, the skin becomes a pronounced yellow, and from this fact the disease derives its name. After two or three days the pulse becomes abnormally slow; there is absolute loss of appetite; the urine shows that the kidneys have been attacked; the discharges from the bowels are black or brown; and there is copious vomiting of a black fluid, indicating more or less profuse hemorrhage into the stomach and bowels. The distinguishing marks by which the disease may always be recognized are the jaundice or yellow discoloration of the skin, the slowness of the pulse, and the black vomit. The essentially important elements are the great destruction of the red corpuscles of the blood, destruction of the liver cells, and interference with the function of that organ. The predisposing causes of this disease are alcoholism, poverty, fatigue, and bad hygienic conditions. It is noteworthy that negroes and very young children are not very susceptible to it. The principal thing in the way of prevention is to destroy mosquitos and protect oneself from the bites of any that may survive. When a suitable preparation of mercury is given in the early history of the disease, it will sometimes save the patient's life. Other medicines are not of very much use. The chief reliance must be upon good nursing, nutritious fluid food, and wholesome surround- ings. CHAPTER XXXVI CONDITIONS PECULIAR TO WOMEN General Remarks.-This class of diseases, which has assumed very great importance in recent years, concerns the genital and urinary organs of the female and the structures which are con- nected with them. The urinary organs are not peculiar to women, of course, but their anatomical relations are quite different from the relations of the corresponding organs in men. The life of the human female is divided into three physiological periods: the first extends from birth to puberty; the second from puberty to the menopause, otherwise called the change of life; and the third from the menopause to the end of life. At puberty, which usually occurs between the ages of twelve and eighteen, the child becomes a woman, is capable of bearing children, menstru- ates, and becomes totally different in many ways. At the change of life she ceases to menstruate and is no longer able to bear children, and the genital organs atrophy or wither, having accomplished their purpose in life. The conditions which are about to be discussed may be divided into those which occur before and those which occur after puberty. Diseases Which Occur Before Puberty.-Some of these are evidences of imperfect development during fetal life (i.e., before birth), while others are the result of accident or some other un- favorable influence to which the individual has been subjected. Defects and Deformities.-Of these there are many, and it would not be prudent or necessary to attempt the description of all of them, especially since some of them are so rare that they come to the notice of the trained specialist alone. A few may be mentioned, however. The bladder may have failed to close, and the urine may all be poured out through an opening in the abdomen. 572 CONDITIONS PECULIAR TO WOMEN 573 The opening may be so large that a portion of the bladder will be exposed. The vagina may be wanting, all the other genital organs being present, or the vagina may be double. The womb may be absent or rudimentary, or it may be double, each part being capable of developing a child to maturity. The ovaries may be absent, or there may be only one, or in very rare cases there may be three. The ducts which lead from the womb to the ovaries may be absent or deformed. There may also be a defect in the rectum, its lower portion or its terminal portion being absent or firmly closed. None of these defects can be remedied except by surgical operation, and its importance is so great that it should only be attempted by one who is accustomd to such work. Some of them cannot be remedied at all and must simply be endured. The external organs of generation may also be deformed by what is known as hermaphrodism, in which the organs of the female bear so close a resemblance to those of the male that it is some- times difficult to determine the sex of the individual. Many mis- takes of this character have been made, the true condition being sometimes discovered after the erroneous opinion has been held for years. As a matter of fact, true hermaphrodism, that is the condition in which an individual has the essential generative organs of both sexes, is one of the rarest of curiosities, if indeed it ever occurs. False or spurious hermaphrodism is not so very un- common. Injuries and the Results Which Follow Them.-The injuries to the genital organs of children and young girls from criminal and brutal violence are sometimes very severe, the tissues being lacer- ated and the effect of fright and actual pain being profound. If the child recovers from such violence the scars and contractions which result are apt to produce permanent deformity of the organs involved. Injuries sometimes occur from accidental thrusts with sticks, from falls astride fences or stones or other hard objects, from carelessness or bad habits; and such injuries may result in irrepar- able damage. Incomplete Development After Birth.-The genital organs may be completely normal and well developed at birth. It must be remembered, however, that they are the organs of an undeveloped being. Growth and change in their structure must continue until the age of puberty is reached to enable them to accomplish properly 574 HOW TO KEEP WELL the function for which they were designed. It often happens that this developing process is arrested, and mature life is reached with immature sexual organs, the individual remaining a child so far as the organs and functions of reproduction are concerned. This condition may persist through life; but in many cases it is suscepti- ble of relief by treatment which is principally surgical, the burden and the misfortune of sterility which is often the cause of great unhappiness being thus removed. The causes of this arrested development are now pretty well understood. Poorly nourished, anemic children whose nutrition in general is at fault, children with constitutional taint, such as syphilis, or tuberculosis, or rickets, children who have been over- worked in school, the brain being developed at the expense of the rest of the body, are frequently sufferers from diseases of this character. Arrested development is also sometimes traceable to acute diseases during childhood, to typhoid fever, to Bright's disease of the kidneys, and especially to the eruptive diseases, measles, scarlet fever, and smallpox. The reason for such results upon the genital organs is not by any means clear, but it may consist in the fact that prior to puberty these organs have no definite function to perform; they therefore do not require so large a blood supply for their nourishment as after puberty has occurred. Now, when disease, especially if it is of an inflammatory char- acter, affects other portions of the body, the blood-supply of the genital organs is drawn upon and diverted to the diseased portions. If this diversion should continue as it often does, several weeks, it might easily happen that the growth of the organs thus robbed of nourishment would suffer permanent impairment. Abscess of the Breast.-If there is any portion of the body of a nursing woman that calls for particular attention, especially during the first few weeks which follow childbirth, it is the sen- sitive breast and its more sensitive nipple. The woman has been weakened by the pain and anguish of childbirth and is in poor condition to resist the attack of infectious germs. If the care and attention she receives are improper or injudicious she becomes an easy victim to inflammation of the breast. I suppose it is possible for infectious germs to come from within the body, but in the great majority of cases they must be introduced from without. Milk may be allowed to remain upon the nipple and decompose; cleanliness of the breast may be wanting; the nurse's or the mother's hands may CONDITIONS PECULIAR TO WOMEN 575 be dirty; and cracks and fissures on the nipple may invite absorp- tion of disease-bearing bacteria. Bacteria, having been introduced through any of the openings in the nipple, quickly make their way into the interior of the breast, and inflammation and suppuration follow. The inflammation may be localized in the tissues immedi- ately under the skin and may be a comparatively mild affair, or it may be more or less diffused through the tissues of the mammary gland and become a much more painful and important affair, or it may develop in the tissues under the gland between the gland and the muscles of the chest. From the very beginning it is the cause of severe pain, aggravated each time the baby is placed at the breast for nursing; and the poor mother, with resisting powers already weakened by her confinement, finds her strength constantly ebbing away and her convalescence and return to her domestic duties retarded. The disease is announced by soreness and tenderness in the breast; the breast becomes hard; and when suppuration begins there is a chill, with fever and perhaps sweating following. If the patient is improperly or unskillfully attended the inflammation may continue until she is worn out or, in extreme cases, succumbs to blood-poisoning and exhaustion. The same care and cleanliness which should prevent a woman from having puerperal or childbed fever should also prevent her from having abscess of the breast. How should we treat the abscess of the breast if we have been unable to prevent its development? Naturally, the first thing is scrupulous cleanliness of all portions of the body, including the breast; and perhaps next in importance is open bowels, assisted by castor-oil every day or two, which may be given in a way that will be perfectly unobjectionable to the stomach or the nostrils. The diet is next in importance and must be simple, sustaining, and of easy digestion. That will mean mainly milk, cold or hot, plain or fermented, with or without Vichy or seltzer or some kind of carbonated water, and nourishing cereals, soups, and gruels. There is no question in my mind that such cases may be greatly benefited by the proper administration of a suitable form of alcohol, and I say this as the result of experience and with full acquiescence in the enforcement of the prohibition law. The abscess itself may be treated in various ways. Those who wait for the pus to break through the skin are usually unjust and unkind to the patient, prolonging her agony and perhaps destroy- ing the functioning of the breast for the future. The method of 576 HOW TO KEEP WELL treatment by means of cupping-glasses has advocates and is said to be efficient in some but not in all cases. The baby should not be placed at the diseased breast; it is agony for the mother and may not be wholesome for the child. In many of the cases it will be prudent and wise to bring about weaning. The Change of Life.-When the change of life has probably oc- curred the monthy hemorrhage ceases and the child-bearing period ceases also. It has been regarded by the profession and the people alike as a kind of bridge, and if a woman succeeded in crossing it she would be comparatively safe for the rest of her life. But she might die; in fact, she was very likely to die, when making the passage. The age at which this change takes place varies, being in- fluenced by race peculiarities, climate, individual physical condi- tion, and many other causes. It may occur before thirty; it may be delayed beyond fifty. In this climate it occurs to the average woman between forty and forty-five-nearer the latter than the former. In extremes of climate, whether hot or cold, it comes early; to those who are very fat it comes early; also to those who have wasting diseases like tuberculosis or who have borne many children in rapid succession. It comes early also to those who are enfeebled by want or exposure or worry or hardship of any kind; in fact, whatever tends to wear out a woman's vitality and resisting power will tend to precipitate the menopause, or change of life. It comes abruptly or gradually; many women simply stop in their recurrent periods; many others are irregular for a longer or shorter time, and finally the hemorrhage reappears no more. There are a great many women who are sufferers from fibroid tumor or other disease of the essential female organs of generation. Such women very often suffer greatly during the change of life; their hemorrhages are very profuse; they continue indefinitely; and they may not only bring the woman to death's door but actually compel her to enter. Anything may happen at this time, and the change of life may be more or less responsible for it; because the woman is entering a new phase of her existence, and with many women it is a difficult matter to adjust themselves to it. The nervous system is the one which is most aroused and disturbed by the change of life; and consequently nervous, high- CONDITIONS PECULIAR TO WOMEN 577 strung women suffer far more while passing through it than those who are more calm and phlegmatic. Almost all women, either when the change is going on or at a subsequent period, suffer from what is known as vasomotor disturbances. The vasomotor nerves are the ones which are supplied to the arteries. They either contract the arteries and diminish the current which is in them, or they relax and permit them to be full to overflowing. In the one case there will be pallor and coolness of the skin; in the other there will be flushing, followed by sweating, and since an unusual volume of blood is forced through the kidneys there will be a great discharge of colorless urine. One or the other of these experiences is of daily, almost hourly, occurrence with many women at this time. These and other troublesome experiences gradually become less troublesome, less frequent; and at length the woman, like a ship that has passed through turbulent seas, glides into the peaceful and serene harbor of old age. Leucorrhea.-This term means a white flow or discharge and refers to the very common and annoying discharge of fluid from the vagina of a white, milk-like appearance. It is entirely different from the whitish or yellowish discharge of an inflammatory origin known as pus, and while it is troublesome, soiling the clothing and irritating the skin, it is not usually an evidence of trouble that is at all serious. If real inflammation of the mucous membrane of the vagina should take place the discharge would no longer be that of leucorrhea but would be pus. Leucorrhea may occur in females at any time of life. It is not so very uncommon in little children as the result of irritation of various kinds, want of cleanliness, worms, etc. It is also not un- common in aged women when the mucous membrance of the vagina has undergone atrophy and degeneration. It is least common in married women, especially in those who have borne children and in whom the anatomical conditions for the drainage of fluids from the vagina offer no obstructions. Like the insensible perspiration, which is constantly being evaporated from the skin, a fluid dis- charge, moderate or slight in volume, is negligible and not trouble- some in such women in the majority of instances. Those who suffer most from leucorrhea are young, unmar- ried women. It is most annoying the day, or two days, preceding the menstrual flow. Why is this? Simply because with the recurrence of the menstrual wave the blood-vessels of all the 578 HOW TO KEEP WELL structures of the vagina are unusually distended. More blood is diverted to the sexual organs at this time than at others. The glands of the vagina are unusually active; the blood-pressure is increased; and in consequence an unusual quantity of this milky fluid transudes into the vaginal canal. A congested condition of the vagina at any time produces a similar result, and this may arise from nervousness, excitement, fear, grief, or any unusual nervous activity. The question of treatment for leucorrhea is a matter of difficulty for reasons which are perfectly obvious. Medicines are of very little use, and it is not desirable that women who are excitable and hysterical should get into the habit of taking medicines of any kind. If there are exceptions to the rule it would be in the oc- casional use of a mild and harmless sedative like asafetida, which is often very soothing and quieting, and is not a drug which one would be likely to take for the pleasure of taking it. It is also extremely important for all women who suffer with leucorrhea to keep the bowels freely open. Most of them are constipated, and constipation aggravates leucorrhea. Those who are thus afflicted may take mineral oil day after day, or castor-oil, or cascara, or such other reliable cathartic as may seem useful. The daily bath is most desirable, though I have never felt it prudent to advise bathing during the menstrual period unless there were particular reasons for doing so. In my experience a cold bath will quickly check the flow, and I have never believed that was rational or desirable. Maternity and Its Allied Conditions.-Pregnancy like menstru- ation is for the majority of women neither the sign nor the accom- paniment of disease but the fulfilment of a law of their being. A woman who is capable of bearing healthy offspring should welcome the fact as one of the greatest blessings of Providence. One who cannot bear healthy offspring should not bear any and is to be pitied. There should be no sympathy for those who for purely selfish reasons shrink from or avoid maternity; and those who for similar reasons interfere with pregnancy not only have an account with conscience which must be settled, but in countless cases ex- perience ample compensation for their misdeeds in the physical ills and sufferings which outraged nature imposes upon them. Far be it from me to say that all married women should bear chil- dren, but the experience of many years has taught me that the CONDITIONS PECULIAR TO WOMEN 579 excuses of many women are too trivial and insufficient for neglect- ing this burden and this duty. The exact duration of pregnancy, that is, the period from the beginning of life, or conception, until the human being is ripe or ready to begin its existence outside the body of the mother, is not a fixed and invariable fact for every individual. In law it is reckoned at 280 days or thereabouts. Pregnancy in a mature well-developed woman, who is suffer- ing with no disease of any degree of seriousness, is a perfectly natural experience, as natural as digestion or sleeping or any other function, and may cause no disturbance of any character from its beginning to its end. Indeed, because it is an incident which is to be expected, from the physiological standpoint, in the development of a woman's life, it often happens that her physical powers are at their very best during its continuance. But it is also a fact that it may be attended with many complications. Morning Sickness.-One of the most common and disagreeable accompaniments of pregnancy, especially in those who are preg- nant for the first time, is nausea, which may also be accompanied with vomiting. It is apt to occur as soon as the patient awakes, and it becomes more troublesome as she arises and moves about. It is seldom troublesome longer than the first three or four months of pregnancy, though it may continue to the very end. It is prob- ably due to an irritation of the stomach, which is reflected, by nerve communication, from the expanding womb. When it is possible, the patient should remain quietly in bed, and after a few hours it may pass away. A mustard-plaster (one part mustard and three of flour mixed with water to a thick paste and placed between two or more layers of cotton or linen cloth) laid under the left breast will often relieve the disturbance of the stomach. In rare cases the trouble becomes serious enough to threaten life. Such cases demand the best and wisest of medical attention. Swellings of Various Parts.-As pregnancy advances, the limbs or other parts of the body may swell and cause great discomfort. This does not necessarily imply serious disease, but only that the circulation is interfered with. Rest in bed for a portion of each day will usually remedy the trouble, and it is something which must not be neglected, or the consequences may be serious. Constipation.-Constipation may be unusually troublesome, especially when the womb has become quite large and presses upon 580 HOW TO KEEP WELL the lower bowel. This must be carefully corrected. Figs, oranges, or apples will sometimes correct the trouble, and an occasional injection of a pint of hot soap and water into the rectum may also be used. Irritability.-The disposition often suffers during pregnancy. Some women become very fretful; others, very emotional; others are subject to strange whims and caprices; and some become melan- choly or delirious. All these conditions call for forbearance from the patient's friends, while the patient herself must summon forti- tude and self-control to her aid. With the end of pregnancy will also come an end of these disagreeable conditions. Parturition or Childbirth and Its Accidents.-The experience which occurs to a woman in giving birth to a child, that is, in ex- pelling it from her body, is known as parturition or childbirth. Heretofore the child has been essentially a part of the mother, its vitality being derived from her vitality; now and henceforth it is to lead an independent existence. Childbirth being a perfectly natural experience, one would sup- pose it would no more be in need of help for its accomplishment than the performance of any other function. Animals have no assistance from midwives; neither do savages. But animals some- times die in labor, as do also savages, because they are unable on account of complications to deliver themselves. It is mainly be- cause of possible complications that midwives and obstetricians will always have a place in human society. To treat at length of these complications would be entirely beyond the scope of this work. Most of them are beyond the reach of the midwife, and when they are observed she will send as quickly as possible, if she is sensible, for a skilled physician. It cannot be expected, therefore, that those who are entirely inex- perienced in such matters as these would be able to manage them with any success. A brief mention of some of the complications of childbirth may not be out of place. This process may be very slow. The contractions of the womb by which the child is expelled may stop for hours, or even for days, and it is not always easy to say why this has occurred. The child may present itself in a faulty position; that is, in such a way that the expellent forces do not act with the mechanical advantage essential to expulsion. There may be violent hemorrhage before or after the child is born, or while birth is in progress. The mother may have convulsions or CONDITIONS PECULIAR TO WOMEN 581 may suddenly become insane during the labor. The relations be- tween the dimensions of the child and those of the canal through which it must pass may be such that it cannot be born in the natural way. All these and many other complications are possible in con- nection with childbirth, and so it is wise and right to throw around this most important function all the safeguards at our command, thus making it as easy as possible for those who must endure its pangs and sufferings. Abortion or Miscarriage.-A few words of advice may be given upon this most important subject. Without defining these terms in strict accuracy, they may be used in general to signify the prema- ture expulsion of the products of conception; that is, of the child and the membranes by which it is enveloped and the structure by which it is attached to the womb of the mother. When pregnancy has occurred, a human life has been launched into existence. That life must not be tampered with but must be protected in every possible way. Serious disease on the part of the mother or other conditions by which her life is really jeopard- ized alone warrant any interference with this life which is within her. There is need of great definiteness and plainness upon this subject. Those who destroy this life without such adequate cause as has been mentioned commit murder, and those who consent to it are accessories. Pity it is that the wretches who carry on this abominable trade and those who permit it cannot suffer as their crimes deserve. With those who submit themselves to the work of the abortionist nature usually exacts heavy retribution; there are few of the serious troubles which are peculiar to women which cause more suffering than those which follow criminal abortion. Accidental abortion or miscarriage may occur at any period of pregnancy, but is most frequent prior to the fifth or sixth month. It may be caused by prolonged exertion of any kind, by sudden strain, by profound emotion, or by violence of any character. When it occurs repeatedly and without any positive or attributable cause it is safe to say that it is due to a diseased condition in the indi- vidual who is thus suffering. Such persons should be under the care and treatment of one who is skilled in the treatment of diseases of the womb, in the intervals between pregnancies; and should pregnancy recur they should be the object of care and attention 582 HOW TO KEEP WELL during its entire period. Under such precaution many women have eventually been enabled to bear living children. The Immediate Care of the Mother and Child after Birth.- It sometimes happens that labor progresses very rapidly or that the midwife or physician is unavailable, and that the child is born be- fore any skilled assistance can be had. A little common sense and self-control at such a time will be of the greatest service. The child usually announces its entrance into the world with a cry. If the cry is not forthcoming vigorous action will be neces- sary to produce it. Life hangs by a thread, and a slender one, too, at such a time. If the child fails to breathe, a few spanks, not too violent may excite the lungs to action, or if this should fail hot and cold water alternately may be sprinkled over the body; the fore- finger may gently remove any accumulation of mucus in the throat; and if this is unsuccessful artificial respiration will be necessary. It is sometimes necessary to continue working over the child for an hour or more, never giving it up as long as the ear placed at the child's chest can detect the faintest evidence of heart-action. When that is still no further effort will avail. One of the first things to be done after the birth of the child is to wipe its eyes gently with a soft dry linen rag and then allow a drop or two of boracic (boric) acid in solution (a teaspoonful in a glass of hot water) to fall into each eye. When the child is born it is still at- tached to the mother by the long cord or navel-string. This may be wound about its neck and must be quickly and carefully re- moved. If neither doctor nor midwife is at hand, or likely to be at hand for an hour or more, the child must not be left unattended. Let some one with clean hands and steady nerve tie the cord with a stout and absolutely clean piece of cord or tape three inches from the child's body, and then tie it again an inch further away. It must be tied very firmly, that there may be no bleeding from the stump when cut. The cord may then be cut with clean scissors between the two ligatures. The baby is then free and may be wrapped in a blanket and taken away. No bath should be given for several hours. (Further directions on this subject will be found in the chapter on Diseases of Infancy and Childhood.) (Chapter VIII.) The mother must be relieved as soon as possible of the soiled garments and bedclothes, and if bleeding should continue she should receive a teaspoonful of the fluid extract of ergot in half a glass of water. This may be repeated in an hour or two if it CONDITIONS PECULIAR TO WOMEN 583 should be required. If the womb contracts promptly after the child is born there is seldom any trouble from bleeding. An excel- lent way to encourage such contraction is to grasp firmly with one or both hands the womb, which may be plainly felt like a globe or ball through the lower portion of the relaxed abdomen. It is some- times necessary to keep up such pressure for an hour or two. It is not necessary, however, when the womb feels hard and firm. The afterbirth, that is, the membranes which enveloped the child in the womb, and the placenta, the thick flesh-like structure by which the child was attached through the medium of the navel- string to the womb, are usually expelled in half an hour or an hour after the birth of the child. It is not well for the uninitiated to attemp to withdraw them from the body; but, having been ex- pelled, they must be at once removed. A firm bandage may be fastened around the abdomen of the mother, her body being carefully sponged with warm water and a clean nightgown put on. Should she desire it, there is usually no objection to giving her a drink of water, a cup of hot tea or coffee, or a glass of milk as soon as her toilet has been made. Of the injuries to the tissues which may take place in the course of childbirth, the experienced physician alone can be the judge. If he is present at the time they occur he will detect and repair them so far as is possible and prudent without delay. Diseases of the Period Which Immediately Follows Childbirth. -Few women in civilized society are so little affected by the sufferings and exhaustion which ordinarily accompany childbirth that they are able to resume their customary duties at once. Hence a period of rest in bed varying from one to three or four weeks follows childbirth, during which recuperation takes place, the geni- tal organs contract and shrink to the condition which they were in prior to pregnancy, and the mother accustoms herself to the new conditions which are involved in the care and nurture of a baby. This is known as the puerperal period or state, or the period of childbed. It is not affirmed that all women observe this prolonged period of rest; it too often happens that work is resumed ofter the brief- est period of rest. Some women are compelled to take up their burdens quickly whether they will or no; others who have great vitality and are unused to inactivity resume their work from choice. Many women do themselves great harm by thus forcing nature to 584 HOW TO KEEP WELL act at a time when rest is an imperative requirement. The period of childbed is one in which there are many dangers. Severe illness of various types is far from uncommon; and, as is well known, many lose their lives at that time after having withstood the strain of pregnancy and the suffering of labor. Childbed Fever.-The most important of the complications which attend the puerperal period is the condition which is known as puerperal or childbed fever. There have been times when ma- ternity hospitals in this country and in Europe have been little better than burying-grounds on account of its ravages. When about the middle of the last century Semmelweiss at Vienna made the discovery that this terrible disease was due to dirt and care- lessness, and that the hands of the physician or midwife were the principal agents by which it was propagated, his statements were received with derision and contempt. Soon afterward he died disappointed and broken-hearted, it is said; but as "the blood of the martyrs is the seed of the church," so was the truth which he had started in motion. To make an unusual application of Pope's line, "We first endure, then pity, then embrace," the unwelcome doctrine of Semmelweiss was put to the test and found true. Especially was its truthfulness apparent when the gospel of cleanliness and antisepsis was expounded by Lister a few years later. At the present time a maternity hospital, instead of be- ing the place over whose entrance it was for many years not inap- propriate to write, "Who enters here let her leave hope behind," is the safest of all places for the woman who is to undergo the ex- perience of childbirth, the rate of mortality from childbed fever being lower than it is in private practice. If the methods of our best maternity hospitals could be carried out in private practice, not alone in the crowded and dirty homes of the poor, but in the spacious and luxurious homes of the rich, this dreaded disease would be practically exterminated. The disease owes its existence chiefly to the fact that during the delivery of the child the soft tissues of the canal, through which it must pass on its journey into the world, are stretched to an enor- mous extent and are often extensively bruised and torn in addition. This condition means the exposure of a large absorbing and wounded surface to the influence of decomposing material which CONDITIONS PECULIAR TO WOMEN 585 may come from within, and to all sorts of possible damage from without, especially from the hands and instruments of those whose duty it may be to attend the sick and injured woman. Suppose a poison of some kind or other is applied to these wounded tissues; it quickly develops, is absorbed into the lymphatic circulation, and thence is carried into the blood, where its continued development affects life at its very center. The woman develops intense fever with all its accompaniments, derangement of the digestive appara- tus, and often of the nervous system; the mind becomes unbal- anced ; and unless she has a great reserve of vitality death is a com- mon result. The disease is the more hopeless if the woman has passed the prime of life, or if she has latent or quiescent disease in any of her organs, or if she is deprived of the best nourishment and the most judicious medical attention. Disease of the kidneys, the lungs, heart, liver, ovaries, and Fallopian tubes complicating childbed fever render it almost surely fatal. Prevention of such a disease must always be aimed at. Should it occur, the principal means of treatment will consist in absolute cleanliness, frequent vaginal injections of very hot water being usually appropriate, and sponging the entire body with alcohol once or twice daily. The bowels must be kept freely open, and the kidneys must be kept active. The bowels, the kidneys, the skin, and the lungs are the means by which the poison of the disease is to be eliminated. The food must be simple, nutritious, and mainly fluid. As much milk as possible should be taken, and also a sufficient quantity of alcohol in the form of whisky or brandy. There is perhaps no substance so efficient in destroying the poison of this disease as alcohol. It is needless to say that this is the use of alcohol as a medicine, and the physician is to be the judge of the propriety of its use. If the stomach of the patient rebels against food it is often desirable to give by mouth only an occasional drink of hot water or a small piece of ice. The physician may find it useful to wash the stomach out, and for days or even weeks it may be necessary to administer all food by the rectum, caution being exercised against using injec- tions which are too large in quantity or substances which are found to irritate the rectum and cause it to expel them. The surgical measures which may be used in this disease have been the sub- ject of much discussion in recent years. If such measures are re- quired it is usually by far the better plan to defer them until the patient has rallied somewhat from the depressing effects of the 586 HOW TO KEEP WELL poison which is working in the body. To do serious operations while the disease is at its height can have, as a rule, but one issue, and that a fatal one. It is no credit to surgery or to a surgeon to operate upon a dying woman, but of course the skilled surgeon must always be the judge as to the condition of his patient. Milk-Leg.-In this condition one or both legs may be swollen, hard, and painful. It is caused by the formation of a blood-clot in one of the great veins of one or both legs, in consequence of which the blood-current behind the clot is obstructed. Effusion of the blood-serum then takes place through the vein and into the sur- rounding tissues. The condition is not without danger, for if the clot is broken up by the pressure from behind and forced onward to the heart sudden death may be the result. Not much can be done in the way of treatment except to elevate the limb upon a pillow and paint the swollen vein with tincture of iodine. Convulsions (Eclampsia).-This is one of the gravest accidents which can occur in connection with the pregnant or puerperal con- dition. The convulsions usually occur just before or during de- livery, but they may continue after the child has been born. They usually signify serious disease of the kidneys, the poisonous ma- terial which should be eliminated with the urine being retained in the body. The convulsions may be repeated three or four times during the day, or they may occur every few minutes. The more frequently they occur the more dangerous is the condition. The principal ob- ject to be attained is to produce a free flow of urine and free per- spiration from the skin in order to get rid of the poisonous material. Hot drinks should be given-tea, lemonade, whisky, and water; hot bottles may be placed at the feet; and the physician may give the tincture of veratrum viride, ten drops in a tablespoonful of water, following with one or two drops in a teaspoonful of water every fifteen minutes until the pulse is brought down to sixty or seventy beats a minute. An injection of a quart of hot water with a teaspoonful of salt will often be of service by unloading the bow- els. In some cases the overloading of the bowels causes the convulsions. Insanity.-This is a somewhat uncommon complication of the period which is under consideration. It may be due to a tendency in the individual or to a peculiarity of disposition; it may be due to shame or mortification when the pregnancy has been illegiti- CONDITIONS PECULIAR TO WOMEN 587 mate, to the severe pain during the process of childbirth, to co- existing diseases of the kidneys or other organs, or to various other causes. It may take the form of melancholy or of mania and delirium, according to the temperament of the individual. It is usually temporary in its manifestation, sometimes lasting only a few days and sometimes several weeks or months. The treatment consists principally in watchful care over the patient, especially since there is often a tendency with her to destruction of herself or her child. Other complications of this period may be piles, constipation, indigestion, and numerous minor ailments, which usually remedy themselves in a short time, and for which ordinary care and com- mon sense will suggest the proper treatment. Menstruation.-Menstruation is the monthly occurrence in women during the child-bearing period of a series of phenomena which are associated with the recurring impulse to reproduction. It means that periodically at fairly regular intervals of about twenty-eight days, or a lunar month, a congestion or excessive supply of blood is diverted to the organs of the sexual apparatus -the womb, ovaries, and breasts-the pressure in these vessels, particularly in the veins and capillaries, being so great that a portion of the blood in them escapes and is discharged from the body through the proper channel, as other waste products are discharged. This discharge tends to increase until it reaches its maximum, and then, as the wave retires and the pressure is re- duced, it diminishes, and finally ceases. This cycle of events may continue as long as a week or it may be limited to two or three days. There are a great many factors which influence its duration and the quantity of blood which is discharged. When the sexual organs of a woman are normally developed and the blood-vessels, nerves, muscles, and other tissues are in a condition of health, menstruation is as uneventful and free from pain and unpleasant symptoms as any other function that is nor- mally performed, as digestion, for example; but when there is faulty development or exciting and irritating conditions of any kind, it is attended with unpleasant symptoms, as in the case with digestion or any other function. When menstruation appears in a girl it usually means that she has passed from childhood to maturity, that is, that she is capable of impregnation and reproduction; but this is not a universal rule, 588 HOW TO KEEP WELL for some females become impregnated without ever having men- struated, and others may menstruate a long time before they are capable of impregnation. It is not the same as ovulation; that is, the shedding of an egg or germ, which is the female essential to impregnation. Ovules or eggs are shed by females almost from the very beginning of life, and this is continued to the end of the child-bearing period. The age at which menstruation is established varies within wide limits, race peculiarities and temperature being the factors by which it is chiefly influenced. In the northern part of the United States a girl usually menstruates at thirteen or fourteen. If a girl is well developed and has normal tissues, menstrua- tion starts without any unusual experience: there is a discharge of blood with perhaps flushing and heat of the skin; the flow continues a few days and stops. It may recur in twenty-eight days, or the interval may be longer. It may not return for a month or two; but after a few months, if conditions are normal, it settles down to regular intervals. When its appearance is irregular, at intervals that are too long or too short, when it continues but a few hours or lasts longer than a week, when the quantity discharged is trifling or excessive, when it is almost colorless or bright red, disease of some kind is present; and it should be investigated and removed as soon as possible. Women who do not menstruate normally may have a great variety of symptoms, such as acute pain in the region of the inter- nal genital organs, backache, headache, faintness, indigestion, nausea and vomiting, and many others. Normal menstruation leaves a woman in unimpaired condition; abnormal menstruation leaves her weak and spiritless, and in some cases the troubles of one monthly period are barely over before those of another begin. The normal color of menstrual blood is dark blue or brown, because it is mainly venous blood and mingled with mucus, epithelial cells, and glandular secretions. Because of its mixed character it does not clot or coagulate like blood freshly drawn from other parts of the body. It is ordinarily inoffensive in odor; if this is not the case it has not been promptly evacuated from the body, and decomposition has occurred. It is important to be scrupulously clean during menstruation, a napkin of absorbent cotton being worn from beginning to end, and changed as often as cleanliness and decent sanitation require. CONDITIONS PECULIAR TO WOMEN 589 Warm water should be frequently used during the period just as it is required elsewhere when the skin is soiled or stained; cold baths are undesirable, for they will usually arrest the flowing of the blood and stop the period prematurely, but there is ordinarily no objection to warm baths. Many women find menstruation painful and troublesome from the time it first announces itself until it ceases to appear. This is particularly the case with those who do not marry and bear chil- dren, and is due either to defective development of the genital organs or to disease of one kind or another, of which they are victims. It is often cured by suitable medical or surgical treatment or both combined. Many cases are cured by marriage and preg- nancy, which is nature's way of curing defective and undeveloped sexual organs. The Prentatal Instruction of Mothers.-It is only recently that the importance of instructing expectant mothers in the hygiene of pregnancy has been recognized as an essential part of the work of boards of health. But what duty could more positively be paramount? It must not be forgotten that from the moment a woman be- comes pregnant she has entered a new state of being, physiologi- cal, it is true, but subject also to a great many accidents and mis- haps just the same as mishaps may occur to any other physiologi- cal function; to digestion or assimiliation, for instance. When a woman is pregnant she shares her blood-current and all it con- tains with her unborn and developing child; whatever it contains, good or bad, must be contributed to the growing child. An un- healthy mother, whether unhealthy in mind, body, or morals, can- not help impressing her child with more or fewer of her peculiari- ties; and so it happens that disease, or emotional shock, or great strain of any kind is quickly communicated to the unborn child, and very often with fatal result, the mother experiencing what is known as a miscarriage. Everybody has seen children who were born with some kind of a birth-mark or with some defect or deformity which was acquired during the prenatal period, and all because of the intimate relationship between the mother and her unborn baby. A woman who is pregnant ought always to realize not only that she is carrying and developing a child which is going to belong to her-to be her baby-but that it is also going to belong to the 590 HOW TO KEEP WELL state and the country and the world. If she realizes this as she ought, she will be very particular and try very hard to take proper care of herself for the sake of this child. If she is obliged to work at a daily task she will try to spare herself and avoid fatigue as much as possible lest it might harm the baby. She will eat only such food as she can readily digest so that her child may have an abundance for his share. She will try to get plenty of sleep; she will endeavor to avoid worry and exposure to wet and cold; she will not give way to anger and fear or to any evil passion; and she will often meditate and consider that she is the only protector, guide, and friend her child can have as long as she is carrying him within her body. If women would only realize this sacred trust, how much more they would get out of this most beautiful of all physiological conditions, and how much more they would put into it, too, for they would then bring into the world, at least in numberless instances, children who were not handicapped with an inheritance calculated more or less to cripple them through life. It is a good plan for a woman who is pregnant to read one or more good books on maternity. If she is unable to get one which she can understand she should talk freely with some good woman who has had a family of chil- dren and has brought them up under her own guidance, not under the guidance of nurses and servants. It is also a good plan for those who live in cities to take advantage of the clinics which are given by boards of health and maternity associations for the in- struction of those who are about to become mothers. There is now very little cause for a woman to approach par- turition without the knowledge of what she should do for herself and what she should do in anticipation for her baby. And pregnant women ought always to remember that the better their preparation has been, whether through books, friends, doctors, or clinics of instruction, the better will be their chances of having a natural and uneventful labor and a healthy and well-developed child, which should be the ambition of every expectant mother. CHAPTER XXXVII DISEASES OF SURGICAL CHARACTER Abscess.-It is a product of inflammation, and inflammation is the root of most forms of human suffering. In an abscess there is always a peculiar, more or less fluid material called pus. There may be much or little of it, a few drops or a quantity amounting to quarts; and it may be liquid like water or so dense that it is almost solid. Sometimes it is thin and deliquescent; sometimes it is thick like cream; and at others it is cheesy in appearance. It also may be colorless, white, yellow, red, or almost black, accord- ing to the constituents of which it is composed. It is a very com- plex substance, being composed of water, disintegrated muscles or tendon or bone or brain, white blood-cells and bacteria. It may come in any portion of the body, and it is very com- mon in the cellular tissue beneath the skin, the gums, the bones, the brain, the liver, the breast, the rectum, the muscles, and the joints. An abscess is said to be warm or cold, according as it is produced by a variety of pus-forming bacteria or by one kind alone, like that of tuberculosis, for example. An abscess may occur near the surface of the body, or deep within the muscles and tendons and joints, or it may be within the organs, or the great cavities of the body. An example of the first would be a felon; of the second, an abscess of the great muscles of the hip or the knee-joint; of the third, an abscess of the liver; and of the fourth an abscess of the chest-cavity, also called empyema. Abscesses are caused in various ways. The majority are due to the influence of what are called the pus-producing bacteria, of which there are many varieties. Various kinds of injuries to the skin are often contributory. The bacteria may be circulating in the blood or may be upon the skin or in the surrounding atmos- phere; and when the conditions of heat and moisture are favorable 591 592 HOW TO KEEP WELL they locate upon the tissue or within the organ which is to be attacked, grow-for they are vegetable organisms-and with the product of their growth cause the formation of pus. The pressure of this accumulation and its corrosive action cause disintegration of the tissues, which resist its progress. The direc- tion of this pressure often is toward the surface, and finally, if the pressure is sufficient, it bursts through and empties itself. Or a protective capsule may be formed around it, and it may gradually become absorbed. The pain of an abscess is sometimes intolerable. As a rule, the nearer the abscess is to the surface, the more painful is it. Motion is interfered with or destroyed in tissues which are the seat of abscess, and any attempt at motion causes increase of pain. When an abscess is approaching the surface, the tissue becomes soggy and more or less movable, this condition being known as fluctuation. An abscess without bacteria may be produced by the action of caustics of various kinds or by chemical or thermal action. The pain and the poisonous effect of the bacteria in an abscess may cause severe illness, with loss of appetite, emaciation, blood-poisoning, and even very serious consequences. When an abscess is emptied of its pus, nature at once begins to repair the damage, the cavity shrinking, and reparative cells being poured into it from the blood-vessels until complete repara- tion has taken place. Adhesions.-An adhesion is, naturally, that which fastens some- thing to something. Adhesions are important because they are evidences that inflammation has been present, because they often cause pain, and because they sometimes lead to conditions that may be serious or fatal. There are usually two surfaces in prox- imity to each other in order that there may be adhesions. It is possible for adhesions to be on only one surface, but it is not usual. There are two ends to an adhesion by which it is attached. An adhesion may be broad like a band or sheet, or it may be narrow like a string, and the attachments also may be narrow or broad. Adhesions are tissues of low organization. Their tendency, as time progresses, is to shrink and contract and get harder. They may disappear altogether and cease to give any trouble, or they may constrict and strangle the parts to which they are attached. They may come at any period of life, to the unborn babe, and to one who has reached extreme age. In any joint or cavity of the DISEASES OF SURGICAL CHARACTER 593 body there may be adhesions. They are most frequent in the cavities of the chest, the abdomen, and the pelvis. The lining membrane of these cavities is called a serous mem- brane; but those cavities, like the mouth, which are lined with mucous membrane, also may have adhesions. When there is in- flammation associated with a membrane-for instance, pleurisy in the chest and peritonitis in the abdomen-its secretion or lubri- cating product is increased. As the inflammation progresses, this secretion becomes thicker and more sticky, and finally glues and fastens adjacent surfaces together. It is possible for the intestines to be so pinched by contracting adhesions which have formed in many places that serious or even fatal consequences may result. Sometimes one who has abdominal adhesions may be relieved by massage; sometimes a surgical operation may be necessary- especially if there is evidence of obstruction-to cut the offending bands. Constipation must be avoided, and an active life is better than a sedentary one. Bandages and Bandaging.-The object of bandages and bandag- ing is to give support and protection to the structures which are bandaged. Sometimes bandages are merely designed to hold dressings in place. A point which must always be remembered with the utmost exactness is that the blood in the veins, which in general are nearer the surface of the body than the arteries, flows toward the heart; therefore when applying a bandage one must always roll it in the direction of the current of the blood in the veins, from the ends of the toes and fingers toward the body, not from the body toward the fingers and toes. Omission to remember this important point has often led to serious consequences from the interference with the blood-current which has resulted. It is also necessary in applying a bandage to adjust it to the curves and irregularities of the part which is being bandaged. If a bandage merely encircles a part, fold after fold, it will not fit the part smoothly as the circumference changes. This difficulty can be met by bending or reversing the bandage with each turn or fold, or as often as may be required. Burns.-Burns are frequently classified as of the first, second, or third degree, according to their extent and severity; but the results in the different degrees of burning are not the same. A first-degree burn in some individuals might be fatal, especially 594 HOW TO KEEP WELL if a large area were involved, while in others it would not be at all serious. In the simplest burns from any source, no matter how extensive or how limited in area, there are redness, irritation, and even inflammation of the skin, but the skin is not blistered and destroyed. In deeper burns, or those of the second degree, there are blis- tering and extensive inflammation. In burns of the third degree the tissues are charred and destroyed, and the constitutional effects are very profound. The result or outcome depends on the depth and extent of the injury, the susceptibility of the skin to the action of heat, and the general powers of resistance of the patient. It also depends upon individual characteristics, on the part or organ burned, and on the age, sex, and temperament of the patient. If as much as one third or one half of the skin is burned, even to a slight degree, death within twenty-four or forty-eight hours would not be unusual. In the burns of the first degree, in addition to the conditions mentioned, there are also swelling and pain; in some cases there are shock and fever, and at length the dead skin peels off. In burns of the second degree, pain, redness, and swelling are more decided; and there are large or small blisters, which may suppurate and cause very bad sores and sometimes heal very slowly, with great contraction of tissue and extensive scarring. The shock in burns of this character may be profound and attended with ulcer- ation of the mucous membrane of the stomach and intestines, and with congestion of the other viscera. In burns of the third degree, not only is there more or less destruction of tissue by charring, but the constitutional symptoms are severe, all the internal organs are intensely congested, and unconsciousness and death are the usual result. In burns of any degree brain-irritation and convulsions are not unusual consequences; and they are also frequently fol- lowed by pneumonia, bronchitis, and laryngitis. The objects sought in the treatment of burns are the relief of pain, the overcoming of shock, and the restraining and limita- tion of reaction and of congestion and inflammation of the internal organs. If burns are slight the principal object seems to be to protect them from the irritating effects of the air. After being as carefully cleansed as possible, they should be covered with olive- oil or a mixture of linseed-oil and lime-water, or thickly powdered with zinc or bismuth; or if these substances are not available they DISEASES OF SURGICAL CHARACTER 595 may be covered with molasses, flour, or white lead paint. These substances should be spread rather thickly on gauze or cheese- cloth and applied to the burned surface, a thick layer of absorbent cotton being applied over the gauze and properly secured. The fluid in blisters may be withdrawn by means of punctures, but great care must be taken to avoid breaking the skin. Dressings must not be renewed more frequently than is essential for cleanli- ness and healing, and great care must be taken in them, for the procedure is painful and will retard healing unless skilfully done. Skin-grafting is often performed in connection with severe burns to prevent extensive scarring and contraction. In burns which are due to acids, the antidote is, of course, an alkali; and bismuth, bicarbonate of soda, or chalk may be applied. If an acid like carbolic acid has been swallowed, one should give the patient plaster scraped from the wall as quickly as possible, or milk, or white of egg. If, on the other hand, the burn is due to a caustic alkali, a weak acid like vinegar will be the proper antidote. For a few days after a person is burned the diet must be spare and extremely simple, the digestive organs being in- competent to do much work. Thirst may be relieved with ice and water and with sedative drugs if necessary. The bowels must be kept freely open, and enemata are often efficient for this pur- pose. Cellulitis.-Beneath the skin and around and supporting all the organs of the body, with extensions into them which aid in giving them shape and form, is a layer of very sensitive tissue called cellular tissue or connective tissue. This tissue is very susceptible to inflammation and may become inflamed from many causes; when it is inflamed it is called cellulitis. Many of the cases of appendicitis include more or less of the element of cellulitis; so also do cases of the very painful disease of the end of the finger known as felon, some of the knee-joint diseases, diseases of the veins, and a vast number of cases of the painful and often infectious diseases of the upper and lower ex- tremities. The cellulitis which is due to cold may possibly have the cold as a distinct cause, and we constantly see people who suffer with it every winter in the form of cracks and fissures of the fingers and toes, which are extremely painful and often difficult to heal as long as the cold weather continues. But the chief underlying cause in most, if not in all, of the cases of cellulitis in 596 HOW TO KEEP WELL connection with wounds and injuries is the influence of poisonous germs or bacteria. A serious case of cellulitis often occurs from the prick of a needle or an apparently trivial cut with a knife, the needle or the knife bearing poisonous bacteria to the blood of the injured person, these bacteria growing in the blood and producing substances which cause cellulitis. Or we may have a serious case of cellulitis in a woman who has just borne a baby, bacteria being communi- cated to the wounds produced in her confinement and developing, it may be, the disease commonly known as milk-leg, the cellular tissue around the veins of the leg being principally involved, while poisons, generated by the bacteria, circulate also through the entire blood-current. Suppose the disease develops from a slight wound; let us say, in a finger. The wound is small and can scarcely be seen. In a day or two the finger begins to swell and be painful; the swelling extends to the elbow, the arm, the shoulder; the glands at the elbow and armpit enlarge and become very painful; red lines make their appearance along the skin of the arm, indicating the involve- ment of the lymphatics. The patient has fever and rapid pulse and perhaps frequently recurring chills; he feels very weak and sick; and finally throbbing and fluctuation at the side of the wound indicate the formation of pus. The thing to do in such cases is to relieve the pain by anodyne drugs internally and soothing applications to the diseased limb, maintain the strength by a sufficient quantity of fluid food, enjoin as complete rest as possible, and encourage sleep. When suppura- tion occurs, the pus must be drained away by a suitable incision. Complete recovery may not occur for weeks or months. It is a question of maintaining the patient's strength until the reparative elements in his blood have outworn or destroyed the poisonous elements which have produced the disease and until recuperation and convalescence have restored him to his normal condition. Dislocations.-By a dislocation is usually meant the displace- ment of a bone from the position in a joint in which it belongs. There may be dislocations or displacements of muscles or of organs or of almost any portion of the body, for none of the tissues is so firmly fixed that it may not be moved from the place where it belongs by violence or disease. If there were no joints or if the joints were rigid the majority DISEASES OF SURGICAL CHARACTER 597 of the useful motions of the body would be difficult or impos- sible. Hence the absolute indispensability that the integrity of the joints be maintained; that is, that the bones which constitute them move in their sockets and in their proper planes. When a bone is thrown out of its socket or its proper plane by violence or dis- ease the whole function of the joint is thrown out of gear; there may be intense pain and inflammation; the whole body may suf- fer in consequence; and the patient becomes crippled and more or less helpless in so far as this particular bone and joint are con- cerned. Some dislocations can be corrected by the individual sufferer. There is no inconsiderable number of cases of loose-jointed per- sons who can dislocate certain bones at will and replace them by means of suitable motions which experience has taught them. There are other persons whose bones are displaced by very little violence, even by so little as turning over in bed, and who are unable to replace them themselves, though replacement is not dif- ficult for one who clearly understands the relation of the displaced bone to the surrounding tissues. There are still others whose bones are dislocated by violence, the head of the bone becoming wedged in the contiguous tissues. Only by the exercise of judicious manipulations and a clear understanding of the mechanical prob- lems involved can proper replacement be made in such cases. There are some diseases which produce dislocations. For instance, a malignant growth may develop in a joint and gradually force the head of one or both of the bones forming the joint out of their position. Many children are born with dislocation of certain bones, as a congenital defect, or the dislocation may be produced in the pro- cess of bringing the child into the world. The commonest varieties of dislocation are at the hip-joint and shoulder-joint. The collar- bone, the lower jaw, and the fingers also are frequently subject to this accident. Less frequent are dislocation of the elbow, knee, and knee-cap. There are, of course, other varieties, but they are infrequent compared with those which have been mentioned. In addition to pain, swelling, and inflammation, as the result of a dislocation, there is more or less hemorrhage when the acci- dent is due to violence; and the force which displaces the bone also tears tissues and ruptures more or fewer blood-vessels. The evidence of the hemorrhage may be a blue or black and blue spot, 598 HOW TO KEEP WELL or it may be sufficient to cause a distinct swelling. In some cases a large artery may be injured, and then the resulting hemorrhage may be of a serious character. When a dislocation occurs it is desirable to have the bone reduced or replaced as soon as possible. The bone having been replaced, it is immobilized by splints or casts, and a chance is given nature to repair the damage done. Usually three or four weeks are required before the use of the bone may be cautiously resumed. With the development of X-ray treatment one can readily determine whether the treatment of the dislocation has been successful and the joint restored to normal conditions. Fractures.-Bone is normally a very firm, hard substance, sometimes as hard as a rock; moreover, it is, in the majority of instances, surrounded and protected by other tissues. But it is not equally hard in all cases; in children it is softer than in adults, and in the aged it is brittle. In certain diseases like rickets and the curious disease known as osteomalacia, it is so soft that those who have these diseases are constantly getting into trouble, and are almost afraid to move lest some mishap occur to their bones. How is the bone broken? In the great majority of cases by the application of force or violence to it, directly or indirectly. Sometimes the violence is so great that it crushes the bone, as in a railroad accident; sometimes it breaks it into two or more pieces, as you would break a stick, with more or less displacement of the pieces; and sometimes it merely cracks it, but injures it sufficiently to prevent its owner from using it. The bones of children frequently do not break completely, but unevenly and imperfectly, as a green stick breaks; finally, when the bones are soft and fragile, they simply come apart or crumble when sufficient force is applied to them; and it may not require very much force, either. When the force is applied directly the bones may be crushed, as when one is struck on the head with a heavy hammer, or the leg is hit by an exploding shell, or one falls from a height and lands on his feet; or it may be split or divided, as when a heavy blow is received on the collar-bone, or when in falling one lands upon the wrist or arm or elbow. When the force is indirect it may be received upon one portion of the body and conveyed to another portion, and the bone may be broken where the force is spent; thus in an automobile accident the body may be struck, but in such a way that the force is con- DISEASES OF SURGICAL CHARACTER 599 veyed to the head and the skull fractured. The violence may be such that there is no immediate evidence of it upon the surface, though swelling and discoloration are almost certain to appear subsequently, or the skin and muscles may be torn and mangled. The first of these is called a simple, the second a compound frac- ture ; and the latter is usually by far the more serious and abound- ing in complications. Some occupations are essentially dangerous, those who practise them being constantly exposed to the risk of breaking their bones, such as carpenters, painters, bricklayers, and workers on steel-frame buildings; and it is only right and just that the lives of such workers should be insured as a part of their compensa- tion. Old people are particularly liable to fracture at the hip- joint, even though the violence exercised be of the slightest degree, on account of degenerative changes which have taken place in the bones and the mechanical disadvantage of that portion of the bone which is usually broken. Children are frequently victims of frac- tures of every variety because of the risks they are constantly taking in their games and sports. How can you tell that bone is broken? The bones are means by which motion of the body is accomplished. Assuming that violence of some kind has been received upon some portion of the body, the first thing that is noticed, if a bone has been broken, is that motion of that portion of the body is impossible or very nearly so. The response to an attempt to move is pain, and there may also be pain without any such attempt. Very soon there is discoloration, if the skin remains unbroken: or if the skin is bruised and ruptured there is bleeding; and this may be profuse if large vessels have been broken. The injured parts swell and the muscles contract and become rigid. If the bone is merely cracked or splintered it is often difficult to say precisely how much damage has been received, the same being true if the bone has been shattered and the ends driven into each other, or impacted. But if the fracture is complete and the ends of the pieces are detached from each other, the moving of one or both of these pieces by the hands of the examining doctor declares that the bone is no longer whole; and if the two ends are rubbed gently against each other a peculiar, creaking sound, called crepitus, is elicited, the meaning of which is familiar to every well- informed doctor. 600 HOW TO KEEP WELL Now comes the question of putting the ends of the bone into such proper relations that the healing will take place without deformity, so that the functions of the bone may be restored to normal conditions. This is called the reduction or setting of the bone, and it is a very important and nice procedure. At the present time we have the inestimable advantage of the X-ray, which gives us a picture of the wounded tissues and shows whether the ends of the bone are in correct relation to each other. If they are in such position-and the picture is incontrovertible evidence of it- the doctor who does the setting has a bulwark of defense against any charges that he has done his work unskilfully or improperly. The next thing, assuming that the skin and any wounds that have been present have been properly cleansed and dressed, is the preparation of the injured tissues for the healing process. Suitable bandages and splints or supports are applied to im- mobilize the broken bone, and complete rest is enforced until the ends have healed or knit together, a process requiring variable periods of time, but several weeks at least. As soon as the setting is completed nature at once goes to work to repair the damage done. Millions of repair-cells are thrown as a bridge across the divided ends of the bone, entirely covering it in, with plenty of material to spare. This cement or sticking material is called callus, and when the process is complete the bone may be almost if not quite as strong as it was originally. The Household Medicine-Chest.-Appliances for surgical pur- poses may be multiplied indefinitely, but there are a few which should be in every household in a chest or closet reserved for this purpose. And this is especially important if such supplies are not easily obtainable. They may never be required; if so, the outlay has been small. If required in a hurry, they may be of priceless value. Small pocket-case of surgical instruments containing scissors, needles, silk, knife, dressing-forceps, artery-forceps, probe, catheter. Rubber bag for hot water-indispensable for applying heat quickly and effectively to the body. Fountain-syringe-rubber, with nozzles of different sizes. Absorbent cotton-half-pound package. Sterilized gauze-one-yard package. Squibb's ether-eight-ounce can. DISEASES OF SURGICAL CHARACTER 601 Muslin bandages-three inches wide, half a dozen. Smelling-salts-one-ounce bottle. Mustard-leaves-can containing half a dozen. Rubber plaster-two inches wide, one roll. Collodion-two-ounce bottle, to cover scratches and small wounds. Paregoric-two-ounce bottle, for pain, diarrhea, etc. Tablets of bichloride of mercury-bottle containing twenty- five, for making solution for cleansing hands, wounds, etc. Oxide of zinc ointment-two ounces. Peroxide of hydrogen-four-ounce bottle. Vaseline-two-ounce jar. Antipyrine-one ounce to arrest bleeding. Lead and opium lotion-four-ounce bottle to relieve pain, re- duce swelling, etc. Scrubbing-brush-three or four inches long, absolutely clean, kept wrapped in sterile gauze or rubber tissue. With these and a few other simple appliances which may be found in almost every house, one is prepared to meet ordinary injuries without much hesitation. It may seem superfluous to say that every house should always keep on hand for emergencies clean towels and sheets, a square yard of rubber sheeting, Castile soap, and means for heating water rapidly. Many things about the house can be quickly extemporized for surgical purposes, such as cigar-boxes (as splints for broken limbs), ladders, barrels, bottles, jugs, bricks, tea-kettles, etc. Immediate Care of the Injured.-A person who has been injured must be placed in as comfortable a position as possible, flat upon the back if the injury has been more than a mere trifle. He should have plenty of air and should be fanned if he is faint. Tight clothing must be loosened, especially at the neck. Torn or injured clothing must be removed, cut away if necessary, es- pecially if it should interfere with the examination and treatment of the injured part. If a wound has been received it must be gently cleansed of blood and anything else which may have soiled or defiled it. If the blood is flowing it may usually be checked temporarily by firm pressure with the fingers. Blood from the veins flows out in a continuous stream; blood from the arteries spurts out in an intermittent jet. Blood from the veins goes toward 602 HOW TO KEEP WELL the heart; blood from the arteries goes away from the heart; this should be remembered if one ties a bandage or handkerchief around a bleeding part. If limbs are broken or displaced they should be restored to their correct position if this can be done without violence. An injured person is usually thirsty, and a moderate quantity of water can be given to him, or he may inhale smelling-salts, or, if an adult, alcohol in the form of whisky or brandy with water may be given. Nothing will spur the weakened heart to action more quickly than alcohol. Peritonitis.-It means inflammation of the peritoneum. What is the peritoneum? The peritoneum is the membrane which lines the abdominal and pelvic cavities in which are located the stomach, pancreas, liver, spleen, intestines, bladder, kidneys, and in the female the all-important reproductive organs. It also covers the lower surface of the diaphragm, the muscular wall between the abdominal cavity and the chest-cavity which contains the lungs and heart. It is, therefore, a tissue of tremendous extent, and if it were all removed and cut into a narrow strip it could easily make a strip a hundred feet or more in length. Fortunately the number of cases in which all this great membrane is inflamed is comparatively small, and when such a thing does occur you might as well throw up the sponge; for though cases of this kind, called general peri- tonitis, have often been reported as cured, it is quite possible that the peritoneum may not have been so universally involved as was supposed by those who reported them. This disease may come suddenly, develop rapidly, and reach its climax in three or four days or a week. If the patient survives a week, he is very likely to improve and perhaps get well, a great deal depending upon his resisting power. This is called acute peritonitis. If the inflammation drags along through weeks and months, improvement alternating with relapse, it is called chronic peritonitis and is almost always one of the manifestations of tuber- culosis. Appendicitis, in many cases, probably in the majority of them, is nothing but peritonitis, the inflammation taking in the peri- toneum of the appendix with more or less of the structures adjacent to it. Peritonitis used to be known as inflammation of the bowels; the ancient doctors could do very little with it, and when a person DISEASES OF SURGICAL CHARACTER 603 got it he usually died unless the powers of nature were sufficient to overcome the violence of the disease. Then came the glorious period of antisepsis and asepsis when this disease was found to be the product of germs and the poisons made by them. By eliminating these it has been found possible to prevent or control peritonitis. The disease may be caused in many ways: something you cannot digest may stir up trouble in your stomach or intestines; the germs which were taken in or were there already develop and cause inflammation; and this extends from the mucous membrane, or inside, to the peritoneum, or outside; or a surgeon may cut the peritoneum in order to get at an abdominal tumor which he wishes to remove, and introduces germs in so doing. The first intimation of this disease is pain, apparently in the intestines. It soon becomes sharp and cuts like a knife; with it there may be nausea and vomiting and great weakness and dis- tress over the entire body. In a longer or shorter time gases are developed in the intestine which swell it out like a balloon. The intestines often become quite paralyzed so that nothing will pass through them. If this paralysis cannot be overcome, the patient will almost surely die. Sometimes the bowels burst or rupture, and then death will quickly result; sometimes pus forms in the abdomen by the quart, and the abdominal cavity becomes a huge abscess; rarely there is hemorrhage, which comes most frequently in the peritonitis which accompanies typhoid fever. Scars.-Scars are the result of wounds and injuries to tissues, whether upon the skin, the skeleton, or the organs and tissues in the interior of the body. All these tissues are susceptible to injury, and all heal by the formation of a scar or of scar-tissue; this is nature's method of healing a wound; that is, of closing a gap which has been made. As soon as a wound or injury is received, nature proceeds to fill up the gap. The blood-vessels in the tissues surrounding the injury pour, through openings in their walls, reparative cells in unlimited numbers, which attach themselves to the sides and bottom of the injured tissues. The sides of the wound also contract, and by degrees the hole is filled. Not content with merely filling the hole, nature heaps up 'the repair-cells above the surrounding surface. The cavity is thus filled with a more or less thick wall of new tissues called scar-tissue, and the part which appears at the surface 604 HOW TO KEEP WELL is the visible scar. This tissue is at first soft and plastic; you could easily pull it apart. But by degrees it becomes harder, and after a sufficient length of time it is too strong and firm to be pulled apart. The scar at the surface also contracts and hardens. Sometimes it shrinks away so that it is barely visible; at other times it remains raised and is ugly and disfiguring. It may even form a kind of tumor, which is known by the name of keloid. When the conditions of the wound are favorable and there is no attack by infectious germs, especially if the wound is a small one, union takes place in a few days; and this is called union by first intention. When the wound is a large and irregular one, with widely separated sides, when the person who has the wound suffers from infectious disease, or when disease-germs find their way into the wound, the process of healing is indefinitely lengthened, there is more or less abundant suppuration, and if healing finally occurs the scar is a disfiguring one and the scar- tissue has poor resistance and may break down at any time. In some cases the conditions which have to do with repair are so bad that healing never takes place; there is just an open wound discharging an offensive fluid, which lasts indefinitely, to the great detriment, of course, of the patient. This form of healing is known as healing by granulation, and the great aim of surgeons is always to prevent it if possible, but there are some cases where it seems impossible to prevent it. Scars and scar-tissue are furnished with nerves and blood- vessels like other tissues, but less abundantly and less perfectly, so that they are always inferior in quality, even at their best, and always to be avoided if possible. Scars are not only disfiguring, but they often interfere with motion, and when connected with organs they may interfere with their function. They are more sensitive to heat and cold than other tissues, and are the seat of great pain sometimes, particularly when they include and pinch one or more nerves. Scar-tissue may also degenerate and become the seat of malignant disease, and when it does thus degenerate the malignant disease may proceed rapidly because of its poor resisting power. Shock.-Any severe injury, whether accidental or effected de- liberately and intentionally by the surgeon, is followed by more or less depression of the vital forces. The nervous centers of the body are particularly involved in such injuries, and the effect which DISEASES OF SURGICAL CHARACTER 605 is produced is called shock. Those who are highly developed and are sensitive in mind and body suffer more keenly from shock than do others; and the resulting depression may be so profound that death will result as the immediate consequence, the vital organs being unable to react from the staggering blow which has been administered. Especially serious on account of the shock which is experienced are accidents in which the body is crushed or mangled, limbs torn away, finger- or toe-nails pulled out, severe burns received, and also those operations in which much blood is lost, limbs removed near the body, or the great cavities of the body, the head, chest, abdomen, and pelvis opened. All opera- tions upon the vital organs of the body are of this order, those in which the intestines are manipulated being particularly severe. The symptoms of this condition are well-marked pallor of the skin, cold sweating, chilliness of the extremities, sighing, shallow respiration, great thirst, and a weak, almost imperceptible pulse. Vomiting and involuntary evacuation of the bowels and bladder are less frequent than the other symptoms which have been men- tioned. Heat is one of the most important remedies and may be applied to the extremities and the sides of the body by means of water- bags, bottles containing hot water, bricks, etc. These must be protected with towels or cloths, or severe burns may be inflicted. The patient is usually unconscious or nearly so and cannot make complaint at the time. An injection into the rectum of a quart of hot salt-water (two teaspoonfuls of salt to the quart) may be slowly made and re- peated every two or three hours if required. The temperature of the water must be such that the hand can be held in it (ioo° to uo° F.) Whisky or brandy may be injected under the skin with a hypo- dermic syringe, a teaspoonful or two being used and repeated in half an hour, if necessary, to spur up the heart-action. If strychnia is at hand, one thirtieth of a grain dissolved in twenty drops of hot water may be injected under the skin; and this may be repeated every hour or two until the heart-action is improved. The patient should be wrapped in blankets and may be fanned if he complains of difficulty in breathing. Death may result in an hour or two in spite of all exertions or may be deferred for twenty-four hours or more. On the other 606 HOW TO KEEP WELL hand, the patient may rally in a few hours or within a day or two. Many cases of shock are now treated successfully by trans- fusion of blood. It is always important that the blood of the one who is giving it should be suitable for the requirements of the recipient. This subject is discussed in the chapter on Some Special Methods of Treatment. (Chapter XXXVIII.) Some of the Minor Procedures Which Are Often Very Useful Counter-irritation is frequently a very useful measure. It means the production of an irritation to relieve an irritation somewhere else. The most familiar illustration is that of the mustard-plaster, which produces a blister of the skin over the stomach for the pur- pose of relieving irritation within the stomach. Blisters may also be produced by the action of heat (thermocautery, electrocautery, etc.) by various drugs including iodine, Spanish flies, sulphuric acid, etc. Leeching is still occasionally resorted to for the purpose of re- moving a small quantity of blood from congested and inflamed tissues. One or more leeches are applied to the surface and al- lowed to absorb the blood until each has filled himself and dropped off. The effect of this kind of treatment is often very beneficial, relieving the pain of turgid and swollen tissues and probably re- moving an appreciable quantity of poisonous material. Cupping is a procedure which is less frequently used than formerly. It consists in applying one or more cupping-glasses upon the skin, exhausting the air which is within them, and thus, by derivation as it is called, bringing to the surface a considerable volume of blood, which is supposed to be drawn away from a part where it was circulating in excessive quantity. This is also a species of counter-irritation. It is called dry-cupping when the skin alone is raised by the exhaustion of the air, wet-cupping when the skin has first been scarified. After the air has been exhausted the internal pressure forces a quantity of blood through the scari- fications which have been made. In other words, it is like leech- ing, a method of removing blood from the body. Poulticing. The object of poultices is to supply heat to the body. The typical poultice of former times was made of flaxseed- meal, to which boiling water was added so as to make a thick DISEASES OF SURGICAL CHARACTER 607 mush. It was then wrapped in muslin and applied to inflamed tissues to relieve pain. It was heavy, dirty, and, as soon as it became cold, disagreeable. Other substances for applying heat in the form of a poultice are salt, bran, hops, etc. Heat may also be applied by means of bricks, electric pads, glass bottles, rubber bags, etc. The electric pad is a very useful contrivance and should be in every household. It can be used on any portion of the body and is cleaner, safer, and more readily available than any other substance or apparatus. Emetics. These are substances which are used to produce vomit- ing. When the stomach is more or less filled with food which is neither being digested nor propelled into the intestine, it is well to empty it and start anew. The stomach, having had a rest, may do the work better thereafter. A glass of lukewarm water will often act promptly as an emetic. This having failed, another glass may be taken in which half a teaspoonful of mustard has been stirred. The Cautery. This term refers to various metallic substances which are heated by means of heating agencies until they glow, and are then applied to tissues to destroy them or to blister them, or to render them incapable of receiving or extending disease. The cautery, or actual cautery as it is called, may be used to stop bleeding, to relieve pain by counter-irritation, to destroy diseased tissue, and for various other purposes. Cold Applications. Cold may be applied to the body in the form of baths, ice-bags, cloths dipped in ice-water and then wrung out, a coil of rubber tubing through which a stream of water is allowed to run, etc. Its principal uses are to relieve pain, reduce congestion, and lower fever. Care must be taken to avoid chilling the surface so much and for so long a time that the vitality of the tissue will be destroyed. This occurs when the tissue is frozen. Some of the purposes to which cold is applied are the following: A person with sunstroke may be immersed in a cold bath (500 to 6o° F.) to reduce the heat of the body. One who is suffering with fever after a severe surgical operation may be sponged off with ice-water. Severe pain in the head may often be relieved by the use of a rubber bag containing ice applied to the head. The rubber coil may be laid upon the abdomen during the fever which may follow a severe operation and water at 400 to 500 F. allowed to run through it continually. Fever may also be reduced by 608 HOW TO KEEP WELL wrapping the patient in a sheet which has been wrung out of cold water, the heat of the body being thus rapidly abstracted. This is called the cold pack. Many other measures by which cold can be applied to the body will readily suggest themselves. Suffocation.-Other terms for this accident are strangling, asphyxia, etc. It means an absence of the functional action of the lungs whereby oxygen is supplied to the blood, or the result of in- troduction into the blood through the lungs of gaseous material which is destructive to life. Suffocation may be complete or partial; the former ends in death; the latter is often recovered from. The heart may continue to beat after the lungs have ceased to expand and contract, but when the latter has continued a minute, or a number of minutes, the vital oxygen being absent or deficient, death will surely result. So also, if the pneumogastric nerve be cut or the center of respiration in the medulla oblongata be injured, respiration will stop at once, and death will ensue. Suffocation may be accomplished in a great variety of ways; it often comes in the process of birth, the impulse to breathe being present as soon as the child's head emerges into the world, but rendered ineffectual by the navel-cord around its neck, the mucus in its throat, etc. (The methods by which resuscitation may be accomplished are mentioned elsewhere. See Methods of Artificial Respiration, p. 609.) A very common method of suffocation consists in drowning, the water filling the stomach and air-passages and of course prevent- ing the entrance of air. Again the inhalation of a foul gas, illu- minating-gas, carbonic acid gas which is exhaled from the lungs, chlorine gas, and many other poisonous gases produces suffocation by displacing the life-giving oxygen. The deadly influence of poisoning by noxious gases was abundantly demonstrated in the World War. When one is strangled by hanging, death may come from shut- ting off the supply of oxygen, or by the injury to the center of respiration in the spinal cord (medulla oblongata). When one is poisoned by opium the respirations become very slow, three or four a minute; enough oxygen is not inhaled for the requirements of the blood; the blood is therefore gradually poisoned; but death may not occur for two or three days, the intoxication of the blood and the vital centers taking place very gradually. The indication, therefore, when one is suffocated or partially suffocated is to restore the rhythmical action of the lungs, DISEASES OF SURGICAL CHARACTER 609 their rising and falling, and to supply the essential oxygen without which all other contributions will be useless. Methods of Artificial Respiration.-When a new-born infant has failed to breathe, or when breathing fails with one at any age, the simplest expedient is Laborde's method of tongue-traction. This consists in grasping the tip of the tongue with the fingers or with forceps, drawing it forward out of the mouth, and then replacing it, doing this rhythmically, methodically, twenty or thirty times a minute. In many cases it has seemed to stimulate the respiratory nerve (recurrent laryngeal) and revive the res- piratory action of the lungs. It has been successfully used many times and can do no harm. When one is dying from poison and the respirations are only three or four per minute, the latter may often be stimulated and quickened by means of the faradic current, one pole being held over the diaphragm while the other is passed along the side of the neck at intervals of two or three seconds, thus stimulating the pneumogastric nerve. In suffocation from drowning the first thing to do is to get rid of the water which is in the stomach and air-passages. The patient may be turned upside down, rolled from side to side, or laid over a barrel with head down and the barrel rolled backward and forward, thus squeezing the water out. The patient should then be laid on the back, the head being lower than the rest of the body, while the operator stands at the side, grasps both hands, and raises them forward and upward as high over the head as possible. After holding them there a minute he brings them down until the arms are at right angles with the body and then brings the hands and forearms forward upon the chest, compressing the chest gently and firmly. The first movement opens the chest to its fullest capacity to let the air in; the second forces the air out. This may be repeated fifteen or twenty times per minute, and in many cases respiration will be restored after more or less exertion. It is as simple and easy a method as any. Surgical Nursing.-Closely associated with antiseptic and aseptic surgery is the modern surgical nurse. Whether male or female, he or she can do much to insure success or failure to the work of the surgeon. When an operation is completed and the patient has received the proper attention after being placed in bed, the nurse's work will be to clear away all soiled material and restore the room as 610 HOW TO KEEP WELL quickly as possible to the utmost degree of cleanliness. During the subsequent history of the case cleanliness is to be the watch- word and the gospel. Special orders will come from the surgeon as the conditions may require. She must not murmur nor com- plain though the hours of service be long, expecting at the same time that the surgeon, who is her chief, will see that she is not imposed upon, and that she will have suitable opportunities for rest and exercise. She must interfere as little as possible with the regular work of the household and by her courtesy and good nature diffuse sunshine not only in the sick-room but in the kitchen or to whatever part of the house her duty may call her. A nurse has the power to become a good angel in a household or to become a nuisance. There are very many of the former. Sunstroke.-We mean heat-stroke when we say sunstroke, be- cause it is intense heat within the body which burns it and pros- trates it. The direct rays of the sun upon the body, especially upon the head, may overheat it. They will do it more quickly when the air is muggy or full of moisture, and even more quickly when it is very still, when not a leaf is stirring. One who lies down and sleeps in the sun is more apt to be sunstruck than one who is sitting or standing and more or less in motion. That is why those who get drunk and fall asleep lying in the sun are so often sunstruck; that is also the reason why you seldom hear of a farmer being sunstruck. Those who work or sleep where the air is very close and hot run the same risk as those who are exposed to the hot sun. Such are miners, stokers, iron-workers, bakers, workers in tunnels, and all who work in the tropics. The hours in such occupations should never be long if heat-stroke is to be avoided. Heat alone will seldom paralyze; dry heat, like dry cold, may be intense but not unbearable, and there are those who insist that it is even enjoy- able. If heat is dry, and particularly if it is in motion, we can stand it to a very high degree. Now, what happens when one is sunstruck or heat-struck? If we make a fire under a pot of water, the pot will be heated, and so will the water. So if we expose the body to a source of heat, its temperature will rise, and also that of the blood which is in it. If the heating process is continued long enough, the blood-vessels become paralyzed, the blood accumulates in the veins and lungs, and the pumping action of the heart becomes insufficient to force DISEASES OF SURGICAL CHARACTER 611 the blood all the way around the body. This means that the heart is paralyzed, and then the person becomes suffocated because enough air cannot get into the lungs, or the suffocation may result because the excess of blood in the vessels of the brain presses upon the nerves which control the act of breathing. Death usually comes very quickly after sunstroke or heat-stroke, and there is no time to lose if we expect to restore the patient to life. The attack begins with headache, faintness, dizziness, and weak- ness; the pulse becomes very rapid, and the body-temperature rises; sometimes it rises ten or twelve degrees before death oc- curs. The skin is usually dry and hot, and the patient may have convulsions or delirium. Two things must be thought of for the immediate relief of one who has been sunstruck: lowering the temperature, and raising the heart-action. The first is done by loosening or removing the clothing, sprinkling or sponging the whole body with cold water, in a bath-tub if possible, and applying cold cloths or sponges to the head. The second is accomplished by applying heat to the feet, especially if they are cold, as is usually the case, and a mus- tard-leaf to the calf of each leg. If the person is conscious you must let him inhale ammonia or camphor, or swallow some water containing one of these drugs. If whisky or brandy and water are injected hypodermically or into the rectum they will stimulate more quickly than in any other way. Vigorous rubbing of the body and extremities is also a very useful procedure. As soon as the patient has reacted a cup of hot, strong coffee or hot milk should be given. Keep the head cool and the feet warm, and you will seldom suffer from this trouble, especially if you sweat very freely. Above all things as preventive measures, an abundance of sleep, simple and easily digested food, plenty of water to drink, an open con- dition of the bowels, and loose and light clothing are necessary. Tetanus, or Lockjaw.-It is the product of a particular bacillus which normally inhabits the intestine of cows, sheep, and horses and is discharged with the contents of the intestine. Hence it is to be found in barn-yards and stables, wherever there is manure or ground which is more or less impregnated with manure. It is one of the bacteria which are called anaerobic; that is, they live apart from the immediate presence and action of oxygen. It is also hard to kill, defying influences which are fatal to many other 612 HOW TO KEEP WELL varieties of bacteria. It may exist free in the atmosphere, or in the dried pus of an infected wound, or on the walls and floor of hospitals. It may occur in the intestinal discharge of human beings, especially those who are employed in caring for animals, like grooms and hostlers, such people being carriers of the germ and immune to it, just as certain people carry and are immune to the germ of typhoid fever. The bacillus has a spore at one end which will develop when it finds the proper anaerobic conditions in a wound. If the wound is an open one and exposed to oxygen, neither the spore nor the bacillus will develop in it, but if oxygen is excluded from the wound the disease may develop in it. If the bacilli enter the blood-stream they may be destroyed by the oxygen in the hemoglobin or by the white blood-corpuscles, and in such cases of course tetanus does not develop. When a wound suppurates, producing nitrogen, carbureted and sulphureted hydrogen, but not oxygen, the bacilli will grow in the pus and develop their poison, which will be absorbed by the nerve- tissue of the brain and spinal cord, and tetanus will ensue. The bacilli remain in the vicinity of the suppurating wound, but their poisonous products are taken up by the blood and deposited in the cells of the nerve-tissues to which they have been carried. Wounds of the hands and feet are those which are most likely to result in tetanus, the germs being derived not only from manure and soil, but from rusty nails, manure-forks, surgical imstruments, frost-bites, splinters, scratches by pins, etc. After the tetanus-germs have been introduced into a wound in which the conditions favor their development, there is an incubation period of ten or fifteen days. Then the muscles of the neck and those which control chewing suddenly become rigid, and the patient yawns frequently, has a chill, and has great pain in the wound. Presently the muscles in the vicinity of the wound twitch, and those of the jaw become fixed, the mouth becoming firmly closed or locked. There are horrible grimaces of the face; the head is drawn back, while the body is bent backward, for- ward, or sidewise, these spasms being extremely painful. In the milder form of the disease, called tetany, there are spasms of the hands, arms, feet, and legs. The muscles may relax, but the spasm is renewed upon the slightest provocation, such as a draft of air or a sudden noise. The muscles of the throat and wind- DISEASES OF SURGICAL CHARACTER 613 pipe may contract so rigidly that the victim will be choked to death. All this time the patient is sweating profusely, his heart beats violently, and his temperature is high; but his mind may remain clear to the very end. Death may come in a few days or a few weeks from suffocation, dilatation of the heart, or exhaustion. Formerly all cases were fatal. Now the mortality is from fifty to eighty per cent. Prevention is the great thing in this disease, and children, in particular, should be warned of the dangers lurking in the causes which have been specified. After every injury, no matter how slight, from knife, splinter, or nail, and after every bruise which makes an open wound, the tissues should be washed and cleaned with hot water, then thoroughly irrigated with strong peroxide of hydrogen, and finally touched with pure carbolic acid, which is as efficient as any antiseptic in destroying tetanus-germs. Tetanus antitoxin has made some headway in reducing the mortality of the disease, but it is not uniformly effective. In this disease a nurse or a doctor, or both, must be in constant attendance night and day, for it is only by persistent fighting that any chance of overcoming the disease is even remotely possible. Ulcers.-An ulcer is merely a sore upon the skin or mucous membrane, or in other words a breaking down of the different layers of cells; and very often it is a sore which shows little ten- dency to get well. It may even go deeper than the skin and eat or corrode all the tissues, including the bones which may be in its course. Ulcers differ distinctly from healthy wounds or sores, which begin to get well as soon as they are formed. Ulcers may be caused by injury, by burns, by diseases like cancer, lupus, syphilis, and tuberculosis, or by poor nutrition in the tissues from any cause whatsoever. They are accompanied by sloughing or destruction of the tissues and sometimes by reabsorption of dead and poisonous material. Not infrequently an ulcerating sore cor- rodes through blood-vessels, and more or less profuse bleeding may occur in consequence; or the individual may suffer great weakness on account of the prolonged discharge which flows from it causing waste of tissue without proper power of repair. The treatment of ulcers should therefore be constitutional to build up the general condition as well as local to try to heal the sore. Constitutional treatment will include suitable hygienic measures, comfortable and well-ventilated apartments, sleep, exer- 614 HOW TO KEEP WELL cise out of doors, good food, particularly milk, and tonics like cod-liver oil, quinine, strychnia, and iron. Locally the ulcer should be kept clean by frequent dressings, with the application of ap- propriate astringent and antiseptic substances, especially the minerals lead, copper, zinc, mercury, and silver. Inflammation of the Urethra.-This important tube is very frequently the seat of inflammatory disease which narrows its caliber, prevents the free discharge of the urine, and may lead to a serious and even fatal disease in the urinary apparatus, the bladder, ureters, and kidneys. It may be due to injuries, but in the vast majority of cases it is caused by the poison of venereal disease. It may be attended by great pain, especially during uri- nation, and the contraction of the canal may be so great that urination becomes difficult or impossible. The urine must then be drawn with a catheter, while the contracted tube is dilated by means of steel instruments (sounds) passed through it; or the stricture may be cut and the urethra then treated to a system of dilatation. Wounds.-What may be understood by the word "wound"? It is any kind of an injury in which the skin is broken and the underlying tissues exposed. A bump in which there is only swelling and discoloration is not a wound; neither is a broken bone, unless with it there has also been a bruise or cut of the skin. Cuts of all kinds are wounds, whether made with a sharp or a dull instrument, whether the skin and the muscles are cleanly divided or gashed and lacerated. Bullets of all kinds produce wounds, and so do all kinds of explosive missiles and all kinds of puncturing instruments. A wound may be no larger than the point of a needle, or it may lay open the body from one end to the other. Wounds are accidental or intentional. A prick of a pin or a sliver under the skin or a cut with a razor when shaving may cause an accidental wound; an injury in battle by a cut, a stab, a bullet, or a shell is an intentional wound. The amount of injury done by a wound does not depend upon its size. One may die from the shock of great injuries, like shell- woUnds or bayonet-thrusts or injuries which come in battle to the vital organs-the brain, heart, lungs, or intestines-or one may die from the loss of blood before help can reach him. But death is just as certain from the poisoned wound on the tip of the sur- geon's finger, produced by a scratch or a dirty knife, or by the DISEASES OF SURGICAL CHARACTER 615 puncture of a needle which carried malign bacteria upon its point. The greatest or nearly the greatest discovery of the nineteenth century was that serious and often fatal disease is transmitted to an open wound by means of bacteria upon persons and things, and that if a wound is properly protected against the bacteria upon such persons and things the disease will not take place, and the wounded person will get well. That meant the annual saving of the lives of thousands of mothers and new-born babies when doctors learned how to keep themselves clean in the lying-in cham- ber. It also meant the rapid recovery of hundreds and thousands of men, women, and children upon whom surgical operations were performed, who but for this discovery would have been sick in bed for months, even if they recovered at all; and finally it meant the quick restoration to health of thousands and tens of thousands of soldiers injured upon the battle-field, whose wounds would have become infected and whom death would have stared in the face if old methods of treatment had not been superseded. Infected Wounds.-What is the difference between a wound that is infected and one that is not infected? The difference is all-important, for it means, on the one hand, prolonged illness, very often an imperfectly healed wound, with possible distortion or deformity, and perhaps a fatal issue, and on the other prompt healing with firmly united tissues, and restoration of function and health, unless some kind of complication sets in. What is infection? The term is defined as an invasion by living disease-producing micro-organisms of any portion of the body where the conditions are favorable to their growth and from which the poison they produce may be carried by the blood and lymph to various portions of the body. These micro-organisms may be either vegetables or animals. If they are vegetables, they are called bacteria; if they are animals, they are of the lowest order, called protozoa. It is not always easy to tell how bacteria and protozoa get into the body and cause disease, but when we have the exposed tissues of a wound the explanation is simple. Bacteria and protozoa are practically everywhere. Remember, some varieties are so small that they cannot be seen with the most powerful microscope. Myriads of them are floating in the air around us, in the ground we dig up, in the water we drink, on the uncooked food we eat, on our hands, on our clothing, in our mouth, 616 HOW TO KEEP WELL and all the way through the digestive canal. Hence it is almost impossible to escape them, and when tissues are laid bare in a wound, if they are exposed for any length of time, bacteria of various kinds settle upon them, grow, produce poisons, and cause the various diseases of which they are the source. Many soldiers in the recent war lay wounded on the battle- field twelve, twenty-four, or even forty-eight hours without any help whatsoever. When these soldiers were reached by the sur- geons their wounds were uniformly infected; that is, bacteria had nested upon them, as it were, had produced poisons which had caused inflammation of the tissues composing the wound, and more or less of this poison had been absorbed into the blood and dis- tributed over the body. Fortunately, early in the war the attention of Dakin, a chemist at the Herter Laboratory in New York, was drawn to the value, as an antiseptic, of a weak neutral solution of sodium hypochlorite. He found that this could be used freely upon wounded tissues and that it would not only prevent infection but would remove it or cure it after it had done more or less mischief. A method of using this continuously for the irrigation of wounded tissues was devised by Carrel of the Rockefeller Institute, and the Carrel- Dakin method was in extensive use in the treatment of our wounded soldiers. The chlorine in this solution destroys the bacteria in the wounds; the wounds heal with comparative ra- pidity ; and thousands of lives were thus saved. Treatment of Wounds.-The skin when unbroken does not absorb; its outer layer is hard, horny, and impervious; but make an opening or break in it, and you expose blood- and lymph-vessels which absorb like a sponge. If the absorbed material contains disease-producing bacteria, the disease they cause will be devel- oped on the tissues which constitute the wound; or, the bacteria having entered the blood, the entire organism may be poisoned. Suppose a soldier is hit by a bullet. The bullet pushes before it a bit of dirty clothing and a bit of dirty skin, the bullet, the clothing, and the skin being all covered with disease-producing bacteria of one or more varieties. It also tears muscles, fascia, vessels, and nerves, and may injure a bone. The bacteria conveyed to this wound find heat and moisture favorable to their development and growth and produce poisons and disease. They encourage fermentation and decomposition in the injured tissues, DISEASES OF SURGICAL CHARACTER 617 and these tissues become gangrenous and converted into pus. Some of them are absorbed and develop in the blood-current, and the entire body may be poisoned. What does the modern surgeon do in a case life this? If he gets the soldier within a few hours after the injury is received he removes the dirt and debris, cuts away tissues that are dead and hopeless, irrigates the wound copiously with a suitable antiseptic solution, brings the sides of the wound together with sutures or stitches if necessary, and then covers it firmly with a suitable bandage of absorbent material, usually cotton-wool and gauze which have been made absolutely sterile. This is the first dressing, and, if there is very little discharge from the wounded tissues into the dressing it may be retained for three or four days or even longer; but if the discharge is abundant and the dressing becomes soiled, it may be necessary to renew it and to cleanse the wound after a single day. In a week or ten days, if the wound has done well, healing will be far advanced; a lighter, less cumbersome dressing may be applied; and the main thing will then be to keep the wounded tissues at rest, remove tension by supporting them with sticking-plaster or other suitable means so that the wound will not be pulled open, and wait patiently until it is firm and hard and the wounded part ready for use again. If a wound is irregular and extensive and varies in depth in different portions, a complication at once arises. It would not do to let the secretions of the wound, which form in greater or less abundance as healing goes on, accumulate in passages and pockets, as this would mean decomposition, suppuration, absorp- tion of poisons, slow healing, and perhaps death. Therefore, in closing such a wound, the surgeon places a sterilized tube of rub- ber, or some other suitable substance, in each passage or pocket, one end of each tube passing through an opening in the skin drain- ing the passage in which it is placed, and permitting the injection of antiseptic and irrigating fluids to wash away bacteria or bits of dead tissue, this being particularly the mode of treatment of wounds which have become infected. Wounds which now require treatment of the kind just mentioned heal much more slowly than those which can be closed immediately and completely, but they heal much better than they used to. CHAPTER XXXVIII SOME SPECIAL METHODS OF TREATMENT Sunlight and Health.-We are not constructed to live in caves nor in any substitute for sunlight. This applies not alone to those who must work during the hours of the night, but to the multitude of all ages and sexes who work continuously by artificial light during the day. Labor of the latter variety is particularly severe for those who have sedentary occupations and are compelled to fix their eyes steadily upon their work for long periods of time. This con- dition will have to be remedied in some way, or the result will be apparent in the poor vision or want of robustness in the city workers of the next generation. Thanks to the development of sanitary science and preventive medicine, a way out of the difficulty may be expected. We are approaching the time when it may be insisted that no room shall be occupied by human beings for residence, work, or pleasure which is not sufficiently bathed by the searching and beneficent rays of the sun, and when those who do night-work shall have the privilege of exchanging it for day-work at suitable intervals. If sunlight cures disease, still more ought it to prevent it; and that is why I plead for its presence wherever men, women, and children live and work. Life and health are of more importance than dollars, and it is hard to think one would sacrifice the life and health of others for such a stake. In the new republic things will be different. Hydrotherapy.-So great is the confidence in the therapeutic value of water that we have whole systems of medicine, by Pries- snitz and others, based solely upon various methods of applying it to the surface of the body. In order that good results may follow its use, it is necessary, 618 SOME SPECIAL METHODS OF TREATMENT 619 first of all and in all cases, that there should be a good reaction. What does that mean? Essentially that the heart should so re- spond when water is applied that the amplitude of its stroke will be increased and strengthened. If its stroke becomes much more frequent and much less strong the reaction has been bad, and the effect of the water will be harmful and not healing. If the boy comes out of the swimming-pool with the activity of a yearling colt, with glowing skin and joyous behavior, the reaction has been good; but if he comes out with teeth chattering, lips and nails blue, and hardly enough strength to put on his clothes, the reaction has been bad, there is something wrong about the boy's organs, and a bath at such a temperature as he has been indulging in is not the proper kind of a bath for him. A bath for medicinal purposes may be cold, cool, tepid, warm, or hot; and the water may be in the form of ice, liquid, or vapor, each form having the proper use and indication. A bath may be taken in a tub, in a shower, in jets, under pressure as in the needle-bath, and with considerable volume and more or less pres- sure from a hose. The entire body may be immersed and bathed or only a portion of it. So we may have a full bath, a half-bath, a hip-bath, a foot-bath, a spray, or a douche, any desired portion of the body being thus treated. Sponges, sheets, and mits are used for various kinds of bath-the bath being taken standing, sit- ting, in bed, or lying upon a slab or table. Massage or friction is a very important addition to the bath and often has a great deal to do with its therapeutic action. What is known as the wet pack consists in wrapping the naked body with a wet sheet at the desired temperature and then covering the body with a blanket. As the heat of the* body is given off to the sheet the latter is warmed and may be changed for another cold sheet if desired. Water alone may be used for the bath at the required tempera- ture, or carbonic acid, salt, iron, sulphur, etc., may be dissolved in it. For some diseases mud is deemed desirable as a bath, and this is particularly the case with certain diseases of the skin. The natural springs throughout the world used as health-resorts con- tain in solution the various minerals which have been found bene- ficial for different diseases. Alcohol and various vegetable oils are often used for bathing purposes in connection with friction. A Turkish bath is very cleansing, but it may be very depress- 620 HOW TO KEEP WELL ing. I have known of sudden deaths while it was being taken. It is a hot-air bath, the first temperature being no° to 1300 F. After perspiration becomes abundant the temperature is raised to 1500 to 2000 F. After submitting to this for a few minutes the bather is rubbed and treated to a douche, and then he is wrapped in a blanket in a reclining position until the skin becomes dry and the pulse normal. Only the most robust persons should take this kind of bath, and it is prohibitive for sufferers from heart, lung, and kid- ney diseases. The Russian bath is a hot-vapor bath, less exhausting than the Turkish. • After perspiring profusely, one is rubbed for ten or twenty minutes and then treated to a cold shower- or pool-bath. One feels much refreshed and cleansed after such a bath. The range of diseases treated by means of baths is very ex- tensive. Fevers, especially typhoid, have been treated with the greatest success by the Brand bath, which is a tub-bath at 64° F. followed by a rub for fifteen minutes, and a wet compress at 6o° F. over the abdomen, repeated every four hours until the tempera- ture is sufficiently reduced. Cold douches are used for anemia, insomnia, and headache; spinal douches with cool or cold water for various forms of nervous disease; warm or hot baths for rheumatism, convulsions, etc. Intravenous Medication.-What is the meaning and signifi- cance of intravenous medication? It means that substances in solution are injected directly into one of the veins of the body, usually a vein in one of the arms. The substance thus injected necessarily is one which is powerful in its action, and frequently, though not always, one which acts with great rapidity. Intro- duced into the blood-current, it is carried directly to the heart and produces its effect upon that organ at once if it is a substance which has a physiological action upon the heart. Or it may be sent out from the heart with the blood-stream throughout the en- tire body, as the blood permeates every portion of the vascular system. Now it is easily understood that such a procedure may be life- saving in its action at the time of a great emergency. But suppose there is no such emergency, and, furthermore, that the substance is unsuited for the purpose for which it is used; or suppose, further, that the instrument used for the injection is not clean and intro- duces deleterious bacteria into the blood-current. Great harm, SOME SPECIAL METHODS OF TREATMENT 621 therefore, may result from such a procedure, and even loss of life. This method of treatment is now in very common use, particularly in the treatment of constitutional diseases like syphilis. Familiarity with any important method of treatment is prone to lead to disregard of the precautions indispensable to their suc- cessful and beneficent use, and it is easy to imagine that one who is not trained to the exercise of the most careful and painstaking pre- cautions is using a very dangerous weapon when he invades the blood-current with his syringe. Treatment of Disease by Means of Light-Rays.-It has long been observed that the rays of the sun passing through various sub- stances had a modifying action upon certain diseases, but not until the beam of solar light had been split up and analyzed by the spectroscope was it possible to differentiate one portion of such a beam from another. Of course it has been known from time im- memorial that the sun's rays affect growth and vitality in plant life; where there is abundance of sunlight there is vigorous life, and it was only fair to presume that this vitalizing effect had its counterpart in animal life. Probably to no one person are we more indebted for the investi- gation of the influence of light upon disease, and particularly disease of the skin, than to the Danish physician Finsen, who was the first to discover the value as curative agents of the violet and ultra- violet rays. The therapeutic influence of Rontgen rays and of radium is not now under discussion. There are two principal effects produced by light when ap- plied to the skin; it tans it, and it produces what is called hyper- emia; that is, brings an unusual quantity of blood into the blood- vessels in and below the skin. The bringing of this excess to the blood-vessels means increase in its temperature, increase in the temperature of the tissues through which it passes, and con- sequently transmission of more energy in the form of heat through- out the body as the blood circulates through it. Light penetrates the tissues of the body more deeply in some individuals than in others, and in blonds or those who have light skins more deeply than in those whose skin is dark; for the pigment in the dark skins absorbs a certain portion of the light and so limits its penetrating power. The absorption of light within the sweat-glands of the skin and the increased blood-supply which it induces stimulates them to unusual activity, thus causing profuse perspiration, which 622 HOW TO KEEP WELL is one of the customary experiences which follow exposure to the sun's rays. One of the most valuable therapeutic effects of light consists in its destructive action upon certain varieties of bacteria. The destructive power of these organisms is often shorn by sunlight, which sometimes kills them and at others deprives them of condi- tions necessary for their development. Beneficial results from the use of light have been claimed in diseases of the ear, boils and car- buncles, tonsilitis, influenza, laryngitis, and many other diseases of an infectious nature in which pain and inflammation are outstand- ing features. It very often happens that the rays of the sun are not available for the treatment of disease or any other useful purpose. It there- fore became a matter of great practical importance to be able to utilize artificial light as a substitute for solar light. It has been found that the incandescent electric light produces effects which are quite similar to those produced by the sun's rays, and on this basis many ingenious machines have been constructed with lights of varying power and resistance which can be projected at will upon any portion of the body which it is considered desirable to subject to this kind of influence. Local Anesthesia.-The difference between living tissue and (lead and paralyzed tissue, or one difference at least, is that you can feel pain in the one and that you can feel nothing in the other. Some pain is not very hard to bear; if you cut yourself in shaving the pain does not usually amount to very much. The majority of well-developed women do not find the pain of childbirth such a terrible ordeal, except, perhaps, with the first baby. Some pain is sickening; it is so severe and so trying to the heart and lungs that one may faint and become unconscious on account of it. Now, I am not one of those who believe that pain ought to be abolished, not altogether. Of course it is not pleasant, but it often serves a useful purpose. Sometimes it is like an alarm-bell telling us for the first time that there is something the matter with us which must be corrected. A baby has colic in the night; it cries and awakens its mother, and perhaps the pain is the means of saving its life. What sort of a person can you imagine one to be who goes through life without a stomachache, a toothache or even a headache? Is it better, then, to bear pain or to try to relieve it? Some SOME SPECIAL METHODS OF TREATMENT 623 pains I think we ought to bear or at least to take as little notice of as possible, and some we should prevent or get rid of as quickly as we can. Anything in the nature of a surgical operation means pain. Even if it is as simple a procedure as paring the nails or cutting the corns, it may give rise to pain which is severe. In all such operations, large or small, I think something should be used to prevent pain. We call this something an anesthetic, and we can give it by the mouth, like opium or some other drug, to cause a general numbness or insensibility, or we can give it in the form of an inhaled vapor like ether or chloroform to cause unconsciousness, or we can give it by making suitable applications upon or into or under the skin. This last method is called local anesthesia, and it is a method which is becoming more and more popular and more and more successful as we become skilled in its use. It acts by paralyzing over the injected area the ends of the nerves by which we become conscious of pain, which are distributed in abundance to every square inch upon the entire surface of the body. There are many substances which can be injected in the form of a solution under the skin and produce this condition of insensitive- ness. Sometimes it can be produced by the mere injection of water, but it is generally better to use some substance with known anes- thetic properties. For a long time cocaine alone was employed for this purpose, but this has a poisonous effect upon some people even in very weak solution, and now there are many useful substi- tutes for it. Some of them are called eucaine, stovaine, novocaine, alypin, etc. It certainly is a great boon to humanity that operations for hernia, hemorrhoids, cataract, and many other grave conditions can now be successfully and painlessly treated surgically without the discomforts and even the dangers which so often accompany the unconsciousness which is produced by ether and chloroform. Massage.-Massage is not so simple a matter as is generally supposed; in fact, it is a highly developed art. It means not merely rubbing or kneading in an aimless, unmethodical, and unsystematic manner, but in addition friction, percussion, rolling, tapping; in a word, manipulation of a definite character of every available portion of the body as a means of exercise or for the treatment of some particular form of disease. The Swedish movement cure devised in the early part of the nineteenth century by Henry Ling, with 624 HOW TO KEEP WELL active and passive movements, is massage reduced to scientific ex- pression. The primary object of massage is, of course, to make the mas- saged tissues, whichever they may be, supple and active, thus over- coming their previous stiffness and inactivity. By this means their blood-supply and their secretions are increased, their nerves and lymphatics stimulated, and the fibers of their muscle, tendon, and fascia urged to more vigorous contractility. This means improved functional life and operation. The different modes of massage may be used together or separately, according to the requirement of the case; and the treatment may be given with the hands alone, with machinery devised for each particular portion of the body, as exemplified in the Zander and Tyrnauer methods of treatment, or with a combination of the two. One objection sometimes offered to this method of treatment is the amount of time it consumes. If the masseur gives from fifteen minutes to an hour and a half to his patient and additional time is spent in necessary procedure before and after the treatment, the time consumed will be more than many think they can afford. It has been used with great success in such functional troubles as neurasthenia, hysteria, and constipation. It is very soothing and very effectual in headache of various kinds and frequently is the very thing to relieve insomnia. In partial paralysis of nerves and muscles with disturbed sensations, as the result of overuse, it has often proved very beneficial. It is perhaps most highly esteemed for its power in overcoming stiffness in the various joints of the body, including those of the spine. In chorea, infantile paralysis, mild neuralgia, and neuritis, and even in severe diseases like loco- motor ataxia and progressive muscular atrophy, it may be very helpful, especially when combined with a suitable form of elec- tricity. Even in diseases of the eye, ear, nose, and throat it may be very beneficial. Transfusion of Blood.-It is based upon the idea that blood is life, or controls life, and consists essentially of fluid or serum, and red and white corpuscles, or cells, which float in the serum. The serum is practically identical with a solution of one tenth per cent of sodium chloride or common salt, and it was long believed that this alone would suffice as a substitute when the circulation was suffering from poverty of the vital fluid. When derived from human blood, the blood, under the earlier methods, was beaten or SOME SPECIAL METHODS OF TREATMENT 625 whipped with a suitable instrument which separated the corpuscles from the serum, the serum being then injected into the rectum or under the skin or into a blood-vessel. The salt solution does very well in an emergency and is almost always available. While this simpler method has not been discarded, the more perfect one of using entire blood, transferred directly from giver to receiver, is now quite generally employed when blood of suitable quality is at hand. If blood is to be transfused successfully, it must be homologous with that with which it is to mingle; hence it is always better, if not imperative, to compare a specimen from the giver with one from the receiver. A little of each may be mixed in a test-tube for a few hours before transfusion, and if there should be agglutina- tion or destruction (hemolysis) of the corpuscles, it would mean unfitness; the blood would clot in the blood-vessels of the receiver, do no good, and probably do harm. Such a test is not always pos- sible in great emergencies, and a certain amount of risk has to be taken. Crile's method of direct transfusion may be taken as the stan- dard, and by it the arm of the giver is brought into direct contact with that of the receiver; the proper artery or vein in the arm of the giver is exposed, likewise the proper vein in the arm of the receiver; a sterilized silver tube is introduced and secured in the opened vessel in each arm; and blood is permitted to flow from one arm to the other for fifteen or twenty minutes, after which the wound in each arm is carefully closed. This means ordinarily the transfer of about nineteen ounces from giver to receiver. Should the giver be greatly weakened by the loss he has sustained, salt solution equal to the volume of blood transfused is sometimes injected into his circulation. In indirect transfusion the blood from the giver is caught in a suitable sterilized vessel and then allowed to run through a steri- lized hollow needle, with or without the addition of a solution of citrate of sodium, into the properly prepared vein in the arm of the receiver. This method is especially applicable to puny infants who require accessions of blood as a life-saving measure. In such cases the blood is injected into one of the veins of the head, about four ounces being used. Until twenty-five or thirty years ago transfusion was principally used for women who had lost great quantities of blood at childbirth. 626 HOW TO KEEP WELL It is now used in any case in which the hemorrhage has been pro- fuse, in serious surgical operations, and in anemia or great weakness from any cause. In the profuse hemorrhage of typhoid fever it is of the greatest value, and it was used extensively during the recent war after injuries and operations. CHAPTER XXXIX POISONS, POISONING, AND ANTIDOTES Poisons and Poisoning.-A poison is something which may do harm to animal or vegetable life. It does not always do it, nor to the same extent; indeed, like opium, arsenic, or mercury it may be directly beneficial; but if more is taken than can be used or got rid of, sickness or death will result. An antidote is something which overcomes the harm done by the poison and may be a poison itself. An overdose of opium will produce sickness and death, but if belladonna, another poison, is given at the proper time and in the proper way, the belladonna will act as an antidote and the poisoned person will get well. Or if the poisoned person, instead of taking belladonna, drinks a pint of warm water containing a tablespoonful of mustard, which is not a poisonous mixture, he will vomit every- thing there is in his stomach, including the opium, and by means of this antidote will also recover. The harmfulness of poisons exists in the substances themselves, not in one's imagination. I may not believe that opium is harm- ful, but if I take enough of it, it will surely make me sick and I will die with certain well-defined symptoms. This will happen in 999 cases out of 1000. The list of poisons is a long one and is constantly being added to. Everybody should know the common ones and their antidotes, for this will frequently mean the saving of life. Some poisons are narcotic; others are irritant or corrosive; and I refer now only to those which are taken internally. Symptoms of narcotic poisoning are drowsiness, sleep, snoring, slow breathing, dark skin, contracted pupils, and unconsciousness, opium poisoning being the type. Or there may be headache, delirium, wakefulness, dilated pupils, dry- ness of the mucous membrane and restlessness, as in poisoning from belladonna. Pain is seldom present in narcotic poisoning, 627 628 HOW TO KEEP WELL but instead, weakness and distress, feeble heart-action and trouble in breathing. Irritant poisons may produce symptoms at once or after they have been absorbed and carried over the body by the blood. Acids and caustic alkalis corrode the mucous membrane of the mouth, throat, and stomach, and cause swelling, pain, and grayish-white appearance of the mucous membrane. Poisons like those from mushrooms and spoiled meat and fish may not produce symptoms at once, but in an hour or two they may cause restlessness, pain in the stomach and intestines, intense itching, etc. In general the symptoms from irritant poisons are severe pain, great weakness, cold and clammy skin, feeble heart-action, vomiting and purging, and a metallic taste in the mouth if the poison is a mineral. The common narcotic poisons are opium, belladonna, chloral, cocaine, alcohol, coal-tar preparations, and illuminating-gas. Opium, including morphine, codeia, laudanum, paregoric, and many other preparations, relieves pain and does other useful things. Belladonna, including atropin, is much used by oculists, and fre- quently is embodied in liniments, ointments, and plasters. Chloral and the coal-tar preparations are chiefly used for the relief of headache and sleeplessness. Cocaine is a valuable local anesthetic, while everybody knows the varieties and uses of alcohol. Wood-alcohol is a very dangerous poison. The common irritant poisons are arsenic, lead, mercury, phos- phorus, and carbolic acid. Arsenic is a valuable medicine and an ingredient in insect and vermin destroyers; it is much employed in the arts and is an ingredient of Paris green. Lead is also a valuable medicine, but painters and many others are poisoned by it. Mercury is indispensable as a medicine but has many victims from fatal poisoning. Phosphorus is an important remedy but is destructive to those who work in it; many people are poisoned by phosphorous matches. Carbolic acid is a valuable medicine but also a corrosive and deadly poison. Certain symptoms call for identical treatment whatever the poison that causes them. Thus weak heart-action and great pros- tration need stimulants to strengthen the heart. For this purpose POISONS, POISONING, AND ANTIDOTES 629 one may use a hot-water bag at the feet, a mustard-plaster on the chest, smelling-salts, whisky, brandy, or strong coffee, provided the patient can swallow. If he is unable to swallow, some form of alcohol may be injected hypodermically or into the rectum. The first thing to be done when a person appears to be poisoned is to empty the stomach by making him drink a pint or a quart of warm mustard-water. It is not easy for one who is unaccustomed to the stomach-tube or clumsy in its use to employ this measure. If the breathing is slow and labored, the poisoned person should be laid on his back, the arms stretched above the head, and the chest compressed by them as they are brought down, this procedure being repeated until the breathing becomes more natural. This is called artificial respiration. The skin of the arms and legs may also be rubbed and slapped or struck vigorously with a wet towel. Pain from the corrosive poisons is often intense and can best be relieved by a hypodermic of morphine. If the victim is drowsy and stupid, rub the hands and feet, slap the body with a wet towel, and slowly move the tongue backward and forward. The restless and delirious must be gently but firmly restrained. These measures can be easily carried out by a person with average intelligence. The use of antidotes requires more judgment, but everybody should know something about their meaning and purpose. It is easy to remember that opium is the antidote of belladonna and belladonna of opium. Stimulation is the measure of greatest importance for the other narcotics; and coffee camphor, or ammonia can easily be procured for this purpose. For poisoning with carbolic or other mineral acids or arsenic, scrape lime from the wall or use lime-water; for lead, use Epsom salts; for mercury, the white of egg; for phosphorus, turpentine. It is well to keep a list of these facts where it can be consulted in a minute and so avoid confusion if one is suddenly called to do something for a person who has been poisoned. Auto-Inoculation.-Auto-intoxication usually means poisoning from some kind of substance which is either in the small or large intestine, particularly the former. It may have been poisonous or potentially poisonous from the beginning, that is, when it was taken into the mouth and passed down into the stomach, and thence into 630 HOW TO KEEP WELL the intestine. The digestive juices have been unable to decompose it or the intestine to evacuate it, and the absorbent vessels of the small or the large intestine have taken it up, it has been carried into the blood, and in the blood it has developed those conditions which give rise to the well-known symptoms of blood-poisoning. Such a result might come from the action of poisonous bacteria which were taken in with the food. Or the auto-intoxication might have been the result of chemical changes which have taken place in substances taken into the mouth and retained in the stomach or intestine. Those who are subject to chronic constipation are frequently victims of this kind of auto-intoxication. Auto-inoculation, on the other hand, means poisoning by means of a poison that is already present, particularly, if not exclusively, upon the out side of the body. For instance, a person has a boil, or a venereal sore, or an infectious disease of any kind upon one of the folds of the skin, perhaps in the groin or in the armpit. In the movements of the body this sore rubs against the skin which is opposed to it, and in a short time a new sore may develop in the place where the friction has taken place. If surgical dressings always were made with these facts in mind, and in all cases in which auto-inoculation was possible, there would be no auto- inoculation. Not all sores are capable of repeating themselves in this way, for the contagious properties of some germs and of the materials of which some sores are composed are very slight, and the resisting power of the skin which is rubbed is sufficient to disregard them. Even so terrible a disease as cancer may not be transferred by auto-inoculation from one part of the body to another. At any rate, this general statement is often made, though I do not think it is quite true, for I believe I can recall one or more instances in which the disease apparently was transferred by auto-inoculation. The important thing to remember is that if a sore is so located that it may be reproduced by contact with another surface there is more than ordinary requirement for protecting that surface and for suitable frequent cleansing and dressing of the original sore. Auto-Intoxication.-The simplest definition of this term would be poisoning caused by absorption of substances, especially of food substances, within the stomach or intestines. If all food substances were completely digested and their end products fully prepared for absorption, auto-intoxication in this POISONS, POISONING, AND ANTIDOTES 631 manner would not occur; but this is seldom the case, for much of that which goes into the digestive organs may cause a bad attack of ptomaine poisoning in one whose digestive apparatus is sensitive and feeble. We read of savages and barbarians who subsist largely on de- cayed animal substances, often eaten hastily in large chunks, with scarcely any mastication; and instead of being poisoned they are nourished and strengthened by them. This is simply because their digestive and resisting powers tolerate that kind of nutriment. A person who has gout or rheumatism or Bright's disease or any severe illness is a poor subject to resist auto-intoxication, and that is probably the reason why we are, or ought to be, always very careful in arranging the diet of those who are sick or invalid. Symptoms which are common in this condition are headache, especially in the forehead or on one side, either continuous for days or interrupted; pallor of the face; nausea; dizziness and vomiting. There also may be fever, loss of appetite, gas in the stomach or bowels, and constipation or diarrhea; or drowsiness by day and sleeplessness by night, palpitations, difficulty in breathing, and sometimes troublesome cough. Troubles of the skin are very common in this disorder, particularly eczema, acne, hives, and intolerable itching. A person who has this trouble must cut off the meat ration altogether or reduce it to the lowest possible limit. He should live on milk, soups, bread and butter, cereals, fsesh green vegetables, and fresh, ripe fruit. He may eat sparingly of eggs, poultry and fish, provided the latter is absolutely fresh and thoroughly cooked; but this cannot be taken as a universal privilege; by those who are sensitive to auto-intoxication or suffer even mildly from it they must be omitted entirely. The bowels must be kept freely open, and nothing is better for this purpose in this condition than castor- oil. A daily warm bath containing bicarbonate of soda or Epsom salts is often of great benefit in relieving the unpleasant symptoms of the skin. Lead Poisoning.-Like so many other substances which are in- jurious to the body when unwisely or improperly used, lead may also be very valuable and useful in its proper place. Its important action is that of an astringent, causing contraction or puckering of the tissue to which it is applied. As a medicine it is not much used 632 HOW TO KEEP WELL internally, but for external use as an application for burns and inflammations of various kinds it is used rather extensively in the form of plasters, ointments, and lotions. Acute lead poisoning may come from absorption through the skin, especially if the skin is broken, or from taking a quantity of a soluble preparation such as the acetate or the subacetate into the stomach. The symptoms are very clearly marked and consist of metallic taste, pain in the pit of the stomach, cramps in the intes- tines, constipation or diarrhea, and persistent vomiting of dirty white fluid. As in most forms of acute poisoning, there is what is called shock-that is, great weakness and prostration-rapid and weak pulse, great thirst, and cramps in the legs. This may result fatally in a short time unless it is relieved. It is well to know that it can be relieved by taking the whites of three or four eggs or a quart of milk, or a couple of tablespoonfuls of Epsom salts in a glass of water. Much more common than acute lead poisoning is the chronic form; and this, as before remarked, most frequently occurs among those who work in lead in some form, whether as painters, glaziers, lead grinders and mixers, plumbers, wall-paper makers, electricians, or type-setters. In some cases it is due to inhaling the fumes of the metal; in the majority it is probably due to absorption through the skin, especially through cracks and fissures of the skin of the hands. Apart from the occurrence as an occupational disease, it may come from cooking utensils, adulterated food, cans or jars, water-pipes, hair-dyes, face-powders, and a variety of other things, but I am doubtful whether it comes very frequently by these means. An important symptom often noticed in painters is a blue line along the gums. When poisoning is well under way there is loss of appetite, metallic state, offensive breath, and great weakness. Painters and mixers are frequent sufferers from severe cramps in the abdominal muscles, commonly known as lead colic; and also from constipation, intense thirst, and swelling of the salivary glands, which gives the patient the appearance of mumps. But chronic lead poisoning may have even more serious symptoms than these when it reaches the stage of paralysis. The most common form is paralysis of a group of muscles of the forearm, which causes the wrist to drop helplessly. Then may follow dizziness, loss of memory, defective vision, squinting, headache, ear-troubles, and POISONS, POISONING, AND ANTIDOTES 633 finally, though of course not always, blindness, convulsions, in- sanity, or epilepsy. If one has worked in lead long enough to feel its poisonous effects the sooner he gives up his occupation the better his chance for recovery. Epsom salts freely taken are one of the best antidotes of the disease. Hot baths and various means to produce sweating must also be freely used in the effort to get rid of as much of the accumulated lead as possible through the skin. Ptomaine Poisoning.-Food substances containing deleterious bacteria, or whatever the poisons may be, sometimes excite suspi- cion by their objectionable smell or taste, but not always, and in many instances there is nothing about the food before or after it is cooked which would lead one who is eating it to imagine that he is consuming something which will poison him. Furthermore, these ptomaine or bacterial poisons are sometimes so resistant to heat that they do not lose their activity and their potentiality for mis- chief after roasting or boiling. The poisons in those foods which are eaten raw or only slightly cooked have no such deterrent to im- mediate activity. The list of foods in which ptomaines may develop is very large and includes meat from diseased animals of all kinds, all kinds of canned meats, vegetables and fruits, sausage, particularly liver and blood sausage, ham, bacon, all kinds of fish, milk, cheese, gelatin, etc. Strangely enough some people are immune to attacks from these poisons. How many there are who eat with relish and apparently without harm game and other meat, and even oysters, crabs, and other fish which have decomposed and smell badly and which would be a deadly poison to others. There is probably no animal tissue which decomposes and de- velops ptomaines more quickly than fish. Why is this? Any kind of fish or water animal that gets his indispensable oxygen by means of gills and not by lungs belongs not to the air but to the water, and when taken out of his natural element he usually dies quickly. The longer he struggles in this foreign element the more his tissues and organs become disturbed and diseased, and the quicker will they decompose. In decomposing, the ptomaines are formed, and they form more quickly under the influence of heat than of cold, so that if fish are kept chilled and iced, they may remain fresh and harmless several days. 634 HOW TO KEEP WELL Ptomaines may develop in the human body from the influence of bacteria associated with such diseases as Asiatic cholera, typhus fever, and lockjaw; that is, apart from the influence of food. The symptoms of ptomaine poisoning vary in severity and char- acter and depend upon the virulence of the poison and the resisting power of the individual. They may appear almost immediately after the poisonous food has been taken, or they may be deferred for hours or even days. The first symptom which is noticed in many cases is itching or pricking of the skin, which grows in intensity until it is almost unbearable. Soon there will be cramps in the intestines, nausea, vomiting, purging, and, in the severe cases, headache, dizziness, rapid and weak heart-action, and collapse. The acute attack may end and the trouble pass off, or it may be prolonged, the secretions drying up and the skin, mouth, and throat becoming parched. There may be hoarseness and cough, swallowing and breathing may be difficult, and the vision may be impaired. Of the complications which come after one has been weakened by the stomach and intestinal symptoms none is to be dreaded, especially by those who have passed middle life, more than those which affect the heart, lungs, and kidneys. These are the pillars of the body, and when one or the other gives out, unless the reserves of resisting power are good, the body is going to fall and go under. Uremia or Uremic Poisoning.-The terms "uremia" and "uremic poisoning" refer to a group of symptoms which result from reten- tion within the blood of substances which are normally eliminated from the body by way of the kidneys. They are present most fre- quently in connection with Bright's disease, but also with cancer, tuberculosis, and abscess of the kidney, cholera, typhus and yellow fevers, in pregnancy and parturition, when the kidney function seems to be entirely out of commission, and in all other conditions which result in more or less complete suppression of the secretion of the urine. There may be acute or chronic uremia. In the acute variety the symptoms may come quite suddenly with Bright's disease, angina pectoris, emphysema of the lungs, and other diseases. There is a form of acute uremia with coma or unconsciousness alone, and another form in which there is unconsciousness with convulsions. In the first of these are premonitory symptoms of headache, dizzi- POISONS, POISONING, AND ANTIDOTES 635 ness, dimness of vision, and drowsiness, and then follows uncon- sciousness or coma. When such an attack comes on there is pallor of the skin and loud breathing with a hissing sound in expiration, and there may be blindness, deafness, and complete suppression of the urine. This condition may continue until death results, or the unconscious- ness may gradually pass off and the patient get better. Much depends on the condition of the kidneys; if they are badly diseased a single attack may prove fatal, and a subsequent one will almost certainly be so. In the convulsive form of uremia the symptoms are suggestive of epilepsy, attacks coming suddenly and being frequently repeated. These attacks also may be followed by complete unconsciousness and death, or by more or less complete recovery. Many women who have uremic convulsions in connection with pregnancy and parturition get entirely well. In the chronic form of uremia the patient is listless and indif- ferent for a long time, slow in movement and in speech. He suffers from ringing in the ears, headache, high blood-pressure, and asthma; these symptoms coming and going for a long time. At length comes unconsciousness with snoring, offensive breath, swol- len mouth, hiccup, vomiting, and diarrhea. There may also be attacks of nosebleed, great itching of the skin, prostration, con- vulsions, and death. The most characteristic symptom of uremia is the presence of albumen in the urine. Great skill and judgment on the part of the physician, nurse, and all other attendants are requisite in the management of uremia. One must know just how far to relieve blood-pressure by bleeding or otherwise, to sustain the heart, to call the skin into service by sweating and so compensate for the kidney inaction, and to deplete the blood of its poisons through the intestines by the wise use of cathartics. Unfortunately, when the kidneys are badly diseased we must be submissive to the fact that an attack of uremia, though recovered from, is but the precursor of another. The Uric Acid Condition.-A few words of interpretation of the conclusions of Professor Porter upon this subject will be proper, for they were prepared essentially for the use of physicians. He means to tell us that uric acid results from the chemical changes which take place in the albuminoid foods-fish, meat, milk, and 636 HOW TO KEEP WELL eggs principally-but that it is never found in these foods, nor does it appear anywhere in the digestive process nor in the blood under normal conditions, but is manufactured only in the cells of the kidneys and is a waste or final product of food changes. It is discharged with the urine, and if there is more of it than there ought to be it means that the great process of oxidation which is constantly going on in the body, and everywhere else, is deficient and is not working properly. When oxidation goes on properly more or less of the uric acid combines with other sub- stances in the kidneys or bladder and is emptied from the body in that shape. For example, it may take up some of the sodium from the table-salt which is in the body and give sodium urate to the urine. An excess or overproduction of uric acid also means that the chemical changes in the albuminoid foods are not going on properly and that the uric acid has produced disease, or perhaps is an evidence of disease of certain kinds, and that the more uric acid there is, the more disease. Now, what are the causes of this uric acid disease or uric acid condition? There are many who have a tendency to the excessive formation of uric acid, and these are said to have the uric acid diathesis. It is not common in early life; it is more common in middle life; it is most common in old age. It may come from a great variety of causes, from worry and want of sleep, from overexertion, from im- proper diet, and particularly from the free use of wine and beer. An excess of uric acid is present in rheumatism, gout, various joint-diseases, and various forms of indigestion. It may lead to formation of stone in the kidney or stone in the bladder, and a uric acid stone is the worst kind one can have, because it is so hard and so little likely to be broken up in its travels. It is very likely to cause more intense pain than the stones which are soft and crumbly. Uric acid, evidently, is sometimes absorbed from the kidneys into the blood when the eliminative power of the kidneys is faulty, and it may be deposited in the joints and other tissues. As it has no regular history and course, it may continue indefinitely and cause great disturbance. The best plan to follow is to keep the bowels and kidneys in a free and open condition, abundance of water and milk being drunk and simple food eaten, especially food of a laxative nature, like bran, oils, prunes, figs, and baked apples. CHAPTER XL VARIOUS MEDICINAL SUBSTANCES AND THEIR PROPER USE The following remarks on medical substances and articles of diet will be found serviceable in the treatment of ordinary affec- tions such as may not require the services of the physician, or in cases in which such services are not at once obtainable. They have been arranged alphabetically for ready reference, and an index of these substances and the conditions for which they may be used follows: Aconite.-This is a very powerful poison, pungent to the taste, and will quickly produce numbness of the skin and mucous mem- brane and dryness of the throat. It is very useful in feverish con- ditions, especially in children. The tincture of the root is the form commonly used. It should be kept in a very small bottle, sealed, and marked Poison. The dose for children is one drop in a teaspoonful of water repeated every half-hour until no more than four or five doses have been taken. For an adult the dose is twice as large. Alcohol.-Very useful for sponging the skin in almost every form of sickness. It is refreshing and stimulating. Alcohol distilled from grain and not from wood should always be used. The bottle which contains it should be corked when not in use, as it absorbs much water from the atmosphere, and also evaporates rapidly. It forms a large portion of all distilled liquors and a smaller portion of fermented liquors. Alum.-Very astringent and antiseptic. It should be used in the powdered form. It is very soluble in water. Useful as an injection for cleansing purposes. It is valuable for leucorrhea and diarrhea and for arresting hemorrhage. A tablespoonful in a quart of hot water is the ordinary strength. 637 638 HOW TO KEEP WELL Ammonia.-In the solid form it is used as smelling-salts and is very stimulating when one is faint or weak. The aromatic spirits of ammonia, a teaspoonful in a glass of water, may be taken in- ternally for faintness or collapse. It will sometimes relieve certain forms of headache. Antipyrin.-This is a coal-tar preparation and is best obtained in five-grain tablets. One or two tablets will frequently relieve head- ache, reduce slight fever, as in cold in the head or grippe, and arrest hemorrhage. For the latter four tablets may be dissolved in two tablespoonfuls of water and applied on cotton to the bleeding surface. Arnica.-A powerful poison, and not to be taken internally. It may be rubbed upon the skin for bruises and sprains. The tinc- ture is the preparation in ordinary use. The bottle should be marked, "poison, for external use." Arrowroot Porridge.-A very good preparation for the sick or convalescent. Stir two teaspoonfuls in a cup of cold milk until all lumps have disappeared. Pour gradually into a pint of milk which is boiling over a fire. Add sugar, nutmeg, and wine to suit the taste. Arsenic.-A poisonous metal but very useful, especially in the form of Fowler's solution as a tonic. It is the essential element in salvarsan and neosalvarsan for the treatment of syphilis and malaria. Asafetida.-A gum of offensive odor. Used in five-grain pills. Excellent in nervousness, hysteria, and distension of the bowels with gas or flatulence. Take one pill with water, and repeat in an hour if not relieved. Aspirin.-A popular proprietary medicine much used in five- grain tablets for the relief of headache and rheumatism. Beef Extract.-An excellent and fairly nutritious tea may be made from this preparation with far less trouble than from the chopped beef. Baume Analgesique.-A French proprietary in which winter- green is the effectual component. It is for external use in rheuma- tism. Bicarbonate of Soda.-An excellent simple remedy for acid stomach, sick headache, and diarrhea with fermentation. Useful for children and also for adults. Add a teaspoonful to a glass of hot water, and drink a portion or all of it slowly. VARIOUS MEDICINAL SUBSTANCES 639 Bismuth.-Very useful to relieve persistent vomiting. The powder only is used. For adults a quarter of a teaspoonful may be used and repeated if necessary in an hour. For a child the quantity must be a quarter or half as much. The subnitrate of bismuth is the form which is most frequently used. Boric Acid.-This is one of the best of our mild and non-poison- ous antiseptics. It is not for internal use. It may be used as a gargle, a mouth-wash, an injection, a lotion, etc., without fear. Hence it is useful in dressing wounds and ulcers, in sore mouth from a variety of causes, in sore throat, leucorrhea, etc. It dissolves freely in hot water. Bran.-Very useful as a poultice. Thoroughly boiled it is often eaten as a laxative cereal. Brown Mixture.-A popular combination for coughs and colds, in tablet and fluid form. Buchu.-Very useful in inflammation of the bladder. A tea may be made by pouring a pint of boiling water over a small handful of leaves. When cold this may be taken in tablespoonful doses every two hours. Camphor.-The safest household preparation of this substance is camphor-water. It is very quieting and soothing for internal use and may also be used externally for sprains and bruises. It is much employed for nervousness, hysteria, diarrhea, and nervous headache. A tablespoonful may be added to a glass of water and a swallow taken every few minutes until one is relieved. Capsicum.-This is used externally as a plaster or ointment to produce irritation or blistering, and internally in the form of tinc- ture in ten- or twenty-drop doses in water. It is an excellent sub- stance to stir up or stimulate the stomach as in dyspepsia or in the weakened condition which follows drunkenness. Carbolic Acid.-This is one of the most valuable antiseptics, but it is also a very corrosive poison and must always be used with much caution. For household use it must only be employed ex- ternally, one part of the pure acid being added to forty of water. It is useful for dressing wounds and sores. Cascara Sagrada.-One of the most reliable laxatives for steady use, in tablet and fluid form. Castor-Oil.-of the most valuable cathartics for children and adults. In constipation from whatever cause it is very efficient. For constipated children a teaspoonful with lemon- 640 HOW TO KEEP WELL juice may be given every night until the constipation is overcome. For adults a tablespoonful with lemon-juice may be given at night. Chamomile.-An excellent old-fashioned remedy as a stimulant and tonic. Half an ounce of the leaves may be added to a pint of boiling water. A wine-glass may be taken before each meal. Champagne.-This is very useful when the stomach is very sensi- tive and vomiting is persistent. It may be given in two-teaspoon- ful doses every half-hour, and milk may be added to it if desired. Charcoal.-In its powdered form it is often useful for acidity of the stomach and fermentative dyspepsia. It may be used in five- or ten-grain pastilles or tablets, alone or in combination with other suitable substances. Chlorate of Potash.-Especially useful as a gargle and mouth- wash. A teaspoonful in a glass of water, used every half-hour, will often be effective for sore throat or sore mouth, especially when associated with fever, swelling of the tonsils, ulceration of the mucous membrane of the tongue, gums, etc. In the case of children it is an excellent household remedy. It must be kept in a dry place, as the crystals absorb water readily from the atmosphere. Chlorine.-This is one of the most powerful disinfectant and bleaching agents known. It is a heavy gas, nauseating and suffo- cating when one attempts to breathe it. It is very destructive to germ-life of every variety. It does not exist free in nature, but is in loose combination in chloride of sodium (common salt), chlorate of potash, chloroform, and various chlorides. The ordinary com- mercial preparation is chlorine-water, which may be used as a gargle for sore throat and as a dressing for offensive ulcers. One part of chlorine-water may be used to four parts of water. Chloroform.-Very valuable as an anesthetic but less safe than ether. Especially useful in childbirth. In the presence of artificial light it is decomposed and chlorine is liberated. It is sometimes used internally in ten-drop doses with water for pain in the bowels and diarrhea, but it is too dangerous for household use. It forms a useful ingredient in a valuable liniment for external use. Cod-Liver Oil.-One of the most valuable tonics we possess. It may be used in tablespoonful doses clear or in emulsion. In anemia, emaciation, and cough it can hardly be surpassed. Cold.-A valuable application either in the form of ice or cloths wrung out of cold water. Cold sponging of the body is useful to reduce fever. An ice-bag may be applied to painful sur- VARIOUS MEDICINAL SUBSTANCES 641 faces, the head, chest, or abdomen. If used too long or applied without discretion it may do harm by interfering with the blood circulation. Collodion.-An excellent covering for bruises. It shuts out the air and gives the tissues a chance to heal. Compound Cathartic Pills.-An excellent but rather powerful cathartic. One or two taken at night will relieve constipation ex- cept in very obstinate cases. Copper.-The sulphate of copper, bluestone, may be applied to ulcers to stimulate healing. It is not so powerful nor so generally useful as the nitrate of silver, commonly called lunar caustic. Copperas.-Sulphate of iron, an excellent disinfectant and deo- dorizer. Half a pound may be dissolved in a sufficient quantity of water and used freely to disinfect discharges from the body. Cloths saturated with it may also be hung around the sick-room. Creosote.-An excellent antiseptic much used in bronchitis and tuberculosis. Croton-Oil.-The most drastic of the cathartics. To be used only in extreme cases, in doses of one to three drops. Digitalis.-The most valuable of all the heart-tonics. There are numerous excellent and powerful preparations of it. Egg-Nogg.-A very nutritious preparation for convalescents and one which is usually well tolerated even by sensitive stomachs, if not made too rich and too sweet. To prepare it take half a pint of cold milk, stir into it the yolk of a fresh egg, then stir into it two tablespoonfuls of brandy and a tablespoonful of lime-water. Then beat up with it the white of an egg, and season with sugar and nutmeg. Ergot.-This is a valuable substance for arresting hemorrhage. Its most frequent application is for hemorrhage from the womb, and it is very often administered after childbirth to cause contrac- tion of the womb and consequent arrest of hemorrhage. The usual dose is a teaspoonful of the fluid extract in a wine-glass of water. It may be repeated within an hour if necessary. Ether.-This is our most valuable substance for producing general anesthesia. As it evaporates very quickly, it is essential that it always be kept in a sealed flask or bottle except when in use. It is very essential that it should be absolutely pure. Eucalyptol.-This is often used as a spray in nasal and throat troubles. 642 HOW TO KEEP WELL Flaxseed.-An infusion may be made by pouring a pint of boil- ing water over a tablespoonful of the seeds. After it has been cooled it should be strained and seasoned with lemon- or orange- peel. It is an excellent remedy for inflammation of the bladder and for cold in the head or grippe. The ground flaxseed or meal is used for poultices. Boiling water is added to the meal sufficient to make a thick paste, and this is wrapped in a piece of linen, the corners being secured so that the meal will not ooze out. The heat from a flaxseed poultice is very soothing for boils, felons, and various kinds of inflammation in which suppuration is to be encouraged and hastened. Formamint.-A pastille containing formalin, useful for soreness and inflammation of the mouth and throat. Ginger.-A teaspoonful in a pint of boiling water makes a very useful tea for the relief of cold and fever. It should be drunk as hot as possible and perspiration encouraged. Glycerin.-For internal use it is employed as an ingredient in cough mixtures. For external use it may be applied to almost any form of inflammatory swelling. Its function is to abstract fluid from inflamed tissues. Gum Arabic.-A teaspoonful in a pint of boiling water makes a pleasant tea when there is soreness of the throat or mouth. It is sometimes recommended as a useful and nutritious drink in fevers. Heat.-This agent may be soothing, stimulating, or depressing. A very hot bath, high atmospheric temperature, various occupa- tions in very hot surroundings are all depressing enough. When there is shock from an injury or operation, very low atmospheric temperature, or collapse from almost any cause, the heart may be stimulated to activity by heat applied to the feet, the sides of the body, or directly over the heart. Dry heat is desired for such con- ditions, and rubber bags filled with hot water, and so covered that the patient will not be burned, may be used. The soothing influ- ence of heat in the form of poultices for many inflammatory con- ditions has been mentioned. Hops.-A tea may be prepared from half an ounce of hops and a pint of boiling water. It is soothing and will sometimes pro- duce sleep. It may be used in irritation of the bladder, nervous- ness, etc. A poultice prepared by wrapping a quantity of hops in silk or VARIOUS MEDICINAL SUBSTANCES 643 linen, and heating them in the oven, is often very grateful for in- flamed tissues, as well on account of its light weight as on account of its soothing influence. Hydrochloric Acid.-This must be used in the dilute form. It is an excellent substance for that form of dyspepsia in which there is an excess of mucus in the stomach. Ten drops in a wine-glass of water may be taken after meals. Insulin.-This is a recent discovery for the treatment of diabetes and is most valuable but must be used only as directed by a physician, and its effects carefully watched. Iodine.-Many combinations of iodine are very valuable, especially the iodide of potash in the treatment of syphilis. Iodine is an irritant and when painted upon the skin leaves a brown stain. It is useful for many painful and inflamed conditions. The tincture is the form which is used externally. It should be kept in a bottle sealed with a rubber cork when not in use, as it evaporates very rapidly. Iron.-This valuable substance is used in many forms (sulphate of iron or copper as has been mentioned). Its chief value is as a tonic in anemia and debility. There is no more useful preparation than colloidal iron, which is the form in which it exists in certain plants. The dose of the tincture for an adult is ten to fifteen drops, well diluted with water, after meals. For checking external hemor- rhage there is no more powerful substance than the persulphate of iron. A very useful tonic is the elixir of iron, quinine, and strychnia. Kumiss.-This is produced by adding yeast to milk and allow- ing it to ferment. The acid character of the product is usually very acceptable to sensitive stomachs, though most people are obliged to acquire a liking for it. It is as nutritious as anything can be and often forms the entire diet in fevers and irritable con- ditions of the stomach. Lead.-This is an ingredient in various lotions and plasters, but in none is it more helpful than in the lead and opium wash or liniment which is a very soothing application for bruises, sprains, and injuries in general in which there are pain and swelling. Lime.-Chlorinated lime, or chloride of lime, is an excellent dis- infectant and deodorizer. It must be used plentifully, if at all, where disinfection is required. Whitewashing dirty walls pro- duces a very agreeable effect, but it must be remembered that if 644 HOW TO KEEP WELL poisonous germs are upon the walls the whitewash will absorb them and they may be liberated again and do harm. Lime-W ater may be prepared by placing a lump of unslaked lime in a pail of water. When the water has taken up its full quantity of lime it will, of course, take up no more; in other words, we have a saturated solution. The surface of this should be skim- med, and the remainder may be strained. Lime-water is very useful when the stomach is sensitive and intolerant. It is frequently added to milk, one part to six or eight of milk. Lysol.-A very excellent antiseptic solution for external use. One or two teaspoonfuls may be used in a pint of water. Magnesium Sulphate.-Commonly known as Epsom salts. It is an excellent remedy for constipation if it is desired to produce abundant watery stools. It is very soluble in either hot or cold water. The dose is one to four teaspoonfuls in a glass of cold water. It is more effective when taken on an empty stomach. Massage.-Skilful and intelligent rubbing is of great service for those who are unable to take sufficient exercise. It should not be violent nor too prolonged. For those who are paralyzed, for the aged, for the infirm and debilitated it is often very helpful. Stimu- lation of the muscular fiber and improvement of the circulation are its chief benefits. Menthol.-This is much used as a spray in nose and throat troubles and as a tablet for coughs and colds. Mercury.-This substance is used in many forms and combined with many other substances. The two principal combinations are the bichloride, or corrosive sublimate, and the mild chloride or calomel. For external use one part of corrosive sublimate may be used with one thousand, five thousand, or ten thousand of water accord- ing as a weak or strong solution may be required. It is one of the most highly valued antiseptics for disinfecting the hands, wounds, or sores and is in constant use by physicians and surgeons. A bot- tle of corrosive sublimate tablets for making solutions should be in every house and marked "Poison." For internal use the greatest value of mercury is in the treat- ment of syphilis. It is also valuable as a tonic, especially when the liver needs stirring up, and as a means of relieving constipation. For the former the bichloride may be used in tablets containing one sixteenth or one thirty-second of a grain, after meals. For VARIOUS MEDICINAL SUBSTANCES 645 the latter, tablets of calomel containing one eighth or one quarter of a grain may be given every half-hour until the bowels move. A Seidlitz powder or a teaspoonful of Epsom salts in a glass of water may be given after the tablets have begun their work. Instead of tablets the calomel may be given in the form of blue-pill, one or two five grain-pills being given at night. Milk Diet.-The use of milk, plain, boiled, or fermented (kumiss, matzoon, zoolak), as a partial or exclusive diet must often be re- sorted to. In fevers, various forms of dyspepsia, and wasting disease of all kinds, nothing can surpass this as a means of nu- trition. It is tolerated by the stomach in more cases of disease than any other substance. Milk-Punch.-A tablespoonful of whisky or brandy in a glass of milk with a little sugar or nutmeg added is a very useful and strengthening stimulant for those who are debilitated or convales- cing from diseases of any kind. Mustard.-Internally this substance is an excellent emetic. If it is desired to produce vomiting quickly a teaspoonful of mustard in a pint of lukewarm water swallowed hastily will usually do it. Externally mustard is an excellent irritant. If it is desired to redden the skin or blister it, to relieve vomiting or congestion of the lungs, this substance may be used. Two tablespoonfuls of mustard and one of wheat flour moistened with enough water to make a thick paste may be spread over a piece of linen cloth, the latter being then closed to prevent oozing of the paste, and placed over the surface which requires irritation. Mustard-leaves are better than the home-made pastes and may be obtained in tin boxes at any reliable apothecary's. Niter.-The sweet spirits of niter is an old and reliable remedy for bladder troubles. A teaspoonful in a third of a glass of water is an ordinary dose. Nitrite of Amyl.-This is prepared in globules which are broken and inhaled when an attack of epilepsy or angina pectoris or asthma is coming on. Opium.-The great purpose of opium is to relieve pain, and it is used for this purpose both externally and internally. Various powerful alkaloids are obtained from opium, none of which is safe or desirable for household use. One preparation may be kept in every house without much fear of bad results from poisoning, 646 HOW TO KEEP WELL the well-known combination paregoric. It is suitable for any age or sex. The dose varies from a few drops for an infant to two tea- spoonfuls when pain is severe and obstinate in an adult. Aside from its use for pain in general, this substance is of great value in summer diarrhea. If there is undigested matter in the stomach or bowels, this must first be relieved by a dose of castor-oil, after which the paregoric may be given at intervals of one or two hours until relief is obtained. Oxygen.-This is put up in iron cylinders and is inhaled for cough, collapse, or shock. It is often a life-saving remedy. Peppermint.-A mild remedy for the relief of pain in the stomach and bowels, especially when caused by gas which is due to fer- mentation. A teaspoonful may be placed in a glass of hot water and drunk slowly. It is useful for either children or adults and is often given in the wind-colic from which babies suffer so fre- quently. Pepsin.-This is obtained from the stomach of the pig, sheep, ox, etc., and is identical with that which is found in the human stomach. Its purpose is to digest albuminous food (lean meat, white of egg, etc.), and when the stomach is unable to furnish enough for the requirements of an individual it may be supplied to him from without. When the digestive powers are weak, al- buminous foods are sometimes predigested with pepsin before being taken into the stomach. Milk is very often treated in this way and the labor of the stomach lightened. Different specimens of pepsin vary much in their digestive power. They should always be fresh when taken. Exposed to the air they quickly decompose. The dose is from one to five grains. Permanganate of Potash.-This is an excellent deodorant for the skin, a solution of suitable strength being applied to the skin with a brush or sponge. The skin is stained, but it will wear off in a few days. Peroxide of Hydrogen.-A very useful preparation for the cleans- ing and dressing of wounds, arresting of bleeding, etc. It may also be used internally for conditions in which it is desirable to introduce oxygen into the tissues or organs. Phenacetin.-This coal-tar product has an extensive employ- ment in the treatment of colds, headache, neuralgia, and grippe. The dose is five to ten grains. VARIOUS MEDICINAL SUBSTANCES 647 Pumpkin-Seeds.-This is the simplest and least dangerous sub- stance for the treatment of tapeworm. The seeds should be dry, and two ounces may be crushed and thoroughly stirred in a glass of water. An hour after taking the mixture a tablespoonful of castor-oil should be swallowed. Of course, the seeds themselves are not to be taken. Quassia.-This is an intensely bitter substance and may be taken freely when a vegetable tonic is required; that is, in debility with general lack of physical strength. An infusion may be made from two drams of the chips of quassia wood in a pint of boiling water, and this may be taken freely. For seat-worms a strong preparation, two ounces to a pint of boiling water, may be given in wine-glass doses until the worms have been expelled. Quinine.-One of our most useful drugs for the treatment of malaria, anemia, and debility. As good a form of the drug as any for ordinary purposes is the sulphate in five-grain gelatin-coated pills. Two may be taken at bedtime and one the following morning if the malarial symptoms are pronounced, this being continued and gradually diminished until the symptoms disappear. For children five grains at a dose will usually be sufficient. Rectal Feeding.-When food is not tolerated by the stomach it must be injected into the rectum. Milk, oil, beef tea, whisky, and other substances may be administered in this way for days or even weeks and nutrition maintained. From six to ten ounces are the limits, as to quantity, which may be injected advantageously. Rhubarb.-A mild laxative, much more frequently used formerly than now. A very good preparation for household use is the rhu- barb and soda mixture, which may be used without fear. The dose for constipation is one or two teaspoonfuls repeated as occasion may require. Rochelle Salts.-A mild laxative, less powerful than Epsom Salts. The dose is a tablespoonful in a glass of water, taken before break- fast. Sage.-An old-fashioned remedy is sage-tea, useful for colds and diarrhea. Half an ounce of the dried and pressed shrub in a pint of boiling water allowed to steep a few minutes, then strained and drunk while still warm, will sometimes prove very useful. Salicylate of Soda, Salol, and salophen are all compounds of salicylic acid and are very valuable in the treatment of rheumatism. 648 HOW TO KEEP WELL Salvarsan.-A preparation of arsenic much used in the treatment of syphilis. It is popularly known as "606." Seidlitz Powder.-A mild laxative to be taken before breakfast. The contents of the blue paper are dissolved in half a glass of water, the contents of the white paper are then stirred in, and it is to be drunk while effervescing. Senna.-A powerful cathartic which causes considerable griping but is very effective in obstinate constipation. An infusion may be made with an ounce of the leaves in a pint of boiling water, the dose being a wine-glass. The compound licorice powder contains senna as its most effective ingredient. Silver.-In the form of the nitrate this substance is astringent and caustic. It is sometimes used internally for diarrhea in one- grain pills, but its greatest value is as an external stimulant and astringent in the form of lunar caustic, upon sores and growths of various kinds. It destroys unhealthy tissue, stimulates healthy ac- tion, and dries up offensive discharges in a very satisfactory manner. Slippery Elm.-A very mild soothing substance used in the form of tablets and infusion or tea, in coughs and colds. Sodium Phosphate.-An excellent laxative. Dose, tablespoonful in a glass of water. Sodium Sulphate.-A very active cathartic. Dose, teaspoonful in a glass of water. Spigelia.-A valuable material for the removal of roundworms (lumbricoids). It is not altogether a harmless remedy and there- fore must be used with caution. The fluid extract combined with senna may be taken in half-teaspoonful doses every four hours until the worms are expelled. Sulphur.-It has many uses, especially in diseases of the skin. The old-fashioned mixture of sulphur and molasses was formerly much used as a spring medicine. Tannin.-An excellent astringent which may be used as a gargle for soreness and relaxation of the throat, and also as a means of arresting hemorrhage from the nose and bowels, and from bleeding surfaces. A teaspoonful in a glass of water is strong enough for a gargle, but to arrest hemorrhage it should be twice that strength. Thoroughwort.-Also known as boneset. An old-fashioned remedy used as a tea, an ounce of the herb being added to a pint VARIOUS MEDICINAL SUBSTANCES 649 of boiling water. This is strained when cold and given in wine- glass doses. It may also be taken hot after steeping a few minutes. For colds and rheumatism it is highly valued by many. It will sometimes act as an emetic. Turpentine.-A very valuable substance for relieving the stomach and bowels of gas. Ten drops may be taken in water by mouth. Two teaspoonfuls in a pint of hot water may be used for an injection, and a teaspoonful upon a cloth wrung out of boiling water may be used for an application upon the abdomen. Valerian.-The tincture may be used in teaspoonful doses in a wine-glass of water to allay nervousness and relieve headache. Hysterical women find this a valued remedy. The ammoniated tincture is an excellent remedy for nervous headache, a teaspoon- ful being taken in half a glass of water. Veronal.-One of the synthetic preparations for producing sleep. Dose five to fifteen grains. It must be used cautiously. Vinegar.-The astringent use of vinegar is sometimes valuable. A sponge or cloth soaked in it and applied to a bleeding surface will usually arrest the bleeding promptly. Wine Whey.-An excellent preparation for the convalescent. Take half a pint of milk and half a pint of sherry wine; mix and let them stand in a warm place five minutes; then strain and sweeten to taste. Wintergreen.-The oil is much used in the treatment of rheuma- tism. One or two drops in water repeated every three hours may be given. Zinc.-Zinc ointment is an excellent household remedy for chapped and burned skin, and for ulcers and sores generally. It is a perfectly safe preparation. INDEX OF DISEASES AND REMEDIES FOR TREATING THEM (CHAPTER XL) Acidity of Stomach Bicarbonate of soda Charcoal Anemia Cod-liver oil Iron Quinine Anesthetic Chloroform Ether Astringent Nitrate of silver Peroxide of hydrogen Vinegar Boils Flaxseed Bruises Arnica Collodion Lead and opium Cathartic Cascara sagrada Castor-oil Compound cathartic pill Senna Cold Antipyrin Flaxseed Ginger Phenacetin Sage Slippery elm Thoroughwort Collapse Ammonia Heat Congestion of the Lungs Mustard Constipation Castor-oil Compound cathartic pill Iron Magnesium sulphate Rhubarb and soda Senna Sodium phosphate Sodium sulphate Convalescence Arrowroot Arsenic Egg-nogg Milk-punch Wine whey Cough Brown mixture Cod-liver oil Creosote Formamint Glycerin 650 INDEX OF DISEASES 651 Debility Chamomile Iron Massage Milk-punch Quassia Quinine Deodorizer Chloride of lime Copperas Lime Permanganate of potash Peroxide of hydrogen Diabetes Insulin Diarrhea Alum Bicarbonate of soda Camphor Chloroform Paregoric Castor-oil Sage Nitrate of silver Disinfectant Chlorate of potash Copperas Lime Mercury Peroxide of hydrogen Drunkenness Capsicum Dyspepsia Capsicum Charcoal Hydrochloric acid Milk Pepsin Emaciation Cod-liver oil Emetic Mustard Thoroughwort Faintness Ammonia Camphor Digitalis Oxygen Felons Flaxseed Fever Aconite Antipyrin Ginger Gum arabic Kumiss Milk Flatulence Asafetida Turpentine Gargle Chlorate of potash Eucalyptol Menthol Tannin Grippe Antipyrin Flaxseed Formamint Phenacetin Salol Salophen Headache Ammonia Antipyrin 652 HOW TO KEEP WELL Headache-Continued Aspirin Bicarbonate of soda Camphor Phenacetin Valerian Hemorrhage Alum Antipyrin Ergot Iron Peroxide of hydrogen Tannin Vinegar Hysteria Asafetida Camphor Valerian Indigestion Bicarbonate of soda Pepsin Inflammation Flaxseed Glycerin Hops Iodine Peroxide of hydrogen Inflammation of the Bladder Buchu Flaxseed Hops Sweet spirits of niter Injection Turpentine Water Insomnia Phenacetin Veronal Irritant Mustard Irritation of the Stomach Kumiss Lime-water Rectal feeding Itch Sulphur Laxative Castor-oil Rhubarb and soda Rochelle salts Seidlitz powder Leucorrhea Alum Boric acid Liniment Chloroform Lead and opium Peroxide of hydrogen M alaria Quinine M outh-Wash Chlorate of potash N ervousness Asafetida Camphor Valerian Neuralgia Heat Phenacetin Pain Glycerin Iodine Lead and opium Opium Paregoric INDEX OF DISEASES 653 Pain in Bowels Chloroform Cold Peppermint Poultices Bran Flaxseed Hops Rheumatism Phenacetin and salol Salophen Thoroughwort Wintergreen Shock Ammonia Heat Sore Mouth Boric acid Chlorate of potash Gum arabic Sores Lunar caustic Zinc Sore Throat Boric acid Chlorate of potash Formamint Gum arabic Tannin Sprains Arnica Lead and opium Stimulant Alcohol Chamomile Champagne Milk-punch Suppuration Flaxseed Surgical Dressing Boric acid Carbolic acid Peroxide of hydrogen Swelling Lead and opium Swelling of Tonsils Chlorate of potash Syphilis Iodide of potash Mercury Salvarsan T apeworm Castor-oil Pumpkin-seeds T onic Arsenic Chamomile Cod-liver oil Iron Iron, quinine, and strychnia Mercury Quassia Ulcers Boric acid Chlorate of potash Sulphate of copper Zinc Vomiting Bismuth Mustard Wind colic Peppermint Worms Quassia Spigelia INDEX OF SUBSTANCES MENTIONED IN THIS CHAPTER (CHAPTER XL) Aconite Alcohol Alum Ammonia Antipyrin Arnica Arrowroot porridge Arsenic Asafetida Aspirin Baume Analgesique Beef extract Bicarbonate of soda Bismuth Boric acid Bran Brown mixture Buchu Camphor Capsicum Carbolic acid Cascara sagrada Castor-oil Chamomile Champagne Charcoal Chlorate of Potash Chlorine Chloroform Cod-liver oil Cold Collodion Compound cathartic pills Copper Copperas Creosote Croton-oil Digitalis Egg-nogg Ergot Ether Eucalyptol Flaxseed Formamint Ginger Glycerin Gum arabic Heat Hops Hydrochloric acid Insulin Iodine Iron Iron, quinine, and strychnia Kumiss Lead Lime Lysol Magnesium sulphate Massage 654 INDEX OF SUBSTANCES IN THIS CHAPTER 655 Menthol Mercury Milk diet Milk-punch Mustard Niter Nitrite of amyl Opium Oxygen Peppermint Pepsin Permanganate of potash Peroxide of hydrogen Phenacetin Pumpkin-seeds Quassia Quinine Rectal feeding Rhubarb Rochelle salts Sage Salicylic acid Salicylate of soda Salol Salophen Salvarsan Seidlitz powder Senna Silver Slippery elm Sodium phosphate Sodium sulphate Spigelia Sulphur Tannin Thoroughwort Turpentine Valerian Veronal Vinegar Wine whey Wintergreen Zinc CHAPTER XLI TUMORS Abdominal Tumors.-An abdominal tumor may be so small that it causes' no outward enlargement, or it may be so huge that it will weigh more than the remainder of the individual. A very large tumor is a menace to life on account of its size and its interference by pressure with important organs and functions, though it is astonishing how an individual can adjust himself to these unusual conditions and carry on the ordinary duties of life. But size alone is not a measure of the importance or the harmfulness of an abdo- minal tumor, for many that are too small to excite attention are the source of the greatest trouble and cause death more quickly than others which are far more conspicuous. Surgical writers classify these tumors as benign and malignant. The former do not come back after being removed. The latter do in many cases. Ovarian, fibroid, and fatty tumors are benign; the various kinds of cancer are malignant. Tumors may grow very fast and become very large within a year. This is especially the case with malignant tumors, but it is also true of fluid tumors, like the ovarian. A tumor may be hard as stone or bone; it may be colloid like jelly or glue; or it may be fluid. The hard tumors usually grow slowly, and the slower they grow the less trouble they cause as a rule. Some women have had fibroid tumors as long as they can remember and have had very little trouble with them. In some cases these tumors shrink and become insignificant after the child-bearing period is over and so produce a spontaneous cure, but this does not happen very often. Tumors may grow in any of the organs in the abdomen or pelvis, and they grow more frequently from the pelvic organs of women than from any others in the body, whether in men or women. The 656 TUMORS 657 liver, gall-bladder, spleen, stomach, intestines, pancreas, and kid- neys are all subject to tumors. It is fortunate for humanity that there are bold and skilful surgeons who do not hesitate to attack these tumors wherever they may be found. Of course, not all of them are proper subjects for attack, for in some cases to attempt to remove them would be absolutely sure to kill the patient. In the great majority of cases they are removable, and if they are seen early, when the patient still has good recuperative powers, their removal may mean many years of useful and happy life. Fatty Tumors.-Fat is obtained partly from the fat-containing foods, which, when digested and emulsified, are carried to the vari- ous parts of the body that need them, and partly as the result of chemical changes which take place within the organs and tissues. But while it is one of the necessary tissues of the body, and an insufficient quantity is an evidence of disease, its presence in ex- cessive quantity is equally an evidence of disease which may be of very serious importance. Thus, when it is present in excess in the structure of the heart, the lungs, or the liver, these organs become seriously weakened and a menace, not only to the health and com- fort of the individual, but to life itself. Even when fat is deposited in huge masses beneath the skin of the abdomen, the legs, the arms, etc., the individual becomes w-eak, clumsy in his movements, and very uncomfortable. One of the curious and interesting varieties of fat formation is the fatty tumor. Such tumors occur on any portion of the body and limbs, but perhaps more frequently on the back than elsewhere, and they may be of the size of marbles or as large as one or both fists. These tumors are raised symmetrically from the surface of the body like a segment of a sphere, usually grow slowly and pain- lessly, and may reach a considerable size before one is aware of their presence. There may be one or several of them, and in rare cases they may be sprinkled over the entire body. If they are located in the track of important nerves, or of those which have unusual sensitiveness, pressure upon them will be painful. They are seldom the seat of inflammation and are chiefly annoying be- cause of the fact of their presence and the uncertainty as to what they will do or become. Because of this fact it is usually wise to remove them. 658 HOW TO KEEP WELL The operation is a simple one, which can be done under local anesthesia, and when such a tumor is onced removed it does not return. Of course, the entire tumor must be removed, for if a portion of it is left it probably will grow again. Fibroid Tumors.-Fibroid tumors are made up principally of what is known as fibrous or connective tissue, but they also may contain more or less muscular tissue, and they have blood-vessels and nerves like all other living tissues. The more fibrous tissue they have the harder they are and the slower they grow; and the more muscular tissue they have the softer they are. The tumors may occur in any portion of the body, but they are particularly prone to attack the womb. Some women show no tendency to the formation of such tumors, while others have a pro- nounced tendency. In negro women they are very much more common than in white women. The affected organs may have only one or two, or they may be riddled with them. Perhaps one or two may grow to a considerable size, while the others may re- main as small as peas or marbles. The greater the supply of blood in the part of the organ where a tumor is located the more rapidly the tumor will grow and the larger it will become. Those which are near the cavity or inside of the organ and those which are on the extreme outside usually become larger than those in the tissue between the inside and the outside. Sometimes the entire organ becomes a single fibroid tumor. The tumors may reach a considerable size before they excite attention. They seldom cause pain, but often are the cause of repeated and severe hemorrhages, especially when located near the inside or cavity of the organ and encroaching on its mucous mem- brane. In some cases a tumor may disintegrate and decompose and the absorption of the decomposed material cause fatal blood- poisoning. Degeneration of a cancerous nature also is possible but does not occur very often. Should the tumor become very large, it would interfere with the functions of the abdominal organs, disturb digestion, and give rise to pressure symptoms which sometimes are distressing. Fi- broid tumors are also a menace to pregnancy. They may cause miscarriage or so interfere with childbirth that it cannot be accom- plished until the obstructing tumor is removed. If they give trouble from their size or from hemorrhage, it is best to remove TUMORS 659 them, and this will often require removal of the organ at the same time. Ovarian Tumor.-There are different kinds of ovarian tumors, but I am going to consider only those which are of most common occurrence, which may include some solid material but for the most part consist of a cyst or sac filled with fluid which may be as limpid as water, or viscid, or like glue, or consist of pure pus. Why these tumors grow in the ovary it is often difficult or im- possible to say. They may originate before birth or at any period of life after birth. I have seen them in children; I have seen them in women more than eighty years old. They may increase to such a size that they will weigh more than the patient herself. They may present no symptoms at all in their early history; often they have been discovered by accident, when an operation was being performed for some other purpose. When the pelvis has become too small to hold them and they extend into the ab- dominal cavity, they may for the first time announce their presence by the enlarged dimensions of the abdomen. From this time their increase in size may be rapid, for they usually meet at first with little resistence from the organs in the abdominal cavity. But when a certain limit has been reached, their presence is constantly felt, and the pressure which they cause upon the abdominal organs may cause all kinds of derangement in those organs, and all kinds of discomfort as a consequence. After they have reached a large size, weighing perhaps forty or fifty pounds, they become a menace to life. The functions of the abdominal organs cannot be properly performed; lying down becomes difficult or impossible; sleep is disturbed; emaciation and weakness follow; and the poor patient may die from exhaustion. Or an attack of peritonitis may occur, and if the patient survives, adhesions form between the tumor and the abdominal organs, and the oftener such attacks occur the more difficult will it be to separate the tumor from the organs when its removal is attempted. Hemorrhages may occur into the tumor or from the organs of the pelvis and endanger life in that way. The patient is constantly uncomfortable and in dread of what is yet to come. There is only one way to treat such tumors, and that is to remove them at the earliest possible moment. The sooner they are removed the simpler the operation becomes and the greater the chance of recovery. 660 HOW TO KEEP WELL Sarcoma.-The tumor which goes under this term belongs to the class known as malignant tumors; that is, it very rarely gets well of itself. It has a vicious tendency to extend to parts of the body more or less remote from the original tumor, and if it is re- moved it is very prone to reappear either at the original site or elsewhere, particularly in one or more of the internal organs. It frequently is called cancer, but it has a structure distinctly different from cancer. Besides, it more frequently appears in those who are under thirty years of age, while cancer is essentially a disease of middle and advanced life. Sarcoma chiefly resembles cancer in the fact that both are malignant and almost always fatal, unless removed very early and under very favorable con- ditions. There are different types or kinds of sarcoma. Some have as their principal constituent a substance resembling glue or mucus. In others this constituent is like cartilage, and there are cases also in which it is real hard bone. They also are distinguished by the shape of the cell which characterizes them, this being spindle- shaped in one case, round in another, and very large with many nuclei in another. The shape of the cell also indicates to a certain extent the degree of malignancy of the tumor, the round-celled tumor being more malignant than the spindle-shaped. In some of the cases the original cells of the tumor are in the body at birth, remaining dormant until some exciting or irritating condition occurs, when they spring into life and develop and re- produce with startling rapidity. A person may to all appearances be perfectly well to-day, and two weeks hence he may have a sar- coma which grows with the luxuriance and rapidity of a mushroom. Sarcoma may come in any part of the body, but it prefers the bones of the arms and legs or the layers of tissue beneath the skin. Less frequently it attacks the internal organs, but it is not unusual for it to be carried to the internal organs, the lungs the kidneys, or the genital organs, and to appear as a secondary development or growth. Probably the most frequently exciting cause of sarcoma is in- jury, a blow, a fall, a bruise, a burn, being quickly followed by the appearance of a swelling, which grows uninterruptedly. In chil- dren the complete history of the tumor may be measured by a few weeks, while with those who are older it may consume several months. TUMORS 661 In a limited number of cases tumors considered unsuitable for operation by good surgeons have been cured by serums containing bacteria which have produced another disease that apparently has destroyed the original one, but in many of the cases thus treated there has been failure. A very early and extensive operation i.pon the more slowly growing tumors, especially if the person is in mature life, may be successful. CHAPTER XLII CANCER Cancer.-The simplest definition that the pathologists have given of cancer is that is it an atypical epithelial newgrowth. This means in ordinary language that it is a lump or tumor composed mainly of epithelial cells of no definite or uniform type or variety. The disease is not at all uncommon in animals and even in fish, and it is frequent in such animals as the horse, dog, monkey, mouse, and rat; but whether the disease in these instances is identical with that which occurs in human beings does not seem definitely settled. What causes it is also indefinite, uncertain, and inconstant. It is commonly said that it is due to injury or irritation of cellular tissue, and that is undoubtedly true; but the same amount of in- jury which will produce cancer in one case will not produce it in another. Therefore, in addition to irritation and injury there must also be peculiar sensitiveness and rebelliousness of the tissues which are injured. This sensitiveness is more often present in middle or advanced life than it is in youth or young adult life. A blow or severe injury to a young person with sensitive tissues might be followed by the development of a malignant tumor, but it would not usually be a cancer, though it might be a tumor of rapid growth and equally as fatal as a cancer. On the other hand, the same kind of an injury to sensitive tissues to one who has passed middle life would in many cases result in cancer. In addi- tion to injury, sensitiveness, and maturity of tissues as causes, it may be said that cancer usually begins in one spot, that it usually has a local origin, and that if it can be removed before it becomes deep-seated and before it has been carried to other parts it is often possible to eradicate it. The lymphatic vessels in a developing cancer take up more or 662 CANCER 663 fewer of its cells and bear them in their current to the nearest lymphatic glands, where they are arrested, and a new center for the growth of the disease is started. From this center other cells may be liberated and carried to other glands, and so the disease is spread in different directions from its original location, and it may spread indefinitely. Whether in addition to injury of the tissues there may also be a germ or parasite which causes cancer we do not know; germs and bacteria are so prevalent and so influential both within and without the body that it is fair to presume that their influence and assistance are not wanting. After a cancer has developed to a certain extent, forming a lump or tumor larger or smaller, whether on the outside or the inside of the body, it breaks and forms a sore; and while ordinary sores tend to heal over and get well, the cancerous sore remains open and tends to get larger and more and more destructive, ending only with the exhaustion of the vital forces and death. Any portion of the body where there are epithelial cells may be attacked by can- cer, and the order of frequency of its location is (i) the stomach and liver, (2) the peritoneum, intestines, and rectum, (3) the female generative organs, (4) the breast, (5) the mouth and tongue, (6) the skin, (7) all other parts of the body. It may be treated by surgical, medical, and dietetic means, and it has been cured by all these means in favorable cases when it has been discovered and treated in its earliest stages. It has been cured by the knife, the cautery, the X-ray, and radium, but the fur- ther it progresses the more difficult it is to get it all out; in the advanced cases the task is an impossible one. It is not contagious like smallpox, but it is possible to inoculate a portion of the body from a cancer which rubs or chafes it. It is not inherited like syphilis, but cancerous parents may have children with weak and sensitive tissues, which in time develop some form of cancer. As it is said to be on the increase everywhere, it becomes very im- portant for everybody who has reached or passed middle life to avoid all kinds of injury and irritation as much as possible, whether from violence, from eating and drinking, from nervous disturbance, or from any other cause. When such a person has any kind of a sore that refuses to heal or heals very slowly, he should lose no time in seeking expert advice as to the nature of the sore. The same is true for those who are constantly losing blood in smaller or larger quantities from any portion of the body. 664 HOW TO KEEP WELL Cancer of the Bladder.-While most of the tumors of the blad- der are said to be non-malignant in the beginning, they have a habit of degenerating and becoming malignant or cancerous if not removed very early in their history. Unfortunately, too, those which are not malignant, so far as can be determined by the micro- scope, may return; and an operation performed ever so carefully may require repetition once or oftener, the cancerous condition ultimately resulting. Cancer of the bladder is a disease of middle or advanced life, and much more common in men than in women. There may be nothing to indicate that it is present until it announces itself by a more or less severe hemorrhage. This hemorrhage may occur at any time, but it occurs most frequently at the conclusion of the act of urination. Pain occurs when the disease is well advanced, and this may be very sharp and agoniz- ing. As the disease progresses, it may take the form of a tumor and extend from the bottom of the bladder upward until it occupies most of its interior, or it may be a thickening and swelling of its wall, extending into the surrounding tissues and invading the neighboring glands. Inflammation, or cystitis, results, with ulceration, formation of pus, disintegration of tissue, and asbsorption of poisonous material. The disease may extend to the ureter and ultimately involve one or both of the kidneys. Urination becomes very difficult; blood, mucus clots, pus, and broken-down tissues are discharged, or may require removal with a catheter; and the patient becomes truly mis- erable and pitiable. Irrigation of the bladder with a hot astringent solution of alum, ergot, or some other substance of that character may be used in an emergency to arrest hemorrhage, and pain may be relieved by suppositories of a suitable narcotic, or such a drug may be given by the mouth or hypodermically. The first appearance of bleeding is the danger-signal, and it never should be disregarded. Cancer of the Breast.-There are many varieties of tumor of the breast or, more correctly, of the mammary gland; but for the general public they are either malignant like cancer or benign; that is, not fatal in their consequence. Probably from ten to twenty per cent of the breast tumors are not malignant. A great many of those which are clearly malignant are now seen and removed in their early history and do not return; that is, those who have them are cured. At the present time the best and most experienced CANCER 665 surgeons are able to cure fifty or sixty or even seventy per cent of their cases, partly because they operate more thoroughly and more radically, and partly because the operations are done in the early history of the disease, before it has spread and extended from its original location. The first thing which excites the attention of a woman who has tumor of the breast is that there is a hard lump which she had not noticed before. It may or may not be painful. It may have resulted from a blow or injury; it may come after a woman has borne and nursed a number of children; or it may come from no particular cause that she can account for. It may come in early life or after the age of forty or fifty. It is more likely to be in the latter part of life than not. The hardness is unusual, for the mammary gland is soft under ordinary conditions, and one who was inexperienced would fail to locate it, particularly if the breast were large. At first this hard lump can be moved about, but by and by it becomes fixed, and by degrees all the surrounding tissues become hard, the nipple may become retracted, there may be a bloody discharge from it, and finally an open sore may develop which will not heal and which corrodes and destroys the tissues. Pain may not be severe at first, but after a time it is sharp and stabbing and continuous and the source of great agony. The arm may become swollen, stiff, and painful; and in the course of one or two years the patient is worn out and dies. If the tumor is not cancerous it is less apt to be painful, and the pain is less severe in character. The tumor does not usually be- come adherent to the surrounding tissues nor is the use of the arm interfered with. It is not always possible to tell before a tumor is examined by the miscroscope whether it is cancerous or not. I would, therefore, urge to the best of my ability, when any one, male or female, old or young, notices any kind of a lump in the breast, no matter whether it has symptoms or not, that a skilful surgeon be at once visited for his opinion, and if he decides that the lump indicates disease, that it be removed immediately. A very early operation is attended with little danger, and it may mean years of useful and comfortable life, while delay even for a few weeks or months may be the signing of one's death-warrant. Cancer of the Intestines.-Men seem to be subject to it more than women, especially those who have passed middle life. It sei- 666 HOW TO KEEP WELL dom occurs under the age of forty-five or fifty, and it is by no means a rare disease. It may attack any portion of the thirty feet of intestinal tubing, but, as a matter of fact, only four per cent of the cases are in the small intestine, while eighty per cent are in the rectum and the remainder in the different portions of the large intestine. It often is difficult to say what causes it. It seems to me that several of the cases with which I have been familiar could be traced to worry and disappointment. Perhaps the greater number of cases are due to the irritation of the intestine caused by re- tained and hardened contents, which, when finally removed, scrape and rasp the delicate mucous membrane of the bowel like a file. Hence prolonged and persistent constipation, one of the com- monest ailments of old men, may be looked upon, in many cases, as the progenitor of intestinal cancer. The tumor, composed of the intestine and its contents, is mova- ble and not very painful at first, but as the disease progresses in- flammation in the tumor causes pain and tenderness, and adhesions form, which by and by may make the tumor rigid and unyielding. As inflammation progresses, a portion of the tumor may be under- mined, and ulceration may form an opening which will allow the accumulated intestinal contents to pass through, or ulceration be- tween neighboring parts of the intestine may take place and a new channel for these contents be provided. Thus diarrhea may alter- nate with constipation and temporary relief be obtained. The disease begins with general disturbance and bad feelings, especially in the intestines. This may last several months before the disease is recognized, and the patient will be constantly com- plaining of indigestion, nausea, pain, constipation, and occasional discharge of blood. Gradually the skin assumes a pallid or green- ish appearance, which is very characteristic of cancer, and the formation of an abdominal tumor should lead definitely to the de- termination of the ailment. The duration of the disease is usually less than one year. If it is discovered early, before adhesions have formed and ex- tension has taken place to adjoining tissues, it often is possible, by removing a sufficiently large segment of the intestine, to cure the disease, or, at any rate, to retard its development materially. If the disease is far advanced and obstruction to the evacuation of the bowel demands relief, an opening may be made in the intestine CANCER 667 above the disease and the intestine secured to a wound made in the skin, either in the middle line of the abdomen or in the groin, par- ticularly the left one. This attachment soon becomes permanent and forms the new opening for the escape of the bowel contents. This often retards the progress of the disease and permits the patient to live several months in more or less comfort, though the constant passage of the intestinal contents through this artificial opening brings with it a train of evils which are not easy to bear. Cancer of the Larynx.-Excessive use of the voice, constant use of very hot liquids or solids or raw spirits, immoderate smoking, and injuries of various kinds predispose to its occurrence. On the other hand, I have known of its occurrence in men who have led the most blameless and temperate lives. In those whose tissues are weak and of poor resisting power and whose family history points to a tendency to malignant disease, irregularities and ex- cesses of one kind or another may precipitate this form of cancer- ous ailment. At least two forms of constitutional disease which are prone to attack the larynx may be mistaken for cancer, these dis- eases being tuberculosis and syphilis. The early symptoms of laryngeal cancer may not be particularly alarming. I have known those who had no suspicion that anything serious was the matter until the disease was too far advanced to take efficient measures for its relief. There may be no external in- dication that disease of this significance is present. The voice may have an unusual metallic character; there may be difficulty in swallowing; and as the disease progresses there will be hoarse- ness, cough, and difficulty in breathing. In some cases there will be an enlargement of the glands in the neck; and, when the disease has made great progress and the products of decomposition from broken-down tissues have been absorbed, there may be pallor of the skin and the peculiar facial appearance which comes with all forms of cancer and which indicates constitutional infection. Pain may be absent until late in the development of the disease, or it may be very sharp and troublesome from an early period. The disease may attack one or both of the vocal chords, besides in- volving the other structures of the interior of the larynx. Sooner or later an ulcer appears, there is destruction and decomposition of the tissue, the breath becomes exceedingly offensive, and there may be more or less abundant ejection of pus, blood, and decom- posed tissue. 668 HOW TO KEEP WELL The progress of the disease is rather slow. Its entire course may occupy two or three years. Much may be done by a skilful laryngologist to relieve its pain and its offensive features. If ever the powerful narcotics are a blessing and a comfort, they are such when applied directly to the tissues involved in cancer of the larynx. Early surgical operation is said to have cured not a few cases. Removal of a portion or the whole of the larynx has been done in a large number of instances. There may be hope in radium. It is used in some cases, but experience is probably not yet suf- ficiently matured to say what the limit of its usefulness may be. The great thing to be desired is an early diagnosis and treat- ment by one who is both skilful and judicious. Opening the larynx and the permanent use of a tube are practised frequently. This may give great comfort and may delay for a long period the march of the disease. Cancer of the Liver.-Cancer seldom originates in the liver; it is almost always brought to it from elsewhere, especially from the digestive organs, because the blood from these organs, flowing through what is known as the portal vein, is carried directly to the liver and carries the germs of cancer, whatever they may be, with it. It is also transmitted from other organs in its vicinity which may be the victims of this disease. It seldom occurs in early life; it occurs most often in the two decades from forty to sixty, and it has no characteristic symptoms by which it may be made out in its early stages. Therefore, when a person suffers from loss of appetite, distress after eating, nausea and vomiting, and a careful examination, con- firmed, it may be, by an X-ray examination, shows that the stomach is the seat of cancer, it becomes important to watch carefully for its extension to the liver. By and by the patient will lose strength and emaciate and will complain of soreness and pain in the region of the liver. In most cases this organ will now be found enlarged and protuberant, and over its convex surface will be scattered hard lumps or nodes, which can easily be made out through the thin abdominal wall. All over the surface of the abdomen enlarged veins will be seen, and it will not be long before additional prominence will be given to the abdomen by the presence of dropsical fluid, which may require removal for the patient's comfort or even his very existence. The lower limbs will also be puffed and swollen with CANCER 669 fluid which has been forced into the tissues from the veins, just as it has been forced into the abdominal cavity. Jaundice is present in many cases, but not in all, beginning as a slight yellow discoloration and gradually becoming deeper as the obstruction increases in the circulation. Whether jaundice be present or not, there is almost always a waxy appearance of the face and of the skin in general which is quite characteristic of cancer and is often termed the cancerous cachexia. Sometimes there are hemorrhages into the skin, making black and blue spots of smaller or large size, and almost always there is more or less fever. Should other diseases break out, like influenza, or pneu- monia, or fever of any kind, in those who are suffering from cancer of the liver, they would almost surely be fatal on account of the sufferer's weakened powers of resistance. The disease may last only a few months; it rarely lasts more than a year. Cancer of the Rectum.-There are several varieties of it, and it may begin near the extremity of the rectum or at any point above. In some cases there is merely a thickening and hardening of the rectal tube, extending over part or all of its circumference; in others there is a hard or soft ring, more or less raised above the mucous membrane which constitutes its inner surface or lining; while in others one or more tumors, varying in size, project into its cavity. As the disease progresses, the mucous membrane at its surface breaks, and a sore or ulcer forms, which constantly tends to progress and spread in all directions. This sore may extend deeply and perforate the wall of the rectum, giving rise to hem- orrhage and inflammation, which may lead to a fatal issue; or it may result in the extension of the disease to the neighboring tissues and organs. It is usually accompanied by an abundant discharge of pus and blood of a peculiarly offensive character. It is also apt to lead to a contraction or stricture of the rectum, which makes the evacuation of its contents very difficult and painful. When the disease begins it may not give rise to any noticeable symptoms, or if there is bleeding, it may be mistaken for an attack of hemorrhoids. Very soon, however, it causes a sense of dis- comfort, and this, in a short time, becomes actual pain. Diarrhea may be an early symptom, and this alternates with constipation. When the disease has reached this stage, hemorrhages are frequent and copious, producing great weakness of the patient. He be- comes emaciated, and as the poisons which are developed from 670 HOW TO KEEP WELL the decomposing discharges of the sore are absorbed, the skin assumes a peculiar pallor or waxy appearance, which is one of the distinguishing accompaniments of cancer in all its forms. Though these are all striking symptoms, it must be remembered that not all tumors or other diseases of the rectum are cancerous, or necessarily lead to cancer. They do emphasize the importance, however, of attention to all diseases of the rectum including hemorrhoids and fistulas, especially when they are attended with copious discharges of pus or blood. They also show the im- portance of avoiding constipation and injuries to the rectum of all kinds. If the cancerous rectum is entirely removed in the early history of the disease, a complete cure is possible. Even if complete cure is not obtained, and operation which is done before the disease has invaded the neighboring tissues and organs may give comfort and relief for a long time. When complete removal is no longer possible, the intestine may be permanently opened in the groin or the lower part of the abdomen with great relief to the most distressing symptoms. Other methods of treatment consist in the use of X-ray, radium, and the actual cautery, but they seem to me distinctly inferior to the timely use of the knife. Medical treatment, so far as I am aware, seems to be of little if any real value. Cancer of the Skin.-Favorite sites are the eyelid, the nostril, the cheek, the forehead, or the scalp. Very often it appears on the site of a mole or wart or wen, which may have existed for years, perhaps even from birth, which emphasizes the necessity of get- ting rid of all such growths. It seldom comes until after middle life, occurs more often in men than in women, and frequently does not manifest itself until old age with its degenerative change has announced itself. It begins as a scab or scale upon the skin which is picked off or drops off. A new scab forms, and by and by a sore appears which shows no tendency to heal. This sore may remain super- ficial a long time, finally working more deeply into the tissues. It is accompanied with an offensive discharge and corrodes the tissues which are in its way as it spreads. Thus it eventually may destroy a portion of the nose, the eyelid, or even the eye, or produce an unsightly sore upon the face or scalp. This process may take a long time, sometimes five or ten years, or even longer. CANCER 671 The slowly progressing form remains localized perhaps until the very end, but there is a variety of cancer of the skin which takes a different and more rapid course. This variety, called mela- noma, is engrafted upon a mole or birth-mark. The health of the patient in such cases is undermined rapidly and a fatal issue re- sults within a few months. In the slowly progressing cases, unless treated with great care and cleanliness, there is more or less absorption of decomposed material, which gradually causes general intoxication and blood- poisoning, pallor of the skin, emaciation, and great weakness. As the sore extends and enlarges, it frequently corrodes blood-vessels, and hemorrhages result which may be quite profuse and exhaust- ing. With the blood-poisoning there is constant though perhaps not excessive fever, and as the disease advances pain may be a prominent and troublesome symptom. In the cases which are recognized early and submitted to in- telligent treatment the services of either the surgeon or the derma- tologist may be required. The surgeon removes diseased tissue and that which is adjacent to it and closes the wound at once, many cases being thus completely cured. The dermatologist may make use of the X-ray or radium or the actual cautery, or he may employ various forms of the potential cautery. Of the latter many are available, including preparations of mercury, arsenic, zinc, the ultra-violet rays of light, electricity, carbonic acid snow, trypsin, etc. Cancer of the Stomach.-Influences producing the disease are to be found in certain unhealthy occupations in tobacco and alcohol, in long-continued errors of diet, and in the inheritance of weak and depraved tissues. In about half the cases there is a lump or tumor. In the other cases the disease infiltrates certain portions of the wall of the stomach and gives no outward manifestation. By the time the disease is far enough advanced to have formed an appreciable tumor or has infiltrated the stomach wall to a con- siderable extent the patient will have become weakened and anemic and will often have lost weight to the point of emaciation. The motion or motility of the stomach, which is an important element in digestion, will be greatly arrested, and the secretion of the acid gastric juice checked and interfered with. As a conse- quence there will be persistent indigestion, loss of appetite, particu- larly for meat, and more or less persistent belching of gas, nausea, 672 HOW TO KEEP WELL and vomiting. The material vomited may be sour, bitter, or fetid, and offensive; and at frequent intervals there will be distressing heartburn. Pain in the stomach may be constant or intermittent; and it is sometimes dull and boring, at others sharp and stabbing. Sometimes it is worse after eating, and sometimes it is relieved by eating. At times the patient will be obstinately constipated, and at other times he will be distressed by uncontrollable fetid diarrhea. There are various means of determining the disease in addition to the symptoms which have been mentioned. Of these the X- ray picture is one of the most valuable, for it often permits one to locate and define its exact seat. Examination of the contents of the stomach chemically, bacteriologically, and microscopically is also of the greatest importance, and not only tells us how the organ is performing its functions but what is taking place in its diseased tissues. One of the most satisfactory and widely used means of diagnosis of this character is the Ewald test meal, in which between one and two ounces of toast with eight ounces of tea or water are taken on an empty stomach. At the end of two and a half hours this is supposed to have been digested and is removed from the stomach with its other contents. These, when examined, inform one of the digestive power of the organ, together with the bacteria, lactic acid, diseased tissue, pus, blood, mucus, etc., which were in it and assist very materially in making a correct diagnosis. The treatment of cancer of the stomach is surgical, medical, and dietetic. Comparatively few surgeons have had very large ex- perience in the surgery of the stomach. The operation is techni- cally too difficult and calls for a higher grade of judgment than the average surgeon possesses. If the disease is not far advanced and one can have the benefit of a skilful surgeon there is a chance for a comfortable survival for a number of years. The medical treatment consists essentially if not wholly in the use of anodynes to relieve pain. I do not know of any drug which will cure the disease or even arrest its progress. The value of radium and X-ray is problematical to say the least. They are often tried, just as a drowning man clings to a straw. Irrigating the stomach with warm water is frequently soothing and helpful. Alkalies like bicarbonate of soda and magnesia are often very beneficial. Food should be simple and principally fluid. CANCER 673 Peptonized or fermented milk and predigested foods of various kinds are desirable. The bowels must be kept freely open, intestinal infection being always a possibility to be guarded against. The mouth and throat must be constantly under the influence of suit- able antiseptics, remembering that they are the avenues of ap- proach to the seat of the disease. Cancer of the Tongue.-This disease is often caused by the con- stant friction of a rough and dirty pipe, or by the excessive heat from constant smoking, or by the constant irritation of nicotine. Tobacco, therefore, has much to do with it. The irritation of rough and decayed teeth may cause it, or the persistent use of strong alcoholic drinks, or irritation of any kind, if it is long continued. It usually comes in middle life or later and is much more common in men than in women, as might be inferred. If it attacks the back portion of the tongue, it is more serious and progresses more rapidly than when it attacks the front portion, for it is nearer the glands of the mouth and neck, and it is also nearer the great blood-vessels of the neck. A sore or warty growth in the irritated portion of the tongue may be the first thing noticed, or stiffness in the neck and difficulty in moving the tongue and in articulation. There may also be darting pains in the neck, ex- tending up into the ear. After a few months the glands in the neck become hard, swallowing becomes difficult and painful, and there is a constant discharge of saliva from the mouth. When the disease is far advanced the neck is swollen and the mouth constantly offensive; one is continually threatened with poisoning from the infectious discharges, or starvation from in- ability to take proper nourishment, and hemorrhage from extension of the disease into one of the large blood-vessels. The proper thing to do, therefore, the moment the disease is discovered, is to consult a first-class surgeon and have the diseased organ removed. Frequently it is not necessary to remove more than one half of the tongue, the remainder serving a perfectly use- ful purpose. But it cannot be too strongly emphasized that if permanent results are to be expected the disease must be attacked in its incipiency, and by one who is not afraid to do as extensive an operation as the conditions may call for. Cancer in Women.-Cancer of the uterus is one of the most common forms of malignant disease; it seldom occurs until after the fortieth year, and, singularly enough, is rarely seen except in 674 HOW TO KEEP WELL women who have borne one or more children. The more severe a woman's experiences in childbirth have been, and the less re- sisting power her tissues possess, the more probable is it that she will have cancer, and particularly at that time in life when chil- bearing is over and the tissues have lost the strength and resiliency of youth. Even in extreme old age, when the uterus has atrophied and shriveled and almost disappeared, it may be attacked, though attacks come most frequently in the decade from fifty to sixty. The first noticeable symptom is hemorrhage. It may be slight, a few drops, or it may be so profuse that the woman is exhausted before it stops. A symptom like this must never go unheeded. If it is due to cancer, it will soon be repeated, and the time for successful interference may have passed. The disease extends in all directions, and frequently is carried by the lymphatic vessels to neighboring glands, or even to remote portions of the body. The bladder, kidneys, and rectum are almost certain to be involved if the patient does not succumb in the earlier stages. The ab- sorption of decomposed material produces general infection, which is evidenced by weakness and prostration and a ghastly pallor or waxy appearance of the skin. This waxy appearance is one of the conspicuous characteristics of internal cancer. Pain may or may not be present ; many women go through the entire history of the disease without much suffering from this source. Its duration may be a few months, a year, or even longer, according to the resisting powers of the patient and the care and treatment received. If careful and thorough surgical treatment is given at an early period the disease may be arrested, and there doubtless have been cures. Radium may be of service, but its use is not yet sufficiently understood, or, at any rate, experience with it is not yet sufficiently mature to enable us to regard it as a dependable remedy. The same criticism, and to an even greater degree, may be made of the X-ray. In many cases it has done positive harm. The total removal of the organ by means of the cautery knife has been very successful with a few surgeons, but for some reason it never has reached the stage of popular use by the surgical pro- fession. Probably it is the most successful means that has been offered thus far. Cancer cures without number have been advo- cated for this form of the disease, but none has stood the test of time. Early diagnosis and early surgical treatment are the mea- CANCER 675 sures most likely to bring success of all that have yet been sug- gested. The proposition that women who have borne children should submit to examination by a competent gynecologist at intervals of six months, beginning with the fortieth year, if methodically car- ried out, would result in the early detection and successful treat- ment of many cases of uterine cancer. CHAPTER XLHI MISCELLANEOUS SUBJECTS Care of the Aged.-A few, very few, doctors have devoted their attention to this subject technically known as geriatrics. There are a few private sanitariums and asylums, besides the poorhouses, for old people; but aside from these the field for making the clos- ing period of life comfortable and happy and useful is practically unworked. The beginnings of life have received the most thorough and painstaking consideration, and the department of pediatrics is one of the most creditable and useful in the whole field of medical science and art. It is not an agreeable thought that the medical profession has done so little to ameliorate the wants and woes which are the heritage of the aged. It is true that when old people are attacked by acute disease they receive, as a matter of course, such attention as their symp- toms seem to demand, such attention as is usually deemed appro- priate at any period of life, but often with the feeling that the game is bound to be a losing one and therefore without the en- thusiasm or interest which would be called forth in a younger person. We do not often hear or imagine that we hear the proposal: what is the use of prolonging the stay of those who are helpless and infirm? Such a question in a community of animals and savages where food is scarce and living quarters very limited and inferior may have its apologists, but it is not worthy of a civilized and Christian community in which there is so much of supplies of all kinds that it is unnecessary that anybody should be hungry or cold. Nor is it in keeping with the best traditions of the medical profession, which, theoretically at least, regards no living person as beyond relief or help. When Napoleon was retreating from Syria and he supposed that his wounded soldiers would fall into the merciless hands of the Turks, he asked Desgenettes, his surgeon- 676 MISCELLANEOUS SUBJECTS 677 in-chief, to give each a lethal dose of opium. Desgenettes refused, saying: "It is not my business to kill, but to cure." It is true that the aged by reason of their infirmities often re- quire care and attention which are beyond the means of the one who provides for the family and who with his utmost endeavors may be barely able to provide food and shelter for his wife and children. Who is not familiar with the picture of aged men and women sitting or lying neglected and lone in their homes or in pub- lic places, listless and indifferent to what is going on around them, shunned by all, provided meagerly with the necessities of life and few if any of its comforts? These people, properly and pa- tiently cared for-and the care of the aged often requires great patience-might often be occupied with light but useful work; and work is the blessed medicine for many of the ills of life. Entertainment suited to their taste and intelligence could be provided. When they are not helpless their personal habits could be regulated and carelessness in their persons and manner remedied; and instead of being repulsive and unattractive, they could become a source of joy and satisfaction to those who ministered to them, and radiate an atmosphere of peace and serenity. To organize such a movement as this in every community is the work not merely of philanthropists and Christians but in the highest degree of physicians and nurses. Statistics are constantly informing us that longevity is greater than at any previous period in the history of our country. It would be creditable to our genera- tion if this longevity could be utilized and beautified with the abun- dant means which are at the command of every praiseworthy undertaking. More homes, more comforts, more tenderness and solicitude for those who have passed the meridian of life, and who, in the nature of things, must before long reach the end of their journey. Noise.-One of the most noteworthy facts in our modern life, particularly our industrial life, is the amount of noise associated with it. It is true that one gets accustomed to much of it, particu- larly if it is repeated day after day, year in and year out, as a part of life's routine. One gets accustomed to the hum and roar of machinery, the monotonous hammering of metals, the loud droning of the aeroplane engine, and countless other noises more or less deafening and confusing which come in the course of the daily task. 678 HOW TO KEEP WELL But all noises are not borne equally well by all people, and they take their toll of victims in deafness, insanity, digestive disorders, nervous diseases, and various other ailments. The noise of battle at close quarters often ruptures ear-drums and causes permanent deafness and nervous disorders. Noise, at least of certain kinds, has a stimulating effect on the young. The more there is the better they like it, but it depresses the aged and terrifies the sensi- tive and nervous. The noise of a terrific thunder-storm may be enjoyed by some because of its sublimity and grandeur, but there must be few who appreciate its grandeur if exposed to its fury. Noises which are becoming prevalent everywhere are those of the automobile and its accompanying horn. Go where you will on a pleasant day, the auto's noise is unescapable. A noisy automobile, with its unnecessary horn-blowing, is a nuisance which ought to be abated by law. The great number of private garages in close proximity to houses of suburban cities, with their hammerings and explosions of gas, are creating a nuisance which calls for a remedy. These noises, of course, are more disturbing in summer, when doors and windows are open, than in winter. They often disturb those who are endeavoring to worship in church. To the ill, the nervous, and the sensitive they are a source of positive harm. Inasmuch as many are so situated that they cannot get away from the torment, it certainly would be most desirable if in every munici- pality there were an ordinance for the regulation of automobile noises. Only such horns should be used as have a musical note. Boards of health should have power to inflict penalties upon those who defy the feelings and sensibilities of their fellow-citizens, as so many thousands of automobilists are doing every day. Occupational Diseases.-In the year 1713 a careful Italian ob- server, Ramazzini by name, published a small book concerning the disastrous effects of their occupation upon metal-diggers, gilders, chemists, and tin-workers. In the earlier days the occupational diseases were due as much to uncleanly ways of living and to un- hygienic shops and houses as to poisons and actually unhealthy conditions in the work itself. At the present time the tendency is becoming more and more general in all civilized communities to surround the workman whose occupation is hazardous in any way with suitable safeguards to insure his life and health, and to try to teach him to be careful and avoid preventable disease and accident. Of those who work in the open air, farmers have the best chance MISCELLANEOUS SUBJECTS 679 of health, but they are often sufferers from digestive diseases on ac- count of poorly cooked food. Fishermen suffer from exposure and frequently from too exclusive a diet of fish. Sailors often suffer from tuberculosis because of poor sleeping-quarters, poor food, bad habits, etc. Bad air causes lung-disease, anemia, tuberculosis, and skin-diseases to workers in many occupations; among them are tanners, blacksmiths, miners, bakers, millers, knife-grinders, and others. In many of these occupations there is not only bad air, but the inhalation of or contact with particles of dust which injure the lungs, the teeth, the mucous membrane, and the skin. Diseases from working in metals are numerous. Those who work in copper, lead, arsenic, phosphorus, mercury, tin, zinc, and brass may suffer poisoning of a serious or even fatal nature, and the injuries to both the soft and the hard tissues in their occupations are often very distressing. Railroad men have the ailments which come from exposure, like rheumatism, eye-strain and other eye- troubles, and kidney-diseases from excessive shaking; and they are constantly exposed to serious accidents. Those who work in tunnels and caissons and elsewhere under high atmospheric pressure have serious difficulties connected with their blood and nervous systems, while those who work at great elevations, mountain-climbers, aviators, etc., often suffer from seri- ous lung-disease in connection with diminished air-pressure. Work- ers in chemicals are particularly subject to diseases of the lungs and the skin. Of such are bleachers, who work in chlorine and sulphur and acids, aniline dye-workers, starch-makers, workers in acids, ammonia, and many other chemicals. Athletes and those who work in strained and trying positions are sufferers from diseases of the heart and lungs. Very often periods of dissipation follow periods of hard training in athletics, and collapse and early death are the result. Rupture and aneurism also come in those occupations in which great strains are of frequent occurrence, porters, blacksmiths, and draymen being frequent sufferers. Those who are exposed to loud noises, especially boiler-makers and riveters, frequently become deaf. Those who work under intense light, especially if the light is shifting and uncertain, suffer from impairment of vision. Brewers and saloon-keepers suffer in multitudes of cases from excessive use of alcohol, the lungs, the liver, and the kidneys being the or- 680 HOW TO KEEP WELL gans most frequently attacked. Those who are constantly on their feet, including cooks, waiters, house-servants, policemen, and sales- men, often have flat feet, varicose veins, and constipation. Glass-blowers, potters, and band-players on brass instruments suffer from emphysema of the lungs, a distressing and often seri- ous trouble, caused by injury of the lung-tissue and escape of air into it. Those who work in india rubber and inhale carbon bisul- phide and those who inhale benzine and turpentine suffer from headache, poor sight and hearing, and intestinal cramps. Indi- gestion is very common with those whose eating and drinking habits are irregular, like cabmen, various classes of public officials, and commercial travelers. Instrument players, typewriter operators, and bookkeepers often have cramps and palsies of the hands. Printers in great numbers suffer from tuberculosis. Sedentary workers, shoemakers, and tailors suffer often from hemorrhoids, constipation, and indigestion. In many of these occupations disease is often preventable, and inasmuch as health is the most valuable asset a working-man or woman can have, it behooves him to study this subject with the greatest care. INDEX Abdominal cavity, 45 tumors, 656 Abducens nerves, 36, 82 Abduction, 284 Abnormal mental conditions, 375 Abortion, 581 accidental, 581 Abscess, 591 cold, 287, 591 of the breast, 574 of the kidneys, 535 of the liver, 591 of the lungs, 519 of the rectum, 500 wartn, 591 Absorption, 67 Acari, 266 Accidental wounds, 614 Accommodation, muscles of, 425 Acid, 58 carbonic, 61 hydrochloric, 65 indigestion, 487 reaction, 72 stomach, 650 Acne, 234 Aconite, 637, 654 Acromegaly, 401, 417 Action, reflex, 78 Active congestion, 327 Acute and chronic indigestion, 205 disease, 183 gastritis, 480 indigestion, 205 inflammation, 160 inflammation of the kidneys, 537 " " pancreas, 559 " " " tonsils, 466 myocarditis, 531 peritonitis, 602 pleurisy, 518 rhinitis, 454 tuberculosis, 178 uremia, 634 Adam's apple, 55 Addison's disease, 402 Adduction, 284 Adductor muscles, 24 Adenoids, 403 Adhesions, 592 abdominal, 593 Adrenalin, 405 Adrenals, 405 Afterbirth, 88, 583 Age of puberty, 89 Aged care of, 676 hallucinations of, 383 Agminated glands, 68 Ague cake, 221 dumb, 568 fever and, 104 Air, no and sunlight, 114 apparatus, 510 composition of, no diseases of the lungs, 510 impurities in, 112 in Mammoth Cave, 100 in motion, in in the sleeping-room, 115 residual, 74 supply, in Airing, 193 Albinisms, 235, 273 Albinos, 236 Albumen in the urine, 536 serum, 61 vegetable, 62 Albuminoid ferment, 61 Albuminoids, 44, 57, 60 Albuminuria, 536 Alcohol, 59, 124, 585, 637, 654 injection in tic douloureux, 371 methyl, 125 wood, 125, 628 Alcoholism, 125, 126, 166 acute, 125, 126 chronic, 125, 126 Alimentary canal, 43, 65 681 682 INDEX Alimentary- Continued carbonated, 54 phosphates, 58 Alkaline reaction, 58 Alopecia, 236 Altitude, 98, 102 Alum, 637, 654 Alveolar process, 13 Amaurosis, 424 Amblyopia, 424 from tobacco and wood alcohol, 424 Ammonia, 638, 654 Amnesia, 375 Amnesic aphsia, 376 Amoeba, 464 Amoebic dysentery, 495 Amoeboid movement, 69 Amusements, 122 Anaerobes, 72 Anaerobic bacteria, 227 Anemia, 339, 650 of the brain, 351 pernicious, 345 Anemic, 339 Anesthesia, 168 general, 501 local, 501, 622 spinal, 399 Anesthetic, 623, 650 Aneurism, 320 Angina diphtheroid, 473 Ludwig's, 471 pectoris, 526 ulcero-membranous, 473 Vincent's, 473 Angioma, 166, 321 cavernous, 321 Animal heat, 75 magnetism, 151 Ankle, 13 joint disease, 284 sprained, 311 Ankylosis, 284 bony, 285 fibrous, 285 hard, 285 of the jaw, 285 of the joints, 285 soft, 285 Anopheles mosquito, 221, 397, 567 Anosmia, 452 Antibodies, 143 Antidotes, 627, 629 Antigens, 143 Antipyrin, 638, 654 Antisepsis, 603 Antiseptic gargles, 651 soap, 147 surgery, 591 Antiseptics, 168 Antistreptococcus serum, 472 Antitoxin, 215 diphtheria, 143 preventive, 252 tetanus, 613 treatment, 214 Anus, 47, 65 Aorta, 28, 54 arch of, 29 Aphasia, 376, 437 Apoplexy, 322 Appendicitis, 491 Aqueous humor, 42 Aquiline nose, 456 Arachnoid, 34 Argyrol, 473 Arms, legs, and feet, 283 Arrangement of the nervous system, 79 Arrowroot porridge, 638, 654 Arsenic, 638, 654 Arteries, 27 coronary, 28 hardening of, 324 pulmonary, 29 Arterial system, 28 Arterio-sclerosis, 324, 508 Arthritis, 285 acute, 286 deformans, 286 rheumatoid, 296 Articulations, 14 Artificial feeding, 198 light, 621 respiration, 609 Asafetida, 638, 654 Asepsis, 603 Aseptic surgery, 603 Asphyxia, 190 Aspirin, 638, 654 Asthenopia, 425 Asthma, 511 wheezing in, 512 Astigmatism, 425 Astringent, 650 Ataxia, 356 Atheromatous disease, 324, 328 Athletics, 120 Atony of the stomach, 487 Atrophic rhinitis, 453 Atrophy, 181 of the liver, 552 physiological, 181 progressional muscular, 366 Auditory canal, 445 nerves, 36, 43, 83 Aura, 351 Auricle left, 28, 54 right, 27, 54 Auscultation, 534 INDEX 683 Autohypnotism, 385 Auto-inoculation, 629 Auto-intoxication, 381, 460, 629, 630 Auto-suggestion, 377 Autumnal catarrh, 564 Aviation sickness, 513 Axis cylinder, 36, 77 Bacillus cholera, 174 colon, 171 colon infection, 175 common intestinal, 174 diarrhea, 174 Eberth's, 568 Kleb's-Loeffler, 213 Lactic acid, 174 tuberculosis, 174 Pfeiffer's, 470 scarlet fever, 174 typhoid fever, 174 Backache, 309 Bacteria, 615 anaerobic, 227 in milk, 173 pus producing, 161 yeast, 171 Bacterial inflammation, 160 therapy, 176 Bacteriology, 139 relation to health 139 Baked apples, 207 Baldness, 237 Ball and socket joint, 16 Bandages and bandaging, 593 Barber's itch, 238 Basedow's disease, 412 Bath brand, 620 carbonic acid, 335 cold, 191, 578, 619 foot, 619 full, 619 half, 619 hip, 619 heat, 619 hot air, 620 mud, 619 needle, 619 pool, 620 Russian, 620 shower, 620 Sitz, 619 tepid, 619 Turkish, 619 vapor, 620 warm, 619 Bathing, 122, 151, 191 sea, 153 Beading of the ribs, 222 Beans, 133 Bed wetting, 548 Beef extract, 638, 654 Bell's palsy, 348 Bends, 342 Benefits, of mixed diet, 129 Benign tumors, 656 Beri-beri, 349 dry, 349 wet, 349 Bicarbonate of soda, 638, 654 Bichloride of mercury, 644 Bile, 47, 67 Biliary colic, 492, 554 Bilious headache, 357 Biliousness, 551 Bilirubin, 61 Biliverdin, 61 Birthmarks, 166, 321 Bismuth, 639, 654 injections, 500 Black measles, 217 vomit, 571 Blackheads, 235 Bladder, 50 cancer of, 664 diseases of, 547 inflammation of, 547 irrigation of, 548 irritable, 549 irritation of, 549 stone in, 544 Bleeders, 542 Bleeding piles, 495 Blepharitis, 426 Blindness, 165, 424 heredity, 165 Blood, 57 circulation of, 27, 70 composition of, 69 direct transfusion, 625 diseases of, 339 indirect transfusion of, 625 poisoning, 330, 340 pressure, 326 scrofulous, 231 transfusion of, 606, 624 Blood-vessels, diseases of, 320 Blue babies, 242, 533 line on the gums, 632 pill, 644 stone, 641 Blushing, 392 Body, 282 composition of, 50 disinfection of, 146 functions of, 56 joints and articulations of, 14 temperature, 186 vermin on, 28 Boils and carbuncles, 239, 650 684 INDEX Bone diseases of, 315 kinds of, 4 number of, 4 porosity of, 3 turbinated, 461 Bony ankylosis, 285 Bony spurs of the septum, 457 Boracic acid, 639, 654 Bothriocephalus latus, 277 Bowels, inflammation of, 602 stoppage of, 506 Bow legs, 315 Brain, 80 anemia of, 351 softening of, 369 Bran, 639, 654 Brand bath, 620 Brass pipes, 118 Breast, abscess of, 574 bone, 8 cancer of, 664 inflammation of, 574 milk, 199 nursing, 196 pang, 526 Breast milk, constituents of, 199 Breath, offensive, 462 Breathing, 72, 511 deep, 173 expiratory, 212 shallow, 511 Bright's disease, 537 chronic, 538 Bronchi, 51, 73 Bronchial tubes, 54, 73 Bronchitis, 211, 514 acute, 515 capillary, 515 chronic, 514 Bronchopneumonia, 212 Bronze color of skin, 402 Brown mixture, 639, 654 Brown-S6quard, 402 Bruises, 650 Brunner's glands, 67 Buboes, 406 Bubonic plague, 406 bubonic form of, 406 pneumatic form of, 406 serum of, 407 Bachti, 639, 654 Bulb, olfactory, 82 Bunion plasters, 300 Bunions, 300 Burke Foundation, 184 Burns, 593 Bursa, 292 Bursitis, 292 Cachexia, cancerous, 669 Caffeine, 130 Caisson disease, 342 Callosities, 301 Callus, 600 Calomel, 552, 645 Calories, 63 Camphor, 639, 654 Canal, alimentary, 43 inflammation of external auditory, 448 inguinal, 503 verteoral, 79 Cancer, 662 in women, 673 of bladder, 664 of breast, 664 of gall-bladder, 555 of intestines, 665 of larynx, 667 of liver, 668 of rectum, 669 of skin, 670 of stomach, 671 of tongue, 673 Cancerous cachexia, 666, 669 Cane sugar, 59 Canker sore, 468 Cannabis indica, 124 Capillaries, 20 Capillary Bronchitis, 515 Capsicum, 639, 654 Carbohydrates, 61, 62, 133 Carbolic acid, 639, 654 Carbon, 59 Carbonic acid, 61, 112 baths, 335 snow, 322 Carbon monoxide, 112 Carbuncles, 240 Care of aged, 676 of eyes, 423 of feet, 299 of new-born infant, 190 of teeth and mouth, 131 Cartilage, 9, 285 Cascara, 639, 654 Casein, 61 Castor-oil, 279, 465, 639, 654 Cataleptic, 385 Cataract, 427 Catarrh, autumnal, 564 chronic, 454 dry. 453 intestinal, 504 nasal, 453 of stomach, 474 Catarrhal otitis, 446 inflammation, 160 Cathartics, 405, 650 drastic, 495 lubricative, 495 INDEX 685 Cathartics-Continued saline, 495 Causes and treatment of dysentery, 496 Cautery, 607 Cavernous angioma, 321 Cellulitis, 595 centernerve, 32 cerebellum, 34, 80 Cerebral hemorrhage, 322 Cerebrospinal meningitis, 227 system, 79 Cerebrum, 34, 80 Cerumen, 447 ganglia, 39 Cervical nerves, 31 Cesspools, exhalations of, 104 Chafing, 248 Chamomile, 640, 654 Champagne, 640, 654 Change of climate, 102 life, 572, 576 Chapped hands and lips, 241 Charcoal, 640, 654 Chemical treatment of water, 109 Chest, 8, 52 cold on, 211 Chicken breast, 222 Chicken-pox, 218 Chilblains, 302 Childbed fever, 584 Childbirth, 580, 583 painless, 399 Childhood, diseases of, 190 Chiropody, 304 Chloral, 125 Chlorate of potash, 640, 654 Chloride, iron, 104 lime, 104 Chlorine, 640, 654 Chloroform, 640, 654 Chlorophyl, 61 Choice of climate, 101 Cholera, bacillus, 174 infantum, 209 Cholesterin, 60, 553 Chondrin, 61 Choroid, 42, 433 Choroiditis, 429 Chronic Bright's disease, 537 catarrh, 457, 474 catarrhal otitis, 446 congestion, 337 disease, 183 indigestion, 205 inflammation of the kidneys, 537 inflammation of pancreas, 559 meningitis, 227 myocarditis, 531 nasal catarrh, 454 nephritis, 538 peritonitis, 602 rheumatism, 296 rhinitis, 452 tuberculosis, 178 uremia, 634 Chyle, 30, 67 Ciliary body, 433 processes, 42 Circulation of blood, 27, 70 Circumcision, 23, 27 Circumduction, 284 Cirrhosis of liver, 552 Clairvoyance, 382 Cleanliness, 137 Clergyman's sore throat, 472 Climate, 92 choice of, 101 Climatology, 93 Clinical thermometer, 563 Clothing, 120, 195 Club-foot, 303 Coagulation, 60, 69 Coal-gas, 112 Coal-tar derivatives, 124 Cocaine, 124, 623 Coccygeal ganglia, 39 Coccyx, 6, 36, 39 Codein, 124 Cod-liver oil, 640, 654 Cold, 640, 650, 654 abscess, 287 applications, 607 bath, 96, 191, 607 douche, 620 in head, 454, 455 on chest, 211 pack, 608 some of effects of, 96 winter, 514 Colic, 205, 492 appendicular, 492 biliary, 492, 554 copper, 492 gall-stone, 554 kidney, 492 lead, 492, 632 mucous, 492 painter's, 492 ulcerative, 492 wind, 492 Colitis, mucous, 493 ulcerative, 493 Collapse, 650 Collar-bone, 9 Collodion, 646, 654 Colloidal iron, 347 Colon bacillus, 171 Colony system, 352 Color blindness, 429 sense, 430 686 INDEX Coloring materials, 57, 61 Column, spinal, 6 Coma, unconsciousness of, 634 Common bile-duct, 47 Composition of air, no of blood, 69 of body, 56 Compound cathartic pills, 641, 654 licorice powder, 648 Condensed milk, 199 Condition, uric acid, 635 Conditions, abnormal mental, 375 maternity and its allied, 578 peculiar to women, 572 Congenital dislocation of hip, 287 Congestion, 327 active, 327 chronic, 327 headache, 352 of lungs, 327, 650 passive, 327 Conjunctivitis, 431 granular, 443 Consciousness, subliminal, 390 Constipation, 206, 494, 579, 650 chronic, 494 Constituents of breast milk, 196 of water, 107 Constitutional disease, 328 Contraction of tendons of palm, 288 Convalescence, 183, 650 Convulsions, 226, 58 uremic, 635 Convulsive uremia, 635 Copper, 641, 654 colic, 492 Cord, spinal, 79 Cords, vocal, 55 Cornea, 42 ulcer of, 444 Corns, 304 hard, 305 soft, 305 Coronary'arteries, 28 Corpuscles, 69, 143 red, 69 white, 69 Corrosive poisons, 627 sublimate, 624 Cough, 515, 650 Counter-irritation, 606 Cow pox, 140 Cow's milk, 199, 200 Cramps in muscles, 308 in the stomach, 134 reflex, 308 Cranial nerves, 36, 81 Creosote, 646, 654 Crepitus, 599 Cretinism, 421 Crile's method of transfusion, 625 Cross eye, 431, 435 external, 432 internal, 432 vertical, 432 Croton-oil, 278, 495, 641, 654 Croup, false, 210 membranous, 215 spasmodic, 210 Croupous tonsilitis, 466 Crystalline lens, 42, 427 Crystallizable nitrogenous materials, 57, 61 Cupping, 606 dry, 606 wet, 606 Cupping glasses, 606 Curvature lateral, of spine, 293 Cyanosis, 242 Cystic duct, 47 Cystitis, 547 Cystoscope, 547 Cysts, sebaceous, 267 Daily ration, 63 Dakin, 616 Dakin-Carrel solution, 341 Dandruff, 243, 268 Day-dreams, 382 Deafness, 446 hereditary, 165 Debility, 184, 651 Decompression, 342, 616 Deep breathing, 173, 510 Deformities, 572 of nose, 456 Delayed dentition, 222 Delirium of fever-stricken, 568 Delusion, insane, 378 Delusions, 378 Dementia, paralytic, 364 precox, 364, 380 pi'fecox, paranoid form of, 364 senile, 393 Dentifrice, 132 Dentition, 194 Deodorant, 646 Deodorizer, 257, 651 Depilation, 249 Depilatories, 249 Depressant, 125 heart, 125 Derivation, 606 Dermatitis, 243 Descending vena cava, 54 Detachment of retina, 432 Development, 194 Deviation of septum, 457 Dextrine, 59 INDEX 687 Diabetes, 559, 651 treatment with extract of pancreas, 561 Diaphragm, 21, 45, 53, 74 Diarrhea, 207, 651 bacillus of, 174 infective, 207, inflammatory, 208, 209 summer, 207, 496 Diastase, 61 Diathesis, uric acid, 636 Dick test, 216 Diet, 128, 133 Griffith, 204 mixed, 130 starvation, 559 suitably balanced, starvation, 132, Digestion, 64, 134 organs of, 43 Digestive disorders, 205 ferments, 134 Dilatation of heart, 347, 527, 533, 641, 654 of stomach, 479 Diphtheria, 212, 470 antitoxin, 143, 473 false, 214, 216 Diphtheritic croup, 215 Diphtheroid angina, 473 Diplopia, 435 Direct transfusion of blood, 625 Disease acute, 183 Addison's, 402 ankle and joint, 284 atheromatous, 324 Basedow's, 412 bladder, 547 blood, 339 blood-vessel, 320 bone, 315 Bright's, 537 caisson, 342 carriers, 228 chronic, 183 constitutional, 328 ear, 445 eruptive, 219 eye, 423 foot, 299 gall-stone, 554 gland, 400 Grave's, 412 heart, 221, 526 hip-joint, 291 Hodgkin's, 413 hookworm, 275 infancy and childhood, 190 infectious, 161 inherited, 165 intestinal, 491 joint and tendon, 282 kidney, 232, 535 knee-joint, 293 labyrinth, 373 liver and gall-bladder, 551 lung and air apparatus, 510 medical, 183 Menidres, 449 middle ear, 450 mouth, 460 mouth, throat, and lung, 290 nail, 256 nasal accessory sinus, 457 nervous, 348 nose, 452 nutritional, 181 occupational, 359 organic, 159 pancreas, 558 parasitic, 275 period which immediately follows child-birth, 583 Pott's, 294 precautions for prevention of in- herited, 165 Raynaud's, 334 Riggs's, 464 salivary gland, 407 shoulder, elbow, and wrist joints, 289 skin, 223, 233 specific constitutional, 328 spleen, 418 stomach, 474 surgical, 591 seat-gland, 408 Thomsen's, 312 throat, 471 tongue, 467 valvular of heart, 533 which occur before puberty, 572 winter, 655 Disinfectants, 104, 651 Disinfection, 145 of body, 146 of clothing, books, and small articles, 146 of rooms, furniture, carpets, etc., 147 of water and food, 145 Dislocation, congenital, of hip, 287 Dislocations, 596 Disorders, digestive, 205 nutritional, 181 Distillation, no Disturbance, vasomotor, 577 Dizziness, 372 Dorsal ganglia, 39 Double vision, 432, 435 Douche, 619 cold, 620 spinal, 620 Drainage, 104, 617 688 INDEX Drastic cathartics, 495 Dreams, 381 Drooping eyelid, 441 Dropsy, 539 Drowsiness, 151 Drug habit, 500 Drugs, habit-forming, 123 Drum, ear, 445 membrane, 445 Drunkenness, 126, 651 Dryness, 103, 114 Duct, cystic, 47 hepatic, 47 thoracic, 30, 68 Ductless gland, 181, 400 Dumb ague, 568 Duodenum, 45, 46 ulcer, 508 Dura mater, 33 Dysentery, 209, 495 amoeba, 464 amoebic, 495 causes and treatment, 496 epidemic, 495 Dyspepsia, 475, 651 symptoms and treatment, 476 Ear, 43 disease, 445 drum, 445 external, 43 inner, 445 internal, 43 middle, 43, 445 middle, disease, 450 noises and drumming, 451 ringing, 451 structure and function, 445 wax, 446 Earache, 445 Eberth's bacillus, 568 Eclampsia, 586 Eczema, 224, 244 of scalp, 223 Eczematous skin, 245 Edema, 188, 332 of the larynx, 520 of the lungs, 521 Egg, 87 Egg-bear mg, 89 Egg-nogg, 641, 654 Elastine, 61 Elbow-joint, 283 diseases, 289 Electrolysis as a depilatory, 249 Elevator sickness, 477 Emaciation, 651 Embolism, 517 of lungs, 517 Embolus, 330, 517 Emetics, 481, 607, 651 Emetine for Riggs's disease, 465 Emotions, 163 Emphysema, 530 of lungs, 524 of skin, 524 pulmonary, 524 Empyema, 518 Emulsification, 62 Endarteritis, 328 Endocarditis, 528 Endocrinology, 181, 400 Enema habit, 497 Enemata of Epsom salts, 506 Enlarged glands of the neck, 409 Enlarged spleen, 419 Enterocolitis, 209, 498 Enuresis, 548 epidemic, 496 Epilepsy, 350 masked, 351 Epinephrin, 405 Epsom salts, 279, 495, 645 enemata, 506 Erectile tumor, 321 Ergot, 641, 654 Eruptive diseases, 219 Erysipelas, 246 Erythema, 247 Esophagus, 44, 45 Ether, 641, 654 Eucalyptol, 641, 654 Eustachian tube, 445 Ewald test meal, 672 Excessive growth of hair, 248 Exercise, 153 muscular, 122 Exhalation, 74, 510 cesspool, 104 Exophthalmic goiter, 410 Exophthalmos, 410 Expiration, 55 Expiratory breathing, 212 Extension, 284 Extensor muscles, 24 External cross- eye, 432 External ear, 43, 448 Extract of pancreas, treatment of dia- betes with, 561 Eye, 42 care of, 423 disease of, 423 foreign bodies in, 433 globe of, 42 inflammation of, 438 strain, 229 Eyeball, 42 protrusion, 410 Eyelid, drooping, 441 inflammation, 438 Facial muscles, 18 INDEX 689 Facial- Continued nerves, 36, 83 neuralgia, 355, 371 paralysis, 348 Faintness, 651 Falling of intestine, 506 of stomach, 478 Fallopian tube, 50, 88 False group, 210 False diphtheria, 214, 216 Far-sightedness, 87 Fasciae, 18 deep, 18 superficial, 18 Fat, 60, 61, 62, 133 mineral, 132 Fatty heart, 529 tumors, 657 Feces, 58 Fecundation, 88 Feeding after first year, 204 artificial, 198 infant, 196 mixed, 198 Feeling, hallucinations, 383 Feet, care of, 299 diseases of, 299 Felon, 595, 651 Female generative organs, 50, 88 Femoral hernia, 503 Ferment, 61, 134 albuminoid, 61 digestive, 134 Fermentation, 616 Fever, 563, 651 and ague, 104 childbed, 584 hay, 564 intermittent, 104 lung, 523 malarial, 104, 220, 567 puerperal, 584 rheumatic, 295 scarlet, 215 spotted, 227, 570 tertian, 568 typhoid, 568 typhus, 570 yellow, 571 Fever-stricken, 563 delirium of, 568 Fibrin, 70 Fibrin ferment, 61, 69 Fibrinogen, 61. 69 Fibroid tumors, 658 Fibrous ankylosis, 285 Fibula, 13 Filtration, 108 Finlay, 571 Finsen, 624 Fissure, 168, 499 Fistula, 500 Flannel jacket in bronchitis, 211 Flat foot, 306 Flat nose, 456 Flatulence, 651 Flaxseed, 642, 654 Flexion, 284 Floating kidney, 419, 539 ribs, 8 specks in the eye, 423 Fluid tumors, 656 Fluorine, 57 Follicular tonsilitis 466 Fontanel, 194 Food, 61 preparation of, 130 Forearm, 10 Foreign bodies in eye, 433 Forest and plain, 99 Formamint, 642, 654 Fowler's solution, 638 Fractures, 598 compound, 599 simple, 599 Freckles, 250 Freely movable joints, 15 Frenum, 469 Freud, 391 Friction sounds, in pleurisy, 522 in pericarditis, 532 Frost-bites, 302 Functions of body, 56 Furuncle, 650 Gall-bladder, 47 cancer of, 555 diseases of, 551 inflammation of, 554 Gall-stone colic, 554 disease, 554 Gall-stones, 553 Ganglia, 32, 36, 39 semilunar, 39 Gangrene, 329 diabetic, 329 diphtheritic, 329 dry, 329 hospital, 330 lung, 519 moist, 329 senile, 329 skin, 329 white, 329 Gargle, 651 Gastralgia, 479 Gastric juice, 57, 65 Gastritis, acute, 480 Gelatin, 61 Generative organs, female, 50, 88 male, 50 Geriatrics, 676 690 INDEX German measles, 217 Gigantism, 401 Ginger, 642, 654 Gland, agminated, 68 Brunner's, 67 diseases, 400 ductless, 181, 400 enlarged neck, 409 lachrymal, 41 Lieberkuhn's, 67 lymphatic, 31 mammary, 51 oil, 268 pituitary, 400 salivary, 44, 45, 65, 407 sebaceous, 235, 236, 267 solitary, 68 sweat, 408 thymus, 181, 400, 412, 419 thyroid and thyroid ism, 421 Glandular organ, 47 Glauber's salts, 495 Glaucoma, 436 Globe of eye, 42 Glosso-pharyngeal nerves, 36, 83 Glucose, 47 Gluten, 62 Glycerin, 642, 654 Glycogen, 47 Glycosuria, 540 permanent, 541 temporary, 541 transient, 541 Goiter, 412 exophthalmic, 410 Goldenrod, 564 Gorgas, 566 Gout, 289 Graafian follicles, 89 Grand mal, 351 Granular conjunctivitis, 443 Gravel, 545 Grape sugar, 59 Graves's disease, 412 Griffith diet, 204 Grippe, 470, 651 Gristle, 61, 285 Growing pains, 221 Growth and development, 194 hair, 248 Gullet, 44, 45 paralysis, 84 Gum arabic, 642, 654 Gums, spongy, 464 Habit, 119 drug, 500 enema, 497 tobacco, 127 Habit-forming drugs, 123 Hair excessive growth, 248 peculiarities, 249 Hallucinations, 379, 382 feeling, 383 hearing, 383 in children, 383 in the aged, 384 sight, 383 smell, 383 Hammer toe, 290 Hamstring muscles, 24 Hands, chapped, 24 Hard ankylosis, 285 Hardening of arteries, 324 Hare-lip, 167 Harvey, 27 Haste in eating, 119 Haunch, 6 Haunch-bone, 11, 12 Hay-fever, 564 Head, 5, 282 cold in, 454, 455 noises in, 446 Headache, 229, 352, 651 bilious, 352, 357 congestion, 352 nervous, 230, 353 neuralgic, 357 paroxysmal, 357 sick, 357, 551 Healing by granulation, 604 Health, 159 effect of sunlight, 618 influence of deep breathing, 510 inspection, 138 relation of bacteriology to, 139 school-children, 138 Hearing, 87 hallucinations of, 383 standard of, 445 Heart, 53 depressant, 125 dilatation of, 527 disease, 221 diseases of, 526 fatty, 529 hypertrophy of, 529 sounds of, 70, 526 valvular disease of, 533 Heartburn, 487 Heat, 642, 654 animal, 75 prickly, 224 stroke, 610 units, 63 Heating, xi6 Hebephrenia, 384 Hematuria, 541 Hemianopsia, 437 INDEX 691 Hypnotic state, 385 Hypnotism, 151, 382, 385 Hypochlerite of soda, 342 Hypochondria, 359, 386 Hypoglossal nerves, 36, 84 Hypophysis, 400 Hypo thyroidea, 421 Hypothyroidism, 421 Hysteria, 359, 387, 652 Ichthyol, 300 Ichthyosis, 252 Iletin, 558 Ileocecal valve, 47 Ileum, 45, 47 Iliac region, 24 Illusions, 379, 388 Imbecility, 359 Immediate care of injured, 601 Immediate care of mother and child after birth, 582 Immobile joints, 15 Immunization, toxin-antitoxin, 214 Impetigo, 253 Impregnation, 88, 89, 91, 165 Impurities in the air, 112 Incandescent electric light, 621 Incompetent valve, 534 Incomplete development after birth, 573 Indian hemp, 124 Indican, 543 Indicanuria, 543 Indigestion, 481, 652 acid, 481 acute, 481 chronic, 481 intestinal, 482, 505 nervous, 484 Indirect transfusion of blood, 624 Induced sleep, 151 Infancy diseases of, 190 hygiene of, 190 Infant care of newly born, 190 feeding, 196 foods, 199 tables for feeding, 203 Infantile paralysis, 624 infected wounds, 615 Infection, 171 from colon bacillus, 175, 536 mixed, 171, 473, 523 various means of, 140 Infectious disease, 171 precautions for prevention, 165 Infective diarrhea, 207 Inflammation, 160 acute, 160 Hemicrania, 357 Hemispheres, 34 Hemoglobin, 61, 69 Hemolysis, 625 Hemophilia, 343 Hemorrhage, 652 cerebral, 322 from lungs, 518 from stomach, 481 Hemorrhoidal veins, 501 Hemorrhoids, 501 Hepatic duct, 47 Hermaphrodism, 573 Hernia, 502 femoral, 503 inguinal, 503 strangulated, 503 Heroin, 124 Hiccough, 353 Hinge joint, 16 Hip, 12, 284 congenital dislocation of, 287 disease, 91 Hives, 251 wheals in, 251 Hobnail liver, 552 Hodgkin's disease, 413 Hogarth's line of beauty, 8 Homesickness, 390 Hook-worm disease, 275 Hops, 642, 654 Horse serum, 497 Hospital gangrene, 330 Hot air bath, 620 Hot springs, 94, 297 Hours of sleep, 193 Household medicine chest, 600 Housemaid's knee, 292 How may water which is of doubtful purity be rendered harmless?, 109 Humor aqueous, 42 vitreous, 42 Hydrocarbons, 57, 59, 186 Hydrocephalus, 230 Hydrochloric acid, 65, 643, 654 Hydrogen, 59 Hydrophobia, 354 Hydrotherapy, 152, 618 Hygiene in relation to sanitation and health, 92 of infancy, 191 of the mouth, 460 Hyoid bone, 9 Hyperemia, 621 Hypermetropia, 437 Hyperthyrodea, 421 Hyperthyroidism, 421 Hypertrophy of the heart, 529 Hypnosis, 385 Hypnotics, 125 692 INDEX Inflammation-Continued bacterial, 160 bladder, 547, 652 bowels, 602 breast, 574 catarrhal, 160 external auditory canal, 448 eyelids, 438 eyes, 438 gall-bladder, 554 suppurative, 604 tear-duct, 438 urethra, 614 veins, 333 Inflammatory diarrhea, 209 rheumatism, 286, 295 Influence of various climatic conditions upon health, 93 Influenza, 470 Ingrowing nail, 257 Inguinal canal, 503 hernia, 503 Inhalation, 74, 510 of fire, 520 of steam, 520 Inherited disease, 165 Injections of bismuth, 500 of paraffin, 456 under skin, 456 Injured, immediate care of, 601 Injuries andresults which follow them, 573 Inner ear, 445 Inorganic substances, 56, 57 Insane, paralysis of, 364 Insensible perspiration, 57 Insomnia, 395, 652 Inspection of school children, 138 Inspiration, 55 Insulin, 558, 562, 643, 654 Intentional wounds, 614 Intercostal neuralgia, 355 Intermittent fever, 104 Internal cross-eye, 432 Intestinal catarrh, 504 indigestion, 505 stasis, 506 Intestine, common bacillus of, 174 falling of, 506 prolapse of, 506 Intestines, cancer of, 665 diseases of, 491 Intravenous medication, 620 Intubation, 215 Iodine, 300, 643, 654 organic 411 Iodoform, 300 Ipecac, 496 Iris, 42, 433 Iritis, 439 leeches in treating, 443 Iron, 57, 643, 654 chloride of, 104 colloidal, 347 Irrigation of bladder, 348 of stomach, 483 Irritability of bladder, 549 Irritant poisons, 627 Irritation of stomach, 652 reflex, 79 Islands of Langerhans, 400, 558, 562 Itch mite, 266, 652 Jaundice, 191, 555 Jaw, ankylosis of, 285 Jejunum, 45, 47 Joint, 14 ankylosis of, 285 ball and socket, 16 disease, 284 elbow, 283 freely movable, 8, 15 hinge, 16 hip, 284 immobile, 15 knee and ankle, 284 ossification of. 284 rotatory, 16 shoulder, 283 wrist, 284 Joslin, 562 Juice, gastric, 57, 65 hepatic, 67 pancreatic, 48, 67 Keloid, 604 Keratin, 61 Kidney, abscess of, 535 acute inflammation of, 537 chronic inflammation, 537 floating, 419 movable, 539 stone in, 543 Klebs-Loeffler bacillus, 213 Knee joint, 284 cap, 12, 292 housemaid's, 292 Knee-joint disease, 293 Knock-knee, 316 Koch, 176 Kumiss, 643, 654 Labor, 88 Laborde's method, 609 Labyrinth, 43, 445 disease of, 373 Lachrymal gland, 41 Lactic acid bacillus, 174 Larkspur, 281 Laryngitis, 519 INDEX 693 Larynx, 55 cancer of, 667 edema of, 520 spasm of, 519 Lateral curvature of spine, 293 Laveran, 566 Laxative cereal, 636 Lead, 643, 654 colic, 492, 632 poisoning, 631 Leeching, 606 Left auricle, 28 handedness, 169 ventricle, 27 Leprosy, 254 Lethargy, 151 Leucemia, 344 Leucoplacia, 468 Leucorrhea, 232, 577, 652 Lice, 200 eggs of, 281 nits of, 281 Lichen planus, 255 Lieberkuhn's glands, 67 Ligaments, 16 Light, 137 artificial, 622 solar, 621 spot of retina, 42 treatment, 621 Limbs, lower, 11, 23 upper, 9, 23 Lime, 57, 58, 643, 644, 654 carbonate, 58 chloride, 104 phosphate, 58 Line of beauty, 8 Ling, 623 Liniment, 652 Lips, chapped, 241 Lister, 330 Liver, 47 abscess of, 591 atrophy of, 552 cancer of, 668 cirrhosis of, 552 diseases of, 551 hob-nail, 552 sugar, 47, 59 torpid, 556 Lobar pneumonia, 212 Local environment, 105 Lock-jaw, 611 Locomotor ataxia, 356 Lubricating cathartics, 495 Ludwig's angina, 471 Lumbago, 309 Lumbar ganglia, 39 nerves, 36, 80 Lumbricoids, 276 Lunar caustic, 648 Lung, 54 abscess, 519 breathing, 54 congestion, 327 diseases, 510 edema, 521 embolism, 517 emphysema, 524 fever, 211 gangrene, 519 hemorrhage, 518 Lupus erythematosus, 255 Lymphadenitis, 414 Lymphangitis, 414 Lymphatic glands, 31 Lymphatics, 30, 71 Lymphoid tissue, 403 Lymph vessels, 31 Lysol, 644, 654 Magnesium phosphate, 58 sulphate, 644, 654 Malaria, 565, 652 fever, X04, 220, 567 poisoning, 567 Male-fern, 278 generative organs, 50 Malignant tumors, 656 Malnutrition, 181 Mammary glands, 51 neuralgia, 355 Marasmus, 230 Marrow, 3 Masked epilepsy, 351 Massage, 207, 229, 623, 644, 654 Mastication, 134 Mastoiditis, 448 Materials, coloring, 57 crystallized nitrogenous, 57, 61 Maternal nursing, 196, 198 Maternity and its allied conditions, 578 Measles, 217 black, 217 German, 217 Medical diseases, 183 Medication, intravenous, 620 Medicines, spring cleansing, 648 Medulla oblongata, 34, 80, 81 Medullary substance, 77 Melancholia, 359, 388 Melanin, 61 Melanoma, 670 Membrane, drum, 445 mucous, 65 serous, 45 Membranous croup, 215 sore throat, 473 Meniere's disease, 449 vertigo in, 449 Meningitis, 227 acute, 227 694 INDEX Meningitis-Continued cerebrospinal, 227 chronic, 227 Menopanse, 572 Menstruation, 197, 587 abnormal, 588 normal, 587 Mental conditions, abnormal, 375 Menthol, 644, 655 Mercury, 644, 655 Mesmerism, 161 Metabolism, 63, 421 Methyl alcohol, 125 Middle ear disease, 450 Migrane, 357 Mild chloride of mercury, 644 Milk, 57, 133 bacteria in, 199 breast, 199 condensed, 199 cow's, 199, 200 diet, 645, 655 leg, 586 modified, 200 of magnesia, 207 Pasteurized, 203 peptonized, 497 punch, 645, 655 sugar, 59, 201 top, 200 Mineral, fat, 132 oil, 62 salts, 132 springs, 107, 152 water, 152 Miscarriage, 581 Miscellaneous subjects, 676 Mitral valve, 54, 534 Mixed diet, 130 feeding, 198 infection, 473, 523 nerves, 36, 83 Modified milk, 200 Moisture, 101 Moral influences at school, 139 Morning sickness, 579 Morphine, 124 Mothers, prenatal instruction of, 589 Motion, nerves of, 36 Motor impulse, 84 nerves, 78 Motor oculi nerves, 36, 82 Mouth, diseases and hygiene, 460 ulcerated, 210 wash, 473, 652 Mouth breather, 462 Movable kidney, 539 Mucin, 61 Mucous colic, 493 colitis, 493 membrane, 65 Mucus, 65 Multiple, neuritis, 363 sclerosis, 358 Mumps, 218 Murmur, 221, 528, 534 Muscle, 16 accommodation, 425 adductor, 24 cramps, 308 extensor, 24 hamstring, 24 involuntary, 16 sheaths, 16 skull and face, 19 strain and rupture, 310 troubles, 308 voluntary, 16 Muscular exercise, 122 progressive atrophy, 366 rheumatism, 295 sheath, 26 Mustard, 645 Myocarditis, 530 acute, 531 chronic, 531 Myopia, 87, 440 squinting in, 440 Myopic, 440 Myosine, 61 Myxedema, 415 Nail bed, 256 Nails, ingrowing, 257 diseases of, 256 Narcotic drugs, 162 poisoning, 627 poisons, 627 Narcotics, 125 Nasal accessory sinus, diseases of, 457 Nasal catarrh, 453 chronic, 454 Nausea, 206 Navel string, 88, 583 Near-sighted, 87 Near vision, 440 Necessary hygienic conditions for school- room, 135 Neck, 20 enlarged glands of, 409 Neosalvarsa,n, 648 Nephritis, 537 chronic, 538 Nerve abducens, 36 auditory, 36, 83 center, 32, 80 cervical, 36, 80 coccygeal, 36, 80 cranial, 36, 81 dorsal, 36 ending, 77 INDEX 695 Nerve-Continued facial, 36, 83 filament, 77 glossopharyngeal, 36, 83 gray tissue, 77 hypoglossal, 36, 84 lumbar, 36 mixed, 36, 83 motor, 36, 78 motor oculi, 36 oculo-motorius, 82 olfactory, 36, 41, 81 optic, 36, 41, 82 pathetic, 36, 82 pneumogastric, 36, 84 root, 36 sacral, 36 sensory, 36, 78 sheath, 77 special sense, 36 spinal, 36 spinal accessory, 36, 84 sympathetic, 40 tissue, 77 trifacial, 36 trigeminus, 82 vasomotor, 577 white tissue, 77 Nervous excitement, 359 headache, 230 indigestion, 484 system, 31, 76 system, arrangement of, 79 system, diseases of, 348 system, sympathetic, 36 Nervousness, 359, 652 Nettle-rash, 251 Neuralgia, 360, 652 facial, 355, 361, 371 intercostal, 355 mammary, 355 stomach, 479 Neuralgic headache, 357 Neurasthenia, 359, 362 Neuritis, 363 multiple, 363 Nevus, 166 Newly born, care of, 191 Nez retrouss^e, 456 Nicotianin, 127 Nicotine, 127 Nightmare, 382 Night-terrors, 226 Nipple, 52, 197, 202 Nitrite of amyl, 527, 645, 655 Nitrites, 527 Nitroglycerin, 527 Nitrogenous materials, crystallizable, 57. 61 Noise and drumming in the ears, 446 Normal daily quantity of urine, 72 Nose, aquiline, 456 deformities, 456 diseases, 452 flat, 456 polypi, 458, 462 saddle, 456 Nosebleed, 331 Nostalgia, 389 Nursery, 191 Nursing, breast, 196 maternal, 196, 198 surgical, 609 wet, 198 Nutritional diseases, 181 disorders, 181 Nystagmus, 358 Oatmeal, 133 Obesity, 186 Obstruction, valvular, 534 Occupation, 121 Occupational diseases, 359, 678 Oculo-motorius nerves, 82 Offensive breath, 462 breath from metallic poisoning, 462 odor of the skin, 257 Oil, castor, 279 Croton, 278 glands, 268 mineral, 62 olive, 60 Oleine, 60 Olfactory bulb, 82 nerves, 36, 41, 81 Olive-oil, 60 Opium, 124, 645, 655 Optic nerve, 36, 82 Orange juice, 207 Orbit, 42 Organ, glandular, 47 Organic disease, 159 iodine, 411 substances, 56 Organotherapy, 421 Organs, digestive, 43 female generative, 50, 88 male generative, 50 sense, 39 Osmic acid injection in tic douloureux, .372. Ossification of the joints, 284 Osteomalacia, 317 Osteomyelitis, 318 Otitis, chronic catarrhal, 446 Outer ear, 445 Ova, 50 Ovarian tumor, 659 Ovaries, 50, 88, 89 Oviducts, 88 Ovulation, 89 Ovum, 90 696 INDEX Oxygen, 59, 73, 514, 523, 646, 655 Ozena, 453 Pain, 161, 652 bowels, 653 Painless childbirth, 399 Painter's colic, 492 Palm, contraction of tendons of, 288 Palmitine, 60 Palsy, Bell's, 348 scrivener's, 373 shaking, 367 wasting, 366 Pancreas, 48 diseases of, 558 inflammation of, 559 Pancreatic fluid, 48 juice, 48, 67, 505 Pancreatin, 67 Papillae of tongue, 41 Paraglobuline, 61 Paraldehyde, 125 Paralysis, 322 agitans, 367 facial, 348 infantile, 624 of gullet, 84 of insane, 364 rheumatic, 348 stroke of, 322 progressive general, 364 Paralytic dementia, 364 Paranoia, 364 Parasites, 275, 566 Parasitic disease, 275 Parathyroid, 400 Paregoric, 646 Paresis, 364 general, 364 Paronychia, 257 Paroxysmal headache, 357 tachycardia, 533 Parturition or childbirth and its acci- dents, 580 Pasteur, 330, 355 Pasteurized milk, 203, 465 Patella, 292 Pathetic nerve, 36, 82 Pathology, 56 Pavement, 105 Pellagra, 258 Pelvis, 6 Pemphigus, 259 Penis, 50, 90 Peppermint, 646, 655 Pepsin, 61, 65, 646, 655 Peptone, 60, 61, 66 Peptonized milk, 497 Pericarditis, 531 friction sounds in, 532 Pericardium, 53, 531 Perineum, 21 Periosteum, 4 Periostitis, 318 Peritoneum, 24, 45 inflammation of, 230 Peritonitis, 230, 602 acute, 602 chronic, 602 general, 602 tubercular, 177, 230, 602 Permanent glycosuria, 541 teeth, 13 Permanganate of potash, 646, 655 Pernicious anemia, 345 Peroxide of hydrogen as depilatory, 249 Perspiration, 57 insensible, 57 Petit mal, 351 Pfeiffer's bacillus, 470 Phagocytes, 143, 341 Pharyngitis, 472 Pharynx, 44, 45 Phenacetin, 646, 655 Phimosis, 232 Phlebitis, 333 Physiological atrophy, 181 Physiological periods in women, 572 Physiology, 56 Pia Mater, 34 Pigeon breast, 222 Pigment layer of the retina, 442 Pile-bearing area, 501 Piles, bleeding, 494 Pilocarpin, 408 Pinworms, 278 Pituitary disease, 416 gland, 400 Pituitrin, 417, 514 Pityriasis rosea, 260 Placenta, 88 Plasma, 69, 143 Plasmodium of malaria, 5661 Playground, 138 Pleura, 54, 74 Pleurisy, 212, 522 acute, 518 effusion in, 212, 518, 522 friction sounds in, 522 Plexus, solar, 39 Plumbing, 117 Pneumococcus, 171 Pneumogastric nerves, 36, 84 Pneumonia, 211, 523 broncho, 212 lobar, 212 Poison ivy, 260 oak, 260 sumac, 260 Poisoning, lead, 627 malarial, 567 narcotic, 627 INDEX 697 Poisoning-Continued ptomaine, 631 Poisons, 627 corrosive, 627 irritant, 627 narcotic, 627 uremia and uremic, 634 Poisons, poisoning, and antidotes, 627 Polypi of the nose, 458, 462 Pomegranate root, 279 Pons Varolii, 34 Porosity, 3 Portal vein, 30 Port wine stain, 167, 321 Potable water, 105 Potassium, 57 carbonate, 58 chloride, 58 phosphate, 58 sulphate, 59 Potatoes, 133 Pott's disease, 294 Poultices, 607, 653 Poulticing, 606 Power of intense cold, 95 Precautions for prevention of infectious disease, 165 Pregnancy an indication for weaning, 197 duration of, 579 Prenatal instruction of mothers, 589 period, 589 Preparation of food, 130 Presbyopia, 87 Preventive medicine, 92, 131 Prickly heat, 224 Priessnitz, 618 Progressive general paralysis, 364 muscular atrophy, 366 Prolapse of intestine, 506 Prostate gland, 50, 417 Proteids, 61, 133 Protozoa, 615 Protrusion of eyeballs, 410 Prurigo, 262 Pruritus, 262 Psoriasis, 263 Psychasthenia, 385, 390 Psyche, 382, 390 Psychoanalysis, 390 Psychoasthenia, 390 Psychology, 390 Psychopathy, 390 Psychosis, 391 Psychotherapy, 391 Ptomaines and ptomaine poisoning, 631, 633 Ptosis, 441 Ptyalin, 61 Ptylism, 408 Puberty, 572 Puerperal fever, 584 Pulmonary artery, 29, 54 emphysema, 524 valve, 534 vein, 54 Pulse, 28 Pumpkin seeds, 278, 647, 655 Purpura, 264 Pus-producing bacteria, 461 Pyemia, 341 Pyelitis, 543 Pylorus, 46 Pyorrhea, 457, 464 Quality of the soil, 103 Quassia, 278, 647, 655 Quinine, 647, 655 Quinsy sore throat, 466 Rachitis, 222 Radium, 621 Radius, 10 Ragweed, 564 Raynaud's disease, 334 Rays, Rontgen, 621 ultra-violet, 621 violet, 621 Reaction, 143, 153, 161 Recesses, 138 Rectal feeding, 647, 655 Rectum, abscess of, 500 cancer of, 669 Red corpuscles 69 Red gum, 191 Reflex action, 78 cramps, 308 irritation, 79 muscular action, 79 Refraction, 42 Region, iliac, 24 Relation of bacteriology to health, 139 Reproduction, 87 Reproductive organs, 88 Residence in city compared with resi- dence in country, 93 Residual air, 74 Respiration, 72, 511 artificial, 609 Respiratory apparatus. 73 Rest, 154 Restlessness at night, 193, 222 Retina, 42 detachment of, 432 right spot of, 42 pigment layer of, 442 Retinitis, 442 Revery, 382 Rheumatic fever, 295 paralysis, 348 Rheumatism, 172, 221, 295, 653 chronic, 296 698 INDEX Rheumatism-Continued heart complications of, 286 inflammatory, 286, 295 muscular, 295 Rheumatoid arthritis, 296 Rhinitis, acute, 452 atrophic, 453 chronic, 452 Rhinoplasty, 456 Rhubarb and soda, 647, 655 Ribs, beading of, 222 false, 8 floating, 9 true, 9 Rice, 133 Rickets, 222 Riggs's disease, 464 Right-handedness, 170 Ringing in ears, 451 Ringworm, 265 Rochelle salts, 495, 647, 655 Rontgen rays, 621 Roman wormwood, 564 Root, nerve, 36 Ross, 96, 566 Rotation, 284 Rotatory joint, 16 Roundworm, 276 Run-around, 253 Rupture, 310 Russian bath, 620 Sacral ganglia, 39 nerves, 36 Sacrum, 6 Saddle nose, 456 Sage, 647, 655 St. Vitus's dance, 225 Salicylate of soda, 647, 655 Salicylic acid in rheumatism, 295 Saline cathartic, 495 Saliva, 65 Salivary glands, 44, 45, 65 disease of, 407 tumors of, 408 Salivation, 408 Salt, 58, 132 Salts, mineral, 132, 648, 655 Salvarsan, 648, 655 Sanitarium treatment, 127 Sanitation and hygiene in their relation to health, 92 Santonin, 277 Sarcoma, 666 Scabies, 266 Scalp, eczema of, 223 Scarlet fever, 215 bacillus, 174 Scars, 603 Scar tissue, 603 Schick test, 214 School, 135 moral influences at, 139 Sciatica, 366 Sclera, 42 Scleroderma, 267 Sclerosis, multiple, 358 Scopolamin and morphia, 399 Scrivener's palsy, 373 Scrofula, 231 Scrofuloderma, 231 Scrofulous blood, 231 Scrotum, 91 Scurvy, 188, 222 Sea bathing, 153 Sea-level for residence, 102 Seasickness, 485 Seat-worms, 647 Sebaceous cysts, 267 glands, 234, 236, 250 matter, 267 Seborrhea, 250, 268 Second childhood, 393 Second sight, 87 Seidlitz powder, 648, 655 Self-consciousness, 392 Self-suggestion, 377 Semen, 50 Semi-circular canals, 445 Semilunar ganglia, 39 Seminal fluid, 91 Semmeweiss, 584 Senile dementia, 393 Senna, 297, 648, 655 Sensation, 85 Senses, special, 85 Sensory nerves, 36, 78 Septicemia, 330 Septum, 462 bony spurs of, 457 deviation of, 457, 462 Serous membrane, 45 Serum, 45 albumen, 61 anti-streptococcus, 472 horse, 497 of Beebe's method, 412 of bubonic plague, 407 Serums, 143 Setting of bones, 600 Shaking palsy, 367 Shallow breathing, 511 Sheaths, muscle, 16, 26 Shingles, 269 Shock, 604, 653 in burns, 593 Shoulder, 283 disease of, 289 Shoulder-blade, 10 Sick headache, 357, 551 Sickness, aviation, 513 elevator, 477 INDEX 699 Sickness-Continued sleeping, 396 Sight, 86 hallucinations of, 383 Silica, 57 Silver, 648, 655 Sinus, nasal, disease of, 457 Sitz bath, 619 Skeleton, 3 Skin, 27 bronze color of, 402 cancer of, 670 disease of, 223, 233 eczematous, 245 emphysema of, 530 grafting, 593 offensive odor of, 257 whiteness of, 273 Skull, muscles of, 19 Sleep, 147, 395 balmy, 147 hours of, 193 induced, 151 Sleeping sickness, 396 Sleeplessness, 395 Sleep-walker, 382 Slippery elm, 648, 655 Smallpox, 218 vaccination, 219 Smell, 86 hallucinations of, 383 Smelling-salts, 602 Snorers, mouth breathing of, 462 Sodium, 57 carbonate, 58 chloride, 58, 62 phosphate, 58, 648, 655 sulphate, 59, 648, 655 Soft ankylosis, 285 Softening of the brain, 369 Soil, quality of, 103 Solar light, 621 Solar plexus, 39 Solaria, 101 Solid tumors, 559 Solitary glands, 68 Somnambulism, 382, 397 Somnambulist, 382 Sore mouth, 460, 653 Sores, 460, 493, 653 Sore throat, 473, 653 clergyman's, 472 membranous, 473 quinsy, 463 Sounds of heart, 70, 526 Sources of water-supply, 105 Sour stomach, 487 Spach's method, 203 Spaghetti, 133 Spasmodic, closure of air passages, 519 croup, 210 Special senses, nerves of, 36 Specific constitutional disease, 328 gravity of urine, 72 Sperm cells, 90 Spermatozoa, 90 Spermatozoon, 87 Spigelia, 648, 655 Spinal accessory nerves, 36, 84 anesthesia, 399 column, 6 cord, 32, 79 douche, 620 nerves, 32, 36 Spine, lateral curvature of, 293 Spleen, 48 diseases of, 418 enlarged, 419 Spongy gums, 464 Spotted fever, 227, 570 Sprained ankle, 311 Sprains, 310, 311, 653 Spring-cleaning medicines, 648 Springs, hot, 297 mineral, 152 sulphur, 297 Sprue, 465 Squint, 432, 435 Squinting in myopia, 440 Stammering, 370 Standard of hearing, 445 Staphylococcus, 471 Starch, 59, 62 Starvation diet, 559 Stasis, intestinal, 506 Steapsin, 67 Stearin, 60 Stenosis, 534 Sternum, 8 Stethoscope, 534 Stewed prunes, 207 Sties, 270 Stimulant, 629, 653 Stimulation, 629 Stomach ache, 602 acid, 487 atony of, 487 cancer of, 671 catarrh of, 474 dilatation of, 479 diseases of, 474 falling of, 478 hemorrhage of, 481 irrigation of, 483 irritation of, 483 neuralgia of, 479 sour, 487 subacidity of, 486 superacidity of, 487 ulcer of, 489, 508 Stone in kidney and bladder, 544 Stoppage of bowels, 506 INDEX 700 Strabismus, 432 Strain, muscle, 310 Strangling, 608 Strangulated hernia, 503 Streptococcus, 171, 174, 246, 471 Stridor, 215 Stroke of paralysis, 322 Structure, body, 3 ear, 445 Stuttering, 371 Subacidity of stomach, 486 Subclavian vein, 68 Subconscious, 390 Subliminal consciousness, 390 Substances, inorganic, 56 nitrogenous, 57 organic, 56 Suffocation and artificial respiration, 608, 609 Sugar, cane, 59 grape, 59 liver, 59 milk, 59, 201 Sul phonal, 125 Sulphur and molasses, 648, 655 Sulphur springs, 297 Summer diarrhea, 207 Sun-baths, 101 Sunburn, 271 Sunlight, 100, 114, 618 Sunstroke, 610 Superacidity of stomach, 487 Suppuration, 604, 653 Suppurative inflammation, 604 Suparrenal capsule, 50, 400 Surface water, 105 Surgery, antiseptic, 591 aseptic, 591 Surgical, diseases, 59 dressing, 630, 653 nursing, 609 Sweat-glands, 408 diseases of, 408 Sweating of head, 222 Swedish movement cure, 623 Sweet spirits of niter, 645, 655 Sweetbread, 181 Swelling of tonsils, 653 Sycosis, 272 Sympathetic nerves, 39, 40 nervous system, 36, 79, 85 Symptoms and treatment of dyspepsia, 476 Synovial fluid, 285 Synovitis, 297 Syntonin, 61 Syphilis, 165, 231, 653 Tables for infant feeding, 20 x, 203 Tachycardia, 532 paroxysmal, 533 Taenia, cucumerina, 277 mediocanellata, 277 solium, 277 Taenicide, 277 Talipes, calcaneo-valgus, 303 calcaneus, 303 equinovalgus, 303 equinovarus, 303 equinus, 303 valgus, 303 varus, 303 Tannin, 648, 655 Tapeworm, 277, 653 Taste, 85 Tear-duct, inflammation of, 438 Teeth, 13, 132 permanent, 13 temporary, 13 wisdom, 14 Teething, 224 Temperature, body, 186 Temporary teeth, 13 glycosuria, 541 Tendons, palm, contraction of, 288 diseases of, 282 Tenesmus, 504 Tertian fever, 568 Test, Dick, 216 Schick, 214 Testicles, 50, 90 Tetanus, 611 antitoxin, 613 Tetany, 401, 612 Theine, 130 Thigh, 12 Thomsen's disease, 312 Thoracic duct, 30, 68 Thorax, 8, 52 Thorough wort, 648, 655 Threadworm, 278 Throat, 44, 45 diseases of, 471 Thromboangitis, 335 Thrombosis, 335, 336 Thrombus, 335, 369, 517 Thrush, 209 Thymus gland, 181, 400, 419 Thyroid, 400 extract, 421 Thyroidin, 421 Thyroidism, 421 Thyro-iodine, 415 Tibia, 13 Tic douloureux, 371 Tobacco habit, 127 Tongue, cancer of, 673 disease of, 467 Tongue traction, 609 Tongue-tie, 469 INDEX 701 Tonics, 346, 653 Tonsilitis, 465 croupous, 466 follicular, 466 Tonsils, acute inflammation of, 466 Top milk, 200 Torpid liver, 556 Touch, 85 Toxin-antitoxin immunization, 214 Trachea, 51, 55 Tracheotomy, 215, 472 Trachoma, 443 Trance, 151 Transfusion of blood, 606, 624 Transient glycosuria, 541 Traps, 118 Treatment, antitoxin, 214 chemical, 616 light, 621 of diabetes with extract of pancreas, 561 some special methods of, 618 Trench feet, 307 Trichin®, 131 Trichinosis, 280 Tricophyton, 265 Tricuspid valve, 54, 534 Trifacial nerves, 36 Trigeminus, 82 Trional, 125 Trunk of "body, 21, 282 Trypanosoma, 376 Trypanosomiasis, 396 Trypsin, 67 Tubercular peritonitis, 177, 230 Tuberculosis, 165, 176 acute, 178 bacillus, 174 chronic, 178 spinal, 294 Tumors, 656 abdominal, 656 benign, 656 erectile, 321 fatty, 657 fibroid, 658 fluid, 559, 656 malignant, 656 ovarian, 659 salivary gland, 408 solid, 559 Tuning-fork, 446 Turbentine, 278, 649, 655 Turbinated bones, 461 Turkish bath, 619 Twilight sleep, 399 Tympanum, 445 Typhoid fever, 568 bacillus, 174 vaccine, 143 Typhus fever, 570 Tyrnauer, 624 Ulcer, 529, 613, 653 of cornea, 444 of duodenum, 508 of stomach, 508 Ulcerated mouth, 210 Ulcerative colitis, 493 Ulcero-membranous angina, 473 Ulna, 10 Ultra-violet rays, 621 Unconsciousness of coma, 634 Unpunctuality, 120 Upper limbs, 9, 23 Urea, 61 Uremia, 634 Ureter, 50 Urethra, 50, 90 inflammation of, 614 Uric acid condition, 635 diathesis, 636 disease, 636 Urine, 57, 71 albumen in, 536 normal daily quantity of, 72 specific gravity of, 72 Urochrome, 61 Urticaria, 251, 332 Uterus, 88 Utility of tea, coffee, and their sub- stitutes, 130 Vacations, 122, 155 Vaccinations, 140, 141 Vaccine of typhoid fever, 143 virus, 142 Vaccines, 142, 506 Vaccinia, 140 Vagina, 50, 88 Valerian, 649, 655 Valetudinarian, 94 Valve, 533 aortic, 53 ileo-caecal, 47 incompetent, 534 mitral, 54, 533 pulmonary, 533 tricuspid, 54, 533 Valvular disease of heart, 533 obstruction, 534 stenosis, 534 Vapor bath, 620 Varicose veins, 336 Varioloid, 219 Vas deferens, 91 Vasomotor disturbance, 577 nerves, 577 Vegetable albumen, 62 Veins, 29, 30 hemorrhoidal, 501 702 INDEX V eins-Continued inflammation of, 333 portal, 30 pulmonary, 54 subclavian, 68 varicose, 336 Vena cava, 54 Ventilation, 115 Ventricle, 27, 54 Vermifuge, 277 Vermin on the body, 280 Veronal, 125, 649, 655 Vertebrae, 6, 36 cervical, 6 dorsal, 6 lumbar, 6 Vertebral canal, 79 Vertical cross-eye, 432 Vertigo in Meniere's disease, 373 Vesicula seminalis, 91 Vessels, 30 lymph, 31 Villi, 47, 68 Vincent's angina, 473 Vinegar, 649, 655 Violet rays, 621 Vitality of nails affected by cold, 256 Vitamines, 63, 64, 133 Vitiligo, 273 Vitreous humor, 42 Vocal cords, 55 Vomitting, 206, 653 Walnut juice as hair stain, 249 Warburg's tincture, 566 Warte, 274 Waste-pipes, 118 Wasting palsy, 366 Water, 57, 62 brash, 487 chemical treatment of, 109 constituents of, 107 in head, 230 mineral, 152 on brain, 230 on knee, 293 passage, 50 pipes, 118 potable, 105 sources of, 105 supply, 125 Waterlogging, 322 Watershed, 106 Wax in ear, 446 Weaning, 197 Weighing, 192 Wen, 267 Wet-nursing, 198 Wheals in hives, 251 Wheezing in asthma, 512 White plague, 176 White substance of Schwann, 36 White swelling, 293 Whiteness of skin, 273 Whooping-cough, 220 Why are there so many kinds of diseases of the skin?, 233 Wind, 99 Wind colic, 492, 653 Windpipe, 55 Wine whey, 649, 655 Winter cold, 514 Winter diseases, 241 Wintergreen, 649, 655 Wisdom teeth, 14 Womb, 50, 88 Women, cancer in, 673 conditions peculiar to, 572 Wood-alcohol, 125, 628 Word blindness, 437 Worms, 653 pin, 278 round, 276 seat, 278 tape, 277 thread, 278 Worry, 120 Wounds, 614 accidental, 614 infected, 615 intentional, 614 treatment of, 616 Wrist, disease of, 289 Writer's cramp, 373 Wry neck, 313 X-ray, 506, 545, 600 burns, 249 examination, 507 picture, 179, 506, 554 treatment, 598 Yeast bacteria, 171 Yellow fever, 571 Yellow jack, 571 Zander, 624 Zinc, 649, 655