WOOD’S 
'n 
HOUSEHOLD 
PRACTICE « MEDICINE 
HYGIENE AND SURGERY 
A PRACTICAL TREATISE FOR THE USE OF 
FAMILIES, TRAVELERS, SEAMEN, MINERS, AND OTHERS 
EDITED BY 
FREDERICK A. CASTLE, M.D. 
ijst T"wo ■voi/ttiisxes 
ILLUSTRATED BY OVER SEVEN HUNDRED FINE WOOD ENGRAVINGS 
Volume II. 
NEW YORK 
WILLIAM WOOD AND COMPANY 
1880 Copyright by 
WILLIAM WOOD & COMPANY. 
1880. 
Trow’s 
Printing and Bookbinding Co., 
205-213 East szth. St., 
NEW YORK. CONTENTS OF VOL. II. 
ACUTE INFECTIOUS DISEASES. 
t 
By JAMES T. WHITTAKER, A.M., M.D. ; ELY VAN DE WARKER, A M., M.D. ; 
ely McClellan, m.d. ; and albert h. crosby, a m., m.d. 
Page 
The Nature op Acute Infectious Diseases 3 
Continued Fevers, , . 14 
Typhoid fever, 14.—Typhus fever, 28.—Yellow fever, 83.—The plague, 37.— 
The black death, 38.—Relapsing fever, 39.—Miliary fever, 41.—Dengue 
fever, 44.—Hay fever, 45. 
Malarial Fevers, 50 
Simple intermittent fever, 52.—Remittent fever, 53.—Irregular forms of mala- 
rial fevers, 54. 
Various Acute Infectious Diseases, 58 
Influenza, 58.—Epidemic dysentery, 00.—Spotted fever, 61.—Epidemic diph- 
theria, 63. [For Whooping Cough see page 833.] 
Acute Eruptive Diseases, 69 
Small-pox, 09.—Chicken-pox ; measles, 72.—Scarlet fever, 74—Table of distin- 
guishing signs of eruptive diseases, 79. 
Epidemic Cholera, 79 
Hydrophobia and Rabies, 95 
Glanders—Farcy, 113 
Mumps, 115 
VACCINATION. 
By FRANK P. FOSTER, M.D. 
History and nature, 119.—Course, 121.—Mode of performing, 122.—Complica- 
tions, 125. IV 
CONTENTS. 
CHANCROID AND SYPHILIS. 
By HENRY G. PIFFARD, A M., M.D. 
Page 
Chancroid, . 129 
Nature and Cause ; Bubo, 129.—Treatment, 130. 
Syphilis, * .... 131 
Nature; chancre, 131.—Secondary syphilis, 133.—Tertiary syphilis; hereditary 
syphilis, 134.—Treatment, 135.—When may syphilitics marry, 138. 
THE SKIN AND HAIR. 
By JAMES C. WHITE, M.D. 
Structure op the Skin, 143 
Care op the Skin, 147 
Nature and Causes op Skin Diseases, 148 
Diseases op the Skin, 152 
Class I.—Disorders of the Cutaneous Glands. 
A. —Disturbances of the Sebaceous Glands, 152 
Excessive secretion of sebum, 152.—Unnatural dryness of the skin, 153.—Dan- 
druff, 154.—Comedo, 155.—Milia, 156. 
B. —Disorders of the Sweat Glands 156 
Excessive sweating of the feet and bands, 156.—Offensive perspiration, 157. 
Class II.—Inflammations. 
A. —Transient Inflammations, 158 
Erythema, 158.—Nettle-rash; hives; urticaria, 159.—Dermatitis: chilblain. 160. 
—Heat-rash, 161.—Arnica-poisoning; ivy-poisoning, 162.—Erysipelas, 165. 
—Boils, 166.—Herpes; fever-sore; cold-sore; shingles, 167. 
B. —Chronic Inflammations 168 
Eczema ; salt rheum, 168.—Psoriasis, 170.—Acne ; face-pimples ; blossoms, 171. 
Class III.—Hemorrhages. CONTENTS. 
V 
Class IY.—Hypertrophies, Overgrowths. 
Page 
A. —Excessive Growth of the Cuticle, . . 173 
Callus, 173.—Corns; warts, 174.—Fish-skin disease, 175. 
B. —Excessive Growth of Pigment 175 
Freckles, 175. 
Class V.—Atrophies. 
Class VI.—Ulcerations. 
-Class YII.—New Growths. 
Mother’s marks, 177. 
4 
Class VIII.—Neuroses or Disturbances op tiie Sensibility of the Skin. 
Itching, 178. 
Class IX.—Parasitic Affections. 
A. — Vegetable Parasites, 178 
Ringworm, 179.—Ringworm of the beard; sycosis; barber’s itch, 181.—Ring- 
worm of the nails; mange, 182.—Favus, 185.—Tinea versicolor, 186. 
B. —Animal Parasites, • 187 
Scabies; itch, 187.—Lice, 190. 
The Hair in Health and Disease. 
Care op the Hair, 193 
Diseases op the Hair, 194 
Excessive growth, 194.—Loss of hair; baldness, 195.—Loss of color; graying; 
canities, 196. 
THE HANDS AND FEET. 
By LEROY MILTON YALE, A.M., M.D. 
Care op the Hands, 199 
Diseases and Deformities op tiie Hands, 200 
Hang-nail; run-around or onychia; felon, 201.—Warts, 203.—Deformed hands 
and feet, 204. 
Care op tiie Feet, 205 
Diseases and Deformities op tiie Feet, 210 
Corns, 210.—Bunions, 212.—Ingrowing toe-nails, 213.—Chilblains, 214.—Per- 
spiring, hot, and cold feet; stone-bruise, 215.—Fissures of the toes ; 
clubbed feet or talipes, 216.—Flat-foot, 218. VI 
CONTENTS. 
THE EYE AND ITS DISEASES. 
By D. B. ST. JOHN ROOSA, A.M., M.D., and EDWARD T. ELY, M.D. 
Pape 
Anatomy and Physiology op the Eye, 221 
The orbits, 221.—The eyeball, 222.—The optic nerves; the appendages of the 
eye, 229.—The lachrymal apparatus, 232. 
Phenomena op Vision, 234 
Cake op the Eyes, 241 
Tired eyes; care of the eyes in childhood, 241.—Quality, quantity, and point 
of admission of light; the character of type, 242.—School-houses, 243.— 
Atmospheric conditions, 244.—Reading in railway trains; reading in bed ; 
training the eyes to look at distant objects, 245.—Reading music; blurring 
of vision, 246.—Pain in the eyeball; loss of sight; test letters, 247.— 
Jaeger’s test-types, 248.—Snellen’s test-types, 249.—Floating bodies before 
the eyes of persons with good vision; influence upon the eye produced by 
habits of life, 250.—Length of time that eyes may be continuously used, 251. 
Cake op Inflamed and Injured Eyes, 252 
Darkening of rooms ; poultices and other applications, 252. 
Diseases op the Eyes, 254 
Inflammation of the edges of the lids, 254.—Styes or hordeola, 255.—Tumors of 
the eyelids, 256.—Displacement of lids outward or inward ; paralysis of 
the muscles of the eyelids, 257.—Paralysis of the muscle that shuts the 
lids, 259.—Twitching of the eyelids ; spasmodic closure of the lids ; bruises 
of the eyelids, 259.—Wounds of the lids ; affections of the tear-apparatus ; 
lachrymal diseases, 260.—Inflammation of the conjunctiva or conjunctivitis ; 
cold in the eye ; catarrhal conjunctivitis, 263.—Purulent conjunctivitis, 265. 
—Consequences of conjunctivitis, 267.—Thickening of the lining of the 
lids, granular lids or trachoma, 268.—Growths upon the mucous membrane 
of the eye or pterygium, 269.—Adhesion of lids to the ball or symblepharon; 
foreign bodies on the outside of the eye, 270.—Inflammation of the cornea or 
keratitis ; ulcers of the cornea, 272.—Spots upon the cornea, 273.—Inflam- 
mations of the cornea ; pustular inflammation of the cornea; phlyctenular 
keratitis; scrofulous keratitis , inflammation of the cornea from inherited 
syphilis, 274.—Results of inflammation of the cornea, 275.—Conical cornea; 
diseases of the sclerotica or white of the eye ; inflammation of the iris; 
iritis, 276.—Excessive and constant enlargement of the pupil or mydriasis ; 
contraction of the pupil or myosis, 279.—Congenital defect of the iris ; cata- 
ract, 280.—Diseases of the retina, the choroid, and the optic nerve, 283.— 
Diseases of the retina, 284.—Diseases of the choroid; diseases of the optic 
nerve ; diseases of the optic nerve and retina from the abuse of alcohol, to- 
bacco, etc., 285.—Diseases of the vitreous humor, 287.—Undue hardness of 
the eyeball or glaucoma, 287.—Injuries of the eye ; foreign bodies in the eye, 
288.—Artificial eyes ; cross-eyes, squint or strabismus, 290.—Paralysis of the 
muscles of the eyeball; constant oscillatory movement of the eyes ornystag- CONTENTS, 
VII 
Page 
mus, 293.—Inability to use the eyes continuously when there is no lessening 
of the sharpness of sight; conditions of the eye requiring the use of spec- 
tacles, 294.—Presbyopia, 296.—Hyperopia, 298.—Myopia, 300.—Astigma- 
tism, 302.—Color-blindness; simulated blindness, 303.—Hysterical blind- 
ness, 304. 
THE EAR AND ITS DISEASES. 
By ALBERT H. BUCK, M.D. 
Anatomy and Physiology, 307 
Diseases of the Ear, 312 
Deafness, 312.—Earache, 313.—Discharge from the ear, 316.—Ringing in the 
ears; foreign bodies, 318.—Syringing the ear, 317. 
Care of the Ears, 320 
General Remarks, 320 
DEAF-MUTISM. 
By JOHN W. CHICKERING, Jr., A.M. 
Statistics, 325.—Causes, 326.—Cure, 329.—Education, 330.—History of deaf- 
mute education, 331. 
THE HOSE AND ITS DISEASES. 
By FRANK H. BOSWORTH, A.M., M.D. 
Anatomy and Physiology, 347 
Diseases of the Nose, 353 
Cold in the head, acute nasal catarrh or acute coryza, 354.—Chronic nasal ca- 
tarrh or chronic coryza, 358.—Stink-nose or ozsena, 363.—Ulceration of the 
nasal cavity, 365.—Tumors in the nasal cavity, 367.—Deviation of the sep- 
tum ; perforation of the septum ; foreign bodies in the nose, 369. —Bleed- 
ing from the nose or epistaxis, 370.—Fracture of the bones of the nose ; loss 
of the sense of smell or anosmia, 372.—Glanders; influenza ; restoration of 
nose, 373.—Deformities of the nose, 374. VIII 
CONTENTS. 
THE THROAT AND ITS DISEASES. 
By J. SOLIS COHEN, A.M., M.D. 
Pago 
Anatomy and Physiology, 377 
Care of the Throat, 378 
TnE Voice, 380 
Care of TnE Voice, 384 
Diseases of toe Throat, 386 
Sore throat, 386.—Enlarged tonsils, 387.—Inflammation of the tonsil; quinsy 
sore throat, 389.—Diphtheria, 390.—Relaxation of the palate; elongated 
uvula ; chronic pharyngitis; clergyman’s sore throat; chronic sore throat, 
392.—Acute laryngitis, inflammation of the larynx, 394.—Chronic laryn- 
gitis; chronic inflammation of the larynx, 395.—Croup, membranous 
laryngitis ; hives, 397.—Spasm of the larynx or false croup, 402.—Aphonia 
or loss of voice, 403. 
DISEASES OF THE RESPIRATORY ORGANS. 
By ALFRED L. LOOMIS, A.M., M.D. 
Bronchitis, 407.—Acute capillary bronchitis, 409.—Membranous bronchitis, 410. 
—Chronic bronchitis, 411.—Asthma, 416. —Pulmonary emphysema, 420.— 
(Edema of the lungs, 423.—Congestion of the lungs, 424.—Apoplexy of the 
lungs, 425.—Hemorrhage from the lungs or hemoptysis, 426.—Gangrene of 
the lungs, 428.—Cancer of the lungs, 429.—Pleurisy, 430.—Subacute pleu- 
risy, 431.—Chronic pleurisy or empyema, 433.—Pneumo-hydrothorax ; in- 
flammation of the lungs or pneumonia, 435.—Croupous or lobar pneumonia, 
436. —Catarrhal pneumonia, 441.—Interstitial pneumonia, 443.—Pulmonary 
consumption; catarrhal consumption, 444.—Fibrous consumption; tuber- 
cular consumption, 445. 
Peculiarities op Affections of the Respiratory Organs in Children, . 456 
Bronchitis; spasmodic asthma; congestion of the lungs; dropsy of the lungs 
or pulmonary oedema, 456.—Collapse of the air-cells or atelectasis, 457.— 
Pleurisy ; pulmonary consumption; inflammation of the lung, 458. 
THE KIDNEYS IN HEALTH AND DISEASE. 
By A. BRAYTON BALL, M.D. 
Anatomy and Physiology, 463 
The Urine, 406 
Color, 406.—Odor; reaction, 4G7.—Quantity; density, 469.—Temperature; 
composition, 471. CONTENTS. 
IX 
Page 
Deposits in the Urine, 471 
Urates, 471.—Uric acid, 472.—Phosphates, 473.—Oxalate of lime, 474.—Pus or 
matter; blood, 475. 
Diseases of the Kidneys, 470 
Saccharine diabetes, 476.—Insipid diabetes, 480.—Congestion of the kidneys; 
Bright’s disease, 481.—Acute Bright’s disease, 482.—Chronic Bright’s dis- 
ease or chronic inflammation of the kidneys, 484.—Granular or cirrhotic 
disease, 485.—Waxy disease, 486.—Gravel, calculi, or stone in the kidney, 
488. 
Rarer Diseases of the Kidneys, 489 
Inflammation of the pelvis or pyelitis ; cancer of the kidney, 489.—Hydatids of 
the kidney, 490.—Movable or migratory kidney, 492. 
Rare Anomalies of the Urine, 493 
Chylous urine; chyluria; intermittent hematuria, 493. 
THE MALE GENITO URINARY ORGANS. 
By EDWARD L. KEYES, A.M., M.D. 
The prepuce ; phymosis, 498.—Para-pbymosis ; cutaneous affections of the 
penis, 500.—Cancer of the penis; wounds aud contusions of the penis; the 
urethra, 501.—Deformities of the urethra, 503.—Neuralgia of the urethra ; 
inflammation of the urethra, 503.—Stricture of the urethra, 505.—The 
prostate, 500.—Neuralgia of the deep urethra; prostatitis, 507.—Tubercle 
and cancer of the prostate; enlarged prostate, 508.—The bladder, 514.— 
Irritability of the bladder, 515.—Cystitis, 516.—Catarrh of the bladder, 
519. —Retention of urine ; gravel, 520.—Stone in the bladder, 521.— 
Tumors of the bladder ; diseases of the testicle and cord, 523.—Varicocele, 
520. —Swelled testicle, 527.—Orchitis; hydrocele, 528.—Tumors of the 
testicle, 529. 
DISEASES PECULIAR TO WOMEN 
By A. REEVES JACKSON, A.M., M.D. 
Introduction, 533 
Anatomy and Physiology, 534 
Menstruation, 538. 
Female Hygiene, 541 
Pelvic Diseases in Women, 545 
Menstrual derangements, 545.—Leucorrhoea ; pain, 546.—Itching of the geni- 
tals, 547.—Painful, difficult, and frequent urination, 548.—Amenorrhoea, X 
CONTENTS. 
Page 
549.—Dysmenorrhoea, 552.—Leucorrhoea 554.—Menorrhagia and metror- 
rhagia, 556.—Displacements of the uterus, 560.—Polypus of the womb, 566. 
—Fibrous tumors of the womb, 564.—Ulceration of the womb, 566.—Ova- 
rian tumors, 568. 
IDIOCY AND NERVOUS DISEASES OF ADULT LIFE. 
By ALLAN McLANE HAMILTON, A.M., M.D. 
Idiocy, 573 
Unusual Forms op Idiocy, 576 
Nervous Diseases of Adult Life, 581 
Cerebral congestion, 581.—Cerebral anasmia, 583.—Spinal ansemia or spinal irri- 
tation ; headache, 584.—Giddiness, 586.—Sleeplessness, 588.—Alcoholism, 
delirium tremens or chronic alcoholism, 590. —Hemiplegia, 593.—Paraplegia 
or paralysis of the lower half of the body, 596.—Locomotor ataxia or tabes 
dorsalis; paralysis from pressure, 597.—Facial paralysis; neuralgia, 593. 
Epilepsy, 603.—Writer’s cramp, 605.—Wasting palsy, 006.— Shaking palsy, 
607.—Catalepsy ; ecstacy, 608. 
INSANITY. 
By JUDSON B. ANDREWS, A.M., M.D. 
Nature op Insanity, 611 
Causes of Insanity, 614 
Predisposing causes, 614.—Exciting causes, 617. 
Classification of Insanity, 618 
Mania, 020.—Melancholia, 622.—Dementia; paresis, 624. 
Early Symptoms of Insanity, 626 
Asylums for the Insane, 631 
THE MOUTH AND TEETH. 
By FRANK ABBOTT, M.D. 
Anatomy and Physiology, 669 
The upper jaw, 640.—The lower jaw; the teeth, 641.—First dentition, 644.— 
Shedding of temporary teeth, 647.—Wisdom teeth, 649. 
Diseases op tiie Teeth, 650 
Decay or caries of the teeth, 650.—Gum-boil or alveolar abscess, 652.—Tartar or 
salivary calculus, 653.—Artificial teeth, 654.—Individual care of the teeth, 
656.—Action of medicines on the teeth, 657 ; Peculiarities of dentition, 659. CONTENTS. 
XI 
DISEASES OF THE DIGESTIVE ORGANS. 
By FREDERICK A. CASTLE, M.D. 
Page 
Introductory, 608 
Deranged Digestion or Dyspepsia, 065 
Loss of appetite ; unnatural appetite, 668.—Nausea ; vomiting, 669.—Hiccough; 
foul breath, 671.—Water-brash or pyrosis; heart-burn or sour stomach; 
discomfort in the stomach and bowels, 672.—Swelling of the belly, 678.— 
Diarrhoea, 674.—Constipation and costiveness, 675.—Changes in appearance 
of fecal matter, 678.—Other symptoms of dyspepsia, 679.—Recapitulation, 
680. 
Diseases of the Digestive Organs, 681 
Stricture of the gullet or oesophagus ; inflammation of the stomach, or gastritis, 
681.—Neuralgia of the stomach, or gastralgia; inflammation of the bowels, 
686.—Colic; dysentery or bloody-fiux, 688.—Inflammations, unnatural 
growths, etc., 690.—Peritonitis, 691.—Typhlitis, 692.—Ulceration of the 
stomach and bowel; cancer of the stomach, 698.—Other diseases of the 
digestive organs; diseases of the liver, 694.—Jaundice. 695.—Gall-stone or 
biliary colic, 697.—Gin-drinker’s liver or cirrhosis of the liver, 698.—Con- 
gestion of the liver, 700.—Waxy liver; fatty liver, 701. 
DISEASES OF THE RECTUM AND ANUS. 
By WILLIAM H. VAX BUREN, A.M., M.D. 
Anatomy, 700 
Malformations of the Anus and Rectum, 706 
Diseases of the Anus and Rectum, 708 
Painful itching of the anus, 708.—Hemorrhoids or piles, 709.—Fissure of the 
anus, 710.—Ulcer of the rectum, 712.—Stricture of the rectum, 718.—Fis- 
tula in ano, 715.—Abscess near the anus or rectum, 717.—Polypus, 718.— 
Falling of the bowel, 719.—Cancer of the rectum, 721.—Impaction of faeces, 
722.—Foreign bodies in the rectum; Relaxation of the sphincter, 728.— 
Neuralgia of the anus; wounds and contusions of the anus and rectum, 
724.—Specific ulcers and eruptions; general remarks, 725. 
DISEASES OF THE ORGANS OF CIRCULATION. 
By EDWARD G. JANEWAY, A.M., M.D. 
Inflammation of the sac covering the heart or pericarditis, 729.—Inflammation 
of the interior of the heart or endocarditis, 731.—Inflammation of the sub- 
stance of the heart or myocarditis ; chronic valvular disease. 733 —Over- 
growth or hypertrophy of the heart, 737.—Dilatation or overstretching of XII 
CONTENTS. 
Page 
the heart, 739.—Fatty degeneration, 741.—Embolism or thrombosis, 742. — 
Blue-disease or cyanosis, 745.—Angina pectoris, 746.—Palpitation, 747.— 
Rupture of the heart; aneurism of the heart, 748.—Diseases of the arteries, 
749.—Diseases of the lymphatics, 750.—Diseases of the veins, 751.—Leuco- 
cythasmia or leukaemia, 752. 
DISEASES OF THE BONES AND JOINTS. 
By BENJ. LEE, A.M., M.D. 
Introductory, 758 
General description of joints, 759.—Anatomy of the Spine, 760.—Diseases of the 
spine, 762.—The detection of angular curvature, 764.—Lateral curvature 
of the spine, 772.—Diseases of the hip-joint or coxalgia, 775.—Diseases of 
other joints, 779.—Inflammation of the synovial membranes, 780.—Rickets, 
781.—Dropsy of the joints, 783.—Hysterical joints, 784.—Softening or 
fragility of the bones ; house-maid’s knee, 787.—Ganglion, 788. 
GENERAL SURGERY. 
By GEORGE F. SHRADY, A.M., M.D. 
Fatty tumors; fibrous tumors, 792.—Vascular tumors, 794.—Horny tumors, 
795.—Bony tumors, 796.—Cystic tumors, 797.—Cancer, 798.—Aneurism or 
ruptured blood-vessel, 806.—Hare-lip or split-lip, 809.—Cleft palate, 812.— 
Abscess, 815. 
DISEASES OF THE GENERAL SYSTEM. 
By FREDERICK A. CASTLE, M.D. 
Scurvy, 819.—Anaemia; chlorosis, 820.—Rheumatism, 821. —Acute rheumatism, 
822.—Subacute rheumatism; chronic rheumatism, 824.—Crick in the back 
or lumbago ; crick in the neck ; deforming rheumatism. 825.—Gout, 826.— 
Dropsy, 828.—Sunstroke, 830.—Sea-sickness, 831.—Whooping cough or 
pertussis, 833. 
NURSING AND DIET FOR THE SICK. 
Nursing, 839 
General remarks, 839.—Nurses’ dress, 840.—Talking, 841.—Noise; visitors, 
rest and exercise, 842.—Sick-room; ventilation; thermometer, 843.— 
Flowers in the sick-room; beds, 844.—Water-beds, 845.—Fever-cot, 846.— 
Bed-sores, 847.—Clothing, 848.—Appliances; bed-pans, 849.—Urinals; 
back-rests; support for bedding, 850.—Cushions; Water- and ice-bags and CONTENTS. 
XIII 
Page 
tins, 851.—Invalid lifts; invalid chairs, 852.—Night-chair; bed-tables; 
mosquito netting, 854.—Bandages; roller bandages, 855.—T-bandage ; 
plaster-rollers, 856.—Starch-bandage ; many-tailed-bandage, 857.—Applying 
bandages, 858.—Sticking-plaster, 859.—Leeches, 860.—Cups; poultices, 
861.—Syringes and enemas, 863.—Baths; foot-bath, 864.—Vapor-bath; 
moving patients, 865.—Sweeping; screens; sick-room cooking, 866.— 
Champagne-tap; ice, 867.—Catheters; rubbing; sponges; compresses. 
868.—Laced stockings ; knots; nausea, 869.—Medicine measures; dropping 
medicine; pills, 870.—Powders; suppositories, 871.—Blisters ; hot stupes; 
cold applications; liniments, 872.—Lotions; issues; moxas; cautery; se- 
tons; drainage-tubes, 873.—Temperature, and the use of the thermometer, 
874.—Other signs of disease; reports, 876.—Operations, 887.—Caring for 
the dying and the dead, 878. 
Diet and the Preparation of Food for the Sick 881 
General directions, 881.—Rules to be observed in feeding the sick. 885.—Diet 
for the critically sick, 887.—Diet for the sick and convalescent, 888.— 
Recipes, 889. 
MATERIA MEDICA. 
General Remarks, 899 
Doses ; weights and measures, 901.—List of household remedies, 902.—Astrin- 
gents, 903.—Tonics, 904.—Stimulants; sedatives; anti-spasmodics; ano- 
dynes or analgetics; anaesthetics; excito-motors, 905.—Depresso-motors ; 
alteratives; emetics, 906.—Cathartics; diuretics; diaphoretics, 907. 
Forms in which Medicines are Prepared, 908 
Infusions; decoctions; tinctures, 908.—Ointments; cerates; vinegars; medi- 
cated waters; confections ; plasters ; fluid extracts; solid extracts, 909. — 
Glycerites; liniments; pills; powders; suppositories; syrups, 910.—Loz- 
enges, or troches; wines, 911. 
Glossary, 915 
Index, 919 Acute Infectious Diseases. 
BY 
JAMES T. WHITTAKER, A.M., M.D., 
OF CINCINNATI, OHIO, 
PROFESSOR OF PRINCIPLES AND PRACTICE OF MEDICINE IN THE MEDICAL COLLEGE OF OHIO ; 
LECTURER ON CLINICAL MEDICINE IN THE GOOD SAMARITAN HOSPITAL, 
ETC., ETC. ; 
ELY VAN DE WARKER, A.M., M.D., 
OF SYRACUSE, N. Y. ; 
ely McClellan, m.d., 
surgeon, u. s. army, 
AND 
ALBERT H. CROSBY, A.M., M.D., 
OF CONCORD, N. H. THE ACUTE INFECTIOUS DISEASES. 
There is a class of diseases especially characterized by their 
rapid dissemination by contact; by the intensity or virulence of 
their manifestations, and by the comparative shortness of their 
duration. With these characteristics, this class of diseases is ap- 
propriately grouped under the title of the Acute Infectious Dis- 
eases. 
The course and conduct of these diseases in the body resemble, 
to some extent, the action of poisons ; hence they are often called 
“blood-poisoning” or septic (cttjtttos, putrid) diseases. 
The poison, whatever its nature, once introduced, in however 
small quantity, into the blood, so swiftly induces manifestations of 
disease in the whole body as to resemble the action of a yeast or 
ferment, a little of which “leaveneth the whole lump,” and hence 
these diseases are also called the zymotic (tvM, ferment) diseases. 
Finally, because these diseases, under the unfavorable hygienic 
conditions which still surround us, are able to spread over whole 
sections of country—over whole countries—indeed, unless checked 
by natural causes, over the whole globe, they constitute what are 
known everywhere as the epidemic or pandemic diseases. 
Types of these diseases are Asiatic cholera, small-pox, chicken- 
pox, measles, scarlet fever, typhus and typhoid fevers, and diph- 
theria. In the very fore-front of the acute infectious diseases stands, 
or stood (for our improved sanitary conditions, faulty as they still 
are, have prevented its development in modern times), that most 
terrible of all scourges to man—the plague. At the extreme oppo- 
site end of the list we may read mumps, whooping-cough, and in- 
fluenza (a pronounced sample of which, “ the epizootic ” of 1873, 
confined nearly every horse of this country to his stall for several 
days); and along the column, at different places, erysipelas, child- 
bed fever, and dysentery, when epidemic, as in ships, hospitals, 
and camps ; the so-called pyaemia and septicaemia, blood-poison- 
ings which supervene upon abscesses and wounds ; with vaccinia, 
hydrophobia, malignant pustule (charbon), and snake-bites, etc., 4 
TIIE ACUTE INFECTIOUS DISEASES. 
as poisons communicated from animals to man ; and finally, the 
cattle-plague as a typical example of this class of affections in the 
lower animals themselves. 
The characteristic feature of all these diseases is infection. It 
matters not that they are not all alike propagated by immediate, 
direct, or personal contact. In some diseases the contagious ele- 
ment is fixed close to the body affected, or is attached to objects 
once in contact with the body. This is the case in the eruptive 
diseases proper—small-pox, measles, or scarlet fever, for instance. 
In other diseases the poison is more volatile ; it is dissipated from 
the body and disseminated to greater distance through the air, as 
in cholera and yellow fever. In still other cases, as in typhoid 
fever, dysentery, and cholera again, it is the dejections, the dis- 
charges from the intestinal canal, which chiefly convey the con- 
tagium, to finally infect the soil, and through the soil or sewage 
canals, by filtration to great distances, the drinking-water of our 
wells and cisterns and running streams. To breathe infected air, 
or drink infected water, though distant from the focus of infection, 
suffice to engender cholera, dysentery, or typhoid fever ; while the 
contagion of syphilis, and probably of diphtheria, must be lodged 
upon the mucous membranes ; and vaccinia, hydrophobia, malig- 
nant pustule, the virus from venomous animals, to produce infec- 
tion, must be inoculated into the very blood itself. 
But, even in cases of widest dissemination, the regular advance 
of the disease may always be strictly observed. The contagious 
element of cholera, for instance, the most widespread of all the 
epidemic diseases of our times, may not overleap at a bound great 
expanses of land or water. The ocean, which carried from the new 
hemisphere to the old new twigs and leaves of plants, to excite in the 
mind of Columbus suspicions of the existence of other lands, was 
for all time an impassable barrier to this disease, until it was di- 
rectly conveyed across in the memorable year of 1832. There 
must be intervening centres of infection, if there be not direct 
transportation, to effect the spread of infectious disease. 
The advocates of spontaneous (autochthonous) development or 
origin of infectious disease become fewer every year. So far as those 
diseases are concerned whose cause can be most distinctly traced— 
cholera and yellow fever, for instance—the line of infection, when 
accurately pursued, is always found to correspond with the line of 
transportation by water or rail. The increased velocity of travel 
in our day, with the correspondingly increased swiftness of trans- 
portation of disease, is the embarrassing element in tracing the 
course of disease to its original seat. A week and two days may 
now suffice to introduce from Europe to our whole country a THE ACUTE INFECTIOUS DISEASES. 
5 
sweeping epidemic of cholera, and, under favorable conditions, 
but a few days are required to carry yellow fever from New Or- 
leans to New York. Thus the advanced knowledge of sanitary 
science in our day, to which we may chiefly ascribe our compara- 
tive exemption from the devastating epidemics of ancient times, is 
counteracted to some extent by the increased facilities for trans- 
portation of disease to new centres, the absence of which alone 
saved the human race in the middle ages from almost utter ex- 
tinction. 
We come now to consider the cause of acute infectious dis- 
ease. 
The ancients had but little difficulty with this momentous ques- 
tion. The origin of epidemic disease was easily explained by the 
crude superstitions attached to celestial phenomena, or by the 
fatuous assertions of theosophy. The sudden appearance of a 
comet was an omen of direst import, whose significance was only 
fully revealed by a coincident or subsequent plague. An eclipse 
of the sun inevitably portended evils as diabolical as diverse. 
Even as late as the end of the seventeenth century, an edict was 
actually published by the Elector of Darmstadt, in protection 
against the mischief entailed by a solar eclipse * : Or the mis- 
conduct of a people or ruler excited the vengeance of an irate 
god, who vented his displeasure—in the peradventural absence 
of sufficient redemption—in famine and fire and plague. Lebert 
informs us that in India it was a popular belief that the pre- 
vention of human sacrifices had excited the anger of the gods, 
and relates, in proof, the story of the wife of a Hindoo, in Palcala, 
who resorted to every device to obtain permission to violate the 
law by being burned upon the grave of her husband, who had died 
of cholera. She maintained that she had done the same thing four 
times already in previous states of existence, and that if she might 
repeat it now for the fifth time, the cholera would cease in four- 
teen days. The rajah at last gave his consent; but the ashes of 
the poor fanatic, it is needless to state, did not assuage the disease, 
which continued just the same in its work of desolation. A 
timely earthquake or volcano, an inundating tidal wave, a violent 
storm, have been repeatedly brought into service in explanation 
* “His Highness having been informed that on Wednesday morning next, at ten 
o’clock, a very dangerous eclipse of the sun will take place, orders that on the day pre- 
vious, and for a few days thereafter, all cattle be kept housed and the 
cellars and garrets of houses guarded, so that the atmosphere may not obtain lodgment 
and thus produce infection, because such eclipses frequently occasion whooping-cough, 
epilepsy, measles, paralysis, fever, and other diseases, against which every precaution 
should be taken.” 6 
THE ACUTE INFECTIOUS DISEASES. 
of the development of epidemic disease. “ The wells have been 
poisoned/’ was the cry during the plague of Athens, and every- 
where since ; a formidable uprising of the people having once (1832) 
been excited in Paris under this belief. 
At last it came to be observed that epidemics prevailed entirely 
independently of any of the causes alleged, and in the meantime 
great advance had been made in all the natural sciences. Atten- 
tion was gradually being directed by the chemists to their expla- 
nations of fermentation and decomposition : processes considered 
analogous to those which occur in the body in infectious disease. 
For many years the theory then prevailed that the acute infec- 
tious diseases depended upon the presence in the blood of some 
fermenting matter, which induced changes in the whole body in 
the same manner as in the resolution of sugar into alcohol and 
carbonic acid gas, or as in the resolution of dead animal matter into 
water, ammonia, and various gases, the products of common decay. 
It was at this time that the acute infectious diseases were called 
“zymotic.” And now there developed as a kind of offshoot from 
physiology, the separate department of biology, a science which 
had to deal with the lowest forms of animal and vegetable life. 
Biological studies only became possi- 
ble, of course, with the perfection of 
the microscope, as all these forms are 
far beyond recognition with the naked 
eye. The theory had long ago been 
broached, even by the writers of an- 
tiquity, that many diseases were due 
to the entrance into the blood of low 
organic forms ; but such extravagant 
ideas were entertained regarding these 
forms as soon to bring the theory into 
ridicule and disrepute. Liebermeister 
relates that one writer of the seven- 
teenth century proposed in real ear- 
nest that, during the prevalence of epi- 
demic disease, the animals which were regarded as the cause of 
it, and which, according to the common notion, were said to fly 
about in the air, something like a cloud of locusts, should be 
killed by making a great uproar with blowing of trumpets and 
firing of cannons. “ Others described the animals, which were 
supposed to have the form of moths, as armed with crooked bills 
and pointed claws.” Fantastic figures of them were drawn, and 
great fires were built in streets and public squares to burn them 
up. Nearly a century of oblivion thereupon enshrouded the para- 
Figure 1.— The Torula or yeast- 
planfc, which develops most often in 
fluids containing sugar, and is essen- 
tially the cause of alcoholic fermenta- 
tion—largely magnified. THE ACUTE INFECTIOUS DISEASES. 
7 
sitic theory of infectious disease. What contributed especially to 
its resurrection, was the discovery that the processes of fermenta- 
tion and decomposition are not at all chemical, in the ordinary 
sense of the term, but are entirely vital. Fermentation was found 
to be dependent upon the development in the fluid of an infinite 
number of vegetable growths of distinct and definite form, known 
as the Torulce Cerevisice: rounded or ovoid bodies, which multiply 
with marvellous fecundity, until the process of fermentation is 
Fig. 2. 
Fig. 3. 
Figures 2 and 8.—Saccharomyces Cerevisice, from beer. The first shows the plant during 
active germination; the second, from a deposit of beer-yeast after fermentation has ceased. 
complete, when they gradually sink to the bottom. A minute 
quantity of these torulse (yeast) introduced into any saccharine 
solution, speedily effects its fermentation by their rapid increase 
in number and size. The process of decomposition likewise de- 
Figure 4.—Minute organisms magnified 750 diameters. A. Bacteria usually found in stale 
milk and some other putrefying fluids, where they exhibit very active movements. B. Micrococci 
developing in urine and presumed to cause, by their presence, the conversion of urea into carbo- 
nate of ammonia. C. Motionless jointed rods, called Bacilli, which develop in infusions of hay. 
D. Another form of bacterium possessing power of active motion, and existing in fluids under- 
going putrefaction. 
X750 
pends upon the rapid multiplication of definite parasites, the so- 
called vibrios and bacteria of putrefaction, always present in 
the air, and when once brought in contact with dead organic 8 
THE ACUTE INFECTIOUS DISEASES. 
matter, they increase by myriads until entire resolution is brought 
about. 
As the subject stands at present, it must be confessed that the 
bulk of evidence is in favor of the germ or vital theory of zymosis, 
that is, that the acute infectious diseases depend upon the presence 
in the blood of parasites—the lowest forms of life. The question 
of the animal or vegetable nature of these organisms has lost all 
interest since it has been conclusively determined that any differ- 
entiation between animal and vegetable life is impossible. A great 
number of observers have already recognized germs in various 
forms of infectious disease : in cholera, in erysipelas, scarlet fever, 
childbed fever, diphtheria, and especially in pyaemia and septicae- 
mia, the blood-poisonings referred to, after abcesses and wounds. 
Peculiar and special forms have been established in different dis- 
eases, and, what lends the strongest support to this theory, the 
inoculation of healthy animals with these special forms engenders 
the special disease. 
Nowhere now, therefore, is there any question of the spontane- 
ous origin of infectious disease. Everywhere is recognized a home 
where the disease is indigenous, and a route along which it is 
spread. The mouths of the Ganges and Brahmaputra are the cen- 
tres of cholera, lower Egypt of the plague, the Antilles of yellow 
fever, Ireland of typhus. Small-pox first showed itself in Ger- 
many in 1493, an importation from the Netherlands, but it was 
not until 1527 that it was transported to our continent, making its 
first appearance in Mexico, slaughtering myriads, and then grad- 
ually extending over the whole of North America. Scarlet fever, 
which is first heard of in Arabia, was not seen in our country 
until 1735. It reached Iceland in 1827, South America in 1829, 
Greenland in 1847, and Australia in 1848. Measles has not yet 
been carried to Australia. Cerebro-spinal meningitis, in every 
respect the most irregular of all epidemic diseases, first fell upon 
our country in 1806. All this disease, all infectious disease, is of 
exclusively parental birth. 
The parasitic theory is the only theory which reconciles in any 
kind of harmony the different factors in acute infectious disease. 
It offers a ready explanation, in the first place, for their conta- 
gion. The germs, being themselves the elements of the disease, 
are given off in myriads in every direction in the air or from the 
infected body. 
It is only by reflecting upon the fact that the air swarms at all 
times with invisible germs—that even the blue of the sky is caused 
by vast numbers of bodies floating in the atmosphere, so small as 
to be undistinguishable by a microscope magnifying 15,000 times— THE ACUTE INFECTIOUS DISEASES. 
9 
that we may form some adequate conception of the silent, unseen 
and almost unknown worlds of life about us. 
Pettenkofer has recently called attention to the constant agita- 
tions in the ocean of air, at the bottom of which we live, even 
when the motion is not perceptible as wind, as in a crowded room. 
The constantly rising columns from heated surfaces, from human 
bodies and gas-lights, the descent of colder air, the currents and 
counter-currents, make such streams and eddies and miniature 
Figure 5. 
Figure 6. 
Figures 5 and 6.—Particles of dust collected from the air, as they appear when magnified 350 
diameters, and consisting of organized bodies resembling those shown in foregoing illustrations, 
together with amorphous substances. 
whirlwinds as would render an audience unable to keep their 
seats, if they were rendered visible to the naked eye. But how 
much greater would be our amazement, wonder and distraction— 
how intolerable, indeed, our existence, if we should also see the 
myriad hosts of living organisms with which the air is filled. 
“ Facevano un tumulto, il qual s’aggira 
Sempre in quell aria senza tempo, tinta 
Come la rena quando il turbo epira.”—Dante. 
But it was flights of fancies like these which first brought the 
germ-theory into disrepute. These myriad parasites are friends, 
not enemies to man. Dead organic matter, whether of animal or 
vegetable origin, would be well-nigh indestructible if all these 
minute and apparently useless organisms, which are the causes of 
putrefaction, were themselves destroyed. “Life would be impos- 
sible, because the return to earth and air of all that had ceased to 
live would be suddenly suspended.” 
The close observation of a long series of years has put us in 
the possession of most of the data in the natural history of infec- 
tious disease. Thus, we have learned first that manifest attack 
does not follow immediately upon exposure to the disease. There 
lapses, first, a period during which the disease lies latent in the 
body, hatching, as it were—the so-called period of incubation. In 
some cases the length of this period may be determined to a day, 
by the experiment of inoculation. Thus, the incubation period of 10 
THE ACUTE INFECTIOUS DISEASES. 
vaccinia is three days ; of small-pox, after inoculation, two days ; 
without inoculation, twelve to thirteen days ; of scarlet fever, two 
to seven days; of typhus, seven to fourteen days ; of typhoid 
fever, twelve to sixteen days ; of measles, ten days; of intermit- 
tent fever, one to fourteen days; of syphilis, two to four weeks; 
of the plague, two to seven days; of cholera, two to three days; 
of yellow fever, two to nine days ; of hydrophobia, three to sixty 
days. 
Then supervene the various stages characteristic of each dis- 
ease, each stage of more or less definite duration, marking off a 
definite phase in the course of each affection. We know, again, 
what are the infecting structures, what is the period of greatest 
infection, and what is the duration of infection for each disease. 
The parasitic theory best explains also the swiftness and viru- 
lence of the symptoms of infectious disease. Dallinger and Drys- 
dale describe the development of monads, certain germs, under 
observation. At first, the normal, almost oval form divides into 
two, even to the exquisitely delicate hair-like process upon its sur- 
face. This was accomplished in six or seven minutes. “ At this 
rate a single form would give rise to a thousand like itself in the 
course of an hour, to about a million in two hours, and to a num- 
ber greater than the generally assumed number of human beings 
now living in the world in three hours.” The apparent sudden- 
ness of appearance of multitudes of such organisms is thus easily 
explained. Davaine has calculated that a single bacterian parti- 
cle would, in the course of twenty-four hours, become the parent 
of 4,096 such particles; in forty-eight hours to over 16,700; and 
between the sixtieth and sixty-second hours their numbers reach 
one to seventy-one trillions. “If each spore, of one species only 
of the higher fungi, germinated and reproduced its parent, the 
children would, in the first generation, and in the course of a 
very few days, form a carpet all over the earth.”—(Smith, Nature. 
Aug. 4, 1870, p. 276.) 
Thus the swift manifestation and often virulent expression of 
the symptoms of acute infectious disease correspond to the mirac- 
ulous fecundity of the parent-germ. 
The parasitic theory, again, best explains the immunity con- 
ferred, in the rule, by a single attack against a repetition of the 
same disease in the same body. Fermentation having been once 
effected in a saccharine solution, any further process of this kind 
becomes impossible. The germs of fermentation have consumed 
in their development and growth all the matter capable of their 
nutrition, and additional germs, subsequently introduced, must 
simply starve to death, or at least remain inert. The tissues—now THE ACUTE INFECTIOUS DISEASES. 
11 
recognized as stabile things, not consumed and renewed in the 
ordinary processes of force and heat-production, as once believed— 
having furnished to the germs of disease whatever of their nutri- 
ment it may have contained, ceases for all time to be capable of 
nourishing the same kind of germs again. Hence, a repetition of 
the same disease, if the consumption shall have been complete, is 
quite impossible. From what has been previously said regarding 
the arrest of epidemics, it may be readily understood how, in the 
exceptional cases, other conditions may have arrested the growth 
of germs before the blood has become entirely impoverished. 
Lastly, the parasitic theory best explains the specificness of 
acute infectious disease. Each one of these diseases reproduces 
itself alone. Measles begets measles, small-pox begets small-pox, 
cholera begets cholera. Figs would be born of thistles, or grapes 
of thorns, as soon as cholera of small-pox, or diphtheria of typhoid 
fever. The introduction into the blood of the specific germ begets 
the specific disease. In speaking of that typical infectious disease 
already referred to, malignant pustule (charbon), Pasteur remarks : 
“So it matters not in what manner the bacteridia (the germs of 
charbon) be transmitted or transported, they give rise only and in 
all cases to charbon. We may speak of charbon, therefore, as the 
disease of the bacteridia, just as trichinosis (the disease from af- 
fected pork) is the disease of the trichina, or as scabies (itch) is 
the disease of its (insect) acarus.” 
But the parasites or germs do not always multiply in the blood 
or in the body; hence, not all acute infectious diseases are con- 
tagious. Small-pox gives off its contagion from its eruption in 
greatest virulence just before the vesicle becomes a pustule, in 
the exhalations from the skin and from the blood, from which 
even the placenta does not filter it off. In measles the disease 
may be inoculated with the blood, the tears, and the sputum. 
Scarlet fever infection is in the exhalations from the skin and 
lungs, and that of typhus irradiates in every direction from every 
surface and secretion. These are eminently the contagious dis- 
eases. In the case of others, yellow fever, the malarial fevers, 
cerebro-spinal meningitis, the poison is in the air—is, in no sense, in 
the body; the germs productive of the disease do not multiply 
in the blood, nor migrate from it to others about the infected indi- 
vidual. Local colonization, multiplication, and universal dis- 
semination mark the history of the purely contagious diseases ; 
colonization and chemical change characterize those which re- 
main simply infectious. 
Whatever theory of the nature of the infectious diseases we 
may adopt, it is upon our acceptance of their contagion or infec- 12 
THE ACUTE INFECTIOUS DISEASES. 
tion that we base all hope of their final extermination. The germ- 
theory offers us, in this respect, the most enticing prospect. It 
seems now a long way off to the time when Lepidus said to An- 
thony, “ Your serpent is bred now of your mud, by the operation 
of your sun; so is your crocodile;” to the time when Virgil de- 
scribed how the shepherd Aretmus succeeded in producing swarms 
of bees from the entrails of a steer exposed for nine days to putre- 
faction ; or, when Van Helmont knew how to generate mice out of 
some sawdust and an old shirt. And yet, even in our day, we 
have relics of these views in the advocacy of spontaneous genera- 
tion of germs, and spontaneous generation of infectious disease. 
The recognition of the fact that these diseases are never spon- 
taneous in development, but that their germs are always some- 
where in lurk to burst forth when the proper conditions arise, as 
smouldering embers burst into flames, would protect us in great 
measure from invasion, or, if attacked, would limit their dissemi- 
nation to the narrowest possible limits. Pure water, pure air, ab- 
solute cleanliness, disinfection, quarantine, and, in proper cases, 
isolation of the sick, then suggest themselves at once. It is the 
partial revolution already thus effected by sanitary science which 
has “changed the type of disease” in our day, for the triumph 
of modern medicine consists not so much in the cure of the dis- 
ease in an individual as in the prevention of its attack upon the 
multitude. 
In one of his recent papers Pasteur has remarked : “ I think it 
would be of great interest to multiply researches on this subject, 
and to compare the organized corpuscles disseminated in the air 
at one place during different seasons, and at different places at the 
same time. It appears that our knowledge of contagious diseases, 
especially at periods when epidemics rage, would be increased by 
work carried on in this direction.” 
Here is a suggestion of the highest practical import. We have 
expenditures of large sums of money by the heads of civilized gov- 
ernment everywhere, for purposes of coast survey, for meteorol- 
ogy, and for astronomy—all exceedingly valuable in their way; but 
for the higher purpose from every point of view, economic as well, 
of the discovery of the conditions which engender, spread, or check 
infectious diseases, we are almost entirely dependent upon the 
unassisted, and, too often, unrecognized or unappreciated labors 
of individuals. 
And yet “all the other mighty casualties of nature, such as 
earthquakes, volcanic eruptions, mountain avalanches, hurricanes, 
inundations by sea, have never, in the history of the world, even 
approximately destroyed as many lives as a single ordinarily ex- THE ACUTE INFECTIOUS DISEASES. 
13 
tensive epidemic.” The regiments of men mowed down in battle 
with the modern scientific instruments of death are, in the same 
war, but handfuls to the holocausts of infectious disease. In peace 
as in war, these diseases are, though silently, continuously at work. 
The annual mortality records of any of our larger cities show a 
frightful percentage of deaths from infectious diseases. In Cin- 
cinnati alone—as a sample—they caused 1,975 out of the 5,710 
deaths in the year just past. Nearly one-tliird of all the deaths in 
this city, statistically one of the healthiest in the United States, 
during that year—a year without an epidemic—were produced by 
causes which are, for the most part, in the power of man to prevent. 
At the head of all preventive measures stands a rigid and relent- 
less quarantine. The most deadly of all the acute infectious dis- 
eases, the oriental plague, has been shut off from Europe for so 
many years, chiefly by the Russian military cordon, as to have for 
us now only historical interest. So the rigid detention of infected 
vessels in the harbor of New York will render impossible, in that 
city, a repetition of the yellow fever scenes of the last century. 
Yellow fever in the epidemic of last year was absolutely locked 
up in Memphis, where it had lived over from the year before, by 
relentless quarantine at all the cities of the South. Perhaps the 
time is not far off when Asiatic cholera may be as effectually block- 
aded from our entire coast. 
After quarantine comes, in proper cases, isolation of the sick, 
which is, of course, quarantine on a diminutive scale. The history 
of the disease in Iceland shows that small-pox may be completely 
stamped out from a country, and compulsory vaccination and re- 
vaccination may secure for countries not so fortunately situated 
the same results. 
When an infectious disease may not be prevented, it may be 
circumscribed to the narrowest possible limits. Our knowledge of 
the parasiticidal properties of the various disinfecting agents is 
yet in its infancy, but there is no doubt of the superior value of 
dry heat in the destruction of disease germs. 
Of the various disinfecting drugs, the place in the front rank is 
still held by carbolic acid. The best is the purest, which is too ex- 
pensive for extensive use. The penetrating fumes of burning sul- 
phur, or of chlorine, from the chloride of lime, will best disinfect 
rooms and closets, after their evacuation. Then comes the long 
array of disinfectants, simple and compound, which are, for the 
most part, of more value to their proprietors and to the advertising 
columns of newspapers than to the people at large. And, thus, in 
brief, do we attempt to combat the acute infectious diseases. 
These are the diseases which have decimated armies, disabled 14 
THE ACUTE INFECTIOUS DISEASES. 
fleets, and extinguished cities, empires, and whole races of men 
from off the face of the earth, as at Athens, Venice, and Rome. 
They “have given the death-blow to an advancing civilization, or 
left a strange and enduring impress upon the intellectual life of 
great nations.” And they are the diseases, as the Registrar-Gen- 
eral of England has recently pointed out, which, while they seize 
the infant from its mother’s breast, and do not spare the old man 
the end of his days, yet vent their direst evils upon maturity in its 
vigor and prime. They are emphatically the “ morbi populares.” 
THE CONTINUED FEVERS. 
Typhoid Fever. 
Typhoid fever is the most frequent of all the grave, acute infec- 
tious diseases, and is among the most frequent of all diseases. Like 
all the acute infectious diseases, it spares no age, sex, or condition, 
though it shows preference for the years of youth and adolescence. 
Thus, Murchison found that more than half the cases occur between 
the ages of fifteen and twenty-five, more than one-fourth under fif- 
teen, one-tenth between twenty-five and thirty, after which the lia- 
bility to the disease rapidly diminishes. But undoubted cases have 
been recorded as occurring between the ages of seventy and ninety. 
Like most of the acute infectious diseases, typoid fever may 
appear at any place and at any season of the year, though it occurs 
in our climate in greatest frequency in the month of October, next 
in November, then in September and August. The smallest number 
of cases occur in April, next in May, February, and March. Like 
all the acute infections, one attack secures immunity from others. 
Typhoid fever is so called because it resembles, or is like ty- 
phus. Typhus (rvcfyos) is the Greek word for smoke. Scholarly 
Greeks used the word in a secondary sense to express conceit 
(“because it clouds or darkens the intellect”), and the old Greek 
physicians soon adopted it as the best term to express the mental 
haziness or stupor occasioned by low forms of fever. In fact 
“typhus,” in this sense, was used by Hippocrates. The Germans 
to this day speak of the Geistes-umneblung, the intellectual foggi- 
ness of typhoid disease, and such a hold has this name obtained 
in the course of succeeding centuries as expressing the most ob- 
vious sign of the disease, that it will never be substituted until 
the characteristic germ, causative of it, shall have been definitely 
discovered and described. 
Because of the pre-eminent suffering of the nervous system, the 
disease has been called nervous fever (Nerven-Fieber); from its in- THE ACUTE INFECTIOUS DISEASES. 
15 
sidiousness and slowness, nervosa lenta ; because of the local lesion 
in the intestines (first recognized by Prost in 1804), it has been 
called enteric fever, in exact localization, ileo-typhus; and because 
of its apparent origin from putridity, pythogenic (7I putrefy) 
fever, but none of these names possess superiority sufficient to 
have displaced the old Greek word for smoke and mental clouding. 
Typhus and typhoid fevers have, however, nothing more in 
common, and this they share with all acute infectious disease. 
Yet for many years they were considered as only different forms 
or types of the same disease ; typhus showing its main expression 
in an eruption on the skin, and typhoid in an ulceration of the 
glands in the small intestine. This association of these two dis- 
eases has been fatal to a proper understanding of either. Typhus 
and typhoid fevers are just as different affections as scarlet fever 
and measles, and the knowledge of this fact, which has only been 
definitely fixed as such within the last twenty or thirty years, has 
dissipated much of the obscurity surrounding both affections. 
For it is now known that each disease is produced by its own 
poison alone. It is not yet absolutely, perhaps it would be fairer 
to say even approximately, known what the poison is, but the evi- 
dence to the effect that each is sui generis is already overwhelming. 
The poison of typhoid fever lives in the discharges from the 
alimentary canal. The alimentary canal is also the avenue by 
which the disease enters the body in new infection. In the vast 
majority of cases this avenue is reached by infected drinking wa- 
ter. The dejections (stools) from a typhoid fever patient find their 
way by percolation through the soil, at a distance, at times, of even 
two hundred feet, from vaults, sewers, the various receptacles, 
to cisterns, reservoirs, and running streams feeding houses and 
communities with water to drink. It is a singular statement to 
make, but it is generally conceded to be true, that human beings 
who do not drink, or in some way consume human excrement, 
seldom suffer from typhoid fever. A few illustrations may suffice 
to make this statement plain : 
In Croydon 400 persons were suddenly attacked with typhoid 
fever, and all these cases occurred in a quarter supplied with 
water from a single reservoir. Dr. Carpenter predicted the dis- 
covery of the admixture of sewage, which was found to be 
the case. Purification of the water was followed by immediate 
cessation of the epidemic. Jaccoud reported to the Paris Acad- 
emy, during the recent discussion of typhoid fever, the case of a 
village in Norway in which the disease had been hitherto almost 
unknown. The village consisted of forty-four houses and con- 
tained seven springs of water. An epidemic of typhoid fever broke 16 
THE ACUTE INFECTIOUS DISEASES. 
out in 1870. Upon investigation it was found that five of the seven 
springs had been contaminated with excrement. In the thirty- 
six houses whose 294 inhabitants received their water from the 
poisoned springs were 121 cases of typhoid fever, while among 
the thirty-two inhabitants of the remaining eight houses, supplied 
from the two pure springs, was not a single case. 
The same author reported, also, a nearly similar condition of 
things in the epidemic which broke out in Halle in the same year. 
Here the impurity of the drinking water was recognized by the 
taste, and by the presence of microscopic parasites (bacterias and 
vibriones). From close study of 106 cases, Jaccoud concludes, 
“ the typhogenic [typhoid-causing] poison of feculent matter is 
absolutely demonstrated.” 
But it is not the excrementitious matter of itself which commu- 
nicates the disease. The excrement to be poisonous must contain 
the poison in it. The excrement is thus merely the vehicle of the 
poison, else typhoid fever would prevail universally ; for only the 
smallest amount of excrementitious matter is ever conveyed away. 
It is computed of the city of Munich, for instance, that 150 loads 
of excrementitious matter accumulate in it every day, and of this 
amount, on an average, but ten loads are removed. Seven-eighths 
of it, thus, remain to be drunk up by the soil and to be sunk 
beyond, and raised to the level of, possible infection of drinking- 
water, according to the fluctuating level of the subsoil water. In 
the sewered cities of our own country, the danger of contamina- 
tion in this way is very much diminished, but this advantage is 
counteracted, in large measure, by the faulty construction of wa- 
ter-closets, whereby the emanations from the infectious diseases 
of a whole city are brought into the living rooms, or, as in the 
often quoted case of the Prince of Wales, into the very bed-cham- 
bers of the otherwise best constructed houses. 
That excrementitious matter of itself does not engender the 
disease is proven by the fact that individuals whose avocation is to 
deal with it are not oftener than others attacked. Thus Dr. Guy 
compared the past and present condition of ninety-six nightmen 
(vault cleaners) with about the same number of bricklayers, 
laborers, and brickmakers, and, after a most critical investigation, 
concludes: “An examination of the tabulated results must con- 
vince the most sceptical that the health of scavengers is fully 
equal to that of the laboring man with whom they are compared. ” 
Mr. Harley, who makes this quotation, says : “ This agrees with 
the observations of M. Parent du Chatelet and others on the 
health of men who work in sewers,” and alludes to the practice of 
emptying the contents of privies, as manure, over gardens and 17 
THE ACUTE INFECTIOUS DISEASES. 
fields without injury, other than to their sense of smell, to the 
inhabitants. He cites, also, from personal observation, two instan- 
ces where he had known the inhabitants of a house to be exposed 
for months to the direct emanations, in the one case of a large 
cesspool, in the other, of a common sewer. “In both cases a 
leaden pipe, in communication with the water-closets, was carried 
down inside the house and thence into the sewer or cesspool. 
After several unsuccessful explorations, it was discovered that 
rats had eaten a large hole in the pipe leading to the cesspool, and 
through this aperture the fetid exhalations from its surface arose 
directly into one of the sitting-rooms and a passage of the build- 
ing, and on hot and damp days the effluvia were intolerably offen- 
sive. The cesspool was emptied at this time, and I witnessed the 
process. The contents were semi-fluid, of a dirty-black color, and 
the surface of the pool was covered with large bubbles of gas. 
Now although several persons were continually exposed to filthy 
exhalations, in the one case for many months, and in the other 
for several years, none suffered from diarrhoea or typhoid fever.” 
If the typhoid-fever poison developed itself in excrementitious 
matter, the disease would be almost omnipresent, at least would 
coexist with defective sewage. But this is not the case. It is true 
that Ireland, a country notoriously defective in sewage, has been 
almost depopulated by epidemics of typhus and typhoid fever; but 
it is also true that Brazil, a country equally defective in this regard, 
and in every other sanitation, baking perpetually, too, under a 
tropical sun, and reeking with animal and vegetable decomposi- 
tion, has been singularly exempt from severe epidemics of this 
disease. The poison of typhoid fever does not develop; it pre- 
exists in the excrementitious matter, and is derived from some 
case of the disease. Hence, matter which does not contain the 
poison is not infectious. 
In his work on the Practice of Medicine, Austin Flint relates 
the particulars of a case exceedingly instructive in this regard. 
A little settlement, called North Boston, situated about eighteen 
miles from Buffalo, consisted, in 1843, the time of the observation, 
of nine families, all within an area of a hundred rods in diameter : 
“but the few houses in which the disease occurred were closely 
grouped together around a tavern, the house farthest from the 
tavern being only ten rods distant. A stranger from New Eng- 
land, travelling in a stage-coach which passed through this settle- 
ment, had been ill for several days, and, on arriving at this stopping- 
place, was unable to proceed further. He remained at the tavern, 
and after a few days died. He was seen by several physicians of 
the vicinity, and there can be no doubt that his disease was the 18 
THE ACUTE INFECTIOUS DISEASES. 
same as that with which others were subsequently affected. Up 
to this time typhoid fever had never been known in that neigh- 
borhood. The sick stranger was seen by the members of all the 
families in immediate proximity to the tavern, with a single excep- 
tion. One family, named Stearns, having quarrelled with the 
tavern-keeper, had no intercourse with the family of the latter 
and very little with the other families, all of whom were tenants of 
the tavern-keeper. No member of Stearns’ family saw either the 
sick stranger or any of those who were taken ill after the stran- 
ger’s death. Members of the family of the tavern-keeper were the 
first to become affected ; the first case occurring twenty-three 
days after the arrival of the stranger. Other cases speedily oc- 
curred in the surrounding families. In a month more than one- 
half the population, numbering forty-three, had been affected, and 
ten had died. Of the families immediately surrounding the 
tavern, that of Stearns alone escaped ; no case occurred in this 
family. 
“The occurrence of the disease produced great excitement in 
the neighborhood ; poisoning was suspected, and Stearns was 
charged with having poisoned a well used in common by all the 
families except his own. A fact which encouraged this suspicion 
was, the common well being owned by the tavern-keeper, he had 
refused permission to use it to Stearns, who had, in consequence, 
been obliged to dig a well for his own use.” That the disease was 
typhoid fever is attested by the fact that Dr. Flint made an exam- 
ination of the body of one of the victims of the disease, and found 
the characteristic lesions in the intestines. In commenting upon 
this case, the author observes : “The fact that all the families in 
which the disease prevailed were supplied with water from a com- 
mon well, and the fact that the family in which no case occurred 
did not obtain water from this well, afford ground for suspicion 
that a virus derived from the excreta was conveyed in the water 
drank.” 
But typhoid fever is removed from the category of contagious 
diseases, strictly speaking (infection by contact with the patient), 
by the fact that the dejections must be received into the alimen- 
tary canal to produce infection. In respect of contagion, there ex- 
ists, therefore, a most marked difference between typhoid and 
typhus disease. Typhus fever is most emphatically contagious. 
Murchison informs us that in Ireland, in 1847, “no less than 500 
medical men—about one-fifth of the entire number—suffered from 
typhus, and of these 127 died, and Griesinger relates that in the 
Crimean war, at the height of the epidemic among the French, 
out of 840 attendants in twelve hospitals, 603 were taken sick dur- THE ACUTE INFECTIOUS DISEASES. 
19 
ing a period of fifty-seven days, more than eighty surgeons dying 
of the disease in the course of the campaign.” Liebermeister, who 
makes these statements, adds that Niemeyer in one epidemic was 
obliged to employ a former criminal, who had just recovered from 
the disease, as nurse, because all the attendants were sick. 
But it is very different with typhoid fever. The physicians, 
relatives, nurses, attendants, are very seldom attacked with the 
disease ; that is, they are not more frequently attacked than if not 
in attendance upon a case. Murchison states that 2,506 cases of 
typhoid fever were treated in the London Fever Hospital in four- 
teen and a half years, and in all this time “ only eight cases origi- 
nated in the hospital.” Typhoid fever is, therefore, not a conta- 
gious disease, and no one need have the least fear of it from simple 
contact with a patient. It is not the exhalations from the lungs 
or skin, it is not the clothes or bedding (if clean), it is not the 
touch and not the odor : it is the stools which contain the poison 
and spread the disease. 
To explain the immunity of attack enjoyed by persons in con- 
tact with the disease, it was long assumed that the dejections were 
not infectious from the start, but became infectious later, that the 
stools, innocent when fresh, in some mysterious way developed 
the poison, perhaps by allowing time for the multiplication of 
germs, in the course of a few days after their discharge. But it 
is far more rational to recognize the lapse of time necessary to se- 
cure the introduction of the discharges into the alimentary canal. 
Moreover, the immediate action of the poison'Iias been demon- 
strated by direct experiment; for Letzerich has just reported the 
effects attending the injection of two rabbits, with a solution 
(0.5 cc.) of the excreta of a young man who died of the disease two 
days after the experiment. The animals sickened at once with 
the symptoms of typhoid fever, and died of the disease, one on the 
twenty-first, and the other on the forty-eighth day. Post-mortem 
examinations revealed the changes characteristic of the disease, 
and revealed, at the same time, the development in myriads, in the 
blood, in the spleen, the liver, kidneys, and mesenteric glands, of 
microscopic parasites. 
They who have charge of the bed-linen, so often soiled with the 
discharges, are the persons, above all others, who soonest contract 
the disease. Hence it is that washerwomen so frequently suc- 
cumb. A most significant observation is that of De la Harpe, who 
found that the first series of persons infected by an imported case 
of typhoid fever were almost always females. 
The truth is, the poison of the disease grows feebler with age, 
and finally dies out altogether. Bouley long ago observed that 20 
THE ACUTE INFECTIOUS DISEASES. 
when common decomposition commences, the poison of the disease 
is killed. “ The more putrid the odor, the less is the danger of in- 
fection.” And Chauveau, who has made such brilliant disclosures 
regarding the germs of analogous infectious diseases, has clearly 
shown that the common germs of putrefaction are fatal to the 
germs peculiar to, and causative of, these diseases. It is putre- 
faction which secures the reduction of all living matter to the 
mineral state. 
But the poison of typhoid fever will long resist destruction un- 
der conditions favoring its life. How long, may be seen from the 
following observation related by v. Gietl: 
A villager, who had contracted typhoid fever at Ulm, returned 
to her native village, a place where typhoid fever had not existed 
for many years. The excrements of this person were thrown on 
the dunghill. Several weeks later, five persons were employed to 
remove this dunghill. Of these five, four were attacked with 
typhoid fever and one with gastric symptoms and swelling of the 
spleen. The excrements of these five persons were buried deep in 
the dunghill. Nine months two persons were employed in 
completely removing this dunghill, and one of the two was at- 
tacked and died of the disease. 
Cases like this put the question beyond dispute that infection 
may also occur through the air. But it does not by any means 
follow of necessity that the infection is effected through the lungs, 
for the inhaled poisonous particles (liquids, microscopically free 
of particles, are never infectious) may be easily carried from the 
passages of the nose and throat, where they adhere for a time, to 
the stomach and intestinal tube. At any rate, it must be admit- 
ted that air as well as water may act as the vehicle of the poison 
of typhoid fever. Moreover, the poison may enter with still other 
media than water or air. Widespread epidemics of the disease 
have originated in England from poisoned milk. Here it is highly 
probable that the milk was infected by contaminated water used 
for purposes of dilution. Typhoid fever has been produced also 
from eating poisoned meat. Some caution must be exercised here, 
however, in the acceptance of every kind of statement; for 
some of the cases of so-called typhoid thus produced have turned 
out to be cases of trichinosis, and others septic poisonings of pe- 
culiar nature from mere putridity of meat. Yet the possibility of 
infection in this way cannot be altogether dismissed as yet. Dr. 
Walder, of Zurich, reported a most remarkable epidemic as oc- 
curring in that place in May, 1878, clearly traceable to eating the 
flesh of a calf that had died of the disease. 
On May 10, 1878, a choral festival was held at Kloten, Canton 21 
TIIE ACUTE INFECTIOUS DISEASES. 
Zurich, attended by about seven hundred members of the neigh- 
boring choirs. A public breakfast, consisting of veal stew and 
sausage, took place at 9 a.m. At 3 p.m..there was a somewhat 
similar repast, with the addition of soup, potatoes, salad, and wine. 
Water was drunk by only a very few persons, and always mixed 
with wine. Of those who took part in these meals, five hundred 
sooner or later fell ill, thirty to forty per cent, on the fifth and sixth 
days thereafter, and ninety per cent, within the first eight days. 
Though there was every variety in form, the disease for the most 
part ran a typical course, and in several of the fatal cases the diag- 
nosis was confirmed by examination after death. 
It turned out upon the close investigation to which this case 
was subjected that the farmer who sold the calf had suffered from 
typhoid fever, and “ during one of the fits of severe diarrhoea, in 
the first weeks of his illness, he must have passed a motion in the 
neighborhood of the stall, as during this time he was continually 
attending to the cattle himself.” 
What seemed to lend confirmation to this origin of the dis- 
ease, and to prove the possibility of infection from diseased meat, 
was a later observation by the same physician, in which a calf was 
almost certainly infected by a human being. The calf in this case 
was given to drink of water from a bucket which had been used 
for washing the viscera of two patients who had died of typhoid 
fever and on whom a post-mortem had been held. “After an in- 
cubative stage of exactly ten days, the calf was taken ill, and, after 
it was killed, four days later, the pathological changes found were 
exactly the same as in the other case, and microscopically the 
calves’ intestines in both cases were indistinguishable from a 
human intestine in the same stage of typhoid fever.” 
Symptoms.—Typhoid fever is eminently an insidious disease. 
In typical cases it creeps upon the individual almost without his 
knowledge. There is a period of general lassitude, a feeling of 
lack of interest, indifference, apathy. There is a sense of general 
languor and depression. The patient is everywhere ill at ease, 
restless, dull, drowsy, but sleepless. What sleep there is does not 
refresh. This is the period of malaise. The work of the day, 
which may have been hitherto a resource and delight, becomes an 
aversion, a monotony, a drag. Here is already the envelope of 
fog or smoke, which so much impressed the old Greek physicians 
as to give its name to the disease. 
An individual is thus exposed to the poison of the disease, and, 
if susceptible to its action, after a period, varying from a single 
day to several weeks, begins to experience the prefatory symptoms 
—the so-called prodromata, of the disease. In about ten per 22 
THE ACUTE INFECTIOUS DISEASES. 
cent, of the cases this stage is absent altogether, and the disease 
begins at once with some of the marked symptoms. But usually 
there is the preface of listlessness, depression, dull frontal head- 
ache, loss of appetite, vertigo, ringing in the ears, and irregular 
chills. From three to ten days this prefatory stage may last, 
and then the disease runs its course in three pretty distinct weekly 
periods. 
The first week may begin with a regular chill, severe or slight 
(it may be absent), which is followed by such weariness and weak- 
ness as to send the strongest man to bed. Once in bed, the patient 
remains there throughout the whole duration of the disease. So 
great is the prostration that mere lifting of the head from the pil- 
low produces dizziness and sickness at the stomach. Pretty soon, 
if not from the very start, there is headache, stupefaction, vacancy. 
It requires effort to excite interest. A sharp nose-bleeding is a quite 
characteristic sign in the earlier stages, and often there is some 
bronchitis, as evidenced by the cough. As the most marked local 
evidence of the disease is found in the intestines in the form of a 
series of ulcers affecting certain glands in its mucous membrane, 
the symptoms on the part of the bowels manifest themselves early 
in the attack and play an important part throughout its course. 
Diarrhoea is the rule in typhoid fever, but the first week of the 
disease is quite frequently characterized by constipation. Serious 
mischief has been incurred by the administration of purgatives in 
relief of this constipation before the nature of the disease is known. 
During this stage of constipation, when it exists, or in the early 
periods of the disease, the abdomen may be sunken and have a 
doughy feel, but a little later it is puffed out, full, it may be, tense 
and even drum-like to the touch and stroke. There is tenderness 
to pressure, which also elicits gurgling, most marked in the lower 
region of the belly on the left. 
When the disease is fully and fairly under weigh, diarrhoea is 
and remains a most prominent symptom. The stools of typhoid 
fever are also characteristic. After the ordinary contents of the 
bowel have been removed, the discharges are thin and brownish, 
to become, later, of light-yellow “ochre” color, and “pea-soup” 
consistence. In a certain proportion of cases (five to seven per 
cent.) the stools contain, or consist of, more or less disorganized 
blood, but such hemorrhage, unless copious or frequent, does not, 
as a rule, impart much additional gravity to the case. 
Typhoid is even now distinguished from typhus fever in Ger- 
many by a different surname; typhoid being known as Typhus 
abdominalis, and typhus as Typhus exanthematicus. An exanthem 
is an eruption, and true typhus is characterized by such a general THE ACUTE INFECTIOUS DISEASES. 
23 
eruption over the whole surface of the body as to be called “ spot- 
ted fever,” a very faulty name, oftener used, also, for cerebrospi- 
nal meningitis. But typhoid fever is not devoid of an eruption 
on the skin. Towards the end of the first, or beginning of the 
second, week of the disease, there appears upon the surface of 
the chest or abdomen, or both, a scattered series of rose-colored 
spots, which disappear upon pressure, to reappear on its relief. 
When this eruption was first observed it was thought to be pathog- 
nomonic, that is, to be a sign absolute of the disease: but more 
extended observation soon disproved this view, and relegated the 
eruption to a very subordinate place. For whole epidemics of 
typhoid fever have been characterized by its absence (notably 
those at Tourraine), and Chomel states that “ in seventy cases he 
could not find any trace of the eruption in more than sixteen, 
though it was searched for at all stages of the disease.” Never- 
theless, when present, which is much more frequently the case 
than Chomel has represented, it furnishes very valuable corrobora- 
tive evidence in doubtful cases. 
Add to these symptoms a coated tongue with a tendency to 
dryness, a dry skin, and scanty and dark-colored urine, all symp- 
toms of the fever (the range of which is reserved for special con- 
sideration) and the story of the first week is told. 
In the second week the same symptoms all persist, hut in 
graver form. The nervous system is nearly completely benumbed. 
The patient must be sharply addressed, or even shaken, to elicit, 
even then, only a partially or totally unintelligible or irrelevant 
response. There is now either active delirium with incessant activ- 
ity, at times even mania, or profound nervous prostration, sleepi- 
ness or stupor. The patient now lies, like a leaden image, wholly 
upon the back, unable, in bad cases, to even turn upon the side. 
This is a dangerous period of the disease, and if the fever now 
run very high, death may supervene. The abatement of the fever 
towards the end of the second week—a very common occurrence— 
attended by a profuse sweat, or discharge of urine, moisture of 
the tongue and surface, and dissipation of the fog about the brain, 
indicates the resolution which is to end in complete recovery. 
Should the disease drag on to the third week, the stupor and 
delirium persist, and the prostration becomes still more profound. 
The patient now slips down in the bed, requiring to be continually 
lifted up ; the urine and faeces may be discharged involuntarily or 
even unconsciously ; the diarrhoea may become excessive—stools 
every half hour ; the urine still more scant or almost entirely sup- 
pressed ; the black tongue cracks and bleeds, the gums and teeth 
are incrusted with sordes, the heart’s action can scarcely be felt, 24 
THE ACUTE INFECTIOUS DISEASES. 
the surface is hot and dry, or cold and clammy. There is twitch- 
ing of the fingers, starting or jerking of any or all the members, 
more or less constant mumbling and muttering ; in the worst cases 
pinched and sunken features, such almost total abolition of sen- 
sation that flies crawl unnoticed over the face, and the last hours, 
before complete exhaustion, are spent in picking at the bed-clothes. 
“ After I saw him fumble with the sheets, and play with flowers, and smile upon his 
fingers1 ends, I knew there was but one way,” 
commented Dame Quickly upon Falstaff. Such is the picture of 
typhoid fever at the very height of the disease, a picture so typi- 
cal as to have impressed its name upon any other disease showing 
its signs, as a typhoid condition of that disease. Here, now, at the 
close of the third week is the period of greatest danger. The 
heart, degenerated in its substance, as is every other muscle, if 
the fever shall have reached a certain height, or continued high a 
certain length of time, may, on the slightest effort, as attempted 
elevation in bed, straining at stool, etc., become suddenly para- 
lyzed and suddenly end the scene, or may gradually fail to supply 
the wants of the brain, and thus induce the fatal termination by 
gradual exhaustion. But here, too, in the midst of this imminent 
danger, a profuse sweat, a profuse discharge of urine, above all 
things, a sudden fall of temperature may dissipate the clouds, and 
recovery, with a long and tedious convalescence, gradually set in. 
In truth, it is the rule that the fever “ breaks ” on the twenty- 
first day of the disease, leaving the patient, like a ship after a 
violent storm, a good deal of a wreck, but with full capabilities of 
complete restoration in the safe harbor of repair. 
The early recognition of typhoid fever, a,nd the future of an in- 
dividual case, at any time, is largely determined by the fever as ac- 
curately registered by the thermometer. Typhoid fever has, as 
Wunderlich has shown, “atypical and cyclical course.” In the 
first week the fever gradually increases ; in the second week it is 
continuous; in the third week it is remittent; and in the fourth 
week (the beginning convalescence) it is intermittent—that is, in a 
typical uncomplicated case of typhoid fever. The range of the 
thermometer shows the following typical course (Fig. 7.). 
During the first week of the disease the temperature rises one 
degree every day, and the evening temperature is always one 
degree higher than the morning. So a temperature of 103° or 104° 
on the first, second, or third day would almost, of necessity, ex- 
clude typhoid fever. Such a temperature should not be reached 
until towards the close of the first week. The degree to which the THE ACUTE INFECTIOUS DISEASES. 
25 
temperature does rise at this time will indicate, for the most 
part, the general severity of the disease. A single elevation to 
107° Fahr. is fatal. 
“ Fiedler saw, with one 
single exception, all 
patients die whose 
temperature in the 
morning rose to or 
surpassed 10G|-0 Fahr. 
Of those whose tem- 
perature in the morn- 
ing rose to 105£° Fahr., 
even if only on one 
day, more than half 
died.” But even a 
lower temperature 
may prove fatal if sus- 
tained too long. A 
temperature of 104° 
Fahr., or even of only 
103° Fahr., sustained 
throughout the fourth 
or into the fifth week 
and beyond, is a very 
grave sign. Any 
marked sudden eleva- 
tion of the tempera- 
ture, at any time in the 
disease, means some 
complication whose 
cause must be care- 
fully searched. Sud- 
den fall of the temper- 
ature at any time in- 
dicates resolution and 
favorable termination, 
though a fall below 
the normal degree may 
be the first sign of col- 
lapse and death. The 
range of the thermom- 
eter is, therefore, watched throughout the whole course of the 
disease with an interest that may at any time become anxious 
and intense. 
Figure 7. —Schematic representation of the course of 
the fever. The lowest morning and highest evening temper- 
atures are given and joined by the straight lines. Fahren- 
heit’s scale. 26 
THE ACUTE INFECTIOUS DISEASES. 
Probabilities.—The future of a given case of typhoid fever (the 
prognosis) is determined with the greatest difficulty. A walking 
case, a case whose symptoms are so slight as to escape recognition, 
may end in death by perforation of the bowels and inflammation 
of the interior of the abdomen (peritonitis), and the gravest case, 
with high fever and delirium, may end in recovery. Upon no one 
symptom may a prophecy be based. Children and aged people 
are easily affected with delirium, which, therefore, is not so grave 
a symptom in their cases. That the delirium, etc., is not caused 
by the fever alone is proved by the fact that the highest tempera- 
ture a case may reach is never so high as in relapsing fever, an 
analogous disease from different and known specific causes, which 
is unattended with delirium, sleeplessness, or coma. It is there- 
fore not justifiable to base the prognosis upon the brain symp- 
toms or upon temperature alone. The strength of the individual, 
the hygiene of his surroundings, must be taken into account, as 
well as the totality of the symptoms, in estimating the results in a 
given case. After all, on the grand average, typhoid fever is 
fatal in only about fifteen per cent, of all the cases. 
The Treatment of typhoid fever demands all the skill of the 
most able physician. Not because there is any specific in its 
cure, for such there is not, and perhaps never will be until its spe- 
cific cause is known, but because of the complications which may 
momentarily arise and the excesses of individual symptoms which 
may momentarily be presented. The treatment of an ordinary case 
of typhoid fever is really more a question of management than 
prescription of drugs. The disease is the storm, the patient is the 
ship to be conducted safely through it. The physician is simply 
the pilot to steer away from known rocks, and not to try to allay 
the storm. The first injunction in such a case is to give the pilot 
supreme command. The officers go below when the pilot steps on 
board, or at most hold themselves under orders. 
The attendants may be of the greatest assistance in securing a 
perfect hygiene. Too minute attention cannot be given to cleanli- 
ness. A typhoid fever patient should really have two beds, that 
he may be lifted (absolutely without effort on his part) from one 
to the other, while the utmost cleanliness is secured. The patient 
should lie in bed and be kept in bed throughout. The bladder and 
the bowels should be evacuated only in a bed-pan. The food 
should be taken on the back from a spoon or a suitable drinking- 
dish. There should be absolute peace of body and of mind, so far 
as external circumstances may secure this condition. Quiet should 
reign in a room containing a typhoid fever patient. Above all 
things, the room should be constantly filled with fresh air. Expe- THE ACUTE INFECTIOUS DISEASES. 
27 
rience has shown that patients affected with fevers of any kind 
do not take cold. It is better to have a draught of air over a pa- 
tient than to have the openings of a room closed up. The dis- 
charges should be disinfected at once, and then burned. To empty 
the contents of vessels into sewers and vaults, is to spread the 
contagion of the disease. The best disinfectant is pure carbolic 
acid. A mixture of equal parts of glycerine and carbolic acid 
should be kept in the room, and a quantity of it should be kept all 
the time in every receptacle for the discharges. For general dis- 
infection a teaspoon to a tablespoonful of this mixture should be 
poured (from the spoon) on to hot coals in a shovel, and, carried 
everywhere, about the room, be held for a time under the bed. 
A second case of infectious disease rarely occurs in a house whose 
recesses are thus penetrated with the vapor of carbolic acid two or 
three times a day. 
The diet must be always thin, but highly nutritious. The best 
drink is milk. A pitcher of cold milk should stand continually in 
the room, and be regularly administered at stated intervals. Cham- 
pagne, raspberry vinegar, toast-water, and mucilaginous drinks 
are grateful beverages when kept cold. Nothing allays nausea 
and stomach distress so well as cracked ice, which, however, must 
not be given too freely when the diarrhoea is too profuse. Wine 
whey and koumiss are indicated when the hour for light stimula- 
tion arrives; sherry, whiskey-punch, egg-nog, and brandy in 
great prostration. Beef-essence has lost its place as the main re- 
liance in the way of food, its virtue being chiefly its heat. It is 
mostly too heavy for the delicate digestion of typhoid fever ; beef- 
tea (bouillon) is better. Milk is and remains the main reliance. 
The idea that milk is “feverish” is a most vulgar error. Jellies 
have only the semblance, none of the substance of food, and are, 
hence, except for the sugar they contain, worthless. Wine-jellies 
are somewhat nutritive, because of the wine, but the other varie- 
ties of gelatines should be delivered over to the confectioner to be 
used only in ornamentation. 
Flowers do no harm whatever. Pettenkofer has clearly shown 
that the air over a forest is the same as over a sea or a desert, 
so small is the amount of carbonic acid gas exhaled in the night; 
and so small is the amount of oxygen exhaled in the day, that they 
do no good except from an aesthetic point of view. Dead and dying 
flowers are too suggestive to be ever allowed in a sick-room. 
The convalescence is the trying period in the history of the dis- 
ease. Though a second attack is very rare, relapses are very fre- 
quent, and are mostly due to indiscretions. 
An individual is not yet even convalescent until the thermom- 28 
TIIE ACUTE INFECTIOUS DISEASES. 
eter falls to the normal temperature and remains there for several 
days. Relapses are more fatal than original attacks, because of 
the debility already produced. The thermometer will register the 
occurrence of a relapse at once. A house is not fitted for the care 
of a case of typhoid fever unless furnished with a medical ther- 
mometer. 
JAMES T. WHITTAKER, M.D. 
Typhus Fever. 
Cause.—In the year 1501, typhus fever, as we know it now, was 
first described. It is a germ fever, and is the scourge of armies 
and aggregated masses of badly-fed men. The disease has in 
modern days centres of activity, at which points the character of 
the inhabitants and their mode of life favor the propagation and 
preservation of the infecting germs. Ireland has for many years 
been such an epidemic centre, and we may regard it as much the 
birthplace of typhus, as India is of cholera, or Egypt of the plague. 
In certain provinces of Russia, in Silesia, Westphalia, Hanover, 
Northern Italy, we find such centres existing for years, seemingly 
until its appropriate material is exhausted. In the United States 
typhus was introduced by the Irish at the time of the great famine, 
and has existed ever since at points of aggregation. 
Typhus was believed at one time to be of spontaneous origin. 
All that appeared essential for the outbreak of the disease was 
filth, bad food, and crowded masses of men and women. These 
were the conditions of its growth, not of its development,—the soil 
in which the germ had its nourishment. But we find it disappear- 
ing at times, even at a centre of greatest activity, only to return 
suddenly without an apparent cause. Formerly, and even now, 
among a few, this was believed to be clearly explained only by 
spontaneous development. In the light of the germ theory this is 
not an explanation. It is not difficult now to believe that the 
germs were latent, that they existed potentially, not actively; 
and when surrounded by favorable conditions again assumed ac- 
tivity. If the disease were to seek an entirely new centre of ac- 
tivity, it is more scientific to conceive of an importation of the 
germs from some existing centre of contagion, than of a spontane- 
ous birth of new germs. 
The infecting germs once having gained lodgment, the disease 
is propagated by contagion. In but few diseases is this more evi- 
dent. In hospitals the nurses and resident physicians are much 
more liable to attack than the visiting physicians. With propin- 
quity and persistence in exposure, the disease is but rarely escaped. THE ACUTE INFECTIOUS DISEASES. 
29 
Every article used about the patient may act as a carrier of the in- 
fecting essence. The infection may lurk about an article of cloth- 
ing, or utensil, for an indefinite time, either in an active condition, 
or dormant, and ready to renew its powers of activity and propa- 
gation, whenever placed in favoring conditions. The contagion 
power of different epidemics vary. The more people, the more 
patients that are concentrated in a limited space, the more active 
becomes the contagion. Thus, in camps, prisons, on ship-board, 
in crowded tenement houses, the infecting germs act with their 
greatest virulence. While aggregation will not of itself produce 
the disease, it seems the natural habitat of the germs. 
Even in the conditions most favorable to the greatest intensity 
of the germs, improved hygienic conditions lessen the contagious- 
ness of the disease. Lebert, in the hospital in which he observed 
the disease, says, that in the wards which were well ventilated, 
even in winter, none of the physicians or students contracted 
typhus. The same author observed that men working in the 
open air were more liable to attack than those who had confined 
occupations, such as locksmiths, joiners, cobblers, and tailors. 
In the place referred to (Breslau), children of both sexes were very 
liable to the disease, which is not true of ail epidemics. 
It has been asserted that the disease may have its origin in 
famine. Such seemed to be the experience in Ireland. This can 
hardly be so. Famine may debilitate and may develop physical 
conditions that favor the onset of any disease, but it cannot in- 
fect, or of itself originate infecting germs. Years of famine, 
especially in the latitude of Ireland, are generally cold and wet; 
and a steady condition of moisture favors the growth of germ life, 
and consequently years of famine may also be periods favorable 
to the growth and dissemination of the essential elements of typhus 
fever. 
Hirsch, who studied the atmospheric conditions of thirty-five 
epidemics of typhus, shows that this disease is much more inde- 
pendent of meteorological conditions than typhoid fever. These 
conditions are by no means constant, even in epidemics of equal 
intensity. Lebert believes that the influence of the surface satu- 
ration of the soil is great. From this cause, the typhus germs, 
like those of nearly all infectious diseases, find breeding places in 
the surface-water, and thence find their way readily into wells 
and springs, thus infecting the drinking-water. Even Hirsch ad- 
mits that the disease is favored by low, damp places. 
Men are more liable to attack than women, the difference being 
55 and 44 per cent. The ages of twenty to forty years showed the 
greatest liability to attack. The decades preceding and follow- 30 
THE ACUTE INFECTIOUS DISEASES. 
mg these two extremes exhibited a less favorable disposition to 
the disease, while in infancy and old age the liability regularly 
diminished. 
An attack of typhoid fever does not exempt one from an attack 
of typhus, and the opposite is true ; but a comparative immunity 
against a second attack exists after the individual has recovered 
from typhus. This is the rule for all contagious eruptive dis- 
eases. 
Symptoms.—The disease begins by what are called prodromes, 
or signs. This is the rule, hut there are exceptions. These are, 
pains in the head, neck, back, limbs, loss of appetite, nausea or 
vomiting, sleeplessness, a sense of extreme fatigue, mental dul- 
ness, and gloom. These signs last for a varying period, a few 
days usually, now and then several weeks. During this time 
the patient may be able to work. If the attack be very severe, 
these warnings may be absent, and the first sign be the explosive 
outbreak of the disease. Sometimes these initial symptoms may 
end here, the after-fever being but slight and transient. This is 
called the abortive form. 
The prodromes over, the patient is ready for the full onset of the 
fever. This is oftentimes a chill followed by fever, like an inter- 
mittent, but chill, or not, the fever quickly follows with consider- 
able intensity. At this stage the skin is hot and red, the face 
swollen, the eyes bloodshot, and the headache severe and con- 
stant. Mentally, the patient is confused and dull, with giddiness 
on getting up, and ringing in the ears. The pains in the limbs 
and joints are severe. Sore throat and nasal catarrh are com- 
mon. 
The pulse is peculiar. From a natural beat to 100 in the morn- 
ing, it rapidly increases to 115, or 125 in the minute toward even- 
ing. At first the pulse is full and strong, but soon becomes soft 
and feeble. Lebert noticed that in some cases with profound 
stupor, which were quickly fatal, the range of the pulse was be- 
low the normal. 
The temperature rapidly increases, so that on the morning of 
the third day it ranges from 103° to 104° Fahr., and in the evening a 
degree higher. This is about the range of bodily heat for the first 
week. A high morning and evening temperature indicates a grave 
case. A marked remission or subsidence in the morning, no mat- 
ter what the evening heat may be, is a favorable sign. The tem- 
perature is high during the first part of the second week, rarely 
passing the limit of 107.5° Fahr. After that, and even before, in 
light cases the fever begins to decline. 
From the very onset great muscular weakness is present, and 31 
THE ACUTE INFECTIOUS DISEASES. 
increases very rapidly. There is considerable bluntness to sensi- 
bility, as the patient makes but little complaint of the severe pains 
in the back and limbs. 
Mind.—Apathetic and drowsy as he appears, yet sleepless 
nights are the rule. He answers questions slowly and with indif- 
ference. He becomes delirious and needs careful watching, or is 
troubled by frightful dreams. 
The tongue is coated, at first white, then yellow, and lastly dry 
and brown. 
In the second half of the first week the eruption, which is a char- 
acteristic of the disease, makes its appearance. It closely resem- 
bles measles, and is classed as a roseola. In some cases it appears 
at the end of the first week, and now and then is not present at 
all. The rash is abundant on the chest, abdomen, back, face, and 
limbs ; and begins to fade toward the close of the second week. 
This closes the congestive febrile stage. Next in order is the 
stage of depression. Mental depression, with more quiet delirium, 
sleepiness, stupor, coma, are the cerebral symptoms. The patient 
has rapidly emaciated. The intensity of the fever has lessened, 
but the pulse has grown small and jerking, beating from 110 to 
140. Sign of catarrhal irritation of the lungs are present, with dry, 
red throat. The bowels are sometimes relaxed, and move off un- 
consciously to the patient. The urine is scanty, dark, contains 
albumen, rarely blood, and in severe cases escapes involuntarily, 
or is retained. At this stage the spleen is found enlarged and 
tender. 
A favorable termination of the case begins in a diminution of 
the fever in from ten to fourteen days, or even at the end of the 
third week. This cessation of the fever is generally sudden—from 
a high temperature to the normal, or below ; the skin becomes soft 
and moist; the tongue begins to clean along the edges ; the urine 
increases in amount, but is heavily loaded with sediment; the 
appetite improves, and the patient becomes convalescent. From 
this point recovery is slow, but not so much so as in typhoid fever ; 
generally in a month the patient returns to his work. 
Recovery is the rule ; eighty-five per cent, get well. Death, 
when it takes place, occurs about the third week, and is generally 
heralded by profound coma and complete prostration. The out- 
look of the case is favorable in childhood and youth, comparatively 
favorable to the thirtieth year, and from that point gradually de- 
clines to one-half between fifty and sixty years of age. Old people 
generally die of lung inflammation. The strong are more liable to 
recovery than the feeble. 
Treatment.—Under this head we may speak of what is more 32 
THE ACUTE INFECTIOUS DISEASES. 
important than treatment, namely, prevention. Typhus, like all 
the diseases in this chapter, gives way before the gospel of cleanli- 
ness. In the crowded slums of a city the doctor who preaches, 
and enforces by the strong arm of the law, cleanliness, does more 
immediate good than a missionary who distributes tracts. Pre- 
vention lies in scattering crowded masses of underfed, dirty and 
neglected humanity; ventilation, improved drainage and pure 
drinking water are equally important. The enforcement of a 
rigid quarantine against distant centres of epidemic is demanded 
imperatively. When in a city, every centre of activity should be 
isolated, or the patients removed, and the infected buildings closed 
and disinfected by fumigation with burning sulphur. When pa- 
tients are treated in their homes, the house ought to be placarded 
to prevent people coming in ; and after the recovery of the patient 
mattresses should be emptied and their contents destroyed by fire, 
and all clothing used about the room, and patient as well as the 
room disinfected by heat and sulphur fumes. 
The layman should not undertake the treatment of a case of 
typhus fever when the services of a physician can be obtained. 
For the benefit of those who cannot obtain immediate aid the fol- 
lowing general plan is given. Lebert says, “I give drugs chiefly 
to satisfy the patients and their friends.” 
Cold is well borne by the patient during the febrile congestive 
stage, therefore the windows should be left open and the patient 
given sponge baths at frequent intervals, with the water at G5° 
Fahr., and be repeated as often as the temperature of the body 
reaches 102° Fahr. The patient should be kept quiet, and experi- 
enced nurses obtained, as the care is exhaustive. Ice-water, lemon- 
ade, and effervescing drinks may be given freely. The diet should 
be fluid, such as milk, beef-tea, broth, and soups, given in small 
quantities every two or three hours. Ice-bags, or cold compresses 
to the head give great relief. There may be no fear of placing the 
patient in a cold bath, even every three or four hours in a severe 
case, and letting him remain there until his temperature is lowered 
to the normal. Lebert gives dilute phosphoric acid in the propor- 
tion of a drachm to four ounces of water and raspberry syrup, of 
which a teaspoonful may be given every two hours. 
Constipation, which is often present, may be relieved by cold- 
water injections. When the strength fails rapidly, stimulants may 
be given more freely than in nearly any other disease. A solution 
of five grains of carbonate of ammonia, thirty drops of ether in 
two ounces of water; or camphor in doses of two to five grains in 
a pill, or powdered with white sugar, every fourth hour, may also 
be given as excitants; large doses of quinine, from fifteen to thirty THE ACUTE INFECTIOUS DISEASES. 
33 
grains when the fever is very high : that is, when the body temper- 
ature is 104°, 105°, and 106° Fahr., may be given for the purpose of 
lowering the heat. Small doses of opium, one-fourth to one-half 
a grain, may be used for the purpose of allaying the pain in the 
head and limbs, and to aid in procuring sleep. 
When the improvement has set in, the diet should be more 
nourishing, but the patient should be guarded against over-feeding 
for the first two weeks after convalescence. 
Work should not be resumed until the strength is fully regained. 
Yellow Fever. 
Cause.—The infecting essence upon which yellow fever depends 
shows marked differences from that of nearly all other infectious 
diseases. The first is its dependence upon certain conditions of 
temperature. The mean temperature must reach at least 72° Fahr., 
in order to insure malignancy in the germs ; secondly, a fall of 
temperature to the freezing point destroys the infecting quality of 
the germs; and thirdly, the ease with which the area of its ac- 
tivity is circumscribed by elevated regions. 
The disease follows the channels of commerce. It breaks out 
in seaports, and, when penetrating into interior regions, follows 
the watercourses of commerce. In breaking out in a city to which 
it is imported, it follows the rule of nearly all acute infectious dis- 
eases, by appearing first in the filth centres—the sailors’ quarters 
and low tenements, especially when near the water, where animal 
and vegetable matters accumulate and putrefy. 
South America is generally looked upon as the active epidemic 
centre of yellow fever, from which point, by the bilge-water and 
filthy holds of vessels, the germs are carried to more temperate 
latitudes. That the disease cannot originate in filth is certain, 
since it has been repeatedly shown that, no matter how filthy a 
ship may be, the disease will not break out among the crew until 
the vessel has touched at some port in which the disease is rife. 
Another trait of yellow fever germs is the extent to which in- 
dividual susceptibility is modified by race and acclimation. The 
history of the disease has shown that the negro race possesses 
nearly a total immunity. People of this race, however, after a 
long residence in a northern climate, lose their race immunity and 
may become victims of the infection. Yellow fever shows its most 
marked potency in the white race; but acclimation may secure 
considerable safety to one of this race. Safety demands, however, 
that these persons reside constantly in a hot, or semi-tropic climate ; 
for, after a residence in a temperate region, a subsequent return 34 
THE ACUTE INFECTIOUS DISEASES. 
to the tropics entails a re-acclimation in order to secure a partial 
exemption from the disease. 
Many able writers believe that the germ of yellow fever is a 
living miasm; that it does not develop in the bodies of the sub- 
jects to be thus spread from one case to another (contagion), but 
that the specific miasmatic germs rapidly propagate themselves in 
the favoring conditions of heat, filth, and moisture. We conse- 
quently find the disease occurring in the hot months in moist re- 
gions, like the mouths of large rivers in tropical countries, which 
generally form epidemic centres. 
The epidemic in the United States in 1878 was marked by some 
rather unusual traits. Small towns away from large watercourses 
of navigation suffered severely, and the infecting germs showed 
an unusual resistance to low temperature. 
Some forms of occupation predispose to yellow fever, but slightly 
however. All occupations which have to be conducted in a high 
temperature predispose to yellow fever ; while tanners, soap boil- 
ers, candle-makers, scavengers, and all who are engaged in a bad, 
unhealthy atmosphere, are less disposed to the disease. 
Symptoms.—After an exposure to the infection there is a period 
before the development of the disease, varying from twelve hours 
to two or three days. As a prelude to the full onset of the diseaes, 
there are prodroma (signs). These are lassitude, headache, pain 
in the back and limbs. Epidemics of yellow fever occur in which 
early signs are absent. The attack begins with a chill more or 
less severe, with great prostration and restlessness. This is rapidly 
followed by fever as high as 102° Fahr. in a few hours, with in- 
tense headache often confined to one side, congested eyes, flushed 
face, and an anxious expression. The respiration is quick and 
short, and the pulse rapid and full. By the end of the first or 
second day a peculiar corpse-like smell is noticed from the body 
when the bed clothes are raised. The tongue is slightly swollen, 
and covered with a whitish or yellowish fur, with red edges ; while 
the mucous membrane of the throat becomes at first of a bright- 
red color, and then swollen, the gums around the teeth having the 
same appearance. The stomach is very sensitive on pressure, and 
all food and drink are vomited as soon as taken. The bowels are 
constipated, except rarely, when diarrhoea is present. The lower 
portion of the back is the seat of intense pain. The urine is scanty, 
turbid, and, in some cases, from the beginning shows traces of 
albumen. In other cases the urine is suppressed, even from the 
first. The disease has reached its climax on the second or third 
day. The temperature is at the highest, 105° Fahr. ; the skin and 
eyes are jaundiced, the urine loaded with bile, and the evacuations THE ACUTE INFECTIOUS DISEASES. 
35 
from the bowels are clay-colored. Hemorrhage from the nose oc- 
curs, and now and then from the stomach ; this latter is a sign of 
great intensity of infection, and is generally a fatal symptom. 
This completes the first stage. The second stage begins on the 
third or fourth day, and is known by a marked remission of nearly 
all the symptoms. The temperature of the body falls to 100° Fahr., 
or to the normal; the pains in the head and limbs cease, and the 
patient fancies the attack is over. The tenderness over the stom- 
ach and vomiting generally remains ; and albumen in the urine is 
nearly always noticed now, if absent in the first stage. The remis- 
sion lasts from several hours to two days. In very favorable cases 
this may be the end of the attack, and the patient pass at once 
into convalescence. 
The third stage is the usual course of events. The symptoms 
of the first stage return in an aggravated form. The fever reaches 
104° Fahr. in the course of the first or second day. The mind may 
be clear, but an overpowering apathy exists; while a furious de- 
lirium occurs in many cases, in which it is difficult to control the 
patient. The jaundice becomes very intense, reaching a dark, 
coppery color. Hemorrhage is a marked symptom of this stage. 
The blood comes from the mucous membrane of the nose, mouth, 
and all the digestive tract, and sometimes from the skin and gen- 
itals. Hemorrhage into the stomach is the occasion of the name 
“ black vomit ,” and is a very dangerous symptom. 
A symptom equally dangerous is suppression of the urine, and 
is one that causes great suffering. In some epidemics suppuration 
of the glands located behind the angle of the lower jaw is noticed, 
as well as the formation of boils over the body. 
Death usually occurs in this stage. In the last few hours the 
patient falls into a deep stupor, from which he never awakes. 
The act of death is usually attended by convulsive action of the 
diaphragm and twitching of the muscles, while the temperature 
falls rapidly to 100° Fahr., or under. 
A favorable termination of the attack is the occurrence of con- 
valescence directly after the second stage, the continuance of the 
excretion of urine during the third stage, and the absence or slight 
amount of hemorrhage into the stomach (black vomit). When 
the third stage terminates in recovery, the fever abates suddenly 
to the normal with profuse sweating and the prompt disappear- 
ance of all pain. Convalescence is always slow. 
Treatment and Prevention.—The question in yellow fever out- 
breaks is prophylactic (preventive) rather than curative. Preven- 
tive measures must be under the direct care of government. Local 
health boards and measures are, by themselves, hopeless to con- 36 
THE ACUTE INFECTIOUS DISEASES. 
tend with the spread of an epidemic of yellow fever, as we have 
proven to our cost. The strongest quarantine is necessary. All 
intercourse between infected ports and ships in which the disease 
exists must be cut off. The quarantine of infected ships, persons, 
and goods, must exist for at least two weeks. The modern theory 
of quarantine in relation to yellow fever is tending to the complete 
exclusion of manufactured products from infected ports, and from 
vessels known to be infected, while healthy persons after change 
of garments may be allowed to go free. Disinfection, as a means 
of destroying germs as potent as those of yellow fever, is prac- 
ticed on an assumption of its value, rather than from actual 
proof. 
People within the area of an epidemic must avoid panic, live 
temperately, and cleanly, and avoid all conditions known to depress 
the general vigor of the system. Some physicians, who have had 
experience in yellow fever centres, recommend quinine as a pre- 
ventive medicine, and others recommend the use of metallic mer- 
cury, or some of its salts.* [Such as calomel.] 
The treatment of the disease is, unfortunately, by no means 
settled. The treatment is mainly symptomatic; that is, reme- 
dies are directed to each separate phase of the disease as it pre- 
sents itself. At the beginning, a purge of ten grains of calomel is 
quite generally used, and for the pain in the back, dry and wet 
cups or blisters are applied to the parts. Morphine, in small and 
frequent doses to \ of a grain), and small pieces of ice are used 
to control vomiting. The latter is also useful to control bleeding 
from the stomach, and may be used in the form of ice-bags over 
that region. The high fever is in a measure controlled by quinia. 
In the epidemic of 1878 in the southwest, large or ante-febrile 
doses of the drug were given, and with some success. This use 
of quinine consists in making a profound impression by giving 
from twenty to thirty grains at a dose, followed every hour or two 
by ten-grain doses to maintain the effect. From the great irrita- 
bility of the stomach, it is sometimes advisable to administer the 
quinia by means of a hypodermic syringe. 
The strength must be kept up by all possible means, although 
great difficulty is encountered, owing to the constant vomiting. 
[* The late Dr. Josiah C. Nott, of Mobile, Ala., whose experience with yellow fever 
was extensive, said he had observed that persons living in infected districts, but who 
remained in the upper stories of their houses, were much more apt to escape the disease 
than those who frequented the ground floor.—Ed.] THE ACUTE INFECTIOUS DISEASES. 
37 
The Plague. 
Cause.—In Northern Africa, in Turkey, Persia, in Southeast- 
ern Europe, along the Danube and shores of the Black Sea, a dis- 
ease known as the pest, plague, or bubo-plague, has occasionally 
prevailed epidemically for many ages. In the earlier parts of the 
present century severe outbreaks occurred. For the last two de- 
cades, however, these usual centres have been free from the dis- 
ease, if we except Russia during the wdnter of 1878-9. 
The evidence is that the disease is not self-originating, but is 
spread by infection from existing centres of the disease ; that it 
spreads by contagion, although favored in its spread by filth and 
all manner of unsanitary surroundings. We may not, however, 
regard the plague as contagious as small-pox, but that it belongs 
to the class of contagious miasmatic diseases. 
Unlike the yellow fever germs, those of the plague survive the 
most extreme cold weather. The epidemics of Cairo usually abated 
with the beginning of summer heat. No race or sex is exempt 
from infection, although some occupations, such as dealers in oils 
and fat, water-carriers, and attendants at baths, are believed to 
enjoy a partial exemption. Persons over fifty years of age are 
said to be rarely attacked. 
Symptoms.—The disease has a period of incubation [the period 
between the exposure and the development of symptoms] of from 
two to seven days. The first stage seems to be an intoxication 
with the infection germs, staggering gait, thick and confused 
speech, fulness and dizziness of the head ; a chill is sometimes 
present, followed by fever, often not. Following this is intense 
fever; rapid breathing; the tongue covered with a pearl-like coat- 
ing ; there is mild or furious delirium which, toward the end, 
merges into stupor. The tongue becomes dry, cracked, and black, 
and thick, dark crusts cover the gums and teeth. The action of 
the heart becomes weak, the extremities cold, and the lips and 
finger-nails blue. This completes the second stage. If life con- 
tinues the third, or bubo stage, develops. With these local evi- 
dences of infection the fever declines, the pulse grows firmer, a 
thick and ill-smelling perspiration covers the body. The lymphatic 
glands, chiefly in the groin, but also in the arm-pits and round the 
neck, begin to swell and inflame, oftentimes passing rapidly to 
suppuration, in which event an offensive and corroding pus escapes. 
Suppuration is considered a favorable omen. Very often the in- 
flammatory action in the glands ceases short of pus formation. 
More rarely, carbuncles are found on the lower extremities princi- 38 
THE ACUTE INFECTIOUS DISEASES. 
pally, which show a marked tendency to gangrene. In very severe 
cases, black and blue spots (ecchyrnoses), and flea-bite-like erup- 
tions (petechice) appear upon the body. 
In favorable cases convalescence begins on the sixth to tenth 
days, and is very liable to be complicated with continued suppura- 
tion of the buboes. After-effects (sequelae) may be pneumonia, 
abscess of the parotid glands, boils, and a typhus-like fever. 
Death may occur at any stage of the disease, sometimes even 
before the disease has assumed distinct shape, but it usually takes 
place from the third to the fifth days. After the seventh day re- 
covery is the rule, subject to the dangers of the after-effects. The 
plague is the most fatal of all the infectious diseases, the mortality 
ranging from seventy to ninety in a hundred. 
Treatment.—It is not difficult for the reader to realize how little 
benefit is to be expected from treatment in a disease of such rapid 
and fearful character. Cold baths during the height of the fever, 
stimulants during the period of depression, and poultices to the 
buboes and speedy outlet to the pus, are the usual remedies. The 
chief duty of the physicians in an outbreak of the plague lies in 
the direction of preventive measures. The story of the quarantine 
against this disease in some of the epidemics reads like a romance. 
The most rigid quarantine ever known in the history of disease 
has been connected with the plague. The results have been most 
beneficent, notwithstanding the inhumanity and hardship which 
were the outcomes of the strenuous preventive measures. Hirsch 
says that “ the extinction of the plague was a gradual process, and 
kept pace, in a great measure, with the development and perfection 
of the quarantine system as carried out, not only with reference to 
the East, but also between neighboring countries of Europe.” 
The Black Death. 
Most authors agree that the black death and the plague are 
identical. In the fourteenth century this disease, the mortality 
from which exceeded that of any other disease recorded in history, 
devastated nearly all the then known inhabited portions of the 
earth. In the black death all of the symptoms described in the 
plague were present, except that a quickly fatal disease often com- 
plicated the black death. Hirsch thinks that he has found a revi- 
val of the black death in the India plague of 1815-20, and in the 
Pali plague of 1836. These outbreaks were bubo-plagues. 39 
TIIE ACUTE INFECTIOUS DISEASES. 
Relapsing Fever. 
This disease is essentially one of recent history, in the sense 
that it was only identified clearly in 1850. This result was brought 
about by the epidemics of England, Ireland, and Scotland in 1842. 
Bilious typhoid is a phase of the disease, and they will be consid- 
ered together. 
Cause.—Like typhus, relapsing fever is clearly recognized as a 
filth-disease. The infecting germs find their habitat in crowded 
lodging-houses, impure drinking water, and all manner of unclean- 
liness that attends human aggregation. The disease is clearly 
contagious, but also establishes for itself epidemic centres. It 
may be, and Lebert thinks it quite likely, that relapsing fever is 
one of those rare diseases in which the infecting germ has been 
identified. Obermeier found, in cases of the disease in which the 
blood of the patients was examined under a high power of the mi- 
croscope, a minute spiral filament of a diameter of 0.001 millime- 
tre, and a length of 0.15 to 0.2 millimetre, with a rapid twisting 
motion. Other observers have confirmed this, and have observed 
them in great numbers. They quickly disappear on the lessening 
of the fever. Lebert says these filaments (protomycites) were 
never absent in any case observed by him. An incubation period 
(a period between exposure and development of symptoms) of from 
one to seven days, has been observed. 
The disease frequently attacks children, and one-fourth the 
cases occur in persons between thirty and forty years of age ; after 
the fiftieth year a more or less complete exemption is observed. 
Meteorological influence has but little effect; two of the epidemics 
recorded by Lebert were in the summer, and one in the winter. 
Symptoms.—This disease is noted among acute infectious dis- 
orders for the rapidity of its onset. There are, as a rule, no pre- 
monitory symptoms. The disease begins with a high fever; in 
about half the cases only is there a preceding chill, but in place of 
it nausea and vomiting are frequent. The fever is continued and 
intense from the beginning, with all the usual attendants of high 
body temperature. There is a temperature of 102° Fahr. in the 
morning and 104° Fahr. in the evening, and two or three days 
later an excess of 2° Fahr. over both these. Prostration is marked 
from the outset; the pulse rapid though weak, and the tongue is 
thickly coated and soon becomes dry ; the bowels are constipated 
as a rule. 
By the second day a sense of pain and tenderness is noticed on 
the left side, under the floating ribs. These are signs that the 40 
THE ACUTE INFECTIOUS DISEASES. 
spleen is involved. The organ increases rapidly from day to day, 
even hour to hour. The liver also shows symptoms of tenderness 
and slight inflammation. At this stage there are great pain and 
tenderness in the muscles of the body—often of a most severe and 
piercing character. From the fifth to the seventh day these 
symptoms suddenly cease. The fever and pain, with all the at- 
tending symptoms, disappear ; the appetite returns, the tongue 
cleans, and the patient offers all the evidences of returning health. 
This remission of the disease lasts on the average about seven 
days. 
The relapse occurs suddenly, with all the symptoms enume- 
rated in the first stage. The infecting filaments are again found 
in the blood. The only difference that is at all marked between 
the relapse and the first stage is the greater remission between 
the morning and evening fever, to the great comfort of the patient, 
while the liver and spleen again present evidences of inflamma- 
tion. This relapse lasts from three to seven days. Sometimes a 
marked aggravation of all the symptoms occur a few hours before 
the final cessation of the symptoms, which usually occurs in the 
night by a profuse perspiration, with a normal temperature in the 
morning. 
A third relapse is observed in some epidemics, but usually the 
course of the disease is now completed. The patient is left emaci- 
ated and weak. The convalesence is slow, lasting from two to 
four weeks. 
The termination of relapsing fever is generally favorable, the 
death-rate being from two to three cases in a hundred. In epi- 
demics attended with bilious typhoid the mortality is increased 
to about ten per cent. 
Death may take place in the first stage from complications, 
which often consist in implication of the lungs; or from intensity 
of the fever, even in the first stage, or from exhaustion during the 
relapse. A common cause of death is from abscess of the spleen 
resulting in pus-poisoning {pyaemia) ; or from rupture of the ab- 
scess and consequent acute inflammation of the interior of the ab- 
domen {peritonitis). 
It seems needless to repeat all the symptoms of bilious typhoid. 
It is simply necessary to add to the above a marked “typhoid con- 
dition,” a most marked jaundice {icterus), with a less decided 
feature of intermission and relapse, and the reader has, broadly, 
all the prominent morbid events of bilious typhoid. Many good 
authorities regard it, however, as a distinct disease from relapsing 
fever. The treatment is identical with that of the latter. 
Treatment.—Lebert, the great advocate of the expectant method 41 
THE ACUTE INFECTIOUS DISEASES. 
of treatment, virtually says, do nothing. While this is said from 
the purely scientific standpoint, it will not do in practice. There is 
a great moral value in treatment, even when nothing hut negative 
results are expected by the physician. The patient is satisfied 
that something is being done to relieve his sufferings; and the 
friends, that the sick man is not neglected. There is a great dif- 
ference, however, between giving medicine in expectation of a 
cure being performed, and offering the kind attentions and giving 
the simple remedies that mitigate or relieve the symptoms of the 
disease as they present themselves. From the low rate of mor- 
tality, the reader may perceive that relapsing fever is self-limited ; 
that is, it runs its course with a natural tendency to recovery. 
This may be said of diseases which are far more liable to a fatal 
result—such as small-pox and scarlet fever—with equal truth. 
In relapsing fever the diet should be simple, fluid, and cooling 
during the first stage. Headache may be considerably assuaged 
by ice-bags to the head ; and the severe muscular pains will par- 
tially yield to friction with chloroform liniment. One half a grain 
of opium, or four or five minims of “ Magendie’s solution ” as a hy- 
podermic injection of morphia, may be given for the same purpose 
every five to eight hours. The pain and tenderness of the spleen 
is best treated by cold applications or by persistent poultices. 
With evidences of prostration, alcoholic stimulants or wine may 
be given in small and frequently repeated doses. 
Diarrhoea, which is a common feature of bilious typhoid, may 
be controlled by half-grain doses of opium, or two grains of tannin, 
repeated every two to ten hours. In cases of delirium, hydrate of 
chloral in fifteen-grain doses dissolved in a half-wineglassful of 
sweetened water, and repeated every hour until eight doses have 
been given, may be used. 
During the intermission, every measure should be employed to 
keep up the strength in anticipation of the relapse. Quinia in 
three-grain doses every five hours, full diet, and wine, may be 
expected to answer this purpose. The same measures will be use- 
ful during the convalescence. 
As in all the infectious fevers, prophylaxis (preventive meas- 
ures) must receive attention. Herein lies the true medical care of 
relapsing-fever epidemics. The measures already detailed in rela- 
tion to other epidemics apply to this disease. 
Miliary Fever. 
Causes and History.—By this name is meant a specific fever of 
infectious origin, occurring in circumscribed epidemics. In the 42 
THE ACUTE INFECTIOUS DISEASES. 
older history of epidemiology it was known as “ S'udor Anglicus,” 
or “ English sweating-sickness.” The disease acquired its modern 
name by being attended by a fine isolated rash, called “miliary 
eruption.” The disease was first clearly defined in England in 1487. 
In later parts of the middle ages and in other countries, the dis- 
ease prevailed to a varying extent, and sometimes with terrible 
fatality. The disease disappeared for one hundred and sixty years, 
and again received historical notice in the latter part of the eight- 
eenth century. 
The cause shows quite a dependence on meteorological influen- 
ces. Of 174 epidemics tabulated by Hirsch, 59 began in the spring, 
78 in the summer, only 8 in the autumn, and 28 in the winter. 
Heat and moisture may be regarded as essentials to the develop- 
ment of the infection. The disease is not regarded as contagious 
in the general use of the word, although some authors have re- 
garded the fluid in the vesicles as the vehicle of the contagion, but 
observation has shown the error of this. 
Except that the disease is classed among germ fevers, nothing 
is known regarding the direct cause. Both sexes seem equally 
liable to infection, and those in strong, robust health are especially 
disposed to be attacked. 
Epidemics of miliary fever have been observed to occur simul- 
taneously with those of scarlet fever, but the best observers do 
not consider that any relation exists between them. The same 
relation in the order of occurrence, but more marked, has been 
observed in epidemic cholera. The best authorities incline to the 
belief that the coincidence of the two diseases is accidental. 
Symptoms.—The attack is usually heralded by prodromes 
(signs) which last from two to three days. These are irritation 
of the skin, weakness, headache, thirst, a painful sense of oppres- 
sion in the stomach. In mild cases these precursors are wanting. 
The attack occurs, usually, late in the afternoon or at night, and is 
announced by slight chilliness, with profuse sweating, and prick- 
ing and tingling of the skin. This sweat is of an acid reaction, 
and is so profuse that the bedding and mattress may be saturated. 
This is accompanied with severe fever ; the pulse beats at the rate 
of 130 in a minute ; there are violent pulsations of the heart, and 
severe chest-pains leading to irregular or rapid breathing, and ten- 
derness over the region of the stomach. The bowels are generally 
constipated ; the urine is scanty and high-colored, with occasional 
attacks of pain referable to the neck of the bladder and inability to 
pass urine. 
On the third or fourth day the rash appears. This rash (e.r- 
anthem) consists of small, round, shaded, red spots, sometimes ar- THE ACUTE INFECTIOUS DISEASES. 
43 
ranged in groups, at other times generally and regularly diffused. 
In a few hours after their appearance, a vesicle (or small bladder of 
fluid) raises in the centre, at first so small as to be seen with diffi- 
culty, but soon enlarging to the size of a millet-seed—from which 
the disease gets its name “ miliary ”—or even to the size of a pea. 
This vesicle contains a clear fluid, which soon becomes thick and 
yellow from pus, and in a few days (two or three) bursts, dries up, 
and lastly, scales off. The rash spreads usually by regular steps, 
first upon the face and chest, thence to the back and extremi- 
ties, and is sometimes seen upon the mucous membrane of the 
mouth. The duration of the disease is from six to eight days ; 
one, two, or three days being devoted to the sweating stage, and 
the remainder to the eruptive stage of the disease. 
Some epidemics have rarely been attended by fatal results, 
others were very fatal. Death, when it occurs, has usually been 
during the sweating stage. 
Treatment.—Various plans have been adopted to stay the course 
of the symptoms. At one time the eruption was looked upon as a 
crisis in the attack, and was therefore encouraged by drugs which 
favor perspiration, warm drinks, and heavy covering. Consider- 
ing the intensity of the fever this plan must have been cruel in the 
extreme. A more rational plan consists in lowering the excessive 
bodily temperature of the first stage by quinia in ten to fifteen- 
grain doses, repeated every two to five hours, and cold sponge- 
baths. The acute headache and chest-pains may be allayed by 
grain doses of opium (for adults). The tenderness and painful 
sense of tightness over the stomach is best treated by mustard 
poultices, or by injections of six to eight minims of morphine solu- 
tion (Magendie’s) under the skin. Purgatives should be avoided. 
Acetate of potash, in thirty-grain doses dissolved in water, may 
he given to assist the kidneys, and fluid diet and acid and cooling 
drinks may be freely employed. 
The tendency of the treatment is toward the expectant method. 
This is true, as the reader has seen, of nearly, if not all, the spe- 
cific, acute infectious diseases. This is highly proper, as by this 
means the people are educated to regard less the false laws of cure 
than the important measures of prevention. When high and low 
alike are taught that there are no cures for the infectious germ- 
diseases—in the sense that quinine is a cure in intermittent fever 
—they will become more careful of preventive measures, which 
is curative treatment in its best and widest sense. 44 
THE ACUTE INFECTIOUS DISEASES. 
Dengue Fever. 
Cause.—The name “ dengue ” is a Spanish corruption of the word 
dandy, so called from the affected, dandyish gait the patients 
were forced to adopt. It is also called, especially in the Southern 
States, break-bone fever. Dr. Rush described an epidemic of dengue 
in Philadelphia in 1780. It has prevailed extensively in the West 
Indies at various periods. In the South, various epidemics of it 
have occurred, the last in 1866. Solitary cases have been observed 
in northern cities—Boston and New York. In 1871-72 an epidemic 
broke out in Arabia, where it was called “ the father of the knee.” 
This epidemic spread to the islands on the east coast of Africa. 
At Port Said the disease is said to prevail every year at harvest 
time. The contagious nature of the disease is not settled, although 
there are facts which show that dengue may be conveyed from dis- 
tant places in articles of clothing, and by other means. Epidemics 
have occurred at all seasons of the year. A singular coincidence 
has been noted between some outbreaks of the disease and yellow 
fever. All nationalities and races, except the negro, are equally 
liable to dengue fever, while recent arrivals in tropic, or near tropic 
regions, appear to have the disease lighter than the acclimated. 
Symptoms.—Evidences of the approaching attack are noticed 
in about half the cases. These are usually chilliness, pain in the 
head and back, and a burning sensation in the stomach. The 
full onset of the disease is attended with fever and by painful 
swelling of the joints, both great and small. The skin of the 
face and neck has a red, swollen look, which often extends to the 
eyes. The fever reaches its height in about twelve hours, and 
is noted for its intensity; as high as 106.7°, 107°, and 108.8° 
Fahr. has been noted by different observers. The fever is con- 
tinuous ; the pulse ranges from 120 to 140, and the respirations 
28 to 30 in the minute. In from two to seven days there is an 
abatement in the symptoms, announced by a critical sweating, 
diarrhoea, or bleeding from the nose. This state of affairs, which 
resembles the intermission of relapsing fever, lasts one or two 
days, and is followed by a return of the fever, of lighter grade and 
less continuous. The relapse is not always attended with a return 
of the pain and swelling in the joints, but is quite certainly compli- 
cated with a skin eruption consisting of small inflamed points— 
sometimes confined to the face, arms, and chest, and in some cases 
extending over the whole body. It lasts from a few hours to two 
or three days. The affection of the limbs and joints is described 
as rheumatic or rheumatoid (resembling rheumatism), and shifts THE ACUTE INFECTIOUS DISEASES. 
45 
rapidly from point to point. This symptom usually diminishes with 
the fever, but in some cases it becomes chronic and yields only 
after weeks or many months. The patient becomes quickly emaci- 
ated and there is great loss of strength, which is recovered only 
after a long convalescence. Relapses after intervals of several 
weeks are not rare, but are usually less severe than the primary 
attack. 
The result of the disease is usually very favorable, but among 
children it is sometimes fatal from secondary implication of the 
nervous system, which, fortunately, is rare. 
Treatment.—The remedies employed in the tropics consist of 
the early use of cathartics and emetics, followed by quinia in three- 
to five-grain doses. Belladonna in large doses is used to relieve the 
rheumatic pains, as well as colchicum in half-drachm doses of the 
wine of that drug. Cold baths in the febrile stage are useful. 
The painful joints may be treated by chloroform liniment, and, in 
case this symptom survives the disease, iodide of potassium in 
five-grain doses three times daily may shorten this most trouble- 
some part of the disease. The great weakness of convalescence 
should be treated by the bitter tonics (such as Colombo, gentian, 
cinchona, or quassia, in doses of two teaspoonfuls of tincture with 
water), wine, and nourishing diet. 
To arrest the spread of the disease, Sheriff recommends the 
isolation of patients and the quarantine of epidemic centres of the 
disease. 
Hay Fever. 
Cause and Distribution.—The disease known as autumnal ca- 
tarrh, summer catarrh, hay asthma, Catarrhus cestivus, and Bos- 
tock’s catarrh, has been known and studied since the early part 
of this century. The morbid or infecting essence has never yet 
been identified. The evidence of those attacked show that the 
disease is not due to atmospheric causes, but to vegetable dust, or 
pollen. The outbreak occurs during the midsummer or early fall, 
and at the time when flowering plants are in their most active 
condition. Many patients, when they first approach a meadow in 
bloom, or a field of new-made hay, or ripe grain, at once feel an 
attack coming on by the tingling of the nose and sneezing. 
Blackley experimented with the pollen of seventy-four kinds of 
plants, from many of which he obtained, by either inhaling the 
pollen-dust, or placing it on the lining membrane of the nose, 
symptoms closely resembling those of hay fever. Blackley further 
shows, by careful experiment, that the disease always prevails at 
those seasons when the largest amount of pollen is diffused through Extent of Hay-Fever in the Eastern Portion of the 
United States. 
The shaded portions of the map represent the sections 
where hay-fever is more or less prevalent. The occurrence 
of the disease elsewhere has not yet been established. 
Tua™ 1—— 
_ - V»n zmo i aoo THE ACUTE INFECTIOUS DISEASES. 
47 
the air. Wyman, in his monograph on this subject, gives the 
following reasons for a belief in the vegetable origin of the dis- 
ease : 1. It has a fixed time for its appearance, namely, the time 
of flowering of many plants. 2. A fixed time of disappearance, 
when vegetation declines. 3. It disappears on the appearance of 
frost. 4. The existence of the disease in certain regions only. 5. 
Its entire absence at sea. 
Wyman has tabulated those regions of the United States which 
are exempt from the disease, some of which are resorted to for 
the purpose of cure. It will be of value to condense this table for 
the use of our readers : The White Mountains and vicinity; the 
group of the Franconia Mountains ; the Green Mountains ; the 
regions east of the White Mountains ; the plateau and mountains 
of the Adirondack region; the New York and Ohio plateau; the 
Alleghany Mountains ; the Great Lakes and the Upper Missis- 
sippi River. The New York and Ohio plateau has an average 
height of about 1,500 feet above the sea, and is regarded by Wy- 
man as nearly totally exempt. The Lake Region has only a 
general elevation of 400 feet. It is safe to assert that no region 
is safe, to those liable to attack, that is under 1,000 feet above the 
sea-level, especially in regions of rank vegetation. 
The age of those attacked is usually under fifty years. Twice 
as many men as women are attacked, but this may be in a meas- 
ure explained by the fact that those who are much exposed to the 
open air are more liable than others who lead an indoor life. It 
has been asserted that the disease belongs to the educated classes ; 
but this is not so, judging from Wyman, unless the bricklayers 
and blacksmiths are all learned. Zuelzer says that the disease 
never appears among the residents of the rural districts, but expe- 
rience in the United States certainly shows the contrary. Certain 
persons are exempt; but why, it is impossible to say. That the 
exempt classes owe their immunity to ignorance, or country life, 
is absurd. Those with a nervous temperament are more exposed 
to attacks than others, and hereditary influence is believed to 
exert a predisposition to the disease. 
[Dr. George M. Beard, of New York, has published a work on 
hay fever, based on the study of several hundred cases. His 
theory is that hay fever is a neurosis—that is, a functional dis- 
ease of the nervous system. According to this theory, the disease 
is subjective instead of objective—a part of the constitution. The 
external irritants, which are infinite in number, such as pollen of 
grains and weeds of various kinds, heat, sunlight, and so forth, 
being of a secondary and tertiary character, are powerless of them- 
selves to produce the disease, unless acting on a nervous idiosyn- 48 
THE ACUTE INFECTIOUS DISEASES. 
crasy—that is, a nervous system specially sensitive to the influence 
of some one of these irritants. 
Dr. Beard has described a new form of the disease, which he 
calls the July cold, or middle form, which links together the early 
form, or June cold, with the later form or autumnal catarrh. The 
disease may exist from May until November, and indeed, all the 
year round in some cases. All the different forms are essentially 
one disease, whenever occurring. The disease is therefore an unity, 
there being no distinctions in symptoms or character between the 
early and middle forms. Dr. Beard claims that this theory ac- 
counts for all the phenomena of the disease. The treatment is by 
sedatives and tonics, such as arsenic, belladonna, nux vomica, 
cold, powdered camphor, the bromides, choral, electricity, Turkish 
baths, etc., and by this treatment nearly all cases can be relieved. 
—Ed.] 
Symptoms.—The disease assumes two forms—the catarrhal 
and the asthmatic. The first is the lighter form, and runs its 
course with comparatively little trouble to the patient. The first 
symptom is a tingling in the nose, with a clear watery discharge 
from that organ, attended by violent sneezing occurring in parox- 
ysms, sometimes with a profuse flow of tears. The mucous mem- 
brane of the nose swells, sometimes so that the nostrils are closed; 
but this usually passes off during the night, to return again the 
next day. With the swelling of the mucous membrane of the 
nose the excessive irritability of that organ ceases. The dis- 
charge, as the case progresses, may become slightly bloody, and 
later, thick and pus-like. The attack now and then begins in the 
eyes, with symptoms similar to those in the nose ; but, at any rate, 
the mucous membrane of the eyes (conjunctiva) becomes swollen 
and inflamed, with profuse secretion of tears in nearly every case 
as it advances. The lining membrane of the mouth and throat 
(fauces) usually shows some signs of inflammation, such as tick- 
ling, sense of dryness, and redness on inspection. The catarrhal 
inflammation may extend as far as the Eustachian tubes (leading 
to the ears), even to the extent of developing a temporary deafness. 
The asthmatic form generally presents more serious, even 
alarming symptoms. The asthma is of many degrees of severity : 
from the lightest cough and expectoration, to great difficulty of 
breathing (dyspnoea), croupy inspiration, with anxious and dis- 
turbed expression, the patient sitting erect, clenching the hands, 
and making violent respiratory efforts. In these more severe 
forms, a more or less active fever presents itself, combined, in 
severe asthma, with very rapid pulse. This form is sometimes 
attended with chills. 49 
THE ACUTE INFECTIOUS DISEASES. 
This disease may be distinguished from nervous asthma by the 
attacks of hay asthma occurring in the day-time and in the fresh 
air, and the tendency to persist during the season favorable to 
the disease. The attacks last from three to six weeks, and reach 
a spontaneous cure with remarkable rapidity as the season closes. 
Blackley says that the intensity of the disease depends upon the 
quantity of pollen floating in the air, and the sensitiveness of the 
patient. 
Treatment.—No form of treatment has been discovered which 
appears to exert any control over the disease. The surest form of 
treatment is a change of residence as soon as the attack declares 
itself. Any of the regions in which the disease is known to be 
excluded will exert a curative, or at least favorable influence over 
the disease. The White Mountains, the Adirondacks, and the re- 
gion of the Great Lakes, are favorite places of resort for those 
who are yearly liable to attack. Wyman says that quinine has 
been more successful than any other drug. It should be com- 
menced at least four weeks before the expected attack, and taken 
to the amount of two to three grains before each meal, and con- 
tinued during the attack. Arsenic, in the form of Fowler’s solu- 
tion, in two- to three-drop doses after each meal, is said to exert a 
favorable influence. The bowels should daily be slightly acted 
on by laxatives like Congress water or citrate of magnesia. Local 
applications, like colored glasses, to protect the eyes, cold water 
to the eyes and nose, or a solution of borax (biborate of soda), 
will afford comfort to the patient. A five or ten grains Dover’s 
powder will add much to comfort during the night. A chlorate of 
potassium solution* used as a gargle relieves the throat as much as 
anything that can be used. 
For the asthma, smoking stramonium leaves has been used 
with fair success. A secret remedy composed of three parts of 
these leaves and one part of saltpetre, the fumes of which are to 
be inhaled while burning, has had considerable reputation. The 
Espic cigarettes, composed, according to Wyman, of— 
Belladonna leaves four and a half grains. 
Hyoscyamus “ two and a half grains. 
Stramonium “ two and a half grains. 
Phellandrium “ three-fourths of a grain. 
Opium “ one-fifth of a grain. 
Powdered and rolled up in paper. 
Two cigarettes are to be used during one attack. Paper saturated 
* [Made by adding a drachm to three or four ounces of water.] 50 
THE ACUTE INFECTIOUS DISEASES. 
with saltpetre, and its fumes inhaled while burning, is a popular 
remedy. 
The patient should have a nourishing diet, avoid dust, smoke, 
and night air, and wear flannel next to the skin. 
Malarial Fevers. 
We shall consider under one head the general cause of the dif- 
ferent fevers of this type. It is difficult to give a brief popular re- 
sume of the latest form of scientific thought upon this interesting 
and important matter. In this group of fevers we have a very 
strong confirmation of the germ (contagium vivum) theory of dis- 
ease. The disease, in some of its various forms, is generally more 
or less confined to particular regions {endemic). It sometimes be- 
comes generalized, and prevails extensively among a people {pan- 
demic). Marshy regions, or countries liable to extensive over- 
flows of water, are the usual seats of the morbid cause. Salt- 
water marshes, as where fresh and salt water mingle at the 
flood of the tide, are more noxious than fresh water alone. This 
is supposed to be due to the sea water killing the fresh-water 
plants, and causing poisonous emanations from the decomposing 
matter. Many instances are noted in which the most favorable 
conditions for the development of malarial poison exist, and yet 
the locality is perfectly free from the disease. These exceptions 
are not accounted for. When marshy regions are perfectly drained, 
or when malarial districts pass under cultivation, the disease gen- 
erally disappears, or exists in a modified form. Malarial regions 
have been rendered innoxious by the cultivation of sun-flowers 
(Maury) ; the cultivation of the sweet flag {Acorus Calamus) has 
been attended with the same result. Malaria is known to exist 
under other conditions than in marshy places. In extensive over- 
turning of the earth, as in building canals and fortifications, in clear- 
ing off the forests and bringing new lands under cultivation, intense 
forms of fever have been developed. Under conditions not yet ex- 
plained, malaria may exist in very elevated and dry regions, as, 
for instance, in the Tuscan Apennines, at the height of 1,100 feet; 
on the Pyrenees, at 5.000 feet; in Peru, at 10,000 and 11,000 feet; 
and on the island of Ceylon, at 6,500 feet. Hertz thinks that it is 
proven that in an elevated and dry region, with a stratum of loose 
soil overlying clay, or other impermeable soil, when a large amount 
of surface-water charged with vegetable matter percolates through 
the surface and is retained by the impermeable stratum, a condi- 
tion favorable to malaria is induced. 
It is established that a certain degree of heat is essential to the THE ACUTE INFECTIOUS DISEASES. 
51 
development of malaria. The north and south limits of the dis- 
ease are 63° of latitude of the first, and 57° of latitude of the latter ; 
or north, by the isothermal lines of 59° to 59.8° Fahr. The dis- 
ease generally prevails during the hot months, and summers of 
unusual heat will often develop malarial poison of such unusual 
intensity that it will break loose from its endemic haunts and in- 
vade regions usually free from the disease. The same is true of 
tropical malaria. The fever of Zanzibar prevails from March to 
May, and on the Guinea coast from June to October. In temperate 
zones August and September are the malarial months ; and in 
countries in which the snow melts off in February, outbreaks of 
malarial disease may be expected as early as May. Jilek demon- 
strated that in the excessive malarious district of Istria the extent 
of malarial diseases corresponded to the amount of the rainfall. 
Marsh-fever poison may be spread by the wind. The malarious 
germs extend from an endemic centre in the direction of the pre- 
vailing winds. 
No race or nationality is exempt from the disease. The negro 
race is not exempt even in its native haunts. On the Gold 
coast of Africa, for instance, to a careless observer they may ap- 
pear so, compared to the white race exposed to the fatal malaria of 
that country. All periods of life are equally subject to the poi- 
son. It may be modified, however, in its expression by age and 
sex. Children may suffer from intermittent bowel complaints, 
youth to the continued form of fevers, and middle life to the more 
typical forms of intermittent. Men are more subject to the febrile 
forms of malarial poisoning than women, probably from their more 
exposed occupation, while in women the poison often assumes the 
form of neuralgias, especially of the nerves of the face (trigeminus 
nerves). The condition of the system has much to do with the pre- 
disposition to attack. Causes which seriously disturb the nervous 
balance—anger, fear, sleeplessness, hunger, fatigue, and excessive 
mental exertion—may predispose the system to attack. Exposure to 
the air at night, sleeping in damp beds, or sleeping on the lower 
floor of a house, living in dwellings too densely shaded, may favor 
the onset of the disease in some of its protean forms. Weak and 
anaemic persons are more liable to attack than those in robust 
health. Residents of malarial regions are sometimes suddenly 
attacked by the malarial fevers on removing to a cool, elevated 
country. Any sort of cooling down, especially after overheating, 
exposes one to an attack after exposure to the poison. [Exposure 
to the direct rays of the sun is liable to bring on an attack of ma- 
larial fever in those who are subject to it.—Ed.] 
The malarial poison may, in a certain manner, remain dormant 52 
THE ACUTE INFECTIOUS DISEASES. 
or latent in the system, with or without a previous attack of 
fever. A person once having an attack of fever may suffer 
repeated attacks for months, or even years, after removal to a 
non-malarial country ; or a person may suffer an attack, after a 
residence in malarial districts, months after his removal to a heal- 
thy region. It is possible to gain a certain immunity by acclima- 
tion. Strangers are more liable to attack than old residents. Ac- 
climation does not give anything but an accommodation of the 
system to the morbid cause. 
Simple Intermittent Fever—Ague—Chills and Fever. 
Symptoms.—This form of malarial fever may be preceded by 
premonitory signs, such as forehead headache, a sense of languor, 
loss of appetite, and profuse sweating at night, with a bad, bitter 
taste in the mouth, and the tongue coated white around the edges 
and yellow in the centre, the urine scanty and high-colored. This 
condition lasts from six to eight days. 
Following these signs we have the first stage of the fever—the 
chill. 
The chill may vary from the slightest shudder to trembling of 
the body and chattering of the teeth ; with the chill is severe back- 
ache, pain in the head ; the face is pale and shrunken ; the hands 
and finger-nails become blue and numb, and the body covered with 
“goose-flesh” (Cutis anserina). Nausea is often present, and if 
food has been recently taken there may be vomiting. The pulse 
is small, frequent, and hard ; respiration rapid, and mental dis- 
turbance ranging from mere agitation to active delirium may be 
observed. Notwithstanding this appearance of cold, the thermom- 
eter placed in the mouth, armpit, or bowel, shows already the 
presence of fever. The duration of the chill is from a few min- 
utes to several hours. 
The hot stage follows and gradually culminates. As the chill 
subsides, flashes of heat travel from the extremities toward the 
trunk; this sensation recedes, followed again and again by the 
feeling of invading heat, until the fever is fully developed. The 
intense pain of the chill is partially relieved, but the heat-pain be- 
comes very severe; the blood-vessels of the temples and neck throb 
violently. The face glows with heat; respiration is quick, the 
pulse hard and rapid. The patient is restless and excited, and 
often delirious. This, the febrile stage, lasts from three to twelve 
hours. 
The sweating stage follows and develops gradually as the fever 
declines. All of the distress and pain subsides, and during the THE ACUTE INFECTIOUS DISEASES. 
53 
sweating stage the patient falls into a quiet sleep. The urine be- 
comes free, and throws down, on cooling, a brick-dust sediment. 
After this stage the patient often feels quite well and returns to 
his duties; but sometimes, especially in lengthened stages, the 
head is a good deal disturbed, the tongue is coated, the stomach 
bloated, and the bowels irregular, while the skin is sallow.. The 
region of the liver and spleen are usually sensitive to pressure. 
Occasionally there is a slight fever toward night, with disturbed 
rest. In prolonged intermittents the fever in this manner may 
pass into the remittent form. 
This is the typical course of events. There are many deviations 
from it, but they do not alter the general course of an intermit- 
tent fever. 
Following these three stages is a period of intermission (apy- 
rexia). The length of this intermission defines the type of the 
fever. When the attacks recur every twenty-four hours, we have 
a quotidian fever; when an intermission of forty-eight hours exists, 
the fever is tertian or every third day, and with one of seventy-two 
hours the fever becomes quartan. In temperate climates the fever 
is usually tertian in form. Rare forms of the disease are those in 
which the paroxysms recur every fifth, sixth, or seventh day, and 
so on, to even the thirtieth day ; and the double types, as double 
quotidian, double tertian, and double quartan. 
Remittent Fever. 
Symptoms.—The lightest form of the disease is commonly 
known as bilious fever, or bilious remittent; sometimes, with 
highly irritable stomach, the disease is termed gastric remittent. 
The attack begins suddenly with a chill, followed by loss of 
appetite, nausea, sour stomach, headache, dizziness, and sleepless- 
ness. Diarrhoea and jaundice are generally present. The fever, 
after a course of four to twelve hours, gradually declines in a 
sweating stage, in which the patient feels considerably relieved, 
but during which the fever continues, to return to its full force at 
an uniform hour daily. This is termed the remission. The recur- 
ring fever may be preceded by a slight chill, but the usual form is 
an increase of the fever without a chill. The duration of the 
attack is from three to ten days, or the remittent may pass into 
the intermittent form. In occasional cases the jaundice and color- 
less stools persist for some weeks after the conclusion of the attack. 
A more severe grade of remittent begins in the same manner as 
the above in a more aggravated form, with only marked remis- 
sions in the earlier stages, and after a few days assuming nearly a 54 
THE ACUTE INFECTIOUS DISEASES. 
continuous form. At first of a vigorous form, the disease drifts 
into a typhoid or depressed (adynamic) type. Serious complications, 
such as convulsions of various character, profound insensibility 
(coma), dysentery, pneumonia, and inflammation of the spleen, 
are liable to arise. The attack generally ends in about two weeks 
in marked remissions and sweats, or passes into a simple inter- 
mittent. 
A still more severe form is the fever of the tropics. The per- 
nicious character of this kind is shown from the beginning of the 
attack ; the extreme prostration, the early condition of apathy, 
and a tendency to collapse, define the danger. The early stage, 
oftentimes, instead of drifting at once into the continued form of 
fever, shows indefinite and irregular increase of fever and remis- 
sions, which gradually drift into a low, continuous form, and the 
patient falls into an apathetic condition, and dies in a condition of 
stupor. Of this character is the Chagres fever, and the highly fatal 
fever of low tropical coasts and deltas. 
Another form long known, and not yet fully defined, is a bilious 
remittent, characterized by jaundice and bloody urine, and com- 
monly known under the French name otfievre bilieuse hematurique. 
The fever is known only in the most malignantly malarious dis- 
tricts of the tropics, and then only during the prevalence of a ma- 
larial epidemic. 
Irregular Forms of Malarial Fevers. 
Under this caption we may arrange a number of anomalous 
fevers of this origin, some of which are, however, quite common. 
A form of fever quite generally common throughout the United 
States is one described under the name of typho-malarial. There 
is much confusion in the description of this fever; even in the 
reports of army surgeons in the late war of the rebellion, with 
whom the disease must certainly have assumed its most- typical 
form, there is much conflict of description. Very often the disease 
is but a degeneration of the simple intermittent toward the con- 
tinued form. * The fever and chill may be both slight and of irreg- 
ular sequence ; and yet there are grouped about these two condi- 
tions, of which the latter is not essential, a few well-marked 
* [By one class of observers, also, the term has been employed to indicate the presence 
of malaria, and also of a septic poison, such as sewer-gas, which differs from the specific 
poison that gives rise to typhoid fever. There is yet another class of observers who doubt 
the existence of such a form of fever, and regard the so-called typhoid element as noth- 
ing more than a “typhoid condition ”—alow condition, liable to be developed in connec- 
tion with remittent fever, as well as many other diseases.—Ed.] THE ACUTE INFECTIOUS DISEASES. 
55 
typhoid symptoms. [See page 14.] The tongue has a dark, 
thick coating down the centre, with red edges and tip; there is 
more or less intestinal irritation, complete loss of appetite, and 
rapid emaciation. The fever is of a most irregular character, 
often showing distinct remissions; often these are wanting, how- 
ever, or so slight as to require careful observation with a thermom- 
eter to show the fact. The remission, or partial subsidence of the 
fever, sometimes lasts several days, the patient meanwhile not 
making any gain in appetite or strength. 
The mind is clear, usually slightly apathetic; the stomach 
critical, but rarely so irritable as to reject its contents. Sometimes 
the disease prevails epidemically, like the outbreak of typho- 
malarial fever in Central New York in the spring of 1878. The 
fever of the same name, observed by army surgeons, was essen- 
tially different, due no doubt to the exposures, fatigue, and un- 
hygienic life of the army. 
The course of the disease is not uniform: two to five or six 
days is oftentimes the duration of the attack, or it may persist as 
many months. A slow and varying convalescence terminates the 
attack, with a marked tendency to relapse. 
The malarial cachexia is a term used to describe the general 
break-up of the health from malarial poisoning. Hertz applies 
the word intoxication to this condition of the system. The symp- 
toms are loss of appetite, metallic taste in the mouth, a disposition 
to vomit, and gas in the stomach, a yellow coating upon the 
tongue, dryness of the throat and mouth, and a feeling of pain 
and weight in the stomach, with rumbling of the bowels. Usually 
there is a tendency to diarrhoea. There are marked nervous dis- 
turbances, such as dizziness and derangement of vision, tickling 
and burning in the feet and hands, and pain in the shins and lower 
part of spine. Debility is marked, and the patient fancies himself 
very ill. This light form of malarial poisoning soon passes away 
on the removal of the cause, and is generally promptly removed 
by treatment, although relapses are frequent. 
A pernicious form of malarial poisoning is described, but is 
happily rare. This is called pernicious fever. It gets this name 
by being specially dangerous from involving important organs. 
This form is usually intermittent. One of the most frequent com- 
plications is that of the nervous system. Excessive headache, 
dizziness, and confusion of speech are its signs. After the chill, 
which is liable to be accompanied by convulsions, the patient falls 
into stupor and profound unconsciousness. He lies in this condi- 
tion for many hours, with hot, flushed face, dilated pupils, and 
folded limbs. The attack ends in a profuse sweating stage. If 56 
THE ACUTE INFECTIOUS DISEASES. 
the patient survives the first chill, he usually dies in some of the 
succeeding ones. 
Another form is that resembling cholera, and is so called. In 
this we have profuse watery evacuations during the fever, cramps 
in the limbs, coldness, vomiting of yellowish fluid, and great thirst 
terminating in collapse. 
Yet another form is the cold (algid) intermittent. The attack 
begins with a chill, but it is not until, or after, the resulting fever 
that the patient grows cold. The body becomes excessively cold ; 
the temperature in the armpit being 84° Falir., instead of the 
natural temperature, 98£° Fahr., while the mouth shows a temper- 
ature of 86° to 88° Fahr. The pulse is about forty, and the res- 
pirations as low as ten to the minute. The patient is conscious 
throughout, but is very apathetic. 
There is a hemorrhagic form, characterized by loss of blood 
from the bowels. 
The attack known as congestive chill must also be classed 
among these forms of pernicious fever. The danger in these at- 
tacks occurs during the chill, and consists generally of sudden 
and fatal congestion of the lungs. The author remembers seeing 
a case of this kind in Louisiana, which was appalling in the speed 
and agony of the death which followed. 
These forms of malarial poisoning are rare in the temperate 
malarious regions, and, as a rule, are seen only in those of the 
tropics. The congestive chill occurs in the southern part of the 
United States, and is even here, happily, but rarely met with. 
Treatment.—So widespread and prevalent are malarial dis- 
eases in some of their many forms, that for once we can depart 
from our rule and make treatment more important than prevention. 
The treatment of simple intermittent may be divided into stages. 
The cold stage requires but little attention. Avoid deluging 
the patient with hot drinks and stimulants, as these means will 
not cut short the chill. Stimulants must also be given with care, 
or not at all. A bed well warmed, and friction to the body and 
limbs, are all that is usually required. In case collapse is threat- 
ened, stimulants (wine or whiskey) may be given freely, warm 
applications, or mustard drafts to the feet and body may be used. 
In the hot stage, cooling drinks in small quantities, cold spong- 
ing, cold to the head, if there is much disturbance thereof, is 
about all that can be done. We must remember that the fever is 
self-limited. 
The sweating stage requires no special treatment. The patient 
is better left alone. It is well to change the dress and bed linen 
after this stage is concluded. [When the perspiration is profuse THE ACUTE INFECTIOUS DISEASES. 
57 
and long-continued, drying the skin with warm towels will help 
to arrest it.—Ed.] 
The real treatment is during the intermission. The one drug 
that has gained universal use is quinia, usually in the form of the 
sulphate. Small doses should be avoided, and ten-, fifteen- or 
twenty-grain doses be given in such a manner that the last one is. 
taken about five hours before the anticipated chill. Two doses of 
one of the above quantities are usually sufficient. One full dose is 
generally sufficient to prevent a relapse. In case the patient is be- 
coming debilitated, the persistent use of quinia is indicated—about 
three or five grains three times daily. Children from ten to fifteen 
years of age should be given about six grains at a dose, and of 
younger age, a single dose of four grains, or two doses of two 
grains. When the stomach rejects the drug, or in cases of perni 
cious fever in which it is desirous of producing a profound impres- 
sion on the system rapidly, the drug may be injected in neutral solu- 
tion under the skin. It may also be given by injection into the lower 
bowel, but is liable in the latter case to produce purging. Sulphate 
of cinchonidia is now being largely used in place of quinine. To 
produce the same effect the dose should be about one-fourth larger. 
The treatment of the pernicious forms must be governed by the 
special indications in each case. In these cases alarming symp- 
toms crowd one on the heels of another and demand the best skill 
and energy of a physician. 
In regard to the administration of quinia in the other forms of 
malarial diseases described above, nothing can be added of a 
popular, practical character to the above method. All forms of 
the disease should be regarded as sufficiently serious to require 
the counsel of a physician. 
Among preventive measures, drainage, cultivation of the soil, 
pure drinking-water, avoiding exposure to night air in swampy dis- 
tricts, high and dry sites for dwelling-houses, avoiding all ex- 
cesses, liberal diet, the prompt attention to any state of ill-health 
or depression—above all, avoiding known malarial regions, may be 
mentioned. If obliged to reside in these districts, quinine as a 
preventive should be resorted to in two- or three-grain daily doses. 
The surface-water of swamp lands ought not to be drank under 
any circumstances without having been boiled. 
The counter-influence of certain forms of vegetation on the 
malarial poison has been already referred to. The growth of the 
sun-flower and Acorus calamus (sweet-flag), has long been known 
to modify a malarious condition of the atmosphere. In the last ten 
years marked attention has been drawn to the sanitary effect of 
planting the Eucalyptus globulus in malarial regions. All ac- 58 
THE ACUTE INFECTIOUS DISEASES. 
counts show that the growing trees, in any number, greatly lessen 
or modify the poison. This tree is a native of Australia, grows to 
a great size, has large leathery leaves rich in volatile oils. The 
leaves have the peculiarity of growing upright, so that both sides 
are equally exposed to light and air. The oily extract from the 
leaves has been used internally in malarial diseases, with the result 
of curing eighty per cent, of the cases. 
It seems proper to guard the general reader against some wrong 
conclusions, that seem, at present, very popular, namely—quinine 
never enters the bones, or causes rheumatism, or loosens the teeth, 
or produces permanent deafness in either its curative or preven- 
tive use in malarial diseases. Many of the ill feelings following a 
•course of malarial disease, which are regarded as the result of 
the free use of quinine, are the after-effects of the disease itself— 
the malarial intoxication—and call for the further use of the drug. 
In this popular account of these diseases the writer has thought 
best to omit mentioning doubtful means of treatment. 
Influenza, or Epidemic Catarrhal Fever. 
Cause and Natural History.—Under these names is described 
an epidemic disease defined by a catarrh of the respiratory organs, 
and often of the digestive organs also, accompanied by rapidly 
developed weakness, headache, and pain in the limbs, with more 
•or less fever. 
The disease is noted for the vast extent of territory over which 
it will expand epidemically. It prevails independently of the 
atmospheric conditions which are known to favor catarrhal dis- 
eases, and is believed to depend upon miasmatic influences, the 
special form of which is not understood. The disease was first 
noted in 1510. Outbreaks of it occur in any latitude, and at any 
season of the year. The disease generally advances in epidemic 
waves from the east and north-east to the west, or, more rarely, 
radiates from an epidemic centre ; occasionally several of these 
>centres exist simultaneously at widely separated points. 
Epidemics of this disease develop usually with explosive vio- 
lence, so that in twenty-four hours, the inhabitants of whole cities, 
or wide extents of country, will be prostrated by the influenza ; 
while the decline is generally as rapid as the rise. Epidemics last 
from one to three months as a rule, No attempt is now made to 
prove the contagiousness of the disease. It attacks all ages and 
sexes ; first women, secondly males, and lastly children. This is 
•especially true of some epidemics, but not of all. Nothing is known 
concerning the exciting cause ; but, whatever the morbid essence 
may be, the atmosphere is probably the agent of its diffusion. 59 
THE ACUTE INFECTIOUS DISEASES. 
Symptoms.—The beginning of the disease is defined, usually, 
by a chill, or chilly sensations, alternating with flashes of heat, 
lasting for a few hours, very rarely for more than a day. The 
fever is sometimes quite marked, even when the disease is of a 
light character; it is remittent rather than continuous, and is 
worse at night. 
The catarrhal symptoms develop early, and involve the mucous 
membrane of the head, throat, and lungs. The discharge from the 
nose is profuse and irritating; the eyes are bloodshot and over- 
flow with tears ; the throat is sore, the voice hoarse, with tickling 
in the throat; cough from the onset is troublesome, dry, and 
spasmodic, often disturbing the patient at night. In many patients 
this is accompanied with difficulty of breathing, pain in the chest, 
or catching pains or stitches in the chest-wall. The prostration of 
the strength is very marked,' and the patient quickly takes to his 
bed from an overpowering sense of exhaustion. In addition, there 
are nerve-pains (or neuralgias) in the limbs and at the root of the 
nose. In some epidemics, there is sleeplessness and mental irrita- 
bility, and in others apathy and drowsiness. 
In uncomplicated cases the end is recovery, and the duration of 
the attack is from three to five days, terminating generally in a 
gradual subsidence of the symptoms. Occasionally the recovery is 
not complete, but is retarded by general debility, coughs, or severe 
headaches, and impaired appetite. Influenza is, however, often 
fatal to aged people, and in those who are debilitated from chronic 
diseases. 
Treatment.—In ordinary cases the treatment should be mild. 
Rest in bed ; warm foot-baths ; mustard plasters, and gentle stim- 
ulation, or warm drinks to promote perspiration, with frequent 
doses of muriate of ammonia in solution (one drachm to four 
ounces of water), a dessertspoonful every two hours. These are 
usually sufficient. Five to ten grains of Dover’s powder in case 
of pain, and inhalations of vapor of warm water, will add to the 
comfort of the patient. In cases of aged people, or in those greatly 
debilitated, the patient must be carefully watched, and stimulants 
and tonics early resorted to. Violent cough in such subjects ought 
to be allayed, for which an excellent prescription is : 
Powdered muriate of ammonia Thirty grains. 
Sulphate of morphia Three grains. 
Tincture of blood-root (Sanguinaria canadensis) Four drachms. 
Syrup of ipecac Four drachms. 
Syrup of liquorice. One ounce. 
To be mixed in two ounces of water, and to be given in teaspoonful doses every three 
to six hours. 60 
THE ACUTE INFECTIOUS DISEASES. 
Diarrhoea, which may be occasionally present, can be controlled 
with small doses of Dover’s powder, or of Tully’s powder (five 
grains), given in a little cold water. Inunctions of oils or glyce- 
rin over the nose gives considerable relief to breathing. If the 
fever should prove persistent, quinia in three to five-grain doses 
should be given every five hours, or it may be of use as a tonic, 
in two to three-grain doses, given thrice daily. 
Nothing, scarcely, can be said about preventive treatment. 
Aged persons and consumptives should be guarded against expo- 
sure, and confined to their rooms during an outbreak of an epidemic. 
Epidemic Dysentery. 
Cause.—Dysentery of the type defined in this chapter is an epi- 
demic disease of the tropics, or of camp-life. This epidemic dys- 
entery does not differ, in the manner in which it affects the bowel, 
from that which might be caused by irritating food, or from 
poisons, acids, or arsenic. Moisture and high temperature favor 
the development of the disease, or rather of the peculiar miasma- 
tic tendency; for evidently a certain miasmatic factor is necessary, 
since in some tropical climates the disease is not known, notwith- 
standing other conditions are favorable. 
The majority of writers deny that the disease is contagious, but 
Huebner thinks there is a limited contagion by means of the excre- 
tions, and every dejection of a dysenteric patient must be consid- 
ered as dangerous. Certain articles of food predispose to the 
disease. When torpidity of the bowel exists, as it generally does 
before the onset of the disease, it permits lodgment of the food in 
the irregularities of the large intestine, and thus induces a catarrh 
of the bowel. 
Symptoms.—The disease begins in a simple diarrhoea, which 
lasts from three to five days. The symptoms then become urgent; 
there is abdominal pain, a constant desire to evacuate the contents 
of the bowel (tenesmus), which consist mostly of thick mucous 
streaked with blood, and which, as the disease advances, becomes 
bloody mucous, or pure blood. The fever is moderate and of a re- 
mittent type, with headache, dizziness, and thirst. The bowel- 
symptoms have daily periods of remission, the early part of the 
day being comparatively free from straining, which generally 
comes on to torment the patient during the night. 
In mild cases the end is recovery in from eight to ten days. In 
severe cases the symptoms gradually augment and the patient 
succumbs to exhaustion. Sometimes the case terminates in chronic 
dysentery, which may linger for months, or even years. The dis- THE ACUTE INFECTIOUS DISEASES. 
61 
eased changes (pathology) consist usually of a catarrhal inflam- 
mation proceeding to ulceration of the large intestine. The death 
ratio of tropical dysentery varies from twenty to eighty per cent. 
Treatment.—The disease gives way better before a mild laxa- 
tive treatment than any other. It is well to begin with an emetic 
dose of ipecac (fifteen to twenty grains of the powder in warm 
water), followed every other day by cathartic doses of castor oil 
(one ounce). Soothing injections greatly relieve the pain, burning, 
and tenesmus of the rectum, such as linseed or slippery-elm tea, 
or of starch and laudanum (one to two drachms of the latter to 
each enema). Injections of very warm water are usually grateful 
and beneficial. The diet should consist of milk, uncooked beef- 
juice, strong soup, soft-boiled eggs, milk porridge. Cold drinks 
should be avoided, as they usually cause griping pains in the large 
intestine. Stimulants are to be avoided. The patient should be 
kept warm. All evacuations are to be at once carefully destroyed, 
and vessels and linen disinfected with chloride of lime or carbolic 
acid, and the room thoroughly ventilated daily. 
Epidemic Cerebro-Spinal Meningitis—Spotted Fever. 
Cause.—Nothing is known of the original source of this disease. 
All writers now admit that it is infectious. It prevails in tempe- 
rate regions and not in the tropics, and generally in the winter and 
spring. Childhood shows a marked susceptibility to the disease. 
Attacks are favored by bad hygienic surroundings, such as damp, 
overcrowded, ill-ventilated living and sleeping rooms, and the 
saturation of the soil with the results of decomposition. 
Whether the disease originates in a miasm or contagion is not 
yet settled. Ziemssen’s idea, which is the most acceptable, is that 
the specific poison is a “morbific germ, which primarily arises in 
the human body, and infects healthy neighbors only when it has 
undergone a certain, still unknown modification by means of cul- 
tivation in suitable intermediate individuals.” This does not imply 
contagion in the sense of small-pox or typhus. 
Symptoms.—The disease begins abruptly and with symptoms of 
serious sickness—chill, high fever, terrible headache, and vomit- 
ing, which is repeated whenever the patient gets up. In the more 
serious cases loss of consciousness is observed from the first, or 
a deep stupor, delirium, convulsions, and stiffness backward of 
the neck ; sometimes the whole muscular system of the back is in 
a continuous (tonic) spasm. The fever is often moderate, and of 
no particular type. The skin becomes highly sensitive to external 
impression (hypercesthetic), so that every touch and movement of 62 
THE ACUTE INFECTIOUS DISEASES. 
a limb elicits expressions of pain. The pain in the head is terrible, 
so that even in unconsciousness the patient strikes the head with 
the hands. Then follow eruptions upon the skin ; first, like cold- 
sores (herpes) upon the face, then irregular red patches (erythema) 
upon the body, flea-bite spots (petechice), or like prickly-heat (ur- 
ticaria). The eruption is not always present. About the third 
day the tongue becomes dry and cracked, the bowels are consti- 
pated, rarely is there diarrhoea. 
When the attack is to end in death, nervous irritation subsides, 
and the signs of depression increase; complete unconsciousness, 
involuntary evacuation of the bladder and bowels, extremely high 
fever, rapid pulse—too much so to be counted. Toward the end 
convulsive movements in the limbs, paralysis of the nerves of the 
face, or of one-half the body, profound stupor, and death are the 
usual order of events. 
In case of a termination in recovery, the irritability of the ner- 
vous system continues, with pain on the slightest movement; the 
eyes are painfully affected by light, and the ears by noises; the 
vomiting ceases in five or six days; the headache and stiffness of 
the neck gradually diminish, and convalescence begins in one or 
two weeks, and may be very protracted from the extreme emacia- 
tion and nervous disturbance. 
Varieties of the disease are the fulminant, or explosive, in which 
death ensues in a few hours ; and contrasted with this the abortive 
forms in which the attack is slight and undergoes a spontaneous 
recovery; the intermittent form, and the typhoid epidemic variety, 
none of which require for our purpose here more than mention. 
Examinations after death show that the force of the disease is 
expended upon the brain and spinal cord, the envelopes of which 
(the dura mater and pia mater) are congested and inflamed, while 
the substance of these parts exhibits rupture of small blood-vessels 
and softening. 
The mortality for all ages will average about forty per cent., the 
larger share of which occurs in childhood. 
Treatment.—The treatment of this severe disease is designed to 
meet the symptoms as they arise. The intense head-pains are very 
much relieved by ice-bags to the head and back of the neck; and 
the same application along the spine assuages very considerably 
the stiffness and pain in this region. 
Removing small quantities of blood by means of leeches or cups 
from the back, neck, and temples, gives temporary relief. The 
use of general blood-letting and mercury, although resorted to, is of 
doubtful utility. Quinia is of no particular use except in doses of 
fifteen to twenty grains to control high temperature ; but as mod- THE ACUTE INFECTIOUS DISEASES. 
63 
erate fever is the rule, and as the temperature does not become 
excessive except toward a fatal termination, there is but scant 
opportunity to use this drug with good results. 
Opium and morphia (its active principle) are remedies of great 
value in this disease. It is not rare to hear it popularly said that 
“pain never kills anybody,” but those who say this, little know 
the disastrous consequences of persistent and excessive pain. It 
is better to give the morphia hypodermically in one-eighth-grain 
doses repeated every one to two hours, if it is not well tolerated 
by the stomach. In this manner a few hours of quiet sleep may 
be gained each day. Ether applied in the form of spray upon the 
back of the head and neck, and along the spine, acts both as a 
powerful cooling agent and a local anodyne. 
At a later stage in the disease, iodide of potassium, in three- 
to five-grain doses every five hours, is a powerful agent in causing 
absorption of the inflammatory thickening of the envelopes of the 
brain and spinal cord. The inflammation of the brain sometimes 
results in deaf-mutism in children under three years of age, or loss 
of sight, or dropsy of the head in older children or adults, as results 
of the attack, treatment of which conditions is very nearly hope- 
less. 
The diet should be concentrated fluid nourishment given in 
small and frequent quantities during the height of the disease, re- 
sorting to solid food when convalescence is established.* 
Epidemic Diphtheria. 
Cause and Natural History.—Isolated cases {sporadic) will be 
considered here in connection with the epidemic disease, since such 
cases do not essentially differ from the latter in their course and 
treatment. 
The idea has, in some way, become popular that diphtheria is a 
comparatively modern disease ; the contrary is true. It is one of 
the oldest known epidemic diseases. Diphtheria is, according to 
Oertel, whose general description we are following, a miasmatic 
contagious disease. It occurs in isolated (sporadic) cases, as well 
as epidemically, and may be restricted to a locality {endemic). 
Statistics hitherto show that soil and drainage have but little if 
any effect upon the origin and course of the disease. The seasons 
are of some influence, as the mortality is greatest during the fall, 
winter, and early spring. Hygienic relations have a marked ef- 
fect. Poverty and uncleanliness; crowding of many people in 
* See, also, the Chapter on the Nervous Diseases of Infancy and Childhood. 64 
THE ACUTE INFECTIOUS DISEASES. 
damp, ill-ventilated living or sleeping rooms; the emanations 
from privies, sewers, and manure-heaps, are favoring conditions. 
Crowded work-rooms or factories, school-rooms, and orphan asy- 
lums are favored fields for the operation of the contagion. 
That the disease may be diffused by actual contact with affected 
persons is well proven. It may, however, be communicated by 
the peculiar miasm, or epidemic tendency. It will thus infect va- 
rious persons in the same house or family in which a case of the 
disease has existed ; it will also attack other families who have not 
been in such relations with an existing focus of the disease. The 
first is an instance of contagion ; the other of epidemic tendency. 
The disease has been successfully inoculated upon the mucous 
membranes of animals. The virulence of the contagion depends 
upon the severity of the case in which the specific poison had 
its origin. This is only true generally, as a light case may induce 
a fatal attack. This difference may be explained by the predis- 
position of the individual to the diphtheritic inflammation. This 
contagion may be carried through the air, or be diffused by the ex- 
halations or secretions of the patient. The poison may cling to 
certain places, houses, or rooms, in which the disease may break 
out sporadically after long intervals. The existence of catarrhal 
inflammation of the mucous membranes of the head and throat 
is thought to increase the liability to infection. This liability is 
greatly increased in children ; adults take the disease, but not so 
readily or severely. An attack of the disease affords no im- 
munity against a second attack ; on the contrary, it seems to 
render many persons liable to a renewal of the attack. 
Recently the disease is supposed to hold certain relations to 
minute forms of vegetable organisms. These forms are so minute, 
that Oertel says they are upon the very border lands of the visible. 
These organisms are commonly known as bacteria, of which there 
are several forms. One of these, the spherical bacteria (micrococ- 
cus)> penetrates the tissues wherever a diphtheritic membrane ap- 
pears ; another form is the rod-like bacteria, found only in the 
mouth and fauces. These are the two principal organisms that 
hold an important relation to the disease ; several other forms are 
observed, but are not yet classified.* 
The facts noticed are these : when lower and less active forms 
of minute vegetative life (leptothrix buccalis, oidium albicans) are 
found in simple ulceration, catarrhal or otherwise, in the throat 
and mouth, round and rod-like bacteria quickly crowd out and 
destroy them when diphtheria occurs ; and when the false mem- 
* See page 7 for description and illustrations. THE ACUTE INFECTIOUS DISEASES. 
65 
brane is cast off and diphtheritic inflammation subsides, the higher 
forms of bacteria disappear, while the lower return. These para- 
sites are not the bacteria of decomposition, for those of diphtheria 
when inoculated into animals multiply with wonderful rapidity, 
and produce serious illness, while those of decomposition, when 
inoculated, form generally local abscesses. These vegetable para- 
sites are not a matter of accident, but are inseparable from the 
diphtheritic disease. Eberth says, “ without bacteria (micro- 
cocci) there can be no diphtheria.” 
The incubation of the disease is variable, and depends upon the 
intensity of the infecting force. Between the lodgment of the 
germs upon the tissues, and the local evidence of the disease, a 
period of about forty-eight hours exists. 
Symptoms.—I shall first describe the lighter or catarrhal form. 
The first evidence is a slight feeling of indisposition, which in 
grown subjects is generally not regarded, followed by a dryness of 
the throat and pricking pain in swallowing, and slight swelling of 
the tonsils. On inspection, the palate and throat (fauces) appear 
of a vivid red, while the mucous membrane appears thickened. 
The next event, after an interval of a few hours or a day, is the 
appearance of small white or yellowish-white spots arranged in 
groups or irregular circles, on the tonsils. In the more active 
cases, slight fever, 102° or 103° Falir., lasting two or three days, 
occurs with pain in the head and dulness of the intellect. 
In the course of twenty-four hours or more, the redness of the 
throat lessens, as well as the puffy look of the mucous membrane, 
while the points covered by the membranes become dirty yellow in 
appearance, standing out upon the general surface. On the third or 
fourth day, the false membrane becomes detached, and the case 
is practically over. In more severe forms the fever persists longer, 
the glands in the neck and under the jaw become slightly enlarged 
and tender, while the redness of the throat and adhesion of the 
membranes persist. From the fourth to the sixth day, a sudden 
increase of the fever is noticed, ranging from 103° to 104° Fahr., 
with high pulse and hot and painful head. Dryness, burning in 
the throat, pain in swallowing, and a rapid extension of the false 
membrane are observed. The general symptoms are evidence 
that the system at large has become infected ; and in this manner 
the catarrhal may become the croupous form of the disease. 
The croupous form begins with marked fever, resembling the 
early symptoms of scarlet fever, headache, the back and limbs are 
painful, and there is prostration, vomiting, restlessness, or drowsi- 
ness—the latter especially with children, together with dryness of 
the throat and pain in swallowing. The glands of the neck and 
Voii. II.—5 66 
THE ACUTE INFECTIOUS DISEASES. 
under the jaw become tender and swollen. At this stage the throat 
becomes red, the mucous membrane having a puffed, bloated 
look, glistening as if varnished, while the tonsils and deeper 
parts become greatly enlarged. But a few hours are needed to 
develop a false membrane, either in groups or extensive patches, 
first over the tonsils, and then gradually extending over that por- 
tion of the throat seen through the open mouth. In the course of 
ten or twelve hours the swollen mucous membrane has assumed 
a dirty, or grayish-wliite color, and the membrane has become 
thick and leathery, and may be removed in strips, leaving a raw- 
appearing mucous membrane beneath, which is generally covered 
with a layer of pus after twenty-four hours or so ; or, after about 
the same interval, by a renewal of the false membrane. 
During the progress of the disease, the general and local symp- 
toms do not always run a parallel course ; the local disease ex- 
tends, while the fever subsides, and the patient is lured into a false 
idea of recovery. In the same way, pain in swallowing, and sore- 
ness in the throat may diminish while the exudation is slowly ex- 
tending into the great air-passage of the throat (larynx and 
trachea). Usually, however, the fever and general disturbance 
increases with extension of the local condition. In addition to an 
extension of the inflammation, a large quantity of semi-fluid, 
sticky mucous is secreted, which, unless the mouth and throat is 
carefully cleansed with disinfecting gargles, becomes intolerably 
offensive. 
As the false membrane extends into the larynx, the symptoms 
of obstructed breathing come on, which are so terrible to witness 
in young children, and which may prove fatal by suffocation. The 
invasion of the larynx occurs early—usually in three to five days. 
The symptoms of croup may be the result of thickening and infil- 
tration of the mucous membrane of the opening of the upper air- 
passage, and not from the membrane. 
Albumen is noticed in the urine in about two out of every three 
cases of diphtheria, and is a useful guide in removing doubt in a 
suspicious case of sore throat. 
In severe cases, usually, a new danger arises from poisoning of 
the system by absorption of the decomposing secretions of the 
throat. These cases are defined by the extreme offensiveness of 
the breath, the great rise in the fever, and signs of extreme pros- 
tration, while the glands of the neck become enormously swollen. 
Recovery from this form is very rare. 
Secondary affections are paralysis of the muscles of the palate, 
impairment of vision and, more rarely, paralysis of the arms and 
legs. These effects of the attack are developed slowly, not usually THE ACUTE INFECTIOUS DISEASES. 
67 
earlier than the second or third week, and even so late as the 
fortieth day. The ordinary termination of paralysis caused by 
diphtheria is in recovery, in light cases in from six to eight weeks, 
and in the more severe, in as many months. 
Every well-marked case of diphtheria must be looked upon as 
dangerous to life, until it ends in recovery. This is invariably the 
rule in children. Isolated (sporadic) cases are more favorable than 
those occurring in the epidemic variety of the disease. The mor- 
tality of different epidemics ranges from thirty to forty per cent., 
the rate of mortality increasing in proportion to the number of 
children attacked. In children the outlook is always of the 
darkest character, while in adults, good health and constitution 
usually enable the patient to recover. 
Treatment. — The local measures are very important. The 
means which Oertel recommends, and which have the sanction 
of other high authorities, is the inhalation of vapor of hot-water; 
under this treatment the formation of pus is favored in the mu- 
cous membrane of the throat, which tends to form a line of 
demarcation against the further extension of the false membrane. 
A croup-kettle, or any other vessel which can be covered by a 
funnel, to conduct the steam to the mouth, is the proper means.* 
Common salt, or chlorate of potassium (fifteen grains to the 
ounce), may be added to the water. In severe cases, inhalations 
should be used every half-hour for ten or fifteen minutes, and 
gradually at lengthened intervals, as the diphtheritic inflamma- 
tion subsides and membrane is cast off. For the purpose of limit- 
ing the danger of absorption of infecting material from the throat, 
a gargle of chlorine water, made as follows, may be used : 
Chlorate of potassium i an ounce. 
Muriatic acid 2 drachms. 
Water 1 quart. 
Put the first two into a strong quart bottle, and as the fumes which arise are given 
off, pour in the water. Keep the bottle corked. 
Another gargle may be made thus : 
Permanganate of potassium 24 to 48 grains. 
Water 1 pint. 
Or, 
Oil of thyme 1 drachm. 
Alcohol pint. 
Water | pint. 
Of either of the above, one or two tablespoonfuls, repeated once or twice, may be 
used each time. 
* See, also, chapter on the Throat. 68 
THE ACUTE INFECTIOUS DISEASES. 
In very young children a swab or syringe may be used to clean 
the throat. Caustics and strong solutions of iron, and other as- 
tringents should by no means be applied to the throat. 
When the larynx becomes involved, with obstruction to breath- 
ing, the case is urgent, and strong means require to be taken to 
remove the obstruction. The membrane may be detached, in some 
cases, by giving emetics. Syrup of ipecac, in teaspoonful doses 
given with warm water; alum, in teaspoonful doses dissolved in 
water, in cases of small children; or from one-half to one grain 
of tartrated antimony (tartar emetic) in case of older children 
or adults, in water, are useful. Efforts have been successfully 
made to remove the membrane from the opening into the air-pas- 
sage (glottis) by means of suitable instruments. The vapor inhala- 
tions should also be used more energetically. When suffocation 
is imminent, an opening into the wind-pipe (tracheotomy) has been 
resorted to, but has been followed by death in nearly every clearly 
proven case of diphtheria. The most that can be said in favor of 
the operation is, that the terrible symptoms of suffocation are 
relieved, the patient meanwhile gradually dying by the less painful 
method of slow blood-poisoning from the open wound. 
The general treatment must be directed to moderating the fe- 
ver, for which quinia, in doses proportioned to the age of the patient, 
of two and a half to ten or fifteen grains, may be given. The 
quinia is also useful in sustaining the vital forces. When the gen- 
eral symptoms improve, constitutional treatment may be for a time 
suspended, carefully watching, meanwhile, the bodily temperature 
and the strength. If strength fails in the later stages, iron in the 
form of tincture of the chloride, in doses of three to fifteen drops, 
two to three times a day, according to the age of the patient, may 
be given in a couple of teaspoonfuls of glycerin and water. Under 
the same circumstances stimulants may be resorted to in proportion 
to the depression and the age of the patient. For small children, one 
part of brandy to two parts of syrup of orange-peel may be given 
in doses of a teaspoonful or more; or the stronger wines for older 
children and adults. The amount of stimulants a patient in a 
condition of approaching collapse will consume in the course of 
the day is astonishing. If the pulse were to sink and the bodily 
temperature rapidly decline, no benefit could be gained from either 
stimulant or tonic treatment. In cases in which prostration is 
marked, hypodermic injections of brandy are very valuable. 
The treatment of the milder forms of paralysis is simple, as 
the tendency is toward a spontaneous cure. Iron and quinine, in 
quantities mentioned above, will prove useful in cases in which 
debility is present. Electrical treatment is to be resorted to with the acute ineectious DISEASES. 
69 
caution, and never except under the advice of a physician skilled 
in its use. 
The preventive treatment, spoken of so frequently in relation 
to other infectious diseases in this chapter, will apply with great 
force to this scourge of our modern civilization. If public hygiene 
could be brought to what yet exists as ideal perfection, there is no 
doubt that diphtheria could be stamped out. 
Acute Eruptive (Exanthematic) Diseases. 
Under this group is included a class of diseases which arise from 
a specific contagion, and are distinguished by peculiar appear- 
ances upon the skin. These are measles {rubeola), scarlet fever, 
{scarlatina), chicken-pox {varicella), small-pox {variola), and the 
artificial disease of vaccination {vaccinia). The latter is treated 
of hereafter. 
Small-Pox. 
Cause and Natural History.—We are able to say nothing about 
the cause of this disease further than that it is the result of a spe- 
cific poison or contagion, from which no period of life is exempt. 
The disease spreads by means of a specific poison, “ which is gen- 
erated in the body of a small-pox patient and conveyed directly or 
indirectly to a predisposed person,” and produces in him an attack 
of the disease. This poison is contained in the small-pox pustule 
or eruption, and also in the secretions of the body. The contagious 
stage of the disease is when the pustule contains matter in its ear- 
liest stage ; it can be conveyed, however, before the eruption has 
appeared. An attack of the disease gives exemption from the dis- 
ease for the remainder of life, as a rule. 
Symptoms.—After exposure to the contagious poison, a period 
of ten to thirteen days passes ; then occurs the first (initial) stage. 
This is ushered in by a chill, or by several chills, followed by fever, 
which lasts until the eruption appears. During the fever the head- 
and back-ache are intense ; the latter, in epidemics of small-pox, is 
a symptom recognized as most characteristic by many people. The 
tongue is covered by a whitish-yellow coat; the breath has a pe- 
culiar “ greasy ” and offensive odor; the appetite is destroyed, 
and nausea and vomiting are not unusual. When the mind is dis- 
turbed, it usually is limited to talking strangely, more rarely there 
is delirium, while nearly all suffer from sleeplessness. Toward the 
end of the first stage the throat becomes red and swollen, while 
distinct red spots, which are not rarely noticed, are very important 70 
THE ACUTE INFECTIOUS DISEASES. 
in defining the disease even during this stage. In late years atten- 
tion has been called to a rash, greatly like that of scarlet fever, 
which appears during the initial or commencing fever (and hence 
called the initial rash), and which is usually seen on the abdomen 
and inside of the thighs. 
At the end of the third or on the beginning of the fourth day 
the eruption appears ; first upon the face, scalp, nose, and upper 
lip. Its first appearance is that of slightly red spots, from a 
millet-seed to a pin-head in size, and is attended by burning and 
itching. A few hours later, small, red, sliot-like points appear 
upon the back, breast, and arms, gradually invading the whole 
body. On the second day of the eruption (the fifth of the disease) 
these t points have become dark red, enlarged and elevated 
{papules). On the third day of the eruption these elevated points 
become filled with a clear milky fluid {vesicles). These vesicles 
enlarge until the seventh or eighth day, when they become conical 
in form and about the size of a pea; and as this gradual enlarge- 
ment takes place the point becomes depressed {unibi Heated). On 
the eighth day, the eruption, which has been gradually growing 
cloudy and pearly, becomes thick and yellow ; the vesicles are now 
filled with matter {pustules), and this defines the stage of suppura- 
tion. These points of suppuration sometimes merge one into the 
other, becoming what is termed confluent. This is the terrible 
stage of the disease, in which, from the swelling of the skin and 
underlying parts, the face is distorted beyond recognition. 
Upon any point of the surface that has been scratched or irri- 
tated, the maturation occurs with greater intensity. At the same 
time the small-pox eruption appears upon the mucous membranes, 
especially of the mouth and throat, where it runs essentially the 
same course as that upon the general surface of the body. 
As soon as the eruption appears, the initial fever, the pain in 
the head and back, and the nausea or vomiting, subside. 
When the vesicles become filled with matter {pustules), fever 
again makes its appearance. This is called the “ suppurative fe- 
ver,” and continues from three to eight days, attended with rest- 
lessness and want of sleep. 
On the eleventh to the twelfth day the pustules begin to dry, 
forming, on the thirteenth or fourteenth day, hard, brown scabs, 
which are cast off by degrees, attended by intolerable itching, the 
general surface often appearing red and spotted. 
A form of the disease called varioloid occurs in those who are 
partially protected by vaccination, or in those who have naturally 
a slight susceptibility to the small-pox contagion. In this form 
the initial fever is lighter; the eruption remains in the form of THE ACUTE INFECTIOUS DISEASES. 
71 
vesicles, which do not become pustules ; and there is no suppura- 
tive or secondary fever. 
When an attack of true small-pox terminates in death, the 
usual signs are dry tongue and delirium, with dysentery, diar- 
rhoea, hemorrhage, pneumonia, or bronchitis, the two latter gen- 
erally appearing in the course of the secondary fever. In the con- 
fluent form, death may occur in the suppurative stage from 
exhaustion. 
Before Jenner’s discovery of vaccination, deaths among children 
were fully one-tenth of the whole number of cases, and now, where 
compulsory vaccination is in force, the death-rate in infancy is only 
about two per hundred. The average mortality for all ages is 
from fifteen to twenty per cent., according to the severity of the 
epidemic influence. 
Treatment.—In the initial stage we can do nothing but alle- 
viate the general condition. The room should be kept at a tem- 
perature of 60° or 70° Fahr., and the patient should be kept cool 
(popular prejudice to the contrary notivithstanding), giving lemon- 
ade or Selters water, and milk with lime-water for food. 
When the eruption appears, the treatment must be governed by 
circumstances. The best way to manage the eruption is to apply 
cold-water compresses, especially to the face and hands ; the 
swelling, redness, and pain, are thereby very much lessened. 
Pitting is not prevented by this means, or any others, such as appli- 
cations of tincture of iodine, or mercurial ointment. The throat 
may be gargled with 
Chlorate of potassium 2 drachms. 
Water 1 pint. 
Or, 
Permanganate of potassium 30 grains, 
Water 1 pint, 
as already described in speaking of diphtheria, or with a tea 
made with one ounce of marsh-mallows steeped in a pint of boil- 
ing water and sweetened slightly. 
The diet should be beef-tea, milk, milk and egg, broths, or por- 
ridge. In case of restlessness and delirium, hydrate of chloral, in 
ten or fifteen-grain doses, dissolved in well-sweetened water, may 
be given if the throat is not too sore ; if this cannot be given, the 
following may be substituted: 
Bromide of potassium 5 to 10 grains. 
Sulphate of morphia | grain. 
Water 1 ounce. 72 
THE ACUTE INFECTIOUS DISEASES. 
If the patient shows signs of failing vitality, or of collapse, 
stimulants may be freely used. When the crusts begin to be cast 
off, warm bathing may be used with advantage. 
Prevention.—Vaccination and re-vaccination as often as every 
five to eight years, and whenever there is an epidemic of the dis- 
ease. 
Chicken-Pox—V arie ella. 
Cause.—This disease has been supposed to hold peculiar rela- 
tions to small-pox, which idea is now obsolete. The disease can- 
not be communicated by inoculation. It is doubtful if it is conta- 
gious, it certainly is not in the same sense as small-pox. One 
attack protects the system against a second, but not against small- 
pox, and the disease usually occurs in epidemics, mostly among 
children. 
Symptoms.—Fever, without a previous chill, usually very light, 
sometimes scarcely noticeable, and lasting two days, is the initial 
symptom. On the second day the eruption appears, first as small 
red spots, which quickly form vesicles. The eruption usually 
appears in successive crops, for two or three days. The vesicles 
are clear and transparent, or slightly yellowish, and easily broken, 
and they maturate on the fourth or fifth day. They dry up and 
form small, brown crusts by the sixth day, leaving on the surface 
red but not depressed spots. Now and then, when a vesicle is 
scratched, a pit will form, but this is rare. 
Treatment.—No special medication is required. At most, a 
dose of a teaspoonful of calcined magnesia and light diet for a day 
or two will meet all the demands. 
Measles—Rubeola. 
Cause.—This disease, like all others of its class, originates in a 
specific, contagious influence that is generated in the bodies of 
those affected with the disease, and is capable of infecting others 
either by personal contact or through the air. It prevails generally 
in epidemics. 
Symptoms.—The early symptoms are headache, pain in the 
limbs, lassitude, and chilliness followed by fever. With the devel- 
opment of the fever (sometimes before it), are symptoms of catarrh 
of the nose and throat, red and watery eyes, huskiness of the voice, 
and a hard, dry, hoarse cough. Sometimes the fever is nearly ab- 
sent, the catarrhal symptoms being all that are noticeable of this 
stage, but cases are not unfrequent in which the intensity of the 
early fever is extreme. During this stage very young and teething 73 
THE ACUTE INFECTIOUS DISEASES. 
children are sometimes attacked by convulsions. On the begin- 
ning, or toward the end of the fourth day, the rash appears in the 
form of fine, red, slightly elevated spots, which disappear on pres- 
sure. These appear first upon the face, neck, and chest, generally 
covering the lower limbs in forty-eight hours. The rash soon runs 
together in irregular, crescent-shaped clusters, with intervening 
spaces of very nearly healthy skin. The eruption feels rough to 
the finger, with now and then small elevated points, or small vesi- 
cles scattered over the surface, with itching and tingling on the 
third day of the eruption, which is the height of the disease. 
The fever and catarrhal symptoms continue during the rash. 
On the eighth day of the disease (fourth of the eruption) the rash, 
fever, and catarrh decline together. The red color gives way to a 
dirty yellow tinge, ending in fine bran-like scabs, and is complete 
in four or five days. 
There are many diversities in the time of appearance of the rash, 
in the rash itself, both in duration and extent and in the fever 
and catarrh. The disease is sometimes of a malignant character 
and quickly fatal. From the dark color of the eruption one variety 
is popularly called “black measles but this is fortunately rare. 
Pneumonia and bronchitis are the most dangerous complica- 
tions. Inflammation of the bowel, with diarrhoea and inflamma- 
tion of the eyes and throat, are common ; the latter, when occurring 
in a membranous form (like croup), is nearly always fatal. The 
danger is greater of a fatal ending to cases of measles occurring 
in old people and in young children, and in winter than in warm 
weather. 
There is a slighter and shorter form known as Rotheln, or 
“ German measles,” and to which some writers give the name of 
rubeola, which term I have used as a synonym of measles. 
Treatment.—Like all the specific eruptive diseases, the treat- 
ment mainly consists in relieving unfavorable symptoms as they 
occur. Light cases do not require any attention other than rest. 
The diet should be simple and nutritious. Cooling and effervescing 
drinks, with one to two-drop doses of tincture of aconite root at 
intervals of an hour, when the fever is high, will afford comfort 
to the patient. 
If the catarrhal cough is troublesome, the following may give 
relief : 
Muriate of ammonium BO grains. 
Sulphate of morphia 3 grains. 
Powdered licorice-root 1 drachm. 
Water 4 ounces. 
Give a teaspoonful every four or five hours. 74 
THE ACUTE INFECTIOUS DISEASES. 
When signs of pneumonia present themselves, they should be 
attended to as if resulting from an ordinary attack of that dis- 
ease. If symptoms occur which resemble croup or diphtheria, the 
treatment described in speaking of diphtheria should be resorted 
to. 
Malignant measles should be treated like typhoid (low) con- 
ditions, elsewhere described in this chapter. [See page 32.] In 
case the eruption suddenly disappears, hot baths, or foot-baths of 
mustard and water, with mint teas, will tend to restore the rash. 
The same means may be employed if the rash is slow in appear- 
ing. The convulsions which sometimes attend the outset of the 
disease in early childhood are to be treated by hot baths, mustard 
poultices to the feet and limbs, cold applied to the head, and three 
to five-grain doses of bromide of potassium dissolved in an ounce 
of water and given every hour. 
Diarrhoea (which is often present), when moderate, is not to be 
interfered with; but when violent, teaspoonful doses of chalk 
mixture every hour, in case of children, may be given ; similar 
doses of paregoric in adults will answer the same indication. 
Prevention.—The most efficient method of prevention is isola- 
tion of the patient. Attempts have been made to modify the 
disease by inoculation. The result is said to be favorable, but the 
measure has never become popular. 
Scarlet Fever—Scarlatina. 
Cause.—A disease having its origin in an acute specific conta- 
gion or virus conveyed from a patient to an unaffected individual. 
We can say nothing more than this without invading the field of 
speculative epidemiology, than which nothing can be more unsat- 
isfactory to the popular reader. 
Symptoms.—The period which elapses between exposure to the 
disease and its outbreak averages from four to seven days. With 
or without any preliminary chills, languor, or pains in the back 
and head, the fever sets in with flushed face, furred tongue, loss 
of appetite, nausea, or vomiting.* The intensity of the fever 
may be of all possible grades. Sometimes in advance of the fever, 
and at other times just after its onset, inflammation of the throat, 
with swelling and intense redness, presents itself. The tongue 
[* In many cases this is one of the first symptoms which a parent will observe, while, 
in a small number of instances and in young- children, a convulsion is the first to attract 
attention. —Ed. ] 75 
THE ACUTE INFECTIOUS DISEASES. 
exhibits red points (papillce) upon its surface, with red edges and 
tip.* 
On the second day, usually, of the fever, the rash makes its 
appearance ; first upon the neck and breast, whence it gradually 
extends over the whole body. At first it is in minute red spots or 
points, which rapidly run together in large patches, and in the 
course of a few hours form a continuous scarlet rash over the body. 
Sometimes the skin appears swollen, or small vesicles and minute 
prominences are scattered through the general eruption. The 
rash, however, offers many exceptions to the above. 
The fever is continuous through the whole course of the erup- 
tion. The disease is at its height from the fifth to the ninth day, 
when the rash fades, the fever abates, and is quickly followed by 
scaling off of the cuticle (desquamation), which process is often 
attended by itching and irritation of the surface. A few days 
after the beginning of desquamation, albumen may be detected in 
the urine in nearly all cases of scarlet fever. 
Simple forms of scarlet fever occur in which the throat symp- 
toms are wanting (scarlatina simplex), and such cases are usually 
mild. 
Another and very serious form is that in which the throat 
symptoms are the most prominent event (scarlatina anginosa). 
The eruption is usually later in making its appearance, and, as a 
rule, is less copious. Patches of what resembles false membrane 
appear early upon the tonsils. The breath has an offensive odor. 
The glands under the jaw and at its angle are swollen and painful. 
Swallowing is painful and difficult. A thick mucous is secreted in 
the throat, which clings to the surface and is difficult to swallow or 
cough up. The inflammation often extends up the nose, which 
discharges an offensive and irritating mucous. The coating upon 
the tongue disappears early in the attack, and the tongue itself 
becomes dark red and smooth, or with projecting points {papillce). 
As the disease abates the incrustations of false membrane upon 
the tonsils gradually disappear, leaving the surface red and some- 
times ulcerated. Recovery is slower in this form, and secondary 
diseases are more liable to be developed. Suppuration of the 
glands of the neck and general blood-poisoning are not rare results. 
The disease is now and then malignant in its form {scarlatina 
maligna, malignant sore throat). This phase of the disease is 
very fatal—often even in its first stage. 
[* These red points are often sharply defined in the midst of a whitish or yellowish 
coating of the tongue, and give it an appearance similar to the seeds of a strawberry ; 
hence this condition is commonly known as a “ strawberry tongue.” This is not, how- 
ever, strictly characteristic, as is popularly supposed, for it is seen in other diseases.—Ed.] 76 
THE ACUTE INFECTIOUS DISEASES. 
A long train of evils (sequelae,) often follow scarlet fever. Sup- 
purative disease of the throat, ears, and neck; troublesome and 
even dangerous diarrhoea ; inflammation of serous membranes, as 
of the brain (meningitis), of the chest (pleurisy), or of the bowels 
(peritonitis) ; inflammation of the joints, resembling rheumatism ; 
and, most serious of all, dropsy, are among the more common after- 
effects. The dropsy is due to disease of the kidneys, and is at- 
tended by scanty urine containing albumen.* 
The results in a case of scarlet fever are always uncertain. 
Not only are its immediate results highly dangerous, but the after 
effects as well. The grade of the disease in each epidemic has an 
important bearing upon the expectation of results (prognosis). 
Female patients bear the disease better than males, but it is very 
dangerous in pregnant and lying-in women. The greatest mor- 
tality occurs in children under ten years of age. The mortality 
of the first year of life is estimated by Fleischmann at 75 per cent.; 
from the second to the fourth year at 43 per cent. ; from the fifth 
to the twelfth year a*t 19 per cent. ; and from the thirteenth to the 
twentieth year 5 per cent. Others place the aggregate mortality at 
5 per cent. 
Treatment.—A disease, the course of which cannot be cut short 
or interrupted, tends naturally toward recovery. The proper 
course, therefore, is to be prepared to attend to each symptom as 
it becomes more or less urgent, and not to make attempts at cura- 
tive treatment. The simple form of the disease, or that in which no 
urgent throat symptoms present themselves, is to be treated by rest 
in bed in a room having a temperature of about 60° Fahr., until the 
peeling off of the outer skin is completed, with full or sponge baths 
daily at the temperature of 65° to 95° Fahr. Simple gargles of 
chlorate of potash or muriate of ammonia are useful. [See formu- 
las below.] If the stomach is irritable for a day or so, food should 
be given sparingly ; milk and broths may, however, be used. Other 
than this it may not be necessary to give medicine at all. 
If the fever is very high, use cold baths. Old-time prejudice must 
give way before the fact that a cold bath in the high temperature of 
scarlet fever is never harmful and always useful. Blood-poisoning 
may in a measure be counteracted or retarded by quinine in doses of 
three to fifteen or twenty grains, according to age ; or, as Thomas 
recommends, the sulphocarbolate of sodium to the extent of fifteen 
to sixty grains daily, in doses of three to nine grains each, dissolved 
in water. Collapse is to be treated by free use of brandy, or car- 
* [This result is said to be most common in cases where the amount of rash on the 
skin has been least. —Ed. ] THE ACUTE INFECTIOUS DISEASES. 
77 
bonate of ammonia, in three to ten grain doses in solution in water, 
and given frequently. In case of retarded eruption, use mustard 
poultices, friction of the surface, or a warm bath, if not contrain- 
dicated by excessively high temperature. Anointing the skin with 
lard, cosmoline, the rind of bacon or ham, or with a lump of cocoa- 
butter, will sometimes favor the eruption, and will always tend to 
relieve the itching and tingling of the skin. 
For ordinary throat symptoms nothing need be done further 
than has already been mentioned. [See below.] In very young 
children it is impossible to do anything locally, on account of the 
excitement of the patient caused by any attempt to make appli- 
cations to the throat. Cold fomentations to the swollen glands 
of the neck, slight incisions with a knife, in case of adults, and 
pencilling with a solution of nitrate of silver in children, when the 
tonsils threaten suffocation by enlargement, may do some good; 
but these measures must, of course, be left to a physician. 
Chlorate of potassium 2 drachms. 
Water 1 pint. 
Or. 
Permanganate of potassium 1 drachm. 
Water 1 pint. 
Or, 
Chlorate of potassium | an ounce. 
Muriatic acid 2 drachms. 
Put the two substances into a strong bottle, and, while the fumes which arise are 
escaping, add a quart of water and cork the bottle. 
Or, 
Carbolic acid (pure) 1 drachm. 
Hot water pints. 
Let it cool and use as a gargle. 
DISINFECTING GARGLES. 
. During convalescence, nourishing diet, tonics, and preparations 
of iron will assist nature in rousing the exhausted vitality. 
The various complications that attend a case of scarlet fever 
are to be treated like independent affections, such as are described 
in other portions of this volume. 
Great importance must be given to prevention (prophylaxis). 
This is best accomplished by removing the well from the sick, or 
by rigid seclusion of the latter in a remote part of the house, to 
which only the attendant is admitted. Carpets, window drapery, 
and all unnecessary furniture of every kind must be removed from 
the room. Ventilation should be constant, but no draughts should 
blow directly over the patient, though this may not be particularly 78 
THE ACUTE INFECTIOUS DISEASES. 
feared. Expectoration, urine, and discharges from the bowel 
should be received in vessels in which carbolic acid solution or 
chloride of lime is contained. The patient’s linen should be 
changed often, and at once put, before boiling, in carbolic acid 
solution made by adding an ounce of pure carbolic acid to a bucket 
of hot water. Instead of handkerchiefs, which are in great de- 
mand about a patient, inexpensive pieces of cotton cloth, or soft old 
muslin, should be used and burned directly afterward. The attend- 
ants should be religiously neat in their persons, frequently washing 
the hands in disinfecting fluid (such as the carbolic acid solution 
mentioned above), as well as disinfecting their clothes before 
coming in contact with well persons. For articles of clothing that 
cannot be washed, the best way to disinfect is to expose them to 
the heat of an oven and then airing and beating them. The fine 
scales that are cast off from the skin during the peeling of the 
outer skin are supposed to be highly infectious, and great care must 
be taken to prevent them flying about the house or room. Cover- 
ing the body with olive oil and then carefully bathing the patient 
is a good plan. The patient ought not to be allowed to mingle with 
the family until the scaling off of the skin is completed. The room 
should then be disinfected with burning sulphur upon a hot shovel,* 
newly painted, papered, or whitewashed, and kept open to the air 
for some time before it is used again by the family. 
The invariable rule should be to guard young children under ten 
years of age, by all possible means, from scarlet fever infection. 
Table of the Distinguishing Signs of the Eruptive Diseases. 
It is sometimes not an easy task to distinguish one eruptive 
disease from another. It is believed that the following table, con- 
densed from Dr. Da Costa’s graphic description of these diseases, 
will prove useful to the general reader • 
DIFFERENCES BETWEEN SCARLET FEVER, MEASLES, AND SMALL-POX. 
Scarlet Fever. 
Measles. 
SmaU-pox. 
Period of attack after expo- 
sure : from a day to two 
weeks. 
Period of attack after expo- 
sure : seven to fourteen 
days. 
Period of attack after expo- 
sure : six to twenty days. 
Fever with great heat of 
skin, very high pulse, per- 
sists through eruption. 
Fever moderate, heat of 
skin and pulse rather in- 
creased by eruption. 
Fever very high, with 
bounding pulse, great 
pain in loins, and relief 
on appearance of eruption. 
* [See, also, section on Cholera, page 92.] THE ACUTE INFECTIOUS DISEASES. 
79 
Scarlet Fever. 
Measles. 
Small-pox. 
Eruption on second day, 
first on neck and chest; 
spreads rapidly. 
Eruption on fourth day, first 
on face ; spreads slowly 
in about forty-eight hours 
over the rest of the body. 
Eruption at end of third or 
beginning of fourth day; 
first on lips and forehead. 
Eruption uniform, or in 
large patches, scarlet line 
interspersed with raised 
spots and some small 
vesicles, seventh day 
from its appearance, fol- 
lowed by very complete 
desquamation (scaling). 
Eruption in crescent-shaped 
patches, between which 
is healthy skin; lasts five 
days, followed by incom- 
plete peeling of the sur- 
face of the skin in very 
fine scales. 
Eruption first papular for 
first day, then becomes 
vesicular, then pustular; 
on eighth day pustules 
maturate. (See descrip- 
tion of eruption in section 
on Small Pox.) 
Sore throat, rarely catarrh 
of the nose or cough. 
Nasal catarrh and catarrhal 
cough very constant; 
rarely sore throat; bron- 
chitis. 
Often sore throat and dry 
cough ; bronchitis only as 
a complication. 
Red “ raspberry tongue.” 
Tongue coated, may be red 
at edges ; does not lose 
its coat. 
Tongue coated, swollen; 
may be red at edges. 
Brain - symptoms frequent 
and grave. 
Brain-symptoms rare ; not 
severe. 
Brain-symptoms frequent. 
No secondary fever. 
No secondary fever. 
Always secondary fever. 
After effects: kidney dis- 
ease, dropsy, inflamma- 
tion of the eyes, discharge 
of matter from the ears, 
deafness, chronic diar- 
rhoea, enlargement of 
lymphatic glands. 
After effects: chronic bron- 
chitis, inflammation of 
eyes. 
After effects : chronic diar- 
rhoea, enlargements of 
lymphatic glands, various 
diseases of eyeballs and 
eyelids. 
ELY VAN DE WARKER, M.D. 
Epidemic Cholera. 
The offspring of vice, penury, and superstition, vitalized by the 
intense heat of the tropical sun acting upon masses of organic 
matter, the result of luxuriant vegetation and the nastiness of hu- 
man animals, epidemic cholera was born in the Delta of the Ganges. 
Nourished by the filth-sodden earth and polluted atmosphere ; ag- 
gravated by the requirements of an intolerant priestcraft; pan- 
dered to by the brutal sensuality of Oriental life; sustained by 
victims from the constantly arriving hordes of devotees, the dis- 
ease spread from the place of its birth and early secured recogni- 
tion from the world. 
The necessities as well as the superstitions and views of man- 
kind extended the area of cholera power. The annual religious 
and commercial gatherings of the Asiatics became centres from 
which the disease was diffused among all Oriental nations. Ar- 80 
THE ACUTE INFECTIOUS DISEASES. 
mies and caravans upon the land, boats and rafts upon the rivers, 
merchantmen and war-vessels upon the high seas, were the active 
agents ; while the passive, but no less powerful agent was the total 
disregard of sanitary laws evinced by all nations of the East. As 
years passed, all the great lines of travel were marked by the dis- 
ease. Ascending the Ganges to the mountains of the Punjaub, it was 
carried into Afghanistan, Persia, and Turkey in Asia, coming out 
upon the Black and Caspian Seas, and thus advancing on Europe. 
Descending the east coast of Hindostan, the Presidency of Madras 
was infected. Crossing the almost unknown interior of the Em- 
pire, the Presidency of Bombay was added to the endemic area, 
and the populous cities of Madras on the east and Bombay on the 
west coast of the peninsula became centres for the export of the 
pestilence. Descending the Indus, a third maritime focus was 
established at the city of Kurrachee. 
Arabia received the disease from Hindostan, fostered it by the 
vast concourse of devotees who assemble yearly at her holy cities, 
and in turn delivered it to the inhabitants of the Mediterranean 
coast and of the continent of Africa. 
Cholera having overrun the old world, it was in order that the 
new should be conquered. In 1832 the disease crossed the Atlantic 
Ocean. This transit was the result of no mysterious agency of 
sun, air, or water. Those natural forces had no part in the diffu- 
sion other than that they facilitated the descent of a vast army of 
emigrants upon the shores of North America who brought with 
them their personal effects and cholera. Since 1832, whenever 
Europe has been visited by cholera, the lines of epidemic diffusion 
have reached the American continents. 
While it is true that there are other acute infectious diseases 
which have occasioned, in the aggregate, as many deaths, and 
which are as insidious in their approaches, still there is that about 
epidemic cholera which makes its name a terror. The suddenness 
with which the blow descends, the wonderful transformation which 
takes place in the patient, the rapidity with which the disease 
runs its course, and its capriciousness in the selection of its vic- 
tims, surrounds it with a deeper gloom and a greater appearance 
of mystery than any other known disease. 
There is, however, nothing mysterious about cholera. We are 
able to account for its occurrence with far greater certainty than 
we can account for the spread of some other infectious diseases. 
We are able to arrest the disease, to stamp it out, and the spread 
of sanitary knowledge will soon render it impossible for an epi- 
demic of cholera to gain power upon American soil. 
Causes.—Epidemic Cholera is a specific disease of the stomach THE ACUTE INFECTIOUS DISEASES. 
81 
and intestine, which arises from a special cause and not from any 
combination of causes. It is an acute infectious disease, but it is 
not infectious in the same way in which small-pox, scarlet fever, 
or diphtheria, are infectious. It cannot he induced by inocula- 
tion. It is not induced by contact with a patient suffering from 
the disease ; but it is caused when the specific poison gains access 
to the alimentary canal of a predisposed individual. [One whose 
condition of body disposes it to the action of disease under the ap- 
plication of an exciting cause.] 
This specific poison of cholera is a product of decomposition 
which takes place in all the discharges which occur from the per- 
son of an individual suffering from the disease in any of its stages. 
This decomposition is hastened or retarded by the same laws which 
govern the process in all organic matter; but, in the decomposi- 
tion of “ cholera stuff ” (the term which will he applied to all chol- 
era discharges), there is a defined period in which this specific 
poison is developed, and during which it manifests its virulent 
power. Before that period has been reached, there is no poison ; 
after that period is past, there is no poison. It is, therefore, evi- 
dent, that if the decomposition of “cholera stuff” be prevented, 
the development of the poison is also prevented. 
This stage of virulent activity is limited to the period when, 
by the aid of a microscope, small moving bodies, which are 
known as vibriones, may be seen moving through a drop of the 
liquid. Therefore we can but reason that whatever will hasten 
the process of decomposition in this “stuff,” hastens the develop- 
ment of the specific poison, and contrariwise. It is not thought that 
these vibriones can, of themselves, produce cholera, hut it is known 
that they indicate, by their presence, the fact that the molecular 
matter has reached that degree of development which constitutes 
the cholera poison. 
We know, it is true, but little about this specific poison of 
cholera, but we do know that the disease can be acquired only by 
the contact we have described, and that there are three factors 
which must be combined before the disease can be developed. 
These factors are : 1. The specific poison of cholera. 2. The 
taking of it into the body by the digestive passages, or the inges- 
tion of the specific poison. 3. A predisposition on the part of the 
recipient of the poison. When these three factors are present, 
then the disease will occur, but it is essential that they be equally 
positive. 
When the specific poison of cholera has been swallowed and 
comes in contact with healthy gastric juice, the latter, by virtue of 
its acidity, utterly destroys the poison. If, however, the gastric 82 
THE ACUTE INFECTIOUS DISEASES. 
juice has not its normal acid reaction, then the specific poison meet- 
ing only alkaline fluids, is able to reproduce itself—that is, from the 
cells which were originally swallowed a vast number of similar 
cells are formed. These cells possess the peculiar power of fast- 
ening themselves upon, and of destroying, by their contact, the 
little epithelial cells which cover the mucous membrane lining 
the digestive apparatus, as it also lines all other cavities or sur- 
faces of the body. Vast patches of the intestinal epithelium are 
stripped off, exposing the delicate blood-vessels, which pass in 
folds and loops in every direction. From these uncovered vessels 
all that portion of the blood which is fluid enough to find its way 
through the remaining walls, flows out and is collected within the 
intestinal cavity, and as millions of these vessels are uncovered, 
there is nothing surprising in the fact that a fatal loss of water 
may occur in a very short time. It is to this rapid and absolute 
abstraction of water from the system that all the symptoms of the 
disease are due. 
In its cause, and in all that which results from that cause, 
cholera differs from every other known disease, although upon 
its border-lands are to be found diseases which present shades of 
resemblance which have induced some to consider them all as 
from a common stock, but it is a grave error. Cholera is simply 
—cholera. Every case of cholera has its origin in some preceding 
case of cholera. An epidemic of the disease occurring in British 
India, reaches out its arms and embraces all nations of the world, 
and the earliest and latest victims of that epidemic outbreak are 
as surely united in the chain of disease-influence as if they were 
dwellers in the same house, and not separated by thousands of 
miles. 
Symptoms.—An attack of cholera is generally preceded by a 
slight, painless diarrhoea, one which may be characterized as a 
“looseness of the bowels.” The patient has a sense of discomfort 
in his abdomen, a rumbling of the bowels, and an occasional desire 
for an “action.” A sensation of sickness, or indisposition [ma- 
laise] attends this stage, which may last from one to five days, 
attracting greater or less attention according to the character of 
the patient. The diarrhoea is attended with gradually increasing 
fatigue or lassitude, and inability to undergo any muscular exer- 
tion. It is in this stage of the disease that the specific poison is 
being reproduced within the patient’s body, and it is of vital im- 
portance that in cholera times such symptoms should not be disre- 
garded, as at this time the progress of the disease may be ar- 
rested. 
In the majority of cases the infected person retires to his bed THE ACUTE INFECTIOUS DISEASES. 
83 
at night without greater symptoms of impending danger than 
upon any previous night; but during the early hours of the new 
day he is awakened by an active desire to go to stool, which is 
usually so urgent that a night-vessel or the first convenience at 
hand must be used. Relieved from the desire which but a moment 
before was so active, he returns to his bed and falls asleep. Let 
us examine the contents of the vessel. We find it nearly full of a 
clear liquid, which looks like water. It has a sweetish, sickening 
smell, like to that which comes from the carcass of a fresh! y- 
killed animal. If we take a little upon our fingers, we will find it 
to be slightly sticky or glutinous, and if we reflect the rays of 
light into the vessel we will see numerous small transparent bodies 
floating about and gradually settling on the bottom. It is the 
characteristic rice-water discharge of cholera. 
While we have been thus engaged, the patient again becomes 
restless. He springs from his bed in the rush to relieve himself, 
and returns pale and complaining of a sensation of prostration, 
and with a slight nausea. In a few moments the desire returns, 
and is as uncontrollable as at first. The prostration becomes 
marked. The nausea gives place to vomiting, and cramping of 
the extremities follows. As the case advances, the patient is no 
longer able to leave his bed, which is soon deluged with the dis- 
charges. The surface of the body is cold to the touch, but com- 
plaints are made of intense heat. The skin on the fingers and 
toes becomes shrivelled like that upon the hands of a washer- 
woman, and livid in color. Water is constantly demanded, but 
it is no sooner drank than it is vomited. The voice loses its volume 
and expression and becomes husky, low, and unnatural. The 
features become pinched, and denote intense anxiety. The eyes 
are unnaturally bright. A profuse perspiration bathes the sur- 
face of the body. The pulse becomes threadlike and then disap- 
pears. The exhibition of restlessness is fearful to behold. It 
requires intense effort to breathe. Moments have the weight of 
years, and the patient who, but a few hours past, was a strong, 
vigorous man, a delicately beautiful woman, or a charming child, 
is transformed into a helpless, moaning, mumbling octogenarian. 
A general deepening of all the symptoms occurs, and the pa- 
tient is in collapse. The crampings which seemed to have sub- 
sided may return, and when they return, the last agony of the 
patient is worse than the first. Death may quickly close the agony, 
or it may be that after hovering between life and death for hours, 
the severity of the symptoms may subside, but the patient is left 
shattered by the violence of the storm to face the dangers of a 
slow and tedious convalescence. 84 
THE ACUTE INFECTIOUS DISEASES. 
This is the outline of an ordinary attack of epidemic cholera. 
The case is not, however, always as mild as that which has been 
described. Occasional cases are seen in which the patient passes 
almost instantly into profound collapse. The various stages of 
the disease either do not exist, or they are so intimately blended 
and occur so rapidly that there is nothing to mark where one stage 
ends and another begins. Fortunately such cases are very rare. 
Mode of Propagation.—Cholera is diffused in various ways, but 
the medium most frequently selected is water. In Eastern coun- 
tries, where little or no care is taken to maintain a supply of pure 
drinking-water, the disease is almost invariably diffused through 
its agency, and it has been found, by those who have carefully 
studied the histories of many cholera epidemics, that in the major- 
ity the cause is found to have been polluted water. Leakage from 
sewers and drains often infect wells, cisterns, or other receptacles 
of water, and the use of such water induces the disease whose 
specific poison was mixed with the contents of the sewer or drain. 
Cholera is a striking illustration of the fact that when wells or cis- 
terns, or the basins of springs are so badly protected that rain wa- 
ter, flowing over the surface of the ground has free access to them, 
they may become infected with the cholera or other specific poison. 
To a modified extent cholera may be diffused through the me- 
dium of the atmosphere. The “cholera-stuff” having been depos- 
ited in an impure privy, an active and virulent development of the 
poison takes place, and all who enter the privy are liable to the 
infection. How ? Individuals do not eat or drink the contents of 
privies, and if cholera is a disease of the digestive organs, how 
could it be acquired from such a locality ? The gases which arise 
from the fetid pit carry upward with them the specific poison, 
which is inhaled, and becoming entangled in the saliva, it is swal- 
lowed. Indeed it is by no means certain that an individual sit- 
ting at stool over a cholera-infected privy may not receive the 
specific poison upon the exposed mucous surface of his rectum, 
and that in this way his intestinal epithelium may be infected as 
effectually as if the poison had been swallowed. The atmosphere 
of a room which has remained closed and without cleaning or 
ventilation after the termination of a case of cholera, may induce 
the disease in individuals who use the apartment at a later date. 
The atmosphere about the mouths of sewers and drains maybe- 
come infected from the discharge of such vents, although the point 
at which the “ cholera-stuff” was emptied into the drain may have 
been at a long distance from the point at which the final discharge 
occurred. Exhalations from soil which has been polluted by leak- 
age from broken or defective sewers or drains, may charge the sur- THE ACUTE INFECTIOUS DISEASES. 
85 
rounding atmosphere with the cholera poison. Exhalations from 
cesspools, garbage heaps, or from any masses of decomposing 
matter, will contain the cholera poison, provided £ ‘ cholera stuff” 
has been added to the original mass. 
In any of these ways the atmosphere may be charged with the 
cholera poison, but the power of the atmosphere in diffusing the 
infection is confined to a limited space. An individual seated or 
standing in such a privy, or working in the fetid drains or at 
their mouths, or laboring on infected soil, or living over infected 
ground, cesspools, or garbage heaps, is exposed to the infection. 
Those who reside within a few yards of such places may be ex- 
posed to the infection, provided that the direction of the prevailing 
winds are toward such habitations ; but the morbid influence can 
be exerted to no greater distance, for the poison is rapidly oxydized 
and its power destroyed. 
The poison of cholera may be diffused by food which may be- 
come polluted in various ways. Cooks and bakers who are suffer- 
ing from the premonitory diarrhoea, or from the disease in its more 
aggravated form, have been known to continue at their work with 
hands and clothing soiled with the discharges. Such persons, 
in handling articles of food, could not fail to pollute the articles. 
Broken or defective drains not infrequently discharge into cellars 
in which vegetables are stored. Meat may become polluted in 
cholera-infected slaughter-houses. Milk may be polluted from dilu- 
tion with infected water, or from the pans in which it has been 
stored having been washed in such water. Vegetables or fruit 
may be polluted through the media of winged insects, who, having 
fed upon exposed discharges from the patient, alight upon the 
object with portions of the “ cholera-stuff ” still adhering to their 
bodies. 
Cholera may be diffused by fabrics which have been soiled 
with cholera discharges, and upon which the discharges have 
dried. Articles of all kinds, clothing, bedding, carpets, curtains, 
towels, chairs, tables, bedsteads, chamber-vessels, cups and sau- 
cers, tumblers, spoons, plates, and dishes, may be, and often are 
the media by which the disease is diffused. In such instances 
the “cholera stuff” drying upon the article, no decomposition 
has occurred ; when the article is handled, the dry “ cholera 
stuff,” disturbed by motion, breaks off, and atoms float in the air 
which, when inspired, may occasion the disease. If these things 
be true, why is it that greater numbers of individuals are not at- 
tacked in every epidemic ? 
As yet, no pandemic (that is, an epidemic which attacks the 
whole of a population) of cholera has been known in the world. 86 
THE ACUTE INFECTIOUS DISEASES. 
Should epidemic cholera ever assume so malignant a type that 
the third factor which we have given as an essential for a cholera 
outbreak has no longer existence ; or, in other words, should the 
poison of cholera ever become so powerful that every individual 
to whom it gains access will become a subject of the disease, no 
matter how powerful may be his digestive organs, then this world 
will surely be depopulated. 
Two individuals may drink an equal amount of cholera-in- 
fected water, one in high health, the other suffering from some 
temporary derangement of the digestive organs. When the poison 
reaches the stomach of the first individual it is at once acted upon 
by the normal gastric juice, the acidity of which promptly de- 
stroys the poison. It is cast out of the body with other debris, 
and the individual is unconscious of the contact. In the second 
instance, the poison reaches the stomach at a time when the gas- 
tric juice is not normally acid. The poison immediately assumes 
its power of aggressive development, and passing into the intesti- 
nal canal, meeting only alkaline fluids, the development is rapid 
and an explosion occurs. During an epidemic of cholera, it is par- 
ticularly those whose systems are vitiated by other diseases ; those 
suffering from depression of the nervous forces from any cause, 
but especially that which attends excessive fatigue, fear, or sen- 
suality ; those who live in open violation of all hygienic laws ; 
those who are impoverished by want or disease, who are liable 
to its attacks. 
Cholera exists only where it has been carried. The disease 
can be developed only when the molecular matter contained in 
the discharges from a case of cholera are deposited in a locality 
favorable for its rapid decomposition, which is, in this case, not a 
process of destruction, but of new development, and a fresh explo- 
sion of cholera can only occur when a portion of the specific poison 
has gained access to the digestive apparatus of a predisposed in- 
dividual. It is a law of nature, that organic matter undergoes 
decomposition more rapidly when it is added to other organic 
matter in which the process has already occurred, and while it is 
true that this cholera development takes place when the “ cholera 
stuff ” is placed upon the surface of the earth in a favorable lo- 
cality, so is it also true that the same development occurs when 
the poison is added to decomposing organic matter within the 
human intestines. Is it not true that numerous human whitened 
sepulchres exist ? Those who clean the external surfaces of their 
bodies with care, but who deliver their internal surfaces over to 
uncleanness. During days of epidemic sway such individuals are 
food for the disease. THE ACUTE INFECTIOUS DISEASES. 
87 
Prevention.—The best way to treat cholera is to prevent its 
occurrence. The surest way to prevent epidemics of the disease 
is to maintain all communities in good sanitary condition. No 
magazines of decomposing organic matter should be permitted 
to exist, as but a minute spark of cholera poison is sufficient to 
cause an explosion. It is no time to institute sanitary precau- 
tions when an epidemic is on a community. The terror which 
the disease inspires renders it impracticable. That which has not 
been effectually accomplished before the outbreak of the epidemic 
must remain undone. 
While the requirements of health demand that constant clean- 
liness of habitations be maintained, in times of cholera the ne- 
cessity is more imperative. Dwelling houses, from garrets to 
cellars, should be kept scrupulously clean; debris of all kinds 
must be removed, and perfect ventilation must be secured. The 
exhalations from the ground upon which the house is built should 
never be permitted to pervade the house. No portion of the house 
should be ventilated at the expense of the remaining portions. 
Apartments occupied as water-closets, bath-rooms, or wash-houses, 
should be isolated, and the ventilation of all rooms which have 
sewer-connections should be a matter of constant care. The 
house-drains should be kept in perfect order, and all discharge- 
pipes should be flushed each day, and at least once each week 
be treated with a solution of some active disinfecting agent. 
Privy-vaults and cesspools should be kept empty and clean by 
frequent disinfection. In rural communities the practice of def- 
ecating on the surface of the ground should be warmly con- 
demned. 
The water-supply should be an unceasing source of solicitude. 
In city houses care should be taken at short intervals to test the 
imperviousness of service pipes, and water should be filtered before 
being used for drinking purposes. Wells and cisterns and the ba- 
sins of springs should be kept free from all organic impurities. 
The walls of wells and cisterns should be carefully examined for 
leaks from contaminating sources, and the direction and source of 
underground streams should be determined, that it may be known 
whether or not they have been subjected to pollution from fsecal 
or other organic matter. If such source of pollution be found, the 
use of the water must be abandoned. Stables, cow-houses, chicken- 
houses, pig-pens and their surroundings should be kept as clean 
as practicable. Fire, as a destructive disinfectant, should be 
employed upon all decomposing organic matter for which no 
profitable use can be had. 
This outline embraces facts with which every well-regulated 88 
THE ACUTE INFECTIOUS DISEASES. 
family should be conversant, and the laws upon which they are 
founded should be observed at all times; but there remains for 
consideration certain precautions which individuals should adopt 
during cholera times, in order that they may hold an immunity 
from the disease. We shall consider them under the heads of 
personal cleanliness, dress, and diet. 
Personal cleanliness, which is necessary at all times, becomes 
doubly so during a cholera epidemic. Scrupulous care of the per- 
son secures the removal of that which may, and often does prove 
to be the nucleus of disease. In the sultry weather in which we 
are usually called upon to meet epidemics of cholera, daily baths 
are among the most important adjuvants of health. In the early 
morning they invigorate to meet the fatigues of the day, and at 
night they encourage refreshing and strengthening sleep. Per- 
sonal cleanliness is not confined to the external surfaces of the 
body ; it is quite as necessary that the inner surfaces should be 
subjected to a daily cleansing. As cleanliness of the external sur- 
faces can only be secured by the use of water, so is it with the in- 
ternal surfaces. A glass of pure cold water drank immediately 
upon leaving the bed in the morning, and a visit to the closet after 
breakfast, not made in haste but with deliberation, will, in the 
majority of instances, prove effectual. Should it, however, fail, a 
small portion of table salt added to the draught of water, and the 
employment of an enema of water will induce the desired result. 
The surface of the body should be fully and warmly protected, 
both by day and by night. Under-garments which have become 
saturated with perspiration should be removed, the surface of the 
body briskly rubbed, and dry articles substituted. Whatever may 
suddenly check perspiration should be avoided. A broad flannel 
bandage worn over the abdomen and around the person will im- 
part a sense of comfort. Clothing which has been worn during 
the day should never be exposed in sleeping apartments during the 
night, and they should always be well aired before being again 
taken into use. 
While it is advisable to fie careful as to diet and rigidly to avoid 
all articles of food that experience has proven to be indigestible, it 
is as necessary not to produce any sudden or radical change. 
The digestive organs should be encouraged to the performance of 
their duty by the presence of well-prepared food. The use of the 
various condiments is to be encouraged. It is well, during an ep- 
idemic, for persons to indulge their appetites in their own houses, 
and from kitchens over which they may exercise full control. 
Vegetables and fruit, before they are eaten or prepared for the ta- 
ble, should be carefully washed in pure water. Such articles of THE ACUTE INFECTIOUS DISEASES. 
89 
diet, either ripe or unripe, never of themselves caused a case of 
cholera since the disease was created ; but they may, when imma- 
ture, occasion disturbances of the stomach, which experience has 
proven to favor the development of the disease. 
The source of the water-supply of a family should be a matter 
of the greatest solicitude, and when a constant supply of pure 
water has been obtained, none other should be used. It is far bet- 
ter to suffer the pangs of thirst for a time, than it is to drink water 
from any unknown source. If none other can be obtained, pure 
ice can usually be purchased, and from it drinking water may be 
obtained. Suspected water must always be actively boiled and 
filtered before it is used for any domestic purpose. During a 
cholera epidemic it is advisable that each person should take 
into his stomach a certain amount of acid drink each day. Lemon 
or lime-juice may be freely used ; the mineral acids only when 
advised. 
Whenever it is practicable, the soiled clothing of a family dur- 
ing an epidemic should be washed only upon the premises. Innu- 
merable instances are known in which the diffusion of the disease 
has been traced to infected localities in which clothing was washed. 
Can a case of cholera he so managed, that there will exist no 
danger of the disease being communicated to others ? 
Most assuredly, yes ! No fear of personal danger need blanch 
cheeks when a cholera victim is in a house, provided a few simple 
precautions are adopted. Believe, truly and sincerely, that cholera 
is an acute infectious disease, resort to those measures which sci- 
ence has placed within your grasp, and you are perfectly secure 
in ministering to all the wants of the sufferer during his hours of 
anguish and pain. 
It has already been stated that cholera is diffused through the 
discharges from the bowels of individuals infected with the dis- 
ease in any of its stages. I fully believe that the discharges of 
the stage of premonitory painless diarrhoea, when the specific 
poison has but just begun its work in the intestines, are far more 
virulent in diffusing the disease than are those of the later stages 
when the rush of water has swept the intestines clean. When 
cholera is known to be in the country, every case of diarrhoea 
should be looked upon with suspicion, and it should be treated as 
if it were known that the poison had gained access to the patient. 
The individual should submit himself to absolute rest, and place 
himself in the hands of his medical adviser, and every point at 
which he has defecated should be actively disinfected. 
The house in which a case of cholera develops, should imme- 
diately, but without confusion, be set in order. The objects to be 90 
THE ACUTE INFECTIOUS DISEASES. 
secured are three-fold. To secure the comfort of the patient and 
the convenience of rendering him assistance. The disinfection of 
all the excreta [perspiration, urine, faeces], and of all articles 
which may have been soiled by them. The jinal disposition of the 
disinfected excreta. 
All superfluous articles of furniture should be removed from 
the room. The windows should be so arranged that perfect ven- 
tilation may be secured. The bedstead should be drawn out into 
the room, so that access may be had to it from all sides. The mat- 
tress should be covered with an oiled or other impervious cloth, 
upon which a blanket or soft quilt is folded. There will be re- 
quired for use about the patient a plentiful supply of towels and 
some soft cloths ; also pitchers, tumblers, and spoons, from which 
medicines, drink or nourishment may be administered ; also sev- 
eral chamber-vessels. These articles, when once taken into use, 
should not be mixed with those in use by other members of the 
household. 
To render the excreta powerless, that is, to prevent the devel- 
opment of the specific poison, it is necessary that the alkalinity of 
the discharges should be destroyed ; so long as they remain alka- 
line there is danger of decomposition, and when decomposition 
occurs the specific poison is developed. It is necessary to render 
these fluids acid, and when a strong mineral acid is employed in 
sufficient quantities, the minute particles of matter are destroyed. 
Until a proper disinfectant can be obtained, vinegar should be 
largely added to each evacuation and vomit, but as soon as pos- 
sible the following solutions should be prepared : 1. In a large 
bucket (one which will contain three or four gallons) five pounds 
of copperas should be placed, and the bucket be nearly filled with 
water, when three ounces of strong sulphuric acid should be 
added, and the mass mixed with a stick. A portion of this solu- 
tion should be mixed with each lot of “cholera stuff,” which is to 
be disposed of, in the proportion of at least one-fourth of the bulk. 
As the disinfecting fluid becomes exhausted, the supply must be 
renewed, and a full quantity must always be on hand and ready 
for use. This disinfecting solution must be kept at the point at 
which the “ cholera stuff ” is to be disposed of, where a small tub, 
filled with an acid solution (sulphuric acid one ounce, to water 
one gallon), should be in readiness, that all vessels, after hav- 
ing been emptied of their cholera contents, may be immersed 
therein. 
In close proximity to the sick room should be a large tub half 
full of the acid solution (sulphuric acid one ounce, to water one 
gallon), into which all clothing and other fabrics taken from the THE ACUTE INFECTIOUS DISEASES. 
91 
person or bed of the patient, or which have been soiled by the dis- 
charges, should be placed. 
In the sick room, a quantity of water acidulated with the sul- 
phuric acid, in the strength of one-half ounce of the acid to the 
gallon of water, should be prepared, in which the hands of at- 
tendants and the body of the patient may be frequently bathed. 
With this solution, the carpets, floor, or clothing of attendants 
should be cleaned, should they become soiled. 
As long as possible, the cholera discharges should be received 
in porcelain vessels:—the discharges in chamber-vessels or bed- 
pans, the vomit in basins—and each time that the vessel is used it 
should be immediately carried from the room and treated with 
the copperas solution. When the discharges pass involuntarily, 
they should be received upon old cloths which, when saturated, 
should be removed from the bed and thrown into the disinfecting 
tub, The limbs and person of the patient should be frequently 
bathed in the acidulated water, which will be found to impart a 
greater sensation of relief to the patient than all the stimulating 
frictions which can be used. 
The final disposition of the “ cholera stuff ” must be governed 
by the locality in which the patient resides. In cities, the excreta, 
after having been disinfected, must of necessity be cast into soil- 
pipes which enter into the general system of sewers, and if the pri- 
mary process of disinfection has been effectually performed, and 
the pipe which is to be used has been treated plentifully with the 
copperas solution, it will be, probably, as safe a disposition as can 
be made of them. The process is as follows : Douche the drain-pipe 
with several gallons of the disinfectant. When a vessel is to be 
emptied see that, by stirring, the “ cholera-stuff ” and the copperas 
solution are intimately mixed. Empty the vessel so carefully as 
to avoid smearing the sides of the drain. Wash the vessel in pure 
water, which must be emptied into the drain. Immerse the ves- 
sel in the sulphuric-acid solution, allow it to dry, and it is ready 
for use. It is obvious that all this can only be accomplished when 
its execution is in the hands of an intelligent person, who should 
be called upon to perform no other duties. 
In rural districts, the excreta must be disposed of beneath the 
surface of the ground. A pit should be dug, into firm earth pref- 
erably or that which has not been disturbed for a length of time, 
and in such position that drainage from it will not affect any sup- 
ply of water. A quantity of copperas should be placed upon the 
bottom of this pit, so as to cover it completely for several inches 
in depth, and upon it a layer of fresh earth should be placed. Into 
this pit the “cholera-stuff,” treated as has already been described, 92 
THE ACUTE INFECTIOUS DISEASES. 
should be thrown, and each deposit should be covered with fresh 
earth. When the pit has been filled to within a foot of the sur- 
face, it should be covered in, and a new pit in its immediate vicin- 
ity prepared. Into these pits all water used in cleaning vessels 
must be thrown. 
Should the case terminate fatally, all articles of clothing should 
be immediately removed from the person and bed of the patient 
and placed in the tub containing the acid solution. If the mattress 
be soiled it should be saturated thoroughly with the acid solution, 
or, what is still better, it should be burned. A blanket or a shirt 
may be thoroughly and completely disinfected, but common sense 
would indicate that to obtain the same result with a mattress 
would be almost impossible. The body of the victim should be 
carefully washed in the acid solution, and while this work is being 
performed, soft dry cloths should be so placed that they will absorb 
all liquids which may flow from the body. Before it is dressed 
for the grave, a towel, folded in length, should be placed between 
the buttocks and should be confined by a napkin applied as upon 
the person of a child. When the body is placed in the casket, 
which should not be long delayed (although indecent haste is rep- 
robated), a quantity of copperas should be placed under the hips 
and in such position that it will act upon any fluid which may 
escape. The casket containing the body should be placed in a 
cool, well ventilated apartment. Should it be desirable that the 
body be surrounded by ice, it will be necessary to treat the ice, the 
water which will result from its melting, and the box in which the 
body is placed, as if they were cholera discharges in the one case, 
and articles soiled with cholera discharges in the other. 
The chamber which has been used during the illness should 
now be closed as completely as possible, and should, with its con- 
tents, be subjected to an active disinfection with sulphurous acid 
gas, which is to be obtained by burning sulphur. The room should 
remain closed for at least twenty-four hours. 
While this work is going on, a fresh supply of the acid liquid 
should be prepared, and into it all the articles which have been 
soaking in that first prepared should be removed, and after re- 
maining in it a few hours, they may be removed and washed in 
pure water. Valueless articles should be destroyed by fire; no 
useless memento of the case should remain. All fluids which have 
been employed in this work of disinfection must be disposed of in 
the manner indicated. 
At the end of twenty-four hours, the chamber which has been 
undergoing disinfection may be opened and ventilated. The fur- 
niture should be removed and the floor and walls carefully cleaned. THE ACUTE INFECTIOUS DISEASES. 
93 
Carpets and curtains should be beaten and well aired, and tlie 
solid articles should be washed in the acidulated solution. Then 
the room will again be ready for occupancy. 
Should the attack not be fatal, and the patient pass into the 
slow and uncertain stage of convalescence, it becomes necessary 
to exercise still greater care to prevent the formation of the infec- 
tious property. The involuntary discharges have ceased, and if 
the bed has been arranged as directed, it will be possible to do much 
toward improving the local condition of the patient. By drawing 
upon the under sheet, he may be moved to one side. The oil-cloth 
then can be carefully sponged with the acid solution, and all points 
of moisture found on the mattress can be saturated with the same. 
Dry and well warmed blankets should be placed upon the bed, and 
the patient, having had his soiled clothing cut from him, his body 
bathed in the acid solution and enveloped in flannels (all of which 
may be accomplished in less time than it takes to describe it), is 
to be lifted and placed, without the expenditure of an ounce of the 
strength which is now of such vital importance, in a dry, warm, 
comfortable bed. When that is done the first step is taken toward 
success—but how seldom is it thought of ! The writer has many 
times stood beside the beds of individuals who had passed safely 
into convalescence from violent attacks of cholera, and found that 
the patient was lying upon beds and surrounded with clothing 
covered with decomposing “cholera stuff.” A more pitiable sight 
can hardly be conceived. Not infrequently we hear of persons 
who die from a relapse of cholera. It is no relapse of which they 
die. It is nothing more nor less than a new attack of the dis- 
ease, occasioned by a second poisoning with cholera, the speci- 
fic poison of which has developed from the excreta of their own 
bodies. 
During the stage of convalescence all of the discharges from the 
patient must he treated as if they were fresh cholera stools. 
Treatment.—In view of the rapid course, and often the fatal 
character of this disease, although competent medical advice is at 
once demanded, it is not always obtainable, especially when many 
miles intervene between the person affected and the nearest avail- 
able physician. It is therefore evident that instructions should 
here be given regarding the things which may be done without 
loss of valuable time. 
An individual suffering from diarrhoea, which may be sus- 
pected as being premonitory of an attack of cholera (and when 
the disease is known to be in the country, every diarrhoea should 
be viewed with suspicion), must immediately assume a recumbent 
posture, and remain absolutely at rest until the diarrhoea is 94 
THE ACUTE INFECTIOUS DISEASES. 
checked. By rest, it is not intended that the patient should 
lounge idly about; but he should undress, go to bed, and there 
remain absolutely quiet until he has received medical attention. 
Until such time as the physician arrives, he may take a tea- 
spoonful of paregoric after each action of the bowels, and he 
should drink freely of any acidulated water, as lemonade, a solu- 
tion of citric acid, or vinegar and water. 
In times of cholera danger, every family should be provided 
with a cholera prophylactic—that is, a preventive remedy which, 
with the approbation of the family physician, may be used as ne- 
cessity may demand. A mixture of aromatic sulphuric acid and 
laudanum is about the most efficacious which can be employed. 
It may be prepared in the proportion of one ounce of the acid to 
half an ounce of the laudanum, and the dose for an adult will be 
thirty drops, for a child over ten years of age, ten drops, and for 
a child under ten years of age, five drops, in a little water every 
one, two, or three hours, as occasion may require. It has been 
demonstrated by experience, that in the great majority of cases 
the premonitory diarrhoea will be checked by this treatment. 
Should it be, however, that the first knowledge of the case is 
when it has reached the second stage, or that of the rice-water 
discharges, early and prompt treatment is of vital importance. 
The patient should be placed in bed, and every convenience fur- 
nished him which may serve to husband his strength. It is now 
imprudent to give opium in any form, except under medical ad- 
vice ; but acids should be promptly given. Where access can be 
had to a drug store, a supply of dilute sulphuric acid should be ob- 
tained, and thirty drops, or half a teaspoonful, in a wineglassful 
of water should be given every fifteen or twenty minutes, until 
the discharges are arrested. The dose for a child over ten years 
of age would be fifteen drops, and for one under ten years, ten 
drops. Until the acid can be obtained, vinegar, in teaspoonful 
doses, should be given every ten or fifteen minutes ; and this course 
of treatment should be continued until a sufficient amount of the 
acid has been taken to change the contents of the stomach and 
intestines from the alkaline to the acid state. 
A broad flannel bandage should be passed around the person 
and over the abdomen, and tightly pinned. A coarse towel should 
be compactly folded, and should be tightly pressed against the 
anus, that it may act as a plug, and the patient should be en- 
couraged not to yield to the inclination to empty the bowel. 
It is as possible to destroy the cholera poison within the human 
intestines as it is to destroy it in any other locality. To my medi- 
cal brethren I would suggest the employment of pure sulphurous THE ACUTE INFECTIOUS DISEASES. 
95 
acid, as a remedy from which good results may confidently be ex- 
pected. 
These are the measures which science advances for the destruc- 
tion of epidemic cholera. The subject has been treated in detail, 
and it may seem that a needless reiteration of principles has been 
made ; but the success of the method depends upon the faithful 
performance of each and every detail. It may be urged, and with 
truth, that the method laid down, is within the grasp of the 
wealthy alone ; that the poor, those in moderate circumstances, 
are those among whom cholera epidemics most frequently com- 
mence, and that such individuals will be unable to avail them- 
selves of it. In all communities, the rich and the poor are mixed 
together, and the treasure of one class must be freely used to re- 
lieve the necessities of the other. It is no question of philan- 
thropy, but it is one of life or death. The rich man’s money may 
save his life, or the lives of his wife and children, if he employs it 
in stamping out the disease in the hovels of poverty. Cholera 
gives no quarter, therefore all should join in giving it the coup de 
grace. 
ely McClellan, m.d. 
Hydrophobia and Rabies. 
This is one of the most dreadful of the diseases known to man, 
and until within a few years it has been so rare in its occurrence 
that it has generally been considered a danger too remote to require 
special care or special legislation as a protection. Recently, how- 
ever, there has been an astonishing increase of hydrophobia, both 
in this country and in Europe. During the year 1877, six persons 
died of this disease in the State of Connecticut alone, while in the 
first six weeks of 1878, the writer has noted no less than eight 
deaths occurring from this cause in four of the New England 
States, and mention of such cases is constantly being met with in 
the daily journals. Recent cases have not only proved the exist- 
ence of this disease in many animals other than dogs, such as the 
wolf, fox, skunk, and cat, but they have shown that creatures 
hitherto unsuspected, have the disposition and ability to commu- 
nicate the disease to man. A well authenticated case recently 
occurred in Northern Ohio, where a rabid gray fox was seen to 
bite several hogs which were confined near a dwelling-house, and 
one of these animals afterward bit a young man who died of hy- 
drophobia. In January, 1878, a gentleman in Boston was bitten 96 
THE ACUTE INFECTIOUS DISEASES. 
upon the finger by a tame rabbit, and in less than six weeks he died 
of hydrophobia in its worst form. The rabbit was known to have 
been bitten by a dog which died shortly afterward, and it is prob- 
able that the disease always originates in animals of the dog family. 
Twenty-five years ago the disease was so rare that the writer went 
nearly one hundred miles to see a case of genuine hydrophobia, 
and at the bedside of the patient he met medical men who had 
come even greater distances to see this rare and frightful disease. 
After witnessing the horrible contortions and terrible suffering of 
a victim of hydrophobia, one cannot wonder that less than two 
centuries ago the ignorant masses of Great Britain, panic-stricken 
with fear of contagion, should have smothered the wretched pa- 
tient between two feather-beds, both to end his torment and to 
secure their own safety. 
As this is a practical work intended for practical readers, the 
writer proposes to describe rabies as it occurs in the dog, and the 
hydrophobia which ensues when a human being is bitten by a mad 
dog. This is done partly for the reason that the disease when it 
occurs in the dog may be detected in its early stages, and before 
there is much likelihood of its being communicated. 
The cause of the recent increase in these diseases is attributed, 
mainly, to the increase in the number of dogs kept, which is pro- 
portionately greater than the increase in population. It is also 
partly due to inadequate legislation and to almost criminal laxity 
in the enforcement of such laws as we have. In almost every 
State there is a periodical scare, when general statute and city or- 
dinance as to license and muzzling are enforced in a spasmodic 
manner for a short time, but when the scare is over the dog in- 
creases and multiplies, all untaxed, and goes unmuzzled to its heart’s 
content. Statistics show that in one municipality in the north of 
England during the year 1876, one man in five was bitten by dogs 
(twenty per cent, of the population), while during the same year 
in ten counties in Scotland one thousand sheep were killed by dogs. 
It is a well known and admitted fact that in the States of New 
Hampshire, Vermont, and New York, a majority of farmers have 
been obliged to give up the once lucrative business of sheep-breed- 
ing, owing to the increase in the number of dogs, and their rava- 
ges among the flocks.* 
* [ Germane to this subject, is the statement of Dr. Alexander Hadden, of New York 
City, based upon observations made by him while sheep-raising in his younger days, that 
castration of the male dog destroys his sheep-killing propensity by depriving him of the de- 
sire for the company of other dogs. He says that a solitary dog never engages in this 
relic of his wolfish state, but that when he sets out on one of these forays, he first asso- 
ciates with him some other dog, who, when the pasture is reached, may or may not en- THE ACUTE INFECTIOUS DISEASES. 
97 
It is claimed by a recent and eminent authority, that the 
marked increase in rabies is caused by the great disproportion 
which exists in the sex of dogs, the males far outnumbering 
the females, and he asserts that in Africa and India, where the 
females are not destroyed, rabies is unknown. He also refers to 
the fact that ungratified sexual instinct does undoubtedly cause 
a sort of periodic madness in certain wild animals—notably the 
elephant and the deer. However this may be, the over-stocking 
with dogs in our own country being admitted, and the animals 
being plentiful everywhere about us, how shall we know when 
a dog has rabies, in order that we may protect ourselves and our 
families by securing the diseased animal in season ? 
The writer has recently had an opportunity of seeing a dog which 
undoubtedly suffered from rabies for a week before it died, but in 
describing the symptoms of the disease he will also draw largely 
upon the graphic account of rabies by the venerable Hr. Gross, of 
Philadelphia, and a more recent description from the pen of Dr. 
Watson, of London. This last author, in his admirable article upon 
hydrophobia and its prevention, says that “ It is well to bear in 
mind the distinction between that disease in the human species, 
and rabies in the canine.” He argues that there would be no hy- 
drophobia were there no rabies ; there can be no rabies unless it 
be communicated by a rabid animal—the word rabies simply mean- 
ing mad or rabid. But they are not identical diseases, for rabies 
in the dog is quite distinct from hydrophobia in man. The term 
hydrophobia is often erroneously applied to both maladies, but the 
rabid dog is never hydrophobic; i. e., he never fears water. The 
writer of this paper cannot quite agree with one statement quoted 
above, for it is not yet proven that rabies only occurs by inocu- 
lation, that is, by one dog biting another, and so on, for many sci- 
entists distinctly declare that it does happen spontaneously and is 
developed by some unknown cause. Another erroneous impres- 
sion also prevails very generally, viz. : that it usually occurs in 
hot weather, “dog-days,” so called, whereas the fact is just the 
reverse, for a careful examination of newspaper files for the 
gage in the destruction of the sheep ; but one or the other of the pair is quite as likely 
to lie in the shadow of some bush or fence and watch the other in his onslaught. Bitches 
are very apt to go with other dogs on these excursions, but they do so most often as ob- 
servers and not as active participators in the hunt. Dr. Hadden also states that he has 
never found castration to destroy the value of the dog either for hunting or other pur- 
poses, but that it abolishes the sexual instinct only, and therefore renders him unlikely 
to engage in these wild hunts. The loss of desire to associate with other dogs would, 
moreover, render the castrated animal less liable to contract rabies from the bites in- 
flicted by one running wild. —Ed. ] 98 
THE ACUTE INFECTIOUS DISEASES. 
past ten years show a larger proportion of cases during the cold 
months. 
Symptoms of Rahies in the Dog.—During the month of Feb- 
ruary and the first week of March of 1878, an epidemic of rabies 
existed in the city of the writer’s residence, having started 
from a large English pointer dog, whose madness was apparently 
spontaneous. This dog, in five days, was known to have bitten 
more than one hundred dogs within an area of ten miles. Several 
of the dogs so bitten afterward became rabid and were killed, 
while others, at the time of writing, are now showing the prelim- 
inary symptoms of the disease. The history of the madness as it 
was developed in the case of this pointer, proves it to have been a 
typical case, as he had nearly all the symptoms described by Dr. 
Gross and Youatt, and some few which they do not mention. 
This dog was a quiet, peaceable animal, trained for bird-hunting, 
and, like most sporting dogs, an arrant coward, always avoiding a 
fight by running away, or refusing to defend himself if caught 
and attacked. Early in February he was observed to be restless 
and sullen, paying no attention to the voice of his master, but 
wandering about the house and grounds in an uneasy manner, 
occasionally throwing himself rather than lying down, then start- 
ing up again and resuming his purposeless walk. At times he 
seemed to be gazing at something in the air with his eyes wide 
open and the pupils dilated, and again, with contracted eyelids he 
seemed to be squinting at some object he could not see distinctly. 
Something about one ear annoyed him very much, for he was con- 
stantly scratching it with one hind foot, but careful examination 
revealed no wound, scar, or disease of the skin. He refused food 
from the very first, but would drink water eagerly, which, after a 
few minutes, was usually vomited up. The morning of the third 
day he was seen to grasp the leg of a coal-stove in his teeth, and 
to chew instead of biting it, and a few minutes afterward he 
seized a bit of iron that lay upon the floor and attempted to swal- 
low it. A bit of anthracite coal next attracted his attention, and 
this he swallowed at once. Subsequently he swallowed lumps of 
manure, chips, lumps of ice, the peelings of vegetables, and gar- 
bage of all kinds, but nothing in the way of food. The owner at- 
tempted to tie him up the forenoon of the third day, but before he 
could be secured he escaped from the stable and begun “running 
a-muck,” biting every dog he could catch, but devoting only a mo- 
ment or two to any one dog unless it happened to be a very small 
one, when he would seize it by the back and carry it some distance 
before dropping it. One very small tiny terrier was thus carried 
for a dozen or more rods and only dropped when the owner pur- THE ACUTE INFECTIOUS DISEASES. 
99 
sued and attacked him with a club. He seized the end of the club 
and bit it savagely, but did not offer to touch the man. It was 
noticed that when he thus picked up a small dog he invariably 
chewed it during the whole time he had it in his mouth. 
Upon one occasion he overtook a small company of half a dozen 
dogs of various sizes ; the large ones he simply bit once and then 
left them for another, but a small dog was carried some dis- 
tance and chewed as described above. One dog ran from him and 
sought refuge upon the piazza of its master’s house. The rabid 
dog pursued and caught it, and was chewing it when a woman 
hearing the outcry came out and attacked the pointer with a 
broom. He dropped the terrier for a moment, seized the broom 
in his teeth and worried it as a dog does a rat, but the instant the 
broom was snatched from his mouth he again attacked the little 
dog and was with difficulty driven off. Toward night he returned 
to his master’s house completely exhausted, and allowed himself 
to be tied up in an outhouse. It was noticed at this time that there 
was a very copious flow of saliva from his mouth, and that he was 
suffering from an accumulation of a sticky, tenacious phlegm or 
mucus in his throat, which he would try to eject by retching and 
working about the corners of his mouth in a frantic manner with 
both paws, as though he were trying to pull something out which 
choked him. He was evidently very thirsty, for he made eager 
attempts to drink, but most of the water was wasted from the 
irregular motion of his tongue in lapping it. There was also a 
spasmodic twitching of the muscles about the head and neck, like 
that seen in a dog after partial recovery from a dose of strychnine. 
At this time the animal was secured by two ropes attached to his 
collar, one of them very large and both hard and well twisted. 
When his master opened the door of the stable the next morning, 
the dog rushed past him into the street with fragments of both 
ropes attached to his collar. During this day he was seen chasing 
and biting dogs four miles from the city upon a road that leads to 
the north; two hours later he was again pursuing his victims in 
the streets of the town, and still later he was seen in the streets of 
a village seven miles from town due west; being easily recognized 
by his persistence in following and biting other dogs, and by the 
bits of rope he carried upon his neck. Late in the afternoon he 
made his way home with a staggering, uncertain gait, and with 
still more of the spasmodic twitchings of the muscles. For the 
first time he was cross toward the children of the family, giving 
vent to a hoarse growl when interfered with, but he permitted a 
young girl of twelve to tie him securely, this time a chain being 
used instead of a rope. There was some paralysis of the hind- 100 
THE ACUTE INFECTIOUS DISEASES. 
quarters, as they frequently gave way under him when he at- 
tempted to walk. There was the same vacant stare and following 
of some illusory object in the air with his eyes, and the same de- 
praved appetite for excrement, etc., as before. During this last 
raid he was seen to bite a pig and a hen, and shortly after he 
was chained up he sprang at and attempted to bite a horse which 
was led past him. He also seized and savagely bit the run- 
ner of a sleigh while in motion near him, and for the first time 
made an attempt to attack his master, but was restrained by the 
chain. 
The tongue was now so much paralyzed that he could drink no 
water, and the saliva absolutely poured from his mouth. His eyes 
were constantly in motion and apparently bloodshot. The morn- 
ing of the fifth day he was attacked with spasms and was merci- 
ful despatched. One of the dogs bitten by this animal began to 
sulfer from rabies in a fortnight from the time he received the in- 
jury, and the third day afterward bit a young woman severely 
through the base of the thumb. At present writing she has suf- 
fered no inconvenience, and the wound has healed kindly. 
Youatt’s description of rabies in the dog is so true and so 
graphic, that it is quoted entire. He says . “ In the greater num- 
ber of cases there are sullenness, fidgetiness, and a continual shift- 
ing of posture. For several successive hours, perhaps, he retreats 
to his basket or his bed. He shows no disposition to bite, and he 
answers the call upon him laggardly. He is curled up, and his 
face is buried between his paws and his breast. At length he be- 
gins to be fidgety. He searches out new resting-places, but he 
very soon changes them for others. He takes again to his own 
bed, but is continually shifting his posture. He begins to gaze 
strangely about him as he lies upon his bed. His countenance is 
clouded and suspicious. He comes to one and another of the 
family, and fixes on them a steadfast gaze, as if he would read 
their very thoughts. ‘ I feel strangely ill,’ he seems to say; have 
you anything to do with it ? or you ? or you ? Has not a dog 
mind enough for this ? If we have seen a rabid dog at the com- 
mencement of the disease, we have seen this to the life. Delirium 
is an early and characteristic symptom ; the dog sees imaginary 
objects, and often springs at them with a furious dart, he is rest- 
less, and excessively irritable, gazing wildly around and snap- 
ping at everything within reach. The saliva is secreted profusely, 
and collecting at the corners of the mouth, the animal makes fre- 
quent attempts to detach it with his paws ; his appetite is strange- 
ly perverted, and he will sometimes greedily devour horse-dung, 
or even his own excrement; the voice is changed in character, THE ACUTE INFECTIOUS DISEASES. 
101 
being generally hoarse, and more or less shrill; the eyes are 
singularly bright, and the thirst is intense and insatiable, the dog 
drinking frequently and having no fear whatever of water, as is 
not the case with the human subject. The disease now tends 
rapidly to a fatal issue. The muscular power being greatly ex- 
hausted, the animal finds it difficult to sustain himself upon his 
limbs ; he reels and staggers about like a man in a drunken fit; 
his tail is depressed and his tongue protruded ; the eyes have lost 
their brightness, and are of a dull, glassy appearance ; the breath- 
ing is hurried and panting; finally, worn out by his sufferings, 
the poor creature dies, either from convulsions or from exhaustion, 
the attack having lasted from three to five days.” Youatt adds, 
that “the power of giving the infection exists in all the confirmed 
stages of the disease, and continues even for twenty-four hours 
after the death of the animal.” 
Dr. Watson, of London, adds to these symptoms, “a slight 
squinting of the eyes and twitching of the face ; an earnest lick- 
ing of some part on which a scar may generally be found ; if 
the ear is the affected part, he scratches it incessantly and vio- 
lently ; if the foot, he gnaws it until the skin is broken. Occa- 
sional vomiting and depraved appetite is noticeable; then the 
animal becomes irascible and flies at strangers ; is impatient of 
correction, seizing the whip or stick ; quarrels with his own com- 
panions ; eagerly hunts and worries the cats ; demolishes his bed, 
and if chained up, makes violent efforts to escape, tearing his 
kennel to pieces with his teeth. If at large, he usually attacks 
such dogs as come in his way, but if naturally ferocious, he will 
diligently and perseveringly seek his enemy.” 
♦ Dr. Watson quotes Mr. Youatt as saying, that in his opinion 
“the dog is subject to what we call ‘spectral illusions he starts 
up and gazes earnestly at some real or imaginary object. He ap- 
pears to be tracing the path of something floating around him, or 
he fixes his eyes intently on some spot on the wall, and suddenly 
plunges at it; then his eyes close, and his head droops. Fre- 
quently, with head erect, he utters a short and very peculiar 
howl; or if he barks, it is in a hoarse, inward sound, unlike his 
usual tone. The breathing is laborious, and the drawing in of the 
breath attended with a singular grating, choking noise.” 
Billroth, a distinguished German surgeon and writer, says, “We 
distinguish a raving and a quiet madness; previous to both of them 
the dog is downcast and eats but little. After this state has lasted 
a week, the raving madness begins ; the dog runs about in a pur- 
poseless, objectless manner, apparently urged by some inward 
anxiety ; if irritated, he bites at anything that comes in his way ; 102 
THE ACUTE INFECTIOUS DISEASES. 
the mouth is dry, etc. ; he emaciates, he totters, his hind legs be- 
come paralyzed, and in three or four days he dies.” 
Upon making an examination of the bodies of dogs dying from 
rabies, nothing unusual is found, except a certain amount of in- 
flammation of the stomach, due, no doubt, to the various foreign 
bodies the dog has swallowed. This fact, however, is important, 
as affording a satisfactory test in the case of an animal suspected 
of rabies, for if, after death, we find this inflammation, and 
especially if the stomach contains such substances as coal, hay, or 
straw, sticks, horse-dung, iron or lead, as well as a quantity of a 
dark fluid, like thin molasses, which, in fact, is altered blood, we 
may fairly conclude that the dog was mad. 
The writer has been thus prolix in describing the symptoms of 
rabies in the dog, because he deems it of vital importance that his 
non-professional readers should be able to recognize the disease in 
season to protect themselves and the community from the possible 
results of a mistake or an oversight in this matter. 
Mode of Communication.—The virus of rabies resides in the 
saliva, or in the saliva mixed with other fluids of the mouth and 
throat. This fact has been established by experiments made upon 
the lower animals. Thus a dog, cat, hare, and hen were inocu- 
lated with the saliva of a rabid dog, and the disease followed in 
every case. A sponge wet in the saliva of a mad dog was rubbed 
upon a sore on the back of a sheep, and the animal subse- 
quently perished from rabies. A silk thread wet in the fluid from 
the sore upon the sheep was drawn through a bit of skin upon 
another sheep, and the disease was again communicated. The 
disease has been repeatedly provoked in dogs by inserting the 
saliva of rabid horses and asses. It is, however, still uncertain 
whether the disease can be communicated from one person to an- 
other. An assistant in one of the English hospitals was bitten by 
a patient laboring under hydrophobia, but no ill effects followed. 
Ur. Gross says that rabbits, fowls, etc., die from inoculation with 
human saliva without exhibiting any of the ordinary symptoms 
of hydrophobia. It must be kept in mind that hydrophobia means 
simply “ fear of water,” and that man alone develops this symp- 
tom. Youatt decides the question in the affirmative, and says 
that the saliva of a human being suffering from hydrophobia can 
undoubtedly convey the disease to another human being, but the 
context leads us to suppose that the saliva must come in contact 
with a sore or scratch, or some abrasion of the skin. Dr. Watson 
agrees with Youatt, and cautions the friends of hydrophobic 
patients to guard against the contact of the saliva with any 
sore or abrasion of the skin, or with the inside of the mouth and THE ACUTE INFECTIOUS DISEASES. 
103 
nose, as he infers that the mucous membrane may also absorb the 
poison. 
Dr. Watson relates the result of an experiment, which certainly 
confirms Youatt’s theory. Two healthy dogs were inoculated 
with the saliva of a patient in one of the Parisian hospitals, who 
died the same day. One of these dogs became mad forty days af- 
terward. This dog was allowed to bite others, which in their 
turn became rabid also ; and in this way the malady was propa- 
gated for several months. Although these facts do not fully settle 
the question, still the results are sufficiently startling to warn us 
against any carelessness in treating or nursing a patient sick with 
hydrophobia. In fact, every precaution should be taken to guard 
against contagion, while the unhappy patient should be dealt with 
gently, and his every wish gratified as far as is consistent with 
the safety of others. 
The inoculation in hydrophobia is usually effected by a tooth, 
which, however, need not necessarily penetrate deeply, as the dis- 
ease may be communicated by the slightest scratch. One case is 
reported where death was produced by the licking of a wart upon 
the face, by a little poodle supposed to be mad. Although it is 
probable that the true skin, when sound, does not absorb the poi- 
son, it seems that the mucous membrane does. A man endeav- 
ored to untie a hard knot by the help of his teeth. Eight weeks 
afterward he died of hydrophobia. It was then discovered that 
a mad dog had been tied with this cord. A woman was attacked 
by a rabid dog, but escaped with some rents in her gown skirt. 
In the act of mending it, she pressed down the seam with her 
teeth. She also developed hydrophobia and died. Horses have 
died mad after eating straw upon which rabid pigs had lain. As 
regards the transfer of the poison of hydrophobia to man, it is a 
relief to know that all who are bitten do not contract the disease, 
the saliva containing the virus no doubt being wiped off as the 
teeth penetrate the clothes. Where the teeth pass through leather 
the immunity is even greater. No accurate statistics of the per- 
centage of deaths to the number bitten are attainable. Authori- 
ties vary considerably, from one in thirty, twenty-five, and twen- 
ty, down to one death in fourteen cases, but even the last average 
is probably too low. One of the earliest recorded series of cases 
gave twenty-one bitten, and only one death. Another with fifteen 
bitten gave three deaths. 
The saliva of the rabid wolf would seem to be highly virulent, 
for, of twenty persons bitten by a mad wolf in 1774, in France, 
nine died. In 1817 twenty-three persons were bitten, and fourteen 
perished. Four out of eleven, and eighteen of twenty-four died 104 
TIIE ACUTE INFECTIOUS DISEASES. 
who were bitten at different times near Rochelle in France. Still 
later, nineteen were bitten, of whom twelve died within two 
months. In all, one hundred and fourteen persons were bitten 
by rabid wolves, and among them sixty-seven fell victims to 
hydrophobia. These beasts, it is said, always fly at a naked 
part, and hence the fatality of their bites. There is no doubt, 
however, that the majority of persons bitten by mad dogs escape 
the disease. It is probable that some persons are not susceptible 
to the poison in a high degree, for, of seventy-five persons bit- 
ten in this country, a majority did not take the disease, notwith- 
standing that in forty of the cases the bite was upon the hand ; 
on the face in fifteen, on the leg in eleven, and on the arm in 
nine; or to sum up, fifty-five were bitten upon naked and ex- 
posed parts against only twenty bitten through the clothing. 
The facts are stated with the hope of modifying the nervous de- 
pression and abject fear that ensues when one is bitten, the case 
being regarded by the victim as hopeless, and hence a state of 
mind ensues that actually invites the disease. Take the proper 
precautions and apply the appropriate remedies, if bitten, but de- 
termine at once that you belong to the majority, and that hydro- 
phobia is not to be your portion. 
If a person bitten by a dog supposed to be rabid cannot take 
this hopeful view of his case, another and most anxious inquiry 
next arises, viz., how long does the danger of hydrophobia con- 
tinue ? When is the peril fairly over, and after what lapse of 
time may the injured person lay aside all apprehension of the dis- 
ease ? Unfortunately, no satisfactory reply can be given. I)r. 
Watson says that in a vast majority of cases the disorder has 
broken out within two months of the bite. But he admits that 
the exceptions to this rule are very numerous. Two of the three 
cases treated by Dr. Gross developed at the end of four weeks, and 
the third did not manifest itself until nine months after the bite. 
In eighty-nine cases analyzed by Dr. Blatchford, the average 
period was about seventy days, the minimum in twenty-three 
cases was thirty days, and the maximum time six months and 
twenty days. Many well-authenticated cases give a wide range 
of time, as for example—one in seven days; one in thirty days ; 
one in eighteen months ; one in four years ; one in five years ; 
one in nine years, and one in twelve years ; but Dr. Watson 
argues of the last five cases quoted, that some unsuspected inocu- 
lation must have occurred, some fresh application of the poison - 
ous virus; and this he states, notwithstanding the fact that the 
man who died of hydrophobia at the expiration of seven years had 
been closely confined in prison for more than two years prior to THE ACUTE INFECTIOUS DISEASES. 
105 
the invasion of the disease, where he was out of the way of dogs 
altogether. The investigations of different observers have proved 
only two facts of value in this direction—viz., that the time elaps- 
ing between the bite and the disease is considerably shorter in 
animals than in man, and in very young persons than in adults. 
Hydrophobia is not peculiar to any age, as it has been observed 
in infants at the breast, and in every period of adult life, even to 
second childhood. Neither has sex any influence, although for 
obvious reasons women are less exposed to the bites of rabid ani- 
mals than men. It prevails in most, if not all countries, and at 
all seasons of the year. 
Another curious question also remains unanswered, and that 
is, where is the virus or poison hidden during the irregular period 
between the bite and the disease ? Writers have expressed a 
variety of opinions, some locating it in the scar ; some in the 
glands ; some in the blood; and some assert that it may become 
enclosed in a little sack which finally is ruptured, letting the poi- 
son free to be absorbed into the general circulation, and thus begin 
its deadly work weeks, months, or years after the bite. 
Symptoms of Rabies in Man.—The wound inflicted by a rabid 
animal usually heals kindly like any punctured wound, the scar, 
perhaps, remaining a little red and tender, as it does after an ordi- 
nary bite, but the system exhibiting no sign of disease. After a 
longer or a shorter time, when hydrophobia is about to develop, 
the part begins to itch, burn, or smart, and soon becomes sore and 
irritable, hot, numb, or rigid; pain darting through it in different 
directions, and sometimes extending to a considerable distance 
beyond the site of injury, as from the hand to the shoulder, or 
from the foot to the knee or groin. Sometimes a red line may be 
traced from the scar either up or down or in both directions, and 
sometimes, though rarely, the old scar opens, developing an un- 
healthy looking sore. About this time the patient feels unwell 
generally ; his head aches, and he has unpleasant dreams ; he 
feels melancholy and depressed, and has occasional chills, while 
the system is in a highly nervous and excited condition. 
The poison, says Gross, is now fairly at work, and in a few hours 
—generally from ten to twenty-four—it explodes with frightful 
violence. The disease has now reached its second stage ; the 
dread of water and the difficulty of swallowing have declared 
themselves ; in a word hydrophobia is fully established. The pa- 
tient on attempting to drink is suddenly seized with a spasm in 
the throat, and finds he is unable to swallow a particle of fluid ; 
he tries and tries, but every effort is only succeeded by a renewal 
of suffering, and presently he dashes away the cup as if it were 106 
THE ACUTE INFECTIOUS DISEASES. 
charged with some deadly poison, unwilling again to bring it to 
his lips. Though tortured with thirst and the dryness of ashes in 
his mouth, he will endure this rather than subject himself to the 
dreaded spasm. Should he succeed in forcing down a few drops, 
he will instantly be seized with a choking cough, convulsive 
twitchings, and lividity of the face, forcing him to jump up in bed 
and to pant for breath. 
He complains of a sense of constriction in his throat and chest; 
says he cannot breathe and sighs often and deeply ; has a frequent 
desire to clear his mouth of a thick and tenacious saliva, which 
greatly aggravates his sufferings. He now begins to complain of 
the air in the room, the slightest contact with cold air being a 
source of profound torture ; the agony thus caused being greater 
than that occasioned by the attempt to swallow fluids. The open- 
ing of a door, the slightest movement of a fan, or even the slightest 
whiff of air directed from the attendant’s mouth upon the body, 
instantly brings on a paroxysm of this kind. Light and noise too 
are always offensive, and hence the patient usually insists upon 
the room being kept dark, quiet, and closed. 
The mind is now peevish and fretful, and nothing that can 
be done pleases the sufferer, who, in consequence, often quarrels 
with those who are nearest and most devoted to him. Some- 
times the imagination is wholly perverted; he fancies that he 
hears noises and sees objects that have no existence ; he gets out 
of bed, walks about the room, screams or gesticulates like one 
affected with delirium tremens. 
The above are the symptoms generally seen in this stage and so 
well described by Gross, from whom most of this description is 
borrowed, but there are numerous exceptions. The case seen by 
the writer many years ago was one of these, for so far from being 
irritable or unreasonable, his only fear was that he might injure 
his friends, and he would actually ask to be properly secured so 
that no accident could possibly happen during the paroxysms. 
His mind was apparently clear even when he was suffering the 
most, and the efforts he made to suppress any manifestation of 
the agony he was enduring were extremely touching. We now 
come to the third and last stage, which is characterized by an 
aggravation of all the previous symptoms ; the countenance has 
a haggard and distressed appearance, horror and anxiety being 
depicted on every feature. The pupils of the eyes are dilated, and 
the eyes have a wild, glaring expression ; the tongue is dry and 
parched; the voice is hoarse and shrill, so much so, that it 
strongly resembles that of a dog ; the breathing is short and pant- 
ing : more or less delirium is present, often amounting to complete THE ACUTE INFECTIOUS DISEASES. 
107 
mania; the strength is much impaired, and the pulse, small and 
feeble, beats from one hundred and thirty to one hundred and 
sixty in a minute, which is very rapid, as the natural pulse is only 
about seventy-two to the minute; paroxysm after paroxysm recurs, 
until the frame is worn out by exhaustion, and death mercifully 
closes the scene, usually in a sudden fit of suffocation. Some- 
times a calm is experienced a few hours before death; the spasms 
subside, the power of swallowing returns, the mind becomes clear, 
and the patient sinks, perhaps, into a tranquil sleep, from which 
he awakes only to pass away quietly and peacefully. The dura- 
tion of the attack varies from eighteen hours to a week, the 
average being about three days. Many other symptoms have 
been observed from time to time by different observers, but as 
this work is not intended for medical readers, a general descrip- 
tion is deemed sufficient. No intelligent person could possibly 
mistake the disease after reading the concise but graphic descrip- 
tion from the pen of Dr. Gross, the most of which has now been 
given. It is only necessary to bear in mind the dread of water, the 
difficulty of swallowing, and the suffering caused by contact with 
a current of cold air, to enable any person to recognize a case of 
hydrophobia, even when no history of a previous dog-bite can be 
obtained. It is almost unnecessary to add that the disease is 
always fatal, as there is no reliable history of a case of recovery 
upon record. 
Treatment.—The secular papers occasionally give the details 
of remarkable cures effected by such remedies as “elecampane,” 
“arsenic,” etc., but none of them have stood the test of scientific 
scrutiny. No attempt will or should be made in a work of this 
practical character to give any directions for the treatment of 
hydrophobia, as this disease, more than almost any other, comes 
exclusively within the domain of medical practice. Even the 
most skilful physician can do little, except to palliate and relieve, 
and to effect this, opium and morphia are given either by the mouth 
or by injection, and ether or chloroform by inhalation. In an emer- 
gency, any or all of these may be used to the extent of quieting 
the sufferer, but a physician should always be summoned if within 
reach. The friends of a person afflicted with hydrophobia should 
guard themselves while caring for the patient, taking care that he 
does himself no injury in his frightful paroxysms, and avoiding 
all contact with the saliva he throws off so freely, and which, ac- 
cording to all reliable authorities, is either the propagating virus 
itself, or else serves as a vehicle for it. 
The important question to be considered is the treatment of 
the bite of a rabid animal, whether dog, cat, or fox. Dr. Watson’s 108 
THE ACUTE INFECTIOUS DISEASES. 
plan of establishing a quarantine for all the dogs in Great Britain, 
and keeping them closely confined for eight or ten months, is not 
practicable, in this country at least, and he also assumes that 
rabies is only propagated by contagion, and that it is never de- 
veloped spontaneously, which proposition is by no means con- 
ceded. A criticism in a New York journal upon this idea of Dr. 
Watson suggests that measles and scarlet fever might as well be ob- 
literated from off the face of the earth, and advises that all the chil- 
dren in the land be tied up and isolated for a year, simply to try the 
experiment. As the isolation of the children is about as probable as 
the quarantine of the dogs, let us consider what shall be done when 
one’s self or one’s friend is bitten by an animal supposed to be mad. 
The first question which arises is, should the bitten person, or a 
friend for him, suck the wound, and thus try to draw out the 
venom ? The answer to this from both Youatt and Watson is de- 
cidedly Ao / The danger of infection through chapped or abraded 
lips, tongue, or mouth, is too great to permit the risk. The very 
first thing to be done, if the bite is upon a limb, is to put on a 
ligature of some kind, such as a cord, shoe-string, handkerchief, 
cravat, or a strip from the underclothing, between the wound and 
the heart, and to draw it tightly enough to shut off the superficial 
circulation at least. A stick inserted in or under the ligature and 
well twisted, adds to the efficiency of the measure. Then, with a 
sharp knife, cut out every tooth mark, being sure to include some 
sound flesh all around and below the wound. This must be done 
as thoroughly as recommended in the section upon Snake Bites, 
and the same expedient may be used to secure thoroughness, viz., 
insert a little plug, whittled to fill the tooth wound, and then make 
two elliptical cuts, one each side of the wound, bringing the ends 
together, and making the two cuts meet below the wound, so that 
the entire depression made by the tooth will be removed with a 
considerable thickness of sound flesh all around it. Every tooth 
mark must be thus treated, and then bleeding should be encour- 
aged by cupping or the application of warm water, while the liga- 
ture about the limb may be loosened a little to secure more pro- 
fuse hemorrhage. When this has lasted for some little time, the 
surface of the wound or wounds may be dried, and the parts thor- 
oughly cauterized. The best material for this part of the treat- 
ment seems to be the ordinary lunar caustic. Youatt, who trusted 
to this agent, was bitten seven times and escaped, and he assures 
us that he had operated with lunar caustic upon more than four 
hundred persons, all bitten by dogs unquestionably mad, and that 
he did not lose a case. A distinguished London surgeon in charge 
of a large hospital asserts that ten times that number had been THE ACUTE INFECTIOUS DISEASES. 
109 
treated at the hospital by the cutting and bleeding treatment 
alone, without a single fatal case, but he admits that all the dogs 
were not known to have been rabid. Now, if to the free cutting 
out of the wounded parts, the thorough burning with lunar caus- 
tic is added, the bitten person must secure the maximum of safety. 
Bear in mind, that to be efficient, the ligaturing of the limb, and 
the cutting out of the wound, or the latter alone, if the bite is upon 
the face or trunk, should be instantly performed. If the bitten 
party is alone, and without a knife, he must apply the ligature as 
thoroughly as possible, and procure aid in making the excision as 
soon as may be. When the cutting and consequent bleeding has 
been thorough, he can afford to wait a short time until a physician 
or the caustic can be procured. A French physician prefers the 
treatment by actual cautery, that is, the destruction of the poison 
and the tissues of the bitten part, by searing them with a red-hot 
iron ; and a person might be bitten under circumstances where 
this would be the readiest and the safest course to pursue. The 
poison would undoubtedly be as thoroughly destroyed by applying 
strong nitric acid (aqua-fortis) to the interior of the wound, but 
even then it would be wise to cut the wound out first, and apply 
the acid afterward. If the teeth of the rabid animal have pene- 
trated between two bones, as, for example, when the bite has been 
inflicted upon the hand, the cutting out must be performed with 
care, otherwise a portion of the virus will be left behind. It may be- 
come necessary to remove a portion of the bones also, for, as Dr. 
Gross well remarks, any local sacrifice is justifiable to secure im- 
munity from so horrible a disease. The patient should cheerfully 
consent to the amputation of a limb even, if his safety demands 
it. If possible, the cutting and cauterizing may be performed 
while the patient is under the influence of ether or chloroform, or 
the spray of ether from an atomizer, or even from a syringe, may 
be thrown upon parts [or a lump of ice, or ice and salt may be used 
to freeze the skin] to secure local insensibility to pain during the 
use of the knife and caustic,' but no time should be wasted in 
waiting for the arrival of the ether or chloroform. The subse- 
quent treatment of the wounds made by the knife should be that 
of any open wound, viz.—the poultice, often changed—or the water 
dressing at first, and the warm poultice afterward, and perfect 
rest. The system should be supported by a generous diet, with 
stimulants and quinine, if necessary. 
ALBERT H. CROSBY, M.D. 110 
THE ACUTE INFECTIOUS DISEASES. 
[Resume of the Symptoms of Rabies in the Dog-. 
The following resume of symptoms presented by a rabid dog is 
taken from the writings of Fleming, Youatt, and Bouley, and 
should become familiar to every person who keeps a dog, or is 
liable to be brought much in contact with the animal: 
1. The disease is not characterized by fits of fury at its commencement, but is, on 
the contrary, to all appearance a benignant malady, though even then the saliva or foam 
is virulent or poisonous. The dog is, at this period, very dangerous, by its licking rather 
than biting, for as yet it has no tendency to use its teeth. 
2. At the commencement of the disease the animal’s temper becomes changed ; it is 
dull, gloomy, and silent, seeks solitude, and withdraws into the most obscure corners. 
But it cannot rest long in one place ; it is fidgety and agitated, goes here and there, lies 
down, gets up, prowls about, smells, and scratches with its fore-paws. Its movements, 
attitudes, and gestures at times would indicate that it is haunted by, and sees, phan- 
toms ; it snaps at nothing, and barks as if attacked by real enemies. 
3. Its appearance is altered; it has a gloomy and somewhat ferocious aspect. 
4. In this condition, however, it is not aggressive so far as mankind is concerned, but 
is as docile and obedient to its master as before. It may even appear to be more affec- 
tionate toward those it knows, and this it manifests by a greater desire to lick their 
hands and faces. 
5. This affection, which is always so marked and so enduring in the dog, dominates 
it so strongly in rabies that it will not injure those it loves, not even in a paroxysm of 
madness, and even when its ferocious instincts are beginning to be manifested and to 
gain the supremacy over it, it will yet yield obedience to those to whom it has been ac- 
customed. 
6. The mad dog has not a dread of water; but, on the contrary, will greedily swallow 
it. As long as it can drink it will satisfy its ever-ardent thirst; even when the spasms 
in its throat prevent its swallowing, it will, nevertheless, plunge its face deeply into the 
water, and appear to gulp at it. The dog is, therefore, not hydrophobic, and hydropho- 
bia is not a sign of madness in this animal. 
7. It does not generally refuse food in the early period of the disease, but sometimes 
eats with more voracity than usual. 
8. When the desire to bite, which is one of the essential characters of rabies at a cer- 
tain stage, begins to manifest itself, the animal at first attacks inert bodies, gnawing 
wood, leather, its chain, carpets, straw, hair, coals, earth, the excrement of other ani- 
mals, or even its own, etc., and accumulates in its stomach the remains of all the sub- 
stances it has been tearing with its teeth. 
9. An abundance of saliva is not a constant symptom in rabies in the dog. Sometimes 
its mouth is humid, and sometimes it is dry. Before a fit of madness, the secretion of 
saliva is normal ; during this period it may be increased, but toward the end of the mal- 
ady it is usually decreased. 
10. The animal often expresses a sensation of inconvenience or pain during the spasm 
in its throat, by using its paws on the side of its mouth, like a dog which has a bone 
lodged there. 
11. In “dumb madness,” the lower jaw is paralyzed and drops, leaving the mouth 
open and dry, and its lining membrane exhibiting a reddish-brown hue ; the tongue is 
frequently brown or blue-colored, one or both eyes squint, and the creature is ordinarily 
helpless and not aggressive. THE ACUTE INFECTIOUS DISEASES. 
111 
12. In some instances, the dog vomits a chocolate or blood-colored fluid. 
18. The voice is always changed in tone, and the animal howls or barks in quite a 
different fashion to what it did in health. The sound is husky and jerking. In “ dumb 
madness,” however, this very important symptom is absent. 
14. The sensibility of the rabid dog is greatly blunted; when it is struck, burned, or 
Figure 8. — A dog suffering from “dumb rabies,” in which paralysis of the muscles of the 
mouth and throat prevent closure of the jaws. 
wounded, it emits no cry of pain or sign as when it suffers or is afraid in health. It will 
even sometimes wound itself severely with its teeth, and without attempting to hurt any 
person it knows. 
15. The mad dog is always very much enraged at the sight of an animal of its own 
species. Even when the malady might be considered as yet in a latent condition, as soon 
as it sees another dog it shows this strange antipathy, and appears desirous of attacking 
it. This is a most important indication. 
16. It often flees from home when the ferocious instincts commence to gain an as- 
cendency ; and after one, two, or three days' wanderings, during which it has tried to 
gratify its mad fancies on all the living creatures it encountered, it often returns to its 
master to die. At other times it escapes in the night, and after doing as much damage 
as its violence prompts it to, it will return again toward morning. The distances a mad 
dog will travel, even in a short period, are sometimes very great. 
17. The furious period of rabies is characterized by an expression of ferocity in the 
animal’s physiognomy, and by the desire to bite whenever an opportunity offers. It al- 
ways prefers to attack another dog, though other animals are also victims. 
18. The paroxysms of fury are succeeded by periods of comparative calm, during 
which the appearance of the creature is liable to mislead the uninitiated as to the nature 
of the malady. 
19. The mad dog usually attacks other creatures rather than man, when at liberty. 
When exhausted by the paroxysms and contentions it has experienced, it runs in an un- 
steady manner; its tail pendant and head inclined toward the ground ; its eyes wander- 
ing and frequently squinting, and its mouth open, with the bluish-colored tongue, soiled 
with dust, protruding. In this condition it has no longer the violent aggressive tenden- 
cies of the previous stage, though it will yet bite every one—man or beast—that it can 
reach with its teeth, especially if irritated. 112 
THE ACUTE INFECTIOUS DISEASES. 
20. The mad dog that is not killed perishes from paralysis and asphyxia. To the 
last moment the terrible desire to bite is predominant, even when the poor creature is 
so prostrated as to appear to be transformed into an inert mass.—Fleming. 
“ The idea that dogs are not rabid when they can drink and do not seem afraid of 
Figure 9. — A dog in the furious stage of rabies. 
water is . . utterly erroneous, and would appear to owe its origin to the presence of 
hydrophobia in man, which ... is a marked symptom in him. Therefore beware of 
a sick dog, even when it drinks with avidity, for an aversion to water in rabies does not 
exist at any period of the disease. 
Whenever a dog is observed to persist in tearing the carpets, cushions, and other 
articles in rooms; when it gnaws boards or the wood of its kennel; devours its straw, 
soil, etc., without exhibiting any tendency to bite people, it ought to be suspected; for 
these signs are but a prelude to those of a more serious character, and the poor animal 
is, in reality, venting that ferocity on inanimate objects which will soon be directed 
toward everything animated. 
A sudden and strange alteration in the familiar voice of a dog should at once at- 
tract attention and elicit inquiry ; the rabic cry or howl is a sure warning, and affords 
just grounds for alarm, as it is one of the precursory symptoms of the furious stage of 
the disease. 
Suspicion should always attach strongly to a dog which does not manifest a certain 
degree of pain, and receives punishment without uttering any cry or complaint. When, 
for instance, a dog is pursued in a locality because it is without an owner, and is a 
stranger, if it remains mute, notwithstanding the menaces and the blows to which it is 
subjected, there is every cause for suspicion. There is also reason for apprehension 
when a dog bites itself persistently in any part of its body, and does not stop because of 
the pain it should experience. 
When a dog . . . contrary to its habits and natural inclination, becomes sud- 
denly aggressive to other dogs, it is time to take precautions. Such manifestations are 
very significant, and, if understood, they may be utilized in averting danger from other 
creatures. 
We should always look with suspicion upon a dog which, after being absent from THE ACUTE INFECTIOUS DISEASES. 
113 
its home for some days, returns again, and especially if it is emaciated and covered with 
mud, and perhaps with blood. 
The dog, and at particular times, when he is more than usually salacious, may, and 
does, diligently search the urining places ; he may even, at these periods, be seen to lick 
the spot which another has just wetted; but, if a peculiar eagerness accompanies this 
strange employment; if, in the parlor, which is rarely disgraced by this evacuation, 
every corner is perseveringly examined, and licked with unwearied and unceasing indus- 
try, that dog cannot be too carefully watched; there is great danger about him ; he may, 
without any other symptom, be pronounced to be decidedly rabid. I never knew a sin- 
gle mistake about this.—Youatt. 
Distrust, says Bouley, a dog when it commences to be unwell; every sick dog 
should, as a rule, be suspected. More particularly distrust a dog when it becomes dull, 
morose, and seeks for solitude ; which appears not to know where to rest; which is al- 
ways on the move, prowling, snapping at the air, and suddenly barking at nothing, when 
all around is perfectly still; whose countenance is sombre and only assumes its usual 
animated expression by brief starts. Beware of the dog that seeks and scrapes inces- 
santly, and exhibits aggressive movements against phantoms; and, finally, beware, 
above all, of the dog which has become too fond of you, and is continually endeavoring 
to lick the hands or face.”—Fleming, “ Rabies and Hydrophobia,” 1872, p. 197. 
Glanders—Farcy. 
This is a disease natural to animals of the horse family, but 
which may be communicated to other animals and to human 
beings. It is called glanders when it affects principally mucous 
membranes, and farcy when the skin is chiefly the seat of the 
disease. In either locality, the essential feature of the disease is 
the development of a number of lumps or tubercles, varying in 
size from that of a pin’s head to that of a pea. These tubercles 
afterward open to the surface, giving origin to ulcers which re- 
semble a chancroid (see chapter on Chancroid and Syphilis), and 
discharge a matter which varies in appearance and at different 
times; being like true matter, greenish, streaked with blood, or 
yellowish, and showing a tendency to form crusts or scabs about 
the margins of the sores. When the sores are close together they 
are apt to unite and form ulcers of irregular shape, which show 
little disposition to heal. The matter becoming mixed with the 
mucous from the nasal cavities (when this is the seat of the dis- 
ease) causes a discharge from the nostrils, which is not often 
very considerable in amount, but which, when brought in contact 
with a scratch on the skin, or an abrasion of the mucous mem- 
brane of the nasal cavity, mouth, or eye of another person, is 
capable of reproducing the disease. When the disease mainly 
affects the skin the lumps are called “ farcy buds,” and these 
generally become inflamed, and burst, like boils, or form abscesses 
beneath the skin, sometimes of considerable size. 
Horses are affected with a variety of the disease in which the 114 
TIIE ACUTE INFECTIOUS DISEASES. 
lungs are more particularly its seat, when there may be little or 
no nasal discharge, but the animal has a short, muffled cough, 
shortness of breath, and other symptoms which lead to the 
ion that he suffers from “heaves,” the true nature of his disease 
being overlooked. 
When the nostrils are affected, the partition or septum is the 
place where the ulcers may usually be found. The discharge may 
be limited to one nostril, and is said to be always greatest on one 
side if the disease affects both. The lymphatic glands under the 
jaw and near the neck are always enlarged in such cases, the ani- 
mal is feverish, and it is said that a sign of value is the rough and 
dingy appearance presented by its coat of hair. 
The disease, as above intimated, may be communicated by in- 
oculation with the discharges from the sores, but it is probable 
that in many cases, particles of the poisonous matter floating in the 
air may be inhaled and come in contact with the mucous mem- 
brane of the air-passages, and so cause the disease. This renders 
it important that every horse affected with a cough and having 
the other symptoms above described, should undergo a critical ex- 
amination. 
Grooms, and others whose occupation leads them to be much 
about horses, are particularly liable to infection with glanders ; 
but instances are also known where persons crossing a street have 
been inoculated by the discharge blown into their faces by pass- 
ing horses. This fact should render every person careful in ap- 
proaching the head of a strange horse. 
Symptoms in Man.—When human beings are the subjects of 
the disease, the nose and face are, for obvious reasons, the most 
common seat, although “ farcy buds ” also make their appearance 
in other localities. From one day to two weeks may elapse after 
infection before the disease makes its appearance. The patient 
then has a high fever, with occasional rigors, quick pulse, intense 
headache, and pain in the muscles and joints, profuse perspira- 
tion, and dark-colored urine. The mucous membrane of the nose 
soon shows signs of inflammation, and an eruption of red points 
appears on the skin, and afterward become tubercles or “farcy 
buds.” The discharge from the nose, at first watery, soon becomes 
thicker, sticky, and profuse, and still later, greenish, or mixed 
with blood. The eruption is apt to be greatest on the face, and 
pursue a rapid course. The cavity of the mouth and throat be- 
come the seat of disease, the eruption on the face becomes a col- 
lection of spreading ulcers, the eyes are inflamed, the patient 
grows feeble and delirious; has “ typhoid symptoms,” as they are 
called, and stupor and death soon follow. In the latter stage of THE ACUTE INFECTIOUS DISEASES. 
115 
the attack, the whole face and the mucous membrane of the air- 
passages partake in the diseased condition, and abscesses, often of 
considerable size, form in various parts of the body. 
Treatment.—There is no treatment yet known which will pre- 
vent or arrest this malignant form of blood-poisoning. It is only 
possible to adopt measures which make the patients more com- 
fortable, such as cleanliness, and the relief of pain, hunger, thirst, 
and restlessness. 
Whenever a horse is known to be affected with glanders or 
farcy, it should be killed without the least possible delay, and its 
carcass should be buried beyond the reach of other animals or 
men. Its stall, harness, and articles which may have come in 
contact with the discharges from the ulcers, should be fumi- 
gated with burning sulphur and alcohol, or burned when their 
value is not too great. The laws of most countries are very strin- 
gent in their requirements in these respects, and no on-e who has 
witnessed the occurrence of this horrible disease in the human 
subject will hesitate a moment in securing their careful enforce- 
ment. 
Mumps—Parotitis. 
This is among the least infectious of the diseases of this class, 
many persons escaping it altogether. It is most common among 
children ; rarely occurs after thirty years of age, and sometimes 
takes place in grown adults when they are massed together, as in 
camps, jails, asylums, etc. Males are more often affected than 
females. The disease consists of a swelling of one or both paro- 
tid glands—usually both. 
Symptoms.—After two or three days of fretfulness, loss of ap- 
petite, and, it may be, some fever, a child has a swelling of the 
gland on one side, filling up the space behind the lower jaw and in 
front of the ear. This is accompanied with pain when the mouth is 
opened, and there is some fever, a coated tongue, and discomfort or 
pain of the head. The swelling increases in size until the third to 
the fifth day, the fever having passed off when the swelling becomes 
well defined. From this time the swelling subsides, and by the 
tenth to the fourteenth day it has usually,passed quite away. In 
scrofulous children, however, its course is apt to be slower, and its 
duration, therefore, longer. The flow of saliva is often increased, 
but there is no such fetid odor of the breath as occurs in excessive 
flow of saliva from mercurial poisoning or ulceration of the inner 
surface of the mouth. When the swelling is at its height, there 116 
THE ACUTE INFECTIOUS DISEASES. 
may be some difficulty in swallowing, though this is not commonly 
the case, since the swelling pushes outwardly. 
A noticeable effect of the swelling of mumps is the pushing 
outwardly of the lower end of the ear, and the increased breadth 
of the face at the angle of the lower jaw, giving the face a comical 
appearance. When the gland is much swollen and hard, it may 
cause so much pressure on the nerve which passes across it to go 
to the muscles of the face, that a temporary paralysis of these 
muscles may be produced. 
Two or three days after the disease has made its appearance on 
one side, the parotid of the other side usually becomes affected 
and goes through a similar course to the first one. 
Matter rarely forms in the swollen gland, but in a few cases the 
testicles of adult males and the breasts of females become swollen 
and painful about the time that the disease commences to decline 
in the parotid, and these organs go through pretty nearly the 
same course of pain and swelling as the others. It is thought that 
‘'taking cold” may have something to do with this complication, 
but it is quite as likely to be a natural consequence of the disease. 
Treatment.—At the outset a laxative, such as a teaspoonful of 
elixir of Rhamnus frangula, or buckthorn, may be of service, but it 
might as well be omitted unless the head aches or is hot and the 
tongue is coated. 
Cold applications to the throat are not usually of service in 
limiting the amount or duration of the swelling, and it is thought 
by some that a resort to this treatment has a tendency to cause the 
“transfer of the disease,”as they say, to the breasts or testicles. 
Dry and warm applications are usually most comfortable, if their 
presence does not cause discomfort. Bags of hot bran, or a bat of 
cotton-wool may be applied to the throat. Food should be given 
in such form that it can be sucked through the partly closed teeth, 
and so avoid the pain caused by opening the mouth. Earache is 
sometimes relieved by these hot applications, or by syringing the 
ear with water that is 105° Fahr., or a trifle warmer. 
If the testicles become swollen, the patient should rest in bed 
and wear a suspensory bandage or handkerchief so arranged as 
to support them, and swollen breasts may be similarly treated 
and enveloped in cotton alone or covered with oiled-silk or gutta- 
percha tissue.—Ed.] Vac cination. 
BY 
4 
FRANK P. FOSTER, M.D., 
OF NEW TOES CITY. VACCINATION. 
Vaccination (from vacca, a cow) is the practice of communi- 
cating to man, or to certain of the lower animals, by inoculation, 
a disease known as cow-pox, or vaccinia, chiefly for the purpose 
of preventing small-pox. 
During the latter part of the eighteenth century, Edward 
Jenner, an English physician, became impressed with the impor- 
tance and probable truth of a tradition, held by dairy-men and 
others, to the effect that persons who had contracted cow-pox 
were thereby rendered insusceptible to small-pox. For many 
years he investigated the subject carefully and systematically, 
and in 179$ he published his first work upon vaccination, in which 
he took the ground that the inoculation of the human subject with 
the virus of cow-pox was a sure preventive of small-pox. The 
idea was not original with Jenner, for, apart from the traditional 
belief to which allusion has been made, there is good reason to 
believe that intentional inoculation with cow-pox had been done 
before, for the purpose of preventing small-pox ; but he cleared 
up many doubtful points in the matter—showed the necessity of 
using the virus of true cow-pox only, with which other diseases 
of cows had before been confounded, and of employing it at a cer- 
tain period in the course of the disease ; and substituted a precise 
method of inoculation, whereby the unpleasant results which 
sometimes followed accidental (casual) inoculation were for the 
most part avoided. In short, he reduced the whole matter to a 
system, and made its universal employment practicable. To him, 
therefore, belongs the credit of whatever benefits have resulted 
from vaccination. The practice was speedily adopted by the 
whole civilized world, and, except for occasional factious opposi- 
tion, has ever since held its ground, having wholly supplanted the 
old practice of small-pox inoculation (variolation). 
The disease cow-pox (called “natural” cow-pox in cases in 
which it occurs without known cause, i. e., in which the source of 
infection is unknown) is an analogue of small-pox, and is there- 
fore, along with horse-pox, sheep-pox, etc., one of the varioliform 120 
VACCINATION. 
diseases. Many have, indeed, considered it to be but a modified 
form of small-pox, resulting from the infection of small-pox being 
communicated to the cow. This theory is supported chiefly by 
the fact that artificial variolation of the cow (a difficult matter to 
accomplish) gives rise to a disease which it is difficult, if not impos- 
sible, to distinguish from natural cow-pox. Jenner maintained, 
however, that it originated from horse-pox, by the virus of that 
disease being inoculated upon the udder by the hands of the milkers, 
who were often ostlers also. Numerous experiments made in Jen- 
ner’s time seemed to contradict this view, but it has recently been 
re-affirmed, chiefly by Depaul,* who has shown the necessity of 
discriminating between true horse-pox (a general eruptive disease, 
running a definite course) and “grease” (an affection of the heels 
of horses)—a distinction which Jenner and other early investiga- 
tors do not seem to have made. It is certain that artificial inocu- 
lation of the cow with matter taken from the “grease” of horses 
has produced in this animal a disease which we cannot distinguish 
from true cow-pox. We may therefore conclude that cow-pox 
may originate from either small-pox or horse-pox, and that perhaps 
it may occasionally arise independently of either. Concerning 
the origin of horse-pox, nothing is known. Sheep-pox is a malig- 
nant disease, communicable by poisons given off by the animals 
affected, and which float in the atmosphere, in which respect 
it, together with small-pox, differs remarkably from cow-pox and 
horse-pox, which are communicable only by actual inoculation. 
Natural cow-pox affects chiefly, if not solely, milch-cows, but 
is easily communicable to the male animal or to the young of either 
sex, by artificial inoculation. It is usually a mild disease, and on 
that account is sometimes overlooked, so that it is doubtless of 
more frequent occurrence than is generally supposed. It is said 
that in India it occasionally assumes a malignant character. It is 
characterized by the formation of pocks on the teats and udder. 
When fully developed, the pock is a circular, ring-shaped vesicle, 
varying in size from that of a pea to that of a twenty-five cent 
piece. The ring-like border is raised somewhat abruptly above 
the surrounding skin ; is of a lustrous, pearly, bluish, rosy appear- 
ance, and the centre of the pock is depressed (umbilicated). The 
vesicular border contains a limpid or slightly straw-colored, viscid 
fluid (lymph), which is situated in and beneath the epidermis (or 
outer layer of the skin), in a number of little separate chambers 
(whence the vesicle is said to be multilocular). The true skin 
(derma), which forms the “floor” of the pock, is thickened and 
* A physician of Paris. 121 
VACCINATION”. 
gorged, with blood, especially in its papillary layer, so that, on 
pinching up a pock between the thumb and fingers, it is felt to be 
seated upon a hard, stiff base, resembling a button, and freely 
movable upon the deeper parts. Subsequently the clear lymph 
changes to an opaque, whitish, pasty mass, so that the vesicle 
loses its lustre, and eventually dries into a reddish brown crust, 
which, upon falling, leaves, if it has not been interfered with, a 
reddish, slightly depressed scar, which afterwards becomes white. 
Various inflammatory complications may be provoked by rough 
handling or injury of any sort, thus rendering the disease quite 
troublesome ; otherwise it is usually at an end within a fortnight. 
The general symptoms are usually limited to slight feverishness, 
which lasts for a few days only, and sometimes is altogether 
wanting. As a rule, the disease occurs but once in the life of a 
single individual. 
In the human subject the vaccine disease usually pursues the 
following course : in from three to five days after vaccination, a 
small, hard, reddish, pointed elevation of the skin, called a papule, 
forms at the point of inoculation, accompanied by slight itching. 
On the sixth or seventh day this papule is found to have grown to 
the size of a split-pea, or larger; to have assumed a vesicular 
(resembling a little blister) appearance at its border, and to have 
become depressed at its centre. On the eighth day (inclusive) the 
pock, after vaccination with long-humanized virus, has acquired 
its greatest size; after the use of bovine virus (that is, virus 
taken from a cow or calf), or humanized virus of few removes, 
it keeps on growing larger for several days longer. Thus far it 
has kept the same general appearance as before, the whole pock 
being situated superficially and movable upon the parts beneath. 
On the ninth day the pock has increased in plumpness, but it is 
usually more opaque or tallow-like in appearance, a brown incrus- 
tation has begun at the centre, and the whole is surrounded by a 
sharply-defined, bright redness of the skin, in the form of a disk 
of from one to two inches in radius, called the areola. At this 
time there is generally some fever, lasting for a day or two. The 
further course of the disease consists in the gradual fading of the 
areola (beginning at the centre) and the transformation of the 
entire pock into a hard, dry, translucent, brittle, brown crust, or 
scab, which falls off some time between the fifteenth and thirty- 
second days, leaving a somewhat depressed scar, which is usually 
permanent, and which often shows numerous radiating furrows 
or lesser depressions (like the pits on a thimble), which latter 
appearance is termed foveolation. 
In cases of revaccination, the disease usually runs a more rapid 122 
vaccination. 
and less regular course, and in particular, the typical areola is apt 
to be replaced by an extensively diffused redness. 
In the great majority of cases vaccination produces no incon- 
venience beyond a trifling feverishness and local soreness for a 
few days, but occasionally certain complications and ulterior 
effects take place. In persons suffering from certain skin diseases, 
especially eczema, the latter interfere with the success of vaccina- 
tion, and are apt to be aggravated by it. They may also be devel- 
oped by vaccination, in persons predisposed to them. The subjects 
of certain morbid constitutional taints, such as the scrofulous and 
the syphilitic, are prone to have their diseased tendencies roused 
into activity by vaccination. A few diseases, such as syphilis 
and erysipelas, may actually be conveyed in vaccination. Besides 
this, the wound of vaccination is liable to become infected by any 
atmospheric or other contagium which may gain access to it, 
such as those of erysipelas and diphtheria; but no more so than 
any other slight wound. Inflammatory complications are some- 
what more frequent, affecting the skin, the tissue lying below it, 
and the lymphatic vessels and glands; but they rarely prove 
serious. If the pock be injured, an ulcer or open sore is apt to 
result, but it usually yields promptly to appropriate treatment. 
Vaccination is accomplished by inoculating the specific product 
of the pock—the virus, which exists in the lymph contained in the 
vesicle. To obtain this lymph, which is contained in a number of 
separate compartments of the pock, the vesicular border should be 
punctured with a needle (in several places, so as to open a sufficient 
number of the compartments), at the proper period of the disease— 
just before the formation of the areola, usually on the eighth day 
inclusive. Great care should be taken not to draw blood. The 
lymph exudes in drops, and should be as clear as water, otherwise 
it is unfit for qse. It may be used at once, by transferring it 
immediately to the person to be vaccinated ; or it may be allowed 
to dry on slips of quill, or ivory, or pieces of glass, or sealed up in 
capillary glass tubes. The method by immediate transfer (arm-to- 
arm method) is the surest of success ; but it is not always practica- 
ble, and moreover it involves most risk of communicating infec- 
tious diseases. Dried lymph is the best form of preserved virus. 
The slips, if carefully preserved, retain their activity for several 
weeks, as a rule—occasionally for two or three years. They 
should be kept perfectly dry, and in a cool and dark place. Fluid 
lymph in capillary tubes is apt to become inert very soon, but it 
sometimes remains active for a long period. Still another form 
of vaccine virus is the crust or scab which is formed by the dry- 
ing up of the pock. This form is not to be recommended, for it VACCINATION. 
123 
is very uncertain in its results, and its use is particularly apt to 
be followed by inflammatory complications. 
If dried lymph be used, it should be moistened with a drop of 
cold water just before the operation ; the lymph in a capillary tube 
should be blown out on to a clean piece of glass or porcelain, and 
when a tube has once been opened, no portion of its contents 
should be kept for further use; in using the crust, a sufficient 
amount of it should be powdered and made into a paste with 
water. However prepared, the virus should be applied to a wound 
made for the purpose—either a puncture or an abrasion. The 
latter, which is most to be recommended, is best made by scraping 
off the outer portion of the skin over a space as large as a pea, 
taking care not to wound the true skin. A lancet is a convenient 
instrument, and the manipulation is the same as for erasing ink- 
marks from paper. After having sufficiently cleared away the 
dry cuticle to expose a surface of moist skin-tissue (no matter 
whether or not it shows the color of blood), the virus should be 
applied to the moist surface, and briskly rubbed upon it for a full 
minute or more. The arm should be kept bare for a few minutes, 
but no plaster or other dressing need be applied. Everything used 
in the operation, including the vaccinator’s hands, should be scru- 
pulously clean. Inattention to this point is the cause of a great 
majority of the unpleasant results which sometimes occur. 
A child may safely be vaccinated at any age, but, unless 
demanded by actual exposure, it is well to postpone the proceeding 
until the age of two or three months, and it is desirable that the 
child should not be teething or suffering from any disease, particu- 
larly disease of the skin. Every person should be revaccinated 
as often as once in five years, and whenever small-pox prevails. 
For good reasons, the left arm is usually chosen as the portion of 
the body to be inoculated. It is well to make two separate inocu- 
lations—one at the insertion of the deltoid muscle (see figures on 
next page), and the other at a point an inch or more distant from 
the first, over the posterior border of the same muscle. It is some- 
times customary in Europe, in the case of females, in order to 
avoid any appearance of the scar which follows vaccination, to 
make the inoculation upon the outer surface of the leg. In the 
case of infants this is probably quite as successful as when the 
arm is chosen; but in adults, unless the precaution is taken to 
remain quiet during the course of the disease, and keep the foot 
and leg raised to the level of the body, the inflammation and swel- 
ling will be greater than when the arm is used. 
Of late years, bovine virus has been very much used, and 
presents certain advantages, the chief of which is that it entirely 124 
VACCINATION. 
abolishes the risk of conveying syphilis, provided the following 
rules are observed : use a pe7'fectly clean instrument, and do not 
apply the same instrument without previous cleaning, or the same 
quill, or other material charged with vaccine, to more than one 
person. There are various sorts of bovine virus, viz. : (1) from a 
case of natural cow-pox (primary vaccine); (2) from a variolated 
Fig. 11. 
Fig. 10. 
Fig. 12. 
Figure 10.—An instrument sometimes employed instead of a knife or lancet, to produce 
scratches, into which the virus may be rubbed. 
Figure 11.—Showing the point on the outer surface of the right arm, where vaccination is 
commonly made. 
Figure 12.—The crosses show the place on the outer side of the right leg, where vaccination 
may be made. 
cow (variola vaccine); (3) from a retro-vaccinated cow, i. e., a cow 
inoculated with humanized vaccine; (4) from an equinated cow, 
i. e., a cow inoculated with horse-pox; and (5) from a cow or calf 
inoculated with virus which has been propagated through cows or 
calves from a case of natural cow-pox. The last-mentioned variety 
is the one generally used, and is to be preferred. 
Vaccination almost invariably confers complete protection 
against small-pox for the time being; but very frequently this 
immunity becomes impaired or altogether overcome in the course 
of years, so that the individual finally becomes liable to contract 
the disease in its modified form (varioloid), or even unmodified. 
Hence the necessity of revaccination. Small-pox sometimes oc- 
curs within a very short time after vaccination. Such an occur- 
rence is usually due to the fact that exposure to small-pox had 
already taken place before the vaccination—too long before for the 
latter to prove efficient. After exposure to small-pox, vaccination 
should be resorted to at once, although there is a decided proba- 
bility that it will suffice if done within three days (inclusive). VACCINATION. 
125 
After the symptoms of small-pox have once appeared, vaccination 
is of no use whatever. 
The inflammatory complications which sometimes follow vac- 
cination are to be treated as they would be if due to any ordinary 
cause. Excessive redness, with severe burning and itching, is 
usually very much alleviated by a weak lotion of carbolic acid, 
a teaspoonful to a pint of cold water, or the following liniment 
applied on a couple of folds of soft muslin or linen cloth. 
Stramonium ointment One Troy ounce. 
Solution of subacetate of lead Thirty drops. 
Linseed oil Four fluid ounces. 
Mix. 
When the articles above mentioned cannot be readily obtained, 
a teaspoonful of sugar of lead may be added to a pint of cold water, 
and a double thickness of muslin or linen, wet with it, may be kept 
on the inflamed spot. 
Ulceration of the pock (generally due to injury) may be treated 
by dusting the ulcerated surface with equal parts of powdered 
starch and oxide of zinc, and the same may be used to check an 
immoderate flow of lymph after a pock has been opened for the 
purpose of obtaining lymph. 
Contact with underclothing, and scratching or rubbing, is pretty 
sure to increase the inflammation and swelling that follow vaccina- 
tion. They may also cause a rupture of the pock, and, by disturb- 
ing the natural course of the disease, produce a troublesome sore. 
Care is especially needed when flannel underclothing is worn, and 
it may then be advisable to cover the inflamed part with a piece of 
soft muslin or linen, greased on its underside with fresh tallow or 
simple ointment, and fastened sufficiently tight to prevent its slip- 
ping about. 
In nearly every case in which the arm is the part chosen for 
inoculation, the lymphatic glands in the arm-pit become more or 
less swollen and tender. This complication is increased if the limb 
is much used, and is lessened by keeping the arm quiet. When 
sufficiently severe to demand attention, a bag of hops wet with hot 
water and laid in the arm-pit will probably be all the treatment 
needed in addition to rest. 
FRANK P. FOSTER, M.D. Chancroid and Syphilis. 
BY 
HENRY G. PIFFARD, A.M., M.D., 
% 
OF NEW YORK, 
PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF THE CITY OF NEW YORK, MEDICAL 
DEPARTMENT ; VISITING PHYSICIAN TO CHARITY HOSPITAL. CHANCROID AND SYPHILIS. 
Chancroid. 
A chancroid is an ulcer or sore, generally occurring upon the 
genital organs of either sex, though it is sometimes met with in 
other parts. It is always the result of contact with matter derived 
from a similar sore, and usually appears within a few days (three 
to ten) after exposure. The ulcers are somewhat painful, and 
freely secrete an abundant and whitish pus or matter, which is 
highly contagious, and capable of producing a new chancroid, if it 
comes in contact with a scratch or abrasion of the skin of any part 
of the body, whether of the person bearing it, or of another. Chan- 
croids vary in number, and from two to five or more are not unfre- 
quently seen upon the same person at the same time. They may 
vary from the size of a pea to that of a three-cent piece. If un- 
treated, these sores usually persist, under favorable circumstances, 
for one or two months before healing. If, however, dissipation be 
indulged in, or the organs which bear them be put to unnecessary 
use, chancroids usually inflame, become more painful, increase in 
size and are, naturally, longer in healing. If the patient at the 
same time be in poor health, they may become “phagedenic,” 
that is to say, the parts surrounding them rapidly mortify, and 
a considerable portion of the adjoining tissues may be sacrificed. 
Bubo.—During the second or third week, or even later, of the 
existence of a chancroid, a painful swelling in one or both groins 
may appear. This swelling is called a bubo, and may persist for 
a few weeks, producing a moderate sense of discomfort, and then 
gradually subside and disappear. On the other hand, it may rapidly 
increase in size, become exceedingly painful, and matter may form 
in its interior. The skin over it becomes reddened and thinned, 
and the bubo, unless opened by the surgeon, ultimately bursts and 130 
CHANCROID. 
discharges a greater or less quantity of pus. It does not, however, 
immediately heal like a boil or ordinary abscess, but continues to 
discharge for weeks, and sometimes for months. When the hole 
finally closes, a very perceptible scar remains. If phagedena at- 
tacks the bubo, a great deal of additional damage may be done, 
and a year or more may elapse before final recovery takes place. 
The bubo is the result of the conveyance of the poisonous virus 
by the lymphatic vessels from the original sore to the neighboring 
glands. It does not, however, “ get into the blood ” and infect the 
system at large, after the manner of syphilis. Consequently, 
when it is once cured, there is an end of the matter, and the pa- 
tient is physically as well off as before, except as regards the local 
injury that may have been inflicted. This is, however, some- 
times serious and considerable. 
Treatment.—If left to itself, the chancroid will in most cases 
heal in one or two months, if the patient keeps it scrupulously 
clean and abstains from spirituous potations, sexual intercourse, 
etc. If, however, he is negligent in these respects, its duration is 
indefinite, and he runs the further risks of phagedena and in- 
creased liability to bubo. Under careful treatment, the duration 
of the sore may be very much abridged. The object of treatment 
is to destroy the virulent character of the ulcer—that is, to change 
it into a simple sore, with a tendency to heal. This may be ac- 
complished in several ways. First, and most quickly, by the appli- 
cation of a powerful caustic, followed by the use of some simple 
powder or lotion. The ordinary “ caustic ” of the shops (nitrate 
of silver) is not sufficiently active, and is of little use in this con- 
nection. Treated actively, chancroids not infrequently heal in a 
couple of weeks or less, and the chances of bubo occurring are very 
much lessened. 
Secondly, less active, astringent, or stimulating applications 
may be employed. With these the treatment may be prolonged 
for a month or more. The first method is decidedly the best, 
and the only objection to it is the temporary pain produced by 
the cauterization. This is quite sharp at the moment, but does 
not last long, and should be borne for the sake of the advantages 
that attend it. If a bubo appears, it will require applications of 
tincture of iodine, pressure or poultices, according to circumstan- 
ces. If matter forms, the bubo must be opened with the knife or 
the pus be abstracted in some other manner, and when this be- 
comes necessary, the sooner it is done the better. 
Under all circumstances, cleanliness and correct living are in- 
dispensable to the rapid cure of either chancroid or bubo. SYPHILIS. 
131 
Syphilis. 
The diseases of the genital organs, elsewhere described [see Ure- 
thritis (See Index) and Chancroid], are of small moment in compari- 
son with the one that now engages our attention. Although painful 
and inconvenient for the time being, they rarely, except in case of 
stricture, leave any serious after-effects; and these are confined 
to the guilty party, and may be considered in the light of a penalty 
that nature so often exacts of the transgressor. With syphilis, 
however, the case is widely different, for in many cases, imper- 
fectly treated or neglected at the beginning, the disease harasses 
the patient for years, and even accompanies him to the grave; 
and in not a few instances is the direct cause of the fatal event. 
It may also be conveyed in various ways, as we shall see later, to 
innocent individuals, and inflict a degree of misery that cannot be 
easily calculated. 
The origin of syphilis is obscure, and its first causes, whatever 
they may have been, have thus far eluded the most exhaustive re- 
searches. The first clear and distinct accounts of the malady date 
back to the latter part of the fifteenth century, at which time the 
disease became very prevalent in Southern Europe, from which it 
rapidly spread over the rest of the continent and the adjacent 
countries. At the present time it is universally distributed wher- 
ever civilized man has gained a foothold. The disease spreads by 
contagion, and every case (except when hereditary) is the result of 
direct contact with the syphilitic poison. There are no reasons 
for believing that it, any more than small-pox, is spontaneously 
generated at the present time. There are no reasons for believing 
that it originates simply from dirt, filthy habits, or excessive pro- 
miscuous intercourse. These causes may possibly produce the dis- 
eases previously described, but syphilis depends on a definite and 
specific poison, derived from another person, who in turn received 
it from still another, back to the first case, the origin of which is 
unknown. The first symptom or sign of syphilis is the chancre. 
Chancre.—The chancre, like the chancroid, from which it must 
be carefully distinguished, usually appears upon the genitals. 
Unlike the chancroid, it does not appear within the first few days 
after it has been contracted, but usually delays its advent for two 
or three weeks, sometimes longer. In the meantime there may be 
nothing to attract the patient’s attention, nothing that the most 
careful inspection will reveal, that will lead the patient to suspect 
or enable the surgeon to declare that syphilis has been contracted. 
This period of latency, or of “incubation,” as it is called, is finally 132 
SYPHILIS. 
terminated by the appearance of a small reddish-brown pimple, 
which, if taken between the fingers, is found to be a little firmer 
than the natural tissues of the part. In a few days this pimple 
increases in size, and usually ulcerates a little and looks something 
like a small chancroid, except that it does not secrete as much 
matter as the latter; that is to say, it is dryer. It will be found to 
offer a good deal of resistance to pressure between the fingers, due 
to a hardened layer, called the “induration,” which forms at its 
base. This induration differs in degree in different cases, some- 
times being very slight, at other times exceedingly distinct. The 
chancre is rarely painful, and usually does not attain any great 
size, and in some cases causes so little inconvenience as to escape 
notice altogether, by those who are not on the lookout for trouble. 
Not unfrequently men who have taken risks will make a rigid 
daily inspection for a week or so, and if they fail to discover any- 
thing wrong by this time, consider themselves safe, and give the 
matter no further attention. They are consequently surprised a 
week or two later by the appearance of the chancre. If, in the 
interval between the contraction and the appearance of the sore, 
they have had intercourse with several women, they usually 
charge the difficulty to the account of the wrong person. If, as 
sometimes happens, the chancre appears and disappears without 
having attracted the notice of the patient, he is still more surprised 
when the surgeon informs him that some eruption on the skin, or 
other trouble for which he seeks advice, is syphilitic, and will de- 
clare most vehemently that he has never had a chancre, and 
therefore cannot understand how such can be the case. Usually 
a chancroid is much more annoying to the patient, and much more 
likely to attract his attention and alarm him than a chancre. 
Although, as a rule, the chancroid and the chancre present 
quite different appearances, it sometimes happens that the charac- 
teristic aspect is absent, and it becomes difficult to distinguish one 
from the other. In some cases the most experienced surgeons are 
unable to decide positively whether a certain sore is a chancroid, 
or, consequently, a local disease not followed by a constitutional 
infection, or whether it is really a true chancre, to be inevitably 
succeeded by the secondary stage of syphilis. Chancres, unlike 
chancroids, usually come singly or, at the most, but two or three. 
If a patient have two or more sores at the same time, one of them 
may be a chancre, and the other a chancroid, which have been 
contracted at the same or at different times. 
The usual duration of the chancre, when untreated, is from one 
to two months. After it has existed for a week or ten days, the 
patient will generally find that he has some enlarged glands or SYPHILIS. 
133 
kernels in the groins; these may attain the size of a hazel-nut, or 
even of a pigeon’s egg, but are rarely painful, and almost never 
inflame and suppurate like the bubo that follows chancroid. At 
the same time other glands in the body enlarge and become hard, 
but as a rule their presence is first discovered by the surgeon. 
Although often quite innocent in appearance, the chancre is 
very contagious, and is the most frequent, though not the only, 
medium by which syphilis is transferred from one person to an- 
other. 
From one to two, rarely as late as three, months after the ap- 
pearance of the chancre, a new set of symptoms arise. These 
mark the beginning of the secondary period of the disease, or con- 
stitutional syphilis, as it is often called. 
Secondary Syphilis.—This does not always commence in the 
same way. In the majority of cases the first thing that attracts 
attention is the appearance of a number of small red spots upon 
the skin; these last for a few weeks and disappear, to be followed 
by a distinct eruption of pimples scattered over the surface. 
These, as well as the little red spots which first appeared, usually 
respect the face, and confine themselves to the covered portions of 
the body. After a time these also disappear, without leaving any 
scar or mark other than a slight stain that in time fades away. 
Later, however, quite large pimples, called “ tubercles,” appear, 
which may remain as such, or change into pustules, and become 
covered with crusts and scabs. At this time the face and scalp 
usually come in for their share of the disease, which is now ap- 
parent to every observer. These tubercles and pustules always 
leave little scars or “pits” in the skin, something like those of 
small-pox. Still later, large pustules and ulcerations form, and, 
if numerous, render the patient a disgusting object to all with 
whom he comes in contact. 
The skin, however, is not the only part of the body that suffers 
in secondary syphilis. About the time that the first eruption ap- 
pears, the mouth and throat are liable to become sore. The throat 
becomes inflamed, the tonsils swollen, and ulcers appear on them 
and on the palate. These extend and destroy the parts to a greater 
or less extent. At the same time small, slightly raised whitish 
spots, called “ mucous patches,” may appear on the lips, tongue 
or other mucous membrane. These give rise to a secretion which 
is fully as contagious as that of the chancre, and are not infre- 
quently the source of infection, through the medium of pipes, 
drinking vessels, and kisses. The person thus innocently in- 
fected contracts a chancre at the point where the infection is re- 
ceived, namely, on the lips, tongue, or inside of the mouth. 134 
SYPHILIS. 
In women mucous patches frequently occur upon the genital 
organs also, and thus prove a source of infection fully as danger- 
ous as the chancre. 
The eyes also are liable to suffer, usually in a painful manner, 
and if neglected, impairment of vision usually results. Still, other 
parts of the body may become affected during the early and mid- 
dle periods of the disease. 
During the whole of the secondary period, the patient’s general 
health is apt to deteriorate, and after a time he becomes subject to 
various pains, specially noticeable in connection with the long 
bones, as those of the arms, legs, and breast-bone, and not con- 
fined to the joints, like ordinary rheumatism. These pains are 
most severe at night, and interfere greatly with the sleep, and con- 
sequently with the comfort and health of the sufferer. At daylight, 
however, they subside or disappear entirely, to recur on the fol- 
lowing night, and so on indefinitely. Coincident with them, pain- 
ful lumps, called “ nodes,” may appear on the shins and else- 
where. These various symptoms do not last forever, but after a 
time disappear, and may be followed by a varied interval (per- 
haps months, perhaps years) of comparative comfort, when, with- 
out apparent cause, symptoms pertaining to what is termed the 
tertiary period, supervene. 
Tertiary Syphilis.—After the disease has spent a portion of 
its energy on the more external parts of the body, it not infre- 
quently attacks the deeper regions. The cartilages of the nose, 
and the bones, especially of the palate, nose and skull, are apt to 
suffer; they become “ carious,” that is, rotten, and come away in 
small pieces, and their loss results in more or less disfigurement 
of the features. The vital organs, such as the liver and kidneys, 
are also liable to be invaded by the disease, and, still later, the 
spinal cord and brain. If any of these organs are affected, the 
disease may prove slowly or rapidly fatal. 
Such is the picture that neglected or mistreated syphilis not 
unfrequently presents to the surgeon’s eye. The description is 
not overdrawn, for, while some patients may escape most of the 
troubles enumerated, others may suffer from them all and 
more. 
Hereditary Syphilis.—During the early periods of the disease, 
that is, during the existence of the chancre or of mucous patches, a 
man may convey the disease to his wife, and if she become enceinte 
after she has contracted the disease, her offspring, if she has any, 
are liable to be affected. Nature, fortunately, limits the number 
of such offspring by miscarriage, or premature delivery; or if, by 
chance, a few are born alive, they usually succumb within a few SYPHILIS. 
135 
months. Sometimes they pass through childhood and reach adult 
life, but they are apt to suffer much and variously on the way. 
It is probable that even in later periods of the disease a man 
may beget syphilitic children. In tertiary syphilis, however, the 
infection of wife or offspring is believed, by most authorities, to be 
impossible. 
Treatment.—Judicious treatment of syphilis fortunately robs 
this disease of most of its terrors, as many cases are undoubtedly 
cured permanently, while in many others the amount of incon- 
venience produced by the disease is reduced to a minimum. The 
treatment, however, is tedious, and, to secure the best results, re- 
quires the active co-operation of the patient. The physician may 
prescribe, but if his directions are not strictly followed, the patient 
can hardly expect the benefit that would otherwise accrue. 
One of the first points to be attended to is general hygiene. Good 
health, good food, good air, suitable clothing, freedom from undue 
exposure to the elements, regular exercise and methodical habits, 
constitute more than one-half of the treatment. Per contra, the 
absence of these essential elements will greatly impair the effects 
of the best of treatment, and not unfrequently lead to relapses, 
annoying alike to the physician and the patient. Temperance is 
a sine qua non of successful treatment, and if reformation in this 
respect is necessary, the patient must fairly make up his mind to 
undergo the requisite self-denial. 
The period required for successful and radical treatment will 
vary from one and a half to two and a half years, during the 
whole of which time the patient should be under the immediate 
supervision of his physician. He must fully understand at the 
beginning that he has gotten himself into very serious trouble, 
and that it will take time and faithful attention on his own part 
to secure him immunity from suffering in after years. In other 
words, if the case is taken in hand at the beginning, and treat- 
ment is carefully followed up for the period named, the probabili- 
ties are strong that the patient will suffer but little from his dis- 
ease during the period named, and not at all during the rest of 
his life. This is a much more cheerful prospect than would have 
been offered thirty or even twenty years ago, for at that time the 
idea was prevalent, both with the public and with the profession, 
that syphilis was not permanently curable. At the present day, 
however, the experience of the author and that of most surgeons 
who see much of the disease, warrants the statement that a con 
siderable proportion of cases are permanently and radically cura- 
ble. There is but one drug, however, that can be relied upon to 
accomplish this end. This drug is mercury. There is a very prev- 136 
SYPHILIS. 
alent notion that mercury, although capable of relieving the dis- 
ease, is apt to accumulate in the system and produce diseases or 
give rise to discomforts greater than those which pertain to syph- 
ilis itself. This idea was justified to a great extent by the results 
that followed mercurial treatment in former times. The facts are 
these: If a dose of a suitable preparation of mercury is taken, it 
is immediately absorbed into the blood and circulates throughout 
the body. In a few hours, however, it begins to escape from the 
blood through the kidneys and may be found in the urine. If now 
the daily dose be greater than the kidneys and other excretory 
organs can daily remove, the drug will naturally accumulate in 
the system, and its presence there in undue quantity is harmful. 
On the other hand, if the dose is not larger than the kidneys are 
capable of removing, the drug simply acts its part in neutralizing 
and eradicating the disease, and passes out of the body without 
leaving behind any undesirable consequences. The practice of 
the best surgeons at the present day is to give mercury for long 
periods, months at a time, with brief or even with no intermis- 
sions, but to give it in extremely small doses. Formerly, it was 
thought necessary, to salivate. At present, salivation is considered 
not only unnecessary but harmful. It is a misfortune that must 
be sedulously guarded against. The patient’s own watchfulness 
must serve him here. Having received from his physician a pre- 
scription for mercury in pills or in a mixture, as the case may be, 
with directions as to dose, his first duty is to follow absolutely the 
directions given. If, after he has taken the medicine for a few 
days or weeks, however, he finds that his gums are becoming pain- 
ful or his teeth sore, salivation is imminent and the medicine must 
be immediately discontinued, and not resumed until the patient is 
able to consult his physician and receive further advice in the 
matter. It is not always possible to determine, in the beginning, 
the proper dose that each patient should receive, as the disease 
differs in severity in different cases, and the patients themselves 
differ in their susceptibility to the action of the medicine. Saliva- 
tion, therefore, is rarely the fault of the physician, but is more 
frequently due to lack of care and watchfulness on the part of the 
patient. After complete recovery from the salivation, if it should 
occur, the mercury is resumed as long as may, in the judgment of 
the physician, seem proper. It is probable that it will be necessary 
to continue its use for a considerable period. If this course were 
strictly followed there would be fewer cases presenting the severe 
symptoms we have already described. 
Many patients, however, fail to comprehend the real gravity of 
their position, and discontinue all treatment as soon as the symp- SYPHILIS. 
137 
toms for which they have sought advice have disappeared. They 
seem to imagine that when the eruption has faded that the dis- 
ease itself is cured, and that the necessity for further medication 
no longer exists. A few weeks or months later a relapse awakens 
them from their fancied security, and they return to their physi- 
cian complaining that his treatment has failed to cure them. 
Quite as often they consult a different physician and abuse the 
last one for not having done that which was simply impossible. 
A few weeks’ treatment again relieves them temporarily, and 
with the disappearance of their trouble they discontinue medica- 
tion. Another relapse occurs in due time, and the folly of submit- 
ting to but a short course of treatment is repeated until at last the 
general health becomes seriously impaired and perhaps wrecked 
for life. The proper course is for the patient to carefully select in 
the beginning the physician to whom he entrusts his case, and to 
stick to him continuously until he is told that he requires no fur- 
ther supervision. Under ordinary circumstances entire suspen- 
sion of treatment is not prudent in less time than eighteen months 
or two years. If , during this period, he is under judicious treatment, 
and if he, at the same time, takes proper care of himself , he is not 
likely to suffer any particular inconvenience from his disease ex- 
cept the nuisance of continual medication. This, unfortunately, 
cannot be helped, but must be borne with as much resignation and 
philosophy as the patient is able to command. 
The relations of the patient to himself and to his physician are 
not, however, the only ones that are to be considered. In con- 
tracting syphilis he, at the same time, acquires a grave responsi- 
bility that no honorable man would think of shirking. It becomes 
the duty of the syphilitic to use every means to prevent others from 
innocently acquiring the disease from him. During the first few 
months of the disease, while there are sores upon the genitals or 
about the mouth, the disease is actively contagious, and intimate 
association with another is likely to result in infection. This part 
of the subject is too important to permit us to veil our meaning by 
the use of delicate phraseology, and we shall therefore distinctly 
detail, in plain words, the matters we think it necessary that the 
patient and others should be acquainted with. There are those 
who think lightly of their intercourse with public women, and who, 
having contracted the disease, do not hesitate to keep up their pro- 
miscuous habits. They are, of course, aware that they may, 
by so doing, infect some other woman, but this does not re- 
strain them. With a feeling, perhaps, of general enmity against 
the mercenary portion of the sex, they sow wide-cast the seeds of 
disease. Each one thus infected may in turn distribute the malady 138 
SYPHILIS. 
to a score of fresh victims. The State Prison is the proper place 
for a man who would thus knowingly and wilfully expose so many 
of his kind to the risk of infection. Every proper-minded man, 
therefore, will abstain absolutely from cohabitation as long as 
there is any danger of conveying the disease. This, however, is 
not the only precaution that must be taken. The syphilitic may, 
by chance, have a fiancee, or a sister or a mother. The habitual 
and proper caresses that are customary in the family circle must 
be abstained from. More than one sister, more than one mother 
have received infection through the kiss of a brother or of a son. 
These innocent ones must be protected at all hazards. As regards 
the fiancee, there is not the slightest doubt in the writer’s mind as 
to the proper course to he pursued. The marriage engagement 
should be broken, and the sooner the better, and not renewed ex- 
cept under the advice of a competent physician. 
There is still another source of infection that must be borne in 
mind. The disease may be transferred from one to another 
through the medium of a pipe or a drinking vessel. This may 
curb sociality a little, perhaps, but it must necessarily be submit- 
ted to. 
Syphilis may also ho conveyed from a syphilitic infant to its 
wet-nurse, and vice versa from a diseased wet-nurse to her nursling. 
The position of a married man who contracts the disease is 
particularly trying. Cohabitation and marital caresses must of 
course cease upon the first appearance of disease, and should not 
be renewed until the patient’s physician assures him that danger 
of infection no longer exists. The unhappy results which follow 
a disregard of those precautions are familiar to every physician 
in metropolitan practice. During the past year, two striking in- 
stances have fallen under the observation of the writer. In the 
first case, the husband, having contracted the disease, gave it to 
his wife, and within a few months their three children, from three 
to eight years of age, became infected. Subsequently two inti- 
mate friends of the family were numbered among the victims. 
In the second case, the husband, then the wife, and afterwards 
five out of seven children contracted the disease, all within a little 
more than a half year. We need not dwell further upon this point, 
but pass to another concerning which the syphilitic often desires 
very particular information. This is the question of marriage. 
When may syphilitics marry ? This is a question that cannot 
be hastily answered. Before attempting a reply, we will glance 
at some of the facts and circumstances that demand consideration 
in this connection. During the primary stage (existence of the 
chancre) marriage would almost inevitably be followed by infec- SYPHILIS, 
139 
tion of the wife. During the period of the secondary lesions (sore 
mouth, eruptions on the skin, etc.) infection is somewhat less cer- 
tain, but still exceedingly probable. During either of these peri- 
ods, if conception should occur, infection of the unborn child would 
probably result, and, as a consequence of this, either miscarriage 
during the early months of pregnancy, or, if gestation goes on to its 
full term, the birth of a feeble infant, which usually perishes in a 
few weeks or months, with distinct manifestations of the in- 
herited disease. Sometimes the child survives, but only to pass 
through a few years of life with more or less suffering. Fortu- 
nately the second child of syphilitic parents is less likely to suffer 
severely than the first, and after a time the syphilitic tendency in 
the offspring seems to diminish, so that, subsequently, children 
may be comparatively healthy. Surely, no one with this prospect 
before him would think of marrying during the active stages of 
the disease. 
In the tertiary stage, the tendency to the infection of the wife 
or offspring is very greatly lessened, and perhaps does not exist at 
all. If, through neglect or bad treatment, the general health is 
seriously impaired,* no prudent man would think of marrying, 
even were syphilis out of the question. It often happens, how- 
ever, that patients may suffer from some of the late symptoms of 
syphilis, and still enjoy fair and even apparently robust health. 
May persons thus situated prudently marry ? It being granted 
that the chances of direct infection of wife or child are reduced to 
a minimum, it is by no means certain that the offspring will en- 
joy the same average health as children whose parents have not 
suffered from the disease. There is a prevalent notion, both in 
and out of the profession, that many of the diseased conditions, 
termed “ scrofulous,” are the result of syphilis in the parent or 
grandparent. The amount of truth involved in this idea is not 
readily estimated. Certain it is, that in the majority of scrofulous 
cases no satisfactory evidence can be obtained of parental syphi- 
lis. On the other hand, many cases called scrofulous, are really 
examples of hereditary syphilis. While, therefore, it cannot be 
asserted that there is any great probability of the transmission of 
syphilis by persons marrying during the existence of symptoms of 
tertiary disease, it is certainly the part of prudence to refrain from 
any step that may seriously impair the health and well-being of 
prospective offspring. 
When, then, may the person who has been so unfortunate as to 
contract the disease, prudently enter the marriage relation? In 
the majority of cases that have been judiciously treated in the be- 
ginning, the disease will run through its course and spend its 140 
SYPIIILISo 
force within a period of two years, after which a long and fre- 
quently perpetual immunity from the disease is enjoyed. In other 
words, the disease has, to all intents and purposes, been radically 
cured. Of course, when this is the case, there can be no earthly 
objection to marrying. The only question to consider is, whether 
in a given case the disease has actually spent its force. As a 
general rule, it may be stated that if at least two years have 
elapsed since the last manifestations of the disease, the probabili- 
ties of a relapse are slight, and if they should occur, will not be of 
a nature to specifically impair the health of wife or offspring. 
Many instances are known to the writer, and in fact to every sur- 
geon, where men who had been syphilitic, have subsequently mar- 
ried, without detriment to their wives and children. It is not, 
however, safe to rely upon any general rule in this matter. Each 
case should be considered by itself, and the only prudent course 
for one contemplating matrimony under these circumstances, is to 
seek competent professional advice. 
HENRY G. PIFFARD, M.D. The Skin and Hair: 
THEIR CARE AND DISEASES. 
BY 
JAMES C. WHITE, M.D., 
OF BOSTON, MASS., 
PROFESSOR OF DERMATOLOGY IN HARVARD UNIVERSITY. THE SKIN AND HAIR. 
STRUCTURE OF THE SKIN. 
The skin is composed of two layers : the upper—the cuticle, 
epidermis, or scarf-skin; the lower—the true skin, cutis vera, or 
corium. The cuticle 
is thin, and consists of 
cells which in its low- 
est part are soft and 
round, in the upper 
layers are flat, dry, and 
horn-like, and serve to 
protect the more sensi- 
tive and delicate struc- 
tures beneath. The 
cuticle is easily remov- 
ed by violence, and be- 
comes white and soft- 
ened (parboiled) when 
immersed for a consid- 
erable time in water. 
It is constantly renew- 
ed beneath by the de- 
velopment of new cells 
from the upper surface 
of the true skin, as its 
outer layers are imper- 
ceptibly cast off. The 
true skin has a thick- 
ness of \ to 1| lines, and 
a complex structure. 
It is made up in great 
part of bundles of firm 
and elastic fibrous tissue running in various directions, and it is 
this substance which gives to it, when converted into leather, its 
elasticity and durability. Its upper surface is thrown up into 
Figure 13. (After Neumann). — Magnified section of 
healthy human skin: a. The horny layer of the cuticle, scarf 
skin, or epidermis, b. The Malpighian or mucous layer of 
the epidermis, c. The papillae developed on the surface of the 
corium, or true skin. d. The true skin. e. Collections of 
fat-cells underlying the true skin, f The duct or canal of a 
sweat-gland, h. The convoluted portion of a sweat-gland lying 
below the true skin. i. The shaft of a fine hair. k. Root of 
the hair. 1. A sebaceous gland emptying into the hair follicle*. 144 
SKJLN A.N.D 11 AIR. 
Figure 14. (After Sappey).—The papillae of the true skin, showing the terminations of 
nerves and loops of capillary blood-vessels. 
minute conical elevations, called papillae, which project for some 
distance into the cuticle, and contribute to the irregularities of 
the exterior of the skin (see Fig. 13). Some 
of these papillae contain networks of small 
blood-vessels ; others the terminations of 
nerves, and are, therefore, the organs of 
touch and sensibility. It is traversed in 
all its parts by an abundant system of 
capillary blood-vessels, which accounts for 
the free escape of blood when the skin is 
pricked or cut; and it contains also chan- 
nels and vessels for the flow of lymph (see 
Fig. 14). 
The skin possesses, moreover, two sets 
of secreting organs — the sweat and the 
sebaceous glands. The sweat-gland con- 
sists of a tube which runs from the open- 
ings or pores upon the surface of the cuti- 
cle perpendicularly downward to the lowest 
portion of the true skin, or the loose fatty 
tissue which lies beneath, where it is coiled 
upon itself in many convolutions (see Fig. 
15). Being closely surrounded by a net- 
work of blood-vessels, the gland is able to 
take from the blood its watery elements 
with great rapidity, and to pour out the 
perspiration upon the surface of the body 
very copiously. The number of these 
glands is very great, and they are distrib- 
uted over the whole surface ; indeed, it has 
Figure 15. — A sweat- 
gland. 145 
SKIN AND HAIR. 
been estimated that it is as high as seven millions, and that the 
whole system of tubes amounts to twenty-eight miles in length. 
Through them a quart of sweat, consisting chiefly of water with 
a little common salt in solution, may be daily poured over the 
external surface in the form of insensible perspiration. 
The sebaceous glands are sacs, either simple or composed of 
several lobules, and are situated in the middle or upper portions of 
the true skin (see Fig. 13). They lie mostly by the side of the 
hair-follicles, and discharge their secretion into the upper part of 
the latter; or, where the hairs are small—the lanugo hairs—this 
Figuke 16. (After Neumann).—Mode in which the solt (lanugo) hairs pass through the 
canals of sebaceous glands. 
arrangement is reversed, the glands emptying directly upon the 
surface of the skin, while the lanugo follicles open into the neck 
of the gland (see Fig. 16). They contain an oily material, pro- 
duced by fatty degeneration of the cells which line and fill the 
sacs, and this substance, absorbed by the hair and spread over 
the surface of the skin, serves to keep both properly soft and 
moist. It is this material which in excess covers the skin of the 
newly-born infant. These glands occur in great numbers over the 
whole body, excepting the palms and soles. 
The skin is also supplied with a fine network of muscular tissue 
and other muscles which run obliquely downward from the under 
surface of the cuticle, and are inserted into the base of the hair- 
follicles (see Fig. 17). Their contraction serves to erect the hairs, 
and to produce the condition of the surface called goose-flesh. 
Their functions in man may be looked upon as nearly obsolete, but 
in some of the lower animals they play an important part in the 
movements of the skin and hair. 146 
SKIN AND HAIR. 
The color of the skin is caused by the presence of a dark pig- 
ment in the lowest layers of cells of the epidermis, and its vari- 
ations in the different races of man- 
kind and in various parts of the body 
depend wholly upon the relative num- 
ber of these pigment-cells, the under- 
lying true skin of the blackest Afri- 
cans being of the same color as that 
of the fairest whites (see Fig. 18). 
The structure of the hairs will be 
described farther on, in the section 
devoted to their diseases. 
Thus, it will be seen, the skin is 
far from being a simple, uniform 
structure, designed as a mere covering for the tissues beneath; 
it is also a highly complex series of organs, and its functions 
are of great importance in the general economy of life. These 
can be merely alluded to, however, 
in this connection. The action of 
the sweat-glands is largely concerned 
in the regulation of the temperature. 
There is also a close relationship be- 
tween their action and that of the 
blood-vessels and kidneys, inasmuch as 
they remove a large part of the surplus 
water from the body when stimulated 
into over-activity by external heat or 
unusual muscular exertion; whereas, 
when they are inactive through sur- 
face chill or disease, the kidneys are 
called upon to do a relative excess of 
this work. The skin, too, is one of the 
great organs of sensation, as nearly all 
our impressions derived from the sense 
of touch, and our appreciation of tem- 
perature, are received through it. Its 
sensibility is most acute at the most 
salient points of the body—the fingers, for instance. Moreover, 
it possesses certain properties of absorption, which are availed of 
in the treatment of disease. 
Figure 17. (After Sharpey and 
Quain).—a. One of the muscles which 
cause the hairs to become erect. 
Figure 18. (After Koixikeb). 
— a. Pap ill® of the true skin. b. 
Deep layer of cells containing the 
pigment which gives to the skin its 
color, c. Mucous layer, d. Cuticle 
or epidermis. SKIN" AND HAIR. 
147 
THE CARE OF THE SKIN. 
The skin requires frequent washing. It is not only exposed to 
contact with the dust and dirt of its external surroundings, but 
has deposited upon its surface constantly a large amount of per- 
spiration, which on evaporation leaves a residue of salty matter 
mixed with the fatty secretions of the sebaceous glands. The 
worn-off cells of the cuticle, too, which should be always falling 
imperceptibly, are sometimes retained as accumulations of dead 
matter upon its surface, and in some parts, as between the toes, 
readily undergo decomposition and give rise to ill-smelling pro- 
ducts. The odors also connected with the glands in certain re- 
gions, the arm-pits, genitals, etc., are very offensive, and become 
noticeable if not frequently removed. It is evident, therefore, that 
the skin needs frequent washing. It is also true that persons 
engaged in dirty occupations, those living much in the dust of the 
open air, those whose cutaneous secretions are naturally abun- 
dant, those in whom the process of casting off the dead cells is 
sluggish, require more frequent washings than others, so that no 
positive rule can be given as to the care of the skin in this respect 
applicable to all persons alike. Naturally those parts of the body 
most exposed to the air, and those where the glands of the skin 
are most active, need the greatest care. So far as the health of 
the skin is concerned, there is no doubt that it may be maintained 
generally even when the laws of cleanliness are grossly and per- 
sistently violated, although some of its affections are either caused 
or aggravated by want of proper attention in this respect. 
Infants should be bathed daily. Fresh sweet oil or lard should 
first be thoroughly rubbed into any parts where there is a tendency 
to the collection of scales or sebaceous matter, then a little white 
toilet soap upon a wet sponge should be rubbed in until well mixed 
with the oil, after which both are to be washed off with an abun- 
dance of water. The scalp is especially to be kept clear in this way 
of the sebaceous crusts which are so often allowed to form upon 
it. After the bath, finely powdered starch may be applied to any 
parts which are chafed, or between the folds of the joints. In 
childhood the daily bath may be continued with advantage, care 
being taken that the temperature is never excessive, or, with chil- 
dren of feeble vitality, too low. If there is a want of reaction in the 
skin after proper drying and friction, the full bath should not be 
allowed. It cannot be said that for purposes of cleanliness the 
immersion bath is necessary either for children or adults, the 
sponge-bath, or even the wet towel, when better means cannot be 148 
SKIN AND IIAIR. 
obtained, being all-sufficient. Neither can it be said that a wash- 
ing of the whole surface of the body every day is absolutely neces- 
sary to this end, although some parts should be daily washed. It 
is very rare, however, that any harm comes of frequent bathing, if 
performed at proper times. 
Some parts of the skin require the use of soap. There is an in- 
explicable prejudice among the most intelligent classes of society 
against its use upon the face. There is no part which requires it 
so much, for not only are the cutaneous glands here most devel- 
oped and active, but their openings collect and retain the dust to 
which no other part of the body is so much exposed. The neglect 
of its proper use is a frequent cause of what is called a ‘‘bad com- 
plexion.” It will be ordinarily sufficient if a little soap is rubbed up 
in the water with which the face is daily washed, and fresh water 
may be subsequently used if there is any fear of its producing a 
“shiny” look. This appearance is generally due to a disorder of 
the sebaceous glands, which might have been prevented, or may 
be relieved, by a proper use of soap. The mistake, too, is often 
made, by girls and women especially, of not rubbing the face suf- 
ficiently after washing. A thorough friction with a not over- 
smooth towel is often of advantage in removing effete epidermal 
matter and stimulating a sluggish skin. In old persons the func- 
tions of the skin are often tardily performed, and collections of 
sebaceous and dead scaly matter tend to form upon the face and 
scalp, which may be prevented by the use of soap. 
In selecting soaps for the toilet, those which are white and 
mostly free from scents should be chosen, for impure materials in 
their manufacture may be easily disguised by strong odors and 
colors. There is no positive virtue in castile soap, as is so gener- 
ally supposed, nor in carbolic, tar, or other medicated soaps for 
ordinary purposes ; the simpler the soap the better. 
Hard soaps are made by the combination of animal and vege- 
table fats with caustic soda ; soft soaps by their chemical union 
(saponification) with caustic potash. They both owe their deter- 
gent or cleansing properties to the action of the alkalies thus mod- 
ified upon foreign matters upon the skin and its effete epidermal 
cells. Soft soaps are too active in the latter respect for general 
toilet purposes. 
THE NATURE AND CAUSES OF SKIN DISEASES. 
With such great complexity of structure and variety in its 
functions, it is not surprising, considering the proneness of the 
human body to disease, that the tissues of the skin should also SKIN AND IIAIK. 
149 
undergo changes, and that its organs should become disordered; 
indeed, diseases of the skin are very common and very multiple in 
character. These diseases are manifested by alterations in all 
parts of its own structure and in those of its various systems of 
vessels, nerves, and glands ; by a great variety of surface changes ; 
and by modifications in its sensations, color, temperature, dimen- 
sions, etc. So diverse, in fact, are the appearances of the skin 
under the action of disease, that the different forms of tissue- 
change (called collectively eruptions, efflorescences, rashes, humors), 
have been subdivided into groups, which have received distinct 
names. Thus, simple spots not elevated above the general surface 
are called maculae; small elevations are called papules; larger 
ones, tubercles or nodules; still larger protuberances or swell- 
ings, tumors ; little elevations containing a clear fluid, vesicles or 
blisters ; those of a larger size, blebs or bladders ; those which con- 
tain pus or “ matter,” pustules ; large, flat, evanescent elevations, 
whiter than the surrounding skin, as those produced by the bites 
of fleas and mosquitoes, wheals. When the tips of any of these are 
scratched off, or the healthy cuticle is torn up, laying bare the true 
skin, the wound is called an excoriation ; deeper cracks penetrat- 
ing the skin are fissures; larger losses of tissue extending down 
below the papillary layer of the cutis, generally the result of pre- 
ceding disease of the part, are ulcers ; the fluids which ooze from 
an ulcerating or excoriated surface, either serum, blood, or pus, 
dry into firm, protective coverings, scabs or crusts. The hard, 
white tissue which follows deep injury, or destruction of the skin 
through violence or disease, is a cicatrix or scar. The dry, flat 
collections of epidermal cells upon the surface of the skin are 
scales. 
These are the most important forms of eruption which the skin 
presents in disease, and they represent, or are the expression of, a 
great variety of so-called pathological changes in its tissues. Some 
affections are characterized by a single form of eruption through- 
out their whole existence, while in others the eruption is constantly 
changing, one form being converted into another, as the papule 
into a vesicle, and this into a pustule, in their different stages, or 
many kinds of efflorescence may present themselves at the begin- 
ning. It is in this way that so few forms of eruption as those 
above enumerated are capable of forming the great variety of 
combinations of appearances which characterize the very numer- 
ous distinct diseases of the skin. But as these eruptions individu- 
ally do not always represent one and the same pathological con- 
dition of the tissues, or, in other words, may be wholly unlike in 
nature and cause, we are unable to judge of the character and 150 
SKIN AND HAIR. 
relations of skin diseases by the mere form of the efflorescences 
they exhibit. We are obliged, therefore, to consider the nature of 
the tissue-changes represented by these eruptions in determining 
the true character of cutaneous affections. It is on this basis that 
we shall arrange the diseases that we are about to consider, plac- 
ing together those which are most alike in their real nature instead 
of in mere outward appearance. Such an arrangement is called a 
classification. Nine such groups or classes may be recognized of 
practical value, as laid down by Professor Hebra, the distinguished 
dermatologist of Vienna. They are : 1. Disorders of the glands. 
2. Inflammations. 3. Haemorrhages. 4. Hypertrophies or over- 
growths. o. Atrophies or wasting of tissues. 6. Ulcerations. 
7. New growths. 8. Nervous affections. 9. Affections caused by 
animal or vegetable parasites. 
Many erroneous opinions are held concerning the causes of 
diseases of the skin, far more than with regard to those of any 
other tissues or organs of the body. It has been popularly believed 
that the skin in some way serves as a mirror to reflect visibly 
upon its surface the disorders of the internal economy, and that 
“humors” and other vices of the blood work their way outward 
through the skin, and there express themselves in the form of 
various eruptions. The skin has thus lost its individual character 
in its relation to disease, and has come to be held merely as a sort 
of index of the internal system, and the immediate conclusion of 
most persons with any affection of the skin is that the “blood 
must be out of order,” or that they have scrofula, or “a humor.” 
What this last word means nobody knows, so that it may be re- 
garded as something which does not exist; but, so far as concerns 
the relation of the skin to the blood, it may be stated that it is an 
intimate one, as the blood flows freely through it—but no more 
intimate than that of the blood with most other structures of the 
body, and that, so far as can be shown, the condition of the blood 
has no more to do with the causation of skin diseases than of those 
of any other part of the economy. The fact is, that the skin is of 
itself a great series of complex organs, with just the same inherent 
tendencies to disease, and just the same right to its independent 
affections as the tissues of any other organ—the lungs, liver, or 
kidneys, for instance. By this it is not intended to deny that it is 
not a part of, and closely connected with, the general economy, 
and that it sympathizes with the general condition of the body in 
disease, only no more so necessarily than any other of its separate 
parts. Skin diseases, therefore, are in no way to be regarded as 
I>eculiar, or as indicating ordinarily any vice of the general sys- 
tem. We can sometimes recognize their direct causes, which may SKIN AND HAIR. 
151 
be either external or internal in nature, but in the great majority 
of cases we know nothing of their origin, in which respect, too, 
they are like many diseases of other parts of the body. Among 
the external causes are all agents which exercise an injurious 
influence upon it from without, either mechanically, chemically, 
or otherwise, as undue pressure, scratching, extremes of tempera- 
ture, strong acids or alkalies, poisons, irritants, etc., and the 
vegetable and animal parasites. Among the few internal deter- 
mining agencies, more or less powerful, that we have any positive 
knowledge of, are family predisposition, age, and diet. Some 
temperaments are especially prone to certain forms of affection; 
some families show themselves particularly certain dis- 
eases, which may be traced through many generations ; infancy, 
mature life, old age, have each their peculiar forms of disease ; 
while certain articles of food and medicine are capable of exciting 
directly a diseased action in the skin. 
A word may here be said about some errors which prevail 
widely as to the part which some kinds of food play in the produc- 
tion of these affections. It is almost universally believed, for 
example, that fats or greasy articles are the direct cause of “pim- 
ples ” (acne) and other eruptions upon the face. That rich dishes 
like pastry, gravies, etc., may give rise to indigestion, and by dis- 
turbing the general relations of the economy, aggravate and in 
rare cases possibly create a local disorder of the skin, is undoubt- 
edly true, but this is because the fat has been chemically altered 
by cooking. On the other hand, it may be stated that there is no 
reason to believe that simple fats, as cream, milk, butter, cheese, 
oils, or the fatty parts of boiled, roasted, or broiled meats, exercise 
the slightest injurious effect upon the skin, either in health or 
disease. Here, too, it should be added that, beyond question, cer- 
tain mental conditions, grave bodily disorders of one or another 
kind, insufficient diet, and miserable modes of life may conduce to 
the causation of skin diseases by lowering the vitality of the 
general system, and thus also of the skin. 
No place could be fitter than here, in connection with these 
remarks upon the nature and causes of skin diseases, to allude to 
another widespread error: the belief, namely, in the danger of 
curing them. It arose, no doubt, from the theory above men- 
tioned, that they are the expression or striking-out upon the sur- 
face of some internal “ humor,” whence has come the common 
expression of fear lest the eruption be made to “ strike in,” or be 
“ driven in ” to some vital organ. The statement that these erup- 
tions are, in the vast majority of cases, but the skin’s way of show- 
ing its own independent diseases, should dispel such fears ; but it 152 
SKIN AND HAIR. 
may be more positively stated that these eruptions cannot be 
driven to any other part of the economy, and that no harm can 
possibly come from the disappearance or cure of any form of efflor- 
escence or skin disease. That physicians sometimes make state- 
ments which confirm such fears -of the patient or family is true, 
but the only explanation of such advice is ignorance, or the desire 
to avoid the care of cases difficult to manage. There is no more 
reason why we should not endeavor to cure any and every disease 
of the skin than of any other organ of the body, and no more dan- 
ger is to be feared from our results if successful. The combined 
evidence of all dermatologists of high standing upon this point is 
the same. 
Although, as a rule, seldom fatal, diseases of the skin are 
among the most annoying affections which afflict us, partly from 
the great disfigurement to which they so often give rise while 
present, and the scars and stains which may remain as more or 
less permanent marks of their past existence, as well as from the 
intense suffering in the form of itching and other sensations to 
which they so generally give rise. 
THE DISEASES OF THE SKIN. 
Class I.—Disorders of the Cutaneous Glands. 
A.—Disturbances of the Sebaceous Glands. 
The sebaceous glands, it will be remembered (see page 145), 
secrete a colorless, oily fluid, which is poured out upon the surface 
of the skin, through the openings of the hair-follicles, for the pur- 
pose of keeping the cuticle and hair in a smooth, soft state. This 
secretion, the sebum, may be changed in quantity, in character, or 
be prevented from escaping from the follicles ; and these conditions 
constitute the affections of these glands. 
L CHANGES IN QUANTITY. 
Excessive Secretion of Sebum. 
When the sebum is secreted in excess it gives a greasy, shining 
look to the surface of the skin, or the oily matter may be seen 
standing in little transparent and colorless beads at the mouths of 
the glands. This last condition is most frequently observed upon 
the nose. It may be distinguished from perspiration, which it SKIN AND HAIR. 
153 
closely resembles, by its greasing paper, and by its constant occur- 
rence even when the face or body are not at all overheated. It is 
noticed in young people mostly, and is generally associated with 
other disturbances of these glands. The more general greasiness 
of the skin affects the forehead, nose, and cheeks, and is most fre- 
quently accompanied by distended, plugged, and inflamed sebace- 
ous glands. Excessive secretion of sebum to a less degree is often 
a more universal condition of the surface, and is noticed not so 
much by any oily appearance of the skin as by the staining of 
clothing worn next to it, especially by the greasing of the pillow 
or other bodies in frequent contact with the scalp. 
The treatment for excessive secretion consists chiefly in the 
frequent use of the means best adapted to its removal. These are 
the soaps, and in this connection it may be stated that these affec- 
tions are most likely to occur, or to assume a more aggravated 
form, in those persons who have not been in the habit of using 
soap upon the skin sufficiently. Sometimes it is important to 
anoint the face with oil before applying soap, especially if any of 
the glands are stopped. In mild cases a bit of flannel cloth 
stretched over the fingers should be dipped in water, rubbed upon 
the soap, and then rubbed thoroughly into the affected parts, 
which should be immediately afterwards carefully washed with 
water of mild temperature. This may be best done at bed-time, so 
that any redness or glossiness produced by the operation may dis- 
appear overnight; but in rare cases the process should be repeated 
in the morning. 
Unnatural Dryness of the Skin. 
Sometimes, however, the amount of secretion is diminished, 
and this condition is universal, and lasts from infancy through 
life. Its occurrence indicates in a most marked way the impor- 
tant function of these glands, for the skin of persons thus af- 
fected is dry, harsh, and easily cracks, and becomes diseased in 
other ways. 
Treatment.—Little, if anything, can be done to cure this habit, 
but much can be effected for the comfort and better state of the 
skin by anointing it frequently with olive oil, or fresh, strained 
lard. 
II. CHANGES IN CHARACTER. 
As was stated in speaking of the anatomy of the sebaceous 
glands, their secretion is formed by the conversion or fatty degen- 154 
SKIN AND HAIR. 
eration of the cells which fill and line them into a clear, structure- 
less, oily material. At times, however, this conversion is not per- 
fectly performed, and the secretion retains more or less of its cell 
character. When thus modified and discharged upon the surface 
the skin cannot absorb it, so that it forms a scaly deposit which is 
greasy and moist, or dry and branny, according as the cells contain 
more or less oil. This condition, called seborrhasa, affects the face 
and scalp chiefly, and upon the latter it forms the disease known as 
Dandruff! 
After existing for some time, the hairs, deprived of their natu- 
ral sebum, are apt to become dry, lustreless, and to fall before 
their time. Dandruff is, in fact, one of the most common causes 
of premature loss of hair. This condition leads, moreover, at 
times, to inflammatory affections of the parts affected, often to 
eczema of the head (see page 1G9). 
Dandruff is a very common disease, appearing sometimes in 
childhood, but generally not until after puberty, and may last for 
years. It may occur in persons otherwise perfectly healthy, or 
accompany enfeebled conditions of the general system. 
Treatment.—Dandruff upon the face, when mild in character 
and unaccompanied by redness or inflammation, may be treated 
by oils or soaps, as above indicated in the case of excessive 
secretion ; upon the scalp the same method may be pursued, or 
even domestic soft-soap may be used with advantage once or twice 
a week in place of toilet soap, and the softness of the hair restored 
after such frequent washings by the application of some simple 
pomade or cosmoline, a preparation made from petroleum (see 
Formulas). A stiff brush, or worse, a fine comb, should never be 
used to remove the scales. In severe or obstinate cases a physi- 
cian should be consulted. 
III. RETENTION OF SECRETION. 
From causes little understood (it may be changes in the char- 
acter of the sebum or in the openings of the follicles themselves), 
the glands often become stopped. In their mouths may be seen a 
plug of dried or hardened sebaceous matter, which, at first of nat- 
ural color and small, may become dark or even black by collecting 
and retaining the dust which comes in contact with it, and larger 
by the addition of more sebum to it. As the secretion goes on 155 
SKIN AND HAIR. 
forming and cannot escape in consequence of the plug, it distends 
the gland and pushes it up into greater prominence, so that it may 
be seen and felt as a little elevation above the general surface. 
This condition is called 
Comedo 
by physicians, popularly grub or worm, because when the gland is 
squeezed there comes out a little white cylindrical body with a 
black head or tip. This is the sebum moulded into this shape by 
being forced through the narrow neck of the gland, and the black 
head is that portion which has been exposed to the dirt. 
Comedos occur principally upon the face, the forehead, nose, 
and temples chiefly, but may affect any region of the skin. They 
are very common about puberty, and may disappear spontaneously 
after existing several years. They indicate a sluggish state of the 
sebaceous glands, and are often associated with the disorders of 
these organs already described. They are not necessarily con- 
nected with any disturbance of the general health. They may 
occur in great abundance, and when large give the appearance as 
if gunpowder had been blown into the face. In addition to this 
disfigurement they often form the first stage of so-called “ pimples ” 
of the face (acne). As the secretion continues to collect, the 
glands and the surrounding tissues may become inflamed from 
over-distension and form a red, more or less painful elevation or 
pimple of various size, which may suppurate and discharge the 
offending plug of sebum. In this way the comedo may be cured, 
but a worse evil be established. Single comedos may, on the 
other hand, last indefinitely, and generally they require forcible 
removal. 
Treatment.—Comedos may be squeezed out with the nails, but 
they are best removed by pressing perpendicularly over them with 
a watch-key which has a broad edge and narrow aperture, so that 
it shall not cut into the skin. They will come out more easily if a 
little sweet oil be applied to the parts to be operated on, ten or fifteen 
minutes before using the key. But one or two should be removed 
at a time from any one small district of skin, lest too much irrita- 
tion be caused by the severe pressure which is sometimes requisite, 
and the redness or inflammation, which results will generally dis- 
appear in a day or two. This process may be repeated each night, 
at bedtime, and be followed by the use of the oil and soaps as 
above described, for the purpose of preventing such glands from 
being plugged again, and of keeping others in a healthy condition. 
When the plugs are very small and the glands not distended, the 156 
SKIN AND HAIR. 
thorough use of the oils and soaps will alone be sufficient to restore 
the skin gradually to a healthy state. 
Milia. 
The little white, pearly, globular bodies which are sometimes 
seen just beneath the cuticle upon the face, in the vicinity of the 
eyelids, are called milia. A milium is a sebaceous gland which 
has been shut up by the closure or destruction of its neck beneath 
the skin. Thus deprived of its outlet the gland becomes distended 
by its secretion into the little cyst or tumor which has no connec- 
tion with the surface. 
Treatment.—These bodies may be easily removed by cutting 
through the cuticle which covers them to a slight extent, and 
squeezing out their contents by the nails. 
B.—Disorders of the Sweat-Glands. 
These affections, too, may be divided into those characterized 
by changes in the quantity and the quality of the secretion. Only 
a very brief notice of them will be given, as they are of rare 
occurrence. 
The natural quantity of perspiration varies so much in propor- 
tion to external conditions that it is impossible to fix a normal 
standard of amount. Some persons sweat easily and profusely, 
others with great difficulty and never freely; and both are within 
the range of health. But some persons can be said to perspire 
scarcely at all, or only when exposed to an extremely hot tempera- 
ture. In such individuals the glands are present, but inert. Their 
skins are dry and harsh, and are sometimes covered with a fine, 
powdery, scaly matter. This is a defect which generally persists 
through life, and nothing can be done to cure it. Frequent bath- 
ing and oily inunctions make the skin less uncomfortable. 
Excessive Sweating of the Feet and Hands. 
An excess of perspiration is shown by an unnatural and con- 
stant moisture of certain parts of the body, chiefly the hands and 
feet. The former feel cold and clammy when touched, and have 
sometimes even a parboiled appearance. They must be constantly 
wiped to be kept in a state of comfort. Dickens has described one 
of these unfortunate persons in his Uriah Heep. Upon the feet the 
condition is generally much worse on account of the coverings SKIN AND HAIR. 
157 
and the pressure to which they are subject. The soles become 
white and sodden, and often so tender that standing or walking 
causes great pain. The coverings, too, become saturated with 
the perspiration, which after a time may undergo decomposition, 
and give rise to an intensely disagreeable odor which cannot be 
destroyed. 
Treatment.—The boots and shoes thus affected must be thrown 
away, the person should bathe the feet once or twice daily in cold 
water, wear always cotton stockings and low shoes, and dust the 
insides of the former daily with finely powdered starch before 
drawing them on. In this way this horrible odor may be over- 
come and prevented; but when through long neglect the feet are 
badly inflamed, they will generally require the care of a physician. 
This condition has been called “stinking foot-sweat,” but incor- 
rectly, because the secretion is perfectly natural when first se- 
creted, and acquires the odor only by subsequent decomposition 
of its elements and the sodden cuticle. (See also chapter on 
“ Hands and Feet.”) 
Offensive Perspiration. 
There are, however, changes in the quality of the perspiration, 
due to the presence of foul-smelling elements which make them- 
selves noticeable in some parts of the body to a very annoying 
degree, especially in the arm-pits. In some persons the odors are 
so penetrating and disagreeable that they may be perceived in 
spite of extreme cleanliness. 
Treatment.—In such cases there is no other remedy than wash- 
ing the parts most affected twice or oftener daily with soap and 
water (tar or carbolic soap being preferable), and using also, if 
necessary, some perfume about the clothing to overpower the 
unpleasant odors. 
Class II.—Inflammations. 
This group includes many of the most important and most 
common diseases of the skin, which may be separated into the 
transient and the chronic. In the former the course of the inflam- 
mation, either as a whole or so far as its individual forms of 
eruption are concerned, is of short duration ; in the latter it is 
generally much longer, and may be indefinitely prolonged. Inflam- 
mation of the skin is indicated by such signs as redness, heat, 
swelling more or less diffused, or by the occurrence of red spots. 158 
SKIN AND IIAIK. 
papules, blisters, pustules, etc., and by sensations of heat, pain, 
and itching at times. The redness, heat, and early swelling are 
produced by the distention of the capillaries or minute blood- 
vessels with blood. Its fluid portions may escape later, and cause 
additional enlargement of the tissues, elevating them in the form 
of papules, or separating the layers of skin in the shape of blisters. 
The cuticle may be cast off, and liquid ooze in abundance from 
the surface. Other elements—cells—may be added to the fluid 
which escapes between the layers of skin, and pustules or firmer 
forms of eruption be developed, and even deep-seated destruction 
of the lower parts of the skin be caused. These are the ordinary 
manifestations of inflammation of the cutaneous tissues. 
A.—Transient Inflammations. 
Among the most common examples of this form of inflamma- 
tion are the so-called “rashes,” or eruptive fevers—exanthems, as 
they are called by physicians : the bright red, minute spots or 
elevations, and diffused redness of scarlet fever, the duller red 
patches of eruption in measles, and the large pimples and pustules 
of chicken- and small-pox. But as the changes in the skin in 
these affections are only local manifestations of general disease, 
they will be treated of in another chapter (see page 69). 
Erythema. 
This is a name applied to various forms of fugitive redness 
affecting the surface of the skin. It may be either a simple pass- 
ing blush, covering large districts, and accompanied at times by 
some disturbances of digestion and slight feverish symptoms ; or 
an eruption of large and small red papules, situated most com- 
monly on the face and hands, which in some cases are converted 
into blisters ; or the outbreak may consist of both the above forms 
at once. Sometimes the eruption is nearly universal, sometimes 
is accompanied by severe pains in the joints, like rheumatism, 
sometimes is associated with the efflorescence of nettle-rash. All 
these forms are generally of short duration and of no serious im- 
portance. They are sometimes known to be caused by certain 
articles of diet and medicine, but generally the cause of the attack 
cannot be ascertained. 
Treatment.—For the simpler forms a mild laxative, and fre- 
quent bathing of the affected parts with spirit and water, or sal- 
eratus water, are all-sufficient treatment. SKIN AND HAIK. 
159 
Urticaria. 
Nettle-rash—Hives.—This is a very common affection, and is 
characterized by the outbreak of a peculiar form of efflorescence 
not found in any other disease of the skin, called wheals. They 
are familiar to everybody as the form of eruption produced by the 
bite of the mosquito, flea, and other jnsects. There is first noticed 
a limited redness of the skin, accompanied by an itching and burn- 
ing sensation, so that the part is violently rubbed and scratched. 
Soon there appears in the centre of the patch a white spot, of 
irregular circular shape, which rapidly rises above the general 
surface, and stands out in prominent contrast to the surrounding 
skin. Their outlines are at times irregular and notched, and the 
'centre may be somewhat depressed. They may remain in this 
state for a few minutes or hours, sinking down at times as rap- 
idly as they appeared, and leave behind them only a temporary 
redness, or a stain of longer duration possibly if they have been 
severely scratched. This is the ordinary course of an individual 
wheal, whether it be the result of an insect-bite, or one of a gen- 
eral outbreak of hives. The same appearances are produced by 
the sting of plants of the nettle family, whence the name urticaria 
or nettle-rash, from urtica, a nettle. In the disease the eruption 
may be sparse, confined to a limited region, and last but a few 
hours ; or it may cover thickly large surfaces, or even the whole 
body, and not only persist for many hours, but constant eruptions 
may succeed each other almost continuously, or at intervals of a 
few hours, and thus prolong the course of the affection for an 
indefinite period—even months. The size of the efflorescence, too, 
varies greatly—from that of a small pea to uniform elevations 
larger than the two open hands. The surface of the patches feels 
hard and brawny, and is marked by little depressions, the open- 
ings of the follicles. The eruption itches intensely, and produces 
at times very great suffering. It is generally stimulated to ap- 
pear, or is aggravated by the exposure of the skin to the air on 
the removal of the clothes at night, or while dressing in the morn- 
ing, and may wholly disappear during the day. Acute attacks 
are often accompanied by some disorders of the stomach, as nau- 
sea, and chronic cases are frequently associated with and depend 
upon persistent disturbances of digestion. Certain articles of food 
are well-known causes of the disease—strawberries, shell-fish, and 
cheese being the most frequent excitants, but acting very un- 
equally upon different persons and at different times. In the 
majority of cases, however, no cause for the attack can be dis- 160 
SKIN AND JIAIII. 
covered. When caused by any special article of diet the symp- 
toms generally last but a day or two, and two or three days may 
be considered the duration of most attacks ; but sometimes the dis- 
ease becomes chronic, and is then the result of a general state of 
debility, or dependent upon disorders of the internal organs. It 
affects all ages. It is only of serious importance when it persists 
for a long time, and reduces the patient by the harassment of the 
nervous system, and by the sleeplessness which the intense itch- 
ing occasions. 
The Treatment in mild cases should be directed to allaying 
the irritability of the skin, and the avoidance of any exciting 
articles of food. The whole diet of the patient should be carefully 
scrutinized, and everything known or suspected to be capable of 
giving rise to the affection should be excluded. Sometimes every 
ordinary article of food must be omitted in turn before it can be 
ascertained if the attack be due to an error in diet or not. All hot 
and stimulating foods or drinks are to be abstained from, and the 
clothing next the skin should be either old linen or cotton. The 
itching and burning may generally be relieved temporarily by 
washes of saleratus or cooking soda, by vinegar, spirit and water, 
or by the application of very hot water to the surface. Chronic 
urticaria is one of the most stubborn affections the physician has 
to treat, and can only be overcome at times when the fault of the 
inner economy with which it is connected can be discovered and 
removed. 
Dermatitis, Chilblains, Heat-Rash, etc. 
There are various forms of transient inflammation which are 
produced by the action of irritating agencies upon the skin, which 
are classed under the general term dermatitis. Among the latter, 
excesses of temperature are the most frequent causes of mischief. 
The destructive action of extreme degrees of both heat and cold, 
in the form of scalds, burns, and frostbites, will be considered 
elsewhere; the less severe forms of inflammation will be consid- 
ered here. 
Chilblains. 
Chilblains are a low form of inflammation affecting the feet and 
hands—those parts which are most exposed to the chilling effects 
of cold. The symptoms are redness and pnffiness of the skin, 
especially surrounding the joints, accompanied at first by severe 
itching and burning. Later, if the affected parts are rubbed and 
bruised, the skin may crack, or soften and break, and painful SKIN AND HAIR 
161 
sores, slow to heal, be formed. The skin of some persons is 
especially prone to chilblains, not only in childhood, but through- 
out life, which are often evidence of a general want of tone in 
the tissues. The disease is greatly aggravated and often directly 
excited by exposing the feet and hands to rapid alternations of 
heat and cold, as by coming in from the severe cold of winter and 
immediately overheating these parts, while cold or damp, at the 
fire or hot-air register. 
Treatment.—While in their early stages of redness, burning, 
itching, and swelling, they are best treated by rubbing them 
gently at night with a rag dipped in lemon-juice, oil of turpentine, 
or other stimulating applications ; but later, when the skin cracks, 
or open sores are established, more soothing treatment is at first 
necessary. Woollen stockings or warm gloves should be worn, 
and great care be exercised that the parts are not overchilled or 
overheated. 
Heat-Rash. 
During the intense heat of our summers the skin is often so 
over-stimulated as to become affected in several ways. The direct 
action of the sun upon parts exposed is capable of producing so 
great a degree of redness or congestion of its vessels that the skin 
may remain in a state of erythema for several hours or even 
longer, gradually subsiding to its natural condition ; or a more 
severe degree of inflammation may be excited, the redness being 
accompanied by slight swelling, and ending, finally, in the death 
and casting-off (peeling) of the outer layers of the cuticle in thin 
scales, and a tenderness of the affected parts for some time. But 
the most common form of trouble is that known as heat-rash, or 
prickly heat. This is not due to the direct action of the sun’s 
rays, because it generally occurs upon parts not exposed to them, 
but to the excess of work put upon the sweat-glands, in conse- 
quence of which a congestion of the tissues surrounding them 
occurs, manifested by the appearance of minute red points or 
elevations, which prickle and itch in a greater or less degree ac- 
cording to the disposition of individual skins. Having reached 
this point, the eruption or rash may subside after a few hours’ or 
days’ existence, to be redeveloped, perhaps, at the next excessive 
heat. On the other hand, should the great heat be of long dura- 
tion, or the person’s skin be especially disposed to inflammation, 
the simple congestion or erythema may of itself, or in conse- 
quence of the violent rubbing and scratching it generally receives, 
pass into a true eczematous inflammation of a mild or severe 162 
SKIN AND HAIR. 
character. In fact, a vast amount of eczema occurs every sum- 
mer in this country from this cause, especially in children whose 
more tender skins are more easily excited by heat and other local 
irritants. Among the poorer classes living in crowded tenements 
during the summer, where, in addition to the heat, bad air, im- 
proper food, and insufficient care of the skin are to be counted as 
important elements of disease, the skin of children often presents 
much severer forms of disorder, such as boils in great numbers 
over their whole surface, or even large abscesses. 
Treatment.—The proper treatment for skins easily affected by 
heat is the observance of all possible precautions against direct 
exposure to the sun or severe bodily exertion, so that the cutane- 
ous circulation and the sweat-glands may be kept quiet. Should 
the skin be burned, it may be freely dusted with toilet powder (see 
Formulas), or smeared with cold cream ointment (see Formulas), 
to relieve the feeling of tension and the peeling. In heat-rash 
or prickly heat the skin may be bathed with cool water morning 
and evening, avoiding all friction while drying it. Thin cotton or 
linen should be worn in contact with the surface, which may be 
dusted frequently during the day with toilet or starch powder, to 
absorb the perspiration. Warm drinks and excessive drinking 
should be avoided. 
Other forms of dermatitis are produced by the contact of so- 
called poisons with the skin : 
Arnica-Poisoning. 
A not uncommon cause of such inflammation is tincture of 
arnica, so popular a remedy for cuts, bruises, and other troubles, 
as an application in various forms to the skin. The symptoms 
are redness, burning and itching, and the appearance of fine 
papules and vesicles, or even worse forms of eruption upon the 
parts to which it has been applied. The disease is in fact an 
artificial eczema, and may last an indefinite time as such after 
being thus excited into existence. That tincture of arnica has re- 
tained for centuries its popular reputation as a household external 
remedy, it may thank the alcohol it contains, for otherwise it 
would be useless, and its dangerous action upon the skin of many 
persons should be better known. 
Ivy-Poisoning. 
By far the most common form of skin-poisoning, however, is 
that produced by two species of plants — poison-ivy and poison- SKIN AND HAIR. 
163 
sumach. Poison-ivy, as it is popularly called, is not an ivy, but 
belongs to the sumach genus. It is rhus toxicodendron. It is 
sometimes a vine running over or by the side of stone-walls, fences, 
and ledges, or ascending trees to a great height, and sometimes a 
bush of considerable size and thickness. It is found almost every- 
where in New England, in many places growing in great abun- 
dance, and forming dense masses by roadsides, in pastures, and 
along the borders of woods. Its leaves have a marked and very 
characteristic glossy look, and vary greatly in shape, size, and out- 
line. They are ternate, as the botanists say ; that is, they consist 
of three leaflets, one terminal and two lateral, growing in common 
upon a rather long, semi-cylindrical stem. The leaflets are ovate, 
with rather a broad base, more or less pointed, and their edges are 
either entire, or notched and lobed in a great variety of forms. It 
blossoms in June, and the flowers are small and grow in greenish- 
white clusters, mostly in the axils. The berries are small, round, 
and also of a pale greenish-white color. Later in the season the 
leaves assume a great variety of most brilliant colors, and attract 
many gatherers of autumn foliage. 
Of the other dangerous species of rhus (rhus venenata), although 
it is far more poisonous than the above, less need be said, for it 
grows much less commonly than the latter. It is a small tree, as 
its common names (“ poison-dogwood,” “ poison-sumach”) suggest, 
and is found mostly in swamps. Its leaflets, like those of the ordi- 
nary sumach, grow upon a long stem, and vary in number from 
seven to thirteen. They are smooth, broader than those of the 
latter plant, and the terminal one grows from a considerable pro- 
longation of the common stem. In the autumn its foliage sur- 
passes that of all other trees in the variety and brilliancy of its 
tints, and thus attracts to its less frequented haunts not a few 
unwary visitors. 
The virulent principle of these plants is a volatile acid which 
exists in all their parts, but especially in the leaves. All persons 
are not affected by it, but many who can handle the vine, rhus 
toxicodendron, with impunity are poisoned by the tree, rhus vene- 
nata, so much more virulent is the latter. Actual contact with 
the plants is not in all cases necessary for the production of 
their poisonous effects, on account of the volatility of their active 
principle ; and there is good reason to believe that persons highly 
sensitive to the poison not unfrequently suffer from passing by 
places where the vine grows abundantly. The plant is supposed 
to be most actively virulent during the flowering season in early 
summer, but cases of poisoning occur with great frequency 
throughout the autumn, when its leaves take on their seductive 164 
SKIN AND HAIR. 
coloring. Even in the winter the twigs and stems are often found 
still alive for mischief by those who handle them. 
The peculiar effect of the poison is alike in kind upon all who 
are affected by it, but varies greatly in intensity. The inflamma- 
tion it excites upon parts coming in contact or contiguity with it 
is that of an acute eczema, characterized by the eruption of vesi- 
cles of a peculiar lurid or brownish-red color, which may subse- 
quently burst and exhibit the later phases of this efflorescence 
as in other acute inflammations of the skin. In addition, there is 
more or less of swelling and redness of the parts affected, some- 
times to a very marked degree, so that great deformity may thus 
be produced, and the face of the patient be changed out of all 
recognition. These changes in the tissues of the skin are accom- 
panied by intense itching and burning, and often great suffering 
is undergone by the patient in consequence. Fortunately the 
affection is of short duration, the acute stage lasting ordinarily but 
a week or ten days under treatment, and its whole course rarely 
exceeding three or four weeks. Moreover, it is not a dangerous 
affection, although a person severely poisoned over a large surface 
may present a frightful appearance to his friends. Its effects, 
however, are never more than skin-deep. The eruption generally 
shows itself within three or four days after contact, sometimes 
within twenty-four hours. The period of incubation may, how- 
ever, be prolonged to five or six days in some cases, and fresh blis- 
ters may continue to appear for two weeks or more. No danger 
of contagion by contact with the eruption upon another person is to 
be feared. The portions of the body most commonly affected are 
the hands and face, the parts naturally most exposed to contact; 
but other parts handled by the former, immediately after contact 
and before washing, may have the poison thus transferred to 
them, and be similarly affected. No scars or permanent injury to 
the skin or general system are to be apprehended in ordinary 
cases. 
In the treatment of rhus-poisoning the means to be immediately 
used—those to which the term antidote may be properly applied— 
are of great importance. The poison, as has been stated, is a vola- 
tile acid. An alkali would therefore suggest itself as the most fit 
agent to counteract its action. Thorough washing of the parts, as 
soon as possible after contact with the poison, in cooking-soda or 
saleratus water, or in strong soap-suds, especially those of soft- 
soap, which contains an excess of alkali, is therefore the best pri- 
mary treatment. When these or other alkaline preparations are 
not to be obtained, an abundance of water alone should be used as 
soon as possible. After absorption has taken place, or the erup- SKIN AND HAIR. 
165 
tion has begun to show itself, less benefit is to be expected from 
such applications alone. Remedies are then to be used which will 
best control and shorten the inflammatory process in the tissues of 
the skin—those, in fact, which are found to be most efficacious in 
corresponding stages of acute eczema. Among these are some 
which have a special reputation, as solutions of acetate of lead or 
sulphate of copper, applied frequently as a wash. Perhaps nothing 
is better than common black wash used as an evaporating lotion for 
half an hour at a time, twice daily, the lime-water acting also as a 
chemical antidote, if possibly such action is still in season at this 
later stage. In the intervals between the applications of these 
washes the parts may be kept covered -with cold-water dressings, 
with plasters of diachylon ointment, or with a powder of starch 
and oxide of zinc, according to the rules familiar to physicians for 
the treatment of acute eczema. By these means the process is 
checked and shortened, and the sufferings of the patient greatly 
alleviated. 
A brief word of caution to sojourners in the country who are 
unacquainted with these poisonous plants: avoid any vine or bush 
growing by rocks, fences, and woodsides, with glossy leaves ar- 
ranged in threes ; and in the autumn, any particularly brilliant 
tree in swampy places, with leaves resembling, but broader than, 
those of the common sumach. (See also chapter on “Poisons and 
their Antidotes.”) 
Erysipelas. 
Erysipelas—St. Anthony's fire is an acute inflammation of the 
skin, which begins abruptly, spreads more or less extensively 
from its starting-point, runs a definite course, and subsides of its 
own accord, in the majority of cases, without serious injury to the 
skin or the patient. In mild or ordinary attacks the inflammation 
is not deep-seated, the appearances being redness and swelling, 
with sensations of heat and tension, which may spread with a 
more or less well-defined border, and run over a considerable sur- 
face. After a few days the portion of skin first attacked becomes 
less red and swollen, while at the border the disease may still be 
progressing, and gradually returns to its healthy condition, leav- 
ing only a slight scaliness of the surface to mark its seat. The 
whole attack may not last more than a week or ten days. In more 
severe cases water-blisters of various size may form upon the 
inflamed surface, or the inflammation may extend into the deeper 
cutaneous structures, and matter be formed there. The constitu- 
tional symptoms are chill, fever, and disturbances of the stomach 
and head, varying in proportion to the severity of the cutaneous 166 
SKIN AND IIAIK. 
changes. When it attacks the face and scalp—favorite seats of the 
disease—there is often great distortion of the features from the 
swelling, more or less delirium, and subsequently the hair is apt to 
fall, to be reproduced, however. Erysipelas of the face may be 
easily distinguished from other inflammatory affections of the 
part, which are frequently accompanied by marked swelling, such 
as eczema and ivy-poisoning, by the constitutional symptoms 
which are always present in the former, and absent in the latter. 
Erysipelas is apt to recur several times upon the same person, and 
often starts from trivial sores or wounds. It is only in the gravest 
forms of the disease, or in debilitated persons, that a fatal termi- 
nation is to be feared. It is contagious in a moderate degree. 
Treatment.—Its treatment should at once be committed to a 
physician. 
Boils. 
Boils, or furuncles are circumscribed inflammations about the 
glandular structures of the skin (in which form they do not affect 
its deeper portions), or diffused and deep-seated inflammations 
extending to the structures underlying the skin. In the first we 
have a moderate degree of swelling, hardness, and redness about 
the central painful prominence, which soon suppurates, and, if 
opened when ripe, discharges matter and a core, or hardened plug 
of dead tissue; after which the part soon returns to its natural 
condition, or is marked by a scar, according to the amount of 
cutaneous substance destroyed. In the severer forms, larger por- 
tions of skin become very hard, tense, somewhat elevated and red- 
dened, and very painful. Finally, the hemispherical cake, which 
may be as big as a saucer, softens in its central part, and a large, 
deep slough' or core, consisting of the diseased structures of and 
beneath the skin, is cast off. The causes of boils are not well 
understood. They may follow the constant irritation of the skin, 
produced by chronic itching skin diseases; they may occur in 
persons of debilitated habit; they may also occur in those in robust 
health ; they may affect almost every part of the skin; may 
come singly or in crops, and in succession, so as to last a long 
time. 
Treatment.—The smaller variety may, perhaps, be prevented, 
or its course be cut short by applying frequently to the skin in its 
formative stage some sharply stimulating substance, as a saturated 
solution of carbolic acid, or tincture of iodine (see Index). If, how- 
ever, the inflammation has passed beyond the first stage, and mat- 
ter has already formed, it should be allowed* to escape by open- 
ing the boil to its bottom with a sharp lancet, or by the longer SKIN AND HAIK. 
167 
process of softening the tissues and hastening spontaneous dis- 
charge by applying a thick layer of lard or cold cream ointment 
upon cloth over the part. Ordinary poultices are to be avoided, as 
they tend to soften the surrounding skin too much, and induce the 
development of additional boils. In continued outbreaks of boils, 
or furunculosis, and the more serious forms, the physician should 
be consulted. 
Herpes—Fever-Sore—Cold-Sore—Shingles. 
Herpes is an eruption of small water-blisters, always occurring 
in groups or clusters upon limited portions of the body, and run- 
ning an acute course. The most common form is the ordinary 
cold-sore upon the lip, which may arise in connection with a cold, 
with febrile disorders of various kinds, or in consequence of dis- 
turbances along any portion of the alimentary tract, or about the 
genitals. It begins with a sensation of burning, itching, and 
tension, which are soon followed by a redness and elevation of the 
affected part, upon which a cluster of minute'water-blisters arises. 
These, if undisturbed, subside in the course of a day or two, and 
in a few days the part generally returns to its natural condition. 
If, however, the vesicles be broken by rubbing or by the move- 
ments of the lips, and sometimes by the violence of the inflamma- 
tion, crusts of considerable thickness will form and re-form, and 
the sore be protracted for some time, causing much pain and diffi- 
culty in eating and speaking. Cold-sores are apt to recur upon 
some persons through life. 
Treatment.—They may often be prevented when in process of 
formation, by the frequent application of a drop of tincture of 
camphor ; but, when once formed, they should be as little meddled 
with as possible. 
Shingles. 
Shingles is a more extensive eruption of clusters of the vesicles 
of herpes occurring upon certain definite districts of the skin, and 
often accompanied by excessive neuralgic pain in the region thus 
affected. The eruption is arranged in the form of belts or zones, 
running down the arm or leg, round the trunk or neck, or over the 
face and scalp, and always follows the course of some large 
cutaneous nerve. It is in fact primarily a disease of the nerve- 
ganglion or trunk, in consequence of which the skin supplied by it 
or its branches becomes disturbed, and assumes such diseased 
action. Just such changes in the skin may be produced by wound- 
ing one of these nerves. The disease runs an acute course, the 168 
SKIN AND HAIR. 
eruption attaining its full height at any one point in five or six 
days, and, gradually drying up, disappears in a week or ten days 
longer. The vesicles at first contain clear serum, but subsequently 
matter or pus is mixed with this, so that they become opaque. 
Occasionally they contain blood. They may, especially if broken, 
leave permanent scars to mark their seat. The disease affects but 
one side of the body at once, a right or left extremity, or extends 
from the backbone behind, following the course of the ribs, round 
to the median line of the chest or abdomen in front. Upon the 
face it may seriously affect the eye. The affection is not danger- 
ous, but often produces intense suffering while it lasts, and some- 
times, especially in old people, the neuralgia may continue for 
months after the eruption has disappeared. 
Treatment.—The greatest care should be taken that the vesicles 
be not broken. For this purpose soft and fine old linen or cotton 
should be worn beneath the woollen undergarments, and the erup- 
tion may be dusted frequently with fine starch or toilet powder. 
No other applications should be made. In cases where the parts 
surrounding the eye are affected, the physician or oculist should 
be called in at once. 
B.—Chronic Inflammations. 
Eczema. 
Eczema, or Salt Rheum, falls in this division, not because it is 
never acute, but because it is often chronic both in the course of 
its tissue-changes and in its duration in individual cases. Eczema 
is in its many forms of very common occurrence, making, as it 
does, a large third of all cases of skin diseases. It is character- 
ized by a great variety of appearances, according to the seat of the 
disease, its stage, cause, etc. The eruptions in the early or acute 
stage are generally red patches, or papules, or vesicles, or a com- 
bination of the same, confined either to a small area of the skin, 
or scattered over large surfaces. These may last for a short or a 
long time, and disappear without other changes than a little sca- 
liness ; or there may be a continuous or interrupted outbreak of 
similar forms of efflorescence for an indefinite period. These, like 
all other forms of eruption in the disease, are accompanied by a 
great deal of itching, in consequence of which the parts are gener- 
ally scratched violently so as to produce other changes in the skin. 
Either by such violence or in consequence of the excessive inflam- 
mation, the cuticle is removed from the tips of the efflorescence, 
and the serous fluid with which the skin is filled oozes out freely, SKIN AND HAIR. 
169 
and, drying on exposure, forms crusts of a yellowish or greenish 
color. If the violence or inflammation be sufficiently great, mat- 
ter is also formed, or the capillaries of the skin may be ruptured, 
and thus crusts or scabs, composed of dried serum, pus, and blood 
be formed. Distinct pustules may also appear upon the skin, or 
large portions of cuticle be cast off, leaving intensely red and 
moist surfaces, which drip or ooze freely, and upon which crusts 
form later. All such manifestations may come and go rapidly, 
and the skin quickly recover its healthy condition. In case they 
should last a long time, however, or be frequently repeated upon 
any one part, a thickening of the lower layers of the skin is devel- 
oped—infiltration, so called—in consequence of which the skin be- 
comes firm, can no longer be easily pinched into folds between the 
fingers, and, losing its elasticity, cracks readily. Or patches of 
infiltration may develop slowly without such preceding surface 
eruptions, the skin being red, roughened upon its surface, or cover- 
ed with thick scales, which may continue to form for a long time. 
This thickening or infiltration is the chief characteristic of chronic 
eczema, although it may be associated with any of the eruptions 
found in the acute form above mentioned, papules, vesicles, pus- 
tules, or excoriations. Eczema may last for a few days, for 
months, or for years continuously, affecting either a small portion 
of surface, whole limbs, or nearly the whole surface of the body at 
once. Its distribution is often symmetrical on corresponding parts 
of the two sides of the body. Its appearances vary greatly, as 
above stated, according to the parts affected. It never disfigures 
permanently, however severe the course of the disease. It affects 
all ages and classes, the robust and perfectly healthy, as well as 
those suffering from all sorts of internal disorders. It forms one 
of the most frequent and distressing diseases of infancy, most 
often affecting the scalp, when it is called scald-head, or milk crust ; 
and it is apt to recur upon the same person more or less frequently 
through life. With the exception of the class of cases produced by 
the action of irritating agents directly upon the surface of the skin, 
as ivy and arnica above described, sugar and salt upon the gro- 
cer’s hands, lime upon the mason’s, potash upon the type-setter's, 
soap and water upon the washwoman’s, heat and moisture upon 
the baker’s, etc., we know but little of the causes of eczema. It is 
often hereditary, runs strongly in some families, is consistent 
with perfect health otherwise, and may be aggravated by, but is 
rarely dependent upon, disturbances of the internal economy. It 
is no indication that the “ blood is out of order,” or of the existence 
of “a humor,” as is so generally believed. It rarely causes any 
constitutional disturbance, however severe, widespread, or lasting 170 
SKIN AND HAIR. 
the attack. It is never a fatal disease, except, perhaps, that very 
rarely, in the very old or feeble, it may prove to be the last in- 
firmity which the system cannot stand up against. It is, however, 
an exceedingly distressing affection, both on account of the in- 
tense itching and sleeplessness it causes when extensive, the dis- 
figurement it produces while present, and its great obstinacy under 
treatment. 
Treatment.—The management of eczema is a matter of very 
great difficulty, for not only do its many forms of eruption de- 
mand each their own peculiar treatment, but its frequent changes 
make the constant observation of the physician necessary. Too 
often its tendency to relapse baffles for a long time his most skil- 
ful care, and temporary palliation is the only immediate result of 
his efforts. Until a physician can be called the distressing sensa- 
tions in the skin in acute cases may be palliated by the application 
of oxide of zinc ointment, of starch powder, or by such lotions as 
saleratus water, bran water, etc. ; all friction of the skin, and stim- 
ulating and hot food and drinks should be abstained from. As 
already stated, there is no foundation for the so popular prejudice 
against the treatment of this disease. It cannot be made to “ strike 
in ” or be “ driven ” elsewhere, and there is no more reason why 
we should not cure the disease than any to which our flesh is heir. 
Psoriasis. 
This affection is characterized, by the appearance of scattered, 
red, flattened elevations of all sizes, capped with thick white 
scales. It begins in the form of minute red points, which gradu- 
ally enlarge, retaining a circular shape until they reach the size of 
coins of various denominations, being constantly covered with 
firm scales. The elevated patches may continue to increase in 
size until large surfaces of the skin are uniformly covered by 
them or by the blending of contiguous patches ; but generally, after 
reaching the diameter of an inch or two, the centre of the patches 
sinks down, becomes paler, and loses its scales, while the edge 
of the ring-shaped efflorescence thus produced may continue to 
spread outward regularly or in unequal directions, so that most 
variously shaped patches and groups of disease are often presented 
in a case of long duration. The eruption, however, at any point, 
is always the same—a red elevated base covered with firm white 
scales. It may affect any part or all parts of the body at once, 
although in the most inveterate cases some interspaces of healthy 
skin always exist. Favorite seats for single patches, or at the be- 
ginning of a general outbreak, are the elbows, knees, and borders SKIJST AND HAIR. 
171 
of the scalp. It is rarely accompanied by itching, and causes no 
trouble except disfigurement. It may begin at any period after 
early childhood, and is liable to affect persons at longer or shorter 
intervals through life. The course of any one attack is always 
chronic, lasting for months or even years, and some patients are 
rarely free from some amount of eruption. Of its causes, except 
that it is strongly hereditary, we know nothing. It has no con- 
nection with scrofula or other constitutional disease. 
Treatment.—In one sense it is incurable; that is, there is no 
surety that the disease when cured at any one attack may not 
recur in the immediate or distant future—the probability is that it 
will. This, however, is no reason why a case should not be placed 
under the care of a physician, for without treatment the disease 
may last indefinitely, and is often extremely stubborn under the 
action of remedies. 
Acne. 
Acne—Face Pimples—Blossoms.—Acne is an inflammation of 
the follicles of the skin, and occurs principally upon the face and 
upper chest. Its relations to disorders of the sebaceous glands 
have already been spoken of (see page 145). The plugs of hardened 
sebum which stop the mouths of the glands upon the face (come- 
dones) prevent the escape of the sebaceous matter which accumu- 
lates, distending the gland, and, acting as a foreign body, produces 
inflammation of the surrounding tissues in the form of a promi- 
nent red pimple. Sometimes pus is formed in the upper layers of 
the skin, and converts the pimple into a pustule, but as frequently 
in the tissues about the base of the gland, and can be evacuated 
only by a deep puncture. Acne pimples may come, however, 
independently of any visible disturbance of the sebaceous glands, 
and present the same appearances as above given. The inflamma- 
tion may extend much deeper than the glands too, and be felt at 
first as a firm and extensive swelling within the skin, or even 
below it, and later form nodular elevations as large as a bullet, 
which may last a long time, and leave deep indentations or scars 
behind. The eruption, therefore, varies greatly in size and dura- 
tion. In mild cases it is small, and the pimples last but a week 
or two; but even in this form the disease may be of indefinite du- 
ration by the constant outbreak of fresh efflorescence, either con- 
tinuously or at irregular intervals. It is productive of but little 
pain, unless the inflammation is deep-seated. Acne generally 
begins about the period of puberty, when it is a very common 
affection, and lasts for a few years, but it may appear at any time 
of life later, and continue indefinitely. We know but little of its. 172 
SKIN AND HAIR. 
causes. It may be aggravated by disorders of digestion or by dis- 
turbances of the sexual functions, but in the majority of cases no 
such association can be recognized. There is a common impres- 
sion that it may be produced by eating butter and fats. Articles 
of food fried in fat will disturb the digestion of many persons, and 
might thus take share in the development of the eruption in those 
disposed to the disease, but plain butter in any quantity is harm- 
less. There is a modified form of the affection occurring upon the 
face, the nose, and adjoining portions of the cheeks, in which, in 
addition to the ordinary eruption of pimples of varying size, there 
is a great degree of congestion or redness of the parts, and often 
an enlargement of the blood-vessels of the skin, which may be seen 
ramifying just beneath the surface. This is called acne rosacea, 
or the rose, and affects persons generally after middle life. Still 
another form occurs in the bearded portion of the face, which is 
called sycosis, and is one of several affections of the parts known 
popularly as “ barber’s itch.” The eruption is situated about and 
is pierced by the hairs. It is generally a most stubborn and dis- 
tressing affection. 
Treatment.—So far as acne is dependent upon disorders of the 
sebaceous glands, much may be done to prevent it in young people 
by correcting such disorders, as already laid down ; nor can we 
expect the disease to disappear until the skin is restored to a 
healthy condition in this respect. Any faults of the general econ- 
omy are also to be removed, if possible. The treatment of the 
eruption in its severe or inveterate forms is often long and diffi- 
cult, but all cases are capable of great improvement or complete 
cure by medical skill. Its treatment should only be attempted 
with professional advice. 
Class III.—Hemorrhages. 
There are several forms of disease marked by the appearance in 
the skin of blood-spots. They are produced by the escape of the 
blood or its coloring-matter from the capillaries into the cutaneous 
tissues, in the form mostly of scattered, small, round spots. At 
first of a bright red, they may be distinguished from any of the 
eruptions of the inflammatory affections above considered by the 
non-disappearance of the redness under the pressure of the finger, 
for the blood, once escaped from the vessels, cannot be forced back 
again. Generally they are not elevated above the surface, and 
produce so little disturbance of sensation that their presence is 
often discovered only by chance. Although of bright color at first, SKIN AND HAIR. 
173 
this soon fades to a duller shade, and assumes a purplish, bluish, 
and finally yellowish tint, and gradually fades away after the 
manner familiar to all in the so-called “ black and blue ” spot pro- 
duced by a bruise, which is also a hemorrhage into the skin 
through violence. The affections of a hemorrhagic character are 
of different degrees of severity, and are called purpura, or pur- 
ples. In the mildest form the spots are generally small, thickly 
scattered it may be, and occur mostly on the lower legs. There 
may be but a single attack, which lasts long enough only for the 
spots to fade away, but generally the eruption continues to appear 
continuously, or at irregular intervals, for some time. In more 
severe forms the eruption is more general, and is frequently 
accompanied by severe pain in the larger joints, the elbows and 
knees, of a rheumatic character, so that the patient is confined to 
the bed. In the worst forms the hemorrhage is not confined to 
the tissues of the skin, but takes place from the mucous mem- 
branes of the nostrils, mouth, alimentary canal, and bladder, so 
that blood escapes freely from the nose, is spit and vomited in 
great quantities, and passes away with the discharges from the 
bowels and with the urine. It is poured out also into the cavities 
of the chest. It is a most serious and often a fatal disease. We 
know nothing of the causes of purpura. 
Treatment.—In the milder cases the limbs must often be sup- 
ported by bandages or elastic hose; and stimulants, or much 
standing or walking, should be avoided. It is not serious, but 
often persistent. In the more acute variety with the rheumatic 
pains the patient should remain in bed, take only cold articles of 
food, and in both this and the general hemorrhagic form profes- 
sional aid should be sought as quickly as possible. 
Class IV. —Hypertrophies—Overgrowths. 
All the tissues of the skin are liable to disproportionate growths, 
so as to make a great variety of forms of disease. Among these 
only such will be mentioned as are of common occurrence. 
1. Excessive growths of the cuticle.—As the formation of this 
layer depends upon the upper (papillary) layer of the true skin, its 
overgrowth is generally associated with changes in the latter also. 
The principal affections of this sort are : the callus, corn, wart, 
and ichthyosis. 
The Callus. 
The callus is an excessive development and retention of epi- 
dermal cells over prominent joints of the bones, mostly resulting’ 174 
SKIN AND HAIR. 
from unusual and prolonged pressure upon such parts. We find 
them, therefore, mostly upon the hands, in different positions, 
according to their occupation, and upon the soles of the feet. 
They may be regarded as protective shields, and are only objects 
of treatment when rarely they become inflamed. 
Corns. 
The corn is a modified callus, produced in the same way by 
pressure, and consists of small, conical, or flattened masses of 
epidermis, which are constantly forced by the pressure of the 
boot down upon the tender tissues of the cutis, causing atrophy 
and often inflammation of its tissues at such points. When situ- 
ated between the toes, the growth is called a soft corn, because the 
opposing surfaces, by their moisture, keep the cells from harden- 
ing as they form. It is all the more painful on this account. 
Treatment.—With properly shaped and sufficiently large boots, 
corns rarely form, and will often disappear spontaneously when 
the undue pressure is removed. They may be best treated by 
painting them frequently with tincture of iodine, or a strong solu- 
tion of bichromate of potash, and shaving off with a sharp knife 
the hardened outer layers thus acted upon. The corn doctor goes 
deeper and tries to remove the whole conical wedge of epidermis. 
The soft corn should be hardened by powdering frequently with 
tannin and keeping the opposite surfaces constantly apart by 
means of rings of felting, or little rolls of linen. For an inflamed 
corn, the foot should be kept in an elevated position as much as 
possible ; evaporating lotions of spirit and water should be fre- 
quently used, and softening ointments applied. (See also chapter 
on “ Hands and Feet.”) 
Warts. 
The wart is an elongation of a group of the papillae of the cutis 
projecting beyond the general surface, and covered with a thick, 
hard layer of epidermal cells (see Fig. 
19). In its early stage it is soft and 
smooth, but as it increases in size the 
general covering of cuticle is thrown 
off, and the tips of the enlarged in- 
dividual papillae are seen exposed, 
and covered with fine epidermal caps. 
This is called a seed-wart. When seated upon the scalp the 
papillae are still more prominent and distinct. Warts come and go 
very mysteriously, that is, without our knowing why. Situated 
Figttbe 19.—A seed-wart. SKIN AND HAIR. 
175 
ordinarily upon the hands, sometimes in great numbers, they may 
occur upon almost any part of the body. 
Treatment.—They may be removed by scissors, the knife, or 
by tying them off with a strong thread; be destroyed by strong 
caustic, acids, or alkalies, or more gradually by the repeated ap- 
plication of lunar caustic, glacial acetic acid (see Index), or even 
simpler remedies at times. The growth should first be shaved 
down to “the quick” or the bleeding-point, and the remedies then 
applied. The strong caustics should be used with great caution, 
especially over the joints, as they often cause inflammation by 
penetrating too deeply, and often leave disfiguring scars. (See also 
chapter on “ Hands and Feet.”) 
Fish-Skin Disease. 
Ichthyosis, or fisli-skin disease, consists in an enlargement of 
the papillse of the skin over nearly the whole surface, with an 
excessive formation and accumulation of the cells of the cuticle. 
The skin looks as if covered with the scales of a fish, or more 
closely a reptile. Its surface is rough, dry, and of a grayish 
or brownish color where the accumulations are thickest, generally 
upon the outer surfaces of the limbs. The disease shows itself in 
early childhood, and continues through life. It is often hereditary. 
There is a much less serious form of dry skin, called xeroderma, 
in which the surface is more or less scaly and harsh, which is also 
an incurable disease. The skin in both affections may be kept in 
a comparatively healthy and comfortable state by the constant use 
of warm baths with strong soap, and the daily inunction with oils, 
fresh lard, or glycerine and water, 
2. Excessive growth of pigment.—The coloring-matter of the 
skin is formed, as stated in the beginning, in the lowest layers of 
cells of the cuticle, which in the white races are very few. At 
times, however, these become greatly increased in numbers, and 
produce noticeable discolorations. The most common form is tan 
or tanning, the darkening of the skin under the stimulating action 
of the sun’s rays, under which, by long exposure, the whitest skins 
may assume, temporarily, a color as dark as that of the mulatto. 
Another form is the irregular production of pigment-cells in excess, 
called 
Freckles. 
These, however, are not due to the direct action of the sun, 
because they not only are often present the whole year round, 176 
SKIN AND IIAIR. 
but in many people cover thickly parts always protected by cloth- 
ing. More conspicuous, but less widely distributed, are the ir- 
regularly-shaped patches of considerable extent, situated mostly 
upon the face, called moth. These occur frequently in women 
after puberty, and vary a good deal in depth of color. Although 
often called liver-spots, they are in no way connected with its 
functions. Rarely large tracts of skin assume quite a dark color, 
or are interpersed with patches from which the natural color 
has disappeared. General blackening is called melasma. Moles, 
too, and little soft tumors of the skin of various kinds, are often 
deeply colored by excessive pigment-cells. In all these cases the 
coloring-matter is situated in the lowest layers of the cuticle, and 
can only be removed by first removing the layers above. 
Treatment.—No internal remedies will reach the seat of the 
trouble. In excessive freckling and moth-patches, the color may 
be greatly lightened or removed by the frequent or constant use 
of washes capable of producing an unusually rapid casting off 
of the cells of the cuticle, but in no other way. Preparations 
sold for this purpose often contain very dangerous ingredients. A 
solution of borax in water, a drachm to the pint, will be of service 
in slight cases, applied morning and evening. 
Class V.—Atrophies. 
Wasting of the tissues of the skin is so rare, that none of the 
affections included under this class can properly be mentioned 
here. (See Affections of the Hair, page 194.) 
Class VI.—Ulcerations. 
As has been stated, the cuticle is formed by the papillary layer 
of the cutis, and when removed by violence, or in the process of 
disease, is rapidly re-formed by the same agency, and no perma- 
nent injury results. Should the papillae, however, be destroyed, 
the epidermis cannot be restored in this way, and the process of 
repair is then very slow and imperfect. Ulcers are open sores in 
which the skin has been destroyed or removed to a considerable 
and varying depth, the result usually of previous disease in the 
tissues of the part. In consequence of the destruction of the 
papillae, or loss of vitality, or impaired nutrition of parts in which 
the sore is situated, the capability of repair or healing is dimin- 
ished or completely suspended, and the result is a sore which SKIN AND HAIR. 
177 
may last indefinitely, according to its nature. The most frequent 
example is the so-called chronic ulcer of the leg, which in the 
majority of cases depends upon an enlarged or varicose condition 
of the vessels of the part, in consequence of which the skin is 
not well nourished, loses its vitality, and breaks down into ulcera- 
tion. This may attain a very large size, extend deeply, and is 
always slow to heal. It requires most judicious local treatment, 
and the enlarged veins of the integument subsequently need artifi- 
cial compression by an elastic stocking or bandage. 
Class VII.—New Growths. 
This division comprises the most serious diseases which affect 
the skin, but which fortunately are of rare occurrence. Lupus, 
cancer, leprosy, and syphilis are amongst them. The only one 
which can properly be considered here is vascular ncevus, a new 
growth of the cutaneous capillaries. They may be congenital, 
when they are called 
“Mother’s Marks,” 
or start into existence at any subsequent period. The former vary 
greatly in size and color, sometimes covering large surfaces, and 
are of a bright scarlet, crimson, or purplish hue, according as 
they are composed mostly of enlarged arteries or veins. They are 
sometimes firm and flat, at others spongy and erectile. They do 
not increase in size except proportionately with the growth. Often 
new-born infants exhibit faint stains of considerable size, which 
gradually and completely fade out. In the other form, the non- 
congenital, a loop of vessels becomes enlarged, forms a small, red 
prominence, often upon the face, and from this, as a centre, 
minute vascular twigs radiate in all directions. 
Treatment.—Mother’s marks, when small, may be obliterated 
by surgical treatment; but when large and deep, cannot be de- 
stroyed ordinarily. The later forms may be destroyed in a variety 
of ways, and sometimes disappear spontaneously. 
Class VIII.—Neuroses, or Disturbances of the Sensibility 
of the Skin. 
There may be both a diminution and excess of the natural sen- 
sitiveness of the skin, but the most important on account of its 
very frequent occurrence is 178 
SKIN AND HAIR. 
Itching. 
The sensation of itching or pruritus is a symptom which is often 
associated with skin diseases, as the result of changes in the tissues, 
but it occurs also as an independent affection. Pruritus may be 
local or general. About the anus it is a very common and excessive 
annoyance, lasting for years or a lifetime. It may depend upon 
piles, or constipation, but generally its cause is not apparent. The 
scratching which it provokes often excites eczematous inflamma- 
tion of the surrounding skin, which may spread forward upon the 
genitals, and become a most distressing and obstinate affection. 
Pruritus of the female genitals is also common, dependent at 
times upon unhealthy discharges from the parts, or disorders of 
the internal organs. Scratching and rubbing here, too, often pro- 
duce very serious disease of long duration. More general forms 
of itching are apt, in many persons, to come on with the cool 
weather of winter, especially after middle life, even with those 
who avoid the exciting contact of woollen underclothing. It is 
most violent upon the extremities, and often gives rise through 
scratching to aggravated forms of excoriations and eczematous 
inflammation. 
Treatment.—For the latter form, thin cotton or linen under- 
garments should be worn next the skin, washes of borax or weak 
solutions of carbolic acid, etc., should be applied at night to re- 
lieve the itching, which is generally greatest on exposure of the 
skin at that time, and all scratching and friction abstained from 
as much as possible. For pruritus about the anus the parts should 
be frequently bathed with cold water ; delicate and wetted paper 
should be used after stool; lard, cold cream, or cosmoline smeared 
over the parts when the itching is excessive, and no irritation of 
the parts practised. In itching of the female genitals the parts 
should be frequently bathed, anointed with any of the above sub- 
stances, and left undisturbed by rubbing. 
Class IX.—Parasitic Affections. 
1. Vegetable.—There are three well-recognized diseases of the 
skin produced by the growth within its tissues of vegetable para- 
sites. These growths belong to the fungi or moulds, and consist, 
so far as they are represented in these affections, mainly of mi- 
nute spherical bodies or cells, called spores, and fine elongated 
filaments or rootlets, known as mycelium (see Fig. 20), which 
are capable of reproducing themselves when properly transferred SKIN AND IIAIR. 
179 
to other skins, and are of indefinite continuance. From what 
source they originally become parasitic on man is not known, nor 
Figure 20. (After Fox).—Spores and mycelium as seen under a microscope, in the root of 
a young hair removed from the scalp of a patient having ringworm. 
their true relations to other fungi. The most common of these 
affections is : 
Ringworm. 
Ringivorm has received different names as it affects different 
parts of the body. Upon the general surface of the skin it is 
called tinea circinata ; upon the hairy scalp, tinea tonsurans; in 
the beard, tinea sycosis. Upon the skin the disease begins as a 
minute elevated red spot, which increases in size rapidly, becomes 
slightly scaly upon its surface, flattens down in its centre, and thus 
makes a ring which spreads outward and may form a circle of 
one or more inches in diameter. Any portion of this elevated 
ring is composed of papules, or sometimes vesicles and fine scales. 
The central portion loses its redness, but may remain scaly for a 
considerable time. The ring may stop growing at one or more 
points while the remainder spreads, or new ones start up upon 
other parts of the surface, and thus a variety of shapes be formed. 
The growth is capable of spontaneous extinction, but it may cover 
large portions of the body. If any portion of the surface thus 
affected be scraped and the scaly matter thus removed be examined 
by a high power of the microscope, after adding a drop of a solu- 
tion of potash or soda to make the cells of the cuticle transparent, 180 
SKIN AND HAIR. 
there will be seen innumerable little round bodies, of an inch in 
diameter, the spores of the fungus, and a little of the filamentous 
growth. The plant is called trichophyton tonsurans. This form 
of the disease is very common and very contagious. A patch of 
it upon a child will produce others upon its own skin, upon that of 
other members of the family, and its schoolmates with whom it 
associates. It produces some slight degree of itching and burning. 
Upon the scalp, the disease first manifests itself by the falling 
of the hair in circular spots, although not close to the skin as 
if shaven—as in alopecia areata, an affection to be described 
below—but by breaking off one or two lines from the surface 
and leaving the irregular stumps to project. The surface of 
these circumscribed patches is harsh, owing to the projection of 
the hair-follicles as well as of the stumps, and from the thick coat- 
ing of dry and diseased epidermal cells and the parasitic elements 
present. This, however, is not the first stage of the disease, al- 
though that which first attracts notice. It is preceded generally 
by the same appearance of circles of erythema, spreading out- 
ward and healing at the centre, as in ringworm of the skin, but 
without as markedly elevated a rim as in the latter. These, being 
concealed by the hairs, generally escape observation, and it is 
only by watching the development of new points of inoculation, 
as the disease progresses, that its early stages may be generally 
studied. After gaining a hold upon the epidermal cells, as shown 
by these manifestations, with which we are already familiar, the 
fungus soon affects the hairs ; they become dry, lustreless, and 
brittle, and break very easily, leaving the stumps projecting from 
the prominent follicles, as already described. As the disease 
spreads outward from its central starting-point, large, bare spots 
are formed, several inches in diameter, which may run together, 
and thus give rise to a very large and continuous patch ; or, many 
separate points scattered over the scalp may give a spotted appear- 
ance to the whole head. Thus the outlines of the affection are 
constantly changing in every case, but the minute and surface 
appearances of every spot are always the same, viz.: the stumps 
of hair, the white scaly matter, and the prominent follicles re- 
sembling shagreen, or the skin of a plucked fowl, as variously 
described by writers. 
Left to itself, ringworm of the scalp tends to perpetuate itself 
indefinitely. The hairs repeatedly fall and are reproduced, until 
the soil contains no more nutriment for the plant, or the follicles 
are obliterated by inflammation, in both of which conditions a 
local spontaneous cure of the disease results. It will sometimes 
apparently disappear more or less entirely, but almost always SKIN AND HAIR. 
181 
acquires new life, and thus may go on for years unless arrested 
by treatment. 
If we pull out one of the hairs changed as described, and 
examine it by the microscope, we shall find abundance of the 
vegetable growth distending its tissues. 
Ringworm of the scalp is a frequent affection among children, 
and occurs upon the same individual and at the same time with 
ringworm of the general surface. The one may readily give rise 
to the other upon another person. In adults, however, it very 
rarely affects the scalp, and it may exist for months upon the 
hairy portions of the face, and extend from these parts over large 
portions of the body without appearing upon the head. It is in 
orphan asylums that it is most commonly found, and the introduc- 
tion of a child affected with it is often the cause of an outbreak 
which may spread among scores of the inmates, and last for 
months before it can be exterminated. It causes some degree of 
itching, and, as just stated, occasionally a circumscribed inflam- 
mation sufficient to destroy the hair-follicles, and thus produce 
partial baldness ; but it does not affect the health in any way. 
Ringworm of the Beard—Sycosis—Barber's Itch—presents very 
unlike appearances at different times—so dissimilar, in fact, as to 
pass generally for entirely distinct diseases. As just stated, it is 
in one form a very common affection among young men, and its 
real nature is then readily recognized even by the patient. The 
latter appearances are those of ordinary ringworm of the chin and 
those of the scalp affection just described, more or less combined, 
and are called simply ringworm. 
It begins, as upon the non-hairy portions of the face or body, 
in the form of small points, which generally attain the size of a 
pea or a cent before they attract much attention. They spread 
rapidly in a circular form, flattening down in the centre as the 
elevated margin of papules or vesicles enlarges, and are accom- 
panied by a considerable degree of itching and burning. The cen- 
tres of the patches remain more or less reddened and scaly, but 
seldom present the white, branny look so characteristic of their 
seat upon the scalp, probably because the parts are so much more 
frequently washed. The sides of the face are its most common 
starting-point, from which the rings may spread in every direc- 
tion, or new ones may be started from these upon other parts by 
self-inoculation, the itching causing frequent rubbing with the 
hands, and in this way transference of the parasitic elements else- 
where. When the circle spreads beyond the beard, the appear- 
ances of such portions of the patch are identical with those of 
ringworm originally started upon the general surface of the skin. 182 
SKIN AND HAIR. 
The disease may thus run on for some time in the beard without 
any apparent change in the hairs, but sooner or later—the period 
varying greatly in different cases—the hairs begin to fall from the 
parts affected, thus defining the patches more conspicuously than 
before. The hairs break off a short distance above the surface, 
and leave ragged stumps, as on the scalp. Ringworm of the beard 
primarily occurs generally upon those parts of the face which are 
shaven, or, in other words, upon those persons who are shaved ; 
much less frequently upon others, for reasons to be hereafter given. 
After existing thus for months, possibly for a year or more, the 
beginning of those lesions of the skin becomes manifest which 
characterize the second stage of the disease. Simple ringworm of 
the beard becomes, in other words, Sycosis, which begins in the 
form of a small nodule about the insertion of the hair. This 
slowly enlarges and, if the inflammation runs high enough, dis- 
charges pus from its summit, which dries and forms a crust about 
the hair. This process is repeated in the individual follicles several 
times generally, the nodules varying in size and prominence ac- 
cording to the degree of inflammation. In later stages the nodules 
and pustules may be converted into hard and large prominent 
tubercles, giving rise to thicker crusts upon their surfaces as they 
suppurate, or forming large, raw indurations. The tissues beneath 
the skin may in time become involved, and large abscesses be 
formed. Thus the disease may go on for months or years, spread- 
ing gradually over the hairy portions of the face, and affecting 
sometimes the eyelashes and eyebrows. When the inflammation 
is excessive the hair-follicles thus affected are destroyed, and per- 
manent baldness results. Great disfigurement and local distress 
are often caused by it. It forms one of those chronic affections of 
the beard known as barber’s itch. 
Ringworm of the Nails.—The last form remaining to be de- 
scribed is ringworm of the nails. Occasionally some one or more 
of the nails of persons affected with any of the varieties above 
described, or of those having the daily and long-continued care of 
such patients, lose their transparency, become opaque and dry, 
and gradually thicken. Their surface appears rough, and cracks 
easily, and their free edge is blunted. Their substance is brittle, 
and flakes off superficially in the form of scales. If these be ex- 
amined by the microscope, the flattened cells of which they are 
composed will be found filled with parasitic growth. 
Ringworm occurs also upon several of the domestic animals— 
the cow, the horse, and the cat—forming one of the diseases 
called mange, and is often transferred from them to members of 
the household to which they are attached. One of the most com- SKIN AND HAIR. 
183 
mon sources of contagion is the barber’s shop. How this may 
happen is very easily explained. To these shops, in addition to 
the regular customers who are not shaved elsewhere, there resorts 
an irregular set of residents, who are shaved sometimes in one 
place, sometimes in another, and also a large and ever-changing 
multitude of travellers. It is evident that opportunity for the en- 
trance to a shop of cases of so common an affection as ringworm, 
or of one so chronic as sycosis, in all this shifting multitude, will 
not be wanting. 
The question is, how it may be communicated from one cus- 
tomer to another, both of whom have their own equipments, which 
we will accept as reserved for their individual use ? The operator 
uses not only the brush, but his hands also, in lathering a face thus 
affected. These are not always washed before they are applied to 
the face or apparatus of another ; the razor is first stropped, with- 
out thorough cleansing, perhaps, upon the common strop, even 
while the act of shaving is only half finished, it may be ; the towel 
used in wiping the face of the first goes not upon a few afterward ; 
the comb, used upon parts of the face not shaven, goes directly to 
the beard of the next comer. These are the channels of communi- 
cation by which these parasitic cells—so small as to be invisible, 
and incapable of destruction by the soap, water, or washes used 
during the process of shaving—may gain passage from one face to 
another, even when all possible precautions are observed by the 
regular patrons ; when the common property and apparatus of the 
shop are employed, the danger of conveyance is of course largely 
increased. 
There can be no doubt, too, that tinea tonsurans of the scalp 
may be conveyed from one boy’s head to another in a similar way 
by the hair-cutter ; but this is a danger far less to be feared than 
that of the barber’s shop, for the affection of the scalp among 
cleanly children is comparatively rare, while that of the face in 
gentlemen who resort to the latter place, on the contrary, is by no 
means rare. 
Tinea tonsurans is to be guarded against, therefore, in the 
school, whenever a child in attendance is known to be affected by 
it in any form: in the barber’s shop, always; at home, when 
brought into it by any one member of the family ; and at times, 
upon the skin of domestic animals. 
Treatment.—The treatment of ringworm of the general surface 
is ordinarily a simple matter, consisting in the frequent application 
of those substances known to be capable of destroying the plant 
without injuring the skin, for a sufficient time to penetrate to the 
lower layers of the cuticle, below which its growth does not ex- 184 
SKIN AND IIAIU. 
tend. The insufficiency of many of the household remedies is 
their superficial action, the upper growth of the fungus only being 
destroyed, so that the disease returns after being apparently cured. 
Among those which are ordinarily effective in the superficial 
forms are sulphur ointment, sulphurous acid solution, strong solu- 
tions of carbolic acid, and tincture of iodine. They should be ap- 
plied once or twice daily, and as thoroughly as possible without 
over-stimulating the skin. The treatment is to be continued, in all 
forms, long after the surface of the skin appears restored to its 
natural condition. From the hairy portions—the beard and scalp 
—the disease is eradicated with great difficulty, because the par- 
asitic growth extends to the roots of the hair—that is, to the lowest 
layers of the skin. Hair-pulling or epilation is, therefore, almost 
a necessity over the affected parts, by which a large quantity of 
the fungus is removed, and the remedies allowed to penetrate to 
the deepest seat of the growth. The hairs may be pulled out by 
tweezers without much pain, and always grow again. Treatment 
must always be continued uninterruptedly for months, and never 
given up without the assent of the attending physician. 
Favus. 
Tinea favosa, or favus, is by no means as common as ring- 
worm. It may be briefly described as an affection of the scalp and 
external covering, characterized by the formation of large, yellow 
crusts. The shape of these crusts is peculiar, being concave upon 
their upper and exposed surface, circular or ovoid in outline, and 
presenting concentric rings. In size they vary from a minute 
point scarcely discernible by the naked eye, to flattened masses a 
half-inch in diameter when separate, and an eighth of an inch or 
more in elevation above the surface of the skin at their edges. Dis- 
tinct crusts may by confluence, however, form large patches, in 
which their characteristic concavities may be seen more or less 
blended and lost. These peculiarities of shape are caused by their 
seat and the method of their growth. The minute elements of the 
fungus gain entrance to the tissues of the skin, upon which they 
thrive, through the opening of the hair-follicle, and from this as a 
central point extend downward into the hair-canal, and outward in 
all directions into the epidermis. At first a minute globular mass 
is formed, but as the growth increases peripherally it is held down 
at its centre by the clinging of the hair-sheath to the hair, while 
in the free epidermal tissues around it is allowed an upward 
growth. It is the presence of the hair in the centre of each crust, 
therefore, which mainly causes the concavity of the crusts. Upon 185 
SKIN AND HAIR 
the scalp, where the hairs are best developed, this shape is longest 
retained ; while upon the general surface of the body, where it is 
much less frequently met with, the crusts when large wholly lose 
this peculiarity, and form irregular-shaped masses, projecting to 
a much greater elevation above the surface. The color of the 
crusts when young is bright orange, fading to a pale lemon color 
when older. The odor is disagreeable, resembling, as it is thought, 
somewhat that of mice, a significant fact in connection with its 
frequent occurrence upon these animals. These appearances may 
be modified by the bursting of the crusts by rough handling and 
the discharge of their contents, or inflammation may arise beneath 
them from the same cause, and the pus and blood mingling with 
them give rise to the formation of large scabs. 
Upon the scalp, however, its effects are of a more serious na- 
ture. The hairs soon begin to change in color, becoming gray or 
white, lustreless, stiff and brittle, and after a while break off at 
the surface, or are discharged by suppuration with the surround- 
ing favus masses. In this way the disease spreads over the whole 
scalp in time, the baldness beginning generally at the front and 
lateral portions, while the hair upon the occiput may retain its 
position for years. The baldness may be temporary only, in 
case the hair-follicles are not destroyed; but the presence of so 
much foreign matter within them may give rise to so violent 
an inflammation that they and the hair-growth are forever de- 
stroyed. 
Favus affects the nails too, occasionally; generally in persons 
either carrying the growth in some other position, or having 
charge of those affected by it. Their substance, which is only 
modified epidermal tissue, becomes yellow and opaque, their longi- 
tudinal striae are more marked, and their surface has a rough and 
tuberculated appearance. 
If we examine by the microscope the matter of which the favus 
crust is composed, upon whatever part of the body it may be 
growing, we shall find, in addition to more or less epithelium, 
innumerable minute cells of an irregular ovoid shape, attached 
to each other in groups or rows, and long and slender tubes. If 
we remove the hair which pierces the centre of one of the cups, 
with its sheath attached, we shall find the walls of the latter dis- 
tended with the same growths, called Achorion Schonleinii. 
Favus is a rare disease in comparison with the other vegetable 
parasitic affections. It is mostly met with upon the heads of poor 
children, for its elements seldom succeed in developing upon sur- 
faces frequently washed or brushed. Although positively conta- 
gious, it is so in far lower degree than some of the varieties of ring- 186 
SKIN AND IIAIM. 
worm, and it seldom, if ever, runs through schools and asylums 
like the latter. It is frequently observed upon several members of 
the same family, however, and to be developed successively and 
only after long periods of daily contact amongst its individuals. 
It affects children more frequently than adults, and is compara- 
tively more common in the country than in cities. Its course is 
always slow; left to itself it may last a lifetime upon the scalp, or 
until it has entirely destroyed the hair, in which case a sponta- 
neous cure is possible. Upon other portions of the body its duration 
is by no means so chronic, and its eradication by treatment, com- 
pared with its seat upon the scalp, a simple matter. 
Treatment.—The treatment of favus is the same as in ring- 
worm, but it is more obstinate even than that, and when seated 
upon the scalp can only be eradicated by repeated pulling of the 
hairs, and long continued use of so-called parasiticides. (See treat- 
ment of ringworm, on page 183.) 
Tinea Versicolor. 
The third of the vegetable parasitic affections is tinea versi- 
color, or as sometimes called, pityriasis versicolor. It is charac- 
terized by the formation upon the surface of yellowish or buff- 
brown spots of irregular outline, but slightly elevated, and covered 
with fine scales, which are easily scratched up by the nails, or 
removed by scraping with a knife. They vary in size from minute 
points to confluent patches of sufficient extent to cover large por- 
tions of the chest or abdomen. They chiefly affect the front trunk, 
beginning generally upon the chest, and may extend downward so 
as to cover more or less wholly the abdomen, hips, and upper 
thighs, and upward to the shoulders, and thence down to the 
forearms, or creep around the chest to the back. They rarely 
appear below the knees and elbows, or ascend upward upon the 
neck, and never affect the face. In other words, they do not 
generally grow upon those parts of the skin which are exposed to 
the air and light, finding rather upon those parts protected by 
clothing the warmth, and possibly the absence of light, essential 
to the development of the plant. 
When once established, it seldom disappears spontaneously, but 
may go on for years, perhaps dying out largely during the winter, 
to revive and extend over wider areas during the summer. It 
often gives rise to great itching of the parts affected, although in 
some cases the patient is not conscious of its presence through any 
sensation it may cause. It is often mistaken for, and confounded 
with, the pigment-stains upon the skin called moth, liver-spots, or SKIN AND IIAIK. 
187 
chloasma, an affection differing from it in position, anatomical 
seat, course, and clinical history. 
An examination by the microscope of a few of the scales, so 
easily removed, from a patch of pityriasis versicolor, will readily 
establish its nature. We see lying between the upper layers of 
epidermal cells countless numbers of round conidia or spores, 
grouped in clusters, of high refractive power, and resembling 
minute oil-globules. Associated with these are fine tubes of myce- 
lium running in a network of endless intricacy. 
The disease is of not unfrequent occurrence here, although its 
presence is frequently overlooked by its host, and is only dis- 
covered by the physician when examining the naked chest for 
other reasons. It is on this account that it has been said to affect 
consumptive patients especially. There is no other ground, how- 
ever, for such an opinion. Its growth is entirely independent of, 
and unconnected with, the general condition of the person it 
affects, nor does it exert any injurious influence upon the same, 
save the itching it occasions. It is positively contagious,—hus- 
bands giving it to their wives, as above stated, and as also proved 
by direct experiment. The spread of the disease from one portion 
of the body to another is likewise affected by the transplanting of 
the spores in the furrows ploughed up in the healthy epidermis by 
the nails while scratching. Still it is not by any means so easily 
communicated to new hosts as tinea tonsurans, nor is it so easy to 
trace the source of contagion in any particular case. The color it 
imparts to the skin is a property of the fungus, as much as the 
yellowness of the favus crust belongs to the achorion. 
Treatment.—The treatment is more simple than in the two 
preceding diseases, because the plant growth does not extend so 
deeply into the skin, nor affect the tissues of the hair. It consists 
in the thorough application of the parasiticides to the affected 
surfaces, with the free use of soft soap and baths, to be continued 
long after the disease is apparently cured; for, if a single minute 
spore remains undestroyed, it will gradually return. 
2. Animal parasites.—The number of animals which have a 
more or less intimate parasitic relation to the skin of man—ectozoa, 
as they are called—is quite large, but we shall consider here only 
those which are capable of producing upon it serious disease. 
These are the itch insect and three kinds of lice. 
Itch. 
Scabies, or itch, is caused by the sarcoptes, or acarus hominis, a 
minute, mite-like animal, .scarcely as large as the head of the 188 
SKIN" AND HAIR. 
smallest pin (see Figs. 21 and 22); a description of it may be 
found in all works on skin diseases. If we transfer one of the 
females from a person with itch to a 
healthy skin, she immediately digs her 
way by means of her jaws into the cuti- 
cle, and burrows obliquely downward, 
keeping just above the true skin, and 
forming thus a canal, visible by the bulg- 
ing of the surface above, a quarter or half 
an inch in length. As she proceeds she 
lays her eggs behind her, twenty or thirty 
in number (see Fig. 23), and finally dies 
at the end of her burrow. These hatch 
in succession, and the young, issuing out 
upon the surface, dig little pits for sus- 
tenance and for their necessary changes, 
and when mature the young females form 
other burrows, lay their eggs, and thus the stock is kept up. 
Figure 21. (After Anderson). 
—Male acarus, greatly magnified. 
Figure 22. (After Anderson).—Female acarus and eggs (magnified), a, a, a, Eggs in vari- 
ous stages of growth, b, 6, Shells from which acari have escaped, c, c, Fragments of acarL d, 
Female acarus. e, Larva. SKIN AND HAIR. 
189 
Where the little pits are dug by the young and males, small pap- 
ules may be produced, and these, with the burrows of the adult 
female, are the only changes in the skin directly due to the itch- 
insect. But these proceedings cause great irritation of the skin, 
which, with the violent rubbing and scratching that necessarily 
ensue, produces in most persons an eruption of papules, vesicles, 
and later, excoriations, pustules, and other forms of eczematous 
inflammation. Thus, beginning with a slight, inconspicuous erup- 
tion, confined to a small district, the 
disease may extend over nearly the 
whole surface of the body, the head 
alone being exempt, and present the 
greatest variety of efflorescences, 
and of the severest type. The seat 
is ordinarily the hands at first, be- 
cause the disease is generally con- 
tracted by contact with the hands 
of affected persons; and the most 
characteristic eruption, papules, bur- 
rows, and vesicles, is found between 
the fingers and about the wrists, 
where the tissues are soft. Later 
these primary forms, those produc- 
ed— that is, directly — by the ani- 
mals, may be found over other parts 
of the body, but finally may be so 
interspersed with the eruption pro- 
duced by the scratching and be de- 
stroyed by the latter, as not to be 
easily distinguished. From these 
primary forms the animals may be 
easily extracted with a needle, and 
examined by the microscope. The 
name of the disease sufficiently de- 
scribes its most characteristic symp- 
tom—it is decidedly the itch. The itching is worst at night, after 
the patient is warm in bed, because the animals are most active 
when the skin is warm. The disease was formerly much more 
common in America than at present. During the war of the re- 
bellion it became very prevalent in the army, and being brought 
home by returning soldiers, was spread widely over the country ; 
but it has now nearly become extinct again, and is kept up to 
some extent by fresh importation with immigrants, as it is almost 
a universal evil among the lower classes in many parts of Europe. 
Figure 23. (After Neumann.)—A fe- 
male acarus with her burrow containing 
eggs. The small black dots represent ex- 
crement. 190 
SKIN AND HAIR. 
It is readily transferred from one person to another by exchang- 
ing hands while warm, and by sleeping together. It is often 
introduced into a family by nurses and servants, through the 
children, and may affect every member before its real nature is 
suspected. It may last indefinitely if not treated, but is easily 
cured. 
Treatment.—The patient should be rubbed all over with soft 
soap, and soaked in a warm bath for half an hour, then rubbed 
thoroughly with some appropriate remedy for another half hour, 
which should then be washed off. This process, repeated for three 
nights, at bedtime, is generally sufficient to destroy the animals 
in all their phases of development. The skin will often be left in a 
state of inflammation for some time, varying with the character 
and extent of the secondary eruptions, but will generally return to 
a healthy state rapidly after the cause is thus removed. Sometimes, 
too, the skin is so seriously diseased, that the inflammation must 
be reduced by appropriate treatment before the proper parasiti- 
cides can be applied. No internal remedies are of use. All the 
underclothing worn next the skin, and the sheets used by the 
patient, should be put into boiling water on the first night of the 
cure. The most active remedies are sulphur, soft-soaps, and tarry 
substances mixed with lard or alcohol in varying proportions, 
as follows : oil of cade, soft soap, flowers of sulphur, lard, equal 
parts by weight; or, oil of cade, flowers of sulphur, soft or German 
soap, of each, one part, alcohol, three parts—shake before using. 
Care should be taken not to use them too freely or too often, lest 
they create and sustain an artificial eczema which may be mis- 
taken for remnants of scabies. The skin, after a prolonged attack 
of the disease, is often left in an irritable state for a long time. 
Lice. 
The lice which infest mankind are of three distinct species, 
and they inhabit distinct regions of the body. They are the head- 
louse, pediculus capitis, the clothes- or body-louse, pediculus vesti- 
mentorum, and pediculus pubis. Louse-disease is called phthiria- 
sis. The head-louse (Fig. 24) lives only upon the hair of the head, 
to which it attaches its eggs, large enough to be readily seen by 
the unaided eye, and called popularly- nits, and subsists by punc- 
turing the scalp and drawing blood through the bite. It multiplies 
rapidly and produces by its ravages great irritation of the scalp. 
The scratching in turn excites still further inflammation, often true 
eczema, so that the hair is glued together by the discharges, and 
forms with the lice and accompanying products of disease an in- SKIN AND HAIR. 
191 
describably filthy mass. In consequence of the inflammation the 
glands in the neck often become greatly swollen, and the eczema 
often extends to the parts below the original seat of the disease. 
Lice are very common among the dirty classes of society, and 
often find their way to the most cleanly families through the 
children at public schools, through wet-nurses, and are no doubt 
sometimes taken in public conveyances. 
Treatment.—To get rid of them the scalp and hair throughout 
should be soaked for two hours in crude petroleum, then washed 
thoroughly with soap and water, and when dry, drenched with 
strong alcohol. This should be repeated for three or four days in 
succession. The nits may remain attached to the hairs, but are 
harmless after this treatment. They may be removed subse- 
Figure 24.—Head-Louse. 
Figure 85.—Clothes-Louse. 
quently by scraping with the blade of a knife or scissors. Kero- 
sene may be used instead of petroleum, but sometimes produces 
unpleasant symptoms. 
The body-louse (Fig. 25) is more properly a clothes-louse, for 
it breeds upon the clothing, and only bites the skin to draw blood 
as its food. It is somewhat larger than the head-louse, which it 
closely resembles. It lays its eggs in the folds and seams of the 
garments, and may be readily discovered by examining these 
parts. Its bite produces a small papular eruption, which from 
scratching is generally capped by a minute crust of dried blood. 
The whole surface, except the head and hands, which it never 
invades, may be thickly covered in this way, and, interspersed 
with it, long scratches produced by the nails occur. It is thickest 
upon the trunk, especially about the upper chest. 
Treatment.—The treatment is to be directed to the clothes, not 192 
SKIN AND HAIR. 
to the skin, which recovers its healthy condition after the lice are 
destroyed. All the clothing that can be so treated should be 
thrown into boiling water, and the outer garments should be 
—- baked or ironed along their seams and 
folds with as hot an iron as can be used 
without burning them. The bed-clothing 
may be treated in the same way, but it 
is rarely necessary. The body may be 
thoroughly washed with soft-soap before 
putting on fresh clothing. 
The pubic louse (Fig. 26) differs great- 
ly in shape from that of the head and 
body, and is somewhat smaller. It at- 
taches itself and its eggs to the short hairs 
of the body, especially about the genitals, 
but may be found even upon the eyelashes. It, too, bites the 
skin about the roots of the hair and produces great irritation. 
Treatment.—It may be destroyed by petroleum and thorough 
washing, or by applying mercurial ointment cautiously to the 
parts overnight. 
Figure 26.—Pubic Louse. 
THE HAIR IN HEALTH AND DISEASE. 
The hairs upon the surface of the body vary greatly in size 
and length, but their structure and mode of growth are nearly 
identical everywhere. They are developed within the so-called 
hair-follicles or glands, which are tubular cavities composed of 
several concentric layers of cells, inversions of the epidermal tis- 
sues, extending to all depths into the skin, the largest of them 
into the tissues below the skin even. At the bottom of the folli- 
cle its walls project upward, and form a conical body called the 
papilla (see Fig. 27). It is at this point that the tissues of the 
hair have their origin in the form of minute cells, which, at first 
round and plastic, become, as they are pushed upward into the 
canal of the follicle, compressed, firmer, and shortly assume the 
elongated, thread-like, interlacing shape which makes up the body 
of the hair. Within the follicle, too, the hair is surrounded by 
several envelopes composed of cells called root-sheaths. It is por- 
tions of these which are seen to be attached to the hair when for- 
cibly pulled out. The hair proper is composed of the root, the 
globular, bulging part which surrounds the papilla, and the shaft 
which extends from the root obliquely upward through the skin 
and above its surface sometimes to great length. The shaft, or SKIN AND HAIR. 
193 
substance of the hair proper, consists of three structures : The 
outer is a thin transparent covering of flattened scalelike cells, 
laid one above the other, like shingles 
upon a roof, to which the hairs owe 
their felting property. Within this is 
the main portion of the hair, the corti- 
cal substance, composed of compressed, 
elongated cells, with interspaces filled 
with air and pigment-matter. The cen- 
tre is often more or less hollow, and is 
called the canal or medullary portion. 
The color of the hair is due to the 
amount of pigment-matter in the cor- 
tical portion, and of the air-spaces it 
contains. Connected with the upper 
parts of the follicles, and discharging 
their contents into its neck, are the 
sebaceous glands, the oily secretion of 
which is here absorbed by the tissues of 
the hair, and permeates its whole length, 
rendering it soft and glossy. The dura- 
tion of life and rate of growth of the 
hairs vary greatly according to position 
and the individual; they are constantly 
falling and being reproduced through 
life. When pulled out by violence they 
always grow again, because the folli- 
cle which produces them is not thus 
destroyed. 
Care of the Hair. 
The hair is so remotely a part of our 
vital organization, being in its extra- 
cutaneous portion only an appendage 
to the skin without sensation, that it is 
regarded almost as foreign to ourselves 
as the garments we wear. Fortunately, 
under ordinary circumstances it needs 
but little care on our part; it is more apt 
to suffer from improper treatment. For 
its management in a healthy state very 
few rules are necessary. The brush should be not very stiff, and 
should be used only often enough to keep it well arranged. Too 
Figure 27. (After Biesiadecki). 
—Magnified hair from beard. «, Se- 
baceous gland. £>, Muscle which 
moves the hair, c, The hair contain- 
ed in its sheath, and having at its 
lower extremity its enlarged root and 
the papilla from which it grows. 194 
SKIN AND HAIR. 
stiff brushes, or the too rough use of them, are of no service to the 
hair, and often do harm, if it tends to fall, or if there be any dis- 
ease of the scalp. Combs should be used only to part or disentan- 
gle the hair, and should have blunt round points. A fine-toothed 
comb should never be used, and neither comb nor brush should 
ever be applied to the scalp for the purpose of removing dandruff ; 
they only aggravate the disease. The scalp and hair should be 
washed with soap and water as often as may be necessary to keep 
them clean, a period which varies greatly in individuals, and ac- 
cording to residence. The habit of wetting or washing the hair 
daily is not objectionable, if there is no tendency to premature 
baldness. If the hair is too dry, there is no objection to the 
moderate use of plain pomades, but washes and dressings of un- 
known character should not be used. If the ends of the long hair 
in females become dry and tend to split, they should be dipped 
occasionally in a little sweet oil. 
DISEASES OF THE HAIR. 
Excessive Growth. 
The natural quantity of hair varies greatly in different nations 
and at various periods of life. That form of excessive develop- 
ment only will be mentioned which is a source of great annoyance 
in females—the undue growth of the fine hairs upon the face, 
amounting sometimes to a well-marked moustache and beard. 
The trouble may begin to develop at any age after puberty, and 
attain its maximum growth rapidly or gradually. 
Treatment.—Unfortunately it cannot ordinarily be permanently 
relieved. The affected parts may be shaved, but the hair grows 
immediately, and becomes stiff and strong, so that the process 
must be repeated, as upon a man’s face. Caustic pastes may be 
applied to the skin, which burn off the hair a short distance within 
the follicles ; but they grow again in a few days, and the process 
must then be perpetually repeated. Moreover, they often irritate 
the skin, and thus possibly promote a more active growth. The 
hairs may be pulled out singly with tweezers, but this does not 
eradicate the trouble, because they are reproduced, but after a 
much longer interval than by the former two methods. The only 
means by which a radical cure could be effected would be by 
destroying the follicles ; but this can be accomplished only by exci- 
ting so much inflammation in the skin as to produce scars worse 
than the original trouble. The best treatment is to leave the 
growth unmeddled with, for any attempts at removal by the above SKIN AND HAIR. 
195 
methods only make the hair more conspicuous by making its 
growth stronger. 
Loss of Hair—Baldness. 
As has been stated, each hair has an existence of its own, and 
ordinarily falls and is reproduced several times during its owner’s 
life. Up to a certain period, varying with the individual, generally 
between the ages of twenty and thirty years, the hairs are repro- 
duced as rapidly as they fall, so that there is no diminution in their 
number and length ; but there comes a time with nearly every one, 
sometimes protracted far beyond middle life, when the reproduc- 
tion is less active than the fall, so that the hair gradually dimin- 
ishes in length and numbers. This is the natural process of decay 
of the hair, and when it comes on earlier than is natural, it becomes 
premature loss of hair ; the hair has simply grown old before its 
owner. Such a condition is not uncommon, and is often hereditary. 
It falls earliest from the temples, forehead, and top of the head, 
and is more common with men. Very little can be done to prevent 
the loss in such cases. Baldness—partial, or universal—arises, 
however, from a great many other causes. It may be from a gen- 
eral debility of the system, shared in by the hair-producing tissues 
of the skin, as after fevers, childbed, etc.; from local causes of an 
inflammatory nature, as after erysipelas and eczema of the head, 
in the course of vegetable parasitic affections, as already shown; 
and the like. But the most frequent cause of early and progres- 
sive baldness is the disease of the sebaceous glands of the scalp 
called dandruff (see page 154). This change in the glands gradu- 
ally extends down into the hair-follicles, so that the hairs fall be- 
fore their time, and the successive growth becomes more and more 
feeble, and finally ceases entirely. The fall may begin about the 
temples, central forehead, or crown, and gradually extend from 
these centres, or there may be a universal thinning out of the hair. 
This affection is most common from late childhood up to the thir- 
tieth year. A much rarer form of baldness is that in which the 
hair falls in circular patches—one or more—which enlarge more 
or less rapidly, and leave the scalp perfectly clean. This disease, 
the nature of which is not well understood, may extend over the 
whole head, and cause the loss also of the beard, eyelashes, eye- 
brows, etc. In young people the hair may generally be restored 
by treatment; in older persons the results are more doubtful. It 
is called alopecia areata. . 
Treatment.—The treatment of these various forms of baldness 
must vary, of course, with the nature of the affection. When 
there is any disease of the scalp, parasitic, sebaceous, or otherwise, 196 
SKIN AND HAIR. 
it of course must be removed before any restoration of the hair can 
be hoped for. When this has been accomplished, or in cases where 
the hair has fallen from lack of vitality, a more rapid reproduc- 
tion may often be obtained by the use of local stimulants to the 
scalp, by which its circulation is made more active, and the nutri- 
tion of the follicles increased. Washes containing rosemary, can- 
tharides, capsicum, mustard, etc., are among the best for this 
purpose, but their strength should be adapted to the requirements 
of the individual case. In some of the forms of baldness much 
more stimulating applications have to be employed. It may be 
stated, as a general rule, that shaving the scalp is always unneces- 
sary, and that there is never any necessity of cutting the hair in 
these affections. 
Loss of Color—Graying—Canities. 
The color of the hair increases in intensity generally up to the 
period of puberty, retains its natural shade up to middle life, when 
it begins to lessen, and may, in old age, have wholly disappeared. 
The coloring-matter consists of a diffused and granular pigment, 
formed by the papillae, and is situated in the cortical portion. If 
the papilla ceases to produce the pigment, the hair appears white ; 
but in the natural process of growing gray the change is very 
gradual, for not only do some follicles continue to produce colored 
hair long after others have lost this function, but the papillae lose 
this property—not abruptly, but intermittently, so that the hair, 
before becoming entirely white, may be for a part of its length 
only partially or interruptedly deprived of its colored cells. The 
hair, therefore, grows gray by ceasing to be colored as it leaves 
the follicle, and a portion once colored never loses its color. When 
this change begins in early life it becomes premature graying. 
This may be a family peculiarity, or the result of the weakening 
effects of general disease or nervous shock. The hair of a limited 
district may lose its color by local disturbances of nutrition, with- 
out changing otherwise in character. The possibility of sudden 
blanching, not by loss of the pigment, but by changes in the struc- 
ture of the shaft which render it opaque, is still in question. As a 
rule, nothing can be done to restore the loss of color, or to delay 
the process of graying when once started. The only remedy, for 
those who desire it, is dyeing. The composition of some of the pre- 
parations sold largely for this purpose is injurious, as their employ- 
ment is necessarily constant as the hair continues to grow. Cases 
of lead paralysis are reported to have been caused in this way. 
JAMES C. WHITE, M.D. The Hands and Feet. 
BY 
LEROY MILTON YALE, A.M., M.D., 
OF NEW YORK, 
VISITING SURGEON TO BELLEVUE HOSPITAL ; LECTURER ADJUNCT UPON ORTHOPAEDIC SURGERY 
IN BELLEVUE HOSPITAL MEDICAL COLLEGE. THE HANDS AND FEET. 
THE CARE OF THE HANDS. 
The skin covering the hands of those who engage in mechanical 
occupations becomes thick and horny at such places as are subject 
to pressure, and in most cases the hands, as a result of constant 
use, become large through growth of the muscles and deposit of 
fat. When the skin is much thickened it loses some of its flexibility, 
and is more liable to crack in cold weather, or from excessive use. 
When, moreover, the hands are frequently washed with the aid 
of soap, the skin is deprived of the oil which is necessary to keep 
it supple, and chapping or scaling is rendered more probable. It 
is desirable, therefore, for those who suffer from redness and irri- 
tability of the skin of the hands, with dryness and a tendency to 
chap, to use other means for removing dead surface-skin and dirt 
than soap; and a very simple and effectual way is to wash the 
hands in a mush of corn-meal and water. Corn-meal contains a 
considerable amount of oil, which replaces that which is removed 
from the skin in the rubbing. If this method of cleansing be not 
convenient, the disadvantages of soap may be overcome by first of 
all using as bland a soap as possible and by carefully drying the 
hands afterward, and, if possible, rubbing a very small quantity 
of bland grease upon the parts of the hands most liable to crack ; 
vasseline, glycerine, sweet-oil, or even mutton-fat will serve. 
Sportsmen often suffer in cold weather from the irritation of the 
hands caused by the gunpowder (probably the nitre is the active 
ingredient) and moisture. The protection of the hands by oil and 
gloves from which such fingers or parts of fingers as may be ne- 
cessary have been cut off, is the best preventive. If one is obliged 
to handle irritating substances, particularly liquids, a little fore- 
thought, chiefly in anointing the hands, will prove the truth of the 
proverb, “ An ounce of prevention is worth a pound of cure.” 
A few words may well be said about the proper care of the nails. 
These organs in mankind serve but little purpose compared with 200 
THE HANDS AND EEET. 
their use in animals ; being most useful in helping to grasp minute 
objects, and in some degree as a protection to the delicate pulps of 
the finger-tips. They grow from a pocket or fold of the skin at 
their roots, and from the surfaces immediately below them, as 
is evident on slight examination. 
The space between the end of the nail and the finger is very 
liable to accumulate dirt, and this tendency increases with the 
depth of the fissure. In cleansing the nails, therefore, care should 
be used not to deepen this fissure by separating the nail from the 
flesh below it, as is pretty sure to be done when a knife-point or 
other similar instrument is used. * It is better always to employ a 
brush with soap and water. Whether the nails be cut square or 
pointed is entirely a matter of fancy, but in any case they should 
be left long enough to protect the finger-tips, and should never be 
pared on the sides. 
If it is desired to have the nails smooth, the thin skin which, if 
allowed to grow, extends a little way beyond the root, should never 
be scraped off with a hard instrument, but should rather be removed 
by rubbing with a towel while the hands are wet. 
Children, and indeed grown persons, sometimes acquire a habit 
of cracking the joints of the fingers and toes. When it is wished 
to have taper and shapely digits, this should be* avoided, since it 
leads to looseness of the ligaments which strengthen the joints 
and swelling of the sacks which cover the ends of the bones. 
The habit of biting the finger-nails until the projecting tip is 
quite removed and the edge is left ragged, is quite common among 
children and, unfortunately, among adults. It always keeps the 
nails in an unsightly condition, and if it is carried to the degree 
(as often is the case) of “ biting to the quick,” it is a troublesome 
habit, as the finger-tips are rendered sensitive and ‘ ‘ hang-nails ” are 
often produced by it. In children the smearing of the finger-tips 
with something which has a very unpleasant taste will often break 
up the habit, for of course the biting is only habit. Extract of 
aloes, made into a paste with water, has been a favorite application. 
A strong tincture or solution of red pepper sometimes serves; 
adults will, however, rarely submit to such preventive treatment. 
DISEASES AND DEFORMITIES OF THE HANDS. 
Although the hands are exposed to a great variety of injuries, 
the diseases and deformities peculiar to them are not very numer- 
ous. One of the commonest, and generally of least importance, 
is the ordinary THE HANDS AND FEET. 
201 
Hang-Nail. 
This is an injury to the flesh beside the nail, due to a slight 
tear. A little tongue of flesh is turned up, and, by being repeatedly 
struck or rubbed, presently becomes inflamed, and is a source of 
considerable annoyance. 
Treatment.—Generally it yields readily if the part be carefully 
cleaned, dried with a soft cloth, and covered with a piece of adhe- 
sive plaster. The plaster should.be removed daily and a fresh one 
substituted, until the cure is complete. If the trouble is more 
severe or persistent, an astringent, like powdered alum, should be 
slightly applied and the plaster used as before. 
Run-Around, or Onychia. 
This is another annoying ailment, ordinarily not of very great 
importance. It consists of an inflammation of the skin about the 
nail, characterized by the formation of a blister filled with an irri- 
tating watery matter, the blister having a tendency to extend. 
When the blister is broken, a raw or even ulcer- 
ated surface is left. 
Treatment.—The “run-around” is generally 
arrested by carefully removing the skin of the 
blister quite to its edge ; washing away the 
matter and touching the exposed surface with 
a solution of alum or sulphate of zinc, or, in 
severe or obstinate cases, a stick of nitrate of 
silver. As the tendency to this disease gen- 
erally shows a disordered constitutional condi- 
tion, attention should be paid to the general 
health, especially to the state of the digestive 
organs. 
An identical disease is often seen affecting 
the nails of the toes. A severer form of onychia, called onychia 
maligna, demands the care of a physician ; but, until it can be ob- 
tained, the treatment advised for the mild form will at least do no 
harm, and may be of some use. 
Figure 28.—Onychia 
maligna; the acute form. 
Felon. 
Felon, or Whitlow, is a far more serious matter. The seat of 
the trouble is generally the inner or palmar side of the finger, and 
most commonly the pulp of the finger-end. The exciting cause of 202 
THE HANDS AND FEET. 
the trouble is usually some slight injury, a blow, a prick, or inocu- 
lation with some poisonous matter. The first symptoms are deep- 
seated pain, throbbing, tenderness, tension, and hardness of the 
part affected. The skin on the sides and back of the finger pres- 
ently becomes red, that on the inner surface changing little in 
color, owing to its thickness. As the disease advances, matter 
forms, and if not speedily let out may burrow toward the hand, 
involving its structure even, before it finds its way to the surface. 
If, as frequently happens, the tendons become involved, the use- 
fulness of the finger can rarely be preserved unimpaired. After 
the breaking out of the matter, considerable sloughing of the soft 
parts follows, and too frequently of the bone also. One variety of 
the felon seems to begin as an inflammation of the covering of the 
bone. 
Treatment.—In view of the severe course of the felon, it is evi- 
dent that prompt treatment should be resorted to. As soon as the 
first symptoms are recognized, the use of the hand should cease. 
The diseased finger should be soaked for some time—say a half 
hour—in hot water or hot lye, and then covered with a light poul- 
tice of flaxseed meal, and kept elevated on a pillow if the patient 
lies down, or upon a high table if he prefers to sit up. Sometimes 
the pursuance of this treatment for a day or two, together with 
the use of cathartics (such as an ounce of Epsom salts, in the case 
of an adult, a seidlitz powder twice daily, or three compound ca- 
Figure 29.—Position of hands in cutting a felon. 
thartic or compound rhubarb pills), will arrest the disease. If not, 
the advice of a competent medical man should be sought at once ; 
for, if the trouble gets a certain headway, the best surgical skill is 
often unequal to the preservation of the finger in its integrity. If 
the advice of a surgeon cannot be had, it would be probably better 
to trust the cutting of the finger to a non-professional hand than 
to allow it to take its own course. A sharp knife should be used ; THE HANDS AND FEET. 
203 
the cut by preference made upon the side of the finger, to avoid 
the tendon, unless the trouble be at the very tip of the finger; the 
cut should be deep, and, if possible, to the bone, and made toward 
the operator, so that the natural drawing back of the hand by the 
sufferer shall help rather than hinder the cut. After the cutting, 
the part should be poulticed for a time until the dead parts of the 
flesh have separated, and then a stimulating dressing, such as 
balsam of Peru or resin cerate (see Formulas in Yol. II.) should be 
applied. When the process of healing is well advanced, it is well 
to strap the parts with strips of adhesive plaster to compress the 
engorged tissues; and then, as soon as the wound is healed, to 
begin to work the joints of the finger, to prevent the stiffening 
which commonly results from this disease. 
Warts. 
Warts are overgrowths of the papillae of the skin with a cover- 
ing of cuticle (see Fig. 30.)* The common warts so frequently- 
seen need no description. They are commonest upon the fingers 
and hands, especially of young persons. The causes of warts are 
not very clear ; certain kinds of irri- 
tating substances, such as soot, de- 
caying matter, etc., pretty evidently 
tend to produce these excrescences. 
Some warts are certainly contagious ; 
whether the common hand-wart is 
contagious from person to person is 
hard to prove, although a wart in any given place is likely to be 
followed by others in the neighborhood. It has been thought too, 
by some good authorities, that the blood of a wart, if inoculated 
upon another person, would produce warts upon the latter. Warts 
ordinarily give little trouble unless they are in some very incon- 
venient position, as upon the flexures of the finger-joints. They 
are chiefly sources of annoyance on account of their unsightliness. 
Occasionally a wrnrt, through some irritation, may undergo such a 
change in its manner of growth as to present the appearance of 
epithelial cancer ; these, however, are generally situated upon the 
face. Warts of a venereal origin are not here discussed. (See 
Chapter on Syphilis). 
Treatment.—Hard, dry warts are best destroyed by some 
chemical solvent. One of the best is glacial acetic acid. The 
skin around the wart being oiled or washed with a solution of 
Figure 30.—Section through a wart. 
* See also the Chapter on the Skin and Hair. 204 
THE HANDS AND EEET. 
soda to prevent the spreading of the acid, a drop of the latter is 
applied to the wart by means of a small pointed stick. Large 
warts, or those more full of vessels, may be destroyed by tying 
them firmly with a piece of strong silk, or a piece of rubber thread, 
such as can be pulled from an old pair of suspenders. The liga- 
ture need not be tied so tight as to be painful. Warts may also 
be removed with the knife or scissors, if the operator have suf- 
ficient skill to cut only the wart away, and to stay the bleeding if 
it be at all profuse. Mention ought to be made of the remarkable 
suddenness with which warts spontaneously disappear. This 
peculiarity has given credit to many popular cures, and even 
charms. The writer has often been amused to find himself the 
reputed possessor of great skill or magical endowment in this di- 
rection. [This sudden disappearance may be explained in the fol- 
lowing way : The over-grown cells cease to be developed from be- 
low and are replaced by cells of healthy character, which gradu- 
ally push the others upward until they are only kept in place by 
a feeble connection with the cells below. Some ordinary friction 
may now serve to rub them off (just as a loosely-attached scab 
may be removed from the surface of a sore which has quite 
healed), and their fail leaves the healthy layer of the skin uncov- 
ered.] 
Deformed Hands and Feet. 
Clubbed Hands is a rare congenital defect, and can scarcely be 
managed successfully without surgical attention. The best that 
can be done at home is to manipulate the deformed hands in a man- 
ner calculated to bring them toward the normal position, follow- 
ing the general principles mentioned below when speaking of the 
treatment of club-foot. 
The commoner deformities of the fingers are adhesions of two 
adjoining fingers (Fig. 31, Nos. 4 and 5), and the contraction 
of one or more fingers toward the palm of the hand. The former 
cannot be managed by domestic practice. The latter may be 
somewhat improved, and perhaps overcome by constant manipu- 
lation. If there are wounds or burns in the palm of the hand, the 
prevention of deformity should be sought by keeping the fingers 
straight by means of a splint of wood or pasteboard during the 
process of healing. 
Children sometimes present at birth more than the usual num- 
ber of fingers and toes (see Fig. 31). In most cases the “super- 
numerary ” members (as the extra ones are called) are imperfectly 
developed and not capable of being moved independently of the THE HANDS AND FEET. 
205 
others. This peculiarity is very frequently inherited, and capable 
of being traced through several generations. When the extra 
Figure 31.—Varieties of deformities of hands and feet showing deficient fingers (Nos. 1, 11, 
12, and 14); supernumerary fingers (6, 8, and 13), in which last the thumb is wanting; super- 
numerary toes (2, 7, and 9); adhesions of fingers (4 and 5) ; overgrowth of a finger (10). 
members are in the way or unsightly their removal by proper sur- 
gical means is usually a simple procedure, and not attended with 
special risk. 
Cold and Moist or Hot and Dry Hands generally depend upon 
some constitutional cause, and, beyond the observance of regu- 
larity of diet and the ensuring of the performance of the diges- 
tive function, little can be done without medical advice, and fre- 
quently but little with it. Excessive perspiration of the hand, when 
so profuse as to be a source of discomfort, may sometimes be re- 
lieved by using astringent washes ; of which a solution of alum 
(a teaspoonful to a pint of water), or a tea made of white-oak bark 
(half of an ounce to a pint of water) are safe and efficacious. 
THE CARE OF THE FEET. 
The care of the feet should receive some attention before their 
diseases and deformities are discussed. Some deformities are con- 
genital, but more are acquired, and so, too, are most of the diseases 
of this part of the body. The main causes of this group of mala- 
dies are neglect of the proper care of the feet and the improper 
construction of shoes. 
The normal foot is sufficiently rare in adult life to make some 206 
THE HANDS AND FEET. 
comments upon such of its peculiarities as are changed by the 
disorders, not out of place here. The architectural idea, so to 
speak, of the foot is an arch. The chief arch is upon the inner 
Figure 32.—Section through a foot of natural shape. 
border of the foot, resting behind upon the heel and before upon 
the base of the great toe (see above). This arch is tied by the 
plantar fascia, a strong fibrous structure in the hollow of the 
foot and extending from the heel-bone forward to the front of 
the foot. The outer margin of the foot is very slightly arched and 
nearly its entire length comes to the ground in walking. Next in 
importance to the first-named arch is the transverse arch resting 
upon the bases of the great and lit- 
tle toes. This arch is very flexible, 
expanding readily sidewise when 
weight is brought upon it. Another 
peculiarity is the direction of the 
axis of the sole. Thus, a line drawn 
corresponding to the axis of the great 
toe, if prolonged backward, would 
cross the point of the heel. This may be seen by inspecting 
the sole of the foot of an infant that has not worn hard shoes or 
tight stockings. If such a child be placed upon its feet, with the 
inner borders touching one another, the great toes will not diverge 
from each other, but will lie side by side, until the point where 
the toes round off is reached. This fact is of special significance 
with reference to the origin of bunions. 
To keep the feet in a perfectly healthy condition, they should re- 
ceive the same care that is bestowed upon the hand. They should 
receive a daily bath, preferably at night and in tepid water, and 
afterward be carefully dried, especially in places liable to cracks (as 
between the toes), and warmed, except in quite warm weather. 
For aged or feeble persons a sponge bath of spirits and water is 
Figure 33.—Diagram of the portion 
of the healthy foot which comes into 
contact with the ground. TIIE HANDS AND FEET. 
207 
safer. If the feet are very subject to irritation, the bran bath is 
useful, and, if the person be very liable to ‘‘taking cold,” salt may 
be added whenever the warm bath is used. A • 
few moments’ care after the bath, if it be used 
daily, will keep the feet free from corns and cal- 
losities. The readiest method is to scrape them 
with a dull knife or sand-paper. This care of the 
feet is especially requisite when they are subject 
to more than usual irritation, as in marching, 
hunting, etc., or even if the occupation be one that 
keeps a person very constantly upon the feet. 
The dress of the foot is of great importance. 
The stocking should be soft and not too thick. In 
warm weather, silk or thread ones may be worn ; 
in winter cotton ones are necessary, and if there 
be much exposure to cold and damp, and the cir- 
culation be feeble, woollen stockings are desirable. 
The extra warmth of the wool is often offset by 
the tendency to perspiration they excite. The 
stocking should be amply long and wide at the 
toes ; a narrow-pointed stocking often having a 
decided influence in crowding the toes together. 
The seams should be so placed as not to press upon joints or sensi- 
tive points. When a long march is to be undertaken chafing will 
be prevented to a great degree by rubbing the inner surface of 
the stocking over the sole and back of the heel with common 
yellow soap. This is an old and well-approved preventive of irri- 
tation from long walking. 
The shoe should have a sole longer than that of the foot, and 
likewise wider. Its shape should correspond to that of the normal 
foot, and not to the foot in its actual distorted condition. The 
heel should be low and broad. The upper leather should be soft 
and pliable—never patent-leather, as it confines perspiration; snug 
over the instep ; looser, but not baggy, across the base of the toes ; 
and large enough to give play to the toes in front. The elastic or 
laced shoes are the best, as they adapt themselves more agreeably 
to the instep and ankle than buttoned boots. The ordinary last 
has but slight reference to the shape of the foot. The following 
figures, with the one just preceding, will explain this fact. They 
are taken, with slight modification, from the popular but truly 
scientific pamphlet of Dr. Hermann Meyer,* from which most 
of the recent popular treatises on the feet have taken their anatom- 
Figure 34 was 
drawn from the sole 
of a two-years old 
child whose foot had 
very nearly preserved 
its normal shape. The 
dotted line shows the 
axis spoken of. 
* Die richtige Gestalt der Schuhe, Zurich, 1858. 208 
THE HANDS AND FEET. 
ical facts. That proposed by Prof. Meyer, and bearing his name, 
is the best, but can hardly claim to conform to ordinary ideas of 
the fashionable. Of late years shoes have been sold in this coun- 
try with an upward curve in the sole, to correspond to the trans- 
verse arch above described. This is of doubtful utility, except 
when the natural tone of the parts is so impaired as to permit 
dropping of this arch. In health the play of this arch is a function 
which should not be interfered with. The comfort of the feet is 
greatly increased by frequent changes of the shoes, daily at least. 
In this manner any points that may have received undue pressure 
are relieved before any considerable irritation has resulted. 
Figure 35.—Faulty construction of shoe-soles. 
Fig. 35.—A shows the sole of an ordinary “straight” shoe 
for women. B the same for a man. C is the sole of a right 
(man’s) shoe of the ordinary “right and left” pattern. If Fig. 
C is laid upon B, it will be seen that all the difference is in the 
shank behind the line d e, the forepart of the soles being iden- 
tical. The dotted line c, d, is a prolongation of the axis of the great 
toe. [See Fig. 36, C.] 
Fig. 36.—A, B, and C show the deformities of the toes resulting 
from the use of such shoes as have been described. A was drawn 
from a girl set. 22 ; B from another under thirty years of age. The 
dotted line in A shows the ordinary relation of the sole of the shoe 
to the sole of the foot. The upper leather projects beyond the sole TIIE HANDS AND FEET. 
209 
at the sides to accommodate the foot, and so makes pressure, not 
upon the sole of the joints which is prepared for such pressure, but 
Figure 36.—Deformities of the toes from badly shaped shoes. 
upon the sides of the joints, with a tendency to crumple up the 
foot. 
Figure 37.—Soles of the “Meyer” shoe. 
Fig. 37.—A shows the sole of a shoe constructed on the princi- 
ples laid down : a b is the axis of an ordinary shoe : c d is the axis 210 
THE HANDS AND FEET. 
of the foot and of the “ Meyer” shoe. The dotted line shows the 
same shoe with a broad toe. This variation is simply a matter of 
taste, since the position of the toes will not be modified by the 
change, the turning inward of the line of the sole occurring after 
the tip of the little toe has been passed. 
Fig. 37 shows the soles of a pair of properly constructed broad- 
toed shoes, and the departure from what has usually been a fash- 
ionable outline. 
Shoes of this pattern are not easily obtained, except in the larger 
cities. In England, and to some extent in this country, they have 
become known under the trade-name of “ Waukenphast.’ The 
great comfort of a properly constructed shoe is such that one who 
has once worn them will not willingly go back to the ordinary 
form of shoe. 
Fig. 36.—C shows the foot of a young man which was tolerably 
free from distortion. It might at first sight pass for a sound foot; 
but the axis of the toe, c, d, does not correspond with the axis of 
the foot, a, b, as it should in a perfectly normal foot. 
DISEASES AND DEFORMITIES OF THE FEET. 
Corns. 
Corns are excrescences, or indurations of the skin, due to an 
intermittent pressure or friction severe enough to cause irritation, 
but not severe enough to produce a blister. Corns may occur else- 
where than upon the feet, but they then generally receive the 
name of callosities. Popularly corns are distinguished as hard 
and soft, but both those classes really contain several kinds of 
corns. To avoid prolixity, however, the popular classification will 
be here retained. The soft corn is situated always between the 
toes ; is due to the pressure of one toe against another, and is kept 
soft by the moisture of the parts. It generally consists of a spongy, 
white elevation, really an overgrowth of the papillae of the true 
skin, and often takes its rise from the base of a blister previously 
existing. The sensation caused by it is generally one of burning 
or scalding, and frequently as if some small foreign substance, as 
a grain of sand, were between the toes. Akin to this variety are 
the large wart-like corns upon the sole of the foot, and certain 
exceedingly sensitive corns which have but slight induration, and 
are marked with specks and lines of white. The hard corn obtains its 
characteristic from indurated cuticle, disposed more or less distinctly 
in layers. This is much the commonest variety, and is found upon 
the prominences of the joints of the toes, and in similar situations. THE HANDS AND EEET. 
211 
The sensations experienced by sufferers from this variety of corn 
are burning, darting pains, great sensitiveness on walking, with 
an exaggeration of all forms of distress in damp weather, or when 
the corn has been neglected for a time. A hard corn of long stand- 
ing sometimes by its pressure destroys the underlying true skin, 
and a cup-shaped depression in the centre of the corn results ; this 
has received the name of fibrous corn. 
The Treatment of corns is ordinarily simple enough, but must 
be persistent to be effectual. First of all, the sources of irrita- 
tion that occasion them should be avoided as far as possible. Some 
of these have been hinted at in the remarks above upon the care 
and clothing of the feet. If daily, or at least several times per 
week, after the warm foot-bath, the corns be pared or scraped with 
a dull knife, or rubbed down with a piece of pumice-stone, or of 
sand-paper wrapped about a small flat stick, little trouble is likely 
to be experienced. The severer forms of corns are generally the 
result of neglect. Persons who are timid about using hot or warm 
foot-bath may soften the corns by covering them on retiring with a 
piece of lint or linen, soaked in warm water, or a solution of wash- 
ing soda, and laying over this a piece of oiled silk. By morning 
the hardened epidermis will be sufficiently softened to be easily 
scraped away. The corn, if particularly sensitive, may then be 
guarded from pressure by the use of one of the corn plasters sold 
in the shops, or by a plaster made extemporaneously by speading 
a little diachylon plaster (or even yellow wax, if nothing better be 
at hand) upon lint, and laying two or three pieces together to give 
sufficient thickness to the plaster. The centre of the plaster should 
be cut out, in order that pressure shall be made around and not 
upon the corn. Many nostrums for the cure of corns are sold, or 
have popular repute. A safe rule, however, is, to avoid all “corn 
cures ” the composition of which you do not know ; for all violent 
applications are dangerous except in experienced hands. Glacial 
acetic acid is probably the safest of all very effectual destroyers of 
corns or warts. To avoid accidents, the skin immediately around 
the corn should be oiled, and the acid carefully applied by means 
of a small stick, like a match-stick, sharpened. These forms of 
treatment are simply palliative, as a rule; removal of the corn 
entirely by a skilled hand is more effectual. Incomplete removal, 
as is generally practised by professed chiropodists, is only pallia- 
tive. This incomplete operation generally consists in the extrac- 
tion of the centre of the corn, ordinarily composed of vertical fibres, 
and the leaving of the margin of the corn as a protection from 
pressure to the sensitive centre. This can be done by the patient 
himself by previously softening the corn, as above directed, then 212 
THE HANDS AND FEET. 
seizing the centre (called popularly the “ eye,” or “ core ”) with a 
pair of tweezers and carefully cutting around it with a pointed 
knife or pair of scissors, going as deeply as can be done without 
drawing blood or touching ‘‘ the quick.” Inflamed corns must be 
treated with rest, cold applications, or poultices, as the case may 
be. Corns that have suppurated and have remaining openings 
leading into them would better be treated by a competent medical 
man, if his advice can be obtained. 
Soft corns are best treated by the application of a strong 
astringent, tannin, for instance, and the separation of the affected 
toe from its neighbor by the insertion of a bit of linen or lint. 
Bunions. 
In every part of the body there are interposed between the skin 
and projecting parts of bones, or between parts liable to friction 
against each other, little sacks containing liquid, and called in 
anatomy bursce. A number of these bursae exist in the foot. 
When they become enlarged, as the result of irritation, and the 
overlying skin is inflamed, they are styled bunions j but the term 
is generally restricted to this affection when 
situated on the base of the great or little toe. 
The name is, however, carelessly applied to 
corns or simple irritations of the skin in these 
situations, and it not infrequently happens that 
a corn may be placed upon a true bunion. 
The exciting cause of the bunion is always a 
badly constructed shoe ; that is, one too narrow 
at the front part, which crowds the great toe 
outward,* or the little toe inward from their 
proper direction, and at the same time makes 
pressure upon the distorted joints. The first 
symptom is the irritation of the skin, then the 
over-filling of the bursa. If this warning be 
heeded and rest be given to the affected part 
and pressure removed from it, the trouble may 
nearly disappear. But if it be neglected, the joint enlarges, becomes 
red, and exceedingly intolerant of pressure and friction. When 
the trouble is once established, it is liable to become chronic with 
increase of the severity of the symptoms from time to time. 
Figure 38.—Deformi- 
ty of foot from bunion 
and pressure of badly fit- 
ting shoe. 
* It should be noted that here, as in all writing referring to anatomy, “ inward ” 
means toward the centre line of the body, and ‘4 outward ” from that line ; otherwise, it 
might be supposed to refer to the centre line of the foot. 213 
This is particularly true of gouty or rheumatic persons. Some- 
times matter forms within the bunion which may result in its cure, 
or a tedious and troublesome discharging opening may be left. In 
the worst cases the joint becomes involved, and the cutting out 
of the joint becomes necessary. 
Treatment.—The preventive treatment of bunions consists in 
guarding against such defects in the shoe as will deflect the toes 
from their normal direction. If the distortion has already been 
acquired, shoes of proper shape and ample size should be worn, and 
pieces of lint or soft sponge inserted between the great toe and the 
next (or between the fourth and fifth toes, if the little toe be the 
one affected), so as to bring the former back to its proper line. 
The same may be accomplished by carrying a narrow strip of adhe- 
sive plaster from the outer aspect of the great toe around its point 
and down the inner border of the foot. The palliative treatment 
of bunions, such as protecting it with plasters, the use of alka- 
line washes, etc., is essentially the same, the necessary changes 
having been made, as has been given above for corns. 
THE HANDS AND FEET. 
ingrowing Toe-nails. 
This is a malady affecting almost exclusively the great toe, and 
by preference its outer side. Its causes are : a shoe too narrow 
across the toes and a faulty manner of cutting the nails ; gener- 
Figure 39.—Onychia of a toe. (See page 201.) 
Figure 40.—A. bad case of ingrowing toe-nail. The point to the right is a protrusion of the 
nail through the overgrowing flesh. A cut has been made through the flesh on the left side, 
down to the nail. 
Fig. 39. 
Fig. 40. 
ally the two causes are combined. By the sidewise pressure of the 
shoe the nail is bent at its edge and forced down into the flesh; 
the flesh is crowded in the opposite direction upward over the nail. 214 
TIIE HANDS AND FEET. 
The sufferer endeavors to relieve himself by cutting away the of- 
fending part of the nail; this only enables the flesh to ride higher 
over the nail and the sharp corner of the latter, which is generally 
left, irritates more and more the flesh. This becomes inflamed, 
enlarges, and finally ulcerates. As the apparently trifling disorder 
may render walking impossible, it often demands serious surgical 
treatment. 
Treatment.—Of course the first indication should be the remov- 
al of the known causes ; the narrow shoe and the paring of the 
nail should both be abandoned. If the trouble has not advanced 
very far, the relieving of pressure, the allaying of inflammation 
by cold water dressings or applications of sugar-of-lead water 
or a solution of sulphate of zinc five to ten grains to an ounce of 
water, and the elevation of the nail by the gentle insinuation be- 
neath it of threads of lint or cotton-wool, to be changed daily, will 
in a short time generally effect a cure. The cure may be assured 
by continued avoidance of the causes before mentioned. If the 
ulceration be considerable, the application of the solid stick of ni- 
trate of silver is often efficacious, and it has been claimed that the 
perchloride of iron freely applied has cured cases in which the 
removal of the nail had seemed unavoidable. Unfortunately many 
are allowed to reach such a condition that the removal of a part 
or the whole of the nail is the only effectual treatment. This 
should of course be done only by a competent surgeon. 
Chilblain. 
Chilblain is the comprehensive name given to several affections, 
generally arising from exposure to a low temperature with a sub- 
sequent change—generally sudden—to a warmer one. Some per- 
sons are more subject to this than are others—children more than 
adults. The common form of chilblain is a dusky-red, shining spot 
upon the skin, attended with great itching or burning and tender- 
ness. The commonest situation is upon the toes or heels ; but the 
hands, ears, and nose are also affected, parts, it will be noticed, in 
which the circulation is relatively feeble, and which are exposed 
to the severest cold. The pain or itching is generally periodical 
and may be excited by warmth, the taking of a meal, etc. Other 
forms of chilblain more nearly resemble frost-bites, those, namely, 
in which blisters are formed, or worst of all where the flesh dies 
and ulcers are formed. 
Treatment.—If the special exposure to cold be known, the chilled 
members should not be brought at once near the fire, but they 
should be very gradually warmed by enveloping them in woollen THE HANDS AND FEET. 
215 
cloths and by holding them with warm hands, without rubbing. 
If the “frosting” be severe, the method of immersing the part 
in cold water which is allowed to become warmer, or is gradually 
warmed by the addition of small quantities of warm water, seems 
to be as judicious as any ordinarily at command. If, as is usually 
the case, the chilblain is already established, the treatment is to 
relieve the suffering. The avoidance of marked cold or damp- 
ness, or of unusual heat applied to the affected part, is of prime 
importance. The itching is often relieved by the application of 
soap liniment, of spirits of camphor, of spirits of turpentine and 
olive-oil. The common kerosene-oil, either alone or mixed with 
olive-oil, has a repute as a very comforting application. A great 
number of other mixtures have been vaunted, but those mentioned 
are as valuable as any. If the parts be ulcerated, a mixture of 
equal parts of Peruvian balsam and castor-oil applied on linen or 
lint is of much service. In the severer forms of chilblain the ad- 
vice of a physician should be taken if possible. 
Perspiring, Hot, and Cold Feet. 
Perspiration and disagreeable odor of the feet are generally 
best combated by strict attention to the care of the feet, as directed 
above. Astringent washes may sometimes be used to diminish 
the perspiration. As these conditions, when they persist in spite 
of rigid cleanliness, are generally due to some constitutional trou- 
ble, medical advice should be sought regarding them. 
Unusual coldness or heat of the feet are also, as a rule, the mani- 
festation of a disturbance of the circulation, and if a proper atten- 
tion to the clothing of the feet does not remove the trouble, medical 
advice should be taken. 
Stone-Bruise. 
A disease of common occurrence in the country or wherever 
children go bare-footed much is the stone-bruise. This very much 
resembles some of the forms of felon, and is, like them, due to 
slight injuries ; in this instance to blows received from inequalities 
of the ground in walking. Naturally, the stone-bruise is gener- 
ally situated in those parts of the foot that come to the ground in 
walking, and is especially common in the balls of the toes, as they 
are most exposed to injury. There is, generally, a deep pain, with 
tenderness, some swelling and hardness to touch, but rarely red- 
ness. 
Treatment.—When these symptoms appear in the foot of a per- 216 
THE HANDS AND FEET. 
son who has been going barefooted, the foot should be soaked for 
some time in hot water ; if there is much callus on the foot over 
the tender place, some alkali, such as common washing soda or 
potash, should be added to the foot-bath, or hot lye maybe used for 
the bath. The callus should then be gently scraped away. 
Sometimes this treatment, followed by rest and a water-dressing, 
arrests the trouble. If not, a water-dressing or poultice should be 
applied until the formation of matter can be recognized, when it 
should be opened with a sharp knife. The wound should be kept 
open until matter ceases to form within the cavity of the abscess. 
Fissures of the Toes. 
Cracks or Fissures between or beneath the toes are generally 
due to acidity of the perspiration. They generally readily heal if 
the feet are frequently bathed and carefully dried. In very warm 
weather powdered starch or toilet powder may be applied with 
benefit. The itching arising from these fissures can be quite cer- 
tainly allayed and the crack healed, by putting between the toes a 
small piece of linen, or a soft thread of lint dipped in glycerine, or 
oil if preferred, in such a manner that the thread or edge of the 
linen enters the crack and keeps its surfaces apart. 
Clubbed Feet—Talipes. 
“ Club-foot” is a name applied to several deformities of the 
foot. The corresponding surgical name is talipes. The several 
varieties of talipes are designated by the second name of varus, 
valgus, equinus, calcaneus, etc. Varus is where the toes turn 
inward and the inner border of the foot is turned more or less 
upward (Figs, c, d, e). Valgus is where the toes turn outward, and 
the inner border of the foot is somewhat dropped (Figs, f, g). In 
equinus the heel is raised and the toes dropped (Figs, a, b). In 
calcaneus (Figs, h, i) the reverse is true. These varieties are often 
combined one with another. Yarus is by far the most common, 
and is the true club-foot of the popular nomenclature. Club-foot 
frequently is found existing at birth, but it is often acquired in 
childhood as the result of diseases affecting the nerves and muscles 
of the leg. The proper 
Treatment of the deformity demands skilful surgical attention; 
but in the absence of this much may be done through the assiduity 
of the nurse, and in the same way, too, the surgeon may be greatly 
assisted. The management of these cases is easier in proportion 
as it is begun early. If, then, a child is born with, for instance, THE HANDS AND FEET. 
217 
talipes varus, the attendant should proceed as. follows : She will 
seize the foot firmly with the hand, and gently and gradually bring 
it toward its proper position. As this is done, the foot loses its 
characteristic red color and becomes quite white. The foot, prob- 
ably, cannot be brought entirely straight at first, and when this 
whiteness becomes well marked, the foot should be so held for a 
Figure 41.—Different varieties of club-foot or varus : c, d, e, three degrees of severity of ta- 
lipes varus existing at birth ; a, 6, talipes equinus—the latter is the acquired form; J\ g, varie- 
ties of “ splay-foot,” or talipes valgus ; h, i, two varieties of talipes calcaneus. 
moment and then allowed to fall back. This manoeuvre should be 
several times repeated, every time the child is dressed and un- 
dressed, and if done gently the feet may be subjected to almost 
constant handling during the waking hours of the child with tho 
result of gradually coaxing them into their proper position. To 
prevent the skin from becoming chafed in this process, it should be 
powdered freely, and it is well to wash the feet with a solution of 
alum in alcohol or spirits. It sometimes occurs that this persua- 
sive method of treatment is sufficient. But after the lapse of a 
short time, when the skin is hard enough to endure the contact of 
adhesive plaster, a strip of this from three-fourths of an inch to 
an inch in width should be applied, beginning on the inner side of 
the foot just behind the base of the great toe, passing under the 
sole of the foot and up on the outer side of the leg. This may be 
kept in place by a light flannel bandage, if the nurse can lay it even 
and without making wrinkles. The plaster alone, however, will 218 
THE HANDS AND FEET. 
do the same good .without the bandage, but is more likely to slip 
or be dislodged. It should not be forgotten that the best surgical 
advice that can be obtained should be had at the earliest possible 
time; in the meantime the manipulations above mentioned should 
be faithfully attended to. To enter into detail of the subsequent 
treatment would carry us beyond the limits of this chapter ; the 
requirements of each case must be determined by the surgeon to 
whom it is presented. 
Flat-Foot. 
A painful condition of the feet is flat-foot. It is one variety of 
splay-foot, and consists in the dropping of the arch of the foot, 
owing to the relaxing of the liga- 
ments and their yielding beneath the 
superincumbent weight. This acci- 
dent is generally attended with great 
pain upon walking or long standing. 
If the arch be quite dropped, the 
cause of the pain is readily guessed; 
but in cases where the deformity is 
very slight, its real nature is quite 
likely to be overlooked. 
Treatment.—The intelligent treat- 
ment of the trouble demands profes- 
sional knowledge, but in the absence 
of this the pain and discomfort may 
be mitigated by arranging a soft but 
firm pad fitted to the sole of the arch 
while the latter is kept in its proper 
position. This pad may be fastened 
to the sole of the shoe beneath the 
insole, so that it will give to the arch 
the necessary support in walking. 
The pad may be made from a variety of substances ; rubber is very 
good, owing to its elasticity ; cork will serve very well. A number 
of trials and much paring and trimming will probably be necessary 
to the making of suitable support. A much more successful meth- 
od is the one illustrated in the above figure, in which heavy adhe- 
sive plaster is so arranged as to -pass under the instep and connect 
with india-rubber cords or tubes attached to the leg above by 
means of metal plates and adhesive plaster. This, however, re- 
quires the aid of a physician for its management. 
Figure 42.—Apparatus for treatment 
of flat-foot. 
LEROY MILTON YALE, M.D. The Eye and its Diseases. 
BY 
D. B. ST. JOHN ROOSA, M.D., 
OF NEW TORE CITY, 
PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF THE CITY OF NEW YORK, AND OF THE 
DISEASES OF THE EYE AND EAR IN THE UNIVERSITY OF VERMONT ; SURGEON 
TO THE MANHATTAN EYE AND EAR HOSPITAL, ETC., ETC.; 
AND 
EDWARD T. ELY, M.D., 
OF NEW YORK CITY, 
SURGEON TO THE CHARITY HOSPITAL; ASSISTANT SURGEON TO THE MANHATTAN EYE AND 
EAR HOSPITAL. THE EYHC AND ITS DISEASES. 
THE ANATOMY AND PHYSIOLOGY OF THE EYE. 
That which we are accustomed to call the eye is a complicated 
structure of many different parts, not all of which are directly con- 
cerned in the act of vision. The whole may be properly termed 
the visual apparatus, and it may be conveniently described under 
four heads : (1) The Orbits ; (2) The Eyeball, or Globe of the eye, 
—the eye proper; (3) The Optic Nerves; (4) The Appendages of 
the Eye. 
The Orbits. 
The Orbits are the bony cavities in the front of the skull, in 
which the eyeballs are contain- 
ed. (See Fig. 43.) They are 
shaped like four-sided pyra- 
mids. The small ends of these 
pyramidal cavities are directed 
backward and are each pierced 
by an opening called the optic 
foramen (Latin, foramen, an 
opening), through which run 
nerves and blood-vessels. The 
large ends of the orbits open 
upon the face, and these facial 
openings have a strong, bony 
edge which protects the eye- 
ball from blows, etc. The or- 
bits are lined by a layer of 
fatty material, which forms 
elastic cushions for the eye- 
balls to rest upon, and thus 
gives them still further protec- 
tion against injury. 
Figure 43.—Skull, showing the orbits or bony 
cavities which contain the eyes. At the bottom of 
tbe right orbit is seen the optl° foramen- 222 
THE EYE AND ITS DISEASES. 
The Eyeball. 
The Eyeball, or Globe of the eye, lies in the front of the orbit 
and projects a little beyond the lower edge of that cavity. Its 
shape is best described as that of a spheroid, with a part of a 
smaller sphere projecting from the front of it, as is shown in Fig. 
44. Its average diameters are : antero-posterior, about TVv inch ; 
vertical, about y inch ; transverse, about y inch. Its weight is 
to 2 drachms, and its volume is about | cubic inch. The centre 
of the anterior part (the cornea) of the eyeball is called the anterior 
pole of the eye. The centre of the posterior part is the posterior 
pole. A line running through the eyeball from pole to pole is 
called the optic axis. 
Externally, is the wall or capsule of the globe, which is usually 
described as made up of three different layers, the whole being 
about one-sixteenth of an inch thick at the thickest part, which lies 
posteriorly. These layers are called the investing membranes, or 
tunics, or coats of the eyeball. The hollow globe thus formed 
is filled by materials of a fluid and gelatinous consistency which 
are known as the humors of the eye. The following are the 
names of the investing membranes, passing from without inward : 
Figure 44.—Diagram of a vertical section of the eyeball: a, sclerotic; b, choroid; <*, retina; 
d, cornea; e, ciliary muscle; /, ciliary processes ; </, anterior chamber ; h, posterior chamber ; i, 
iris ; l, lens, in its capsule ; m, suspensory ligament of lens, or zonula of Zinn ; n, space occu- 
pied by vitreous humor; p, optic nerve; s, location of ora serrata. 
(1) The Sclerotic and Cornea ; (2) The Uveal Tract, which comprises 
the choroid membrane, the ciliai'y body, and the iris; (3) The 
Retina. The first is called the fibrous layer, the second the vascu- 
lar layer, and the third the nervous or perceptive layer. 223 
THE EYE AND ITS DISEASES. 
The humors are called : (1) The Aqueous ; (2) The Crystalline, 
also called the lens, and (3) The Vitreous. (See Fig. 44.) 
The outermost tunic of the eyeball, called the Sclerotic (from 
the Greek hard), is really composed of tivo different mem- 
branes, as may be seen by Fig. 44. One of the membranes, 
constituting the posterior five-sixths of the tunic, is called the 
sclerotic. The other, forming the anterior one-sixth, is called 
the cornea. This tunic is the toughest of all, and serves to main- 
tain the shape of the globe and to protect the parts within. It is 
the true capsule of the globe, as the other so-called tunics are very 
delicate and are rather designed for the purposes of sight. The 
sclerotic is pierced behind by a roundish opening, about one-twelfth 
of an inch in diameter, for the entrance of the optic nerve. (See 
Fig. 44.) Its anterior portion can be plainly seen, and is known 
as “ the white of the eye.” This part is covered by a glossy mem- 
brane called the conjunctiva. (See p. 231.) 
Figure 45.—1, Optic papilla; 2, yellow spot; 3, arteries; 4, veins—as seen on looking into 
the eye with an ophthalmoscope. 
The remainder (the anterior one-sixth) of the outer tunic is 
called the cornea (from the Latin, cornu, a horn). It is also a 
firm, tough membrane, but, unlike the sclerotic, it is transparent, 
so as to. permit light to enter the eye. It has a beautiful, clear, 
glistening appearance, and is aptly termed “ the window of the 
eye.” It is more prominent than the surrounding sclerotic. If an 
eyeball is cut across, as in Fig. 44, the cornea is seen projecting 224 
THE EYE AND ITS DISEASES. 
from the sclerotic in front, like a part of a smaller sphere engrafted 
upon a larger one. This prominence of the cornea can also be 
seen by looking at another’s eye in profile. The edges of the scle- 
rotic overlap the cornea a little, in front and behind, so that the lat- 
ter is usually described as fitting into the sclerotic like a watch- 
crystal into its case. It must be remembered, however, that the 
two membranes, although so different in aspect, really form one 
continuous tissue, and cannot be separated, as the above compari- 
son with the watch-crystal would seem to imply. The cornea 
contains nerves, but no blood-vessels, its nourishment being derived 
from the vessels of neighboring parts. 
The next layer of the wall of the globe is called the uveal tract 
(from the Latin uva, a bunch of grapes). This name was proba- 
bly given to it on account of the peculiar purplish color seen when 
the eye is cut open. The uveal tract is divided by anatomists into 
three parts, which, although continuous with one another, are quite 
different. These three parts are called respectively, the choroid, 
the ciliary body, and the iris. 
The choroid membrane is the part of the uveal tract which lies 
furthest back. It covers the internal surface of the sclerotic as 
far forward as a line a little in front of the centre, or equator, of 
the globe. This imaginary boundary-line is called the ora serrata, 
or serrated boundary. (See Fig. 44.) The choroid is composed 
chiefly of a network of small blood-vessels. Mingled with these 
are pigmented cells (little cells containing a dark coloring-matter), 
and a few muscular fibres. 
Figure 46.—The choroid coat as it appears after the sclerotic coat has been removed. 
Showing the arrangement of the blood-vessels, etc. 
The ciliary body is the part of the uveal tract beginning at the 
ora serrata and extending forward to the iris. (See Fig. 44.) It 
is composed chiefly of the ciliary muscle, this being covered on its 
internal surface by a thin continuation of the choroid. The ciliary THE EYE AND ITS DISEASES. 
225 
muscle is a layer of muscular fibres, and has the form and position' 
shown in Fig. 44. It is the muscle of accommodation, which will 
be found fully described on page 23. The choroid membrane 
which covers the internal surface of the ciliary muscle is thrown 
into seventy or eighty parallel folds, running from before back- 
ward, and forming a plaited zone like a lady’s ruffle. These folds 
are called the ciliary processes. It may be seen from Fig. 44, that 
the ciliary muscle and processes form a complete circle or collar 
about one-eighth of an inch wide, which runs around the interior 
of the eyeball just behind the edge of the cornea. The region cor- 
responding to this circlet is called the ciliary region of the eye- 
ball, and is of very great importance in diseases and injuries of 
the eye, as they are specially dangerous in this locality. 
The iris (Latin, iris, rainbow) is the part of the uveal tract 
lying in front of the ciliary body. By referring to Fig. 44 it will 
be seen that the membrane is now no longer in contact with the 
outer tunic, but is bent inward away from it, and hangs free in 
the interior of the globe. By looking into another's eye the iris is 
plainly seen hanging vertically, like a circular curtain, a short 
distance behind the cornea. It is, in fact, what is called “the col- 
ored part of the eye.” A circular hole is left in the centre of the 
iris, which is called “the pupil of the eye,” and it usually appears 
jet-black.* The posterior surface of the iris is covered by a layer 
of pigmented cells. The iris contains muscular fibres whose office 
is to alter the size of the pupil. The movements of the pupil are 
largely reflex—that is, occurring without our knowledge or will, 
but simply from the effect of the light which enters the eye. If the 
eye is exposed to a bright light, the pupil contracts so as to lessen 
the amount admitted within the eye; if exposed to a dim light, 
the pupil dilates so as to admit more. The pupil likewise varies 
in size in the accommodation and convergence of the eye, inde- 
pendently of the amount of light (p. 237). The iris also contains 
blood-vessels and nerves. Besides the layer of pigment on the 
posterior surface of the iris, which is designed to prevent the 
light from shining through it into the eye, there are other pig- 
mented cells in the superficial parts of the membrane. It is 
* The reason why the pupil of another’s eye looks black to us is this : The interior of 
the eye would appear illuminated, if at all, by reason of the light which had entered the 
eye being reflected back again to us. Some of the light is so reflected, but these reflected 
rays, in coming out from the eye through the pupil, retrace precisely the same path by 
which they entered. Hence, we cannot place our eye in their path without putting our 
head between the observed eye and the source of light, and so cutting off the illumina- 
tion. This difficulty is overcome by an instrument called the ophthalmoscope, by means 
of which the interior of the eye can be seen through the pupil. 226 
TIIE EYE AND ITS DISEASES. 
chiefly these latter which cause the beautiful colors seen in the 
iris. The different colors of eyes, however, are not so much due 
to differently-colored pigment in the iris as to different quanti- 
ties of the same pigment. Thus in light eyes there is very little ; 
in dark eyes there is more, according to the shade of color. The 
same conditions prevail to a less extent throughout the rest 
of the uveal tract. As a rule, the eyes of children at birth are light, 
and, if they are to be dark, they 
become so gradually, by the 
deposit of pigment in the iris as 
the child grows older. In the 
albino, pigment is almost en- 
tirely absent from all parts of 
the eye, as well as from the 
hair, skin, etc. 
Internal to the choroid, and 
attached to it, is the retina, 
which is the innermost layer of 
the wall of the globe. It ex- 
tends forward only to the ora 
serrata, which was described 
on page 224. (See Fig. 44.) 
It is very delicate and quite 
translucent, and is composed 
chiefly of nerve-tissue designed to receive the images of external 
objects which are formed within the eye. (See page 236.) When 
viewed under a microscope it is seen to be composed of several 
Figure 47.—Showing the entrance of the 
optic nerve into the eye and the spreading of its 
fibres into the retina : a, sheath of optic nerve ; b, 
optic nerve ; d, sclerotic ; </, optic nerve filaments 
spreading into retina; i, the retina; h, location 
of the central artery. 
Figure 48, illustrating the “blind spot” of the right eye. 
different layers. One of these layers of the retina is formed by an 
expansion of the optic nerve after it has pierced through the cap- 
sule of the globe. The nerve-fibres bend over the edges of the 
opening in the capsule, and radiate into the retina in all directions. 
Strangely enough, these fibres are not sensitive to light—that is, THE EYE AND ITS DISEASES. 
227 
when light enters the eye they do not perceive it at all. The point 
of entrance of the optic nerve itself, the optic papilla, forms a 
blind spot of corresponding size 
in our field of view. This is 
called the blind, spot of Mariotte, 
after the man who first described 
it. Its existence can be proved 
by the following simple experi- 
ment : On a sheet of paper draw 
a small cross, and, three or four 
inches to the right of this, make 
a dot about half an inch in di- 
ameter. Hold this paper in front 
of the right eye, and, with the 
other eye covered, look stead- 
fastly at the cross. By moving 
the paper backward and forward 
a point will be found where the 
dot will disappear from view en- 
tirely. The reason of this is, 
that under the above conditions 
the image of the dot falls ex- 
actly upon the optic papilla; 
and, as it is not perceived, the 
experiment shows that the pa- 
pilla is really a blind spot. Be- 
cause the optic nerve-entrance 
is not at the centre of the eye- 
ball, the blind spot does not fall 
directly in our line of vision— 
that is, in the centre of our field 
of view. Hence it occasions no inconvenience, and centuries 
elapsed before it was even discovered. 
One portion of the retina is known as the layer of “ rods and 
cones,” from the peculiar shape of the elements composing it. 
This layer is almost universally considered as the true percep- 
tive layer of the retina. This view is thought to agree best with 
anatomical facts and with the results of experiments. It is as- 
sumed that, in accurate vision, the image of the object is formed 
exactly in this layer of the retina (page 236). 
There is one point of the retina which is of great importance, 
and that is the macula lutea, or yellow spot. This is a region about 
2V to inch in diameter, and situated about TV to -jV inch to the outer 
side of the optic papilla. (See Fig. 45.) In its centre is a little 
Figure 49.—Showing the layers of the re- 
tina, largely magnified ; No. 2 shows the layer of 
optic nerve fibres; No. 9, the layer of rods and 
cones. 228 
TILE EYE AND ITS DISEASES. 
pit or excavation called the fovea centralis. This spot is the 
centre of direct vision ; that is, it is the part of the retina most sen- 
sitive to light and color, and the part which is always turned to- 
ward the object looked at. From this point the sensitiveness of 
the retina grows less and less in all directions. The blood-vessels 
which enter the eyeball through the centre of the optic nerve (see 
p. 229) branch into the retina in all directions. There are no 
vessels whatever in the fovea centralis. There is a layer of beau- 
tiful hexagonal, pigmented cells on the side of the retina next to 
the choroid. (See Fig. 50.) This pigmented 
layer of the retina is continued forward over 
the internal surface of the ciliary body and 
of the iris. It is of great importance for 
vision to have the interior of the chamber 
of the eyeball thus darkened (p. 234). 
The aqueous humor is a transparent, 
watery fluid, filling the spaces indicated in 
Fig. 44 by g and h. The space marked g 
is called the anterior chamber of the eye. 
The space marked li is called the posterior chamber. If the eye is 
looked at from one side, the anterior chamber (see Fig. 44) can 
be seen as the space between the cornea and the iris. 
The Crystalline humor or Lens is a transparent, elastic, bicon- 
vex body looking like an ordinary glass magnifying-lens. It is 
of circular outline, about inch in diameter. It is of quite firm 
consistence. It is enclosed in a transparent, elastic capsule (about 
inch thick), and is suspended by a ligament just behind the 
iris, so that it lies about one-seventh of an inch back from the 
cornea. (See Fig. 44.) It contains no vessels or nerves, and ab- 
sorbs its nourishment from surrounding parts. The suspensory 
ligament of the lens is called the zonula of Zinn (Latin, zonula, a 
little girdle). 
The vitreous humor, or hyaloid body (Latin, vitreum, glass; 
Greek, mAos, glass), fills the interior of the eyeball behind the lens. 
(Fig. 44.) It is a transparent, colorless, gelatinous substance, 
looking like liquid glass. It contains no blood-vessels, and absorbs 
its nourishment from the walls of the globe. A good idea of the 
vitreous humor and crystalline lens can be very easily obtained 
by cutting open the eye of a pig or a sheep. Much can be learned 
about other parts of the human eye in the same way. Eyes of 
animals can be obtained from any butcher. 
Figure 50.—Pigmented cells 
from the human retina, surface 
view, largely magnified. THE EYE AND ITS DISEASES. 
229 
The Optic Nerves. 
The Optic Nerves are the nerves of the special sense of sight, 
and connect the eyeballs with the brain. (See Fig. 51.) They have 
their origin in the base of the brain. These nerves enter the orbits 
through the optic foramina, and, running forward, each nerve passes 
into its corresponding eye a little to 
the inner side and a little below the 
posterior pole of the globe. After 
penetrating the wall of the globe 
the nerve-fibres spread out into the 
retina in all directions, forming 
one layer of that membrane. (See 
p. 227.) At its point of entrance 
the nerve projects into the eye a 
little beyond the level of the inter- 
nal surface of the wall of the globe, 
forming a round or oval promi- 
nence called the optic papilla or 
optic disc. (See Fig. 45.) As soon 
as the nerve-fibres leave the disc to 
branch into the retina they become 
transparent. Hence, in looking into 
an eye with the ophthalmoscope, 
the nerve-fibres cannot be seen bending over from the disc into the 
retina. The disc alone is visible, looking like a round, whitish 
spot, and the appearance is as if the nerve had been cut off short 
at that point. (See Fig. 45.) A main artery, called the central 
artery of the retina, enters the nerve about four-fifths of an inch 
behind the eyeball and runs forward in the centre of it. At the 
optic disc it divides into several branches, which bend over the 
edges of the disc and radiate into the retina. The central vein ac- 
companies the artery in its course and conveys part of the blood 
out from the eye. 
Figure 51.—Base of brain and course 
of the optic nerves. 
The Appendages of the ielye. 
The eyeball is moved by six muscles. These start from the 
walls of the orbit, and are attached to the outer or sclerotic coat of 
the eyeball. Four of the muscles are called the recti muscles, 
from their straight course. The other two are called the oblique 
muscles. (See Fig. 52.) The names of the muscles are the supe- 
rior rectus, the inferior rectus, the external rectus, the internal 
rectus, the superior oblique, and the inferior oblique. 230 
THE EYE AND ITS DISEASES. 
The eyeball, excepting its most anterior portion, is surrounded 
by a membranous capsule (called Bonnet’s and Tenon’s capsule), 
through which the muscles penetrate just before becoming at- 
Figure 52.—Muscles of the right eyeball. 
tached to the sclerotic. The eyeball rotates freely in this socket, 
and its movements are facilitated by this arrangement. 
The eyelids (or, in Latin the palpebrce) are the two protecting 
curtains placed in front of the eyeball. They are movable, and 
can be opened and closed at will, as 
in the so-called opening and shutting 
of the eyes. They also move inde- 
pendently of the will, as when a par- 
ticle of dust strikes the eye, or, 
upon sudden exposure to a bright 
light, etc. This involuntary action 
of the lids protects the eyes from 
many unexpected dangers. The slit 
between the edges of the lids is 
called by anatomists the palpebral 
fissure. It is chiefly the size of this 
fissure which causes the appearance 
of large and small eyes, as the size 
of the globe itself varies but little. 
The outer corner of this fissure (the corner towards the temple) 
is called the external canthus. The inner corner is the internal 
canthus. (See Fig. 53.) 
The lids are composed of several different substances. (See 
Figure 53.—The eyelids : 2, 2, cilia 
or eyelashes; 3, inner canthus ; 4, outer 
canthus; 5, puncta lachrynialia ; 6, carun- 
cular lachrymalis; 7, semilunar fold. 231 
THE EYE AND ITS DISEASES. 
Figs. 13 and 14.) Outside is the skin, which is a continuation of 
the skin of the rest of the body. At the edge of the lid the skin 
grows thinner and passes into a mucous membrane, just as the 
skin about the mouth passes into the mucous membrane of the 
lips. This mucous membrane is called the conjunctiva (Latin, con- 
jungere, to join together), and it lines the inner surfaces of the 
lids, and passes thence over upon the front of the eyeball, covering 
the sclerotic as far as the edge of the cornea, where it ends. * (See 
Fig. 54.) This folding over of the conjunctiva from the upper and 
lower lids upon the eyeball constitutes what are called the su- 
perior and inferior conjunctival folds; also called the retrotarsal 
or palpebral folds. The little pouches thus formed above and be- 
low are called respectively the superior and inferior conjunctival 
culs-de-sac. (See Fig. 54.) A crescentic fold of conjunctiva can 
Fig. 54. 
ig. 55. 
Figure 54.—Vertical section of the upper and lower conjunctival folds : e, eyeball; Z, eye- 
lids ; the fine lines within the lids represent the conjunctiva covering the inner surfaces of the 
lids and reflected upon anterior surface of globe, formingpalpebral folds, and conjunctival culs- 
de-sac at//. Lids drawn away from eyeball to show conjunctiva. 
Figure 55.—1, 1, the orbicularis muscle which closes the eyelids; 2, the cartilage of the up- 
per lid; 3, cartilage of the lower lid; 4, 4, edges of the lids. 
also be seen on the front of the eyeball at the inner corner of the 
lids. This is called the semilunar fold, or plica semilunaris. The 
conjunctiva covering the front of the eyeball (the ocular conjunc- 
tiva) is thin, and is very loosely attached. The conjunctiva also 
dips down into the little glands of the lids, forming a lining for 
them, and also lines the lachrymal passages, becoming thus con- 
* A very delicate prolongation of the conjunctiva, consisting of minute cells, passes 
over the front of the cornea. 232 
THE EYE AND ITS DISEASES. 
tinuous with the mucous membrane of the nose and mouth 
(p. 233). 
Between the skin on the outside and the conjunctiva on the 
inside are enclosed the other structures of the lids. Just beneath 
the skin is a layer of muscular fibres, a part of the orbicularis * 
muscle. (See Fig. 55.) It is what is called a sphincter muscle 
i (Greek, <r<f>tyyw, to constrict), and its action is to close the lids. 
There is another muscle, whose office it is to lift the upper lid, 
called the levator palpebroz superioris muscle. (Fig. 52.) 
Beneath the orbicularis muscle 
is the piece of cartilage which 
forms the framework, as it were, 
of the lid. In the cartilages lie 
the Meibomian glands, so called 
after the anatomist Meibomius. 
(See Fig. 56 adjoining.) They fur- 
nish an oily secretion, which lubri- 
cates the edges of the lids and 
prevents their sticking together. 
This greasing of the edges of the 
lids also tends to prevent the tears 
from running over upon the cheek. 
Beneath the cartilage lies the con- 
junctiva, which has already been 
described. 
The eyelashes or cilia (Latin, cilium, an eyelash) are the rows 
of short, thick hairs on the edges of the lids. Those of the upper 
lid curve upward, and those of the lower lid downward—an ar- 
rangement which keeps them from interfering with vision, and 
from interlocking when the lids are closed. They serve both for 
protection and ornament. 
The small red body seen lying upon the semilunar fold at the 
inner corner of the palpebral fissure is called the lachrymal car- 
Figure 56.—Showing a portion of the 
eyelids as seen from within: 1, Lachrymal 
gland ; 2, openings of the lachrymal ducts ; 
3, 3, conjunctiva lining the eyelids ; 4, open- 
ings of the Meibomian glands; 5, Meibo- 
mian glands ; 6, puncta lachrymalia. 
The Lachrymal Apparatus. 
The lachrymal (Latin, lacryma, a tear), or tear-apparatus of 
the eye, consists of the lachrymal glands, in which the tears are 
formed, and of the lachrymal passages, which are designed to con- 
duct the tears away from the eye after they have served their pur- 
pose. The largest lachrymal gland is situated just above the eye- 
* Latin, for circular. THE EYE AND ITS DISEASES. 
233 
ball, in the outer corner of the orbit, as shown in Fig. 56. Below 
this there are a number of small glands lying in the upper fold of 
the conjunctiva, and called accessoi'y lachrymal glands. The open- 
ings of the ducts, by which the tears escape from the glands, also 
lie in this same fold. 
The lachrymal passages are shown in Fig. 57. If the lids are 
looked at closely, a slight prominence can be seen on the edge of 
each, about one-fifth of an inch from the inner corner. On still 
closer examination, each of these prominences can be seen to con- 
tain in its centre a minute hole, about the size of a pin-hole. This 
hole can be most easily seen in the lower lid by pulling the lid 
down a little with the finger, so as to roll its edge outward. Each 
of the prominences is called a lachrymal papilla. Each of the 
holes is called a lachrymal punctum (Latin, punctum, a small hole), 
and is the entrance to a little 
canal, called a lachrymal ca- 
naliculus (Latin, canaliculus, 
a little channel). These canals 
are about one-quarter to one- 
third of an inch long, and 
about one twenty-fifth of an 
inch in diameter, and run hor- 
izontally along the edge of 
the lid toward the nose to 
empty into the lachrymal sac. 
The lachrymal sac lies in the 
inner corner of the orbit, just 
behind the inner corner of the 
lids. It is a hollow, membra- 
nous sac, of oval shape, about 
two-fifths of an inch long, and 
one-sixth of an inch wide. Below, it opens into the nasal duct. 
(Fig. 57.) 
The nasal duct is a bony canal, lined by mucous membrane, and 
running from the lachrymal sac downward, to empty into the 
lower part of the nose. It is three-quarters to four-fifths of an 
inch long, and about one-eighth of an inch in diameter. (Fig. 
57.) 
The tears consist of water containing a little salt and albumen. 
They are formed in the lachrymal glands, from which they escape 
by the little openings in the upper conjunctival fold (page 231). They 
are constantly spread over the front of the eyeball by the winking 
of the lids, and serve to keep it moist and lubricated. If deprived 
of this moisture the cornea would become dull and opaque. Any 
Figure 57.—Lachrymal apparatus. 234 
THE EYE AND ITS DISEASES. 
excess of tears finds its way to the inner corner of the lids, and is 
taken up by the puncta, and so passes through the canaliculi, sac, 
and duct, into the nose. Aside from the usual flow of tears, there 
is a special flow of them caused by any irritation of the eye, or by 
certain mental states, as of grief. If a particle of dust flies into 
the eye, there is an extra flow of tears at once, and this tends to 
wash the foreign substance out again before it can do harm. The 
tears occasioned by irritation, grief, etc., are so abundant, that 
they may be felt running down into the nose, and those which 
cannot escape in this way flow over the cheek. Under ordinary 
circumstances, most of the tears evaporate, scarcely any passing 
into the nose. If the secretion of tears were entirely suspended, 
the resulting dryness of the eyeball would lead ultimately to its 
destruction for purposes of vision. 
The eyebrows, or supercilia (Latin, supercilium, an eyebrow), 
are the arched elevations of skin and underlying tissue around the 
upper edges of the orbits. They are covered by a row of short 
hairs, which are directed toward the temples. They serve to pro- 
tect the eyes, shielding them from bright light, from the perspira- 
tion of the forehead, etc. 
After the foregoing general sketch of the anatomy of the eye 
the reader will more readily understand a few remarks upon vision. 
THE PHENOMENA OF VISION. 
The eyeball is often compared to a photographer’s camera, and 
the comparison is a very just and convenient one. It is essentially 
a hollow, spherical box, filled with fluids, having its interior sur- 
faces darkened by black pigment, and containing a system of 
lenses by which images can be formed, and a screen upon which 
they can be received. In front is a diaphragm (the iris), with a 
variable central aperture (thepupil) to regulate the amount of light 
admitted. All this is much like the apparatus used in taking a 
photograph. Some recent investigations might tempt us to push 
the comparison still further. Franz Boll, of Rome, Italy, has found 
that the layer of rods and cones of the retina (page 227) possesses 
a beautiful purplish coloring, which is destroyed by the action of 
light upon it, and constantly renewed again (during life) from the 
layer of pigmented cells beneath. This coloring is called the pur- 
ple of the retina, or the sight-purple. Kiihne, of Heidelberg, has 
investigated this subject very thoroughly, and has performed many 
experiments upon it, of which the following will serve hs an exam- 
ple : A rabbit was placed a short distance from a window and its 
head covered with a black cloth. The cloth was then removed and THE EYE AND ITS DISEASES. 
235 
the rabbit’s eye exposed to the light of midday for a few minutes. 
The animal was then beheaded, and the eye removed and preserved, 
with the usual precautions. On taking out the retina, it was found 
to exhibit an accurate photograph of the window, its panes white, 
and its sashes purplish-red. Many other experiments gave similar 
results. From all this we might conclude that the retina is a sen- 
sitized plate, placed at the back of the eye, like that which the 
photographer slips into his camera before taking a picture; that 
the sensitive surface of the plate (the siglit-purple) is worn out by 
the action of light in forming the images, and constantly renewed 
again by the wonderful chemistry of the body ; that the eyeball is 
not only like a camera obscura, but like a complete photographic 
establishment. At present, however, such conclusions would be 
premature, for the facts regarding the retinal purple are not fully 
determined, especially in the human eye; and, although the ex- 
periments upon it have given such striking results, it is not yet 
proven to be essential to sight. 
Although the eye contains only one lens so-called, yet the cor- 
nea and the aqueous and vitreous humors also bend the rays of 
light passing through them, and thus there is really a series of 
convex surfaces, which together form a compound, convex lens. 
These are technically called the refracting surfaces of the eye. It 
is very convenient, in description, to speak of the lens of the eye, 
and the expression is proper enough if the above facts are only 
borne in mind. 
Now, as is well known, convex lenses have the power of causing 
the rays of light which pass through them to converge to a point, 
or to come to a focus, as it is called. It is on this account that they 
are able to form images of objects. Place a lighted candle a few 
feet from a white wall, and hold a strong convex lens * vertically, 
in a direct line with the flame and between it and the wall. Then 
move the lens backward and forward in a line with the flame, and 
a point will be found where a distinct image of the flame will be 
formed upon the wall. An image can be formed of any luminous 
object in the same way. The image will be found to be smaller 
than the object, and upside down. The image is formed, because 
the rays of light coming from every point of the object are made 
to unite in corresponding points behind the lens by passing 
through the latter. The image is inverted, because the rays, in 
passing through the lens, cross each other—that is, those coming 
from the top of the object go to the bottom of the image, etc. 
(See Fig. 58.) 
* One of three or four inches focus. 236 
THE EYE AND ITS DISEASES. 
Now, the rays of light which enter the eye from external objects 
are converged by its compound lens in exactly the same manner. 
All that is required to produce a clear image on the screen (or 
retina) at the back of the eye, is to have the proper relative dis- 
tances between the object, the lens, and the retina, just as in the 
case of the candle, the glass lens, and the wall. In the normal eye 
these conditions are fulfilled in the act of vision. By laying bare 
the retina at the back part of the eye in animals, experimenters 
have seen the inverted images of external objects formed there 
Figure 58.—L, the lens; A, object; ctoi, 56, rays of light from two points of object; B, 
image. 
Returning to the experiment with the candle : as soon as the 
image on the wall is distinct, fix the lens in its position. Then, if 
the candle-flame is moved—if, for instance, it is carried nearer to 
the lens—the image on the wall will immediately become blurred. 
To get a distinct image again under these new conditions, the lens 
must be moved to another point, or must be replaced by one of 
different power. In the camera obscura the lens can be moved 
back and forth, so as to form a clear image, whatever the distance 
of the object. In the eye, however, the distance between the lens 
and the retina (the retina here representing the white wall in the 
experiment) may be said to be unalterable. Hence, as the eye is 
required to see objects at all distances, it must possess the faculty 
of changing the strength of its lens accordingly. Without this 
faculty, the image on the retina could be distinct only within very 
Figure 59.—c, cornea; L, lens; R, retina; RR, rays of light. 
narrow limits. The eye really lias this power, called its power of 
adjustment, or of accommodation. It is required chiefly for vision 
of objects at short distances. As soon as objects are brought near THE EYE AND ITS DISEASES. 
237 
to the eye, the rays of light from them become more divergent, so 
that they cannot be brought to a focus by the lens so quickly. 
Fig. 59 represents two rays of light entering the eye from a 
given point of a distant object.* It will be seen that they are 
united in a point exactly on the retina. 
Fig. 60 represents two rays coming from a point of a near ob- 
ject. It will be seen that they are more divergent. Hence, they 
cannot he brought to a focus so quickly. If not interrupted in 
Figure 60. 
their course, they would be united in a point behind the retina, as 
shown in the figure. In order to unite these rays on the retina, 
the lens must become thicker—that is, its converging power must 
be increased. This is actually done through the faculty of accom- 
modation, and this is what that term means. The change is 
shown in the figure by the dotted lines. The nearer the object, 
the more divergent the rays from it, and the thicker must the lens 
become to keep the focus in the retina. As the object recedes 
from the eye, the lens must become weaker again, which it does 
by becoming flatter—less strongly curved. All these changes in 
the lens are accomplished through the action of the ciliary muscle, 
which is the muscle of accommodation ; and they take place usu- 
ally without any conscious effort on our part. During the act of 
accommodation the pupil contracts, so that the diverging rays 
from the near object are allowed to pass only through the central 
part of the lens, and thus the image on the retina is more distinct 
than it would be otherwise, f If one looks at his own eye in a mir- 
ror, and brings the mirror gradually nearer to his eye, he will see 
this contraction of the pupil take place. 
* In the ideal eye the distance between the lens and the retina is such that rays of 
light, which are parallel when they enter the eye, are exactly focussed in the retina. 
It is found that all rays from distances greater than twenty feet are so slightly divergent 
that they may be regarded as practically parallel. Hence, the perfect eye sees objects 
at all such distances without the use of its faculty of accommodation. This form of eye 
is comparatively rare. 
f Because the spherical aberration of the lens is thus lessened. The lens is so con- 
structed that its density decreases from the centre toward the periphery, and this also 
tends to lessen its spherical aberration. 238 
TIIE EYE AND ITS DISEASES. 
In describing the retina (page 226), it was shown that the macula 
lutea, or yellow spot, was the most sensitive part of it, both as re- 
gards light and color, and the part always directed toward the 
object of sight—the centre of direct vision, as it is called.* 
A single trial will show that, in looking at an object, only a 
small part of it is seen distinctly at one time. The surrounding 
parts are seen, but they appear blurred. This is because the 
image of these parts falls on portions outside of this most sensitive 
point—the macula. (See page 227.) Hold the accompanying circle 
(Fig. 61) about eight inches 
away, and look at it with one 
eye, the other being closed. It 
will be found that the words in 
the centre and the words in the 
margin cannot be read at the 
same instant. When the words 
in the centre can be seen with 
perfect clearness, those in the 
margin will appear blurred. 
As a compensation for this 
limitation of distinct vision, the 
eyeballs can be rotated by their 
muscles in every direction, so 
as to command a very extensive 
field of view. These movements are so rapid and so habitual, that 
most persons are not aware of the limitation named. 
Impressions on the retina have a certain duration, which is es- 
timated to be about one-third of a second. Many familiar experi- 
ments illustrate this fact. A lighted torch, revolved rapidly before 
the eye, gives the impression of a continuous circle of fire. In a 
rapidly revolving wheel, the spokes cannot be distinguished from 
each other. This duration of the impressions prevents vision from 
being interrupted by the winking of the lids. 
The color of light is considered to be analogous to the pitch of 
sound. As the latter is determined by the number of vibrations of 
the atmosphere which strike the ear in a second, so the former 
depends on the number of waves of ether which strike the retina 
in a second. The lowest note of an ordinary musical scale has 
sixteen vibrations per second ; the highest has 20,000 per seconu. 
The number of ether-waves which strikes the retina in a second 
to produce the sensation of red (which lies at the bottom, so to 
Figure 61. 
* An imaginary straight line, drawn through the refractive centre of the eye, from the 
yellow spot to the point looked at, is called the visual line, or the visual axis. Tt does 
not coincide with the optic axis (page 222), and must not be confounded with it. THE EYE AND ITS DISEASES. 
239 
speak, of our color-scale), is estimated at 474,439,080,000,000. The 
number required to cause the sensation of violet, which lies at 
the other extreme of our color-perception, is estimated at 699,- 
000,000,000,000 per second ! 
The two eyes move in harmony with each other in such a way 
that the macula lutea of each retina is always directed to the point 
looked at—that is, the two visual lines meet in that point. An 
idea of these movements may be gained by watching another look 
at an object as it is approximated to the eyes. As the object is 
brought nearer, the eyes are turned in toward each other (or con- 
verged) more and more, so as to keep the two visual lines always 
directed to the point looked at, and thereby to cause an image al- 
ways to fall on each macula. 
Figure 62.—Diagram of the eyes as seen from above, showing the muscular apparatus by 
means of which they are directed toward the same object. 
It thus appears that in ordinary vision with both eyes, there is 
an inverted image of the object formed at the macula lutea of each 
retina. By means of the optic nerves, the impressions which these 
two inverted images make upon the retinae are conveyed to the 
brain, and thence results a visual perception, the object appear- 
ing to us single and erect. 
If one of the eyes is turned so that its macula lutea is not di- 
rected to the same point as that of the other eye, the two retinal 
images will not be united as usual, and the object will appear 
doubled. This double vision can very easily be caused if, when 240 
THE EYE AND ITS DISEASES. 
looking at an object with both eyes, one of the eyes is made to 
deviate a little from its proper position by pressing against it with 
the finger—as by pushing it upward by pressure through the 
lower lid. 
The phenomenon of single, erect vision from the two inverted 
retinal images has occasioned much discussion. Scientists have 
given explanations of it which seem plausible enough, but it can 
hardly be said that the matter is thoroughly understood. In 
speaking of the perception of images on the retina, it must be re- 
membered that there is no proof that the mind takes cognizance 
of them, as such. We can only say that vision is the result of an 
irritation of the nerves of the special sense of sight, as hearing, 
smell, etc., are due to irritations of other special nerves. What- 
ever we may know of the formation of images on the retina, and 
of the changes which they excite there, the perception of these 
impressions by the brain must still seem mysterious to us. 
It is a curious fact that sensations of light and of luminous ob- 
jects can be excited where no light enters the eye, as by blows upon 
the eye, and by certain irritations in eyes which are totally blind. 
In looking at an object near enough to require convergence of 
the eyes, the image of each eye differs considerably from that of 
its fellow. This can be readily seen by looking at a near object, 
and covering each eye alternately. The right eye will see more of 
the right side of the object, and the left eye more of the left side. 
It is the combination of these two different impressions that gives 
us our ideas of solidity and depth—what is called the stereoscopic 
effect. Otherwise, objects would appear unduly flat to us. 
The muscular efforts required to direct both visual lines toward 
an object, and to see it distinctly, are the chief factors from which 
we unconsciously estimate the distance of an object. This is 
largely a matter of education and experience. If only one eye is 
used, it will be found much more difficult to judge of distance cor- 
rectly. 
In the brief outline of the physiology of vision given above, the 
writer has attempted to set forth only the leading facts in a clear 
and simple way. Many points connected with the subject have 
been left unmentioned, and some of them are of great interest. 
The reader who wishes to study the matter further, is referred to 
the standard text-books. 
Considered as a mere optical instrument, the eye has several 
imperfections, which cannot be described here. It is admirably 
adapted, however, to the purposes for which it is designed, and is 
one of the most wonderful and beautiful organs of the body. 
EDWARD T. ELY, M.D. 241 
THE EYE AND ITS DISEASES. 
GENERAL REMARKS UPON THE CARE OF THE EYES. 
In the section upon Diseases of the Eye, the writer has at- 
tempted to so describe them, that in case of the absence of compe- 
tent medical advice, the reader may at least do no harm when 
compelled to undertake the care of these affections. He has also 
incidentally spoken of the precautions necessary to prevent sound 
eyes from becoming diseased. It may, perhaps, be well to preface 
the discussion of the latter subject with some general remarks, 
which may serve as a guide to parents and teachers, and to all 
those who have the responsibility of preventing injury to the vi- 
sion of those under their charge. 
Tired Eyes. 
There is a popular notion that it is much more dangerous to 
tire the eyes by use than it is to tire any other organ of the body. 
It is not necessarily injurious to the legs, or the arms, or the brain 
to become tired, for proper rest may restore all these to their nor- 
mal condition. The same is true in regard to the eyes. Proof- 
readers, sewing women, authors, and mechanics, who use their 
eyes for a long time upon near objects, must of necessity weary 
the muscles which adjust the eye to vision ; but if the weariness 
is compensated for by rest at proper intervals, there will be no 
harm done to the eyes, for they are so constructed that they can 
bear maximum fatigue as well as other parts of the body. Edu- 
cation would cease, all mechanical work would soon have an end, 
if the eyes of school-children and of a certain kind of workmen 
were never tired. Eyes are never overworked, even if they feel 
very tired when the task is done, if their natural power and fresh- 
ness return after the proper intervals of rest during the day and 
sleep at night. 
The Care of the Eyes in Childhood. 
The eyes of children need more care than those of adults. As 
a general principle, intervals of rest between hours of close occu- 
pation with the eyes should be oftener and longer in children than 
in grown persons. The reason of this is, that the eyes of children 
are still in the course of development, and any organ which is 
yet to attain its full growth, requires more care in its use, longer 
and more frequent intervals of rest than one which has already 
reached its full size. 242 
THE EYE AND ITS DISEASES. 
In a subsequent section I have dwelt at great length on the 
use of spectacles, and I need only say here that children whose 
eyes are not diseased, but which require glasses, should not ab- 
stain from using them, but should be provided with suitable spec- 
tacles, and then go on with their studies. Some of the most suc- 
cessful men and women the world has ever seen, have been suc- 
cessful from the knowledge obtained by the aid of glasses. The 
eye that needs a glass is not necessarily very much weaker—that 
is, much less capable of endurance—than one that does not. 
Quality, Quantity, and the Point of Admission of Light. 
All persons, whether young or old, should take great care with 
reference to the quality, and the point of admission of the light 
upon the object to be illuminated. Right-handed persons, if 
they sit with their right side toward the window while writing, 
reading, or sewing, necessarily obstruct much of the light which 
should fall upon the printed or manuscript page or work which is 
before them. For that reason, persons who use their eyes at work 
should endeavor, if right-handed, to have the light fall upon their 
left side, so that none of it will be obstructed by the right arm ; 
and for left-handed persons the situation should be reversed. A 
light that is in front of the worker is injurious, because it is daz- 
zling. For the same reason, and also because the quantity is in- 
sufficient, a light over the head is injurious. Under all ordinary 
circumstances, light falling upon the side is the best. 
Then there should be plenty of light. Reading in the twilight, 
reading by insufficient illumination, or by a flickering gaslight, 
produces injurious effects upon the eyes. It causes a strain on the 
muscles for exact vision. All strain that is continued for any 
considerable length of time is reflected injuriously upon the blood- 
vessels of the eye, and if upon the blood-vessels, it is upon what 
physicians call the nutrition of the eye—upon its health—for the 
blood-vessels are the great sources of repair of waste of tissue. 
The Character of Type. 
The character of type should be carefully considered, and pa- 
rents and teachers should see to it that books which are printed 
from old and much worn plates, or with very small type, are re- 
jected. Books abounding in fine foot-notes should not be used in 
schools. Books printed in the Greek language should be very 
carefully executed. This is also true of German text. It would, 
indeed, be a benefit to the world if the Germans would give up THE EYE AND ITS DISEASES. 
243 
their absurd characters and use the Latin ones, which are em- 
ployed by English, American, French, and many other nations. 
The reason, of course, for avoiding type of this kind, which is not 
accurately and clearly formed, is that the effort necessary to see 
the words distinctly causes a strain upon the muscle inside of the 
eye, described on page 237, which adapts it to vision. A moder- 
ately wide page is less tiresome to the eyes than a very narrow 
one, because the changes in the position of the eyes are not so 
frequent in reading from broad pages as they are in reading from 
very narrow columns. 
School-Houses. 
The builders of school-houses have a great responsibility in ar- 
ranging the desks for the pupils. The principle, as to light, which 
has just been laid down, should be carefully held in view. For, 
as I have said, it is the eye which is in 
the process of development that is pe- 
culiarly liable to be affected by improper 
or defective light. It is just as easy to 
arrange the desks so that the light 
comes in from the left side of the student 
as it is to place them otherwise. 
The height of the desk is also impor- 
tant.* A short-sighted child should not 
be permitted to bend over his or her 
book. Indeed, no person should. It 
would be very well if, in large and well- 
regulated schools, there were a certain 
proportion of standing-desks to which 
pupils might be sent, in order to relieve 
their eyes from strain when bending 
their heads. At any rate, the head 
should never be bent so much that entrance of blood into the eye 
is very much favored, while its return is hindered. So far as pos- 
sible the head should be kept in an erect position, in a line with 
the trunk, while study or any other close work with the eye is car- 
ried on. 
The managers of country school-houses might so arrange things 
Figure 63. — School - desk, 
showing the proper position for 
the book. The seat should be so 
arranged that the head need not be 
bent over, in order that the scholar 
may see distinctly. 
* [The desk here represented is of English manufacture, and is arranged so that 
the back-rest may be adapted to different heights, and the seat may be raised or lowered 
or made to approach or recede from the desk, as the size of the occupant may require. 
—Ed.] 244 
THE EYE AND ITS DISEASES. 
that the grateful shade of trees could be near the windows, and 
thus temper the glare of the sun in summer and of the snow in 
winter. It is surprising that the common advantages of country 
life are not made more complete use of. A few trees, not too near 
the windows of a school-house, would be of great service to the 
eyes of the little students. 
Atmospheric Conditions. 
An atmosphere laden with smoke not only renders reading dif- 
ficult, but is, of course, detrimental to the general condition of the 
eyes. It is much worse to attempt to read or sew in a smoky at- 
mosphere than to be quiet, without occupation of the eyes, in the 
same locality. 
Riding or driving in a very strong wind is sometimes very dan- 
gerous, at least for eyes which are inclined to any kind of con- 
gestion. Many accidents have been caused by the wind striking 
forcibly upon the delicate structure of the eye. For, it is to be re- 
membered, that the invisible wind has a power which is as severe 
as a blow from a tangible object, and it may injure blood-vessels 
so as to give rise to bleeding from them that will do the eyes 
great harm. If obliged to ride or drive against a strong wind, 
most persons will do well to wear blue or smoke-colored glasses 
as a protection against its direct force. Men should at least wear 
broad-brimmed hats. It need hardly be said that acrid vapors of 
all kinds are injurious to the delicate structure of the eye, and 
every person should avoid them as carefully as he would refrain 
from keeping his eyes wide open in a dust-laden atmosphere. 
Broad-brimmed hats are a great protection from such influences 
as those just mentioned, as well as from the glare of the sun, es- 
pecially in cities where it is reflected from the, pavement so as to 
be extremely unpleasant. 
Travellers in mountainous regions, where snow perhaps may 
lie and reflect the light injuriously, should also wear these protec- 
tive glasses. Goggles, or glasses set in cases made of wire net- 
work, as has been said in the section relating to the different dis- 
eases of the eyes, are not suitable, because they keep the eyes too 
warm, and, although they afford protection, they tend to excite 
the very diseases they are designed to avert. 
The light reflected from snow is a fertile source of injury to the 
eyes. Boys and girls while coasting, should have their eyes pro- 
tected, the one by caps with broad visors, the other by hoods pro- 
jecting a little in front of the face. THE EYE AND ITS DISEASES. 
245 
Reading in Railway Trains. 
Thousands of people living in places which compel them to 
travel in the railway trains to and from cities in pursuit of their 
daily occupation, are exposed to injurious effects upon their eyes, 
from the fact that the railway carriages go rapidly through differ- 
ent kinds of light, and roll so unevenly that the object looked upon, 
such as a newspaper or book, cannot be held steadily. In order to 
see distinctly in a moving railway carriage, the eyes must act spas- 
modically, or, at any rate, change their focus often, and hence a con- 
stant strain of the muscles of the eye is produced. If people are 
wise enough to stop when they find their eyes fatigued, it is prob- 
able that much reading can be done in this manner without posi- 
tive injury; but if they continue to read after fatigue and discom- 
fort are experienced, they may expect most serious consequences. 
Reading in Bed. 
Reading in bed is apt to be injurious from a variety of causes. 
The position is usually nearly flat on the back, which is a bad one 
for reading, and the light is apt to be insufficient and inconve- 
nient. Invalids are most apt to read in bed. Fatigue of the mus- 
cles of the eye is, of course, more easily induced in them than in 
strong persons. Women reclining during the menstrual period, 
or in the days after childbirth, should be especially careful. Chil- 
dren recovering from measles and scarlet fever, should be es- 
pecially guarded against using their eyes with small toys, or by 
reading or writing when they are not fully well, and especially 
when they are not yet allowed out of bed. 
The invalids most apt to be injuriously affected by use of the 
eyes upon near and fine objects, are those who have lost much 
blood, and who are weak from this cause, or who suffer from cer- 
tain affections of the brain. These two classes of sick persons, 
even if they are up and about, should be guarded against any 
long-continued use of the eyes upon objects that must be held 
near them in order to see them distinctly, and from reading that 
which requires any considerable mental exertion. 
Training the Eye to look at Distant Objects. 
Those who have the care of young children and youth should 
give much attention to this subject, and practise their charges in 
looking at long distances. Shooting, archery, and the like amuse- 
ments become valuable means for training eyes for distant vision, 246 
THE EYE AND ITS DISEASES. 
and thus of preventing or lessening the elongation of the eyeball, 
which is the cause of near-sightedness. Such sports are as neces- 
sary for the development of eyes as are the common ones of ball- 
playing, cricket, hoople, and so forth, for the development of the 
legs and arms. It is probable that the immunity from near-sight- 
edness which the British people enjoy as compared with the Ger- 
man nations, is due to the variety of out-of-door life which the 
former encourage in their young and old people. 
Beading Music. 
Those who read music are particularly liable to strain of the 
eyes, because exact vision is required to follow the notes. Per- 
sons who should wear glasses for reading will especially need 
them while reading music, and a particularly good light is neces- 
sary to avoid straining the eyes. 
Blurring of Vision. 
Those who are inclined to overrate their symptoms are espe- 
cially liable to do so with reference to their eyes. Any reader, 
with the opinion that fatigue of the eyes is very dangerous, and 
who becomes anxious with regard to the condition of his or her 
eyes, may sometimes have his equanimity restored until proper 
authority can be consulted, by testing the fact as to whether the 
finest print can be seen distinctly, if even for only a few seconds. 
If it can be distinctly made out, even though it causes fatigue, the 
presumption is that the weakness of vision depends upon some 
cause which can be removed. In these cases it is not so much a 
loss of the power of seeing that lias occurred, as of the ability to con- 
tinue to use the eyes. Blurring of the sight, therefore, in cases in 
which distinct vision exists for a few seconds, is by no means so 
dangerous a symptom as the absolute inability to see small objects. 
The latter is always a warning to immediately seek good medical 
advice. The line must, therefore, be carefully drawn between 
tired eyes and eyes which are absolutely unable to see fine objects 
—to make out, as we say, very fine print or the like. 
Oculists call the former condition weak sight, and the latter 
loss of sight. Glasses will often remedy weak sight, while they 
will do no good for loss of sight from disease. THE EYE AND ITS DISEASES. 
247 
Pain in the Eyeball. 
What has been said with reference to blurring of vision, may 
also be said of pain referred to the eyeball. If such pain is less 
after rest of the eyes; if it is, for instance, less in the morning 
after a night’s sleep ; if it is not attended by positive loss of vision, 
it is probably like blurring, one of the symptoms of over-work of 
the eyes, or use of the eyes under improper conditions, such as the 
neglect of wearing glasses for correcting and improving the vision 
when they should be worn, or of their use with insufficient illumi- 
nation, or an incorrect position of the body, and so forth. 
Loss of Sight. 
It is strange that many persons will allow their power of seeing 
to slip away from them without alarm, when they are actually 
unable to see objects which, a week before, they could see dis- 
tinctly. 
Every person who suspects serious trouble with his eyes, should 
test himself by objects of a kind and size, which he knows that he 
has formerly seen distinctly at a given distance, and if he finds 
that he cannot see those objects, he should certainly seek advice. 
But as has been said, mere pain, or mere blurring, without actual 
loss of vision, are not symptoms of as alarming a character as 
this inability to see certain objects that formerly were distinctly 
made out. The writer, in common with all medical men who 
see much of diseases of the eye, has seen so many cases of such 
marked self-deception in regard to the loss of sight, that he is un- 
able to trust the patients’ own opinions with regard to their visual 
power, but is always compelled to resort to an exact examina- 
tion by means of so-called test-letters. 
Test-Letters. 
Oculists, for the purpose of testing the visual power of their 
patients, use a series of sentences, which begin with the finest type 
that is made, and increase in regular order until very large or coarse 
type is used. A specimen of these is given on the following pages. 
Besides, they also employ a series of single letters. The latter is a 
more valuable test. If the letters that are used at the bottom of 
page 249 can be distinctly seen at a distance of twenty feet, there 
can hardly be any loss of sight. If it cannot be, the patient may 248 
THE EYE AND ITS DISEASES. 
simply require glasses. But if the finest print, of which the speci- 
mens are given on this page (No. 1), cannot be read at any dis- 
tance or with any light, there is certainly some loss of normal 
vision. If it can be read fluently and yet there is fatigue after- 
ward, it is probable that the affection, if any exist, can be relieved 
by glasses or by general treatment. If the finest type can be flu- 
ently read, but only when held nearer than six inches, it is prob- 
able that the patient is short-sighted, especially if the test-letters 
cannot be seen at twenty feet distance. If the patient hold the 
test-sentence “No. 1” farther than eight inches from his eye in 
order to read it, it is probable that he is far-sighted, especially 
if he can read the test-letters at twenty feet. The important facts 
to be remembered are : 
I. That an ability to read the test-letters fluently when placed 
at a distance of twenty feet, and “ No. 1 ” at eight inches, constitute 
normal vision. 
II. Inability to read the letters at twenty feet, while “No. 1 ” 
of the test-sentences can be fluently read at a distance less than 
six inches, indicates short-sightedness. 
III. Ability to read the letters at twenty feet, while the test- 
letters “No 1 ” cannot be read at all, or only when held more than 
eight inches from the eye, indicates far-sightedness. 
IV. Ability to read both the letters and the sentences at the 
proper distance, followed by a sense of strain, means weakness 
of vision. 
V. Inability to read either the letters at twenty feet, or the 
sentence “No. 1 ”at any distance, means loss of sight by disease. 
This loss may be estimated by noting the distance at which the 
letters may be made out, if at all, and the number of the test-sen- 
tences that can be read. 
Jaeger’s Test-Types. 
When, In the coarse of human events, it becomes necessary for one people to dissolve the political bands which have connected them with 
another, and to assnme, among the powers of the earth, the separate and equal situation to which the laws of nature, and of nature's God entitle 
them, a decent respect to the opinions of mankind requires that they should declare the causes which impel them to the separation. 
We hold these truths to be self-evident—that all men are created equal; that they are endowed by their Creator with certain inalienable 
rights; that among these arc life, liberty, and the pursuit of happiness. That, to secure these rights, governments are instituted among 
men, deriving their just powers from the consent of the governed; that, whenever any form of government becomes destructive of these 
No. 1. 
No. 2. 
ends, it is the right of the people to alter or abolish it, and to institute a new government, laying its foundations on such principles, and 
organizing its powers in such form, as to them shall seem most likely to effect their safety and happiness. Prudence, indeed, will dictate 
that governments long establised should not be changed for light and transient causes; and, accordingly, all experience hath shown 
that mankind are more disposed to suffer, while evils are sufferable, than to right themselves by abolishing the forms to which they are 
accustomed. But when a long train of abuses and usurpations, pursuing invariably the same object, evinces a design to reduce them 
under absolute despotism, it is their right, it is their duty, to throw off such government, and to provide new guards for their future secur- 
ity. Snch has been the patient sufferance of these Colonies, and such is now the necessity which constrains them to alter their former 249 
THE EYE AND ITS DISEASES. 
systems of government. The history of the present King of Great Britain, is a history of repeated injuries and 
usurpations, all having in direct object the establishment of an absolute tyranny over these States. To prove this, 
let facts be submitted to a candid world. 
He has refused his assent to laws the most wholesome and necessary for the public good. 
He has forbidden his governors to pass laws of immediate and pressing importance, unless suspended in their 
operations till his assent should be obtained; and, when so suspended, he has utterly neglected to attend to them. 
No. 3. 
No. 4. 
He has refused to pass other laws for the accommodation of large districts of people, unless those people 
would relinquish the right of representation in the Legislature—a right inestimable to them, and formidable 
to tyrants only. 
He has called together legislative bodies at places unusual, uncomfortable, and distant from the repository 
of their public records, for the sole purpose of fatiguing them into compliance with hiB measures. 
He has dissolved representative, houses repeatedly, for opposing, with manly firmness, his invasions on the 
rights of the people. 
No. 5. 
He has refused, for a long time after such dissolutions, to cause others to be elected, whereby 
the legislative powers, incapable of annihilation, have returned to the people at large for their 
exercise; the State remaining, in the meantime, exposed to all the dangers of invasions from 
without, and convulsions from within. 
He has endeavored to prevent the population of these States ; for that purpose obstructing 
the laws for the naturalization of foreigners ; refusing to pass others to encourage their migra- 
tion hither, and raising the conditions of new appropriations of lands. 
He has obstructed the administration of justice, by refusing his assent to laws for es- 
tablishing judiciary powers. He has made judges dependent on his will alone for the 
tenure of their offices, and the amount and payment of their salaries. He has erected 
a multitude of new offices, and sent hither swarms of officers to harass our people and 
eat out our substance. He has kept among us in times of peace, standing armies, with- 
out the consent of our legislatures. He has affected to render the military independent 
No. 6. 
No. 7. 
of, and superior to the civil power. He has combined with others to subject us to 
a jurisdiction foreign to our constitutions, and unacknowledged by our laws, giving 
his assent to their acts of pretended legislation. For quartering large bodies of 
armed troops among us; for protecting them, by a mock trial, from punishment for 
any murders which they should commit on the inhabitants of these States; for cut- 
ting off our trade with all parts of the world; for imposing taxes on us without our 
consent; for depriving us, in many cases, of the benefit of trial by jury ; for 
transporting us beyond seas, to be tried for pretended offences ; for abolish- 
ing the free system of English laws in a neighboring province, establishing 
therein an arbitrary government, and enlarging its boundaries, so as to render 
it at once an example and fit instrument for introducing the same absolute 
rule into these colonies; for taking away our charters, abolishing our most 
No. S. 
Snellen’s Test-Type. (No. 20.) 250 
THE EYE AND ITS DISEASES. 
Floating Bodies before the Eyes of Persons with Good Vision. 
Many persons are very much alarmed by the appearance in 
their field of vision, especially when looking toward the sky, but 
sometimes when looking upon the printed page, of objects some- 
what like little rings of mucus or minute soap-bubbles. Many of 
these appearances are merely shadows cast upon the retina. These 
shadows are the result of a disturbed condition of the natural com- 
ponent parts of the vitreous humor. (See p. 228.) They are not 
dangerous; cannot be seen by the physician when he looks into 
the eye with the ophthalmoscope, and they are seen most fre- 
quently in the eyes of those persons who use their eyes continu- 
ously. Other floating bodies in the vitreous, which are really 
dangerous, may always be seen by the aid of the ophthalmoscope, 
and neither improved condition of the general health, nor in- 
crease of the general strength, will ever cause them to disappear. 
They consist of blood and coloring matter which have escaped into 
the vitreous as the result of severe inflammation of the back part 
of the eye. 
The former are found in persons who see perfectly well, but 
who are somewhat annoyed by the appearance of the rings while 
at work. Such persons may, perhaps, be quieted by the assurance 
that if, in spite of such annoyance, they see distinctly throughout 
the entire field of vision, and if they can read the finest print, and 
no loss of the power of seeing objects at a distance has occurred, 
they need have no apprehension as to serious consequences result- 
ing from them. 
influence upon the Eye produced by Habits of Life. 
The habits of life influence the eyes very markedly. Not al- 
ways, but in a large proportion of cases, men who smoke and 
drink habitually and excessively are very apt to suffer, not only 
from inflammation of the outer part of the eyes, but from more 
serious forms of disease of the nerve and the retina. The person 
who is intemperate in smoking or drinking will suffer from his eyes 
exactly as in other organs of his body. These habits cannot be 
indulged in with impunity, and because some people go through 
life almost as inebriates, and yet do not suffer as to their eyes, is 
no more an argument that these habits are not generally injurious, 
than it would be to say that war is not dangerous because many 
people have passed through severe battles without losing their 
lives. Excessive indulgence in venery, whether among the mar- THE EYE AND ITS DISEASES. 
251 
ried or the unmarried, is sometimes a source of muscular fatigue, 
and consequently of congestion of the eyes. 
It should always be remembered that eyes are only—eyes. Men 
and women must not expect to be able to live on insufficient food, 
and labor twelve or fourteen hours daily, with scarcely any inter- 
ruption, without sooner or later reaching the point at which their 
eyes are unable to do their work. There is no organ in the body 
which requires more attention to the general health, the condi- 
tion of the skin, exercise in the open air, good food and proper 
habits in every respect, than the eye. The tissues of this organ 
are peculiarly sensitive to any general influence. 
The constitutional diseases may and do often affect the eye. 
This subject has been fully discussed in the following sections. 
Such diseases are, measles, scarlet fever, small-pox, yellow fever, 
syphilis, rheumatism, diphtheria, lead-poisoning, and so forth. 
Length of Time that Eyes may be Continuously Used. 
It is very hard, if not impossible, to lay down exact rules on 
this point. Perhaps, however, it may be correctly said that chil- 
dren under seven years of age should not be forced to use their 
eyes continuously on small objects held near them, longer than a 
few minutes at a time. In short, they should not go to school be- 
fore that age, unless it be that they may be permitted, after six 
years of age, to be taught by object-teaching, by the so-called 
Kindergarten system. 
Between seven and fourteen, children should not use their eyes 
at reading, writing, sewing, and so forth, more than three hours a 
day. The time spent in reciting is not included in this. Young 
men and young women between the ages of fourteen and twenty- 
one ought to be able to learn all their lessons, write all their es- 
says, practise all their music in a period of five hours a day for 
five days out of the seven. Correct habits of study, that is to say, 
earnest attention to the work in hand, without dawdling, will cer- 
tainly enable most youth of ordinary capabilities to do all their 
hard study in less than five hours a day. As to grown men and 
women, it is well-nigh impossible, in the light of present knowl- 
edge, to correctly name the time that may be daily spent in the 
use of the eyes on near and small objects. Experience as to one’s 
own capabilities, if regarded, will soon settle this question. 252 
THE EYE AND ITS DISEASES. 
GENERAL REMARKS UPON THE CARE OF INFLAMED 
AND INJURED EYES. 
In the various sections of the chapter upon the Diseases and 
Injuries of the Eye, a detailed account is given of the general 
rules of treatment, but a very few general remarks on the same 
subject may not be out of place here. 
Darkening of Rooms. 
One of the common mistakes of those who have not had much 
to do with the care of the eyes, is to say that inflamed or injured 
eyes often require a confinement in a dark room for a longer time 
than a few days. Whatever is necessary in the way of exclusion 
of light, except after surgical operations upon the eye, and in a 
limited number of cases of disease, can be attained by the use of 
light bandages or protective colored glasses. 
The writer has seen several persons who have been very un- 
wisely kept for months and years in very dark rooms on account 
of trouble with their eyes. There are no circumstances which will 
justify any such exclusion of light as this. The influence of the 
sun and the fresh air are just as necessary to the body when the 
patient is suffering from disease of the eyes, as when affected 
with disease of the lungs, and we must look with suspicion upon 
any advice which contemplates keeping any patient with an affec- 
tion of the eyes in a very dark room for a long period of time. 
Light is the true stimulus of the eye, and even diseased eyes, in a 
large proportion of cases, are the better for this stimulus, the same 
as an injured limb at a certain stage of its recovery is the better 
for gentle, active, or passive exercise. 
The writer has seen ludicrous instances of the confinement of 
patients suffering from trifling injuries and diseases of the eyes, 
in rooms from which every beam of light has been rigorously 
excluded, and he has also seen the sad ones, already alluded to, 
where the general health has been seriously undermined, by pro- 
longed exclusion of the light from the eyes of patients who should 
have been allowed to go about in the air and sunlight. 
Poultices and other Applications. 
Any person who prescribes for an eye without a knowledge 
of its anatomy, incurs a serious responsibility. Yet thousands of 
people take this responsibility lightly upon themselves. One of 
the most dangerous remedies thus prescribed is a poultice. THE EYE AND ITS DISEASES. 
253 
Poultices have destroyed so many eyes that, although their 
baneful influence has been alluded to in discussing the different 
diseases of the eye, I must here speak of them. Poultices usu- 
ally quiet pain, but their beneficial effect in this way is more than 
counterbalanced by their dangerous power of softening the deli- 
cate tissues to which they are applied. In case of doubt regard- 
ing an affection of the eyes, it is much better to be content with the 
simple rules for keeping them clean, for keeping them from the 
influence of dust, wind, smoke, and the like, and bathing them 
with cold or lukewarm water, at intervals, and then do noth- 
ing more. It is better, I say, to follow these rules than to run 
any risk by using any wash or application, no matter how bene- 
ficial it may seem to have been in some other cases. 
When severe pain is experienced in the eyes, very hot water 
may be applied for five or ten minutes every hour or so, without 
danger. It should be used by “sopping” the eyes with very soft 
cloth which has been dipped in almost boiling water. The con- 
tinuous application of moist heat to the eyes is very dangerous, 
because the transparent and very delicate front of the eye may be 
broken down by its application. 
Cold water is often grateful and necessary for inflamed eyes. 
It may be applied continuously, if it is agreeable, but great care 
should be taken that it is not allowed to become warm upon the 
eyes. To avoid this, bits of soft cloth may be laid upon a block of 
ice and then upon the eyes. These applications should be changed 
every one, two, or three minutes, according to the heat of the eye- 
lids. A “rose ” attached to a water-pipe is another means of irri- 
gating the eye with cold water. Douches for the eye that are 
worked by pressure upon an India-rubber air-bag, are also useful 
for the same purpose. Plunging the head under water, and then 
opening the eyes in it, seems a harsh method of washing the eyes. 
Many persons practise this. The experience of the writer seems 
to show that it produces no beneficial results that may not be ob- 
tained by a less disagreeable and less dangerous method. 
Water that is slightly impregnated with salt, in the proportion 
of a teaspoonful to a quart, is usually a bland and useful applica- 
tion to eyes that readily redden and become catarrhal. 
It is impossible to lay down any rules that will be sufficient for 
the care of any part of the human frame under all circumstances, 
but it is hoped that the foregoing will at least serve as a guide to 
those who may read them, and who are anxious to preserve their 
vision. 254 
THE EYE AND ITS DISEASES. 
DISEASES OF THE EYE. 
The human eye is subject to numerous diseases, and it is also 
in quite a large proportion of cases so irregular in shape as to be 
only completely useful when aided by spectacles. Moreover, the 
exposures incident to the various employments of adult life, and to 
the amusements of childhood, very often inflict injuries upon it. 
It will be the object of this chapter to furnish some general but 
correct ideas as to the nature and treatment of the affections thus 
variously produced. For the sake of system and order in our 
study, the affections of the lids and of the tear apparatus will be 
first discussed, after which we may pass on to those of the eyeball. 
Inflammation of the Edges of the Lids—Blepharitis Ciliaris. 
The edges of the lids are sometimes red and covered by a thick 
secretion which lies in crusts about the roots of the lashes, and on 
the mouths of the little tubes that are found in the cartilage or 
dense portion of the lids. This condition of things may be neg- 
lected or not properly treated, and may go on to such an extent as 
to destroy the lashes and give the eyelids a very unsightly appear- 
ance. This affection is probably as old as the race. It is particu- 
larly liable to occur in hot, dry, and dusty countries. 
The Bible describes Leah as “tender-eyed,”but says of Rachel 
that she was beautiful and “ well-favored.” The “ tender ” eyes of 
Leah, judging from what the travellers say of the prevalence of 
inflammation of the edges of the lid in the East, were affected in 
the manner that has been described. 
Causes.—These are chiefly to be found in a kind of catarrh 
caused by the presence of irritating substances upon the edges of 
the lids. Among the poorer classes dirt plays an important part 
in producing the disease. It is peculiarly apt to occur, as will be 
seen in the consideration of the use of spectacles, in persons whose 
eyes require glasses, but who do not wear them. Such eyes are 
constantly subject to a strain which may be compared to that 
undergone by any muscles that are working at a disadvantage, 
and which are attempting to do that for which their power is 
insufficient. 
Treatment.—The necessity for perfect cleanliness of the part 
involved in the disease, is the first and last advice to be given in 
all external diseases of the eye in which there is an increase of 
the natural secretions or any formation of pus. Eyes affected with 
diseases of the roots of the lashes, or of the glands at the edges of 
the lids, are best cleansed in the following manner: THE EYE AND ITS DISEASES. 
255 
A teaspoonful of ordinary baking-soda is dissolved in about a 
pint of warm water. Then the eye to be washed should be gently 
closed, and if the patient be a grown person the washing is done 
with his own hand by means of small bits of an old cambric hand- 
kerchief or similar material. If crusts are upon the lids, this 
washing will require some rubbing, and will cause discomfort. 
It is not, however, to be desisted from on this account, but it is to 
be continued until all the crusts are removed. If some of the 
hairs, or all of them, come out, no harm will result, for they will 
soon be renewed. If they are ulcerated at their roots to such an 
extent that they are likely to fall off in a short time, the sooner 
they come away the better for the cure. After the cleansing has 
been thoroughly accomplished, some substance, such as vaseline, 
cold cream, simple cerate, or mutton-suet without salt, should be 
rubbed, in very small quantity, along the roots of the lashes. This 
is to prevent the sticking together of the lids—a very unpleasant 
symptom usually observed on awaking from sleep. The water 
used in cleansing the lids should be tepid. Breast-milk, cow’s 
milk, and other popular washes for inflamed eyelids have no vir- 
tues beyond those of simple water. Their use should not be en- 
couraged. 
Severe cases, or those of long standing, may require, after the 
washing, more energetic treatment, that is, more powerful appli- 
cations, but these should only be made under the advice of a phy- 
sician. If the case is one that is aggravated, or maintained by 
the fact that the patient requires glasses and does not wear them, 
the eyes must be examined by an oculist, and the proper glasses 
prescribed. 
Styes—Hordeola. 
These are essentially small boils at the edges of the lids. They 
begin in the hair-follicles or in the glands of the cartilage. As is 
well known, they are apt to occur in rapid succession on the same 
eye. 
Causes.—It is probable that all boils are in some way, not as 
yet explained, connected with or dependent upon an impairment 
of the general health, so that patients who are affected with styes 
should consider them as warnings with reference to some general 
and worse affection than the one of the eyes. It may be a disor- 
dered condition of the digestive apparatus, or impoverishment of 
the blood, and there may be local causes acting with these. 
Symptoms.—A stye appears as a red, usually small swelling at 
the edge of the lid. It sometimes disappears without breaking, 256 
THE EYE AND ITS DISEASES. 
but more often it suppurates and discharges a small amount of 
pus, when the pain and tension in the eyelid, which have been 
considerable, are relieved. 
Treatment.—The use of small poultices applied to the parts for 
a few hours, and then the evacuation of the pus by a knife in the 
hands of a surgeon, are means of treatment that usually shorten 
the duration, and alleviate the discomfort of styes. In applying 
the poultice care should be taken that it be applied to the stye 
only, and not to the eyeball, for poultices are very dangerous ap- 
plications to the eye itself. Where styes occur in frequent succes- 
sion, physicians are sometimes able to abate them by suitable 
advice and applications. 
The use of very small poultices in the stage of swelling and 
pain, followed up by the application of vaseline, cold cream, mut- 
ton-suet without salt, or the like, when the stye has broken, is 
about all the local treatment that is of service in alleviating its 
pain and discomfort. 
An ointment of the red oxide of mercury, one or two grains to 
the drachm of simple cerate, is said, when rubbed upon the in- 
flamed part, to sometimes prevent its full development. The 
writer, however, has more faith in careful attention to the state 
of the general system, which should be carefully looked into if 
styes continue to recur. If there be any short-sightedness or 
other condition of the eye requiring spectacles, these should be 
properly chosen and worn. 
Tumors of the Eyelid—Chalazion. 
The eyelids are sometimes affected with small growths that are 
not dangerous. These tumors are usually the result of a closure 
of the mouth of the little tubes found in the cartilage of the lid, 
and described on page 232. When the oily matter formed in these 
tubes or glands cannot find its way out in the natural way, it ex- 
tends upon each side and forms quite a lump. The process is as 
purely mechanical as the distention of any flexible tube from over- 
filling. It is probably an inflammation at the mouth of the tube, 
which finally closes it. 
Treatment.—These growths sometimes disappear of themselves 
without any treatment. Sometimes they become so distended as 
to burst, and for some days considerable disfigurement results. 
More frequently, however, the opening at the end of the canal is 
restored, and a cure is effected by the evacuation of the collected 
material. They often, however, do not disappear for a very long 
time, and they should then be cut out by a surgeon. The operation THE EYE AND ITS DISEASES. 
257 
is a simple one, but quite painful, and it is usual to cause the pa- 
tient to inhale ether when it is performed. All the operations 
upon the outer parts of the eye are usually more painful than 
those upon the interior, simply because these parts are more 
abundantly supplied with nerves of sensation than the other. 
Displacement of the Lids Inward or Outward—Entropion and 
Ectropion. 
These deformities of the lids are chiefly produced by two causes : 
inflammations of the lining membrane of the lids (the conjunctiva), 
or injuries of the lids themselves. The natural curvature of the 
lids, as will be seen by a glance at a healthy eye, is admirably and 
exactly adapted for the protection and comfort of the eyeball. 
Any curving in or out of these parts produces very considerable 
discomfort and annoyance. If the lids be turned in, the lashes 
press upon the delicate structure of the ball, and cause serious in- 
flammation. If they turn out, the carrying off of the tears is in- 
terfered with, and the eyeball is exposed to the unpleasant and 
injurious influence of dust, dirt, the wind and the like. 
Treatment.—There are surgical operations for the relief of these 
affections, which are successful in a good proportion of cases ; but 
it should be remembered that these are consequences of disease 
and injuries, and not primary affections, and hence we may not 
expect the results that are to be obtained when the original affec- 
tions are treated. Besides, injuries of the lids are sometimes of so 
destructive a character, that their results are irreparable. 
Individual eyelashes are sometimes displaced without any par- 
ticular curvature of the lids. If their repeated removal does not 
overcome the faulty disposition, their roots may be destroyed by 
surgical procedures. 
Paralysis of the Muscles of the Eyelids. 
All the muscles that move the eye may become unable to do 
their work. As a rule, however, only one, or a group supplied by 
the same nerve, is paralyzed. The muscle that lifts the lid is quite 
often thus affected, and causes what is known as ptosis (a fall- 
ing). In this form of paralysis, the nerve, called by anatomists 
the third cerebral nerve, one that passes from the base of the 
brain to this muscle, as well as to four other muscles of the out- 
side of the eye, is the seat of disease or injury at its origin, or in 
some part of its course. 258 
THE EYE AND ITS DISEASES. 
Causes.—These sometimes act in the womb, and children are 
born with paralysis of the lids, so that they cannot be opened 
widely. Injuries and diseases of the brain are also causes. The 
so-called blood-poisons, such as syphilis, may and do very fre- 
quently cause paralysis of the muscles of the lids. 
Treatment.—The congenital form of paralysis of the upper lid, 
and that resulting from injury, may sometimes be benefited to 
some extent, but generally not entirely cured, by a surgical opera- 
tion, which shortens the lid and thus relieves the paralyzed muscle 
of a part of its weight. That caused by the poison of syphilis may 
often be entirely cured by the treatment appropriate for the con- 
stitutional disease. 
Paralysis of the Muscle that Shuts the Lid. 
The seventh cerebral nerve supplies this muscle (orbicularis). 
It is therefore an affection of this nerve that causes an inability 
to close the eyes. Inasmuch as the muscle with which the cheek 
and lips are moved, are also supplied by this nerve, such a pa- 
ralysis is usually accompanied by a falling down of the angle of 
the mouth, and an inability to pucker the lips, as in the act of 
whistling, etc. If the portion of the nerve that supplies sensa- 
tion to the face is also affected, there is also insensibility as well 
as loss of motion. (See Paralysis of the Face.) For some unex- 
plained cause syphilis is more apt to attack the third than the 
seventh nerve. 
Exposure of the face to a draught of air, the breaking of a blood- 
vessel at the origin or in the course of a nerve, inflammations of 
the neck and face, the excessive use of tobacco, are also well-de- 
fined causes of paralysis of this nerve. 
Sometimes the disease or injury of the nerve causing the pa- 
ralysis affects it before it passes out of the skull. Sometimes it is 
affected in its passage through the drum of the ear, or just after it 
has come out at the angle of the jaw, or even not until it passes 
over the face itself. 
Treatment.—The treatment is, of course, to be directed toward 
the cause, and will vary according to this. Paralysis of the nerve 
from exposure to draughts of air is usually recovered from spon- 
taneously. Electricity and mechanical support are very useful in 
the care of these affections. THE EYE AND ITS DISEASES. 
259 
Twitching of the Eyelids. 
Involuntary movement of the muscles of the lids is a symptom 
usually seen in connection with general disease of the nervous 
system, such as chorea, the so-called St. Vitus’s dance. Indeed, it 
is often a kind of chorea, and the reader is referred to the section 
upon that subject for fuller information. 
Spasmodic Closure of the Lids. 
The eyelids are sometimes firmly and spasmodically closed in 
the course of different affections of the eye. The reason for this 
closure is either an abnormal sensitiveness to light or great swell- 
ing of the lids. This condition is simply a consequence of the af- 
fection that causes the dread of light and the swelling. It will be 
again alluded to in the description of those diseases. 
Bruises of the Eyelids. 
The eyelids are sometimes injured by blows from the fist, or 
from some missile which ruptures the blood-vessels, and permits 
the escape of blood into the loose connective tissue of the lids. 
The condition is popularly known as a black-and-blue eye. If no 
parts deeper than the lid be involved, time will soon effect a cure. 
Cold applications are usually grateful to the eye. It is believed 
by some that the application of ice-water, evaporating lotions, ex- 
tract of witch-hazel, or arnica, hasten the absorption of the blood, 
but this belief is not shared by the writer of this chapter. Iced 
cloths, applied often enough to always have the eye kept cool, 
and never warm, are to be urgently recommended, however, in 
the hours immediately after the injury, since they lessen the heat 
and swelling. Tradition, among the laity, speaks well of a poultice 
of raw beef, an oyster, or the like, and they undoubtedly are 
grateful to the eye ; but such applications are dangerous, espe- 
cially if kept on for many hours in succession, and ought never to 
be made, except under close medical observation. They are agree- 
able to a bruised eyelid, hence their traditional popularity. The 
disfigurement is so great from a black and blue eye, that in large 
towns there are artists who remove it by a skilful painting of the 
discolored parts.* 
[* A solution of nitrate of potash in water, applied with muslin cloths, will often 
change the color from dark to a brighter red. —Ed. ] 260 
THE EYE AND ITS DISEASES. 
Wounds of the Lida 
These should be treated at once by a surgeon, so that deformity 
may be avoided by a skilful bringing together of the divided parts 
by stitches. 
Affections of the Tear Apparatus—Lachrymal Diseases.* 
The diseases of the tear-apparatus are quite common in all 
countries where the climate is variable. In general terms they 
may be said to be most commonly produced by the same influences 
as those which cause a cold in the head. The lachrymal gland 
(see figure on page 233), however, is rarely the seat of disease. The 
chief troubles of the so-called lachrymal or tear-apparatus are in 
the conduction or carrying off of the tears. A “weeping eye” is 
the result of some obstruction in the conducting apparatus. By 
this term, as is perhaps well known, is meant an eye that is con- 
stantly moistened with tears which are not carried off into the 
nostril, but which run over the cheek. Since these passages are 
narrow, a slight swelling of their lining membrane is sufficient to 
impede the passage of the tears. This swelling is generally the 
result of a cold in the head, or rather of the swelling of the lining 
membrane of the nostrils and pharynx, which is continuous with 
that of the tear-passages. This swelling is one of the symptoms of 
a cold in the head. Another prominent symptom is an increase of 
the natural secretion of the membrane covering the eye, lining the 
eyelids and the lachrymal and nasal passages—the conjunctiva. 
This condition increases the work of the apparatus for carrying 
off the tears, while the former diminishes the size of the parts 
through which the tears have to pass. Under the usual treat- 
ment for a cold in the head, or, perhaps, with no especial treat- 
ment, these symptoms pass away, but it sometimes happens 
that the cure is not complete, and the passage into the nose from 
the sac (see figure) is left smaller than is natural, and perhaps, 
also, the little canal leading into the sac. We then have a nar- 
rowing or stricture of the tear-passages. If, added to this, there is 
an increase in the secretion from the mucous membrane lining the 
parts, we have catarrh of the tear-passages. 
These two conditions are usually united in the same case. The 
collection of tears in the corner of the eye, and their escape over 
the cheek are the chief symptoms of a “weeping eye,” when the 
* Before studying this section, it will be well for the reader to refer to the anatomy 
of the parts involved, on a preceding page. 261 
THE EYE AND ITS DISEASES. 
disease is of a mild character. There is, however, a form of this 
trouble in which the mucus collects in such quantities in the sac 
as to enlarge it and form a tumor or swelling at that point. This 
may often be emptied by pressing upon the enlarged sac. Many 
people live for years with such a deformity and inconvenience, 
with no attempt at relief. 
There is danger, when the disease reaches such a point as this, 
that pus or matter may collect in the sac. We then have to deal 
with a very painful and serious affection. The formation of pus 
in the human body is generally ushered in by a chill or, at least, 
chilly and uncomfortable sensations, and when it occurs in the 
eyelids or appendages of the eye there is no exception to the rule. 
The eyelids swell very much at this time, so that it seems as if all the 
tissues of the parts were involved. A mistake is sometimes made 
in supposing that a disease of this kind is an attack of erysipelas. 
A little attention to the history of the previous condition of the 
tear-passages, and a close examination of the corner of the eye over 
the sac, will show the real nature of the trouble. This formation 
of pus is preceded by the ordinary symptoms of what is termed in- 
flammation. These symptoms are heat, redness, swelling, and 
pain. If the disease be not recognized at an early date and appro- 
priately treated, after some days of intense suffering the pus will 
make an opening in the skin of the sac and force its way out. 
Although the patient will get relief from his sufferings, there will 
be apt to remain a permanent opening in the skin. This opening 
is called a fistula. This condition is worse than the originally ex- 
isting “weeping eye.” 
Causes.—The causes of these affections of the tear-passages 
have, perhaps, been plainly enough indicated in the statement 
that they are chiefly the result of an inflammation of the mu- 
cous membrane lining them, or of a continuation of such an in- 
flammation from the nose and throat to the eye. The causes of 
catarrh are discussed in another part of this volume. 
It is sufficient to say here that all improper habits of life, all 
diseases which lessen the power of resistance to changes of tem- 
perature, may be causes of catarrh. Syphilis is also not infre- 
quently a cause of catarrh of the tear-passages, as well as of 
catarrh of other mucous membranes. 
Treatment.—Probably every observant reader of these pages is 
able to recall examples in his own acquaintance of the “ weeping 
eye,” and he will remember that some of these cases have seemed 
to go on for years without causing anything more than consider- 
able inconvenience. Inquiry, however, will often elicit the fact 
that there have been, in most cases, occasional attacks of inflam- 262 
THE EYE AND ITS DISEASES. 
mation that have been very painful and severe enough to keep the 
patient from ordinary employments for several days. 
It is true, however, that some few cases do go through life with- 
out such acute inflammatory attacks. These cases, which may be 
properly called exceptional, furnish no good ground for the neg- 
lect of a “weeping eye.” A simple surgical operation and a few 
weeks of treatment will often cure the disease, and when they do 
not, will very much lessen the chances of the formation of an 
abscess. The treatment, in most cases, is chiefly local and surgical. 
The little aqueduct leading along the edge of the lid to the tear- 
sac is slit up, and made an open 
canal (see adjoining figure). 
The passage going into the nose 
is dilated by means of probes. 
At the same time astringent 
washes are sometimes used up- 
on the parts by means of a syr- 
inge, or by dropping into the 
eye. If there are any constitu- 
tional causes for the catarrh, 
these should be removed by ap- 
propriate treatment, or all local 
means will be of no avail. 
This is especially true of cases 
caused by syphilis. In very bad, 
usually neglected cases, when 
the bone forming a part of the 
walls of the canal has become 
diseased, it is sometimes neces- 
sary to destroy the tear-sac by 
caustic, or the surgeon’s knife. 
Some cases are never thoroughly 
cured by any treatment in the 
hands of the most skilful men, 
but much more is done for them than was accomplished by the 
mode of treatment of years ago, when the disfiguring tubes were 
worn in the eye. 
The local treatment now usually adopted, and which has been 
described, is that suggested by Mr. Bowman, of London. The 
probes used for dilating the parts are gradually increased in size 
until a sufficient enlargement of the narrowed canal has been at- 
tained. Nothing is left in the eye, and after the probing the pa- 
tient is not required to observe any particular precautions, but 
goes about his ordinary employment. 
Figure 64.—Showing the method of prob- 
ing the tear-passages. The little canal in the 
edge of the lid has been slit before the probing 
is done. THE EYE AND ITS DISEASES. 
263 
If an abscess has actually formed, an incision to empty out the 
pus must also be made externally. The scar from such an opening 
is very soon obliterated. Even if an abscess has formed, besides 
opening this it will be necessary to open the canal into the sac, 
and probe the passage into the nose just as if the case were seen 
before the abscess had formed. The treatment is often very 
tedious, but, on the whole, patients seem to be well satisfied with 
the results obtained. 
Inflammation of the Conjunctiva—Conjunctivitis. 
What is popularly known as a “ cold in the eye” is an affection 
of the mucous membrane which lines the lids and covers the front 
of the eye, which is called by anatomists the conjunctiva {con and 
jungo, to join together). This membrane is subject to various 
forms or degrees of inflammation, but they are all modifications of 
the original variety. We may classify them as: I. Catarrhal; II. 
Purulent; and III. Pustular. 
There are many chronic consequences of these forms of dis- 
eases. Some of them have already been discussed in the section 
on the Diseases of the Lids, but they will be included in the classi- 
fication for the sake of clearness : 
1. Turning in of the lids {E'ntropion). 2. Turning out of the 
lids (Ectropion). 3. Thickening of the lining of the lids, granular 
lids {Trachoma). 4. Blear eyes {Xerosis). 
Cold in the Eye—Catarrhal Conjunctivitis. 
An eye that is affected with catarrh presents the following ap- 
pearance : The white of the eye has a generally red color. A 
person who has been trained to observe, will see that all the blood- 
vessels are full of blood, and that there is not a ring around the 
cornea or window of the eye (see Fig. 65) that is redder than any 
other portion. There will also usually be some swelling of the 
lids, and the mucus and tears will flow in such quantities as to keep 
the eyes suffused. The patient will complain that his eyes feel as if 
there were sand in them, and that they became glued together at 
night so that they can be opened in the morning only after they are 
carefully washed. If' the lid be turned over—rather a difficult 
operation for a person untrained to it—the lining membrane will 
be found no longer of a salmon color, with individual vessels to be 
seen, but it will be of a generally red, perhaps velvety appearance. 
There are, however, various degrees of severity of catarrh of the 
membrane lining the lids and covering the front of the eye. Thus 264 
THE EYE AND ITS DISEASES. 
we may have merely the sticking together of the lids with a little 
mucus gathered in the corner of the eye, and so little redness that 
only the practised observer will be able to say that there is any in- 
flammation. 
The diseases which may be mistaken for conjunctivitis are in- 
flammations of the cornea and of 
the iris. Besides, we often meet 
with a catarrh of the conjunctiva 
that is merely a symptom of an 
overworked eye, or one that is work- 
ing under improper conditions, as, 
for example, without glasses, when 
glasses should be worn. It will be 
seen then that it is not safe to con- 
clude that because a patient has 
catarrh of the conjunctiva, he has 
no other or more serious trouble in 
addition to this. 
Causes.—It is hard to say just 
how a person gets a cold in the 
eyes. We do know, however, that 
exposure to a strong wind, to dust, to acrid vapors, or bright light, 
will sometimes be followed by a catarrh of the mucous membrane 
of the eyes. A severe chilling of the surface of the body may have 
the same effect, or excessive use of the eyes with bad or feeble light. 
During the course of measles and scarlet fever, especially the for- 
mer, there is apt to be catarrhal inflammation of the mucous mem- 
brane of the eyes. 
Treatment.—A mild case of catarrh of the eyes requires very 
little medical treatment, while a serious case will demand a very 
prompt and energetic course. The intelligent person will hardly 
need to be reminded that there is a tendency to self-limitation in 
certain diseases of the eye, as well as in those of other parts of the 
body. 
Rest of the eyes, the avoidance of exposure to dust or bright 
light, perfect cleanliness of the membrane, exercise in the open 
air under favorable conditions, with lubrications of the edges of 
the lids with simple cerate or vaseline, or the like, will often be 
sufficient for a really mild case that is not dependent upon any 
faulty structure of the eyes requiring the use of glasses. The mild 
cases will, under this regimen, run their course, and leave the eyes 
as well as ever. [There is said to be a form of conjunctivitis oc- 
curring in malarious subjects, which is cured at once by the use 
of quinia.] After such an attack, it is well, however, to secure, 
Figure 65.—Showing the appearance 
of the blood-vessels in conjunctivitis or a 
cold in the eye. THE EYE AND ITS DISEASES. 
265 
by a careful examination, an assurance that the lids have not been 
left at all thickened. 
A severe case is one in which the lids are swelled, the eyes 
red and suffused with discharge, the edges of the lids very 
sticky, while the eyes are hot and very uncomfortable, with a 
sensation as if sand were in them. In such cases the eyelids 
should be frequently douched with cold water, or cold cloths 
of one thickness should be laid upon the eyes, and changed so 
often that they may never be hot, or even warm. When ice is 
convenient, the cloths, which should bo of delicate muslin, or the 
like, may be laid upon a block of ice, and then upon the eyes. The 
danger in the use of poultices in such cases is very great. If ad- 
vice cannot be obtained, a solution of sulphate of zinc or of pow- 
dered alum, in the strength of two grains of either to the ounce 
of pure water, may be dropped into the eye two or three times a 
day. A few drops is sufficient for this purpose. At night, vase- 
line, sweet oil, cold cream, or the like, should be smeared between 
.the edges of the lids along the eyelashes. The patient should 
not be kept in bed, and in fine weather may walk about as usual, 
protecting his eyes from bright light by blue or London-smoke 
spectacles. Goggles should not be worn, for they keep the eye too 
warm. 
The patient with catarrh of the conjunctiva should avoid all 
places badly ventilated or crowded, or those where there is smoke 
or dust, or a bright light or a strong wind. 
As has been said, the disease is self-limited, and all the treat- 
ment is intended to guide its course rather than to cut it off. 
Patent eye-washes, some of which contain substances that may 
be permanently injurious to the eye, such as lead, should not be 
used. Blisters are of no use, and simply annoy the patient. Poul- 
tices of all kinds, whether of tea-leaves, alum-curd, oysters, or 
bread and milk, are very dangerous to the eyes, and should never 
be used for any affection of any part of the eyeball. It is neces- 
sary not to do too much for a disease of the eye. When there is 
doubt as to what the trouble is, do nothing but keep the eyes 
clean, and get competent advice as soon as possible. 
Purulent Conjunctivitis. 
This is one of the most dangerous of the affections of the eyes. 
Its symptoms are, fortunately, unmistakable. The affection oc- 
curs suddenly, beginning as a catarrh. The eyelids become red 
and greatly swollen, so that they can scarcely be opened. Pus 
streams out of the eyes when the lids are pulled apart, and the pa- 266 
THE EYE AND ITS DISEASES. 
tient complains of a great deal of heat and tenderness in the lids 
and eyes. 
On separating the lids, the front of the eye is red, and some- 
times it is so swollen as to be lifted up and form a ring around 
the cornea, or window of the eye. This inflammation may occur 
in the newly-born infant as well as at any time of life. 
The Causes are a direct contact of the eye with pus from another 
part of the body of the same or another patient—for example, a care- 
less patient suffering from gonorrhoea or leucorrhoea may bring 
some of the poisonous pus between his or her eyelids and thus set 
up an attack. Of course, matter from another eye affected with 
the disease will produce the disease. A surgeon may be unfortu- 
nate enough to allow some of the matter from an eye affected 
with purulent conjunctivitis to enter his own eye. A careless nurse 
may allow some of the discharges from the parts of the mother, 
after childbirth, to dry upon a napkin or upon her hand, and then 
bring it into contact with the conjunctiva of the babe, where it 
will dissolve and cause an outbreak of purulent conjunctivitis. 
It is a highly contagious disease. It should also be remem- 
bered that even a chronic catarrhal conjunctivitis may advance 
to be a purulent one without the direct contact of any poison from 
another part of the body, or from another eye. Hence we may 
not say that every case of purulent conjunctivitis is caused by con- 
tagion. This is rather an important point. The writer was once 
a witness in a case of alleged malpractice, which involved this 
question. It is very important to isolate the patient suffering 
from purulent inflammation of the eye from all persons except the 
attendants, until the discharge has ceased. 
The utmost care should be taken that none of the implements 
used in cleansing the eyes of the patient should ever be used by 
any one else, without a thorough washing and disinfection. If 
one eye alone be affected, it is better to close the other with stick- 
ing-plaster and a bandage, that no pus can be carried into it. 
Treatment.—If possible, a surgeon should be called in to treat 
so formidable a case as that now described, but if the reader of 
these pages is unfortunate enough to be obliged to advise in such 
a case, in the absence of medical aid, or be himself the victim of 
it, he should carry out the rules just stated about contagion, and 
then proceed to apply ice-water or very cold water, night and day, 
and to cleanse the eyes with tepid water at least once an hour. At 
the same time the eyes should be washed with a solution of alum, 
in the proportion of a teaspoonful to a pint of water, six or seven 
times a day. This treatment is applicable to the child just born as 
well as to the adult. In the former case a little more care is to be THE EYE AND ITS DISEASES. 
267 
taken in regard to the use of ice, lest the tender lids become excori- 
ated. In case the very cold water causes great discomfort it should 
not be used. 
Cleanliness of the eyes is the most important part of the treat- 
ment. Small bits of old linen, very soft and very fine, of a single 
thickness, dipped in tepid water, are the best means of cleansing 
the eye. The use of a syringe in unpractised hands is somewhat 
dangerous both to the patient and to the attendant. The surgeon 
may use, in addition, leeches and nitrate of silver, if his judgment 
dictates, but the non-professional attendant should not venture on 
any more positive treatment than that which has been delineated. 
Opening the lids in order to clean the eyes will require some tact 
and patience. The attendant, however, should not be satisfied 
unless he does actually open them by gently pulling them apart, 
after soaking the edges so that the matter may be wiped out, or 
a stream of water be allowed to pass between them. The same rule 
as to poultices, or any kind of continued warm applications to the 
eyes, is to be observed here as in the treatment of catarrh. 
Poultices break down the delicate tissue of the front of the eye, 
and if applied even for a few hours, may ruin the sight. The most 
deplorable consequences of this kind of treatment are constantly 
to be seen in dispensaries and infirmaries, and sometimes in private 
practice. But these remarks are not to be construed as an objec- 
tion to using warm water for a few moments at a time. 
Consequenees of Acute Conjunctivitis. 
Both catarrhal and purulent conjunctivitis, even if they are 
subdued without damage to the front of the eyes, sometimes leave 
behind consequences that are dangerous to the integrity of the 
organ, such as chronic inflammations and distortions of the lids. 
Chronic conjunctivitis should be treated by mild astringents, such 
as alum, two grains to the ounce, and by lubrication of the edges 
of the lids with vaseline, cold cream, mutton tallow, etc. Great 
care should be taken to avoid exposure of the eyes to improper in- 
fluences. But the advice of a medical man can usually be had in 
chronic cases of this kind. This is the more necessary, because a 
case of supposed chronic inflammation of the mucous membrane 
of the eye sometimes turns out to be an inflammation of the 
deeper parts, which is a more serious matter, and requires very 
different treatment. 
The patient who believes that his affection is one of the con- 
junctiva merely, should make himself sure of that fact when the 
opportunity offers. Besides, a chronic affection of the mucous 268 
THE EYE AND ITS DISEASES. 
membrane may, by direct extension, become one of the deeper 
parts. The boundary lines of disease are not always distinctly 
marked. 
Thickening of the Lining of the Lids—Granular Lids— 
Trachoma. 
The so-called granular lids are by far the most frequent conse- 
quences of neglected inflammation of the mucous membrane (con- 
junctiva) of the eye. Lids are, however, often supposed by non- 
medical persons to be granular, when they are not at all so. The 
red line along the edge of the lid, which shows that there is dis- 
ease of the roots of the lashes, or of the glands, is sometimes sup- 
posed to be one of the symptoms of a granular eyelid. Unless the 
lids are turned over so as to expose the membrane lining them (see 
anatomy of eyelids), it is impossible to say, whether or not, they 
are granular. It requires some little knack and experience to turn 
over the upper eyelid, hence the changes there, or the presence of 
foreign bodies upon it may escape notice. The little operation of 
turning over the upper lid is performed in the following manner: 
The patient should sit down with his head supported by another 
person, or leaning against some good support, while the operator 
stands in front. The person whose lid is to be turned over, should 
then look down. This is not always an easy thing to do, for the 
natural inclination when told to look down, is to turn the whole 
head downward, and not the eyes. It is the latter that is wanted, 
for when this is done, for evident reasons, it will be much easier to 
turn over the lid. After the patient has turned the eye well down- 
ward—and this action may be facilitated by telling him or her to 
look at his hand, or the like—the operator seizes hold of the very 
edge of the lid by the fingers of the right hand, and stretches it 
downward, and at the same time presses the skin of the eyebrow 
with some firmness upon the bone. The second stage of the pro- 
cedure consists in turning the lid over the thumb. No pencil, pen- 
handle, nor instruments but the two hands are needed for this 
little operation. The person who learns to perform it will some- 
times be the means of relieving from much suffering, perhaps, a 
fellow-passenger in a railway carriage, who has got a cinder 
under the eyelid. As has been said, it is only when the lids are 
well turned over, that we can say that there are granulations, or, 
to speak more correctly, thickening of the lining membrane of the 
lid. 
When once the lids are turned over, if there are granulations, 
instead of seeing the salmon color of the membrane, we find it of a THE EYE AND ITS DISEASES. 
269 
deep red hue ; instead of perceiving the individual blood-vessels 
like little threads, we find a general velvety appearance, and per- 
haps we see very minute bodies, looking like the spawn of fish or 
frogs. 
As has been said, granular eyelids are the result of an inflam- 
mation of the lining membrane. This being unchecked causes 
the tissue to grow, that is, its natural structures become en- 
larged. The disease is very apt to be associated with a low state 
of the general health and bad habits of life, although a patient may 
be in full health and yet suffer from the disease. If unchecked, 
thickening of the conjunctiva causes deplorable consequences. 
The cornea or window of the eye is finally covered over with blood- 
vessels, or ulcerated, or becomes opaque, and thus the sight is 
very much impaired, and sometimes nearly destroyed. When 
things have gone on to this state, a cure is often impossible. 
Treatment.—While all attention should be paid to any defect 
in the mode of life, or food, or habits of the patient, the treatment is 
pre-eminently local. What are known as astringents, and astrin- 
gent caustics—such as alum, sulphate of copper, tannic acid—are 
applied to the eye by a surgeon, while the patient protects his eyes 
from bright light, keeps them very clean by frequent bathing in 
tepid water, and uses a mild wash of alum, or sulphate of zinc (two 
grains to the ounce) or the like, and anoints the edges of the lids 
with ointments such as have already been mentioned. Patients 
with thickening of the lining of the lids should remember that 
this is a chronic disease, and not self-limited, like many an acute 
one. The golden plan for treating granular lids is that of pre- 
vention. A cure must often be, at the best, only partial; be- 
sides, in many cases, the treatment will require months and even 
years. 
Growths upon the Mucous Membrane of the Eye—Pterygium. 
This is an affection which may, perhaps, arise independently of 
any general inflammation of the conjunctiva, or which may be a 
consequence of it. It is a triangular-shaped thickening of the 
membrane and enlargement of the blood-vessels situated in one or 
both corners of the eye. The apex of this triangle is toward the 
cornea. From its fancied resemblance to the wing of a bat, it has 
the name, in surgical science, of pterygium (little wing). It is prob- 
ably caused by inflammation, and occurs chiefly in those whose 
eyes are constantly exposed to a long sweep of winds on prairies, 
on the seas, etc. It is not necessary to interfere with pterygium 270 
THE EYE AND ITS DISEASES. 
unless it grows upon the cornea, when it may be removed by a 
surgical operation. The scar from the removal of a pterygium 
Fig. 66.—Pterygium. 
Fig. 67.—The operation for removal of pterygium. 
disfigures as much as the disease itself. Astringents and the like 
are of no service in cases of this kind. 
There are other very small, almost infinitesimal tumors some- 
times found upon the conjunctiva, not usually large enough to 
constitute a blemish. They may be cut off if they cause de- 
formity. 
Adhesion of Lids to the Ball—Symblepharon. 
The eyelids sometimes grow to the ball of the eye, in conse- 
quence of burns which have destroyed the mucous membrane. It 
is extremely difficult to break up these adhesions permanently, 
and the most skilful operations do not always succeed. (See Burns 
of the Eye.) 
Foreign Bodies on the Outside of the Eye 
Any substance which has no proper place in or upon any part 
of the body is called, in technical language, a “ foreign body.” The 
lodgment of foreign bodies upon the outside of the eye is of very 
frequent occurrence. Railway and steamboat travel are fertile 
sources of such intruders as cinders, while those who work in ma- 
chine shops are in constant danger from sparks and bits of metal 
entering the eye. In the firing or accidental explosion of firearms 
there is another source of danger from percussion caps or grains THE EYE AND ITS DISEASES. 
271 
of powder. Children climbing up and down trees have been known 
to get buds and bits of leaves on the outside of the eye. 
It is a cardinal principle in examining an eye to first look for a 
foreign body, especially when symptoms of inflammation are pres- 
ent. This can only be done thoroughly when the lids are turned 
over by the method already described on page 268. Any small 
blunt instrument, or even a handkerchief, is sufficient to remove 
an offender from the lid, but to remove one from the cornea, or 
transparent front of the eye, sometimes requires very delicate in- 
struments and much skill. Workmen in machine shops often ac- 
quire much of this dexterity. The danger in working at foreign 
bodies on the transparent part of the eye, is, that they may 
pass through this thin and delicate membrane, or that rude 
attempts to remove them may push them further in. A foreign 
body on the eye is a very painful and troublesome affair, and may 
be serious ; but a foreign body in the eye is always extremely dan- 
gerous, not only to the eye in which it is, but also to the fellow 
eye, so that the utmost care should be taken by the inexperienced 
person when called upon, as he may sometimes be, to remove a 
foreign body from the front of the eye. If necessity compels the 
interference of a non-medical person, he should first place his pa- 
tient in a position where the eye is in a very good light, and where 
the sufferer can lean his head firmly against some support. Then, 
having the assistance of one other person, if possible, he should 
endeavor to tilt, with a delicate bit of wood or the like, the sub- 
stance from off the front of the eye, while he holds the lids firmly 
but gently apart. Only a blunt instrument should be used on the 
eye by any but a surgeon. 
There is a popular notion that “ eye-stones ” * [or flax-seeds] are 
valuable means of removing foreign bodies from the eye. The 
writer knows travellers who carry them constantly, and who not 
only use them on their own eyes, but confidently advise them to 
others. They often accomplish the removal of the foreign body, 
but sometimes they do not; then they cause serious inflammation. 
They act by producing an irritation of the lids, which causes a 
great flow of tears that may wash out the offending body. Be- 
sides, they hold the lid a little off from the ball, and thus give more 
room for the escape of the foreign substance. If there is no per- 
son near the suffering one who is able to turn over the lid, eye- 
stones should not be used, but the following plan may be tried, 
which will usually be successful, unless the foreign body is upon 
the cornea: The lid should be put on the stretch and held away 
* An eye-stone is a hard and smooth substance found in certain shell-fish. 272 
THE EYE AND ITS DISEASES. 
from the ball, and at the same time should be stroked directly 
downward. Rubbing in various directions is to be avoided, for 
thus the foreign body may be rubbed deeper into the tissue. An 
eye-stone has no mysterious virtue, and is simply another foreign 
body introduced into the eye. 
Inflammation of the Cornea—Keratitis. 
About one-half of the whole number of cases of disease of the 
eye involve the cornea. They are very important cases, because 
impairment of the transparency of this beautiful and essential 
membrane, or even a change in its curvature, renders distinct 
vision an impossibility. 
“ Those that look out of the windows are darkened,” for the 
cornea is the medium through which the light enters to undergo 
the changes that transform it into vision. Diseases of the cornea 
are of two general kinds : primary and secondary. 
The primary are perhaps more dangerous. The secondary 
form, consequent upon neglected granular lids, have been already 
alluded to. I shall attempt to describe but a few of the forms in 
which inflammation of the cornea may occur. The general di- 
visions, however, of these dangerous diseases may be thus given : 
I. Ulcers and abscesses of the cornea. II. General opacities. 
III. Blood-vessels upon the cornea. 
Ulcers of the Cornea. 
Ulcers and abscesses of the cornea usually occur in persons 
who are not strong and well, so that a recent white spot, which is 
not a foreign body, is an evidence of some failure in the general 
health. These spots, which the experienced eye may recognize as 
actual losses of substance or little pits in this membrane, are 
usually caused by the change of the proper elements into pus. 
Inasmuch as this tissue is not supplied with blood-vessels, it is 
peculiarly liable to disease, but on the other hand this want is 
somewhat made up by the abundance of nerves, which often give 
timely warning of danger. 
Treatment.—All diseases of the cornea that are not caused by 
foreign bodies, or that are not dependent upon granular lids, or 
other mechanical causes, demand, first of all, attention to the 
general health of the person affected, which usually has been im- 
paired by improper habits of life, constitutional disease, or the 
like. Besides this, the eye should be protected from a strong or 
dazzling light, from dust, wind, tobacco smoke, etc. Protective THE EYE AND ITS DISEASES. 
273 
spectacles of a blue or London-smoke tint, and shades are gener- 
ally necessary. 
Eyes affected with inflammation of the cornea should not be 
used for reading, writing, sewing, nor indeed in any employment 
on objects near at hand. 
Confinement of the patient for any great length of time to a 
dark room is not usually proper in any kind of disease of the eye. 
The most exaggerated notions as to the necessity for the exclu- 
sion of light in such affections are very commonly held. In the 
case of disease of the cornea, the irksomeness of life in a dark 
room, and the absence of fresh air will have an injurious effect 
upon the general health of the patient. Bandages, spectacles, and 
shades, furnish sufficient protection in nearly all cases. These al- 
low the patient to go about in the open air and sunlight. Eyes 
that have been operated upon, and in which it is necessary to se- 
cure union of the cut surfaces by perfect rest, with a few others, 
are the only cases that demand confinement to one room for con- 
siderable time. 
Oculists use various drugs in the treatment of ulcers of the 
cornea, and they sometimes resort to surgical operations. Sul- 
phate of atropia, a preparation of the plant known as Atropa Bel- 
ladonna, is the one most frequently used. The effect of bella- 
donna upon the eye is to enlarge the pupil, and it is thought that 
it contracts the blood-vessels, and relaxes the muscles of the eye. 
Nitrate of silver, leeching, and blisters, are not applicable to 
ulcers of the cornea. Atropia often quiets a very painful eye in a 
short time, but it should not be used, except under medical advice, 
unless absolutely necessary. The strength of the solution ordi- 
narily used, is two grains to the ounce of distilled water, and one 
drop is sufficient at each application. 
Spots upon the Cornea. 
Diseases of a milder type than ulcers, and ulcers that have run 
their course, often leave spots upon the cornea. They are usually 
permanent, although, in the case of young persons, they may 
sometimes be obliterated in the course of time. In recent cases 
surgeons sprinkle irritating powders and place ointments upon the 
eye, which sometimes assist in the absorption of the opacities. 
These dense white spots on the cornea are sometimes improperly 
called cataract by non-medical persons. It is often supposed that 
they may be removed by an operation, but this is incorrect. They 
should not be interfered with in such a way. 274 
THE EYE AND ITS DISEASES. 
Inflammations of the Cornea. 
There are several distinct forms of inflammation of the cornea 
which it is impracticable to describe minutely, as would be done 
in a treatise for students of medicine, but there is one form that is 
so common and so dangerous that an attempt will be made to give 
a sketch of its symptoms. 
Pustular Inflammation of the Cornea—Phlyctenular Keratitis— 
Scrofulous Keratitis. 
Physicians often find very minute bladders upon the cornea in 
young children who are improperly or insufficiently fed. These 
little bladders (vesicles) are usually soon covered by blood-vessels, 
or become ulcers by breaking down and extension, and they are 
generally accompanied by swelling of the lids and great fear of 
the light, so that the eyes are kept tightly closed, and when they 
are forcibly opened hot tears run out. The face is very often dis- 
figured by fissures and ulcers upon it, the lymphatic glands of 
the neck swell, the tongue is at the same time furred, and the 
patient, who is usually a child or young person, has a very sorry 
and distressed appearance. To the inexperienced person this dis- 
ease resembles purulent inflammation of the mucous membrane 
of the eye, but careful observation will show that it is not matter 
or pus, but ivater—tears, that flow out from between the lids when 
they are forcibly opened. This is the great distinction between 
the purulent inflammation of the mucous membrane of the eye, 
and a severe case of inflammation of the cornea, of the kind just 
described. Mild cases, when there is very little swelling of the 
lids, will, of course, not cause any such mistake to be made. 
This form of inflammation very often begins in the conjunctiva. 
A long-continued inflammation of this kind upon the conjunctiva 
will invade the cornea also. 
Treatment.—That which has been said upon page 272, suffi- 
ciently covers the ground as to corneal affections in general. It is 
only necessary to add that no applications that cause pain or even 
severe smarting, should be made to an eye suffering from disease 
of the cornea, unless under the advice of medical authority. 
Inflammation of the Cornea from Inherited Syphilis. 
There is an inflammation of the cornea occurring in young per- 
sons and in children, which is the result of an inherited constitu- THE EYE AND ITS DISEASES. 
275 
tional disease—syphilis. In other words, when one or both parents 
are syphilitic, their children may be born with, or soon exhibit, 
disease of the cornea. The cloudiness of the cornea, is, in these 
cases, usually accompanied by catarrh of the nostrils and throat, 
impairment of hearing, and a peculiar want of development of the 
central upper teeth which causes notches to form in them. Local 
treatment is of very little service in these cases, but the appropri- 
ate constitutional and hygienic treatment will often entirely cure 
the affection. 
Results of Inflammation of the Cornea. 
One of the results of a severe inflammation of the cornea, so 
severe that it bursts and allows the pupil to fall forward upon it, 
is a change in its shape, so that the whole globe is deformed. 
There is a great variety of these disfigurements. The globe is 
sometimes so much enlarged that it cannot be covered by the lids. 
Again, some portions of it protrude, while the other parts of the 
ball retain their proper shape. When the iris or the choroid coat 
of the eye falls forward in this manner, their black or dark color, 
Figure 68.—Partial staphyloma of the 
cornea. 
Figure 69.—Total staphyloma of cornea. 
Such an eye may readily become an irritant to 
its fellow. 
through the thinned white of the eye, cause an appearance not un- 
like that of a brown grape ; hence the medical name for these pro- 
trusions of the eyeball is a “ grape-like tumor”—staphyloma. They 
greatly disfigure the patient, and when the eye is sightless, as 
many of such eyes become, it may be removed by a surgical opera- 
tion, after the individual has attained full growth, and an artificial 
eye may be worn. Sometimes a deformed and protruding eye 
causes a sympathetic affection of the other eye. In such a case 
its removal is imperatively required, and no delay should be al- 
lowed. The subject of sympathetic inflammation of the eye is fully 
discussed on another page. 276 
THE EYE AND ITS DISEASES. 
Conical Cornea. 
This is quite a rare affection of the cornea that impairs the 
sight very much, but which easily escapes the attention of the 
unpractised observer. In this disease the cornea remains trans- 
parent, but its curvature is altered, so that instead of being a cer- 
tain part of a sphere, it assumes the shape of a cone. The affec- 
tion generally occurs in weakly persons, although those who are 
apparently healthy and strong may suffer from it. 
Conical cornea causes very great impairment of vision if it ex- 
ists to any extent. The eye is short-sighted from being lengthened 
from before backward, and from its irregular curvature there is 
great distortion of the images formed on the retina. 
The Treatment of this affection is not, on the whole, satisfac- 
tory, although, at times, something may be done by a surgical op- 
eration which aims to flatten the cone. Spectacles containing only 
a transparent slit are sometimes of service. 
Diseases of the Sclerotica, or White of the Eye. 
The diseases of the white of the eye, or of the sclerotica {hard 
tunic) are not of sufficient importance to lead the writer to do 
more than name them in an article of this kind. This part of the 
eyeball participates in the inflammations of the cornea, and of the 
lids and iris, as well as the interior parts of the eye, and shows this 
by an undue redness, which the careful observer may distinguish 
from that of the mucous membrane covering it. It may also be- 
come so thin in the course of disease as to allow the brown coloring 
matter of the choroid coat to show through. There are persons, 
however, who are born with a thin sclerotica or white of the eye, 
so that the reader may not be alarmed if he detect a faint tinge of 
brown glimmering through the white of the eye. 
The sclerotica may also protrude in various parts and deform 
the eyeball. A wound of the sclerotica is dangerous to the eye. 
Inflammation of the Iris—Iritis. 
This is a dangerous disease, and is sometimes mistaken for one 
that is not so important—that is, catarrhal inflammation of the 
outer membrane of the eye, or, as it is popularly called, a cold in 
the eye, described on page 263. Probably no pictures or descrip- 
tions will give a clear idea of this affection, but I will attempt to 
state some of its prominent symptoms, so that those upon the sea THE EYE AND ITS DISEASES. 
277 
or in remote places who read this section, may be somewhat on 
their guard if called upon to advise in regard to, or if they suffer 
from, an inflammation of the eye. 
1. The first prominent symptom is severe pain in the eyeball and 
about it. This is a symptom found also in some inflammations of 
the cornea, in inflammations of the back part of the eye, so that it 
is not a distinguishing sign of this disease. An inflammation or 
disease of the cornea will soon be detected by any intelligent per- 
son who studies the symptoms on page 272 to 274. 
A cold in the eye does not, as a rule, cause pain severe enough 
to keep a person awake at night. The sensations from a catarrh in 
the eye are rather those of discomfort. With any considerable 
catarrh there is some gluing of the edges of the lids on awakening 
from sleep. This does not usually occur in iritis. The pain from 
iritis is severe, and it is apt to extend in the course of the nerves to 
the forehead, the side of the head, the cheeks, and even to the 
teeth, so that it may be mistaken for neuralgia of the face. Neu- 
ralgia affecting the eyeball is always a serious symptom. It 
may mean an inflammation of the iris, or that other still more 
dangerous affection, hardening of the globe of the eye—glaucoma. 
2. Dread of light and involuntary closure of the eyelids. This 
symptom, as has been shown, is also seen in keratitis, especially in 
that of young children. 
3. Contraction of the pupil. Wherever an eye is very much 
reddened, and medical advice cannot be obtained, the pupil of the 
eye should be carefully examined under a good light. The natu- 
ral or healthy pupil will open and shut, so to speak; at least it will 
contract and dilate under strong light. This test may be made by 
alternately opening and closing the lids in strong light. The lids 
should be closed and then opened very rapidly, and the pupil care- 
fully watched the instant the eye is opened. If the pupil does 
not move, and if there be pain and fear of light, we may strongly 
suspect the existence of an inflammation of the iris. 
4. The character of the redness of the eye is also of great im- 
portance. Only a close observer will get much from this symp- 
tom, however. Such an one will find that the redness in iritis is 
confined chiefly to the ring made by the cornea, as it fits like a 
watch-glass into its case, and that it radiates from this surface— 
that it is not a net-work-like redness such as we see in a cold 
in the eyes. 
If one is obliged to form an opinion in a given case as to 
whether it be an affection of the iris or not, a drop of a solution 
of the sulphate of atropia, of the strength of two grains to the 
ounce, or even much weaker, will soon settle the question. If 278 
THE EYE AND ITS DISEASES. 
the pupil dilates freely and promptly, and becomes large and 
circular in a few minutes, our fear of iritis may be gone. As has 
been indicated, the determination that a case of inflammation of 
the eye is not one of the iris, is a very important matter, for if an 
iritis be not properly treated, the eye 
will very soon be lost. For this rea- 
son, if the reader is obliged to make a 
decision as to whether or not a case is 
one attacking only the outer mem- 
brane of the eye, he should proceed 
with great care, and if, finally, he is 
not able to decide positively, he should 
adopt the treatment for iritis. 
Causes.—The causes of iritis are 
quite numerous, but one of two con- 
stitutional diseases are very apt to be 
at the basis of an inflammation of 
this kind. These are syphilis and rheumatism. Extensive use of 
the eyes may perhaps produce the disease without the existence of 
any rheumatism or syphilis, but by far the larger proportion of 
cases occur in connection with these diseases. In the inflamma- 
tions of the eye occurring after accidental injuries and surgical 
operations, the iris is generally involved. The so-called sympa- 
thetic inflammation is largely one of the iris. 
Treatment.—From what has just been said, the treatment for 
iritis will naturally be both constitutional and local. Here, how- 
ever, the local treatment is pre-eminently important, for if neg- 
lected, serious mechanical impediments to perfect vision may oc- 
cur. The most important local application in a case of iritis is 
some one of the preparations of belladonna. The best of these is 
the sulphate of atropia. It should be used of the strength of two 
grains to the ounce of water, a drop being placed in each eye from 
three to six or more times a day, according to the severity of the 
symptoms. A camel’s-hair brush, a bit of cotton-wool twisted on 
a match or wire, or a dropper, such as is readily obtained in the 
shops, are some of the convenient means of getting the solu- 
tion in the eye. The fluid extract of belladonna, using a solu- 
tion of from one to six drachms to the ounce, or the belladonna 
ointment, may be used in case of necessity as substitutes for the 
more elegant, efficacious, and convenient sulphate of atropia. The 
ointment should be rubbed about the forehead, while the bella- 
donna lotion may be used as an eye-wash. The object of these 
local remedies, upon whose use so much stress has been laid, is 
the dilatation of the sluggish pupil. If the pupil be not kept widely 
Figure 70.—Showing the radiate 
character of the overloaded blood-ves- 
sels in iritis, and also the irregular 
pupil. THE EYE AND ITS DISEASES. 
279 
dilated, it will fall upon the lens of the eye, and become glued to 
it. This will cause two serious consequences. 
1. The lens will become opaque from the adherence of the col- 
oring matter (the so-called pigment of the iris) to its transparent 
surface. 
2. The opening and shutting of the pupil which forms so im- 
portant a part of the mechanism of the eye, and which is an affair 
of momently occurrence, is so much interfered with by the ad- 
hesion of various parts of the circle, that the eye is always in a 
state of irritation, which is analogous to the irregular action of 
clogged machinery. For these two reasons, and for others which 
need not be mentioned, many an eye that has undergone inflam- 
mation of the iris, is destroyed long after the pain, redness and 
dread of light have disappeared. 
Excessive and Constant Enlargement of the Pupil—Mydriasis. 
When the pupil is constantly enlarged, so that it does not dilate 
and contract, it may be a symptom of various diseases. The chief 
cause, however, is a paralysis of the branch of the third nerve, 
which starts from the brain, and which has much to do with the 
motions of the eye. (See Anatomy of the Eye.) It sends off one 
branch to the muscle which contracts the pupil. Of course, a dis- 
ease sufficient to destroy its power, will render the muscle unable 
to do its work. Dilatation of the pupil often occurs in connection 
with paralysis of the branch of the third cranial nerve supplying 
the upper lid, so that the lid drops down and cannot be lifted 
(ptosis). Affections of these nerves are often caused by syphilis, 
but the breaking of a blood-vessel, and a pressure upon the course 
or origin of the nerve, is also a not uncommon cause of this kind 
of paralysis. Certain drugs, such as hyoscyamus, belladonna, and 
stramonium, have a remarkable power in causing dilatation of the 
pupil. They are used by physicians as applications to the eye, 
especially the different preparations of belladonna. Persons wish- 
ing to simulate disease sometimes use these drugs for the purpose 
of deception. 
Contraction of the Pupil—Myosis. 
This is also a symptom of paralysis of the nerve supplying the 
muscle that dilates the pupil, and also of certain diseases of the 
spinal cord. It may also be produced by the local or constant use 
of Calabar bean, or of opium. It is one of the marked symptoms 
of poisoning by the latter. 280 
THE EYE AND ITS DISEASES. 
Congenital Defects of the Iris. 
There are certain congenital defects of the iris which require 
mentioning. The iris is sometimes entirely absent. It is some- 
times cleft or deficient in one part. The pupil may also be out of 
place, and there may be more than one pupil. These are rare de- 
fects, and they are without remedy. Not very unfrequently one 
iris is of a different color from the other. Where the difference is 
very marked, the contrast is almost a disfigurement. This differ- 
ence depends upon the amount of coloring matter in the iris, and 
is of course not amenable to any treatment. 
Cataract. 
Any want of the natural transparency of the lens is called cat- 
aract, from the old idea that a veil fell down before the eye. As 
has been seen on a preceding page, in the Anatomy of the Eye, the 
lens in health is a transparent body, but disease changes this so 
that it becomes completely or partly opaque. 
Cataract may be conveniently divided into four great classes : 
1. Cataract of youth ; 2. Cataract of old age ; 3. Cataract from 
injury; 4. Cataract from inflammation. 
Some children are born into the world with opaque lenses. 
The cause is probably some want of nourishment of the lens when 
the child is in the womb. The lens, as has been seen, depends for 
its support upon the surrounding parts of the eye, for it has no 
blood or lymph vessels of its own. Any interference with the 
health of the blood-vessels of the eyeball may affect the lens. 
When a child becomes a few months old, and does not steadily 
fix its eyes upon any one point when looking, we may suspect 
that there is either an opacity of the lens or, still worse, a disease 
of the retina or optic nerve. Infants of two or three months of 
age, however, do not fix their eyes upon any object, but roll them 
about with no steady gaze. A marked opacity of the lens may be 
detected by any good observer, for, on looking beyond the black 
of the pupil, the grayish-white opacity may be seen ; where, how- 
ever, the opacity is not complete, the use of a lens or of the oph- 
thalmoscope is necessary to distinguish it. 
Treatment.—The only remedy for cataract is a surgical opera- 
tion. No internal or external medication has as yet been discov- 
ered, which will cause an opacity of the lens to disappear. In a 
few very rare cases a cataract may disappear spontaneously. 
When a child is strong and healthy, and it is known by tests that THE EYE AND ITS DISEASES. 
281 
it can perceive light through the cataract, and hence that the re- 
tina and optic nerve are sound, it is proper to operate for the re- 
moval of the cataract. The operation usually performed in the 
case of young children is by means of a delicate needle, which is 
plunged into the capsule or envelope 
of the lens, so as to wound the lens- 
substance itself. This being done, 
the lens-substance escapes into the 
aqueous humor of the eye, swells up 
somewhat, but the most of it is 
finally absorbed, leaving the lens 
very much smaller, or perhaps en- 
tirely removing it. The operation 
is then repeated one or more times 
if necessary, at intervals of time 
that vary according to the amount 
of inflammation that has been set 
up by the operation, until finally 
enough of the lens has been re- 
moved to allow the rays of light to pass without interruption 
through the pupil. 
The operation is not entirely without danger, for in some rare 
cases the inflammation following it is so severe as to cause the 
loss of the eye. As a rule, however, it gives sight. 
2. The cataract of advanced life occurs usually after 55 years of 
age. Prematurely old and decayed people may be affected at an 
earlier period. 
Inasmuch as the symptoms of cataract are similar to those from 
loss of sight from widely different causes, it is not worth while to 
enumerate them here, except that we may'give a few general hints 
that will enable the reader to suspect the existence of cataract in 
given cases. True senile cataract is a painless affection. Loss of 
sight occurring during attacks of pain, notably neuralgia, should 
always excite alarm, and secure, if possible, surgical advice. Per- 
sons affected with cataract are apt, in its early stages, to see better 
in the twilight than in a very great illumination; whereas, in dis- 
eases of the optic nerve or retina, the greater the illumination the 
better the vision. Until the cataract is fully developed, when it 
can be seen as a whitish opacity in the pupil, only one positive 
proof of its existence can be furnished, and that is by the use of 
the ophthalmoscope—the mirror for observing the back of the eye. 
If a disease be cataract pure and simple, and there be no serious 
affection of the back of the eye, the light of a candle will always 
be perceived through the lens, even if it be very opaque. The 
Fig. 71.—Needling a cataract. 282 
THE EYE AND ITS DISEASES. 
lighted candle should be seen throughout all the parts of the visual 
field, even if the patient be looking straight in front of him, while 
the light is being moved about. An eye that is sound except as to 
the opacity of the lens, should always be able to tell where the 
light is, even when the eye is looking directly forward. No eye is 
fit for the operation of removal of cataract that does not thus per- 
ceive the light through the opaque lens. There are diseases of the 
back part of the eye that finally cause opacity of the lens. Some- 
times the friends of patients have mistakenly allowed such dis- 
eases to go on without an effort to check them, waiting for the 
cataract to become fully formed. When cataract occurs in this 
class of cases, it is too late to do anything to effect a cure, because 
the opacity of the lens is sometimes the last stage or an inflam- 
mation leading to blindness. 
Treatment.—A true senile cataract may be removed by an op- 
eration which takes the lens entirely out of the eye. Formerly 
the lens was sometimes pushed away from the pupil by njeans of 
Fig. 72.—Making an opening in the cor- 
nea for the removal of cataract. 
Fig. 73.—Extracting the lens in a cataract 
operation. 
a needle passed into the eye. This operation has been abandoned 
by the medical profession, because the lens thus displaced sooner 
or later acted as a foreign body, and caused an inflammation of 
the eyeball which destroyed the sight. The operation of extrac- 
tion was brought into general use by Beer, an Austrian surgeon. 
It has undergone many modifications since then, notably those 
suggested by the late Professor Von Graefe, of Berlin. About 
eighty per cent, of those operated upon by good surgeons recover 
useful, and some of them excellent sight. 
Cataract sometimes occurs in diabetes. The results of its re- THE EYE AND ITS DISEASES. 
283 
moval in such cases are not so good as those from the removal of 
ordinary senile cataract. 
Diseases of the Retina, the Choroid, and the Optic Nerve. 
Inasmuch as none of the above-named diseases can be known 
positively to exist, except after the eye has been examined by the 
ophthalmoscope, it will not be possible to give more than an indi- 
cation of their nature. Many of them were formerly grouped 
together under the heading of amaurosis, but since the ophthal- 
moscope has been invented—which enables the physician to detect 
and describe such changes in the retina as the escape of blood 
from its vessels, changes in its color and structure, whitening and 
Fig. 74.—One of the methods of using the ophthalmoscope. 
swelling of the optic nerve, rupture of the choroid coat—no such 
rude classification as amaurosis is adapted to these days of better 
knowledge. Before giving a list of the affections that may attack 
the back part of the eye, we may give a brief account of the in- 
vention and nature of the instrument used by physicians for ex- 
amining the retina, choroid, and optic nerve. 
A practicable instrument was first invented by Heinrich Helm- 
holtz, then professor in the University of Konigsberg, in Prussia, 
now, however, professor in Berlin. The scientific men of the world, 
from Aristotle down, had vainly endeavored to give a reason for the 284 
THE EYE AND ITS DISEASES. 
blackness of the pupil. It was known that the lens was transpar- 
ent, as also the vitreous humor (see Anatomy of the Eye), and that 
the choroid coat had very many blood-vessels. Why, then, was 
not some of the red color reflected so that it could be seen through 
the pupil ? By accident—if there are any accidents—in one of the 
rooms of the Berlin University, it was discovered that if light could 
be made to enter the eye in a certain way, its reflection would be 
red, and the pupil would be no longer black. From this stand- 
point Professor Helmholtz proceeded, and he soon invented a 
mirror by which light can be thrown into the eye and caused to 
emerge in such a direction that the retina, choroid and optic nerve 
can be seen by the person holding the mirror. The eye-mirror 
enables the observer’s eye to be in the path of the reflected rays 
without cutting them off, or intercepting them, as the head of the 
observer does, when, without the aid of artificial light and a mir- 
ror, he looks straight forward into the pupils of a person in front 
of him. 
Scores of modifications of Helmholtz’s original instrument have 
been made, and it is seldom or never used exactly as first invented. 
Yet, in spite of this, Helmholtz left no principle to be discovered 
when he presented his first instrument to the world, and he must 
always be considered as the first man who enabled us to see the 
optic nerve, the choroid and retina in the eye of a living subject. 
Diseases of the Retina. 
1. The retina may become inflamed and opaque as a result of 
over-use, or improper use by bad light, and as a consequence of 
syphilis, diabetes, and other diseases. 
2. Its blood-vessels may break in consequence of a change in 
their walls, the result of old age, or from poisonous materials in 
the blood—such as are retained in the course of certain diseases 
of the kidney. 
3. The retina may be separated from the other parts of the eye. 
This accident, which is a very serious one, occurs chiefly in near- 
sighted people. (See Short-sightedness or Myopia.) 
4. The retina may be the seat of cancerous tumors. These 
chiefly occur in young children, and are sometimes not detected 
until the tumors have grown to such a size as to present themselves 
in the pupil as a whitish reflection, which may possibly, by an un- 
trained observer, be mistaken for cataract. Removal of the whole 
eye before the disease has passed through the ball, is the only 
remedy in this desperate disease. 
5. The retina may be congenitally diseased, perhaps as a result THE EYE AND ITS DISEASES. 
285 
of inflammation or arrested development before birth ; for a child 
in the womb is subject to disease as well as one that is born. 
Such patients need a much better light than those who have a 
sound retina, and are, consequently, not able to get around well in 
the twilight or evening. Such cases are often included under the 
term “night-blindness.” 
Night-blindness is an incurable affection, yet sufferers from it 
do not usually become entirely blind, although they may not be 
able to see small objects. 
Diseases of the Choroid. 
The choroid coat of the eye may also be the seat of diseases sim- 
ilar to those affecting the retina, and from similar causes. Since 
it is the continuation of the iris and the ciliary body*(see Anatomy 
of the Eyes), it participates in most of the affections of the pupil 
or iris. 
Diseases of the Optic Nerve. 
1. The optic nerve may become inflamed; it may suffer from 
the breaking of its blood-vessels, and it may shrivel or atrophy. 
The Causes of these various affections are the same as those 
that have been enumerated under the inflammations of the retina. 
2. Pressure upon the optic nerve at its origin in the brain, or 
in its course to the eyeball. This pressure may be caused by the 
breaking of a blood-vessel, by a tumor, or by inflammation of the 
brain. 
Any considerable disease of the optic nerve must cause loss of 
sight, for it is by its action that the impressions of waves of light 
are in some unknown way carried to the brain, there to produce 
vision. 
Diseases of the Optic Nerve and Retina from the Abuse of Al- 
cohol, Tobacco, and so forth. 
It is well known that many persons who are intemperate in the 
use of alcohol and tobacco suffer from what are called “ weak 
eyes.” Their eyes are red and watery. This condition is simply 
a form of conjunctivitis, and is not a serious matter, since a 
change in habit is sufficient to readily cure what is not, at the 
worst, any more than an inconvenience. There is, however, a 
form of disease of the back part of the eye from the excessive use 
of stimulants and narcotics so serious as to require especial men- 286 
THE EYE AND ITS DISEASES. 
tion. Fortunately for the race, only a small proportion of those 
who are intemperate in drinking and smoking lose their sight on 
account of this vice. 
The most prominent symptom of what is sometimes called To- 
bacco Amaurosis is a gradual loss of sight. Whenever the sight 
begins to fail in a person who uses tobacco in excess, especially 
if, at the same time, he uses strong drink freely, we may sus- 
pect the cause. The examination of the eye in these cases some- 
times fails to detect any marked appearance of disease, either on 
the inside or outside. If the tobacco and alcohol be not given up 
entirely by such patients, blindness will result. Indeed, almost 
the only treatment necessary for loss of sight from excess in 
tobacco and alcohol is the total abstinence from these agents. 
Very large doses of quinine sometimes, in very rare cases, pro- 
duce blindness. This is usually temporary, however. 
The blindness in yellow fever is one of the rare symptoms of 
the poisoning of the blood, or pressure upon the circulation in that 
disease. 
Diseases of the Vitreous Humor. 
Affections of the vitreous humor (see Anatomy of the Eye), 
are usually secondary to those of the choroid coat and retina, and 
are made known to the patient by the presence of motes, parti- 
cles, or the like, apparently floating1 in front of the eye. The oph- 
thalmoscope enables the surgeon to see these particles clearly. 
Sometimes they are composed of blood, of coloring matter, or of 
the hroken-up parts making up the normal vitreous humor. 
There is another kind of floating particles seen by the patient 
which need cause no great alarm, for they are often observed when, 
so to speak, they have no real existence. All these appearances 
of floating bodies in the eye are grouped together under the head 
of muscse volitantes (musca, a fly, volitare, to fly about). 
The innocent form does not cause any defect in vision, that is 
to say, the patient is able to see letters or objects just as well as 
ever. The chief annoyance is experienced in perceiving bright 
beads or strings floating about when the subject of them looks at a 
bright and clear surface. They are actually the cells of the vit- 
reous humor, which, in some eyes not necessarily unhealthy, are 
seen in this manner. The appearance of floating bodies in the eye, 
when connected with loss of vision, or limitation of the space in 
which distinct vision is enjoyed, is always a serious symptom ; but 
without these changes it need excite no apprehension. 
Animal parasites have been found in the eye. Their origin is THE EYE AND ITS DISEASES. 
287 
due to eating raw meat in which the germs of these parasites ex- 
isted—just as trichina and tape-worm are due to eating measly 
pork. An expert alone could determine the existence of such 
parasites in the eye, unless they are in the front—the anterior 
chamber. Fortunately, they are exceedingly rare. They may 
also exist in the eyes of animals. 
Undue Hardness of the Eyeball—Glaucoma. 
Glaucoma is an affection of the eye that cannot, as yet, be clas- 
sified under any of the heads that have been enumerated in the 
account of its various diseases. Its nature is not thoroughly un- 
derstood, although we have ample means for its recognition as a 
disease, separate and distinct from any other affection of the eye. 
Since the sight may be irrecoverably lost in a few days, unless it 
be recognized when in an acute form, I shall attempt to impress a 
description of its prominent symptoms clearly upon my readers. 
Although I fear that I shall not succeed in causing the unprofes- 
sional reader to be able to know a case of acute glaucoma when he 
actually sees it, at least, I hope to be able to cause him to suspect 
it. 
I. Glaucoma usually occurs in persons past middle life. 
II. It does not often occur in short-sighted eyes. 
III. Its chief symptoms are : a. Neuralgic pain in and about 
the eye; b. hardness of the globe of the eye; c. rapid loss of the 
power of adjusting the eye for vision, so that glasses must be 
changed very often in order to get those strong enough to do the 
required work; d. there are sometimes sudden and temporary 
attacks of blindness ; e. the pupil of the eye is usually larger than 
is natural. 
The name of Glaucoma, meaning “ green tumor,” is one given 
when the nature of the disease was unknown. It has no signifi- 
cance now, but was suggested by the greenish appearance of the 
pupil, which is one of the advanced symptoms of the disease, and 
it usually appears when the affection has made so much progress 
in the interior of the eye that treatment is of little avail. Some- 
thing was said of this when describing cataract. There is a form 
of glaucoma, called chronic, in which acute neuralgic pain is ab- 
sent, but w’here the other symptoms, especially the hardness of 
the globe, are present to a greater or less extent. The ophthalmo- 
scope enables the surgeon to see that in glaucoma the pressure in 
the interior of the eye is so great that the entrance of the optic 
nerve in the ball is actually a concave instead of being a plane 
surface. 288 
THE EYE AND ITS DISEASES. 
Treatment.—The only effectual treatment for glaucoma is that 
discovered by Professor Yon Graefe in 185G. After investigating 
and experimenting on the eyes of animals, Professor Von Graefe 
made an incision into the eyeball 
of a human subject having glau- 
coma, and removed a piece of the 
iris (iridectomy, cutting off the 
iris). This operation relieved the 
pressure within the eye, and 
cured the first patient operated 
upon. Since that time thousands 
have been operated upon with 
benefit, in all parts of the civil- 
ized world. Of course, however, 
there are patients having glau- 
coma, for whom the operation, 
no matter how skilfully per- 
formed, does no good. 
After all surgical operations, or even after every dose of medi- 
cine, the conscientious medical man may rightly say with the great 
Ambrose Pare, who, after treating soldiers on the field of battle, 
was wont to exclaim, “ I have dressed you, may God cure you.” 
Figure 75.—The operation for iridec- 
tomy. 
Injuries of the Eye—Foreign Bodies in the Eye. 
The varying and innumerable occupations and sports of life 
render the eye of the human race, well as it is protected by lids 
and lashes, and by its position in a bony case, very much exposed 
to injury. From premature explosions, fragments of percussion- 
caps or grains of powder enter the eye. Machinists and all me- 
chanics who work on iron, steel, or the other metals, are often 
struck upon the eye by bits of metal which sometimes lodge there. 
Even farmers at work in the harvest-field are not wholly exempt, 
for blades of grain may strike upon the cornea with such force as 
to lodge there. Children playing with a rose-bush may rub a 
thorn into the eye. Workmen mixing mortar, or carrying it, 
may splash some of the corrosive material so that it strikes the 
conjunctiva. Knife-makers may, by the breaking of a blade, he 
cut upon the eye. Children, with scissors and knives, may muti- 
late the organ of vision. Gunshot-wounds are received in the 
eye. A child, playing with its nurse or mother, may scratch the 
transparent front of the eye. This catalogue of injuries, which 
have occurred and do occur to eyes, might be almost indefinitely 
increased, so that we may almost assert that a large part of the THE EYE AND ITS DISEASES. 
289 
occupations of adult life, and the sports of childhood and youth ex- 
pose the eyes to danger. 
An injury of the eye is always a serious matter, but all injuries 
are not equally serious. A bit of steel in the front of the eye is 
often removed by a skilled fellow-workman, and a few hours’ rest 
or protection of the eye causes the wound to heal, and the organ 
to be as useful as ever. Other particles, however skilfully re- 
moved, may leave a scar behind, although the patient experiences 
no other inconvenience. In other cases, however, the foreign 
body enters the cavity of the eye, whence it can only, in rare in- 
stances, be removed without injury to the globe and destruction 
of vision. 
When the injury is a large wound, the eye is often irreparably 
damaged at the instant of the accident. 
The most serious condition of all that have been enumerated, 
however, is when a foreign body left in an eye, or an injury to it, 
causes what is known as a sympathetic affection of the uninjured 
eye. There is always danger that a foreign body in the eye may 
cause this form of inflammation. It is, therefore, a safe rule to 
remove a foreign body from an eye at all hazards. Of course, 
the expert will find some exceptions to this rule, but the unprofes- 
sional person will not be justified in making any such. 
An injury of the eyeball, especially of that region known to 
medical men as the ciliary region (see Anatomy of the Eye), is 
also, even when there is no foreign body in the eye, dangerous on 
account of its power of exciting sympathetic disease in the fellow 
eye. 
Symptoms.—The prominent symptoms of sympathetic ophthal- 
mia are: 
1. Blurring of the vision, so that the subject cannot continue to 
read, or sew, or occupy the eyes at work on near objects, without 
a fatigue or watering of the eyes. 
2. Inability to bear light. 
When these symptoms occur in the same eye, a patient who has 
a foreign body in one, or who has at any period, however remote, 
severely injured the fellow eye, the case is most serious, and de- 
mands prompt consideration. 
When it has once been decided that the injured eye is the cause 
of the trouble, if a foreign body remain in it, it must be at once 
removed, and if this do not at once arrest the trouble, the eyeball 
in which it was should be cut out. 
In case the sympathetic trouble arise from the injury of the 
fellow eye, without the presence of a foreign body, the rule is also 
to remove the injured eyeball, in order to save its fellow. If these 290 
THE EYE AND ITS DISEASES. 
early symptoms of sympathetic irritation be not carefully noted, 
and the affection pass on to be an inflammation of the iris and 
deeper parts of the eye, removal of the globe of the eye will not 
always, nor indeed often, arrest the disease, and the patient will 
become blind. Hence the necessity for the most careful attention 
to the early symptoms from injuries to the eye, as well as to those 
from foreign bodies that have entered it. 
The subject of foreign bodies upon the eye has already been 
mentioned on a preceding page, and nothing more need be said 
as to the method of removing them. It is hardly necessary to 
say that none but a surgeon will endeavor, except in the direst 
necessity, to remove a foreign body that has fully entered the 
organ of vision. 
Artificial Eyes. 
After an eyeball has been removed by a proper surgical opera- 
tion, the appearance of the patient may be much improved by the 
insertion of an artificial eye. These are made so beautifully of 
porcelain, that if inserted when the muscles that move the ball 
have been left, they will often almost entirely conceal the loss. 
Fig. 76.—Artificial eyes. 
They cannot always be worn, on account of the irritation they 
cause, but generally they can. These eyes cost from five to ten 
dollars each, and one will last with good usage from one to two 
years. 
Cross Eyes—Squint—Strabismus. 
When the muscles that cause the movements of the eyeball act 
together in proper accord, at every motion of the globes the lines 
of vision exactly agree, so that the image of the object looked upon 
is formed at exactly corresponding parts of the two eyes. When, THE EYE AND ITS DISEASES. 
291 
however, the muscles are unequally balanced, one eye will look in 
one direction, and the other in another, just as the head of a horse 
may be turned by his driver away from or toward his fellow, or 
held exactly parallel with it by the use of the guiding rein. This 
deviation of the eyes forms a conspicuous defect or deformity. It 
is chiefly seen in one of two forms : either an eye turns inward or 
outward. There are, however, cases where an eye turns upward 
or downward, although these are rare. The cause of these devia- 
tions is to be usually found in one of two influences : 
1. Paralysis of the muscle of the outer side of the eye will, of 
course, cause it to be so overbalanced by its antagonist that the 
eye is turned inward. This paralysis—to go back to our illustra- 
tion from the reins of a horse—is to be compared to the loss or 
severance of the rein on one side, while the other is still in the 
hands of the driver. 
2. The most frequent cause of strabismus or squint, however, 
is not paralysis. By far the greater number of patients who turn 
their eyes inward or outward, use all the muscles of the eye very 
well, and turn the eye in any direction, but they are not able to 
cause the eye to be moved in such a way that they direct the line 
of vision to exactly the same point when the muscles are all in 
action. This maybe easily tested in the following manner : Let the 
person to be examined close one eye, and cause him to follow the 
finger, a pencil, or some such object while it is moved about, above, 
below, to the other side. If there be no paralysis, the eye will 
follow all these movements without any movement of the head. 
If paralysis exists, however, the patient will move his head in order 
to get a view, and the eyeball will stop in its movement outward 
or inward, upward or downward, according to the muscles that 
are affected. 
The most frequent cause of strabismus is a congenital want of 
development, or excess of development of the eyeball, so that one 
set of muscles acquires a greater power than the others. (See 
paragraphs on Eyes requiring Spectacles.) Thus, eyes that are too 
short most frequently have an inward squint, while an eye that 
is too long squints outward. Comparatively few, however, of 
the cases of insufficient, or too great focussing power of the eyes 
have strabismus as a result, so that we are led to conclude that 
other factors have much to do in causing the deformity. Eyes 
that are too short require convex glasses, but one eye may need 
a stronger one than the other. They are more apt to deviate than 
those that are of the same length, or, to state it more technically, 
that have the same refractive power. A disease such as cataract 
or opacity of the cornea, affecting one eye, and preventing the 292 
THE EYE AND ITS DISEASES. 
use of the two eyes at the same time, assists in causing strabis- 
mus. 
A deviation of the eye inward is usually associated with want 
of focussing power, or with an eye that is too short from before 
backward—the so-called hypermetropic eye. It is usually first 
seen in children when they have reached three years of age, or 
when they begin to fix their eyes upon comparatively small objects, 
such as their toys. Thus mothers constantly affirm that their 
children did not squint when they were born. They are correct, 
but most of these children who afterward squint, would have 
done so immediately after birth had they the power to look at 
objects fixedly or intently. Any one who has observed the habits 
of infants and young children will remember that fixing the gaze 
upon a near object requires considerable use of the muscles that 
pull the eyes inward, and that it is an acquirement just as much 
as learning to walk. It is when the eyes are continuously used 
in this manner that the squint is observed. Sometimes it is 
not constant at first, but periodic; it usually, however, soon be- 
comes fixed. 
Both eyes commonly squint in convergent strabismus, although 
one much more frequently does so. In other words, one eye squints 
by preference, while the other is used for seeing. For some un- 
known reason, the vision of the eye that generally squints becomes 
blunted. The use of tests, such as type, generally shows that the 
squinting eye does not have nearly as good visual power as the 
other. Thus, we often find that the patient is only able to see large 
objects with the eye that deviates. Yet the most exact observation 
of the optic nerve or retina does not always, or usually, find any 
reason for this loss of vision. It is a happy thing for the squinting 
patient that the vision does thus become blunted. Were it not 
so, he would see all objects doubled. Double vision is one of the 
most distressing of symptoms, and although usually observed in 
strabismus from paralysis of the muscles, is seldom found in the 
strabismus arising from an improper shape of the eyes. 
Treatment.—The treatment of strabismus depending upon par- 
alysis has already been dwelt upon in speaking of that subject. 
It will be sufficient to say here, that the cause must be sought 
out, and if the affection be not of too old a date, it may often be 
relieved by appropriate internal treatment. Strabismus depend- 
ing upon a faulty shape of the eyeball—which is, so to speak, 
a local disease—can only be remedied by an operation. Some 
writers contend that the continued use of sulphate of atropia, 
which suspends the power of accommodating the eye to different 
distances, may in time, with the use of the appropriate glasses, 293 
THE EYE AND ITS DISEASES. 
cure the deviation, but the present writer has not been convinced 
by the reports as yet made of the success of this treatment. 
The operation for the relief of strabismus consists in separating 
the squinting muscle from the attachment to the globe of the eye. 
It then grows again to the eye, but at a point farther back, so that 
its power over the eyeball is reduced. It is usually necessary to 
operate upon each eye, although not always, and sometimes more 
than once on the same eye. They are generally not operated upon 
at the same time, but the effect is carefully watched after the first 
operation. The operation for squint is quite painful, and is usu- 
ally performed while the patient is under the influence of an 
anaesthetic. After the operation, the want of vision of the eye 
should sometimes be corrected by the use of the proper glasses. 
Paralysis of the Muscles of the Eyeball. 
This affection is not always so strongly marked as to cause any 
deformity. The eyes may, to all ordinary observation, seem to be 
perfect in their associated movements, and yet one or more of their 
muscles may be paralyzed. The patient, however, will most 
keenly feel even the slightest deviation. If the two eyes are not 
acting in exact harmony with each other, a most troublesome 
double vision will occur. The slighter the deviation, the greater 
will be the annoyance ; hence a paralysis that can only be detected 
by very fine tests will often cause a distressing double vision. 
Any, or even all of the muscles of the eye may be paralyzed. 
The most frequent cases are those in which the eyelid droops, the 
pupil is dilated, and the eyeball turns outward. All these parts are 
apt to be paralyzed at the same time, because one nerve (the third 
of the nerves going out from the base of the brain) supplies these 
parts. The eye may turn in from paralysis of the nerve supplying 
the muscle that draws the eye outward, or the lid may refuse to 
shut from paralysis of the circular muscle, which closes the lids. 
The Treatment of any of these, or other forms of paralysis, de- 
pends upon the cause. Among the prominent causes are syphilis, 
tumors of the brain, rheumatism, pressure upon the trunks of 
nerves from blood-clots, pieces of bone that have been broken, etc. 
Constant Oscillatory Movement of the Eyes—Nystagmus. 
This symptom is seen very frequently in Albinos. The eye- 
balls are never quiet, at least in working hours, but are con- 
stantly being moved about, as if in search of some object upon 
which to rest. The affection is caused by various diseases of the 294 
THE EYE AND ITS DISEASES. 
eye, which prevent the formation of a sharp image upon the re- 
tina. The patient is not able to get a sharp, well-defined image at 
any point. He is like a person looking through an improperly 
focussed opera-glass, which he is not able to adjust. It is prob- 
able that the habit of moving the eyeball in all directions is in- 
duced by the attempt to gain clear vision. The affections causing 
nystagmus are usually incurable. Some of them are want of de- 
velopment and wasting of the retina, dense opacities of the cornea, 
congenital cataract, want of development of the whole eyeball, 
etc. Miners who spend much of their time entirely deprived of 
sunlight, sometimes become affected with nystagmus. This fact 
helps materially to explain its cause. It would seem to arise from 
the want of sufficient illumination to view any one object with 
distinctness. One author believes that nystagmus occurs in conse- 
quence of the prolonged looking upward required in mining. It 
is also said to be a symptom of some diseases of the spinal cord. 
Inability to Use the Eyes Continuously when there is no In- 
flammation and no Lessening of the Sharpness of Sight. 
There is a troublesome combination of symptoms, grouped by 
physicians under the general head of Asthenopia, or weak-sight, 
that usually depends upon the failure to wear glasses when they 
are required. It will be fully discussed under the head of Spec- 
tacles. 
There are, however, some cases in which general muscular de- 
bility, diseases of the other parts of the body, notably of the 
womb, cause what is called a reflex disease, and prevent the pa- 
tient from any prolonged use of the eyes. A careful examination 
of the eye as regards its need for glasses should always be had, 
however, before a case is declared to be one depending upon 
general debility or organic disease of another part of the body. 
The results of the scientific investigations of the past twenty years, 
by showing the true use of spectacles, have rescued thousands of 
condemned eyes from inactivity and uselessness. Asthenopia de- 
pending upon constitutional causes, chiefly requires of course con- 
stitutional treatment. 
Conditions of the Eye requiring the Use of Spectacles. 
The history of the invention of spectacles still remains in much 
obscurity. After the art of making glass was discovered, lenses 
were soon made, and were used as burning glasses. Aristophanes 
(b.c. 424) alludes to them in his comedy of the “ Clouds.” It is said THE EYE AND ITS DISEASES. 
295 
that the vestal virgins used convex lenses to kindle the sacred 
fire, and surgeons also employed them as actual cauterants. Sen- 
eca (a.d. 65) noticed the magnifying power of a bottle of glass in 
enlarging small letters. Roger Bacon, or Friar Bacon, born in 
1214, certainly knew something of spectacles, if he has no claim 
to be their inventor, for a writer, in 1551, thus speaks of a “ glasse ” 
used by Friar Bacon: “ Great talke there is of a glasse he made 
at Oxford, in which men might see things that weare don, and 
that were indulged to be don by power of Evile Spirites.” And 
in his own writings Bacon says, “ This instrument (a plano-convex 
glass, or large segment of a sphere) is useful to old men, and to 
those that have weak eyes, for they may see the smallest letters 
sufficiently magnified.” It is probable that they were in use at the 
time of his death in 1292, whether Bacon knew about spectacles 
himself or not. 
Alexander de Spina, a native of Pisa, who died in that city in 
1313, having seen a pair of spectacles that were made by another 
person, who was unwilling to make his method known, caused a 
pair to be made for himself, and then, in a liberal spirit, made his 
invention public. On the tomb of a Florentine nobleman, who 
died in 1317, it is said that he whom the stone commemorates 
was the inventor of spectacles. The spectacles thus invented, 
however, were those to be used by old persons. Thus their value 
was limited to a relatively small class. Our time has largely 
amplified the variety of assistances to read, so that young and old 
now derive advantage from the great discovery of the uses of 
glass as means of assisting the sight. 
The eyes that require and are benefited by spectacles, may be 
divided into three great classes. There are subdivisions of these 
classes, but in order to simplify discussion I will first speak only 
of these chief varieties of eyes : 
1. The Far-sighted Eye of Old Age. 
This is an eye that has become practically too short—an eye 
with an insufficient focussing power (presbyopia). 
2. The Far-sighted Eye of Youth. 
The eye that is actually and congenitally too short from before 
backward (.Hypermetropia or Hyperopia). 
3. The Near-sighted Eye. 
Or the eye that is too long from before backward {Myopia). 
This classification is no artificial one. It does not depend upon 
the dogmatic assertion of medical theorists, but upon the anatom- 296 
THE EYE AND ITS DISEASES. 
ical structure of the eye, and the inevitable processes of decay in 
human strength, and has been determined by accurate investiga- 
tion and experience. 
While we are indebted to a long line of scientific worthies for 
the gradual progress which has finally enabled us to discriminate 
as to the kind of spectacles which should be worn in different cases, 
to Dr. F. C. Donders, Professor of Physiology in the University of 
Utrecht, belongs the honor of having arranged the whole subject, 
•enriched by very many of his own investigations, in an harmoni- 
ous whole. His great work on the Refraction and Accommoda- 
tion of the Eye, was first written in the Dutch language, but it has 
been translated into the English and German, and is everywhere 
recognized as the highest authority on the subject of which it 
treats. The views that are here presented are mainly derived from 
this work. 
Presbyobia. 
The eye of old age requires spectacles ; not because the cornea 
—the anterior transparent coat of the eye—becomes flattened in 
advanced life as is often said, but because a little muscle within the 
eyeball, called by anatomists the ciliary muscle (see Anatomy of the 
Eye) loses some of its power as old age comes on. This little muscle 
Figure 77.—Sections showing : I. the normal eye ; II. the myopic one ; III. the hyperopic. 
passes around the eyeball and connects the cornea and iris to the 
choroid coat and to the ligament which holds the lens in position. 
The vigor or tone of this muscle becomes impaired with advancing 
years. Its ordinary work is that of making the lens of the eye 
thicker than it is when the eye is in a state of rest. The rays of 
light coming from a near object—from the page we are now read- 
ing, for instance—have a divergent course ; they are continually 
going away from each other; when they come from an object 
much further off they are parallel or nearly so. Thus the rays 
from the music on a piano do not come to the eye of the player THE EYE AND ITS DISEASES. 
297 
as divergently as those from her sewing, which is held nearer than 
the music, and the further the illuminated object is removed the 
less divergent, the nearer parallel the rays become. In every act of 
changing our gaze from a remote object to a near one, the lens of 
the eye becomes thicker ; in other words, during the act of accom- 
modating the vision for a near object. It must then be relaxed, be- 
come thinner, in turning one’s eyes from an object near at hand 
to one that is far removed. The lens also loses some of its natural 
elasticity with advancing age. It can no longer undergo this al- 
ternate change with the same readiness as in youth. Thus we 
have two factors, both acting ivithin and not without the eye- 
ball, that impair the adjusting power of the eye. No eye-cups 
to lengthen the ball, no process of straining upon the eye, will 
ever be of any but the most harmful assistance in attempting to 
overcome these natural and senile changes. 
The small object which the man of fifty desires to see, is held fur- 
ther off than when he was thirty, because he can then have the ben- 
efit of rays of light that are less divergent than those coming from 
it when it is very near him. They will then, of course, not require 
so thick a lens to unite them to a distinct image upon the retina. 
The little, enfeebled ciliary muscle will not be required to do as 
much work. That work has been constantly done, except during 
sleep, ever since our baby-eyes began to look wonderingly from 
the rattle to mamma’s face. As we turned from the book we were 
reading to the landscape before us, in all the multifarious employ- 
ments of life which require a different adjustment of vision, the 
ciliary muscle has become alternately tense and relaxed, the lens 
increased and lessened in size. The vigor of the muscle is at 
last impaired, the faithful servant has become feeble with age. 
Figure 78.—Showing the action of a convex lens placed in front of an eye that is too short. 
The dotted lines show the increased convergence caused by the lens. 
The great invention of spectacles is now made available to restore 
the lost equilibrium. There is not enough power for the work de- 
manded. A double convex lens, just such an one in shape as the 
one inside the eye, is placed outside of it, in front of it, in a specta- 
cle frame. The lens within the eye is thus practically made thicker, 
and the book may be held at the old and proper distance. Perhaps 298 
TIIE EYE AND ITS DISEASES. 
the reader has sometimes wondered why old persons lift up their 
spectacles or remove them when they turn from a book or news- 
paper to the face of some one with whom they wish to converse. 
By remembering what has above been said about the rays of light 
being the less divergent the farther off the object from which they 
come, and that the lens requires to be made thicker in proportion 
to the nearness of the object, this will be easily understood. The 
old people who are to be seen working without glasses, were born 
with an eyeball which is too long. The senile changes which tend 
to shorten the eye are then counterbalanced or neutralized by the 
congenital malformation. This is probably the explanation of 
such cases as those of Cicero, Humboldt, and John Quincy Adams, 
which are sometimes adduced as evidences that old eyes may not 
need glasses. Professor Donders thinks that the most useful eye 
is one that is somewhat short-sighted, for the reason that in ad- 
vanced life glasses need not be used for reading and writing by 
such persons. These subjects are apt to boast of the superiority 
of their eyesight over that of their neighbors. If we place a weak 
concave lens before their eye, we can soon convince them that 
they can see objects at a distance better with than without its aid. 
The superiority of their vision, then, is limited to near objects. 
As a general rule, glasses are required for reading, writing, or 
the like, by all people who are not near-sighted, after the age of 
forty-five. Those who are born with eyeballs that are too short 
(hyperopes), will often require them at a much earlier period. 
Short-sighted people go on until fifty or sixty years of age, or even 
entirely through the three score years and ten, without needing 
glasses to read with. But it is an error to suppose that the vision 
of near-sighted people improves for distant objects as life advances. 
Hyperopia. 
Eyes that are congenitally too short require glasses. This 
state of arrested development includes quite a large proportion of 
human eyes. Many eyes never suffer inconvenience from the de- 
fect, and are able to do their work, until the far-sightedness of age 
occurs, without glasses. To very many, however, in whom the de- 
fect occurs, the inconvenience is so great that no continuous work 
with the eyes is possible, unless provided with spectacles. The re- 
searches of Donders were a great boon, for, supported by his inves- 
tigations, physicians began to prescribe their use to thousands 
who had been before denied them. Until Donders clearly demon- 
strated the anatomical condition at the base of the want of vision 
of this class, their fate was sad indeed. They were deemed un- THE EYE AND ITS DISEASES. 
299 
fortunates who had the eyes of old people, but to whom it was 
dangerous to give glasses, or, still worse, they were considered as 
victims of incipient blindness, which could only be warded off by 
the most vigorous anti-inflammatory regimen. Such patients were 
often confined to darkened rooms, cupped, blistered, and salivated; 
in short, they were in many instances the victims of actual mar- 
tyrdom. The only source of relief — that is, the use of convex 
glasses—was absolutely prohibited, lest the weakness of sight 
should end in complete blindness. 
Those who did not suffer from actual treatment for the un- 
known, anatomical condition, were often denied the privilege of 
using their eyes, and in England were advised to enter upon such 
employments as sheep-farming in Australia, while in other coun- 
tries similar uncongenial occupations were often urged upon those 
who, with the aid of glasses, could have been successful in chosen 
occupations. 
The discovery that hyperopic patients, even when young, 
should wear glasses, and that many did actually put them on, 
without medical advice, much to their benefit, was made in 1848 
or 1849, by Professor Chester Dewey, then in Union College. He 
published his observations in Silliman’s Journal, Vol. VIII., p. 
443, but they escaped the notice of physicians. Hence the United 
States lost the priority in proclaiming relief to a large class of suf- 
ferers. 
It was found by the ophthalmoscope that this class of eyes, 
now under consideration, were too short. Hence, both divergent 
and parallel rays would only come to a focus or unite behind the 
retina. The loss or indistinctness of sight was explained. In con- 
vex glasses, which would make this eyeball, which was too short, 
of the proper length, a remedy was found. There were no evil 
consequences to be feared from their use, since their effect was 
purely mechanical, just as we have seen is the case in the use of 
glasses for presbyopia. There are several grades of this congeni- 
tal shortness of the eyeball. In a large proportion of cases, as has 
been said, no glasses are required, because the patient can over- 
come the defect by a very slight extra and unconscious muscular 
effort. There are some cases, however, where the patient cannot 
see any small type without glasses, nor can he see objects at a dis- 
tance. These cases should have glasses as soon as the defect is 
discovered. 
There is a larger class who can see for a very short time while 
looking at near objects, but whose eyes are soon tired, and inca- 
pable of an ordinary amount of work. This class also should wear 
glasses. There are other subdivisions of this defect. It is only 300 
THE EYE AND ITS DISEASES. 
necessary to repeat what was said when treating of asthenopia or 
weak sight: that all cases of inability to continue to use the eyes 
for a reasonable time, should be carefully examined as to whether 
or not they require glasses. Much of the development of a child’s 
character may depend upon its ability to use its eyes in a proper 
way and for the proper length of time. Far- and short-sightedness, 
uncorrected, may cause many defects more serious than the mere 
inability to see. 
Myopia. 
Short-sighted eyes, or those which are too long from before 
backward, require spectacles. This condition is one in which some 
patients are born. More, however, induce it by improper habits, 
which interfere with correct vision. It is a defect more common 
in Germany, probably, than in any country. If generation after 
generation overwork their eyes under improper conditions of diet, 
illumination, character of type, and so forth, a race of near-sighted 
people, or people who very easily become near-sighted, will be at 
last produced. This has occurred in the cultivated classes in Ger- 
many, and is occurring in the United States to an increasing extent. 
Short-sighted persons do not usually need glasses for reading 
or writing, for the very simple reason that divergent rays of light 
are easily brought to a focus on a retina which is situated further 
back than it should be. Very little tension is required of their 
muscle of accommodation in uniting those rays. But in looking 
at a distance, when the rays of light which strike the eye are par- 
allel, they have trouble. Do what they will, they cannot unite 
such rays to a distinct image on the retina. They unite in front 
of it. 
The reader will remember that his short-sighted acquaintances 
cannot read signs ; that they do not know their friends on the 
other side of the street; in short, they do not see things that are 
somewhat removed, unless they have their glasses on. 
A concave lens, as we all know, disperses rays of light, pro- 
ducing just the opposite effect of a convex one, which collects 
them. Parallel rays are thus changed into those that are diver- 
gent. When a concave lens is placed before the eye, the eyeball 
is, in effect, shortened,—made to approximate one of the proper 
length. 
Any one who has normal eyes, who would like to know how 
indistinctly short-sighted persons see objects at a distance without 
-concave glasses, should step into an optician’s, and put himself in 
their position, by putting on convex glasses, which will make his THE EYE AND ITS DISEASES. 
301 
eye too long. He may, after doing this, also experience the grati- 
fication of a short-sighted person, when he puts on correcting 
spectacles, and looks out on a world of beauty, which he sees dis- 
tinctly for the first time. This latter will be done by neutralizing 
Figure 79.—Showing the effect of a double concave lens in dispersing the rays of light so as- 
to focus them on the retina of an eye, the axis of which is too long. 
the concave glasses by convex ones of the same focal distance. 
The experimenter has thus done what the oculist does for a short- 
sighted patient. The effect that is produced is purely mechanical, 
both in the eye naturally short-sighted, and the one artificially 
made so. 
So far from the use of proper glasses being an injury to such 
patients, they are a positive benefit. A neglect to wear spectacles 
when the circumstances require them, will sometimes cause one 
eye to turn outward, and thus cause deformity. The short-sighted 
eye is essentially a diseased eye, and great care is required in 
its management; but spectacles rightly used assist in preserving 
its functions. 
In the introductory part of this section, great stress was laid 
upon the necessity of a proper arrangement of the school desks 
of children, the illumination of objects, the clearness of the type, 
and so forth. It is a neglect of these precautions, as well as a fail- 
ure to secure a proper amount of out-of-door life, good food, and 
all the other influences necessary to maintain a sound body and a 
vigorous muscular system, which lead, among other defects, to a 
softened and elongated eyeball—in other words, to short-sighted- 
ness. 
It must be constantly remembered, that while far-sightedness 
from age is inevitable, and while the short eyeball of youth is a 
condition with which many are born, short-sightedness is not 
only often entirely acquired, but is also alarmingly increased by 
improper habits. Hence, many of the warnings as to the misuse 
of eyes. 302 
THE EYE AND ITS DISEASES. 
Astigmatism. 
As was said, there are defects requiring the use of spectacles 
other than those described under the three heads that have been 
discussed. The chief of these is astigmatism, from two words 
meaning not coming to a focus. Astigmatism may always be re- 
solved into hyperopia or myopia, or into both. There is hyperopic 
astigmatism, myopic astigmatism, as well as a mixed form, in 
which the two forms of the defect 
are combined in one eye. This 
condition depends upon a defect 
in the shape of the eyes, just as 
do hypermetropia (the far-sighted- 
ness of youth) and short-sighted- 
ness. There is a want of symme- 
try in the refracting parts of the 
eye. Besides being a congenital 
condition, it is sometimes acquired 
from inflammation of the cornea. 
When astigmatism exists, one part 
of the eye may be of the normal 
shape, while another is far- or 
short-sighted ; or the whole eye 
may be of improper length, al- 
though one part is more defective 
than the other. 
The troubles caused by this de- 
fect are more considerable than 
those caused by far- or short-sight- 
edness. Patients see all objects 
distorted, and none of them clearly 
or for any length of time without 
fatigue. Yet persons suffering 
from these inconveniences often go on to adult life without know- 
ing that their vision is remarkably defective, and sometimes they 
recognize that it is without being aware that there is a remedy. 
Exact examinations generally show that astigmatic persons see 
horizontal lines much better than those that are vertical or the 
reverse. A test made with such lines as are represented in the ac- 
companying woodcut will often detect astigmatism. Astigmatic 
patients, if ladies, are apt to indicate it by their inability to put on 
their neckties, and so forth, correctly, and such persons have been 
known to go about straightening pictures that were already prop- 
erly hung. 
Figure 80.—Arrangement of lines to 
test the existence of astigmatism. THE EYE AND ITS DISEASES. 
303 
Although there were isolated cases of correction of this defect 
by the use of glasses, notably the case of Airy, the celebrated as- 
tronomer, it was not until the time of Donders that physicians 
were enabled everywhere to correct it by glasses ground from a 
cylinder. The ordinary convex and concave glasses are ground 
from a sphere. It is probable that this defect, if uncorrected, has 
more effect upon the development of character, than either of the 
simpler forms of improperly-shaped eyes. 
Color Blindness. 
In this affection the patient is not able to properly distinguish 
all the colors of the spectrum. It is sometimes called Daltonism, 
from John Dalton, who first described it in 1794. Persons having 
this defect are usually born with it, although it is sometimes the 
result of disease of the optic nerve. Color-blind persons may not 
be able to distinguish red, or green, or violet, or they may be totally 
color blind, and may only perceive the form of objects. 
Color blindness is more common in males than in females. One 
in twenty-five of males are said to suffer in some degree from this 
defect, while not quite one in a hundred of females are color blind. 
There is no remedy for this trouble. It is a very dangerous one 
when it occurs in men employed in running railway trains or ships, 
for they are not able to positively distinguish the color of the sig- 
nals. In many countries and in some parts of our own, measures 
are being taken to secure an examination of all the railway en- 
gineers and switchmen. The best test for the detection of color 
blindness is that by means of colored worsteds. Those to be 
tested are caused to match the red, green, or violet, by means of the 
hundreds of various tints that are given them to select from. If 
color blindness exists, his inability to match one or more of the 
three colors will soon be shown. The color in which a person is 
blind seems to be gray to him. 
Simulated Blindness. 
For various reasons young persons and even adults sometimes 
falsely assert that they cannot see with one or both eyes. An in- 
experienced person will have difficulty in detecting this deception. 
The physician, however, by means of the ophthalmoscope and 
certain ingenious tests, is generally able to do so. 304 
THE EYE AND ITS DISEASES. 
Hysterical Blindness. 
There is a form of hysteria in which blindness is one of the 
symptoms. There is usually a basis for this simulation in a mod- 
erate defect in vision which the disease of the nervous system 
causes the patient to exaggerate. The treatment of hysteria will, 
of course, serve also to remove the trouble. It is very important, 
however, to act upon the mind of the patient by correcting, as far 
as possible, any real defect in sight that may exist. 
D. B. ST. JOHN ROOSA, M.D. The Ear and its Diseases. 
BY 
ALBERT H. BUCK, M.D., 
OF NEW YORK CITY, 
INSTRUCTOR IN OTOLOGY IN THE COLLEGE OF PHYSICIANS AND SURGEONS ; AURAL SURGEON 
TO THE NEW YORK EYE AND EAR INFIRMARY, ETC., ETC. THE EAR. 
In a treatise like this it seems desirable that the chapter rela- 
ting to the ear should furnish information on the following three 
points : 1. The anatomy and physiology of the ear. 2. The more 
common ailments to which this organ is liable; and 3. The means 
which a non-professional person may properly employ to relieve 
these ailments. 
For practical reasons, these last two subjects will be discussed 
under a single head. 
The ear is composed essentially of three parts, called respect- 
ively the outer, the middle, and the inner ear. The outer ear com- 
prises not only the auricle—that outer portion which can be grasped 
with the hand, and whose configuration is familiar to everybody, 
but also the external auditory canal—a tubular passage, about an 
inch in length by a quarter 
of an inch (or more) in diam- 
eter in the adult. This pas- 
sage is lined with skin 
throughout its entire length, 
but while in the outer half of 
the canal the skin is very 
thick and not at all sensitive, 
throughout the inner half it 
is very thin and highly sen- 
sitive. (Fig. 81.) There is 
also another difference be- 
tween the two parts of the 
canal. In the outer half 
there are numerous little 
side channels or glands (ce- 
ruminous glands) that pour 
forth a clear yellowish fluid, 
which, on exposure to the 
air, soon becomes converted 
into a pasty substance known under the name of ear wax. 
In the inner half of the passage there are only a few of these 
ztmims 
6 LANDS 
HAMMER 
SriRUP 
-ANVll 
i/ALWINDOW 
ZYMPANId.CA\l 7/ 
MIDDLE - EAR 
Figure 81. — (After Heitzmann). — Section 
through the external auditory canal and the tympanic 
cavity, or middle ear. A, the cartilaginous portion of 
the external auditory canal, in which the ceruminous 
glands are the most numerous. B, the bony portion of 
this canal. C, the thin wall of bone separating the 
cavity of the middle ear from the brain cavity above. 308 
THE EAR. 
glands. This passage, furthermore, lies very close to the joint of 
the jaw, so that in earache one is very apt to experience pain when- 
ever the mouth is opened, or attempts at chewing are made. Fi- 
nally, in its deeper half this passage is separated from the brain- 
cavity above by a spongy plate of bone of variable thickness. 
The middle ear (or drum cavity) is a small cavity situated just 
beyond (as we proceed inwards) the deeper extremity of the exter- 
nal auditory canal; the two are, in fact, separated only by a very 
thin membrane—the drum membrane, or membrana tympani. The 
cavity of the middle ear is so small that probably five or six drops 
Figure 82.—(After Heitzmann).—Section through the base of the temporal bone. A, rests 
over the smooth inner surface of the temporal bone, and indicates, by the straight line, the anvil 
bone. B, the tympanic orifice, and B, the central narrow portion of the Eustachian tube 
(divided lengthwise). C, the thin wall of bone separating the cavity of the middle ear from 
the brain cavity above. D, the drum membrane. G, the mucous glands at the opening of the 
Eustachian tube into the throat. H, the malleus, or hammer-bone. The cavities seen in the 
bone at the lower right side are the mastoid cells. 
of water would completely fill it. On all sides, except where it is 
separated from the external auditory canal by the drum mem- 
brane, it is surrounded by walls of bone. In the forward part of 
the cavity is the opening to a small passage-way, which leads 
downward and forward into the back part of the nose. This 
passage way is called the Eustachian tube. In the hinder part of 309 
THE EAR. 
the middle ear is another opening, larger than the first, which 
leads into a small cavity, and then through a countless number 
of minute openings, into a complete labyrinth of bony cavities, 
called the mastoid cells. This aggregation of cavities, some as 
large as a buck-shot, others no larger than a millet seed, are con- 
tained within that rounded mass of bone which one can readily 
Figure 83.—(After Rddinger).—Section through the head, showing the relations of the 
aural cavities and the Eustachian tubes: 1, Cartilage of external auditory canal. 2, Bony por- 
tion of external auditory canal. 3, 4, Drum membrane of the right side. 5, Cavity of the mid- 
dle ear. 6, Dilator muscle of the Eustachian tube. 7, 13, Muscles which lift the soft palate. 
8, Mucous membrane of the pharyngeal orifice of the tube. 9, Drum-membrane of the left side. 
10, Hammer. 11, Muscle which renders the drum membrane tense. 12, Mucous membrane of 
the Eustachian tube. 14, 15, Mucous membrane of the posterior surface of the pharynx. 
distinguish immediately behind the auricle. The floor of the mid- 
dle ear is composed of pretty thick, solid bone, while the roof con- 
sists of a very thin plate of bone, on the other side of which lies the 
brain with its enveloping membranes. (See Fig. 83.) 310 
THE EAK. 
This close proximity of the brain to the drum cavity and to the 
external auditory canal furnishes an explanation of the fact that 
now and then an ordinary inflammation of the ear passes gradually 
into an inflammation of the brain, and destroys life. 
In the centre of the drum cavity is suspended a mechanism con- 
sisting of three little bones or ossicles, called respectively the ham- 
mer, the anvil, and the stirrup. The first of these—the hammer— 
is firmly united with the drum-mem- 
brane, and is able, by reason of the 
looseness of its other attachments (to 
the surrounding bony walls), to follow 
every movement communicated to the 
drum-membrane. The last of this series 
of ossicles of hearing is the stirrup, so 
called from its perfect resemblance to 
an ordinary stirrup. This little bone is 
fastened like a piston in one of the two 
openings that lead from the drum cav- 
ity (or middle ear) to the inner ear. (See Fig. 85.) Finally, be- 
tween these two bones, and firmly connected with each of them, is 
suspended the anvil. This little bone is joined to each of the other 
two in such a manner that an impulse communicated to the ham- 
mer will be taken up by the anvil, and by it be transmitted to the 
stirrup in the form of a piston motion, driving its foot-plate into 
the cavity of the inner ear or labyrinth. 
The latter cavity is well-named, for in no other part of the body, 
not even in the eye, do we find 
such an intricate system of cavi- 
ties, channels, and structures. 
The labyrinth is composed of 
three cavities, or systems of cavi- 
ties, surrounded on all sides by 
very dense, bony walls. Two of 
these cavities—the semi-circular 
canals and the vestibule—need 
not detain us, as we know little 
or nothing concerning the part 
which they play in the act of hear- 
ing. The third cavity, which 
from its close resemblance to a 
snail is called the cochlea, contains 
thousands of delicate cords, in 
regard to which it may safely be said that they vibrate in sympa- 
thy with the countless shades of sound which daily penetrate the 
Figure 84.—The three bones of 
the middle ear (magnified). A, the 
hammer. B, the anvil. C, the 
stirrup. 
Figure 85. — (After Heitzmann).—The 
labyrinth as it appears after its walls have 
been separated from the bone in which it is 
embedded (greatly magnified). A, B, C, the 
semicircular canals. D, the oval window 
E, the round window. F, the cochlea. 6, 
the vestibule. THE EAK. 
311 
ear. From these tensely stretched cords nerve-filaments run to the 
brain, and in some unknown manner convey the sensations of 
sound. (See Fig. 87.) 
The series of shocks into which sound may be analyzed, first 
cause the drum membrane to perform a corresponding series of to- 
and-fro vibrations. The hammer, from its intimate union with 
Fig. 86. 
Fig. 87. 
Figure 86.—Section (magnified) through the cochlea, showing the spiral arrangement of its 
canals. A, A, represent the bony partition which nearly divides the canal into an upper and a 
lower portion ; the balance of the partition, extending from the margin B, B, to the wall of the 
canal, being composed mainly of nerve-fibres and the organ of Corti. C, the oval window into 
which the foot of the stirrup-bone fits. 
Figure 87.—(After Heitzmann).—Section, greatly magnified, across the canal of the coch- 
lea. A, branch of the nerve of hearing. Between A and B is a partition composed in part of 
bone and in part of a tensely stretched membrane (the basilar membrane), which gives support 
to the organ of Corti. The nerve-fibres terminate in the latter organ. 
the drum membrane, performs the same vibrations, and, as already 
stated, transmits them to the anvil, and thence to the stirrup. 
It is very generally believed that if the drum-membrane become 
destroyed (either wholly or in part), the power of hearing will be 
lost. This is an error. The same shocks which cause vibrations of 
the drum-membrane, may also, in the absence of the latter, cause 
similar vibrations of the stirrup. As the vibrations of the drum- 
membrane must reach the labyrinth (and the countless cords con- 
tained therein) through the intervention of the stirrup, so can the 
latter bone vibrate independently of the drum-membrane and the 
other two ossicles—in direct response to the shocks communicated 
by the waves of sound. This mode of transmission of sound is not 
so perfect, as a matter of course, as that which Nature has pro- 
vided, and hence the hearing power in an ear deprived of its drum- 
membrane is correspondingly imperfect. 312 
THE EAIi. 
DISEASES OF THE EAR. 
The ear, being a complex organ—composed in part of bone, in 
part of skin, and in part of mucous membrane—is liable to all the 
diseases which affect these three different tissues. To enumerate 
all these diseases and to describe their several peculiarities, would 
not be in harmony with the aim of this treatise. Furthermore, the 
suffering patient cares very little whether his disease be called by 
this, that, or the other scientific term ; he simply knows what his 
symptoms are, and desires to be relieved of these. It is of symp- 
toms chiefly, therefore, that I shall speak in the present section. 
The necessity for such a course will be at once apparent if we take 
into consideration the fact that the greater, or at least the more 
important portion of the ear cannot be seen except with the aid of 
instruments specially adapted for the purpose. One can therefore 
readily understand how few of the affections of this organ can be 
accurately distinguished, much less properly treated by any person 
who does not possess these instruments and the necessary skill to 
use them. 
Deafness. 
Deafness is probably the symptom concerning which patients 
are most anxious to ascertain information. 
If it develops suddenly in a healthy person, without pain or un- 
pleasant ringing noises, the most probable cause is the blocking-up 
of the external auditory canal with hardened wax. This is very 
apt to happen after a bath. Water enters the canal, softens the 
mass of wax, and causes it to fill the canal as tightly as would a 
cork. After the removal of the wax, the hearing returns. 
If it develops gradually, while the person is suffering from a 
“ cold in the head,” and is associated with ringing in the ear and 
perhaps occasional shooting pains, the cause is most likely to be a 
mild form of inflammation of the middle ear or drum cavity, due 
to an extension of the process known as a “cold in the head,”up 
through the Eustachian tube to the middle ear. Unpleasant sen- 
sations in the ear and more or less deafness usually remain for 
several days, and then gradually disappear without leaving any 
impairment of hearing. Beyond the avoidance of exposure to 
draughts of air and sudden changes of temperature, no special 
treatment is necessary. 
If it develops slowly without any other symptoms (except pos- 
sibly that of ringing in the ear), and is not discovered by the pa- THE EAR. 
313 
tient or his friends until it has already become pretty well marked, 
the cause is probably that insidious process which we term 
“chronic catarrh of the middle ear,” but the exact nature of which 
is not clearly understood. In these cases even the aurist very 
rarely succeeds in improving the patient’s hearing by treatment. 
As the catarrhal process in the ear, however, is apt to be depend- 
ent upon a similar condition of the upper part of the throat, the 
further progress of the trouble may be arrested by making suit- 
able applications to this region. These are the cases which fall 
an easy prey to the advertising quack. The regular practitioner 
of medicine fails to afford the sufferer any relief, and probably 
dismisses the case as incurable. The quack promises a speedy 
cure, and the patient — ready to spend any amount of money to 
recover his lost hearing—very naturally puts faith in this new 
adviser. 
If it develops suddenly or quite rapidly during convalescence 
from cerebro-spinal meningitis (or brain-fever), scarlet fever, ty- 
phoid fever, measles, or small-pox, without other marked symp- 
toms referable to the ear, the cause is probably an escape of blood 
into that portion of the labyrinth which is called the cochlea. Yery 
little is known about these cases of labyrinthine ear disease beyond 
the fact that the loss of hearing is almost always permanent. No 
form of treatment is known to be of any use. On the other hand, 
as young children are most apt to be the subjects of this malady, 
it is important to take early steps for the preservation of the power 
of intelligible speech, which, without special efforts on the part of 
parents or instructors, would very soon be lost. 
If the deafness develops as the immediate result of a fall or 
blow upon the head, the cause is probably either a rupture of a 
blood vessel in the cochlea (see Fig. 86), or a dislocation (or rup- 
ture) of the delicate cords contained in that cavity. Here, again, 
the loss of hearing is more than likely to be permanent. The next 
most important symptom of which patients complain is generally 
Earaehe. 
As non-professional persons can treat the symptom only, irre- 
spective of the exact nature of the cause, I shall confine myself to 
a statement of the great importance of this symptom as a warning 
of impending danger. In by far the greater number of instances, 
an earache will run its course without serious detriment to the 
health of the patient or noticeable damage to his power of hearing. 
In quite a large minority, however, the earache is simply the 
first stage of a severe inflammation of the middle ear—an inflam- 314 
TIIE EAR. 
mation which, if not checked during this first stage, may go on to 
the total destruction of the drum-head, to the establishment of a 
chronic process of- ulceration, rendering the patient offensive (by 
reason of the disagreeable odor connected with the discharge from 
the ear} to those brought into close companionship with him, and 
finally, in a few instances, to death, through inflammation of the 
adjacent brain. Almost every reader of these pages will be able 
to recall to mind instances of the truth of this statement among 
his immediate circle of acquaintances. It would not be far from 
the truth to say that nearly all of these unfortunate individuals 
might have been spared such serious results, had the earache, 
with which the disease commenced, been intelligently treated at 
the very beginning. 
Unfortunately, the day has not yet arrived when every physi- 
cian is able to recognize a commencing inflammation of the mid- 
dle ear, or, having recognized it, to make a cut through the drum 
membrane and so prevent the serious results already described. 
Until that day arrives, blame cannot justly be cast upon the gen- 
eral practitioner who fails to afford the desired relief. On the 
other hand, it is more often the case that the patients themselves 
or their friends are to blame; they send for the physician only 
after the major part of the damage has been done—for hours are 
precious in a matter of this kind. However clearly he may then 
recognize the nature of the disease, and however boldly he may 
resort to the use of the knife, his efforts will at most mitigate the 
otherwise serious results. 
Treatment.—Earache depends upon a variety of conditions of 
the ear, and accordingly requires different methods of treatment 
if the desired relief is to be quickly obtained. As, however, these 
different conditions cannot be distinguished by a non-professional 
person, I shall simply mention those measures which tend to re- 
lieve pain and allay inflammation. 
In the case of a strong, healthy adult, leeches afford the surest 
and speediest means of arresting inflammation and relieving pain. 
They should be applied as close to the external orifice as possible, 
and should be left undisturbed until they drop off of themselves. 
Then the bites may be sponged for a time, say fifteen or twenty 
minutes, with warm water, in order to promote further bleeding. 
After that, a small pad of cotton wool should be laid over the bites, 
then some hard object like a large cork (wrapped up in a piece of 
old linen), and finally a bandage. The object of the latter, which 
should pass over the head and beneath the jaw, is to keep the cork 
or other hard object firmly pressed against the leech-bites until the 
bleeding is arrested. As soon as this has been accomplished, both 315 
THE EAR. 
the bandage and the cork can be removed. The number of leeches 
to be used must depend upon the severity of the pain and the vigor 
of the patient. Three, or at most four, usu- 
ally suffice. In adults of rather feeble phy- 
sique, it will be advisable to apply only 
two leeches. On the other hand, little more 
than annoyance and loss of valuable time 
need be expected from the application of 
only two leeches in a strong adult. In 
children under fifteen or sixteen years of age 
leeches shoidd never he employed except 
under the immediate supervision of a phy- 
sician, or of some person skilled in such 
matters. 
As much, if not all, of the good effept of 
local bleeding may be lost by not making 
the leeches bite at the proper place, it is a 
good plan to mark with a pen and ink the 
exact spots on the skin where the leeches 
are to be applied. The three dots in the ac- 
companying figure show where, in the ma- 
jority of cases, the leeches can be applied 
to the greatest advantage. 
The next most potent means at our command for the relief of 
pain is heat. To bring heat to bear upon the ear, a number of 
contrivances can be employed. The ordinary flaxseed meal poul- 
tice, combining as it does moisture with heat, is perhaps the best 
known of all these contrivances. Poultices, however, are disa- 
greeable things to have in contact with the head. A better plan 
is to fill a soft flannel bag (eight or ten inches square) with hops, 
steep it in hot vinegar and water (or simply in hot water), and 
then squeeze it as dry as possible. This makes a soft warm pillow 
and is usually very soothing to the suffering ear. Several thick- 
nesses of flannel, soaked in hot water and then squeezed as dry as 
possible, furnish another excellent form of warm moist application 
for the relief of earache. So far as the relief of pain is concerned, 
the dry-hot applications are probably equally efficacious. A linen 
bag filled with bran and heated in the oven* will answer fully the 
required purpose. It will be found more convenient to prepare two 
figure 88.—The dots show 
to relieve earache and infiam- 
™tlon of deep parts of the 
(For mode of applying leech- 
es, see chapter on Nursing.) 
* With a little ingenuity one can easily adapt a wire frame to an ordinary kerosene 
lamp (or gas burner). Upon this frame a tin pie-plate should be placed at a distance 
of six or eight inches above the flame. A second plate inverted and placed on top of 
the first one, will then furnish an excellent oven in which the bran-bag can quickly 
be heated to the desired temperature. 316 
THE EAR. 
such bags, as then, while one hag- is in active use, the other may 
be heating in the oven. A heated flat-iron wrapped in flannel will 
also answer the same purpose. 
The heart of a freshly roasted onion is very often laid upon the 
orifice of the ear for the relief of earache. I do not know that 
it possesses any special virtue not possessed by the other hot ap- 
plications just mentioned. 
Sometimes an earache is relieved by allowing a gentle stream 
of pretty warm water to enter and pass out of the ear during a 
period of several minutes. If a Fountain douche or Clarke’s ear 
douche cannot be obtained, an ordinary tin funnel, with a rubber 
tube of suitable size attached, may be made to answer the same 
purpose. „ 
If all these measures fail, and especially if the parts behind the 
ear begin to be tender on pressure, it may be taken for granted 
that the inflammation is extending, and that none of the ordinary 
home remedies can be trusted to arrest the progress of the disease. 
Under such circumstances professional assistance should be ob- 
tained without an hour’s delay. 
It is not a rare occurrence for persons to complain of earache 
when in reality the ear itself, in all its parts, is perfectly normal. 
In these cases the real seat of the difficulty is a decayed tooth, and 
the earache is simply “ sympathetic,” as it is technically called. 
Upon the removal of the offending tooth the earache disappears. 
Next to earache, otorrhoea, or a 
Discharge from the Ear, 
Is the commonest symptom for which patients seek relief. If of 
recent date and immediately preceded by pain of at least several 
hours’ duration, it may be attributed either to an abscess in the 
external auditory canal, or to an inflammation of the middle ear, 
with perforation of the drum membrane. If with the pain and the 
discharge there have been no decided deafness, and if there have 
been considerable tenderness on the outside of the ear, especially 
just in front of the external orifice, it may be confidently inferred 
that the discharge comes from an abscess in the external auditory 
canal. 
If of long standing, the discharge very probably comes from the 
middle ear. If blood makes its appearance in the discharge, the 
inference is a fair one that granulations (“ proud flesh ”) have 
formed either in the external auditory canal, or in the middle ear. 
In such an event it is very important that the ear should be exam- 
ined by a physician who is familiar with diseases of the ear. The THE EAK. 
317 
presence of granulations or of polypi implies the existence of a con- 
dition of irritation sufficiently marked to demand active interfer- 
ence on the part of the physician. Polypi should he removed, as 
they may interfere with the escape of matter, and so favor an ex- 
tension of the inflammation to the brain. 
Treatment.—In cases of discharge from the ear, the point of 
greatest importance is to prevent 
the pus from stagnating in the ex- 
ternal auditory canal, and thus be- 
coming foul and very irritating to 
the parts which it bathes. Syring- 
ing the ear with lukewarm water is 
probably the simplest and at the 
same time the most effective method 
of accomplishing this object. If the 
discharge be scanty, it will probably 
be sufficient to syringe the ear but 
once a day; if it be abundant and 
smell badly, the syringe should be 
used as often as two or three times a 
day. 
In cases of discharge from the ear, the Fountain douche or 
Clarke’s douche will be found to answer the desired purpose even 
better than the syringe. Care should be taken, however, to use a 
nozzle sufficiently 
small, as most of 
those sold in the 
shops, to be used 
in connection with 
the douche are far 
too large to be inserted into the external orifice of the ear. Farther 
on I shall call attention to the precautions which one should observe 
in syringing out the ear. 
I dare not suggest any remedies for arresting the discharge, 
simply because those solutions which in certain cases prove bene- 
ficial, in others only serve to aggravate the condition which causes 
the discharge. At the same time time I must state, in very distinct 
terms, that the commonly received idea, that “ if a discharge from 
the ear he stopped!, it will go to the brain,” is false, and should be 
rooted out of the public mind. To arrest the discharge without 
remedying the condition which gives rise to the discharge, would, 
indeed, be highly injurious ; on the other hand, the arrest of the 
discharge by suitable treatment of the fundamental disease,-is the 
best means of preventing that very disease of the brain, of which 
Figure 89.—Clarke’s Ear-douche. 
Figure 90.—Hard rubber ear-syringe. 318 
THE EAR. 
* 
people are so justly afraid in connection with a discharge from the 
ear. 
Ringing in the Ears. 
By this expression is meant not only ringing in the ears, in a 
strict sense of the term, but also all the different subjective sounds 
of which patients are wont to complain. It is a. very annoying 
symptom, and its source is sometimes found in an accumulation of 
wax in the external auditory canal, in the presence of an insect upon 
the outer surface of the drum membrane, or in the existence of an 
inflammatory condition of the middle ear or neighboring parts ; 
more often, however, no demonstrable cause can be found, and 
one is driven to assume that some unnatural condition of the nerve 
of hearing exists. In the majority of cases of long standing, all 
efforts to relieve this annoying symptom prove unavailing. On 
the other hand, the ringing oftentimes disappears of itself, without 
our being able to assign any valid reason for its disappearance. 
Foreign Bodies. 
Foreign bodies and insects frequently find a lodgment in the 
ear. Unless they are of such a size and shape as to injure the 
walls of the external auditory canal, their presence need give no 
special anxiety. Clumsy and incautious efforts with forceps and 
other instruments often convert a harmless state of things into 
one fraught with suffering and some danger to life and hearing. 
Treatment.—Syringing with lukewarm water is the only means 
which a non-professional person can safely employ for the removal 
of the foreign body or insect. If the insect can be felt moving 
about in the ear, it may be well to drop a few drops of glycerine 
into the passage-way before resorting to the syringe. Sweet oil 
may be used instead of glycerine ; but in that event soap must be 
added to the lukewarm water used afterwards in syringing, as the 
presence of oil in the external auditory canal sometimes gives rise 
to a very rebellious and annoying inflammation of these parts. 
The practice of dropping sweet oil into the ear for the relief of the 
most varying conditions is almost universal ; it being generally 
believed that no possible harm can come from such a practice. As 
the unpleasant results just mentioned are not so very rare, it would 
be safer to make the rule never to use sweet oil in any ear trouble. 
If one is confident that the external auditory canal is blocked 
up by the presence of a mass of hardened wax—e.g., if it can be 
seen or felt—syringing with lukewarm water may be resorted to THE EAK. 
319 
for its removal. If, after reasonably prolonged efforts, the mass 
still remains impacted in the canal, bicarbonate of soda can then 
be employed to soften the mass. The patient should lie upon a 
sofa or bed with the affected ear turned upward. Into the passage- 
way are to be dropped first a pinch of the soda, and then a few 
drops of tepid water for the purpose of dissolving it. This concen- 
trated solution of soda should remain undisturbed in the auditory 
canal about half an hour. The syringing is then to be repeated, and 
if it still fail to dislodge the mass of wax, a second or even a third 
soaking with the soda solution may safely be resorted to. If all 
these efforts fail, professional assistance will have to be obtained. 
Syringing the Ear. 
So many people fail in their efforts to use a syringe successfully, 
that a few simple directions will perhaps prove of value. 
In the first place, almost all glass or lead syringes, or such as 
have to be managed by both hands, are likely to cause pain to the 
patient and to fail of accomplishing the desired purpose. The so- 
called Davidson’s syringe 
is a decidedly better in- 
strument for ear pur- 
poses. The person who 
uses it, however, is very 
apt to throw into the ear 
a stream of too great 
force. The best instru- 
ment is probably the hard 
rubber ear syringe (the 
smaller of the two sizes 
usually sold), which is 
constructed in such a 
manner that it can read- 
ily be managed with one 
hand. (See Fig. 91.) 
In the next place, it is 
a very common error for 
people to hold the nozzle 
of the syringe near the 
outer orifice of the ear 
instead of introducing it into the passage. In syringing the ear, the 
operator should lift the patient’s auricle upward and a little back- 
ward with the thumb and forefinger of his left hand, for the pur- 
pose of making the external auditory canal as straight as possible. 
Figure 91.—Manner of syringing the ear. 320 
THE EAR. 
He should then introduce the short nozzle of the syringe (see the 
figure) as far into the ear as he can without actually blocking up 
the entire orifice. * If he holds the syringe in the right direction, 
the patient will experience no discomfort from the presence of the 
instrument in the canal. On the other hand, if he points it too far 
forward or backward, or in any wrong direction, the patient will 
be pretty sure to give him due notice of his error. In very young 
children the auricle must be pulled backward and perhaps a little 
downward, and the nozzle must be introduced only a very short 
distance into the canal. Finally, the water must neither be too 
hot nor too cold,—that is, from 85° to 90° Fahrenheit,—and care 
must be taken not to use too great force. 
Care of the Ears. 
The discussion of the question of syringing the ear suggests 
very naturally another question—how can the healthy ear be safely 
and effectively cleansed ? In answer to this question, I would say 
that, under ordinary conditions, only that portion of the ear which 
is easily visible requires cleansing. To accomplish this, the 
end of a soft towel, a bit of sponge, some cotton-wool wrapped 
closely round the end of a wooden match, or any other similar con- 
trivance, may be safely used. So long as the person, whose ear is 
thus being cleansed, makes no complaint of pain, it may be taken 
for granted that no harm is being done. 
Still another question is often asked—ought cotton-wool or 
lamb’s wool to be worn in the ears ? In reply to this, I would say 
that the patient’s own feelings should be our guide in this matter. 
The undue warmth produced by the presence of a mass of wool in 
the external auditory canal rather tends to promote a congested 
condition of the parts. Hence, unless the patient feels more com- 
fortable with the wool, or unless the abundance of the discharge 
from the ear renders its use necessary for purposes of concealment, 
I should advise leaving the ear exposed, as Nature evidently in- 
tended it to be. 
GENERAL REMARKS. 
Before closing this brief chapter, I may profitably add a few 
cautions regarding the avoidance of diseases of the ear. 
1. Measles and scarlet fever are exceedingly liable to be fol- 
* If some other form of syringe than that referred to here (and represented in Fig. 
90) be used, the nozzle must not be introduced farther than a quarter of an inch be- 
yond the orifice of the canal. THE EAR. 
321 
lowed by severe inflammation of one or both ears. Hence the 
great importance of prompt interference to prevent the serious 
consequences which might otherwise follow. If parents would 
bear this fact in mind and give the attending physician timely no- 
tice of the approach of trouble in their children’s ears, the number 
of cases of life-long discharge from the ear might be materially 
diminished. 
2. The operation of puncturing the drum membrane is not only 
a perfectly safe operation, but is generally considered by aurists as 
the surest means the physician possesses of relieving pain in the 
ear, and of preventing those profound disturbances of nutrition 
(ulceration, death of the bone, etc.) which cause marked deaf- 
ness and chronic discharge from the ear. For the sake of emphasis 
I might add, that the popular idea that if a drum membrane be cut, 
the opening will never heal up and the hearing will be destroyed, 
has no foundation whatever in fact. . 
3. Laudanum and spirits of camphor, remedies which are very 
commonly prescribed for the relief of an earache,—should never 
be introduced into the ear. 
4. The habit of vigorously scraping the external auditory canal 
with an “ ear-spoon,” not unfrequently leads to the formation of 
an abscess, and should be avoided. 
5. The practice of snuffing up cold water (and sometimes even 
warm water) into the nostrils, is now and then followed by acute 
inflammation of the middle ear; some of the water finding its 
way through the Eustachian tube into the middle ear. The nasal 
douche, unless used with great caution and in accordance with 
certain prescribed rules, is also very apt to give rise to painful 
affections of the middle ear. 
6. —Bathing in salt (and sometimes also in fresh) water is quite 
often followed by earache and deafness, and occasionally by very 
serious inflammation of the ear. There is a popular idea that the 
disturbance is produced by the entrance of the water into the ex- 
ternal auditory canal, and such indeed is beyond all question, in 
certain cases, the fact. In the majority of instances, however, the 
inflammation is caused by the entrance of the water first into the 
nostrils, and thence through the Eustachian tube into the middle 
ear or drum cavity. As a rule, therefore, it will be found unavail- 
ing to stuff the external orifices of the ears with cotton before en- 
tering the water. It is more important to avoid that vigorous 
“ nose-blowing ” which everybody is tempted to indulge in upon 
coming out of the water ; for it is by this act, more than by any- 
thing else, that the water is likely to be driven from the nostrils 
up into the Eustachian tubes and drum cavities. 322 
THE EAR. 
7. Boiler-makers, and those exposed for hours at a time to loud 
noises of any kind (especially such as are accompanied by a strong- 
concussion of the air), should remember that they run a great risk 
of losing their hearing—not suddenly, but slowly and steadily. 
Telegraph operators are also exposed to the same danger, though 
to a slighter degree. 
8. Persons who take quinine in large doses for any length of 
time should be on their guard, as this remedy in a few cases 
seems to be capable of inducing decided deafness. The danger 
commences when the ears begin to ring. The development of this 
ringing or buzzing in the ears should therefore serve as a warning 
that the quinine is either to be stopped altogether for a time, or 
else is to be taken in diminished doses. 
Fig. 93. 
Fig. 92. 
Figures 92 and 93.—Varieties of ear-trumpets. 
Figure 94.—A conversation-tube. 
Fig. 94. 
0. Persons who are very deaf, will often find it possible by 
means of an ear-trumpet or a “conversation-tube,” to hear ordi- 
nary conversation, or public speaking, with more or less ease. It 
is exceedingly rare, however, that the use of the “ false drum 
membranes ” proves of any material assistance to the deaf person. 
ALBERT H. BUCK, M.D. Deaf-Mutism. 
BY 
JOHN W. CHICKERING, Jr., A.M., 
OF WASHINGTON, D. C., 
PROFESSOR OF NATURAL HISTORY IN THE NATIONAL DEAF-MUTE COLLEGE. DEAF-MUTISM. 
The term deaf-mute is commonly applied to those whose sense 
of hearing is, from any cause, either entirely lacking or so defec- 
tive that they are unable readily to communicate with their fellow- 
men by speech. In ninety-nine cases out of a hundred, deafness 
is the only defect, and the person is mute only because his inability 
to hear has rendered him so, and not on account of any deficiency 
in the vocal organs. Hence the word mute is preferred to dumb, 
the latter seeming to carry with it the idea of some physical de- 
fect. 
Deaf-mutes are naturally divided into two classes, technically 
called mutes and semi-mutes. By the former are understood those 
who either were born deaf, or lost their hearing before they had 
begun to acquire the power of speech. By the latter are meant 
those who did not lose their hearing till they had learned to talk, 
and thus make words the vehicle of their ideas. 
A very little reflection will show that the man who has become 
familiar with, his mother-tongue has a great advantage over him 
who has, so to speak, had no mother-tongue, but has been com- 
pelled to acquire, slowly and painfully, not only the vocabulary he 
would use, but also the ability so to unite words as to convey accu- 
rately and idiomatically his ideas either to himself or to others. 
Certain results follow this division into two classes, especially 
affecting modes of instruction, which will appear farther on. 
Statistics.—Few things are more vexatious, nor often more 
mischievous, than unreliable statistics. The old adage that “fig- 
ures cannot lie,” is continually disproved by the contradictory 
results which the same sets of statistics are made to afford under 
the hands of skilled manipulators. The so-called statistics of deaf- 
mutism are not free from either of these causes of error, and yet 
each attempt, however imperfect, renders greater accuracy for the 
future possible. 
It was estimated by M. Guyot, in 1842, that the total number of 326 
DEAF-MUTISM. 
deaf-mutes in the world was 600,000. The latest estimate of the 
probable population of the globe places it at about fourteen hun- 
dred millions. The generally accepted proportion of 1 to every 
1,500 would give 933,000 as the total number of these children of 
silence upon the globe. But we are not without more accurate 
data. The following table is taken from an article by Rev. H. W. 
•Syle, in Appleton’s Encyclopaedia, Revised Edition : 
Countries. 
Date. 
Proportion of one 
in 
Switzerland, Aargau 
1836 
189 
“ Vaud 
1836 
1,112 
769 
Sardinia 
1834 
Norway 
1835 
977 
Sweden 
1840 
1.528 
Denmark 
1834 
1,942 
Holland 
1833 
2;ooo 
2,226 
Belgium 
1835 
Luxembourg 
1835 
2,295 
Prussia , 
1849 
1,364 
France 
1853 
1,212 
1,176 
1,311 
Ireland 
1861 
Scotland 
1861 
England 
1871 
L971 
United States 
1870 
2,380 
The total number reported in the United States in the census of 
1870 was 16,205, but subsequent investigations, made in limited 
regions, seem to indicate that this number is too low, and that 
from 20,000 to 25,000 would be a more accurate estimate. The 
latest and fullest statistics give the ratio in England and the 
United States as not far from 1 to 2,000 ; in Europe about 1 to 
1,500. Respecting the other continents we know very little. 
Causes.—These naturally divide themselves into ante-natal and 
post-natal. The former largely predominate in older countries 
where deafness is only one of many indications of race-deteriora- 
tion, often associated with idiocy, feeble sight, goitre, cretinism, 
and other evidences of mental and physical decay. The latter are 
decidedly in excess in America, where the process of race-deteri- 
oration has hardly begun. These facts appear from the following 
table : 
Total. 
Congenital. 
Adventitious. 
Unknown. 
Great Britain 
4,200 
3,784 
3,288 
1,401 
912 
United States and British Provinces 
1,983 
400 
Under the first head heredity and consanguineous marriages DEAF-MUTISM. 
327 
are placed as the two chief causes. The first of these, however, is 
probably less influential than is generally supposed. Dr. H. P. 
Peet, of New York, makes the computation that the probability 
of deafness among the children of parents deaf from accidental 
causes is only 1 to 1,600; where one parent is congenitally deaf, 1 
to 130 ; where both parents are congenitally deaf, 1 to 10. 
The statistics of five American institutions for 1878 are as 
follows : 
Children deaf-mute. 
Both parents deaf-mute 
35 
One parent “ 
20 
Neither parent “ 
2,501 
Whole number 
2,556 
All conclusions, however, drawn from such tables, need to be 
re-adjusted upon the basis of the ratio of deaf-mute families to the 
whole community. 
Dr. W. W. Turner, in a paper on this subject, shows that in 
24 families in which both parents were congenital deaf-mutes 
there were 57 children, of whom 17, or nearly one-third, were deaf- 
mutes ; and that in 86 families in which one parent was a con- 
genital deaf-mute there were 218 children, of whom 21, or about 
one-tenth, were deaf-mutes. Lacking in agreement as these dif- 
ferent statistics are, they all seem to indicate the inadvisability of 
the inter-marriage of deaf-mutes. 
As to the question of consanguineous marriages as a cause of 
deaf-mutism, the assertion that “ figures cannot lie,” is entirely 
disproved by the radically different conclusions which have been 
demonstrated (at least to their own satisfaction) by different in- 
vestigators. The reports of three institutions in the United States 
and one at Halifax give statistics as follows : 
Famines. 
Deaf-mutes. 
Parents first-cousins 
30 
64 
“ second cousins 
11 
24 
“ second and third cousins 
1 
2 
Distantly related 
17 
33 
Not related 
252 
267 
“ Twenty-five out of these thirty families, containing 53 out of 
the sixty-four deaf-mutes whose parents were first cousins, are 
mentioned in the catalogue of the Halifax Institution, the total 328 
DEAF-MUTISM. 
number of whose pupils has been only 224. This striking excess 
in the relationship of parents among the pupils of this institution 
over those of the other institutions from which we have statistics 
is doubtless due to the fact that the marriage of near kin has pre- 
vailed to a far greater extent in the British maritime provinces 
than in the United States.” Dr. Bemiss, of Louisville, Ky., on in- 
vestigating 833 consanguineous marriages, found that of the 3,942 
offspring, 1,134 were defective, of whom 145 were deaf and dumb, 
and estimated that ten per cent, of the deaf in the United States 
sprang from kindred parents. 
The prevalence of deafness as well as of idiocy, cretinism, and 
goitre, in mountainous districts (the deaf amounting at one time 
to one per cent, of the total population in part of the Canton de 
Yaud, Switzerland), must be partly due to the intermarriages in a 
secluded and stationary population ; and the less proportion of 
congenital to accidental cases in the United States than in Europe 
to the free intermixture of races here. By others the validity of 
these conclusions is strenuously denied, and it is claimed that a 
more extended and exhaustive induction of facts disproves the 
theory. All this clearly demonstrates the necessity for more 
careful collation of reliable statistics. It would, however, seem 
self-evident, whatever might be the result of consanguineous 
marriages in the case of those physically and mentally sound, 
that where any abnormal weakness or liability to disease is a 
marked family characteristic, intermarriages, even between dis- 
tant branches of such a family, would have a strong tendency to 
develop such weakness, each generation exhibiting it in intensified 
form. 
* “ It has been noticed in Europe that deaf-mutism is more in- 
frequent in flat than in mountainous countries, probably only be- 
cause cretinism is more common in the latter. Deaf-mutism is 
more frequently met with in the country than in cities. The affec- 
tion is more common in males than in females. In Bavaria the 
excess is eighteen per cent. In educational institutions the excess 
is much larger, forty-nine institutions in the United States con- 
taining 3,568 males and 2,598 females. It is a remarkable fact that 
this defect is incomparably more frequent among Israelites than 
among Christians. In the Depa rtment of Cologne, in 1849, the pro- 
portion was 1 to 1,814 Catholics, 1 to 2,638 Protestants, and 1 to 
560 Jews.” Consanguineous marriages seem to offer the most 
plausible explanation of this fact. “ This infirmity is met with far 
* Kussmaul, in Ziemssen’s Cyclopedia, American ed., Vol. XIV. DEAF-MUTISM. 
329 
more frequently in the poorer classes.” Alcoholism, on the part 
of parents, is also noticed as a cause of deaf-mutism in children. 
As regards post-natal causes, the American Annals for the 
Deaf and Dumb, for 1878, gives the latest and most reliable classi- 
fication. 
Nine institutions give statistics as follows : 
Number. 
Ratio. 
Congenital 
1,737 
40 
Scarlet fever 
'581 
.135 
C erebro-spinal meningitis 
256 
.06 
Brain fever 
194 
.045 
“ Sores in head” * 
187 
04 
Measles 
111 
025 
Accidents 
91 
.02 
Typhoid fever 
77 
.018 
Whooping-cough 
67 
.016 
Colds?. .7 7 
66 
016 
41 
01 
Hydrocephalus 
35 
008 
Scrofula 
27 
.006 
Pneumonia 
22 
.005 
Diphtheria 
18 
.004 
All others 
828 
.192 
Whole number 
4,338 
“ All others ” include some forty different causes ; among them 
“quinine” and “calomel,” and are often to be taken “cum grano 
salts.” 
Cure.—Upon this point very little is to be said. Medicine and 
surgery alike have been compelled to acknowledge their inability 
to accomplish for the ear any of the triumphs which they have so 
often achieved in behalf of the eye. Especially in early days, 
many an unfortunate deaf-mute “ suffered many things of many 
physicians, and was nothing bettered, but rather grew worse,” 
and too often has suffered cruel tortures, and sometimes death 
itself, at the hands of ignorant pretenders. Seldom will a reput- 
able physician hold out to a deaf-mute any hope of substantial im- 
provement. Of all others the deaf-mute should especially beware. 
But while little can be done in the way of cure, something 
may be done in the way of prevention, and it is gratifying that in 
Great Britain the statistics of three decades show a decided gain : 
the proportion in 1851 being 1 to 1,590 ; in 1861, 1 to 1,432 ; in 1871, 
1 to 1,644. Upon this fact an English writer, Dr. David Buxton, 
thus comments : “If we may regard it as the consequence of direct 
[* Probably diseases of the ears, many of which cases may also be counted as the re- 
sults of scarlet fever.—Ed.] 330 
DEAF-MUTISM. 
sanitary improvements, general attention to the laws of health, a 
more skilful treatment of the diseases which result in deafness, 
and the avoidance of consanguineous and other undesirable mar- 
riages, we have certainly gained a great blessing, and made a grand 
discovery for posterity to profit by. Guided by the light thus 
given, we may hope to see the number of this afflicted class 
brought down to the point at which it may be considered due to 
causes which are beyond man’s control.” 
Education.—While very little has been accomplished in the 
way of cure, for no class has education accomplished more than for 
deaf-mutes. For centuries this class of human beings was neg- 
lected and shut out from the pale of common humanity, not only 
by the thoughtlessness of the ignorant and the cruelty of the un- 
feeling, but by the common consent even of philosophers, states- 
men, and philanthropists. 
Aristotle denied that mutes possess intellect. The Justinian 
Code declared them incapable of civil acts. St. Augustine asserted 
that “deafness from birth makes faith impossible, since ‘faith 
cometh by hearing,’ and he who is born deaf can neither hear the 
word nor learn to read it.” Such was the status of the deaf-mute 
—unable to enter a protest in his own name—without an advocate 
to plead in his behalf. The state did not regard him as entitled 
to the rights of citizenship ; even the church considered him as 
unworthy to enter within her pale. Within the last century all 
this has changed. First, the Christian philanthropist, then the 
statesman has discovered that the deaf-mute has capabilities, and 
therefore rights and duties ; and that, for the enjoyment of the 
one, and the performance of the other, the necessary preparation 
•should be supplied both by church and state. It has been found 
that the deaf-mute is not a poor imbecile ; is not even necessarily in- 
ferior in any respect in mental capacity to his hearing and speaking 
brother. He does labor under the disability of having one avenue 
whereby impressions are received from the outer world closed ; and 
hence the instruction ordinarily given, and the education ordina- 
rily gained through the ear, must be supplied in some other way. 
Hence what he needs is just what every child requires : not 
protection, but education ; not the asylum, but the school, the 
academy, the workshop, the college. Only a means must be de- 
vised by which he can come into easy, rapid, exact communication 
with both books and teachers. 
In every civilized nation such provision is now made. Espe- 
cially has this been done in our own country, where universal suf- 
frage renders universal education an imperative necessity. Now 
every State in the Union, except Florida, makes annual appropri- DEAF-MUTISM. 
331 
ation for the education of deaf-mutes, as having the same claim 
to the advantages of “ free schools ” as any other class of citizens. 
Nor should these institutions any longer be regarded as “asy- 
lums,” nor their pupils as “ patients” or “inmates,” but as simply 
one department of our common-school system ; the very object of 
which is, by providing for the deaf-mute that special instruction 
which he requires, to prevent his needing any asylum, and to send 
him out into the world as a man able to do good, honest, useful 
work, and asking of society only that work and its well-earned 
wages, “a fair field and no favor.” But it must ever be borne 
in mind that this change in popular feeling and judgment re- 
specting the status of the deaf-mute is conditioned solely on his 
being educated. No amount of sentiment or philanthropy can 
make aught of him without education. Lacking this he is still, 
in the eye of the law, non compos, neither legally nor morally 
responsible for crime, though, of course, liable to restraint. Yet, 
further, he is regarded as actually ignorant of the principles of 
right and wrong, of general law, either human or divine, and of 
all sanctions, save in some few specific cases. Mentally, his con- 
dition is thus graphically stated by President Gallaudet, of the 
National Deaf-Mute College : 
“ Having no language in common with his fellow-men ; shut out 
from the stores of information and food for thought, conserved in 
books ; unable to acquaint himself with even the news of the day as 
chronicled iii the journals ; often excited, and perhaps tormented 
with thoughts and queries for which he has no means of exact 
expression ; his mind may be likened to an eagle caged, or a lion 
chained. He will either lapse into the contentedness of ignoble 
bondage, or drag out an unhappy existence, beating at bars, or 
chafing in fetters, from the thraldom of which he is powerless to 
free himself.” 
So soon as the power of education to deliver the deaf-mute from 
this condition is recognized, and the possibility of his education 
demonstrated, it is not strange that popular interest is awakened 
in the subject, and that appeals in his behalf meet a ready response. 
But for centuries no such possibility was even dreamed of, and 
a few instances scattered along the pages of history seemed rather 
like fairy tales than veritable narrative. 
History of Deaf-Mute Education. 
Pliny mentions that Quintus Pedius, a relative of Augustus, 
although a mute from birth, being instructed in painting on the 
recommendation of the orator Messala, made great proficiency in 
that art. 332 
DEAF-MTJTISM. 
The venerable Bede, in the seventh century, gives an account 
of St. John, of Beverly, Bishop of Hagulstadt, who, calling to him 
a dumb youth on whom he was accustomed to bestow alms, and 
making the sign of the cross on his tongue, commanded him to 
repeat the Anglo-Saxon word, gea, yea, which he did, and after- 
wards repeated from the bishop's lips, first letters, then syllables, 
and so on to words and sentences. Add the factor of time, the 
miraculous element disappears, and we see in the good bishop only 
the forerunner of the modern teacher of articulation. The next 
mention of any such case is by Rudolph Agricola (died 1485), 
who records that a certain deaf-mute had learned to write. 
Platenus states that at Basle, in 1530, was a deaf man, who 
could not only write, but could understand the preaching of the 
reformer CEcolampadius from the motions of his lips. 
The first philosophical recognition of the possibility of deaf- 
mute instruction was made by Jerome Cardan, of Pavia (died 
1576). “The instruction of the deaf and dumb,” says he, “is dif- 
ficult, but it is possible. Writing is associated with speech, and 
speech with thought; but written characters and ideas may be 
connected with each other without the intervention of sounds.” 
The first attempt to put this theory in practice on an extended 
scale, and with such success as to compel the notice of contempo- 
raries, was by Pedro Ponce de Leon, a Benedictine monk (1520- 
1584). In 1620 Juan Pablo Bonet, a native of Arragon, published 
the first treatise on the art; The Reduction of Letters, and Art of 
Teaching the Dumb to Speak. He employed the manual alpha- 
bet, gestures, and articulation. In England, during this century, 
several books were written upon the subject, and Dr. John Wallis 
achieved great success as a teacher. In Holland, John Conrad 
Amman published a work in 1692, Surdus Loquens, which is still 
a valuable treatise on the method of teaching articulation. 
But it was not until a century later that the two men who have 
given names to their respective systems, and whose work has 
known no interruption, commenced their work, Heinicke, in Ger- 
many, in 1758, and the Abbe De l’Epee, in France, about 1760. 
At about the same time with the latter, Braidwood commenced 
his work in England ; but its exclusiveness, and his exorbitant 
charges for instruction in the art greatly hindered his usefulness, 
and prevented the rapid extension of his methods even in England. 
Hence the two so-called rival systems have taken the names of 
the German and the French methods respectively ; or, as they 
have been sometimes styled, the artificial and the natural; the 
one relying mainly on articulation and lip-reading as the means 
of communication between teacher and pupil; the other making DEAF-MUTISM. 
333 
special use of the sign language and the manual alphabet; both 
seeking as soon as possible to make the printed page accessible to 
their pupils. By both it is acknowledged that the easy and 
idiomatic use of the vernacular is the prime object of endeavor, 
as the means of acquiring both facts and facility in mental 
operations. 
It is claimed by the extreme advocates of the German system 
that any use of the sign-language, or even of the manual alphabet, 
tends to divert the mind of the pupil from his special object of ac- 
quiring the power of speech; offering to him an easier method, 
indeed, of expressing his thoughts, but one which will by its very 
ease of expression, release him from that unremitting application 
which here, as elsewhere, is the price of distinguished success. 
On the other hand, the followers of De l'Epee claim that for a 
very large percentage of deaf-mutes the acquisition of articula- 
tion and lip-reading to any practical degree is an utter impossi- 
bility, while even the very small number who can attain any de- 
gree of success must for that sacrifice time which might have 
been better bestowed in the acquisition of knowledge and mental 
discipline, with the aid of the sign language, supplemented by the 
manual alphabet, when absolute verbal accuracy is required. 
Here, as elsewhere, the motto, “ In medio tutissimus ibis ” holds 
good, and what is known as the “combined system,” in which 
both methods are employed, is growing in favor. 
A brief description of the two methods may serve to make 
prominent the points of difference. 
Under the French method, a pupil enters school at the age of, 
perhaps, seven years, knowing nothing except a few natural signs, 
which he has employed at home, expressing mainly physical wants. 
He goes into the school-room, is shown the picture of a cat, for in- 
stance, then the word is written upon the black-board, and he is 
made to understand that the word and the picture both stand for 
the same object. When this idea is thoroughly grasped, the same 
word is spelled upon the fingers, and this is shown to be a third 
method of representing the same thing. Lastly, the conventional 
sign for cat is made, indicating the whiskers, and the fact im- 
pressed upon the pupil’s mind that these four are only different 
symbols for one and the same thing. Thus, step by step, a vo- 
cabulary is acquired. When a sufficient number of nouns has 
been mastered, the verb is taken up in the same way, and the idea 
of action communicated by the aid of these four-fold symbols. 
Then these are combined in sentences, and the subsequent prog- 
ress is very much like that of any child learning to talk ; the 
wonder at the ability of the deaf-mute thus to begin with single 334 
DEAF-MUTISM. 
words and pass on to sentences—to commence with the concrete 
and ascend to the abstract—being perhaps no greater than that 
which a little reflection would excite, as to the process by which 
an infant, absolutely destitute of language, and almost of ideas, 
comes to the mastery of his mother tongue. Only as this process 
is going on continually before our eyes, we cease to think of it as 
wonderful. 
It would seem natural that the process should be much more 
rapid in the case of the hearing and speaking child, for whom 
almost every waking moment involves communication with par- 
ents, brothers and sisters, friends, and also constant over-hearing 
of the conversation of others. But, as a matter of fact, it is not 
uncommon that a deaf-mute pupil, entering school in September, is 
capable, the next April, of writing upon the black-board short sen- 
tences with considerable facility. 
As regards mental progress beyond the acquisition of the 
ability to make known wants, and to express simple ideas, it is 
unquestionably true that the excessive use of signs does tend to 
interfere with the idiomatic use of the vernacular, to render read- 
ing laborious and therefore unattractive, and thus to retard the 
fullest development of the mental powers. But against this dan- 
ger the wise and experienced teacher is ever on his guard, insist- 
ing upon dactylology (the use of the fingers) and the use of the 
black-board as correctives, while it is also true that deaf-mutism 
has no monopoly of such tendencies on the part of pupils. 
The sign-language was, in its inception, the adoption by the 
Abbe De l’Epee of natural gestures, observed by him in the inter- 
course with each other of two young deaf-mute sisters, and is, in 
so far, closely related to the sign-language in common use among 
our North American Indians. It has been, by the Abbe Sicard and 
others, supplemented and enlarged, by the addition of many con- 
ventional signs and inflections, so that at present there is little 
difficulty in translating to an audience of intelligent deaf-mutes, an 
address delivered orally, upon any subject, and with nearly the 
rapidity of a good speaker. It admits of all shades of expression 
and varieties of style, compact or diffuse, severe or florid, and in 
the hands of a master becomes vivid and graphic pantomime. In 
fact, it lays claim to being the nearest approach to a universal 
language that the world has ever seen, enabling its possessor to 
carry on conversation with an educated deaf-mute in any country 
in Europe, and with many tribes of savages. 
The manual alphabet is of great antiquity. It is possible that 
something of the sort is intended, when Solomon, in Proverbs vi. 
13, alludes to those who “ speak with the feet and teach with the 335 
DEAF-MUTISM. 
fingers.” Bede tells us of manual alphabets founded on numbers 
even in his day, and there have been many others, facial, brachial, 
and pedal, as well as manual. The two which have come into gen- 
eral use in schools are known respectively as the double-handed 
and single-handed alphabets, the former used principally in Eng- 
land, and the latter more generally in France and the United 
States. Both are formed mainly by attempts to imitate with the 
fingers the outlines of the Roman letters. The latter, however, is 
the easier and simpler, and allows the use of either hand singly. 
The German method relies almost exclusively on articulation 
and lip-reading ; using a few natural signs only so far as may be 
necessary to establish communication between teacher and pupils, 
and in some institutions having recourse to writing in the air in 
place of the manual alphabet. In this method of instruction the 
teacher takes his (or her) place opposite the pupil, calling atten- 
tion to the position of his (the teacher’s) mouth and throat, and 
then seeks first of all to make him perceive the difference between 
a current of air issuing noiselessly from the throat, as in ordinary 
breathing, and the same vocalized ; that is, made to pass between 
the vocal cords in such manner as to throw them into vibration. 
This can be made apparent to the eye, and still more so to the 
touch when the fingers are placed upon the throat. 
When this idea is once communicated to the pupil, and the abil- 
ity acquired to vocalize a current of air, the foundation is laid. All 
other sounds are with greater or less ease, in longer or shorter 
time, developed from this initial sound. He is taught so to modify 
the position of the vocal organ's as to give the different vowel 
sounds by continuous vocalization, and then by suddenly in- 
terrupting the current of air, to produce the different consonan- 
tal effects; as in labials, linguals, palatals, and compounds. 
This process must be largely imitative and tentative in the first 
case for each sound, and a matter of memory at each succeeding 
repetition, so that the average hearing and speaking person, at- 
tempting to analyze his own processes of vocalization, even with 
the help of the ear, would be inclined to pronounce it an impossi- 
bility for the deaf-mute. But, like many other apparent impossi- 
bilities, it has been accomplished in multitudes of cases. Resort 
is frequently had to manipulation in the early stages of instruc- 
tion, an instrument like an ivory paper-folder being used to de- 
press or elevate the tongue and other organs. A hand-mirror is 
also found to be a valuable auxiliary. 
Much study has been bestowed upon the phonetic elements of 
language, and many attempts made to illustrate, by diagrams, the 
position of the vocal organs in uttering the different sounds. 336 
DEAF-MUTISM. 
THE MECHANISM OF SPEECH 
AS ILLUSTRATED IN THE 
SOUNDS OF THE FRENCH LANGUAGE, 
IDtsignccL by Jif Lean Vaxase, 
Direct or of tt)e,Imj)KnjaLJrLsiHuh'/iniarJJeaf'MuLes, 
Palis. 
CONSONANTS. 
VOWELS. DEAF-MUTISM. 
337 
CONSONANTS. 
VOWELS. 338 
DEAF-MUTISM. 
The manual alphabet (single-handed). DEAF-MUTISM. 
339 
ILLUSTRATIONS or VISTllLE SPEECH. 
Fic/J 
* For description, see page 344. 340 
DEAF-MUTISM. 
Helmont, in 1657, published his “ Alphabeti vere Naturalis De- 
lineatio,” in which the different positions for the pronunciation of 
the Hebrew characters are beautifully represented. In 1668 
Bishop Wilkins, the founder of the Royal Society, published his 
“Essay toward a Real Character, and a Philosophical Language,” 
in which are both symbols of sounds, and also plates of the 
positions of the vocal organs in uttering the usual English vowels 
and consonants. Following these, Professor Leon Va'isse, of Paris, 
has prepared a chart of the sounds of the French language, shown 
on pages 1034 and 1035. 
But perhaps the greatest help to the instructor in articulation 
is derived from the system of “Visible Speech” symbols as in- 
vented by Prof. A. M. Bell, of England, and developed and spe- 
cially adapted to deaf-mute instruction, by liis son, Prof. A. G. 
Bell, now of this country, so well known in connection with the 
telephone. In this system the symbols are no longer purely arbi- 
trary, but by their shape and direction indicate at sight the vocal 
organs to be called into play, and likewise the position they are to 
assume. Under this system the acquisition of speech becomes a 
sort of vocal gymnastics, in which the organs are trained to take 
every possible, or at least, needful position for the utterance of the 
sounds of every language. 
It is claimed that any sound possible to be produced by the vo- 
cal organs, even a whistle or a groan, can be so represented by 
these symbols, that any adept, whether deaf-mute or otherwise, 
can, without ever having heard the sound, produce it with abso- 
lute accuracy, even accent and force being preserved. 
It is likewise an excellence of this system, that when the deaf- 
mute pupil trying to produce a certain sound, fails in that, and 
makes another, he can be shown by the symbols the sound he has 
made, as well as that he has failed to make. The pupil is thus 
conducted along the avenue of vocalization till its most shaded 
paths and rocky passes are all familiar and easy, and then he is 
suddenly ushered into what he is told is the royal city of speech, 
his tiresome journey accomplished, and henceforth only the pleas- 
ant task of familiarizing himself with the places and the people he 
meets. This system of symbols is given on the foregoing pages. 
Lip-reading, always more or less closely associated with artic- 
ulation in courses of instruction, seems to be very largely a matter 
of natural endowment rather than of acquired ability, though, of 
course, practice is essential to any high development of the ability. 
But not a few deaf-mutes, without instruction or special oppor- 
tunity for accurate practice, will understand much of what is said 
in their presence, while many others, of marked mental ability, not DEAF-MUTISM. 
341 
only have no such natural gift, but find it almost impossible to ac- 
quire it. 
Both lip-reading and articulation in the case of semi-mutes can 
be preserved or developed to a very considerable extent in the fam- 
ily, where affection, patience, and tact are united in the effort. 
As to the success actually attained by the two systems, the advo- 
cates of each make claims hardly acknowledged by the other. 
While in this country the great preponderance of authority is 
in favor of the French system as the basis of general instruction, 
yet what is known as the combined system is now authoritatively 
endorsed by the convention of principals of deaf-mute institutions, 
in which instruction in articulation is given to semi-mutes, and to 
such others as are found upon trial to possess natural aptitude for 
the acquisition of speech ; while, on the other hand, a limited use 
of natural signs and of the manual alphabet is allowed in many 
articulation schools. 
The main difference of opinion to-day would probably be as to 
the proportion of deaf-mutes in our institutions who can be 
benefited or better instructed and fitted for useful and happy 
lives by the articulation system. Even on this point there is a 
much nearer agreement between those actually engaged in the 
work of teaching by the two systems respectively, than between 
the theorists and writers whose sympathies are warmly interested 
on the one side or the other, and whose confidence of assertion is 
often in inverse ratio to their actual knowledge of the practical 
working of the two systems. 
The late Moritz Hill, of Weissenfels, perhaps the best authority 
on the German side, says: “ Out of one hundred pupils eighty-five 
are capable, when leaving the school, of conversing on common- 
place subjects, with their teachers, family, and intimate friends. 
Sixty-two can do so easily. Out of one hundred, eleven can con- 
verse readily with strangers on ordinary subjects. Many others 
learn to do this after leaving school.” 
Prof. Vaisse says : “In my opinion, nine out of ten can learn 
spoken language so as to derive more or less benefit from it; but 
only five or six will speak with sufficient ease to converse readily 
on all common subjects with their family and friends. 
“ As to their intercourse with their teachers, it extends to a much 
larger number, to seven or eight out of ten. With strangers, in- 
tercourse is much more limited. On some common topics, to be 
sure, it may extend to those seven or eight out of the ten I first 
mentioned, but on all subjects and with ease it will not extend to 
more than two, and often no more than one out of these same ten 
pupils. ” 342 
DEAF-MUTISM. 
Dr. Gallaudet, in his report on Systems of Deaf-Mute Instruc- 
tion in Europe, gives the case of a young man congenitally deaf, 
whom he met in Holland, and with whom he conversed in German 
for a half hour, first in a parlor, then walking along crowded 
streets, and then riding over pavements in a carriage, the conver- 
sation being carried on with perfect ease, and without any resort 
to signs. But such cases are exceptional, both as regards natural 
capacity and educational advantages. 
The problem, as it presents itself in this country, is How can 
the average deaf-mute, with a given expenditure of time and 
money, both limited, be best fitted for usefulness and happiness in 
the world ? The great majority of instructors in the United States 
would answer, “By the use of the sign language and the manual 
alphabet, with instruction in articulation and lip-reading for all 
who are found upon trial to be capable of profiting by it.” For, 
unless instruction in the artificial system can fit the deaf-mute 
for easy intercourse with the outside world, it hardly seems to prom- 
ise enough to compensate for the great expenditure of time and 
labor. The sign language gives him rapid and easy intercourse 
with his teachers, with his family and friends. Dactylology, and a 
limited use of signs, furnishes ready means of communication ; 
and with the outside world writing is always exact, if not rapid. 
As to what are technically known as “ deaf-mutisms,” or those 
mistakes in numbers, tenses, and idioms, such as are often made 
by foreigners in the use of English, it is a somewhat curious and 
interesting, as well as unexpected fact, that they are found as fre- 
quently in the compositions of those instructed by articulation 
alone, as of those who have been taught by signs. 
Institutions.—These are found as follows—though many of 
these statistics are out of date : 
United States 49 
Canada 6 
Great Britain and Ireland 29 
France 61 
Belgium and Holland 10 
Denmark, Sweden, and Norway 23 
Russia 3 
Prussia 49 
Other German States 50 
Switzerland 11 
Italy 15 
Spain 2 
Portugal 1 
Australia 1 
Brazil 1 
Total 311 DEAF-MUTISM. 
343 
It is estimated that these comprise more than 1,500 teachers, 
more than 15,000 pupils, and involve an annual expenditure of 
between four and five millions of dollars. 
The history of deaf-mute- education in the United States is in- 
separably connected with the name of Rev. T. H. Gallaudet, who, 
in the year 1815, went to Europe to investigate the different sys- 
tems of deaf-mute instruction. Deciding in favor of the French 
method, he became a pupil of the Abbe Sicard, and in 1816 re- 
turned home, bringing with him Laurent Clerc, one of Sicard’s 
ablest assistants. In April, 1817, the Connecticut Asylum was 
opened with seven pupils. Its success was so apparent that 
Congress soon made it an appropriation of land, and, on the 
supposition that it would suffice for the needs of the whole 
country, the name was changed to “ American Asylum,” which 
unfortunately it still bears. It is, however, neither the one nor 
the other, and the very suggestion of “asylum” has long since 
been repudiated by all friends of deaf-mutes. But it was soon 
found that other schools were needed, and they gradually in- 
creased till now they aggregate 49 schools, with 6,166 pupils and 
375 instructors. Of these, six are articulation schools. 
The growth of these institutions in the United States may be 
seen from the following table : 
Date. 
Number of 
institutions. 
Number of 
pupils. 
Number of 
teachers. 
1857 
20 
1,721 
2,012 
2,469 
95 
1863 
22 
1866 
24 
iio 
1867 
24 
2'576 
120 
1868 
27 
2'898 
3,246 
170 
1869 
30 
187 
1870 
34 
3.784 
222 
1871 
38 
4,068 
4,253 
4,252 
260 
1872 
36 
271 
1873 
38 
274 
1874 . 
44 
4,'892 
5.309 
290 
1875 
48 
321 
1876 
49 
5,010 
5,711 
6,166 
304 
1877 
49 
356 
1878 
49 
375 
The average time during which pupils are allowed to remain 
in the institutions is six or seven years, and the course of study is 
substantially that of our primary and grammar schools. Several 
institutions have a three years’ additional course, comprising the 
ordinary high school studies. Instruction is also generally given 
in some trade. The majority of pupils, however, leave school 
even before the limit of seven years. 344 
DEAF-MUTISM. 
Our country has the honor of being the first to establish a 
higher grade of education for deaf-mutes. The National Deaf- 
Mute College, located at Kendall Green, near Washington, D. C., 
was established in 1864, and with a faculty consisting of a presi- 
dent and six professors, opens to its fifty students, from all parts 
of the country, substantially the same course of study as our 
other reputable colleges, and confers the degree of A.B. at gradu- 
ation. Forty-two have already taken their degree, besides many 
others who have taken partial courses. 
The late Prof. Henry, and President Gilman, of Johns Hopkins 
University, at a recent commencement, having had the opportu- 
nity of inspecting the examination papers of the various classes, 
pronounced them such as would do honor to the undergraduates 
of any college in the country, and its graduates are, perhaps, as 
successfully discharging the duties of life as any other equal num- 
ber of college graduates. Many of the institutions have their own 
papers, and the American Annals of the Deaf and Dumb, edited 
by Prof. E. A. Fay, of the National College, contains in its issues 
for the past thirty years the most valuable papers in the English 
language, comprising discussions upon almost all questions relat- 
ing to deaf-mutes. In many of the larger cities there are deaf- 
mute associations for religious or literary or social purposes, and 
in New York there is an Episcopal church for deaf-mutes, of 
which Rev. Thomas Gallaudet, D.D., is rector, while services are 
held by himself and his assistant in various parts of the country. 
While deaf-mutism must always remain a calamity, yet these 
various alleviations of their condition have reduced that calamity 
to its minimum, and have brought the educated deaf-mute to the 
position where he need not fear to meet his hearing and speaking 
brethren in fair, honorable competition in most departments of 
human activity. 
Note.—In the diagram on page 339, Fig. 1 shows the derivation of the symbols from 
the different vocal organs called into play. Q indicates that the lips are to be used ; C 
the palate ; U the tip of the tongue ; fl the back of the tongue ; while a line drawn across 
either of these symbols indicates that the corresponding vocal organ is to be closed, 
and —>, that they are to be opened and the breath emitted. I indicates vocalization of 
the emitted current of air, by throwing the vocal cords into vibration, and S a nasal tone. 
Fig. 2 shows the combination of these symbols to indicate different consonantal 
effects. 
Fig. 3 indicates the labials, P, B, M ; the linguals, T, D, N ; and the palatals, K, G, NG. 
Fig. 4 shows the development of various sounds from the first attempt at vocalization 
on the part of a deaf-mute. 
The vowel-sounds are indicated by hooks, dots, and transverse lines upon the sign 
of vocalization, as shown in Fig. 4. 
J. W. CHICKERING, Jb. The Nose and its Diseases. 
BY 
FRANK H. BOS WORTH, A.M., M.D., 
OF NET YORK CITY, 
ATTENDING PHYSICIAN AT THE DEPARTMENT FOR MEDICAL AND SURGICAL RELIEF OF THE 
OUT-DOOR POOR ; LECTURER ON DISEASES OF THE NOSE AND THROAT IN 
BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC., ETC. THE NOSE. 
The nose is the organ which presides over the special sense of 
smell. It consists of two parts, the external—the prominent fea- 
ture of the face—and the internal—the nasal cavities. 
The external nose is composed of a triangular frame-work of 
bone and cartilage attached to the forehead and projecting from 
the centre of the face. The bones entering into its structure are 
the nasal bones, one on each side, and the nasal processes of the 
upper jaw-bones. The cartilages are one upper and one lower 
cartilage on each side, and the cartilage of the septum or parti- 
tion (Figs. 95, 96). On its under surface are two oval-shaped open- 
Fig. 95. 
Fig. 96. 
Figure 95.—The bony and cartilaginous partition of the nose, seen from the left side: ay 
right nasal bone; 6, upper jaw-bone; c, perpendicular plate of the ethmoid bone; d, vomer; e, 
sphenoidal sinus ; 1, inner part of the cartilage of the right side ; 2, the cartilaginous portion of 
the septum or partition. 
Figure 96.—Framework of the nose : a, nasal bone ; 5, part of upper jaw-bone; 1, upper, 
and 2, lower lateral cartilage. 
ings—the nostrils, separated by a partition. The margins of the 
nostrils are provided with a number of stiff hairs which serve to 
prevent the passage of particles of dust, etc., with the inspired air. 
The nasal cavities are two in number, and somewhat irregular- 
ly wedge-shaped. They extend from the nostrils in front to the 348 
THE NOSE. 
pharynx and upper surface of the soft palate behind. They are 
separated in the middle line by the partition before mentioned, 
composed of bone and cartilage. (Fig. 95.) The outer wall of each 
cavity is formed by the perpendicular portion of the palate-bone, 
by the upper jaw-bone, and by a portion of the ethmoid bone. On 
the outer wall we find three scroll-shaped projections of bone, 
called the superior, middle, and inferior turbinated or “spongy” 
bones, which are arranged horizontally, one above the other, and 
nearly parallel, as seen in Figs. 97 and 98 ; they project toward 
the central partition, and divide each cavity into three incomplete 
passages from before backward, called the superior, middle, and 
Figure 97.—Transverse vertical section of the nasal cavities, seen from behind: 1, part of 
the frontal bone; 2, crista galli ; 3, perpendicular plate of the ethmoid bone; between 4 and 4 
the ethmoid cells; 5, the right middle spongy or turbinated bone; 6, left lower spongy bone; 
7, vomer; 8, cheek-bone; 9, maxillary sinus or antrum of Highmore; 10, its opening into the 
middle meatus or passage. 
Figure 98.—Outer wall of the left nasal cavity, covered by the mucous membrane : 1, fron- 
tal bone; 2, left nasal bone; 3, upper jaw; 4, body of the sphenoid bone; 5, projection of the 
membrane covering the upper spongy or turbinated bone ; 6, that of the middle; 7, that of the 
lower ; 8, opening of the Eustachian tube going to the middle ear. 
Fig. 97. 
Fig. 98. 
inferior meatus : the superior meatus lying between the superior 
and middle turbinated bones, the middle meatus between the mid- 
dle and inferior, and the inferior meatus between the inferior tur- 
binated bone and the floor of the cavities. This arrangement of 
the passages of the nasal cavities will be better understood by 
reference to the foregoing figures. 
The roof of each cavity is narrow and arched, and the floor, 
which also forms the roof of the mouth, is made up by horizontal 
plates of bone projecting from the upper jaw and palate-bones, THE NOSE. 
349 
and is completed by the upper surface of the soft palate. (See 
Figs. 97 and 98.) The openings in front are the nostrils, and 
those behind are two oval-shaped 
apertures called the posterior 
nares. (See Fig. 99). On the 
outer side of each posterior open- 
ing is found the opening of the 
Eustachian tube, the vent-hole of 
the inner cavity of the ear. (See 
Fig. 100.) This opening is closed, 
except during the act of swallow- 
ing, when it is drawn open by 
the contraction of the muscles 
brought into play by that act. 
This action is of importance in 
connection with the use of the 
nasal douche in the treatment of 
nasal catarrh. 
The space between the poste- 
rior opening of the nose and the 
pharynx down to the level of 
the soft palate—generally called 
the vault of the pharynx—is real- 
ly a portion of the nasal cavity. 
Figure 99.—The soft palate, as seen from 
behind. 
FIGURE 100.—Showing the Eustachian tubes passing from the back portion of the nasal cav- 
ity to the middle cavities of the ears. 350 
THE NOSE, 
At its upper portion is found a large mass of glands, resembling so 
much the tonsils in the back of the mouth, that it is often called 
the pharyngeal tonsil. These glands discharge freely the mucus, 
which serves to lubricate the food and facilitate its passage down 
the throat. They are liable to become inflamed in connection with 
diseases of the nose, and also separately. 
There are several accessory cavities, which should be described 
in connection with the nasal cavities, communicating as they do 
with them by direct openings or passages, and which are often- 
times affected by the direct extension of disease commencing in 
the nose. These are, in the order of their importance— 
The antrum of Highmore: a large, triangular-shaped cavity, hol- 
lowed out in the body of the upper jaw, and connected with the 
nasal cavity by an opening into the middle passage. (See Fig. 97.) 
The frontal sinuses: two irregular cavities which lie between 
the two plates of the frontal (or forehead) bone, and communi- 
cate with the nasal cavity by a rounded canal, which opens in the 
middle passage also; these sinuses are absent in the child, but de- 
velop with adult life. The ethmoidal and sphenoidal cells or cavi- 
ties—found in the bodies of the bones of the same name—com- 
municate with the nose by open- 
ings into the upper passage. In 
addition to these cavities, the 
tear-duct opens into the nasal 
cavity in the lower passage. 
(See Fig. 97.) 
The nasal cavities are lined 
by a mucous membrane, which 
is continuous with the lining 
membrane of the mouth, phar- 
ynx, and gullet, and extends 
also into the accessory cavities 
spoken of above. 
The nose is the organ which 
presides over the special sense 
of smell; it also plays an im- 
portant part in respiration and 
talking. The roof of the nasal 
cavities is formed in part, as 
we have seen (page 348), by the 
ethmoid bone. Lying upon 
what is called the cribriform 
plate of the ethmoid bone—one on either side—are the two olfactory 
bulbs (Fig. 101), connected with the brain by the olfactory nerves. 
Figure 101.—The base of the skull, seenfrom 
above, the top having been removed, and show- 
ing, at A, A, the location of the olfactory bulbs 
and the openings through which the olfactory 
nerves pass to the nose. THE NOSE. 
351 
These olfactory bulbs are masses of nerve matter, and give off 
about fifteen or twenty branches, which, passing through the bone, 
are distributed to the mucous membrane of the upper third of 
the septum, and of the superior and middle turbinated bones 
(see Fig. 102); the membrane at this portion of the nasal cavity 
being thick and spongy, and containing a large number of 
glands, which keep it in a thoroughly moist condition. The nerves, 
after emerging from the ethmoid bone, divide and subdivide into 
numerous very small branches, until finally they terminate in very 
minute, hair-like extremities, which penetrate between the epithe- 
lial cells covering the mucous membrane, and reach the surface of 
the latter. These nerves are endowed only with the power of ap- 
preciating odors, and do not possess any general sensibility; the 
nasal cavity being supplied with other nerves which give it its 
Fig. 102. 
Fig. 103. 
Figure 102.—Nerves of the outer wall of the nasal cavity : 1, network of the branches of the 
olfactory nerve ; 2, branch of the nasal nerve; 3, spheno-palatine ganglion of the sympathetic 
system of nerves and the branches given off from it. 
Figure 103.—Nerve cells and terminal nerve fibres of the olfactory region: a, epithelial cells ; 
b, olfactory cells ; c, the terminal rods ; e, their extremities, composed of minute hairs. 
sensibility ; but the olfactory nerves possess the single power of the 
sense of smell. This is accomplished by contact of emanations 
from an odorous body with the terminal filaments of the nerve. 
Man, as a general thing, is not endowed with a very keen sense of 
smell, though it may be educated to a very high state ; while, in 
dogs and many of the lower animals, this sense is very acute. 
Emanations from an odorous body can of course only reach the 352 
THE NOSE. 
nerve filaments by being carried in with the breath, anything 
which interferes, therefore, with breathing through the nose, such 
as a cold in the head, necessarily abolishes for the time the sense 
of smell. The mucous membrane in which the nerves are distrib- 
uted must also be in a soft, moist condition; it being probable 
that the odorous particles are dissolved in the mucus which cov- 
ers the membrane, and in a state of solution reach the nerve. 
The moist state of the membrane is provided for by the abundant 
supply of glands with which it is endowed. (See “Mucous Mem- 
branes.”) The sense of smell is intimately related to the sense of 
taste ; for, as we know, anything which impairs the sense of smell 
lessens also the sense of taste : a severe cold oftentimes completely 
destroys the ability to appreciate differences in flavor. No less 
marked is the fact often experienced that the flow of the gastric 
juice is stimulated and the appetite sharpened by what we call 
savory odors. 
Another function of the nose is in talking. While the voice is 
formed in the larynx, and its pitch regulated by the action of the 
laryngeal muscles, its quality is entirely governed by the mouth, 
pharynx, and nasal cavities. Certain sounds are produced by vi- 
brations confined almost entirely to the mouth, such as a, o, i; 
while others are almost purely nasal sounds, such as n, m. The 
great majority of sounds, however, are combinations of the two— 
the nasal predominating in some, the oral in others ; and on 
the correct combination of the two depends a good voice. When 
a nasal sound is uttered the root of the tongue is raised against 
the soft palate and the cavity of the mouth is shut off from the 
current of air which passes from the larynx directly through the 
nose. When an oral sound is uttered, the soft palate is raised 
against the pharynx, and the current of air passes out through the 
mouth. An absence of the nasal character of the voice is quite as 
disagreeable to hear as the characteristic nasal twang for which 
Americans are so much ridiculed. A man talks through his nose 
who keeps open the nasal cavity in the utterance of all sounds. 
This may be due to mechanical interference with the free move- 
ment of the soft palate by tumors, destructive ulceration, or old 
scars; it may be due to paralysis of the palate following diph- 
theria, or some other cause, or it may be the result of habit. 
Again, a man is often said to talk through his nose when the fault 
is that he does not talk through his nose at all. This is the case 
when the nasal cavity is closed by a cold in the head, by one of the 
forms of chronic catarrh, or by the presence of tumors in the cavity 
or lying outside the cavity in such a way as to press the soft palate 
up against the pharynx, as sometimes happens in the case of THE NOSE. 
353 
enlarged tonsils. This, again, may be due, in a measure, to 
habit. 
The remaining function of the nose is in respiration. Normally, 
respiration should be conducted with the mouth closed, the cur- 
rent of air passing through the nose ; thus the air received by the 
lungs is warmer, moister, and cleaner. It is warmer because, in 
order to reach the lungs, it has to pass through a longer channel, 
and has had an opportunity of becoming warmed by the blood- 
warm surface over which it has passed. It is moister on account 
of having become charged somewhat with the vapor which it ab- 
sorbs from the passages, and which is supplied by the abundant 
mucus coating the lining membrane of the nose, and also by the 
overflow of tears which is poured into the nasal cavity by the tear- 
duct. A moist air is always more grateful and less irritating to 
the delicate structures of the lungs than a dry air. It is cleaner 
in that the particles of dust and other matter which float in the 
atmosphere are arrested either by the hairs which are placed at the 
entrance of the nostrils, or by lodging against some of the irregu- 
larities or projections in the nose, where they can do far less harm 
than to the delicate lung tissues. 
On the other hand, when respiration is carried on by the mouth, 
the converse holds true ; there is received into the lungs a cool, dry 
air, carrying with it such vicious matter as may happen to float in 
the atmosphere. Breathing through the mouth may be, to an ex- 
tent, a habit, but in a majority of cases is due to mechanical in- 
terference with the free passage of air through the nose from some 
of the many diseases to which the nose is subject. In nursing 
children, this interference with nasal breathing becomes an ex- 
tremely grave matter when they suffer from a cold in the head; 
not being able to clear the nose, it becomes completely closed, 
and when the child takes the breast, it is very soon compelled to 
drop it to get breath, and between the struggle to breathe on the 
one hand, and the struggle to nurse on the other, the danger is 
very great that the child will succumb from simple lack of nour- 
ishment unless relieved by the re-establishment of normal nasal 
breathing 
DISEASES OP THE NOSE. 
We come now to the consideration of the diseases of the nose ; 
the most frequent and most prominent of these is catarrh. This 
term is derived from the Greek word /carappea), to flow down, and 
was used by the ancients to designate a discharge from the nose, 
which they supposed to ‘‘flow down” from the brain, whereby 354 
THE NOSE. 
the brain was thought to be relieved of deleterious matter ; hence, 
therefore, arose the custom of greeting a sneeze with the hearty 
“God bless you,” which survives to this day in many countries, 
the salutation meaning to convey a congratulation on the supposed 
clearing out to which the brain has been subjected. Properly 
speaking, catarrh is a term applied to that form of inflammation 
of a mucous membrane which is characterized by a fluid or semi- 
fluid discharge—in distinction from croupous or diphtheritic in- 
flammations, which are marked by the formation of a false mem- 
brane—and may attack any mucous membrane in the body, as in- 
flammation of the lining membrane of the bladder constitutes 
vesical catarrh, or cystitis; or inflammation of the lining of the 
larynx constitutes laryngeal catarrh, or laryngitis. Nasal catarrh, 
however, is of so much more frequent occurrence than any other 
form of catarrh, that popular usage simply designates it as 
“ catarrh ; ” and when we speak of one suffering from catarrh, we 
understand the term always to refer to nasal catarrh. A better 
usage would be always, in referring to any form of catarrh, to add 
the proper prefix—as laryngeal catarrh, bronchial catarrh, etc. 
Cold in the Head—Acute Nasal Catarrh—Acute Coryza. 
This is an acute inflammation of the mucous membrane lining 
the nasal cavity, and in a majority of cases is due to “catching 
cold ” by a too sudden cooling of the body after being over-heated, 
by sitting or sleeping in a draught, or by wetting the feet; in 
other cases it may be due to breathing an atmosphere laden with 
particles of dust or other irritating matter; or, again, it may be 
caused by inhaling irritating gases, such as ammonia, iodine, etc. 
Some persons are peculiarly liable to a cold in the head from 
very slight causes; others manifest marked tendencies under 
which one person will have an attack upon entering a room con- 
taining even the smallest amount of ipecac in powder; in another 
the attack is induced by iodine; in another, by musk. These 
individual peculiarities, however, are exceedingly rare. What 
occurs in an acute coryza, is as follows : 
Symptoms.—At the first onset of the attack the mucous mem- 
brane becomes very much congested, the blood-vessels are swol- 
len and distended with blood, and the discharge of mucus is 
arrested, the membrane presenting a dry, glazed appearance. At 
the same time there is experienced a feeling of fulness about the 
nose, with a dry, burning, smarting sensation, with a disposition 
to sneeze ; each breath of air drawn through the nose feels hot 
and irritating; there is also more or less fever, according to the 355 
THE NOSE. 
severity of the attack, manifesting itself in a feeling of lassitude 
and weariness with pains in the limbs, headache, hot skin, and 
chilly sensations. If the inflammation extends to the frontal sin- 
uses (see Fig. 102), the pain at the root of the nose and lower part 
of the forehead is often very severe in character; if the cavities 
of the upper jaw-bone are affected, there is more or less intense 
neuralgic pain in the face; if the tear-ducts are involved, there is 
pain and tenderness in the eyeball, with intolerance of light. 
This stage of the attack lasts from six to twenty-four hours, and 
is followed by a profuse watery discharge, the distended blood- 
vessels becoming relieved by the escape through their walls of the 
watery portion of the blood (the serum). This contains a consid- 
erable amount of saline matter, which gives to the discharge its 
salty taste and its acrid, irritating quality. The glands soon re- 
sume their function, and discharge a large amount of mucus; the 
little epithelial cells, being produced in increased numbers under 
the stimulus of the inflammation, are thrown off in corresponding 
proportion, and we have the watery discharge, soon changing to 
a grayish, transparent mucus; and this, again, to a discharge 
more resembling matter or pus. The duration of the attack is 
from five to ten days, and may either end in complete restoration 
of the parts to a healthy state, or may lapse into a chronic catarrh, 
as the result of the continued action of the original exciting cause, 
or of a lowered state of the system, which fails to throw off the 
disease as readily as it does when in a state of vigorous health. 
Prevention.—Those who are especially liable to take cold should 
always exercise an unusual care in the avoidance of those causes 
which experience teaches them may give rise to an attack of acute 
coryza; and yet an excessive zeal in this direction, showing it- 
self in muffling up the head and neck in wraps on all occasions of 
even slight exposure, is as much to be avoided as the opposite 
extreme. No one ever contracted a cold from exposure of the 
hands or face; simply because the hands and face are accustomed 
to exposure, and are therefore inured to it. An amount of pro- 
tection of the body necessary for comfort, and no more, is a safe 
rule to follow. Excessive covering induces perspiration, which is 
an indication of excessive bodily heat, and involves the danger 
of a too sudden cooling, which is probably the most frequent 
cause of taking cold. This sudden cooling of the body is what 
occurs from getting the feet wet, sitting in a draft, or going from 
a warm room into the open air, and is, of course, always to be 
guarded against. During sleep, it should be remembered, the body 
is peculiarly susceptible, and any cause which may act on it dur- 
ing waking hours, will act with greater force during sleep. 356 
THE NOSE. 
Much may be accomplished, in the way of preventing colds, by 
a daily bathing of the head, neck, and shoulders with cold water, 
either with a sponge, or by dashing the water over the parts, and 
following it by a brisk rubbing with a coarse towel. For those 
especially liable to cold, this simple device is well worth resorting 
to; for, if persisted in, through warm and cold seasons, it will 
often secure a very satisfactory immunity from the attacks. 
Treatment.—As regards the active treatment of a cold in the 
head, it is probable that a large proportion of cases are allowed to 
run their course without any attempt to lessen the severity or 
shorten the duration of the attack ; this is much to be deprecated, 
as it is undoubtedly true that a large number of cases of chronic 
catarrh are due to neglected colds, and one attack particularly, 
if neglected, leaves an especial liability to a second one. 
If active measures are resorted to, on the first onset of the dis- 
ease, for inducing free and copious perspiration, the attack may be 
broken up. This can only be accomplished within the first twelve 
or twenty-four hours before the discharge has fully set in, and 
may be brought on by the free use of hot drinks—such as hot lem- 
onade, a decoction of thoroughwort, or chamomile tea, and the like, 
with the aid of a hot foot-bath, and, perhaps, ten grains of Dover’s 
powder (for an adult), if the attack is severe or the pain and head- 
ache very distressing. The hot drinks should be taken freely, and 
in pretty large quantity. The foot-bath may be continued until 
there is felt a decided warmth throughout the system, and the 
body should then be thoroughly covered with blankets in bed. 
The danger of taking a fresh cold after a “sweat”is not very 
great if one remain in-doors for several hours after rising in the 
morning. After the first or second day has passed, and the dis- 
charge has set in thoroughly, mild, astringent applications may 
be used to limit it and reduce the inflammation of the mucous mem- 
brane and allay pain, such as the sub-carbonate or sub-nitrate of 
bismuth, tannin or powdered chlorate of potash; one part to four 
or six of white sugar or powdered gum-arabic, to be used in the 
form of snuff. If the pain is severe, morphine may be added to 
either of the above in the proportion of one grain to one dessert- 
spoonful of the whole. The snuff should be used after cleansing 
the nose by moderate blowing. Violent blowing of the nose should 
be avoided. The drawing into the nose of watery solution is 
liable to irritate the parts in acute catarrh, and should be resorted 
to sparingly, and plain water should never be used—a solution of 
common salt or baking soda, one teaspoonful to the pint of warm 
water being more grateful and less irritating. When, however, 
the discharge is profuse and yellowish in character, a solution in 357 
THE NOSE. 
tepid water of alum, borax, or chlorate of potash may be used of 
the strength of a half-teaspoonful in a pint, the solution being held 
in the hollow of the hand and snuffed up through the nostril. 
In nursing children, when the closure of the nasal breathing 
space gives rise to such serious consequences (see page 353), a warm 
Figure 104.—Hard rubber syringe, suited for injecting fluids into the nose, eta 
solution of soda or salt, as above, may be thrown gently into the 
nostril and against the swollen membrane, the tip of the nose 
being lifted, and the nozzle 
of the syringe being held 
about a half inch away, and 
not inserted into the nostril. 
The child should be in a sit- 
ting position, with the head 
bent slightly forward. For 
very young children a better 
and safer instrument than 
the syringe is the atomizer, 
such as is used for spraying 
cologne—the solution used be- 
ing the same as above. This 
may be followed by throwing 
in a small amount of astrin- 
gent powder, such as bis- 
muth and powdered sugar, 
in equal parts; alum, tannin, 
or borax, one part in ten of powdered sugar, the application being 
repeated three or four times daily The bridge of the nose may 
also be anointed with oil of sweet-marjoram or goose-grease. 
Nourishment should always be given by spoon to a nursling, if the 
child finds any difficulty in sucking sufficient food from the breast 
or bottle. 
Figure 105.—Atomizer for throwing a spray of 
medicated fluid into the nose, etc. 358 
THE NOSE. 
Chronic Nasal Catarrh—Chronic Coryza. 
-This affection is a chronic inflammation of the mucous mem- 
brane lining the nasal cavities, and is, in the large majority of 
cases, due to repeated attacks of acute coryza, which, each time 
leaving the mucous membrane in an impaired condition, finally 
results in a catarrhal discharge, which continues. In its milder 
form it is characterized by a more or less profuse discharge from 
the nose, consisting either of thick, grayish mucus, or of a yellow- 
ish more purulent substance, and is marked by especial liability to 
the contraction of a fresh cold, which pursues the ordinary course 
of an acute coryza, with the exception that, in subsiding, it leaves 
behind the chronic trouble. The discharge is either gotten rid of 
by blowing the nose, or is snuffed back into the throat and hawked 
out through the mouth. If the posterior portion of the nasal 
cavity with the glands at the vault of the pharynx are involved, 
there is, in addition to the discharge through the nostrils, an ex- 
ceedingly thick tenacious mucus poured out from the glands lo- 
cated there, which is gotten rid of with considerable difficulty; 
falling down between the soft palate and posterior wall of the 
pharynx, it excites an effort at swallowing, which generally fails 
to remove the mass, and it is only detached by a sort of nasal 
screatus which draws it down into the throat, where it is either 
swallowed, or, as it Ishould be, is hawked up into the mouth and 
expectorated ; or, on the other hand, the discharge may be exceed- 
ingly copious, in which case it is of a thinner and less tenacious 
character, constantly dropping down the throat and causing a great 
deal of irritation of the parts below. These symptoms vary very 
much with the daily changes of the weather, and especially with 
the changes of the season, being much aggravated by the damp, 
chilly atmosphere of spring and fall; while during the warm, dry 
weather of summer, they are so far in abeyance as to cause very 
little, if any, annoyance whatever. 
While many cases of chronic coryza may continue for years 
without manifesting anything more than the above-mentioned 
symptoms, there is a tendency in all cases to the development of 
the later form of the disease, which is a thickening or over-growth 
of the mucous membrane. This thickening consists mainly of a 
deposit in the deeper layers of the membrane of connective tissue, 
—small, thread-like fibres, which, once deposited and organized, are 
never absorbed, and can only be removed by surgical means. 
This thickening of the membrane is greatest in extent over the 
scroll-like bones (the turbinated) which separate the cavity into the THE NOSE. 
359 
three incomplete passages running from before backward ; and 
the growth is largely toward the septum or partition wall of the 
nose. As will be easily seen, this thickened condition of the mem- 
brane results in a more or less marked interference with breathing 
through the nose, giving rise to the symptoms spoken of in con- 
nection with the functions of the nose in breathing and in speak- 
ing. (See page 352 et seq.) The excessive secretion still continues, 
but, owing to this obstruction, is removed with considerable diffi- 
culty, and accumulates in the cavity, thereby aggravating the ob- 
struction. The diminished current of air through the nose is com- 
pensated by breathing through the mouth. This causes an abnor- 
mal dryness of the throat, and is a source of no little annoyance ; 
it also gives rise to the familiar phenomenon of snoringj which 
also is caused by any affection which interferes with free nasal 
breathing, such as tumors in the nose or in the upper pharynx, 
enlarged tonsils, etc. 
The explanation of a snore is very simple: the current of air 
through the nose above, and the mouth below, meeting at the bor- 
der of the soft palate, throw it into vibration ; and in all cases 
snoring is probably due to some of the above enumerated causes of 
obstruction to nasal breathing, or to a habit persisting after the re- 
moval of a temporary cause. The characteristic voice, and pecu- 
liar half-silly facial expression, due to a “ stopped-up ” nose, are 
familiar to all, and need no comment. 
A still more chronic form of nasal catarrh is the so-called “dry 
catarrh; ” this, in a large majority of cases, if not in all, results 
from the form previously described, and is characterized by an ab- 
normal dryness of the lining mucous membrane of the nose. As 
shown before, the thickened condition of the mucous membrane, 
in the previously described form of catarrh, is due to a deposit of 
connective tissue ; now, wherever this is deposited, and becomes 
organized, it subsequently contracts, as is seen in an ordinary scar 
resulting from a cut or burn ; as this takes place in the nose, we 
have the thickened condition of the mucous membrane disappear- 
ing, and, instead of it, the membrane becomes shrunken; the glands 
which furnish the mucous discharge are in large part destroyed, 
and the secretion of mucus becomes scanty, the membrane be- 
comes dry and parched, the diminished amount of mucus secreted 
dries rapidly, and crusts are formed in the nose, which are got out 
with difficulty ; there is considerable pain of a burning, smarting 
character, due partially to the dry condition of the membrane, 
and also to pressure on the nerves; the sense of smell is greatly 
impaired if not entirely abolished, a moist condition of the nasal 
membrane being, as before noticed, essential to this function. 360 
THE NOSE. 
The breath, as a rule, is not generally affected in this form of 
catarrh, or, indeed, in any of the above described forms of simple 
nasal catarrh, though in the “ dry catarrh ” there is often noticed a 
Figure 106.—Nasal douche. 
Figure 107.—Nasal douche. 
peculiar musty odor, which is not agreeable. Those forms of ca- 
tarrh which are characterized by fetid breath and offensive dis- 
charges will be described 
under the heads of Ozsena 
and Ulceration of the Nasal 
Cavities. 
Treatment.—All cases of 
chronic catarrh are char- 
acterized by a liability to 
acute attacks; these attacks 
should be guarded against 
by the simple rules of hy- 
giene, as noticed in connec- 
tion with acute coryza. Va- 
rious methods of reaching 
the nasal cavities for treat- 
ment are resorted to—such 
as the nasal douche, nasal 
syringes, spray producers, 
snuffs, and vapors. 
The nasal douche con- 
sists of a bottle or cup, to 
the lower portion of which 
is attached a rubber tube, ending in a nozzle which is made to fit 
Figure 108.—Mode of using the nasal douche. 361 
THE NOSE. 
into the nostril. The cup or reservoir being filled with the fluid 
designed to be used, and the nozzle being inserted in the nostril, 
the cup is raised just above the head, which is bent over a bowl, 
and the fluid flows into one nasal cavity, and, gradually filling it, 
rises and flows over the partition wall or septum, and out of the 
other nostril. Breathing must he carried on through the open 
mouth, and no movement of swallowing must he made during the 
use of the nasal douche. While the device is undoubtedly an 
efficient aid in some cases of nasal trouble, there is, however, a 
danger attending its use, viz.: that the fluid used may pass into 
the Eustachian tube—the passage which leads from the throat to 
the internal ear—and excite inflammation which may extend to 
the inner cavity of the ear, and produce deafness—an accident, 
the gravity of which cannot be over-estimated, and many phy- 
sicians condemn the use of the nasal douche on account of this 
danger. Its efficiency being somewhat limited, and its danger 
being great, the nasal douche should therefore be used with the 
greatest care, if used at all, and should be abandoned the instant 
any symptoms occur with reference to the ear. 
The syringe is certainly safer, and more efficient; but unfor- 
tunately, not so easily used by the patient, except after consider- 
able training. It consists of an ordinary barrel syringe, with a 
Figure 109.—Syringe with nozzle for injecting fluids into the nasal cavity from behind. 
nozzle curved in such manner that it may be passed up behind 
the soft palate, and throw a stream from behind forward through 
the nasal cavity and out at the nostril. 
The atomizer is a simple device by which the medicated fluid is 
broken into fine spray and thrown into the cavity by a strong cur- 
rent of air ; there are many varieties, but all on the same principle 
as the ordinary “cologne spray ” (see Fig. 105). Besides these meth- 
ods, fluids may be applied to the nose by an ordinary cameFs-hair 
brush provided with a handle, or by cotton wrapped in a probe; 
or powders may be drawn in by snuffing; or, in the case of chil- 
dren, the latter may be blown in by means of a tube of glass, 
paper, or goose-quill. Ordinarily, it is well to be somewhat care- 
ful in commencing to use applications to the nose. A simple case 
of chronic nasal catarrh may often be overcome by following the 
general directions laid down for the prevention of the repeated at- 362 
THE NOSE. 
tacks of acute catarrh. If these measures fail, and the discharge 
continues, resort may be had to some of the milder astringents, 
such as tannin, five grains in an ounce of water. Borax, sulphate 
of zinc, or alum, of the same strength, are efficient remedies. They 
may be used with the atomizer, which 
should be preferred to other methods in the 
earlier stages of the disease. If this fails, 
resort may be had to the syringe or douche. 
If there is very much secretion, and it 
shows a tendency to lodge in the cavity, 
an effort should be made to clear the nose 
before making the application. Oftentimes 
the handkerchief is sufficient, but if sim- 
ply blowing the nose does not thoroughly 
cleanse it, a solution of common table- 
salt or baking-soda may be sprayed into the nose ; or the fluid 
being held in the hollow of the hand to the nostril, it may be 
snuffed up. If the solution irritates, the strength should be re- 
duced by adding more water, and if it still causes any smarting, 
the use of a watery solution should be abandoned, and resort be 
had to snuffs ; these may be made up with powdered starch, 
sugar, or gum-arabic, of the same strength as in water, or even 
stronger: as tannin, ten to twenty grains in an ounce of starch 
or sugar ; ten grains of alum or borax, with the same proportion 
of starch or sugar, or bismuth, pure or half strength. 
If the disease has gone on to the stage of thickening of the 
mucous membrane, it will be necessary to use some of the reme- 
dies which promote absorption—following the same directions as 
before as to cleansing, and as to the avoidance of any cause of 
irritation or pain in the parts. Among these are muriate of am- 
monia, five to fifteen grains; chloride of zinc, one grain ; tincture 
of iodine, one to ten drops ; iodide or bromide of potassium, three 
to five grains; nitrate of silver, one grain—all to an ounce of 
water. The addition of glycerine to any of the above named, one 
drachm to the ounce, will prove an excellent aid to the efficacy of 
the remedy. In the earlier stage of thickening, the persistent use 
of these remedies will prove of good service ; but in the later 
stages, when the thickened tissue becomes thoroughly organized, 
it is doubtful if any local application will be of service ; the only 
relief will be in surgical means, at the hands of a skilful physician, 
the parts requiring to be destro3red by caustics or removed with 
forceps. 
“ Dry catarrh ” is an extremely obstinate and chronic affection; 
yet much may be done in the way of relief, if not of cure, by the 
Figuke 110.—Glass tube to 
enable a patient to blow a pow- 
der into his own nose : A, open- 
ing for powder, closed by a cork; 
B, end inserted into nose; C, 
end held in mouth of the pa- 
tient. THE NOSE. 
363 
long-continued use of local applications at the hands of the pa- 
tient. 
In these cases, the secretion being scanty and closely adherent, 
it will require the use of the syringe for cleansing purposes. But 
after the parts are thoroughly cleansed, the spray will be found an 
excellent method of making the application of the especial medi- 
cation required. This form of catarrh being characterized by ab- 
normal dryness and deficiency of secretion, the object of treatment 
is to moisten the membrane and stimulate the secreting glands 
into healthy action. The remedies of especial service in this direc- 
tion are, carbolic acid, one to three grains; kreasote, of the same 
strength ; tinct. sanguinaria (blood root), ten to thirty drops ; tinct. 
myrrh, twenty to thirty drops ; or carbonate of ammonia, one to 
five grains—all to one ounce of water. 
The dryness may be relieved by the inhalation of steam ; and it 
is well at all times that persons subject to dry catarrh should breathe 
an atmosphere pretty well charged with moisture, if it can be done. 
Nasal catarrh is often looked upon as an incurable disease. This 
is undoubtedly a mistake. It is probable that a very large proportion 
of the cases of chronic nasal catarrh are curable, but, in the effort 
to promote a cure sight should never be lost of the fact that a very 
important element in the treatment is the prevention of the fresh 
attacks that are so liable to occur repeatedly, and that the local 
treatment will always fail to accomplish the desired end unless the 
most careful observance is paid to the general rules of hygiene laid 
down before; and, in addition, it should be remembered that the 
cure of a nasal catarrh may be often retarded, if not absolutely 
prevented by the existence of some concurrent disorder—oftentimes 
of a comparatively trivial character—such as constipation, dys- 
pepsia, etc. 
Stink-Nose, or Ozaena. 
Although this disease is generally classed as one of the varieties 
of nasal catarrh, it is considered under a separate head, because, in 
truth, the source of the disease is not in the nasal cavities, but in 
the accessory cavities—the antrum, the sphenoidal sinuses, etc., 
although its prominent manifestation is in the nose. 
Symptoms .—This complaint is, in its origin, a catarrhal inflam- 
mation of the mucous membrane lining, one of the accessory 
cavities of the nose. 
Owing to the character of the part affected, being an almost 
completely closed cavity, the secretion very soon becomes pus, 
and, being retained, undergoes degeneration, which gives it its 364 
THE NOSE. 
extremely fetid, offensive odor. This discharge, escaping from 
the cavity through the opening by which it communicates with 
the nose, pours over the lining membrane of the nose, coating it 
with a thin, greenish-yellow secretion, which, adhering very closely, 
is retained in the nasal cavity and dries, forming crusts or masses 
of foul-smelling, offensive matter, which are detached with con- 
siderable difficulty at intervals of one to three or four days and 
voided—but only to be renewed again. There is not, ordinarily, 
any great obstruction to breathing through the nose ; on the con- 
trary, as a rule, the cavity is quite open and capacious. The sense 
of smell is generally seriously impaired, if not entirely lost. There 
is no pain (more than the sense of fulness) or discomfort in the 
special cavity involved. If the frontal sinus is inflamed, the pain 
and fulness is referred to the bridge of the nose and the lower part 
of the forehead. If the cavity of the jaw (the antrum of High- 
more) is the seat of the disease, these sensations are referred to 
the cheek-bone, often to the extent of severe neuralgic pains. 
Usually, however, the prominent symptom is the offensive dis- 
charge and the fetid breath, which, though not generally per- 
ceived by the sufferers themselves, is so powerful and penetrating 
that it is very noticeable at a distance. As a rule, ulceration of 
the mucous membrane does not occur in this disease, and when the 
discharge has been thoroughly removed, the cavity presents a 
fairly healthy appearance. This should be recognized in all cases, 
as the treatment of ozsena is based on entirely different principles 
from that of ulcerations of the nasal cavity. 
Treatment.—This is one of the most obstinate of all diseases of 
the nasal cavities, and whereas very much can be accomplished 
in the correction of its most prominent and distressing features, a 
permanent and complete cure can only be attained after a long- 
continued and faithfully followed course of treatment. 
In making applications, the syringe will be found most efficient, 
used either to throw the medicated fluid into the nose behind the 
palate, or directly into the nostril. In order to detach the dry 
secretion the stream must be thrown with considerable force. 
The fluids to be used for cleansing purposes are here much the 
same as in catarrh: a solution of common salt, a teaspoonful in a 
pint of water; baking-soda (bicarbonate of soda), or bicarbonate of 
potassa, of the same strength. This cleansing should in all cases 
be thoroughly and carefully done, otherwise, any treatment will be 
of little avail; afterward there may be thrown in by the atomizer, 
by blowing or by the douche, a disinfecting solution, such as car- 
bolic acid or kreasote, five to twenty drops in a half-pint of water, 
or salicylic acid, one or two grains in an ounce of water. If the odor 365 
THE NOSE. 
is very offensive, solution of chlorinated soda (Labarraque’s solu- 
tion) may be used, one or two teaspoonfuls in a pint of water. 
Permanganate of potassa is an excellent application, five to 
twenty grains in an ounce of water. 
These remedies should be used daily, or even oftener, accord- 
ing to the severity of the disease and the rapidity of the formation 
of the fetid secretions. 
Ulceration of the Nasal Cavity. 
This constitutes a totally distinct form of disease from the one 
previously described, although, in many of its symptoms, the resem- 
blance is very close. Its most frequent cause is syphilis, and it 
occurs from two to ten years after the disease has been contracted. 
Its favorite location is on the septum or partition of the nose and 
near the nostril; it may, however, have its seat in any portion of 
the cavity. Commencing as a simple abscess in the deeper por- 
tion of the mucous membrane, which breaks and discharges mat- 
ter, it rapidly develops into an open ulcer, with a free discharge, 
and, destroying the tissues rapidly, eats its way through the 
whole membrane down to the bone or cartilage, which it also at- 
tacks and destroys, when we have what is called necrosis, or death 
of the bone. The bone is discharged in small pieces, which are 
recognized as small, blackish-gray masses in the matter voided, or 
there may come away large pieces, or even the whole of one of 
the scroll-like bones (the turbinated). The ulceration is rapid in 
its destructive advance, and is attended with a profuse mattery 
discharge, which, drying and adhering closely to the surface of 
the ulcer, is gradually built up from below by the fresh matter 
poured out, until there is formed a large mass or crust, made up of 
matter, blood, particles of dead bone and membrane destroyed by 
the ulcer, and discolored also by the particles of dust from the air 
drawn in with the breath. These may be removed at intervals of 
from one to three or four days by the efforts of the sufferer, or 
they may adhere so closely that they can only be extracted by a 
physician; their odor is simply intolerable, and their appearance 
nauseating to an extreme degree. 
Another form of ulceration in the nose is that due to scrofula. 
In this disease the progress is much slower ; the amount of destruc- 
tion is much less; the activity of the ulceration, as in syphilis, is ab- 
sent. We have a slow, sluggish form of disease, but still the same 
tendency to the formation of offensive masses, the same fetid 
breath, etc. To the physician familiar with the two diseases, the 
characteristic difference would be recognized by an examination ; 366 
THE NOSE. 
the sufferer can easily make the diagnosis, however. On the one 
hand, if the disease is syphilis, there is the knowledge of his early 
symptoms, the primary sore, the hard chancre, the eruption, etc. 
If, on the other hand, the disease be scrofulous, there will be 
found existing with it the ordinary symptoms of the disease (see 
Scrofula), and also, in a marked degree, the enlarged glands in the 
neck and at the angle of the jaw. 
Ulceration may be due also to the presence of a foreign body in 
the nose. The variety of articles which have been removed from 
the nose, after remaining even many years without recognition, is 
very great. A tooth, an insect, a button, a small pebble-stone, have 
been known to lie in the nose for periods of from five to twenty 
years, and, on removal, the sufferer, from what was supposed to be 
ozsena, has been entirely cured. Ulceration from this cause is 
characterized by a mattery discharge, an offensive breath, more or 
less obstruction to breathing through the nose; but all in a less 
degree than in syphilitic or scrofulous disease. The ulcer does 
not extend, rarely involves destruction of cartilage or bone, and 
heals kindly on the removal of the foreign body. 
Ulceration, again, may occur from fracture of one of the bones 
or cartilages of the nose, resulting in death of bone. In this case 
there occur the same symptoms as in the other form of ulcera- 
tion, and, in addition, the symptoms resulting from the fracture— 
deformity, pain, etc. 
It is probable that all cases of ulceration may be traced to one 
of the above causes, except those rare cases in which we have ne- 
crosis of bone due to inhaling phosphorus fumes, as sometimes oc- 
curs among those engaged in the manufacture of friction matches, 
or from lead poisoning, or other unusual and obscure cause. 
The Treatment is of course based on the cause of the disease. 
In syphilis, iodide of potassium and mercury should be given, and 
continued for four to six months, to insure complete arrest and 
cure. In scrofula, cod-liver oil, iodide of iron, the hypophosphite 
of lime and general tonics should be administered, and the general 
rules followed out as given in the article on Scrofula. 
If there is a foreign body in the nose, the fact can only be ascer- 
tained by such a thorough examination as will commonly require 
the assistance of a physician. As a rule, there is no further treat- 
ment required besides the removal of the foreign body. 
In necrosis the dead bone should be removed by a surgeon as 
soon as feasible. 
The local treatment in all forms of ulceration is much the same 
as given in the article on Ozaena (page 364), and should in all 
cases be resorted to, in addition to the general treatment di- 367 
THE NOSE. 
rected, in order to limit as far as possible and arrest the destruc- 
tion of tissue. A very valuable aid to the action of the remedies 
advised is the use of iodoform. This is a yellow powder of a 
rather disagreeable odor, but its curative powers are so great in all 
forms of ulceration of mucous membranes, that its disagreeable 
odor should be tolerated for the sake of the great benefit resulting 
from its use. It may be applied in the form of powder, or it may be 
mixed with vaseline or simple ointment: one part in four or five, 
and may be applied with the finger if the ulcer is near the nostril. 
Tumors of the Nasal Cavity. 
The tumors that may occur in the nose are warts, polypi, fibrous 
tumors, and cancer. 
Warts.—These are the same as the ordinary warts which occur 
on the hands, and may occasionally be noticed just within the nos- 
tril, at the junction of the skin and the mucous membrane. They 
never occur deeply within the cavity. They occasion but slight 
annoyance by their presence, and are mainly of importance, from 
the fact that they bleed pretty freely if they are picked or broken. 
Occurring as they do most commonly in children, this may lead 
to serious accidents from their habit of constantly picking at any- 
thing that may happen to lie in the nostril. 
The Treatment is the same as that of ordinary warts occurring 
elsewhere, and consists in the daily application of acetic acid; or 
in their removal by scissors, and the cauterization of the cut sur- 
face with strong nitric acid, all of which should be left to a physi- 
cian. 
Polypus.—Nasal polypus, or, as it is sometimes called, gelati- 
nous polypus, is the most common of all tumors having their seat 
in the nasal cavity. Taking their origin 
in some small point of localized inflam- 
mation— probably one of the minute 
glands of the mucous membrane—they 
grow with more or less rapidity, until, 
by their own weight, they sink down 
toward the floor of the cavity, becoming 
elongated and pear-shaped; their at- 
tachment to the part from which they 
sprang being maintained by a narrow 
portion, called the pedicle or stalk. As 
they increase in size, they mould them- 
selves to the cavity in which they grow. In a very large major- 
ity of cases their attachment is to the middle turbinated bone, 
Figure 111.—Mucous polypi. 368 
THE NOSE. 
and about midway of the passage, and never to the septum. 
They generally occur in groups of from three or four to eight or 
ten, and are rarely confined to one cavity. 
They are soft and yielding to the touch, and of a grayish color, 
being composed of mucin, the main constituent of mucus, and a 
few loose fibres of connective tissue. 
The main symptoms of their existence are, the obstruction of 
the nose, more or less complete, according to their size, the dis- 
charge of a clear watery fluid, and their peculiar action under at- 
mospheric changes, by which they absorb moisture and swell up 
during damp weather. 
They can generally be seen by looking into the nostril, the tip 
of the nose being raised, and are easily recognized by their color, 
which is a grayish-white, almost identical with that of mucus or 
phlegm; by their movability—a probe being pressed against them, 
they are seen to move freely; by their semi-elasticity—being in- 
dented by the probe, the indentations disappearing slowly. 
Treatment.—The only treatment for nasal polypus is removal 
at the hands of a physician, no local application being of any 
avail for relief even, much less for cure. The operation is not a 
difficult one, and is not attended with much pain. 
Fibrous Tumors.—These tumors are of a far more serious char- 
acter than those previously described. They occur in the upper 
portion of the nasal cavity, or in the upper pharynx, and grow 
very slowly, their development being a matter of years ; but it is 
a growth which nothing can withstand, carrying before it, in its 
relentless march, membrane, cartilage, bone, whatever it may 
meet. 
The Symptoms are those due to nasal obstruction, without any 
noticeable catarrhal discharge, and, in addition, the special defor- 
mity that may be caused by the tumor according to its location. 
If it is in the upper part of the cavity, there occurs that peculiar 
deformity called a frog-face, due to a spreading of the root of the 
nose. If the tumor is lower down, it may crowd out one or the 
other of the cheek-bones. 
The only treatment is removal by the surgeon’s knife. 
Cancer in the nose is recognized by the lancinating pain, the 
fetid, peculiarly offensive discharge, in connection with a peculiar 
complexion and appearance of the patient called the “cancerous 
cachexia,” as described elsewhere. 369 
THE NOSE. 
Deviation of the Septum. 
This is a condition in which the septum of the nose deviates 
from the median line. Probably in a majority of people there is a 
slight deviation from the centre, but in some cases the deformity 
exists to such an extent that the projecting part may touch the 
outer wall of the nose, completely closing the nostril of that side. 
This condition might easily be mistaken for the existence of a 
tumor, but an inspection of the other side will easily correct the 
apprehension, as the corresponding depression will then be seen. 
This deformity is generally present at birth, though it is often the 
result of an injury; it has been caused by the habit of blowing the 
nose with the finger pressed against the nostril. 
The only treatment for this condition is an operation at the 
hands of a surgeon, and consists in the removal of that portion 
of the septum which is deflected. This, of course, is only resorted 
to in those cases in which the deviation gives rise to obstruction of 
the nose. 
Perforation of Septum. 
This consists in an opening through the septum from one cavity 
to the other. It is the result of ulceration and necrosis, and in a 
majority of cases is due to syphilis. It may be small in extent, or 
it may involve both the cartilaginous and bony portion of the sep- 
tum. Its existence is not serious, and gives rise to no symp- 
toms. 
Foreign Bodies in the Nose. 
The vicious habit young children sometimes fall into of putting 
small objects into the nose is not more remarkable than the variety of 
things which they put into the mouth—with this difference though, 
that their removal from the mouth is quite an easy matter, while 
from the nose it is oftentimes quite difficult, owing to the fact that 
the entrance is the smallest part. Moreover, a timid child often- 
times refrains from telling what has happened; and an object 
which might easily have been removed at the outset, becomes 
firmly fixed by the swelling of the mucous membrane excited by its 
presence. 
Treatment.—The first effort at removal of a foreign body from 
the nose should always be made by blowing the nose—the free 
nostril being closed by the finger. In case the child is too young, 370 
THE NOSE. 
or too much alarmed to do this, his nose can be blown for him in 
the following manner : While the head is held steadily between 
the knees of an assistant, let the operator apply his or her lips 
closely over the mouth of the child (if it is crying, so much the bet- 
ter), and blow forcibly into it. One effort is commonly all that is 
needed. It is better not to close the free nostril, since it avoids the 
danger of a possible injury to the ear of the child, from a too great 
pressure on the ear-drum. If blowing the nose fails, some simple 
instrument may be used for removing the object by the nostril. 
A hair-pin is ordinarily the first and most convenient aid, but only 
the looped end should be used, unless the object, like a button, has 
a hole or eye into which a hook can be inserted; in which case one 
of the pointed ends may be used, being bent into a hook. With 
care the two points may be used as tweezers. In no case should 
any force be used. Blind groping about in the nasal cavity should 
also be avoided; and if the body is not easily removed or has 
made its way deeply into the nose, its removal should be accom- 
plished by a surgeon. If the object has remained long enough to 
cause swelling of the parts, attempts at removal should be delayed 
until the swelling has subsided, their presence for days or even 
weeks not giving rise to any serious or permanent results; but 
remaining, as they often do, for a much longer period, they cause 
ulceration, with its fetid discharges and offensive breath, as before 
described (page 363). 
Bleeding from the Nose—Epistaxis. 
The mucous membrane of the nose is very abundantly supplied 
with blood-vessels, more so than that of any other portion of the 
air-passages; and owing to its exposed position and liability to in- 
jury on irritation, bleeding is of extremely frequent occurrence. 
It may be the result of direct violence, as a blow or fall; it may 
occur from picking the nose when it is the seat of disease or irrita- 
tion ; or it may be due to an effort on the part of nature to relieve 
the distended blood-vessels of the head when, from any cause, 
there is too much blood circulating in the brain. In this case the 
bleeding is preceded by a sense of pain and fulness about the fore- 
head and eyes, headache, dizziness or vertigo, intolerance of light, 
etc.; all of the symptoms disappearing with the escape of blood. 
Nose-bleed also frequently attends the onset of typhoid and 
remittent fever, in which case it is accompanied by the ordinary 
symptoms of those diseases. It is also a prominent feature of 
scurvy, when there will also, very likely, be bleeding from the 
gums and discolored blood-spots on the skin. It is said to take the THE NOSE. 
371 
place, sometimes, of the monthly period, recurring, as it does, each 
month at the time when the natural flow should appear, this being 
from some cause suppressed, constituting the so-called “ vicarious 
menstruation.” It is common, also, to that class of persons called 
“bleeders,” who bleed freely, and often profusely, from a slight 
wound, or even a scratch. 
If the bleeding is due to a local cause, it is generally confined to 
one nostril; but if the cause is in a general condition, such as 
fever, scurvy, congestion of the blood-vessels of the head, etc., the 
flow is from both sides of the nose. It usually trickles in drops, 
or flows in a small stream, and is not attended by any great dan- 
ger ; but it may become very serious, or even fatal by its amount 
or long continuance without being arrested. 
Treatment.—A nose-bleed, probably in a majority of cases, has 
a tendency to cease spontaneously. Still, it is not well to trust to 
this tendency, for if it lasts too long it is far more difficult to ar- 
rest it than at the outset; hence simple measures should always 
be resorted to, such as pressing the nose firmly between a thumb 
and finger, thus closing the nostril and much of the nasal cavity, 
at the same time raising the hand of the same side as high as 
possible. This position should be maintained for from five to 
ten minutes, or even longer, the object of the pressure being 
to enable a clot to form by which the bleeding vessels may be 
plugged. Of course, blowing the nose should be avoided, not only 
during the bleeding, but for some hours afterward, the effect of 
such an act being .to dislodge the clot and re-establish the trouble. 
Trial may be made at the same time of the application of ice to 
the bridge of the nose, and also to the nape of the neck; in the 
absence of ice a piece of cold metal may be used. These measures 
failing, a further resort is to tie a cord around one of the limbs, 
thus lessening the amount of blood which circulates in the vessels 
of the head by detaining it in the extremities. If the hemor- 
rhage is not arrested by these devices, it will be necessary to use 
local applications, such as ice-water, weak solutions of alum, tan- 
nin, iron, etc., thrown into the affected nostrils by a syringe, 
pledgets of cotton saturated with the astringent and passed into 
the nostril, or plugging the nose before and behind. This latter, 
however, will require the services of a physician, who should al- 
ways be summoned when the attack is not arrested by the simple 
devices above-mentioned. [See also Chapter on Accidents and 
Emergencies.] 372 
THE NOSE. 
Fracture of the Bones of the Nose. 
In addition to a simple nose-bleed occurring from a fall or blow, 
the bones of the nose may be broken. When this takes place, the 
parts become so rapidly and so greatly swollen, that before the ar- 
rival of the surgeon it may become very difficult to recognize the 
true condition or to adjust the parts. It is desirable, therefore, 
that some bystander should know what ought to be done. 
Symptoms.—The fracture may be recognized by the deformity 
which attends it, the natural outline being altered, the bridge 
being sunken at the point where the bone is broken, and also by 
the grating sensation which may be felt on taking the bridge 
between the fingers and making slight pressure—due to the grating 
of the broken edges on each other. 
Treatment.—The parts are adjusted by passing a slender in- 
strument, such as a pen-holder or lead-pencil into the nostril, and 
lifting the sunken fragments into place, and then packing soft 
cotton under them in such a manner as to retain them. The 
swelling of the parts may be controlled by the application of 
cloths wet with ice-water, and frequently changed; or if ice is 
not convenient, water may be used as hot as can be borne with 
comfort and continued for at least half an hour. 
With the greatest possible care in the treatment of a broken 
nose, there is usually some deformity remaining permanently. 
Loss of the Sense of Smell—Anosmia. 
The sense of smell, depending, as it does, on the contact of 
particles of odorous bodies with the minute extremities of the 
olfactory nerve, is necessarily abolished or impaired by anything 
which interferes with the access of these particles to the mem- 
brane of the nose; or, again, by aiiything which impairs or 
destroys the healthy action of the nerve itself; hence it is a fea- 
ture of catarrhal diseases of the nose and of tumors of the nose; 
but the loss of smell is only partial, unless the nasal membrane is 
very extensively involved in the catarrh; or, on the other hand, 
the nasal passage is entirely closed by the tumors. If the disease is 
in the nerves, it is due to some cause existing in the brain or in 
the nerves leading from the brain to the nose; in a majority of 
cases this is caused by blows or injuries, and comes on suddenly. 
Treatment.—If it is due to disease of the nasal cavity, that 
should of course be remedied. If it is due to nerve or brain disease, 
the method of treatment which gives the best promise of relief is 
electricity, administered by a competent physician. 373 
THE NOSE. 
Glanders. 
This is one of the most fatal of the diseases of its class, and 
depends for its cause upon inoculation with the poison of glanders 
or farcy from a diseased horse or mule. 
It is mentioned in this connection on account of the profuse, 
purulent, viscid, and bloody discharge which takes place from the 
nostrils, and which is one of the most prominent features of the 
disease. Later, gangrene of the parts about the nose occurs, and 
is rapidly followed by death. More extended mention of glanders 
will be found among the “ Acute Infectious Diseases.” 
Influenza. 
This properly is the name given to a disease which has pre- 
vailed at times in this country and in Europe as a severe and 
often extremely fatal epidemic, commencing in some one locality, 
spreading with great rapidity over a whole country and attacking 
large portions of the population. The epidemic of 1782, in Europe, 
is said to have attacked one-half the population. The lower ani- 
mals as well man are subject to it. 
The symptoms are those of a severe cold in the head, with the 
addition that it is attended by a very high fever, and a degree of 
prostration rarely met with in connection with that disease. It may 
properly be considered, therefore, a disease of the general system, 
and is due, probably, to germs which, floating in the atmosphere, 
reach the mucous membrane of the nose, and give rise to the 
catarrhal symptoms, and, being absorbed into the blood, cause the 
marked constitutional symptoms above mentioned. Unlike the 
eruptive fevers, the same person is liable to repeated attacks, 
though not in the same season, and it is not contagious. 
Treatment.—The disease runs its course in from six to ten days, 
and cannot be cut short, or aborted, like a cold in the head. Much 
relief may be obtained by the use of the same local remedies as are 
efficient in acute catarrh, and, in addition to this, general tonics 
with nutritive food, and a moderate amount of alcoholic stimulant 
should be given. [See, also, page 58.] 
Restoration of Nose. 
As the result of syphilis, scrofula, cancer, or violence, the 
nose is sometimes destroyed or lost, and the sufferer seeks relief 
at the hands of a surgeon from the terrible deformity which the 374 
TI1E NOSE. 
loss causes. The operation consists in transferring a piece of the 
skin, cut in such a shape that it will fill up the part wanting in the 
nose, from either the arm or the forehead. The new organ being 
sewed in its place, but still connected by a broad attachment to 
the part from which it was taken, the attachment is cut only 
after the piece has grown into its new locality, which generally 
requires about ten days. 
If the arm is used, the piece is cut from the inside of the fore- 
arm, and the hand is bound to the head while the parts grow to- 
Fig. 112. 
Fig. 113. 
Figure 112.—Depressed nose. 
Figure 113.—New nose made from skin taken from the forehead. 
gether. If the new organ is taken from the forehead, as is usu- 
ally done now, the piece is simply cut out, twisted down on the 
nose, and stitched into place, and its attachment is cut at the 
end of about ten days; the wound of the forehead heals readily, 
and leaves but a small scar. The operation is attended with no 
danger, but the result is not very flattering, the new nose being 
a rather shapeless affair as compared with the one formed by 
nature. 
Deformities of the Nose. 
Owing to the results of injuries or to natural deformity, the 
nose is sometimes turned to one side, or has a projecting por- 
tion which renders it unsightly. This is capable, in some instances, 
of being much relieved by the use of an apparatus to be worn at 
night and other convenient times, by which pressure is made by 
pads and springs upon the projecting part. The success of this 
treatment is in proportion to the youth of the patient and the 
recent nature of the deformity. 
FRANK II. BOSWORTH, M.D. The Throat and its Diseases. 
BY 
J. SOLIS COHEN, A.M., M.D., 
OF PHILADELPHIA, 
LECTURER ON LARYNGOSCOPY AND DISEASES OF THE THROAT AND CHEST, IN JEFFERSON 
MEDICAL COLLEGE, PHILADELPHIA; PHYSICIAN TO JEFFERSON MEDICAL COLLEGE 
HOSPITAL AND TO THE GERMAN HOSPITAL OF PHILADELPHIA. THE THROAT 
The throat is a double passage-way through which the air we 
breathe reaches the larynx on its way to the lungs, and through 
which the food we swallow reaches the gullet on its way to the 
stomach. It is therefore a very im- 
portant portion of the body, being em- 
ployed in the two functions of respi- 
ration and alimentation (feeding), the 
former being the more essential of the 
two. 
As shown in the adjoining diagram, 
it will be seen that there are two 
routes by which the air is conveyed to 
the larynx : 1, The normal respiratory 
route through the nostril, as indicated 
by the upper dotted line in the dia- 
gram; and 2, The accessory respiratory 
route through the mouth, as indicated 
by the lower dotted line. The route 
taken by food and drink, the alimen- 
tary route, is indicated in the diagram by the solid line pass- 
ing through the mouth, beyond the larynx, into the gullet (food- 
pipe, oesophagus) behind. The larynx is composed of rigid struc- 
tures which keep its calibre open for the necessary ingress and 
egress of the air in respiration; while the gullet is a soft tube, 
composed of flexible structures, the walls of which are in close 
juxtaposition, except when forced open by the muscular act 
or effort of swallowing to receive the food or drink. As the 
food-pipe is behind the air-pipe, articles of food or drink might 
easily fall into the larynx by accident, were it not for a cover or 
valve at the top of the front part of the larynx, which is pressed 
right down upon it, like a trap-door over a hole or the lid on a 
molasses-jug, in the motion of swallowing, during the momentary 
Figure 114.—Diagram of the routes 
taken by the air to reach the lungs, 
and by the food to reach the stomach. 378 
THE THROAT. 
performance of which act respiration is necessarily suspended. 
If one talks or laughs while swallowing, the trap-door may remain 
open and some food or drink may get down the wrong way and 
enter the larynx, provoking spas- 
modic efforts of cough to expel it 
—an occurrence with which almost 
every one is familiar. 
The nostril is the proper pas- 
sage for respiration, but when 
stopped up by mucus, a swelling, a 
morbid growth, or a foreign body, 
the accessory respiratory route 
(the mouth) must be used for this 
purpose; and in fact it will be found 
that in most instances where peo- 
ple breathe by the mouth, there is 
more or less obstruction of some 
kind in the nose. 
That portion of the throat in 
which the respiratory and alimen- 
tary tracts cross, is known as the 
pharynx, and it extends from the 
base of the skull behind the nos- 
trils (see diagram) as far down as 
the entrance into the gullet, with 
which it is continuous. It is therefore somewhat the shape of 
the top of a buggy-wagon or a barouche. [For an account of the 
anatomy of the parts concerned, the reader is referred to the chap- 
ter on Anatomy.] 
Figure 115.—The soft palate and tonsils, 
as seen from the mouth. 
Care of the Throat. 
Many individuals are very subject to diseases of the throat and 
nasal passages; a slight exposure to wet, change of temperature, 
change of clothing, change of bed-room, or the like, rendering 
them susceptible to sore throat, quinsy, cold in the head or chest, 
or whatever may be the special affection to which they are liable. 
It is useless to attempt to avoid this by taking medicine. Much 
may be done, however, to secure immunity from attacks of the 
kind on slight provocation, by methodically inuring the body to 
withstand the unavoidable exposures to which every active person 
is more or less subject in our variable climate. This is not to be 
done by the use of chest protectors, mufflers, heavy overclothing, 
furs, and like wraps. Far from it. The habitual use of these 379 
THE TIIROAT. 
things only serves to confirm the delicacy of constitution which 
they are fondly believed to protect; and when they are left off, or 
by accident or inadvertence forgotten, a severe attack of the com- 
plaint to which the individual is predisposed is almost certain to 
be the penalty. The causes of the predisposition alluded to are 
various. Sometimes the infirmity is hereditary. People are physi- 
cally very much what their parents make them. Delicate or ail- 
ing parents are likely to breed delicate and unhealthy children. 
Hence the great number of deaths during childhood—weedings out, 
as it were, of the immature. Daily sponging of the body with 
cold water, on rising, is the best method of inuring the skin to 
withstand accidental exposure to wet and changes of temperature. 
Among the exciting causes of diseases of the throat and nasal 
passages may be mentioned: Sudden exposures to excessive 
changes of temperature out of doors and indoors, especially expo- 
sure to cold when the body is overheated, no matter how the over- 
heating may have been produced; sitting, working, and sleep- 
ing in illy-ventilated apartments; sojourn in crowded places, 
whether church, school-room, theatre, court-room, ball-room, or 
street-car; exposure to air vitiated by illuminating gas, coal gas, 
tobacco-smoke, the products of chemical combustion, and the like; 
the indulgence in cold drinks on the top of hot viands; immoderate 
use of iced water in summer time, especially when the body is 
overheated by exercise; too protracted contiguity to patients with 
scarlet fever and diphtheria. 
It is much more rational to prevent disease than to trust to 
getting cured after contracting it. Persons subject to sore throat, 
whether hereditarily predisposed thereto or otherwise, should avoid 
all the sources of injury above enumerated. They should wear 
woollen or silken (animal fabrics) underclothing, changing the 
weight or texture of the garment on the positive approach of 
change of season. 
When going from a warm and especially from a crowded room 
into a chilly outside atmosphere, the precaution to breathe for the 
first few minutes through the nose only, or through the meshes of 
a shawl, handkerchief, or folded veil, is all that will ordinarily be 
needed. 
Where children are accustomed to breathe through the open 
mouth, this should lead to an examination, and it will probably be 
found that enlarged tonsils are the cause of the difficulty, and that 
they require removal by some of the methods to be hereafter de- 
tailed. The harm which results from breathing through the mouth, 
instead of the natural respiratory passage, is that the throat is 
rendered dry and apt to become inflamed ; that the air is not prop- 380 
THE THROAT. 
erly warmed and moistened by passing over the wet and warm 
surfaces of the bones of the nose before it reaches the delicate 
vocal organ, and that dust and irritating matter, which should be 
arrested in its passage through the nose, is carried into the respira- 
tory organs, and becomes a cause of disease. 
[In England, more commonly than in this country, it is custom- 
ary to wear a respirator made of some sort of gauze, or sponge 
over the nose and mouth; but the instances in which such protec- 
tion is needed are far less than would justify the extent of the 
practice, if we except those connected with some of the trades. 
Indeed, among workmen who could derive decided benefit from 
the use of some such means for excluding foreign matter from the 
throat and air-passages, the use of respirators is much too seldom 
resorted to.] 
The Voice. 
A short account of the nature of the voice and its production, 
will insure a better comprehension 
of the method of taking care of it. 
The voice is the sound voluntarily 
made in the throat for the usual pur- 
poses of communication and inter- 
communication ; and it is broken up 
in an arbitrary manner, different as 
adopted by different nations or com- 
munities, by the physical action of 
the lips, tongue, teeth, and palate, in- 
to accentuated or articulated speech ; 
while the modulation of the pitch 
and volume of the sounds gives ex- 
pression to the utterances. The 
voice is formed in the larynx 
(vocal-box) (Fig. 116), on top of the 
windpipe, by the forcible action of 
an outward or expiratory current of 
air striking or impinging upon two 
tense bands or folds of membrane (vo- 
cal cords cv) which run from front 
to back in this box, in close contact 
in front, and movable behind a', their 
to-and-fro movement being similar 
to that of the handles of a pair of scissors. These vocal cords 
are set into vibration just as the reeds of an accordion are set into 
Figure 116.—Section through the car- 
tilages of the larynx, showing the inner 
surface of the right side. /, thyroid car- 
tilage cut through its centre, in front; 
c, c, front and rear portion of the cricoid 
cartilage, similarly divided; a, inner 
surface of the right arytenoid cartilage; 
its anterior projection; cv, thyro-ary- 
tenoid ligament. THE THROAT. 
381 
vibration by the wind from the bellows of that instrument. The 
hard, angular projection in the anterior part of the neck t, more 
prominent in men than in women, marks the junction of the two 
sides of this triangular vocal-box or larynx. If the finger is run 
down this projection, a soft depression cth is felt just before it joins 
a circular base (cricoid or ring-cartilage c), which is situated direct- 
ly on top of the windpipe, of which it is actually an expanded 
continuation. If the finger be held against the soft part just 
indicated while the voice is sounded, the vibrations can be dis- 
tinctly felt, because a thin membrane is there which is actually 
continuous with the vocal cords, which are located a little above 
it in the shape of a rather horizontal Y, the legs of which are 
directed backward. The production of voice is due to the vi- 
bration of these cords, and to the vibration of the air in the air- 
tubes, throat, nose, and mouth, as can readily be felt in the chest 
when one speaks in a deep-toned voice ; and even the trunk and 
limbs vibrate just like the sounding-boards or walls of musical in- 
struments in certain deep and sonorous tones. 
The intensity or loudness of the voice is due to the size of the 
vibrations, or, in other words, to the extent of to-and-fro movement 
impressed upon the vocal cords; the larger the space through which 
they vibrate, the greater is the quantity of air set in motion, the 
larger the wave of sound, and the louder the voice; while the voice 
becomes more feeble as the space through which the vocal cords 
move becomes diminished. Intensity is independent of pitch and 
quality. 
The pitch of the voice (its position in the musical scale) is pro- 
portionate to the frequency of the vibrations; the greater the 
number per second, the higher the pitch. Pitch is independent of 
intensity and quality. 
The quality of the voice (that characteristic which distinguishes 
it from the sound of an artificial musical instrument, and which 
makes it easy to recognize the voice of any one individual as dif- 
ferent from all others) is due to the shape impressed upon the 
sound-waves by the consentaneous action of the different factors 
of the sound (fundamental tones, harmonic and unharmonic over- 
tones, combination tones), owing to the fact that all musical 
sounds are composed of series of tones, most of which are pro- 
duced by vibrations of the sounding body (vocal cords in man 
and animals) in certain aliquot parts, at the same time that it is 
vibrating as a whole. The more harmonious these individual 
tones, the sweeter the sound as a whole ; the more discordant 
these individual tones, the harsher the sound of the voice as a 
whole. The comprehension of this physical fact is rather difficult, 382 
TIIE THROAT. 
and would require a good deal of space for its elucidation. The 
reader is therefore referred for details to works on physics, on 
acoustics, or on sound. Quality is independent of intensity and 
pitch. 
To understand the physical formation of the registers of the 
voice, it is necessary to see the performance. This can be accom- 
plished by placing a small mirror in the mouth in such a position 
as to get a reflected view of the image of the vocal-box (larynx) and 
its contents, as shown in this figure below, in which the image of 
Figure 117.—The larynx in the respiratory position, as seen in an image reflected in a glass 
mirror held far back in the mouth. 
the larynx is seen as reflected in a mirror in the mouth. This in- 
genious and beautiful method of exhibiting the larynx of a living 
person and studying the action of the vocal cords in the forma- 
tion of voice is known as the art of laryngoscopy (viewing the THE THROAT. 
383 
larynx), and the demonstration of its feasibility is chiefly due to 
the assiduous efforts of Mr. Manuel Garcia, a celebrated teacher 
of vocal music in London, who devised it for the purpose of study- 
ing 4he mechanism of the voice. Since the publication of Garcia’s 
observations, the method has been extensively introduced into the 
practice of medicine in the examination and treatment of many 
affections of the throat. 
As depicted in the above illustration, the vocal cords are repre- 
Figure 118.—Method of examining the larynx by solar reflection. 
sented widely separated behind, as seen during a deep inspiration, 
which renders the rings of the windpipe visible below them. 
When the voice is produced, the vocal cords have to come to- 
gether posteriorly, as shown in Fig. 119, leaving a delicate slit 
between them, through which the ex- 
piratory current of air is forced, set- 
ting the cords into vibration ; an ef- 
fect which is readily observed in the 
mirror. Of course the rings of the 
windpipe and all the other structures 
below the vocal cords are shut off from 
view as long as the voice is being 
sounded. When the pitch of the voice 
is raised, the vocal cords are seen to become more tightly stretched, 
and the slit between them to become shorter, so as to leave a 
shorter and more tense portion of the cord free to vibrate ; the 
pitch rising just the same as when the cord of any stringed instru- 
ment of music is shortened, and stretched more tightly. 
Figure 119.—Vocal cords closed, as 
seen in the production of vocal sound. 384 
THE THROAT. 
There are three principal registers of the voice : chest, falsetto, 
and head-notes. In the formation of the chest-notes, the vocal 
cords are seen to vibrate their entire breadth. In the formation of 
the falsetto-notes, the vibration is confined to their edges. In the 
formation of the head-notes (common to women, exceptional in 
men), the vocal cords become so tightly pressed together behind, 
that there only remains an open slit or fissure for little more than 
half the length of the vocal cords, which vibrate only in their 
free edges.* 
SOPRANO. 
CONTRALTO. 
BASS. 
TENOR. 
The usual range of the four varieties of the human voice. 
Care of the Voice. 
When we consider that the entire compass of the voice is due 
to the symmetrical action of two vocal cords, little bands of tissue, 
as thin at their edges as a sheet of ordinary writing-paper, less 
than an inch in length, about one-tenth of an inch in breadth, and 
with but one free surface each, we can readily comprehend how del- 
icate must be the mechanism and arrangement of the nervous and 
muscular structures that animate them and alter their position and 
tension in order to produce those charming effects with which all 
listeners to good vocal music and good oratory are familiar. It is 
no wonder, then, that good voices are so often irretrievably in- 
jured by injudicious management. No teacher of elocution or of 
vocal music should be trusted now-a-days with the training of a 
voice of some consequence to its possessor, unless that teacher has 
a comprehensive acquaintance with the anatomy, physiology, and 
mechanism of the voice. As already mentioned, the special mech- 
anism of the sounds of the chest, falsetto, and head registers are 
dissimilar. If, then, an ambitious teacher tries to force the chest 
tones into the falsetto register, or the falsetto into the head regis- 
ter, he is apt to inflict injury upon the delicate mechanism, whether 
he accomplishes his object or not. The proper points of transition 
can be observed in the mirror, and can be detected by an educated 
* For more detail, the reader is referred to Mrs. Seiler’s reliable work on “ The Voice 
in Singing',” published in Philadelphia. THE THROAT. 
385 
ear, so that there is no excuse for neglecting their study. Surely 
no master, with a real love for his art, should hesitate to avail him- 
self of the advantages to be gained by such observations. The 
manual skill necessary for the manipulation of the throat or laryn- 
goscopic mirror can be acquired in an hour ; the cost of the mir- 
ror is about one dollar. The anatomy of the parts, once carefully 
pointed out in a human larynx, can be thoroughly studied up at 
leisure in calves’ larynges (which can be had from any butcher 
for the asking), and the rest is a question of time and facility of 
comprehension. The result of the outlay, in intelligent knowdedge 
of the tools with which he is to work, will be immeasurably in 
excess of its cost to any teacher of vocal culture, not to count its 
personal advantages in improving his own skill in the use of his 
voice, or in developing the vocal capabilities of his pupils. Any- 
thing which strains the vocal cords, such as screaming, prolonged 
use of the voice, talking or singing in too high a key, using the 
voice to any extent when fatigued, overfed, unwell, or hoarse, is 
sure to be injurious, and should be studiously avoided by all public 
singers and speakers. It is neglect of care of this kind which 
drives so many from the stage, concert-room, and pulpit during a 
prolonged period of inaction ; and it is rare that an injured voice 
recovers all its previous tractability. All those injurious influences 
enumerated in connection with the subject of care of the throat 
are injurious to the voice. A slight congestion of the cords, from 
cold or overstraining, is sufficient to withdraw them from the ex- 
quisite control of muscular effort so essential to the formation of 
pure tones ; and the swelling of inflammation changes their phys- 
ical capacity for tone still more so, and, in addition, sometimes 
prevents their being brought sufficiently near each other to pro- 
duce any tone at all, so that the voice is lost, for the time being, 
unless under the force of violent effort, in itself injurious. One 
should, therefore, cease speaking in public, or singing anywhere, 
the moment there is any manifestation of hoarseness, however 
slight. There is no compromise possible, if the individual is not to 
run the risk of more or less prolonged hoarseness, or trouble more 
serious. Indeed, preachers and professional and domestic vocal- 
ists should speak altogether in whispers whenever their voices are 
hoarse ; and those who do not sing or lecture, and to whom altera- 
tion of the voice is but of little moment, should use the voice as 
little as practicable whenever it is affected. Silence, ice to the 
throat, externally and internally, a smart saline or castor-oil purge, 
and the avoidance, for a few days, of red meat and alcoholic bev- 
erages of all kinds, will, in most instances of slight recent injury to 
the voice, suffice for treatment. In cases of severe injury, and in 386 
TIIE THROAT. 
cases of long standing the advice of the physician is essential. 
Silence in cases of affected voice is more than golden to the indi- 
vidual who is dependent on skill in its use for support. 
DISEASES OF THE THROAT. 
Sore Throat. 
Sore throat may be confined either to the parts back of the 
mouth (palate, tonsils, pharynx), or the deeper portions (larynx, 
windpipe), or it may affect all these structures more or less. Sore 
throat is a frequent accompaniment of scarlet fever, measles, 
small-pox, erysipelas of the face, and other affections. It is one of 
the prominent manifestations in diphtheria. It is also an accom- 
paniment of many cases of pulmonary consumption, especially 
toward their final stages ; and is a very frequent manifestation in 
the constitutional ravages of syphilis, after the system has become 
impregnated with the virus. It may be brought on by voluntary 
or accidental swallowing of hot and corrosive fluids ; by exposure 
to respiration of noxious gases and fumes ; by the inhalation of 
dust, smoke, grit, and the like ; by loud and continuous talking 
and overstraining the voice in various ways ; by the abuse of 
tobacco, alcoholic beverages, highly seasoned food, or of hot and 
cold viands in close succession. 
The most frequent cause of sore throat is exposure to cold when 
the body is overheated. 
The Symptoms of sore throat are pain, redness, swelling, diffi- 
culty of breathing, difficulty of swallowing, cough, expectoration, 
hoarseness, and impairment or loss of voice. The intensity of the 
symptoms vary with the amount of inflammation, the extent of 
surface over which it extends, the nature of the tissue in which 
the diseased process is going on, and the mechanical interference 
with the functions of breathing, swallowing, and speaking. Some 
cases are so slight as hardly to attract attention, and others are 
more severe, so as to interfere with the due performance of one’s 
duties. 
Treatment.—Most cases will get well if they are only left alone 
without resort to any of the numerous advertised syrups, lozen- 
ges, and other remedies. All that needs to be done is to remain 
quiet, avoid conversation, to see that the body is well protected by 
proper clothing day and night, avoiding exposure to cold and wet • 
to suck bits of ice almost continually if the throat is hot, swollen, 
and painful, and to apply iced cloths or bags of pounded ice exter- THE THROAT. 
387 
nally, changing them as soon as they get warm, and to eat very 
plainly cooked food, and very little of it. If the bowels have been 
confined, a smart purging will be useful, and nothing is better than 
a dose of Epsom salt (a tablespoonful for the adult, in a tumbler 
of water, before breakfast) in summer, or of an infusion of senna 
(one or two drachms for the adult) and manna (one ounce for an 
adult) in winter. If the sore throat is not of more than twenty-four 
hours’ standing, it is a good plan to put the legs into hot water well 
impregnated with mustard, until they get very red, take something 
in the nature of a hot drink, and then jump right into bed be- 
tween blankets, and remain there until late the following morn- 
ing. This treatment will often cure a mild sore throat in two or 
three days ; and neglect of it will often convert a mild and easily 
managed case into a protracted and obstinate one. If the treat- 
ment here laid down is not promptly followed by amelioration of 
the symptoms, it may be taken for granted that the case is beyond 
the ordinary resources of home remedies, and the sooner the medi- 
cal attendant is summoned the more quickly will the patient get 
relief and be placed on the road to recovery. Meanwhile, the suf- 
ferer may suck a sal-prunell ball, and cover the neck with a flan- 
nel wrung out of heated camphor-water, or a mixture of oil of 
turpentine with three times as much sweet-oil. 
Severe sore throats should always be reported promptly to the 
physician. Delay of only a few hours often renders it impossible to 
institute measures to restrain inflammatory action, and the disease 
will have to run its course. The neglect of proper management is 
almost sure to be punished by chronic or protracted suffering. A 
brief description will be given of the severer forms of sore throat, 
in order that they may be promptly recognized, and such measures 
advised as are judicious to be employed until the arrival of the 
medical attendant. Any one ignorant of medical subjects and of 
the natural history of disease who meddles with powerful drugs is 
much more likely to do irreparable injury than temporary good. 
It is almost always “ hit or miss,” and the misses inevitably pre- 
ponderate ; not unfrequently they are the immediate precursors of 
fatal results. 
Enlarged Tonsils. 
[The tonsils consist of two rounded or ovoid bodies the size of 
a cherry, and are made up of connective tissue, holding together a 
number of glands which secrete a thick, glairy mucus, and have a 
number of openings upon the surface of the tonsil. They are 
situated on the sides of the throat between the folds of the palate. 388 
THE THROAT. 
(See Fig. 120.) They are often swollen in children and young per- 
sons, as a result, so it is thought, of a scrofulous constitution, and 
quite frequently on account of repeated attacks of sore throat.] 
A slight enlargement of the tonsils produces no unpleasant 
symptoms ; but when they are large enough to project some consid- 
erable distance into the free passage of the throat, they interfere 
with swallowing and sometimes with respiration. They push the 
soft palate away from the back part of the throat and produce a 
nasal twang of the voice, with the addition of a peculiar tone due 
to interference with proper articulation. Sometimes they are large 
enough to touch each other, and they then prevent a proper amount 
of air from entering the lungs, and compel the patient to maintain 
a certain position <of the neck, which renders him what is called 
round-shouldered.” When very large they have been known to 
produce suffocation. The liability of chronically enlarged tonsils to 
become inflamed is quite great, and such attacks are usually severe. 
Sometimes they become ulcerated. Sometimes the glands secrete 
a mucus, which cannot escape freely from the little orifices, and it 
undergoes a transformation into a cheesy material of very fetid 
character. These little masses are often spat out from time to 
time, and when crushed emit a very offensive odor. 
Treatment.—The treatment of enlarged tonsils usually demands 
the use of nutritious diet and often that of cod-liver oil to improve 
the general health. The best home treatment, when they are soft, 
is the application of ox-gall, either fresh or partly dried by evapo- 
ration, twice or thrice daily; the application being made by a 
finger of one hand while the fingers of the other hand support the 
neck outside so as to press the tonsil in both directions. Simple 
compression of this kind, without any local medication, applied 
several times a day, will sometimes promote the absorption of 
these bodies if the enlargement is soft and of recent standing. 
Gargles of water containing chlorate of potassium, alum, white- 
oak bark, or rhatany, are sometimes useful, and so is the local use 
of sprays, as recommended for chronic sore throat. [For the pro- 
portions of these, see the formulas at the end of the second vol- 
ume.] If the increase in size is very great (and these simple 
measures are not of any service after a few weeks’ trial), the ser- 
vices of a surgeon will become necessary to cut off a portion of 
the gland or reduce its size by the application of strong caustics. 
[Pigeon breast is also a result of considerably enlarged tonsils. 
When the diaphragm contracts during inspiration and the floor of 
the thorax is pulled downward, a vacuum tends to be made in the 
chest cavity, air rushes in to fill it from without, and the vacuum 
is prevented. If air is not admitted as rapidly as the vacuum de- THE THROAT. 
389 
mauds, the weight of atmospheric pressure on the flexible walls of 
the chest causes the ribs and cartilages to bend inward and assume 
the appearance characteristic of this deformity. Furthermore, 
the development of the chest is interfered with, and the lungs, 
especially about their upper portions, never acquire the capacity 
essential to health: and as the period during which development 
can take place is limited to youth, the person who has been allowed 
to suffer in the manner described remains deformed for life, and 
is especially liable, it is thought, to the development of consumption. 
Inflammation of the Tonsil—Quinsy Sore Throat. 
This is almost entirely a disease of temperate and changeable 
climates, is most common among persons between sixteen and 
thirty years of age, and is only rarely seen among children. It 
consists of an inflammation of the mucous membrane covering the 
tonsil or of the deeper portion of the glands, and either one or both 
tonsils may be affected, although it is more common that one alone 
is inflamed at a time. Persons who have a tendency to suffer 
from rheumatism are thought to be especially liable to this trouble. 
The most frequent exciting cause (where one can be recognized) 
is exposure to wet and cold, particularly during a north-east wind 
(in the Atlantic States). When atmospheric causes exist there 
will usually be a number of cases in the same community. 
Symptoms.—A chill usually occurs at the outset, followed by 
considerable fever, which is accompanied by aching of the muscles 
generally, “ as if they had been pounded.” There is headache and 
a pain in the throat on the side affected, and the pain will very 
probably be increased by movements of the jaw and efforts to 
swallow. On looking at the tonsil, it is seen to be red and swollen. 
As the disease progresses, the swelling and pain increase, until 
swallowing becomes difficult or almost impossible; while, to aggra- 
vate the trouble, the saliva is increased in quantity, and, rather than 
subject himself to the torture of swallowing, it is allowed by the 
patient to run from the mouth. In a well-marked case of quinsy 
the breath acquires a peculiar odor, quickly recognized when once 
smelled, and the voice becomes thick and muffled, so that the words 
can hardly be understood.] 
The swelling may be so great as to prevent closure of-the mouth, 
on the one hand, and as to impede respiration, on the other, so that 
the patient, for the time being, is in a deplorable condition. In 
cases of moderate severity the symptoms gradually abate; but in 
severe cases they continue until an abscess is formed, and when 
that is discharged spontaneously, or by the surgeon’s knife, the 390 
THE THEOAT. 
severity of the symptoms cease almost instantly, and complete 
recovery ensues in a few days. 
Treatment.—There is some danger in allowing an abscess in the 
tonsil to open of itself, as the pus 
may fall into the larynx, and pro- 
duce suffocation. In all cases, 
therefore, where the tonsil is in- 
flamed, medical aid should be 
promptly solicited. Meanwhile ice 
or iced water externally and inter- 
nally, a purging enema of salt and 
water, and rest in the recumbent 
posture, may be instituted at home 
until the arrival of the physician. 
[The inhalation of vapor from 
hot water will often give tempora- 
ry relief to some of the symptoms. 
The patient must not attempt 
to swallow solid food, but should 
take as freely as the pain of swal- 
lowing will permit, ice - cream, 
soups, gruels, iced milk, custard, 
etc. The prescription of stimu- 
lants had better be left to a physician. The use of guaiacum in 
doses of two grains of the powder, repeated every hour, will some- 
times put an end to an attack in its earliest stages.] 
Figure 120.—Enlarged tonsils and elon- 
gated uvula. 
Diphtheria. 
Diphtheria is a form of blood-poisoning, of which inflammation 
of the throat is but one symptom. It is often fatal; occurs at all 
seasons; is often common in certain localities where there is exces- 
sive ground-moisture from bad drainage; and attacks individuals 
of any age. 
It is due to a peculiar poisoning of the blood, the exact nature 
of which is unknown, but which is believed to be in great measure 
connected with poisonous emanations from defective sewerage. 
Young children who have been weaned from the breast are quite 
liable to it up to the age of ten or eleven years; after which the 
susceptibility declines, though it is never lost entirely. The chief 
manifestation, apart from general symptoms of sore throat, with a 
state of low fever, is the appearance of a peculiar membrane on 
some part of the throat, usually commencing on the tonsils, which 
in some cases may eventually cover the entire throat, the walls of THE THROAT. 
391 
the nasal passages, the larynx, wind-pipe, and bronchial tubes, 
and even other mucous membranes, as well as abraded portions of 
the skin. When the air-passages become involved, there is an 
additional danger from suffocation; but though many cases die 
from this cause, the greater number die exhausted by the debilitat- 
ing effects of the poison. There is a mild form of sore throat, not 
accompa'nied by low febrile symptoms, in which there also appears 
an exudation upon the throat. This is apt to be mistaken for 
diphtheria, but differs from it in there being no tendency to death 
from blood-poisoning. It is often very difficult for even a physi- 
cian to discriminate between the two affections at the outset; and 
hence the occurrence of sore throat with any evidence of a whitish 
or yellowish patch or streak about the tonsils or palate should 
always occasion sufficient alarm to send for medical advice at 
once, for if a mistake is made it may be fatal, inasmuch as severe 
cases of diphtheria are not likely to recover unless judiciously 
managed from the start. If there be languor, fever, sore throat, 
and patches in the throat, especially if there is swelling of the 
glands under the jaw on the side affected, it is quite likely that 
the case is diphtheria. 
Treatment.—A case of diphtheria should be isolated as far as 
practicable from every one but the necessary attendants, and no 
stuffed furniture or drapery should be permitted in the sick-room; 
for the disease is contagious, and the infecting matter is very apt 
to adhere to upholstery, carpets, and the like. The best thing to be 
done pending the advice of a physician, is to place the patient in a 
room of not less than 70° temperature, avoiding draughts, while 
securing free ventilation; and to encourage the patient to keep bits 
of ice in the mouth; to place cloths wrung out of iced water around 
the throat, and replace them every two or three minutes as they get 
warm, and to keep up a plentiful supply of good, strong soup, milk 
punch, and as liberal an allowance of well-cooked animal food as 
can be taken without disgust. There need be no hesitation in giv- 
ing brandy, whiskey, or rum, in small quantities, quite frequently, 
even every hour if the patient is getting weak, so long as there are 
no signs of approaching intoxication. If there are any such signs 
of its intoxicating influence, it is evidence that too much liquor is 
being given. It is useless to mention here any remedies to be used. 
In a malady so serious as diphtheria remedies are unsafe in unskil- 
ful hands. There is no remedy that will cure the disease, but such 
means will be used by the physician as will best keep up the pa- 
tient’s strength, promote his appetite, soothe his sufferings, and 
detach the membrane from the air-passages when they become 
involved. If the physician’s services cannot be promptly secured, 392 
THE THROAT. 
it is usually safe to administer chlorate of potassium (two grains 
to a child about one year of age, five grains to one of twelve, and 
ten to an adult) and tincture of the chloride of iron (five drops to a 
child of a year or two, ten drops to one over twelve, and twenty to 
an adult) in sweetened water made palatable by lemon-juice or 
lemon-syrup, every two or three hours. In bad cases, sleep should 
be disturbed to give the medicine. Sometimes the membranes in 
the air-passages threaten eventual destruction by suffocation, and 
it becomes necessary, as in croup, to avert this danger by making 
an artificial opening into the windpipe through which the patient 
can breathe; and if the deposits be not too extensive below this 
opening, it gives the patient a good chance to live longer, so that, if 
his strength and vitality are sufficient, he may pass through the 
remaining stages of the disease and recover; but the operation is 
not in itself curative. Active measures are still requisite, and 
extra attention is essential to take care that the artificial opening 
does not get clogged up with mucus or false membrane, and thus 
make matters worse than before. Sometimes the matters expec- 
torated accumulate in the mouth in dangerous quantity, and require 
to be removed by the fingers or the mop. This operation, often 
effective in children between two and twelve years of age (in 
whom the small size of the windpipe admits of less swelling of 
the lining membrane than is the case with a grown person), is 
rarely of any avail in the adult. 
Relaxation of the Palate—Elongated Uvula. 
This is a frequent ailment in persons subject to sore throat, the 
chief symptom being a frequent cough from titillation of the 
tongue, or of the valve on top of the larynx, by the tip of the uvula, 
especially while lying down. Many cases of chronic cough are 
due to this cause. (See Fig. 120.) 
The Treatment consists in cutting off a portion of the elongated 
uvula, and thus removing the source of the evil. Slight cases 
and ordinary relaxation of the palate can sometimes be cured by 
the frequent use of pellets of ice in the mouth, or by sucking alum, 
catechu, or borax. A long tapering uvula can rarely be relieved 
without an operation. 
Chronic Pharyngitis; Clergymen’s Sore Throat; Chronic Sore 
Throat. 
Clergymen are by no means the only individuals affected with 
chronic pharyngitis ; public speakers generally, teachers, actors, THE THROAT. 
393 
newsboys, salespeople—in fact, all persons who are compelled to 
use the voice a good deal in all weathers, are extremely liable to the 
affection. Chronic pharyngitis is characterized by increased red- 
ness of the various structures of the throat,—enlarged blood-vessels 
being visible on various portions of the surface, with a rough or 
raw appearance of the parts, and little groups of elevations here 
and there, due to enlargement of the glands which secrete the 
mucus that keeps the throat moist, pliable, and comfortable. There 
is more or less accumulation of viscid mucus, which is prone to 
adhere in strands or clumps to the raw surface. 
The Symptoms are chiefly those of annoying sensations of dis- 
comfort in the throat, with more or less hawking to free the throat 
from mucus. Sometimes, however, there is considerable pain and 
heat in the throat, and often more or less hoarseness from exten- 
sion of the disease into the larynx. (See Chronic Laryngitis.) There 
Figure 121.—Apparatus for making a spray by means of steam-pressure. (Codman & Shurt- 
lefFs apparatus.) 
Figure 122.—Apparatus for making a spray by means of air-pressure. 
Fig. 121. 
Fig. 122. 
is a good deal of apprehension on the part of the public that the 
disease in the throat may extend to the lungs and eventuate in 
consumption; but this does not take place unless the individual is 
predisposed to consumption, or acquires a disposition to it. When 
there is a predisposition to consumption, however, it is quite likely 
that it may be accelerated by this chronic sore throat. 
Treatment.—The disease is a chronic one, usually of long 
standing before it attracts much attention; and it is therefore 
one which requires a good deal of time in its treatment. The 
habitual use of weak gargles of alum, borax, and chlorate of 394 
THE THROAT. 
potash (five to ten grains to the ounce of water), is advisable; 
and it is well to use these solutions in the form of spray by 
means of the so-called atomizer (Figs. 121 and 122), which 
breaks the fluid up into a minute spray, and at the same time 
propels it with considerable force so that the remedy reaches a 
great many parts that cannot be reached by gargling. A care- 
ful attention to easily digested diet is also of great importance; 
while the bowels, kidneys, and skin should.be kept in as healthy 
a condition as possible. If this simple treatment does not suffice, 
the aid of the physician must be invoked to make local applica- 
tions of tincture of iodine, nitrate of silver, or other remedies. 
There is a great deal of prejudice against the use of nitrate of sil- 
ver, which is far the best agent in most cases; and this arises 
from the idea that it is to be used as a caustic to burn something 
away. This is not so. An application of nitrate of silver leaves 
an impermeable white coating on the parts, which protects them 
temporarily from the air and from impure saliva, and thus gives 
the parts beneath the coating a chance to get well. This is the 
whole secret. The application must be thoroughly made by a 
competent person, and need not be repeated until the coating falls 
off, which usually takes place in from one to three days. Two or 
three thorough applications a week, with a strong solution, or even 
with the solid nitrate of silver, will be much more effectual than 
daily pencillings with a weak solution. These applications should 
never be made by unskilful hands, or they will do harm instead 
of good. Hence no directions are given as to the strength of the 
solution and the manner of application. 
Internal remedies are incompetent to cure the disease, no matter 
how skilfully selected ; but they are almost always required to cor- 
rect some defect of nutrition, the continuance of which retards the 
cure ; and these remedies vary, of course, with each individual case. 
Public speakers must use the voice as little as possible during 
the treatment, and the use of tobacco and alcoholic beverages 
should be given up. It is not necessary to observe that absolute 
disuse of voice so essential to prompt recovery in inflammatory 
affections of the larynx itself, in which the vocal cords participate 
directly in the diseased process. 
Acute Laryngitis—Inflammation of the Larynx. 
This is an acute inflammation of the mucous membrane of the 
larynx, from cold or from local injury. It sometimes occurs in pa- 
tients affected with typhoid fever, small-pox, and other diseases ; 
it occurs from swallowing and inhaling hot or acrid substances ; THE THROAT. 
395 
but in the great majority of cases it is the result of abrupt expo- 
sure to excessive changes of temperature. The symptoms, though 
severe, are not threatening, and the inflammation is superficial. 
Still there is a liability to the sudden, or more or less prompt effu- 
sion of serum (fluid part of the blood) beneath the mucous mem- 
brane of certain portions of the larynx, producing a dropsy of the 
part, which may seriously interfere with respiration and even pro- 
duce suffocation if not promptly relieved by the knife of the sur- 
geon,—for medicines are of no avail in this critical condition. 
Whenever, therefore, in the course of a sore throat, any serious 
impediment to respiration takes place suddenly, or during the 
course of a few hours, a physician should be promptly summoned, 
or a fatal disaster, that could otherwise have been averted, may 
ensue from neglecting to do so. 
The Symptoms of laryngitis are pain in the deeper portion of 
the throat (often increased on pressure externally), hoarseness, 
brassy cough, difficulty or pain in swallowing, and some impedi- 
ment to respiration. 
The Treatment consists in maintaining absolute rest in the 
recumbent posture, disuse of the voice, unloading of the bowels 
by a dose of Epsom salt (one ounce for an adult) or other saline, 
and keeping them in a soluble condition, and the local use of ice 
externally and in the mouth. The diet should be fluid and muci- 
laginous, so as to be swallowed with the greatest ease, and acid 
drinks may be allowed if they do not hurt the parts. If the patient 
goes about his usual pursuits, he is liable to a serious and sudden 
increase of the inflammation, which may lead to suffocation before 
he can get medical assistance, and the danger of this complication 
exists in almost every case. An amount of inflammation which 
would be insignificant in any external part of the body, and devoid 
of immediate danger anywhere else, is a very serious affair in the 
narrow portion of the larynx, and apt to end in death by suffoca- 
tion. Most cases of laryngitis, therefore, demand the assiduous 
attention of a physician. If there is much fever, a small dose of 
Epsom salt (one teaspoonful for an adult) and tartar-emetic (one- 
eighth of a grain for an adult), or antimonial wine (a few drops) in 
water, may be taken at intervals of eight, six, or four hours, ac- 
cording to the urgency of the symptoms. 
Chronic Laryngitis—Chronic Inflammation of the Larynx. 
This disease is often the result of a succession of more or less 
acute attacks. Sometimes it is an extension of chronic inflamma- 
tion of the pharynx. (See page 392.) 396 
TIIE THROAT. 
Symptoms.—These are chiefly hoarseness, a brassy sort of 
cough, with or without a sense of pain deep down under the breast- 
bone, due, usually, to-extension of the disease to the windpipe, and, 
finally expectoration. The structures affected cannot be examined 
without the laryngoscope (see Fig. 117, p. 382), and when thus 
examined reveal the usual signs of chronic inflammation, redness, 
swelling, more or less mucus in the parts, and sometimes super- 
ficial ulcerations. There are no deep ulcerations in simple chronic 
laryngitis; but in that form of the disease attendant upon tubercu- 
lous consumption there is certain to be ulceration, often with more 
or less destruction of various tissues, even including the cartilages. 
The same remark holds good with regard to the chronic laryngitis 
of syphilis, and some other blood diseases. Simple chronic laryn- 
gitis, properly managed, is a curable disease (though otherwise 
likely to continue for years uncured) ; so is the chronic laryngitis 
of syphilis, provided the destruction of tissue has not proceeded so 
far as to be mechanically incompatible with life ; but the chronic 
laryngitis of tuberculous consumption is, in most instances, incu- 
rable, though, on the whole, consumptive patients with ulceration 
of the larynx are apt to live a year or two longer, on the average, 
than those in whom the disease does not involve this organ. From 
four to seven years may be said to be the average duration of life 
after the development of tuberculous inflammation in these cases. 
The Treatment of chronic laryngitis demands attention to the 
general health, in the first instance. Scrofulous and consumptive 
individuals need cod-liver oil; syphilitic patients require anti-syphi- 
litic treatment; those who are anaemic or pallid often (not always) 
require iron in some form, and so on, according to the defect or 
injury in the general condition. Local treatment by inhalation of 
medicated vapors, or sprays, or the application of fluid substances 
by means of brushes or swabs, is almost always indicated, and the 
Figure 123.—Sponge attached to a curved whalebone, called a probang, used for applying 
medicated fluids to the throat. 
choice of these must be left to the medical adviser, since much 
harm is done by the injudicious and promiscuous resort to these 
agents without competent advice. In severe cases, especially those 
of tuberculous ulceration, there is great difficulty in swallowing ; 
each effort producing an amount of distress that appears incredi- THE THROAT. 
397 
ble when detailed to those who have not witnessed it. The swal- 
lowing of a little sweet-oil, before each attempt at swallowing 
food, will often be of great service in such instances. Feeding by 
the bowel, for a few days, is often of great use in these cases, let- 
ting the throat rest from swallowing until it is better able to re- 
sume its functions. 
Great difficulty of respiration exists in many cases, and some- 
times threatens suffocation to such an extent as to demand an 
artificial opening into the windpipe. This operation, when timely 
performed, will often prolong life for months in tuberculous cases— 
occasionally for years. In syphilitic laryngitis this operation may 
really save the patient’s life; for the disease itself is not at all ne- 
cessarily fatal, as tuberculous disease is apt to be, and time will 
thereby be gained for the effect of remedies which improve the 
general condition of the system. 
Croup—Membranous Laryngitis; Hives. 
Croup is an inflammatory affection of the upper air-passages 
attended with the formation of a false membrane on the walls of 
the larynx and windpipe and even in the bronchial tubes, similar 
to that which is formed in diphtheria, with this difference: that 
there is no blood-poisoning in croup, and the main source of danger 
is from suffocation. Neither is there the debility in the earlier 
stages of croup that is present in diphtheria. The number of 
respirations keep their normal proportion to the beats of the pulse 
(about 1:4) for a long time, instead of soon losing in ratio, as is 
the case in diphtheria. The disease rarely attacks the adult, and 
is not contagious. The immediate exciting cause of croup in chil- 
dren is usually more or less sudden exposure to cold, as in taking 
a child from the bed to the window to see a procession, and so on. 
The vicious method in which silly parents keep their little children 
half-undressed, with neck and shoulders, and legs and knees, 
more or less exposed, is responsible for many deaths-a-cold by 
which the lives of their little ones are sacrificed at the shrine of 
vanity. 
Symptoms.—Croup usually commences in a cold with the ordi- 
nary symptoms, but in a few days, sometimes in twenty-four 
hours, there is difficulty of breathing with more or less impair- 
ment of voice. Some cases of croup are attended by spasm of the 
air-passage, but not nearly so frequently as is generally supposed, 
many cases being entirely without it. The hoarseness usually 
attracts attention at night or toward morning, for the first time ; 
and at the same time there is a harsh, brassy sounding cough 398 
THE THROAT. 
likened to the sound of a cock’s crow. After a while the cough 
gets hoarse like the voice, and then, often, both become gradually 
muffled, so that they do not attract attention when the child is not 
watched. When the membrane is on the vocal cords, the voice and 
cough will hardly be audible. There is a shrill sound in drawing in 
the breath, and the hollow of the neck just above the breast-bone 
will be seen to become deeper at each inspiration. As the case gets 
worse, the soft parts below and between the ribs will also be seen 
to sink in during inspiration. These phenomena are mechanical 
altogether. Sufficient air to fill the lungs cannot be forced through 
the narrowed air-passages; and hence, as the ribs are raised by the 
action of the chest muscles, the atmospheric air outside presses 
the soft parts inward. When the air-passages are similarly im- 
plicated in diphtheria, the same mechanical phenomena take place 
from the same physical cause. Many cases of croup cannot be 
distinguished from diphtheria. Indeed, some physicians believe 
the two to be identical in character; while others (whose views 
seem most reliable in the writer’s estima- 
tion) contend that there is no element of 
blood-poisoning in croup. To ward off the 
threatened suffocation, the same operation 
is often required as in diphtheria when 
the larynx and windpipe are involved ; 
but the chances of success are infinitely 
better in croup, because there is no special 
blood-poisoning to counteract. 
When a child has the difficulty of breath- 
ing just described, an atmosphere of steam 
from boiling clothes in a boiler, or some 
other means, as a croup-kettle (Fig. 124), 
for instance, or some extemporaneous 
substitute for it, as it is rarely to be had 
when required, should be maintained near 
it, to keep the deposits moist and loose, so that they can be coughed 
out. Raising the clothes now and then out of the vessel diffuses 
an atmosphere of steam about, just as is seen in the laundry or 
kitchen. Slacking lime in the room near the patient is a good 
Figure 124.—Croup-kettle.* 
* [In having this made by a tinsmith, the lamp should be provided with three or four 
wicks, instead of a single one, and the tube for conveying the steam should be longer, 
and made double, that is, with an outer tube somewhat larger than the inner one and so 
constructed that an air-space of about half an inch will intervene. This will serve as a 
non-conductor of heat and prevent the steam condensing to water before it reaches the 
interior of the crib. The funnel in the top is closed with an ordinary cork and admits 
of the introduction of hot water without disturbing the steam-pipe.] THE THROAT. 
399 
method of getting up a vapor of steam ; besides which there is a 
certain amount of mechanical benefit from the minute particles of 
lime held in suspension in the vapor, which assists in detaching 
the membranes from the air-tubes. An occasional vomit of mus- 
tard and water, a tablespoonful to the half-pint, or of equal parts 
of alum and molasses in tablespoonful doses, is advisable in most 
instances, pending the arrival of the physician who should be sum- 
moned at the first moment of alarm. Very few physicians will 
blame a parent for instituting the measures just recommended 
before he reaches the bedside. Anything more active is hardly 
safe in unprofessional hands, unless it be the rubbing of the throat 
and chest with a lotion of turpentine and sweet-oil (half and half), 
the turpentine liniment of the apothecary shops [or that described 
in the chapter of Formulas]. 
Should the case be urgent and no medical aid be at command, 
more active measures may be resorted to to induce vomiting, if 
those mentioned are insufficient. The vomiting is very necessary 
in order to excite involuntary expectoration in young children, 
whose air-passages are rather tolerant of accumulating products, 
and who cannot be taught to make voluntary efforts at cough and 
expectoration. In larger children this necessity for the emetic is 
not so urgent, and sometimes is entirely wanting. In the action of 
an emetic there is a perspiration, so to speak, excited in the inte- 
rior of the air-passage, similar to the visible perspiration in the 
skin so often accompanying this act. This loosens and detaches 
the membrane and excites the paroxysms of cough by which it is 
expelled. Before there is any membrane it is worse than useless 
to vomit the child ; it may be injured and so reduced by it—for all 
emetics are weakening—that it will not have strength to withstand 
this treatment when the time comes for its judicious administra- 
tion. On account of this debilitating tendency, tartar-emetic, or 
antimonial wine, sulphate of mercury (turpeth mineral), or sul- 
phate of copper, should never be used to vomit a young child ex- 
cept by the advice of a competent attendant who knows what he 
is about, and usually has some special reason for resorting to these 
measures. Syrup of ipecac (one teaspoonful to a child about a 
year of age, and a tablespoonful to one of twelve years) may be 
used instead, and repeated, if it does not operate, every ten minutes 
for two or three doses and no more; for, if the emetic fail to vomit 
and be retained in the stomach, it not only is liable to produce 
injurious effects at the time, but will do so afterward if the child 
gets better and stronger, when the stomach and intestines, resum- 
ing their functions, absorb, to their detriment, the drugs that lay 
inert, like a drug in a box, while these organs remain too de- 400 
THE TIIROAT. 
pressed to absorb them. Tickling the back part of the throat with 
a feather, or passing the forefinger down the gullet, is sometimes 
successful mechanically even when drugs fail, and should be re- 
sorted to in preference to powerful drugs, if simple emetics like the 
mustard or alum fail to effect their purpose. But, before any emetic 
is used, it must be certain that there is an indication for it. This 
is surmised by the rattling in the windpipe beneath the breastbone, 
and the difficulty in breathing freely. The emetic may be repeated 
every six or four hours with young children, and on a return of 
symptoms with children of a few years of age. If the bowels have 
not been moved recently, a dose of castor-oil or of magnesia suffi- 
cient to produce a loose stool should be employed. The diet of a 
young child should be milk only ; but eggs, light meat-broths, and 
a moderate amount of farinaceous food (corn-starch, arrow-root, 
tapioca, farina, and so on) may be given to a child of two years of 
age or more. If the child is weak, a dose of quinia (half a grain 
to two grains to a child under two years, and three to four grains 
to one from four to six years or more) may be given and be repeated 
at intervals of six or eight hours ; or the tincture of chloride of 
iron may be given (two drops to a child under one year, three to 
five drops to one from two to three, and ten drops to one of ten or 
twelve) at intervals of four or six hours. If there is much evi- 
dence of inflammation in the throat, the neck may be enveloped 
in a wet poultice of raw cotton or spongio-piline, which is to be 
covered with a layer of oiled silk or oiled paper, to retard evapora- 
tion and keep up the moisture. 
When the voice and cough become muffled, showing the for- 
mation of membrane, the temperature of the apartment is to be 
elevated to 85° or 90°, and the atmosphere is to be kept more copi- 
ously loaded with steam to keep the products soft and easy of 
expectoration. If the methods already narrated are insufficient, 
wet cloths may be hung around the bed or crib, and be changed 
from time to time. A wash-boiler may be brought to the bedside 
and the immersion and withdrawal of towels be kept up. A large 
tin-pan of water may be placed on a portable stove near the patient 
and kept boiling, the vapor being directed over the mouth by means 
of large sheets of stiff paper, or some other contrivance. Care must 
be taken to keep up this evolution of steam without cessation. 
The air of the bedroom should be kept ventilated by an open win- 
dow in an adjoining room or stairway, a screen formed by a sheet 
hung over a line being placed in front of the door of communica- 
tion, or around the bed or crib, to protect the patient from draught. 
If the room is large, the bed may be brought close to ‘the stove, 
with sheets hung around it so as to retain the steam in its vicinity. 401 
THE THROAT. 
The writer knows of no treatment more efficacious than the steam- 
ing in this stage. 
When respiration becomes difficult from accumulation of mem- 
brane in the air-passages, small pieces of lime should be slacked 
by the side of the bed, in any convenient vessel, and the fumes that 
rise from it be directed toward the mouth of the patient by a fun- 
nel-shaped cone of stiff wrapping-paper, or a stiff paper bag (such 
as a flour-bag) with one corner cut off, and inverted over the ves- 
sel. The patient must not be brought too near the hot vapor, and 
the attendant in charge should protect the eyes by the hand or by 
a cloth. This should be kept up for ten or fifteen minutes at a 
time and be repeated every half-hour, hour, or at longer intervals, 
according to circumstances, the indication for its removal being 
increased difficulty in respiration. It excites cough and the extri- 
cation of quantities of the false membrane. 
This treatment by steaming and lime is apt to produce capillary 
bronchitis and even inflammation of the lungs, which require 
attention subsequently, but it often succeeds in overcoming the 
fatal effects of the croup when nothing else will do so. Care must 
be taken to avoid exposure after treatment of this kind, and the 
withdrawal of the steam and diminution of the temperature should 
be accomplished gradually after they have become no longer requi- 
site. When the writer has been asked professionally how it will 
be known when the ebullition of steam is sufficient in bad cases, 
he has been accustomed to reply, “ When the wall-paper gets loose 
from the walls.” 
During all this time care must be taken to sustain the child by 
food, stimulating it, if requisite, by the free use of alcoholic liquor 
in some form. 
[Owing to the prompt relief which often follows the thorough 
inhalation of steam or vapor, and the difficulty which may some- 
times be met with at night and in a cool room in filling the air 
with the necessary amount of vapor, the following plan may be 
found serviceable: 
The child being put into a crib or cradle, if it is not already in 
one, it should be covered with a heavy blanket or quilt supported 
on chairs, or the ends of the crib, if they are high, or upon barrel- 
hoops fastened to the head and foot, so as to form an enclosed air- 
space. 
If a gas-stove or kerosene-stove is at hand, a tea-kettle partly 
filled with water may be put on it and arranged at the side of the 
crib so as to be covered by the blanket. Some person should sit 
constantly by the crib, with the head under the covering, to pre- 
vent the child being alarmed by the procedure, to regulate the 402 
TIIE THROAT. 
amount of steam, guard against the clothing taking fire from the 
stove, and prevent the limbs of the child being scalded by coming 
too closely in contact with the escaping steam. 
Where a portable stove of the kind mentioned is not obtainable, 
a large dish, such as is used in making cake, can be partly filled 
Figure 125.—Arrangement of a crib with blankets for using a croup-kettle. 
with boiling water and will give off steam for several minutes. 
By heating smoothing-irons, or pieces of brick, and immersing them 
gradually into the water in the bowl, an abundance of steam can 
be formed. Lime can also be slacked in a dish so arranged with- 
out the necessity of filling the entire room with its vapor. 
Another method of limiting the space to be filled with vapor is 
to choose a corner of the room into which the crib can be put, and 
a blanket hung across so as to form a curtain.] 
The remarks concerning tracheotomy in diphtheria (p. 392) are 
equally applicable to croup. 
Spasm of the Larynx—False Croup. 
Spasm of the larynx is not an infrequent disease of young chil- 
dren, and is often mistaken for croup. It is a nervous affection, due 
to what is known as £ ‘ reflex irritation. ” The exciting cause may be 
indigestion (especially during teething), worms, earache, or run- THE THROAT. 
403 
ning ears, elongated fore-skin, glandular swellings anywhere, rick- 
ets, or scrofula. There is no special impairment of general health. 
There is a sudden attack of difficult breathing, with a peculiar strid- 
ulous or crowing noise in the throat, and after the spasm has lasted 
a few seconds or a minute, it usually gives way, and then there is 
no more evidence of disease than before. The voice is good; there 
is little or no sore throat. The larynx becomes spasmodically 
closed in the paroxysm, and if it does not let up in a minute or so, 
death from suffocation may result. This result is rare, but does 
occur now and then. These attacks are more frequent at night, but 
take place in the daytime also, and may recur several times in the 
twenty-four hours, or at longer and irregular intervals. The dis- 
ease also occurs in adults, and is a reflex manifestion due to dis- 
eased conditions elsewhere, the same in nature, though not always 
the same in kind, as in the child. Though the disease is compara- 
tively rare in the adult, it is, perhaps, even more proportionately 
fatal. 
The Treatment of this disease during the suffocative spasm 
consists in dashing cold water on the face and chest, in holding 
ammonia near the nose, the use of one of the emetics recommended 
in the foregoing section, and immersion in a warm bath, if acces- 
sible. In a child subject to these spasms, a warm bath should al- 
ways be at command. In the intervals, such general treatment is 
required as the nature of the case demands. Swollen gums should 
be scarified, the bowels should be kept in good condition, running 
ears should be kept well syringed, and so on. In addition to this, 
cod-liver oil or extract of malt are often of great value, with warm 
clothing, avoidance of draughts of air, and of all measures calcu- 
lated to alarm or excite the child. Bromide of potassium and bel- 
ladonna are the drugs most frequently serviceable to counteract 
the tendency to spasm, but they must be given in accordance with 
the direction of an attending physician. 
Aphonia—Loss of Voice. 
Aphonia, or loss of voice, without any other evidence of dis- 
ease, is usually a nervous complaint, due to paralysis of the vocal 
cords, as a reflex result of disease elsewhere. It usually occurs in 
females, and most frequently in hysterical individuals. Some- 
times it persists for weeks or months, occasionally for years ; but 
in most instances the voice comes and goes at irregular intervals 
of a few days or a few weeks. 
Aphonia is sometimes due to tumors of various kinds in the 
head, neck, and chest, compressing the nerves that are necessary 404 
THE THROAT. 
for the muscular movements of the voice ; and in these instances 
the paralysis is usually unilateral. Loss of voice also accompanies 
some cases of inflammation of the larynx ; and sometimes is due 
to the presence of warts or other morbid growths which prevent 
the vocal cords from being properly approximated. A laryngo- 
scopic examination is usually necessary to determine the nature 
of the aphonia. 
Treatment.—Simple nervous aphonia is usually cured promptly 
by the passage of a current of electricity through the vocal cords. 
Sometimes an acrid inhalation will restore the voice by inducing, 
for the moment, spasm of the cords, thus overcoming the paraly- 
sis. The passage of a sponge into the larynx will often do the 
same thing. Sometimes it can be accomplished by the action of a 
smart emetic. The use of a tonic, such as quinia, or cinchonidia 
(which is much cheaper and just as efficacious), in doses of from 
three to ten grains in the twenty-four hours, is often serviceable. 
Aphonia from inflammation of the larynx will pass off with the 
inflammation. Aphonia from disease of the brain, neck, or chest, 
requires treatment for the original disease, all merely local treat- 
ment being injurious. Aphonia from tumors in the larynx requires 
the removal or destruction of such growths. Reflex aphonia re- 
quires treatment of the organ from which the reflex paralysis 
originates (womb, bowels, spinal cord, etc.). 
J. SOLIS COHEN, M.D. Diseases of the Respiratory 
Organs. 
BY 
ALFRED L. LOOMIS, M.D., 
OF NEW YORK CITY, 
PROFESSOR OF PATHOLOGY AND PRACTICE OF MEDICINE IN TnE UNIVERSITY OF THE CITY OF 
NEW YORK ; VISITING PHYSICIAN TO BELLEVUE AND MOUNT SINAI HOSPITALS ; 
CONSULTING PHYSICIAN TO CHARITY HOSPITAL, ETC., ETC. DISEASES OF THE RESPIRATORY 
ORGANS. 
Bronchitis. 
This disease is sometimes called bronchial catarrh. It may be 
acute or chronic. In character it may be mild or severe ; may in- 
volve only the larger bronchial tubes, or it may extend into those 
of small size. When the smaller tubes are involved, the disease 
is called capillary bronchitis. Bronchitis rarely originates in the 
bronchial tubes, but is the extension of a catarrhal process which 
has affected the mucous membrane of the nasal passages, the back 
part of the throat, and the upper part of the windpipe (the larynx). 
Causes.—There are certain conditions which predispose or pre- 
pare a person for an attack of acute bronchial catarrh; such as 
infancy, old age, indulgence in anything which debilitates, breath- 
ing impure air in badly ventilated apartments, and sudden changes 
of temperature. When the body is improperly protected, the ac- 
tion of cold upon the surface very frequently causes a chilling 
which is followed by an attack of bronchitis. 
Bronchitis may prevail epidemically, when it is produced by 
some unknown atmospheric influence, such as is present when in- 
fluenza prevails. It may also be developed as an element of 
measles and the infectious fevers, as well as in connection with all 
those diseases which are due to blood-poisoning, as rheumatism, 
gout, etc. It occurs quite frequently in connection with chronic 
heart disease and during the course of the different chronic dis- 
eases of the respiratory organs. It may also be produced by the 
inhalation of irritating gases, vapors, and particles of dust, such 
as millers, bakers, stone-cutters, and grain-heavers are exposed 
to ; these act directly upon the mucous membrane, and by me- 
chanical irritation cause congestion and inflammation. 
Symptoms.—A simple form of bronchitis, or bronchial catarrh, 
is a “ common cold.” In this form, only the windpipe and the 
first and second divisions of the bronchi are affected. It usually 
comes on with chilliness, more or less sore throat, hoarseness, and 
an uncomfortable feeling over the eyebrows, a copious flow of 
tears, and a watery discharge from the nose. The common form 
for expressing this condition in an individual is, “he has caught 408 
DISEASES OF TIIE RESPIRATORY ORGANS. 
cold and is all stuffed up.” There is aching of the back and limbs 
and a slight febrile excitement. In young and weakly children 
convulsions may occur. As the disease advances and extends into 
the bronchi, more or less pain and discomfort is felt across the 
upper portion of the chest, with a sense of rawness and soreness, 
particularly behind the breast-bone ; this becomes more painful 
after coughing, not unfrequently there is a sensation of tightness. 
The respirations are increased in frequency, and become some- 
what labored. The cough is the most noticeable and the most im- 
portant symptom. At first it is harsh without expectoration ; 
sometimes it is incessant, occasionally it is paroxysmal. The 
cough is usually most troublesome when the individual lies down, 
or when he wakes from a long sleep ; sometimes he coughs and 
coughs, until he is quite exhausted. 
At first, the expectoration is watery, then, as the cough be- 
comes loose, it is frothy and more abundant, gradually it be- 
comes opaque and has a yellowish color, and finally becomes a 
thick, yellow, gelatinous mass. The individual is generally re- 
lieved as the expectoration becomes profuse. This acute catarrh 
may last no longer than two or three days, or it may continue two 
or three weeks. Usually it terminates in complete recovery. This 
form of bronchitis does not destroy life unless it occurs in very 
young children. When it becomes chronic it usually extends in- 
to the bronchial tubes. 
Treatment.—If an ordinarily healthy person takes cold, and 
has a simple attack of bronchitis, it can generally be arrested by 
a warm bath at bed-time, followed by the administration of eight 
or ten grains of Dover’s powder. The following morning he 
should take some saline cathartic (such as Epsom salt) or a full 
dose of castor oil; the latter is preferable in the treatment of chil- 
dren. 
Sometimes three tablespoonfuls of whiskey in a tumbler of hot 
lemonade taken at bed-time will accomplish the desired result. A 
person should remain in a warm, equable temperature for a day or 
two after resorting to this plan of treatment. If it has proved un- 
successful, or has not been resorted to, and the disease has pro- 
gressed so that a person has a cough, with a sense of rawness and 
tightness across the upper portion of the chest, with perhaps some 
chilliness and more or less aching in the limbs, induce profuse 
perspiration, apply mustard paste across the upper portion of the 
chest, administer a saline purge, and let him drink freely of some 
saline water (such as Vichy water). If the unfavorable symptoms 
continue after these means have been employed, send for a phy- 
sician. DISEASES OF THE RESPIRATORY ORGANS. 
409 
Especially be on the watch as regards very old persons and 
young children, whenever their breathing becomes labored, and 
the respirations are increased in frequency. If the pulse reaches 
100 beats per minute, and the temperature, as indicated by the 
thermometer in the arm-pit, registers 102° Fahr., it is important 
that you should immediately consult a physician. 
Acute Capillary Bronchitis. 
A bronchitis is called capillary when the inflammation has in- 
vaded the small bronchial tubes. In the majority of cases, this 
form of bronchitis is an extension of the bronchial catarrh from the 
larger to the smaller tubes ; occasionally the bronchial inflamma- 
tion begins in the small tubes. 
Capillary bronchitis is met with most frequently during infancy 
and old age ; occurring at any other period it complicates some 
disease which has already placed the individual under the care of 
a physician. 
Causes.—Capillary bronchitis and simple bronchitis are the re- 
sults of similar causes. There is great danger that simple may 
become capillary bronchitis; especially is this true when it com- 
plicates measles, whooping-cough, or some of the chronic maladies, 
such as Bright’s disease of the kidneys, etc. 
Symptoms.—The most marked symptom of capillary bron- 
chitis, whether it is a sequence of simple bronchitis, or a compli- 
cation of measles or any chronic disease, is frequent and labored 
respiration. An individual suffering from this form of bronchitis 
may have sixty or seventy respirations per minute and be unable 
to lie down on account of shortness of breath. Great muscular 
effort will attend each respiratory act. The face will be flushed 
and anxious. The pulse will reach 130 or 140 per minute, and the 
body temperature may rise to 103° F. In some cases the tempera- 
ture may be below normal and the pulse may be exceedingly 
frequent and feeble, evidencing extreme exhaustion. At its 
commencement the individual will have a short, hacking cough, 
sometimes paroxysmal in character. At first the expectoration 
is scanty, then thick and tenacious ; in severe cases it is accom- 
panied by a rattling sound. After a time the lips and also the tips 
of the fingers become blue, the veins in the neck become turgid, 
the breathing becomes more and more labored, and, as the patient 
shows signs of exhaustion, frequently a profuse, frothy, watery 
expectoration comes on, which affords no relief to the sufferer. 
Soon signs of suffocation are present, the body becomes covered 
with a clammy sweat, the pulse becomes small, the respiratory 410 
DISEASES OF THE RESPIRATORY ORGANS. 
efforts are more and more feeble, cough and expectoration cease, 
and death occurs from suffocation. General capillary bronchitis 
is a grave disease; especially is it fatal when occurring in infancy 
or old age. 
Treatment.—The principal thing to be accomplished in the 
treatment of this affection is to sustain life until the inflammatory 
process has passed through its different stages. 
Whenever the prominent symptoms of the disease begin to be 
developed, the aid of a physician should be immediately sought. 
If they come on suddenly, and some hours may elapse before the 
physician can reach the individual, the following measures should 
at once be resorted to. Keep the temperature of the room at 70° 
Fahr., and keep the air about the person moist with steam. Give 
him a warm bath, or wrap about him a flannel blanket wet in hot 
water, then cover the body with a dry blanket. The air may be 
rendered moist by dropping heated bricks into buckets of water 
placed around the individual. If the face becomes blue, and th® 
pulse feeble, stimulants may be freely administered. 
Under no circumstances should opiates be administered to per- 
sons with capillary bronchitis. 
Membranous Bronchitis. 
This is a rare form of bronchitis. It may run an acute or 
chronic course. It occurs most frequently in young adults, and 
is more common among females than among males. It is charac- 
terized by a membranous exudation upon the surface of the lining 
membrane of the bronchial tubes. This exudation may be in the 
form of a hollow or cylindrical cast. The former usually occurs 
in the large tubes, the latter in the tubes of small size. In some 
cases the exudation so completely lines and fills the bronchial 
tubes, that casts of the tubes of the size of a small thread are ex- 
pectorated. Usually these casts are of a dull, white color. 
Cause.—The cause of this form of bronchitis is by no means 
certain. 
Symptoms.—There are no symptoms of obstruction in the wind- 
pipe such as are met with in croup. 
In the acute form, the expectoration of the exudation-casts is 
preceded by the symptoms of an ordinary acute catarrh. When 
the disease is fully developed, there is fever, difficult breathing, a 
dry, hoarse cough, and a sense of constriction and oppression 
across the chest. After violent coughing the membranous exuda- 
tion is spat out, and its presence in the expectoration determines 
the nature of the bronchitis. DISEASES OF THE RESPIRATORY ORGANS. 
411 
Symptoms of the chronic form of this trouble are never con- 
tinuous ; there are paroxysms of disease and intervals when the 
patient is apparently perfectly free from the malady. During vio- 
lent fits of coughing, fragments of exudation or casts of the tubes 
are expelled. As soon as this occurs the patient is relieved until 
another membranous exudation takes place, the removal of which 
gives rise to similar phenomena. In some cases scarcely any 
symptoms are present except the cough and membranous expecto- 
ration. There are exceptional cases in which the detachment and 
expulsion of the casts takes place during sleep. 
A single attack of this disease rarely occurs. An individual 
having once suffered from membranous bronchitis will probably 
have repeated attacks of it. The acute form is generally followed 
by serious results ; the chronic form rarely terminates fatally, but 
in most cases is never completely recovered from, and frequently 
leads to the development of consumption. 
Treatment.—There is no known remedy or plan of treatment 
which insures recovery. During the paroxysms the patient should 
be kept in a warm, equable temperature, and steam inhalations 
should at once be resorted to and continued until the paroxysm is 
relieved. During the intervals, exposure to all sources of bron- 
chial irritation, such as inhalation of dust and irritating gases, 
should be carefully avoided, and the general health of the individ- 
ual should be cared for. 
In chronic membranous bronchitis, a physician’s advice in re- 
gard to the general hygiene of the patient during the intervals is 
of great importance. 
Chronic Bronchitis. 
This disease may occur during childhood, but it is essentially a 
malady of adult life. One of its leading features is its tendency to 
recurrence ; the attacks increasing in severity and duration, until 
the individual is rarely free from some manifestation of the dis- 
ease. 
Cause.—Chronic bronchitis may be the sequence of some other 
affection, or it may follow an acute bronchitis. Very rarely is 
it developed in consequence of exposure without some special 
predisposition, such as long-continued irritation of the bronchial 
membrane, constitutional tendency, or some previously existing 
organic disease. In the case of stone-cutters, knife-grinders, coal- 
miners, operatives in factories, etc., the inhalation of some me- 
chanical irritant may affect the bronchial tubes for many years, 
and yet the individual may have scarcely any noticeable bronchial 412 
DISEASES OF THE RESPIRATORY ORGANS. 
symptoms, until an exposure to wet and cold results in acute 
bronchitis ; this will be followed by a catarrh which may remain 
during life, and the disease known as stone-cutter’s, or knife- 
grinder’s consumption will be developed. 
The continued inhalation of impure air, such as is met with 
in badly ventilated apartments, crowded assemblies, etc., predis- 
poses the individual to attacks of bronchitis which may become 
chronic. 
An hereditary or acquired tendency to gout often manifests 
itself in a form of chronic bronchitis. Frequently, in the same 
individual, attacks of bronchitis and gout alternate ; occasionally, 
also, is chronic bronchitis developed in connection with some skin 
disease. When one is active, the other disappears. 
Diseases of the heart predispose to bronchitis, and when bron- 
chitis occurs under such conditions, its course is protracted and the 
danger increased. 
Chronic alcoholism (the prolonged and excessive use of alco- 
holic stimulants) is often a cause of chronic bronchitis. 
There is a condition of the lungs which very strongly favors 
the development of chronic bronchitis, viz., dilatation of the air- 
cells (pulmonary emphysema). Indeed, when emphysema exists, 
it is almost invariably accompanied by chronic bronchitis. 
Symptoms.—The symptoms of this disease vary with the cir- 
cumstances under which it is developed. Cough and expectora- 
tion are present in nearly every case. The peculiarity of the 
cough, the quantity and quality of the matter expectorated, de- 
termine, to a great extent, the character and severity of the bron- 
chitis. 
In the mildest form of chronic bronchitis, the cough is not se- 
vere, the expectoration is small in quantity, and whitish or yellow 
in color. At first, it comes on in the autumn and winter, and dis- 
appears or is mitigated in the summer, except as it is affected by 
cold, damp weather. When this form of bronchial catarrh has 
existed for some time, the cough becomes more violent and con- 
stant, and on rising in the morning, the individual coughs for an 
hour, or even a longer time, and expectorates. The matter ex- 
pectorated is either scanty and tenacious, or thin, semi-transpar- 
ent, and abundant ; sometimes the matter is so sticky that it 
is with difficulty expelled. It varies in color from a light yellow 
to a dark green. The odor of the expectoration is sometimes 
sweet and nauseous, at other times the stench is almost intoler- 
able. The foetor is due to decomposition of secretion which has 
collected in dilated portions of the bronchial tubes. Cases in 
which this fetid odor is present are known as fetid bronchitis. 413 
DISEASES OF THE RESPIRATORY ORGANS. 
The excessive use of alcoholic stimulants is the predisposing* 
cause. 
There is another variety of chronic bronchitis, which has re- 
ceived the name of dry catarrh. In this form, the expectoration 
usually appears in small, rounded masses of semi-transparent, 
tough mucus. Dry catarrh is commonly met with in persons suf- 
fering from gout, dilatation of the air-cells of the lung (pulmo- 
nary emphysema), and in those whose occupation compels them to 
inhale irritating substances, such as dust from mills, marble and 
stone yards, etc. 
If chronic bronchitis accompanies chronic disease of the heart, 
the cough is usually paroxysmal—often violent. In most cases, 
when the paroxysm of coughing comes on, there is a flux from the 
bronchial tubes, and within twenty-four hours the patient may ex- 
pectorate three or four pints of watery, semi-transparent, ropy, or 
gelatinous material, resembling the white of an egg mixed with 
water. In every variety of chronic bronchitis labored and difficult 
respiration is a prominent symptom, yet the respirations may not 
be so frequent as in some other pulmonary affections. 
Ordinarily, in chronic bronchitis, the pulse is not more fre- 
quent, neither is the temperature higher than normal (98£° Fahr.). 
In those cases in which the expectoration is fetid, the tempera- 
ture is elevated one or two degrees. Persons suffering from 
chronic bronchitis, no matter what form of the affection they 
have, become exhausted on slight physical exertion, and are very 
susceptible to changes of temperature. 
This disease seldom, if ever, directly destroys life, and yet, when 
developed in a person past middle life, is rarely entirely recovered 
from. There are many persons who have coughed and expecto- 
rated for twenty or thirty years ; whose shoulders have become 
rounded, and whose chest-expansion has become greatly dimin- 
ished, who are otherwise comparatively healthy. They have suf- 
fered great annoyance, yet their lives have not apparently been 
shortened by the disease. A casual observer might suppose from 
the appearance of such individuals, that they were suffering from 
consumption. Many of the so-called wonderful cures of consump- 
tion of many years’ standing are merely partial recoveries from 
chronic bronchitis. 
Treatment.—In order to treat chronic bronchitis successfully 
or judiciously, the peculiarities of each case must be carefully 
studied. Cough is one of its most prominent and troublesome 
symptoms, yet the cough is not to be treated as though it were 
the disease. If we do this no permanent relief will be obtained. 
In the majority of instances the disease is due either to vitiated 414 
DISEASES OF THE RESPIRATORY ORGANS. 
air, or some previously existing malady. If the cause can be ascer- 
tained, if possible let it be at once removed. For example, if it de- 
pends upon the irritation produced by inhalation of particles of 
dust, such as float in the air of woollen mills, flouring mills, baker- 
ies, grain elevators, etc., at once remove the patient from such 
exposure if possible. Such a patient must avoid sudden changes 
of temperature. The surface of the body must be protected by 
flannel—covering the chest is not sufficient; and the flannel must 
be worn throughout the entire year. The feet must be kept warm 
and dry. The danger of developing bronchitis by wearing damp 
shoes or boots after active exercise is not fully appreciated. Night 
air should be avoided. 
The climate best adapted to all forms of bronchitis is one with 
a moderately warm and dry atmosphere, in a moderately high 
altitude and protected from cold winds. If a person with chronic 
bronchitis cannot remove to a favorable climate, he should avoid 
exposure during bad weather and remain in a well-ventilated 
apartment, with a temperature varying from 65° to 70° Fahr. 
The opinion has come to be quite common that the temperature 
of sleeping apartments should be several degrees lower than that 
of the rooms occupied during the day. The necessity of free ven- 
tilation in sleeping apartments cannot be too strongly urged; 
yet, one can hardly understand how a sudden transition from a 
warm sitting-room to a cold sleeping apartment can be beneficial, 
when under other circumstances it is harmful. I am positive 
that the sleeping rooms of persons with chronic bronchitis and 
those which they occupy during the day, should be of the same 
temperature. The diet of those suffering with chronic bronchitis 
should be of the most nutritious articles, but they should never be 
taken in large quantities at any one time. 
The question is often asked whether stimulants are beneficial 
in chronic bronchitis. This question cannot be answered without 
some qualifications. Unquestionably, in the majority, yet not in 
all cases, the moderate use of stimulants will prove beneficial; 
a glass of claret wine or cider, taken at dinner, will be of ser- 
vice. 
A tonic plan of treatment is generally indicated. If the indi- 
vidual is anaemic—that is, pale, and feeble—and suffers from palpi- 
tation of the heart, some preparation of iron is indicated ; tincture 
of iron is the one I usually employ. This may be taken, ten drops 
at a time, in a tablespoonful of some bitter infusion, like that of 
columbo, quassia, gentian, or wild-cherry bark. etc. Any of these 
infusions may be made by steeping half an ounce of the bruised 
root or bark in a pint of water. DISEASES OF THE RESPIRATORY ORGANS. 
415 
As has already been stated, the peculiarities of each case should 
be carefully noticed. If chronic bronchitis accompanies gout or 
rheumatism, colchicum and alkalies will be found beneficial in its 
treatment. For the gouty condition, twenty drops of the wine of 
colchicum in water may be taken three times each day. For 
rheumatism, the bicarbonate of soda is as good an alkali as can be 
taken, five to ten grains at a dose, three times each day. Its use 
should not be continued more than four or five days at any one 
time. 
If the bowels are inclined to constipation, a teaspoonful of Ro- 
chelle salt in one-lialf tumbler of water may be taken before break- 
fast. If chronic bronchitis accompanies chronic heart disease, in 
its treatment we should aim to relieve the heart. 
Persons with chronic bronchitis are generally endeavoring to 
relieve symptoms ; they seek for something which will cure their 
cough and diminish expectoration. They are very likely to make a 
trial of the different patented medicines which are advertised to 
cure bronchitis, and a great variety of inhalations and balsams will 
be experimented with ; many of these may afford temporary re- 
lief, but they will certainly leave the person in a worse condition 
than he was before their use was commenced. When bronchial 
secretions are excessive, they may be diminished and the condi- 
tion of the patient much improved by the inhalation of steam from 
water impregnated with tar, creasote, carbolic acid, iodine, bal- 
sams, etc. Usually, such inhalations will remove the fcetor which 
is sometimes met with in the breath and expectoration of those 
suffering from chronic bronchitis. 
In the absence of more complete apparatus, vapor impregnated 
with these substances may be inhaled in the following manner : 
Pour into an ordinary quart stone jug about a pint of boiling water, 
to which add a teaspoonful of oil of tar, creasote, carbolic acid, 
tincture of iodine, or any other similar volatile substance,—then 
let the individual place his face over the mouth of the jug and in- 
hale the medicated vapor. During the inhalation the jug and the 
head of the patient should be covered with a towel or cloth to pre- 
vent the escape of the steam. Relief will be afforded if this is done 
for a few moments at a time, three or four times during the day. 
Any of these remedies can be taken internally at the same time. 
If the bronchial secretion is scanty, adhesive in character, and 
is with difficulty expectorated, the cough being attended with vio- 
lent paroxysms, anodynes may be used with the vapor inhalations. 
Pills containing one grain of the extract of henbane, and one grain 
of ipecac, may be found of service. Two or three of these may be 
taken within twenty-four hours. 416 
DISEASES OF THE RESPIRATORY ORGANS. 
In that form of chronic bronchitis so commonly met with in 
elderly people, called “a winter’s cold,” I have found great bene- 
fit derived from drinking hot milk and Selters water before rising 
in the morning. Fill a tumbler with equal parts of boiling milk 
and Selters water, and let the patient drink its contents half an 
hour before rising. This should be continued through the winter 
months. 
Asthma. 
Asthma is so common a disease, that nearly every one is fa- 
miliar with its prominent symptoms; yet medical men have dif- 
fered in regard to its exact nature. At the present time it is al- 
most universally regarded as a spasmodic affection of the bron- 
chial tubes, due undoubtedly to reflex nervous action. Asthmatic 
paroxysms are usually accompanied by a more or less severe bron- 
chial catarrh, which may sometimes precede, and sometimes fol- 
low the paroxysm. 
Persons suffering from organic disease of the heart may have 
asthmatic attacks, although true asthma is spasmodic. 
Causes.—Unquestionably, the primary cause of asthma is some 
constitutional tendency, which is generally hereditary. I have 
seen a well-marked paroxysm of asthma in an infant six weeks 
old and born of an asthmatic mother. The exciting causes of 
asthma are numerous, but they may be conveniently arranged 
into three classes : 
First. There is a class of cases in which the bronchial spasm is 
excited by the inhalation of some irritating substance, which acts 
directly upon the bronchial mucous membrane. In this class are 
included those cases in which the attack is excited by the emana- 
tions from new-mown hay (this form of asthma is called hay-asth- 
ma), from various flowers, from certain animals, as the cat and 
dog, from warm milk, powdered ipecac, tobacco, etc. 
Second. There are cases in which the bronchial spasm depends 
upon causes within the human body ; technically speaking, they 
are reflex in their origin. For example, an attack of asthma may 
be induced by error in diet, by uterine irritation, by the sudden 
application of cold to the surface of the body, by an overloaded 
rectum, or by violent exertion. 
Third. Asthma occurs in connection with other diseases, such 
as chronic bronchitis, dilatation of the air-cells of the lungs (pul- 
monary emphysema), heart disease, etc. 
Every person who has long been subject to attacks of asthma 
knows what will bring on a paroxysm in his individual case, and 
he is susceptible only to that exciting cause. DISEASES OE THE RESPIRATORY ORGANS. 
417 
Symptoms.—An individual who has had repeated attacks of 
asthma, also knows when he is about to have a paroxysm by cer- 
tain sensations which are peculiar to himself, and which no one 
else can so well appreciate : such as itching of the chin, wakeful- 
ness, a peculiar headache, etc. 
Hay-asthma is always preceded or accompanied by sneezing, 
suffusion of the eyes, running at the nose, and bronchitis. Per- 
sons having this form of asthma may have suffered for years with 
irritation of the mucous membrane of the eyes, nose, and throat, 
whenever they have been exposed to the emanations which ordi- 
narily produce it, without having had a distinct asthmatic par- 
oxysm ; yet asthmatic paroxysms are sure to be developed sooner 
or later, differing in no respect from asthmatic paroxysms excited 
by other causes. 
In most cases, these paroxysms come on during the night; the 
individual goes to bed and falls asleep, the characteristic wheezing 
commences, and he soon awakes suffering from a most distressing 
attack of difficult breathing. 
If you carefully notice a person suffering from a severe asth- 
matic paroxysm, you will find that the entire upper portion of the 
chest is motionless, and that the motion in the lower portion is 
limited. There is marked rigidity of the muscles passing from the 
head to the shoulders, to the collar-bone, and to the ribs. The 
head is fixed, the shoulders are elevated and brought forward, the 
individual bends forward and rests his elbow upon his knees, with 
mouth open, and eyes prominent. The surface is covered with a 
profuse perspiration, the face is flushed or livid, the breathing is 
laborious, and noisy or wheezing in character, and the individual 
hastens to an open window or door hoping to find relief. 
The duration of the paroxysms varies ; sometimes they last 
only for a few moments, at other times they continue for hours; in 
exceptional cases they continue two or three days without inter- 
mission. If the paroxysm is prolonged, the extremities become 
cold, blue, and shrunken, and the individual appears to be dying; 
death, however, rarely occurs from uncomplicated asthma. 
The attack usually terminates by free expectoration. In some 
cases the expectoration is a thick, tenacious mucus; in other cases 
it is watery and frothy ; and in still other cases there may be only 
a few small rounded masses coughed up before relief is obtained. 
These attacks have a marked tendency to recur; the length of 
the interval between them varies. Some individuals have an at- 
tack only once during the year; others have an attack every 
month ; and again others have an attack only when brought under 
the influence of some special exciting cause. 418 
DISEASES OF THE RESPIRATORY ORGANS. 
The condition of the individual during the intervals will vary 
according to the nature of any organic disease with which he may 
otherwise be affected. If no organic disease exists, some persons 
are quite well during the interval; others have an almost constant 
sense of constriction in the chest, which renders the breathing 
somewhat labored, especially during exercise. Some suffer from 
a bronchial or nasal catarrh, which constantly predisposes them 
to an asthmatic paroxysm on slight exposure. 
Those who are subject to repeated attacks of asthma find it ab- 
solutely necessary to observe a rigid hygiene, in order to escape 
their attacks, and it is probably due to this fact that this class of 
persons are generally long-lived. 
If the first attack comes on previous to adult life, the interval 
between the paroxysms is usually long, and complete recovery is 
possible. Yet the fact that an individual has had one attack is 
strong presumptive evidence that he will have a second one. If 
the paroxysms can be traced to some cause that may be avoided, 
the chances of complete recovery are good. 
Treatment.—There are two things to be considered in the treat- 
ment of this affection. 
First, the management of the paroxysm. 
Second, the treatment of the individual during the interval, 
with a view to correct the constitutional condition, upon which 
the tendency to the recurrence of the paroxysms depends. 
The object of treatment when the paroxysm is present, is to 
lessen the sufferings of the individual and to shorten the duration 
of the attack. Ascertain the exciting cause of the attack, and if 
possible remove it. If the paroxysm depends upon indigestion or 
upon an overloaded stomach, administer an emetic—a large draught 
of lukewarm water, a teaspoonful of mustard in half a pint of 
water, or from twenty to thirty grains of ipecac may be employed. 
If the attack depends upon the disturbing influence of an over- 
loaded rectum, use a large injection of warm water containing a 
tablespoonful of common salt. If smoke, dust, or any animal or 
vegetable emanation is the cause of the attack, the individual must 
avoid its inhalation. If in a certain locality the individual has 
frequent attacks of asthma, let him remove to one in which he is 
free from the paroxysm. Not unfrequently, permanent relief will 
be afforded simply by a change of residence. 
If the exciting cause is such that it cannot be removed, or if its 
removal is not followed by immediate relief, the individual should 
be placed in a position in which the respiration can be carried on 
with the greatest ease. During an attack, the sitting posture is 
usually the most comfortable position if a chair is used which DISEASES OF THE RESPIRATORY ORGANS. 
419 
will give support to the arms, and so elevate the shoulders. The 
apartment should be kept at a temperature of 65° Fahr., and freely 
ventilated. Next, we should select those remedial agents best 
adapted to afford relief. 
The great majority of persons suffering from asthma acquire a 
practical knowledge of those remedies best suited to their own 
cases. For an emetic, ipecac, tobacco, and lobelia are remedies 
which have long been employed in the treatment of asthma ; and 
stramonium leaves, Indian hemp, hyoscyamus, ether, chloroform, 
and opium, are remedies familiar to those who have had frequent 
attacks of the disease. Some will be promptly relieved by the in- 
halation of the fumes of stramonium leaves ; others, by the inhala- 
tion of a small amount of ether or chloroform ; and again others, 
by the fumes of burning nitre-paper. Chloroform is an agent 
which will generally relieve, temporarily, an asthmatic paroxysm ; 
but the difficulty is, that as soon as the effects of the drug have 
passed off, the paroxysm returns with increased severity. Opium 
in moderate doses will frequently afford relief ; the following is a 
very good combination, viz. : 
Compound spirits of ether One ounce. 
Sulphate of morphia One grain. 
Water One ounce. 
Of this mixture, a teaspoonful in a little water may be taken 
every half-hour until relief is obtained. 
Nitre-paper is one of the oldest and best remedies for asthma. 
(It is prepared by dipping ordinary paper in a saturated solution of 
saltpetre.) When this is used, it is necessary that the apartment 
occupied should be filled with the fumes of the burning paper ; if 
it relieves, it will do so very quickly. 
Coffee and alcohol have become quite favorite remedies in the 
treatment of asthma. Coffee is to be preferred. It should be 
strong and clear, as hot as it can be swallowed, and should be taken 
previous to eating. Often a paroxysm may be warded off by 
taking two or three cups of strong coffee immediately upon the 
occasion of the first asthmatic symptom/ 
Caffeine in two-grain doses, repeated every half-hour, acts in 
the same manner, and as it is tasteless may sometimes be pre- 
ferred. Alcoholic stimulants sometimes afford relief. It is of lit- 
tle importance what alcoholic stimulant is employed, but in order 
to have any marked effect in arresting an asthmatic paroxysm, it 
must be taken hot and in quantities sufficient for the individual 
suffering from asthma to feel its intoxicating effects. Whatever 420 
DISEASES OF THE RESPIRATORY ORGANS. 
remedial agent affords relief, after a time it will cease to have the 
desired effect, and a new one must be tried. The three most relia- 
ble remedial agents are ipecac, opium, and coffee. 
The treatment during the interval between paroxysms must be 
altogether hygienic, for there are no known remedies which will 
prevent their recurrence. Usually, asthmatic individuals are dys- 
peptic. Since proper care with respect to diet will afford exemp- 
tion from many asthmatic attacks, each individual should make 
his own case a special study in this regard. In those cases which 
depend for their development upon certain atmospheric condi- 
tions, a change of residence is all-important. There is no rule in 
regard to such a change ; each individual must decide for himself, 
finding by trial in what place he is free from an attack of asthma. 
If the individual is feeble and poorly nourished, cod-liver oil and 
iron are of service in preventing a paroxysm. 
On all questions of general treatment, the advice of a physician 
should be sought. 
Pulmonary Emphysema. 
In pulmonary emphysema, or dilatation of the air-cells of the 
lungs, there may be simple dilatation of the air-cells without rup- 
ture of their walls, or the two may exist simultaneously. Such 
dilatation leads to the formation of air-sacs, which vary in size 
from a pin’s head to that of a walnut or even larger. As a result 
of the rupture and disappearance of the walls of the air-cells, the 
fine net-work of blood-vessels which surround the air-cells be- 
comes obliterated, and this interferes more or less with the circula- 
tion of the blood in the lungs. Usually both lungs are affected. 
This disease seldom occurs except in connection with bronchitis 
and asthma, although it may exist independently of these. It is 
essentially a chronic affection, comes on slowly, and when once 
developed is permanent. 
Causes.—Forced expiratory efforts, such as occur with violent 
paroxysms of coughing, straining at stool, etc., etc., may cause 
this disease. In many persons there exists either a hereditary or 
an acquired impairment of the elasticity of the lungs, which ren- 
ders the walls of the air-cells more easily dilated, and more easily 
ruptured than usual. Several theories have been advanced to ac- 
count for this impairment, but no theory is altogether satisfactory. 
Dilatation of air-cells may take place around small portions of 
lung tissue rendered inexpansible by disease, such as occurs in 
collapse of some lobules due to obstruction of the bronchial tubes 
leading to them. As a result of bronchial obstruction and pulmo- 421 
DISEASES OF THE RESPIRATORY ORGANS. 
nary collapse, the air-cells immediately adjacent to them become 
over-distended by a forced inspiration or a forced expiration. In 
such instances, the extra distention of some air-cells compensates 
for the want of those which are rendered inexpansible. 
Symptoms.—The most prominent and constant symptom of 
pulmonary emphysema is difficult breathing. When the disease 
is advanced, very slight physical exertion will cause difficulty of 
breathing; if the disease is slight, or in the early stage of its de- 
velopment, only violent and prolonged physical exertion will give 
rise to difficult breathing. In all cases the difficulty of respiration 
is less severe in summer than in winter. When cough is present 
it is due to bronchial irritation ; if there is no bronchitis, there is 
no cough. 
Expectoration varies with the character and extent of the bron- 
chitis, and is not a part of the history of the emphysema. In 
advanced cases, the countenance is peculiar and somewhat charac- 
teristic ; it is of a dusky hue, and has a puffy appearance which 
contrasts remarkably with the wasted appearance of the rest of the 
body. The nostrils are distended, thickened and vascular, and 
expand with each inspiration ; the corners of the mouth are drawn 
downward, the voice is feeble, the individual stoops in the act of 
walking, and his whole body has a cachectic appearance. The 
circulation in the capillary blood-vessels of the extremities is re- 
markably imperfect on slight exertion. There is a gradual but 
steady loss of flesh and strength. Usually, there is no fever. 
Individuals who have reached the advanced stage of this dis- 
ease have characteristic paroxysms of coughing. As the attack 
comes on the face becomes flushed, the paroxysm gradually be- 
comes more and more severe, and when it has reached its climax 
the face and hands become livid, and the body is covered with a 
cold perspiration. An interval of rest then follows; soon this is 
followed by another paroxysm ; thus one paroxysm follows another 
without affording any very marked relief, until the individual is 
completely exhausted. 
As the malady reaches a more advanced stage, the feet and 
ankles become swollen, there is more or less disturbance of the 
digestive functions, and the urine is scanty and high-colored. 
This class of individuals are more or less troubled with hemor- 
rhoids and frequently lose large quantities of blood from the rec- 
tum. 
In the advanced stage of emphysema the shape and movements 
of the chest are altered. There is an unnatural bulging of the up- 
per portion in front, and an elevation of the breast-bone, giving 
to the entire chest a more rounded appearance than is natural, 422 
DISEASES OF THE RESPIRATORY ORGANS. 
which has been termed “barrel-shaped.” The lower portion of the 
chest seems contracted, the shoulder-blades are drawn forward, 
and the individual habitually stoops. The muscles of the neck are 
unnaturally prominent. At the upper portion of the thorax ex- 
pansion on inspiration is diminished or entirely wanting; the 
whole chest moves up and down with inspiration and expiration, 
as if it were composed of one solid piece, and lifted from the 
shoulders. 
When the disease is once developed, recovery never takes place. 
To a greater or less extent it incapacitates an individual for active 
exercise ; it renders life uncomfortable, but rarely, if ever, is it the 
direct cause of death. It increases the severity of an existing bron- 
chitis, and renders one liable to fresh attacks. 
Treatment.—Individuals suffering from pulmonary emphysema 
should carefully guard against taking cold, and should never ex- 
pose the surface of the body to cold. Flannel should be worn next 
the skin throughout the year. All localities and conditions favor- 
able to the development of this affection should be avoided. The 
diet should be the most nutritious and largely animal in character. 
Overloading the stomach should be carefully avoided, as well as 
the eating of those articles of food which have a tendency to pro- 
duce flatulence. Only a small quantity of liquid should be taken 
into the stomach at any one time. 
Systematic exercise in the open air should be taken daily, but 
it should not be carried to fatigue. All violent exercise or great 
physical exertion should be avoided. The regulation of diet and 
attention to general hygiene is of much more importance than the 
giving of medicine. 
Iron is of great service in improving the general nutrition of 
individuals subject to this disease; the best preparation for this 
class of cases being the ethereal tincture of the acetate of iron, 
taken immediately after eating, in doses varying from five to 
twenty-five drops in water. Its use should be continued for some 
time. If dyspeptic symptoms are present, the mineral acid with 
the vegetable infusions will be found serviceable ; the same which 
were recommended in the treatment of chronic bronchitis. 
This disease has certain accompaniments which require special 
treatment. Of these chronic bronchitis stands first. In treating 
this bronchitis I have found iodide of potassium of special service ; 
it should be administered in doses varying from five to twenty 
grains three times each day, and its use should be continued for 
some time. 
In the treatment of heart and kidney complications, the services 
of a physician are required. 423 
DISEASES OF THE RESPIRATORY ORGANS. 
The same rules should govern one in the choice of climate for 
persons suffering from pulmonary emphysema as in the case of 
those suffering from chronic bronchitis or asthma. 
Congestion of the Lungs—(Edema of the Lungs—Apoplexy of 
the Lungs. 
These three diseases are closely allied to each other, and fre- 
quently they are concurrent. In some cases, when congestion of 
the lungs exists, it is difficult to determine whether oedema of the 
lungs is or is not present. In most cases, apoplexy of the lungs 
is associated with or preceded by congestion of the lungs. 
CEdema of the Lungs. 
In this disease the watery portion of the blood (the serum) finds 
its way into the cavities of the air-cells, and into the intercellular 
structure of the lungs. It commonly occurs as a complication of 
such maladies as Bright’s disease of the kidneys, scurvy, purpura, 
etc. It may occur when the circulation in one portion of the lungs 
has been interfered with, as in pneumonia. It may also occur 
during the course of any acute infectious disease (such as typhus 
or typhoid fever), or any acute malady which is attended by heart 
failure. 
Symptoms.—The prominent symptoms of oedema are difficulty 
in breathing and increased frequency in respiration. Frequently 
the difficulty in breathing is sudden in its advent and extreme in 
its character. Unless it complicates some acute disease, there is no 
febrile excitement; the temperature remains normal, the pulse is 
increased in frequency and is feeble. There is more or less cough 
attended by a watery expectoration which is colorless, unless con- 
gestion of the lungs is present, when it will be blood-stained. If 
the oedema is extensive, or if it complicates some other pulmonary 
disease, the lips become blue, the extremities cold and blue, the 
countenance anxious, and the distress of the individual extreme. 
These symptoms can readily be observed. Not unfrequently, oede- 
ma of the lungs occurs in connection with general dropsy and be- 
comes an exceedingly dangerous complication, especially if the 
dropsy depends upon disease of the kidney or heart. When, there- 
fore, an individual, ill with any form of disease which is attended 
by general dropsy, is suddenly seized with great difficulty of 
breathing, accompanied by cough and a profuse watery expec- 
toration, it is almost positive evidence that oedema of the lungs 424 
DISEASES OF THE RESPIRATORY ORGANS. 
has been developed. Under such circumstances prompt and effi- 
cient medical aid is required. 
Treatment.—Extensive oedema of the lungs is too dangerous a 
disease to be intrusted to the management of any one, save a com- 
petent physician. 
If a physician cannot be immediately reached, dry cups should 
at once be applied over the entire chest, in front and behind. [See 
Chapter on Care of the Sick.] If these are not at hand, the chest 
should be covered with mustard poultices. If the oedema occurs 
with general dropsy, administer a full dose of Epsom salt, and, 
as quickly as possible, endeavor to induce free perspiration. If it 
comes on in the course of a fever, stimulants should be freely 
administered, until the aid of a physician can be obtained. 
Congestion of the Lungs. 
Congestion of the lungs may be either active or passive; that 
is, it may be the result of a larger than normal quantity of blood 
having been sent to the lungs in consequence of increase in the 
power and frequency of the heart’s action, or it may be developed 
because there is obstruction to the return of blood from the lungs 
to the heart. 
Causes.—In young persons with contracted chests, active con- 
gestion of the lungs may be produced by violent exercise, such as 
running, jumping, etc. It is probably this form of congestion 
which gives rise to the sudden distress sometimes felt when one 
is running against the wind. Active congestion of the lungs is 
also produced by breathing an atmosphere containing more than 
the normal proportion of oxygen ; such an atmosphere is met with 
in elevated regions, and frequently causes distress in ascending 
a mountain. 
Passive congestion of the lungs occurs in connection with 
chronic heart disease, in which the valves of the heart do not 
properly perform their functions, the blood regurgitates [crowds 
backward] into the lungs, and, as a result, passive or mechanical 
congestion of the lungs occurs. This form of congestion also is 
present in chronic diseases of the lungs, liver and kidneys which 
lead to obstruction in the return circulation. 
Symptoms.—In congestion of the lungs, as in oedema of the 
lungs, there is difficult breathing and cough with expectoration ; 
indeed, it is not always easy to distinguish between them. If the 
congestion is extensive, the difficulty of breathing is urgent, but in 
the majority of cases of passive congestion there will be little or no 
change in the respiration ; the individual becomes accustomed to DISEASES OF THE RESPIRATORY ORGANS. 
425 
slight difficulty of breathing, and suffers no special inconvenience, 
except after active physical exertion. Blood-stained watery ex- 
pectoration is its only positive symptom, and it is the symptom 
which causes alarm. 
An individual with chronic heart disease becomes accustomed 
to shortness of breath and to a certain degree of difficulty in breath- 
ing, but when he begins to expectorate (perhaps profusely) a blood- 
stained watery material, he will become more or less alarmed. 
There is sufficient cause for alarm, as extensive congestion of the 
lungs, either active or passive, is usually sudden in its develop- 
ment, rapid in its course, and, unless quickly recovered from, 
either destroys life in a few hours, or leads to inflammation of the 
lungs. In the majority of cases of chronic heart disease, if ex- 
tensive congestion of the lungs occurs, it will probably destroy life. 
In such cases, whenever blood-stained watery expectoration ap- 
pears, the danger should be fully appreciated. 
Treatment.—This disease is always so grave in character as to 
require the immediate services of a physician. When the disease 
assumes a threatening aspect, the quantity of blood in the lungs 
should be lessened. To accomplish this, resort to dry or wet cup- 
ping over the entire chest [see Chapter on the Care of the Sick] ; 
sometimes this result may be more readily obtained by bleeding 
from the arm. Steam inhalations are serviceable, and may be re- 
sorted to at any period of the attack. 
Apoplexy of the Lungs. 
Pulmonary Apoplexy and pulmonary congestion are very fre- 
quently associated with each other. 
It is not necessary to devote much space to the consideration of 
this disease, for when it occurs, either a physician is in regular at- 
tendance upon the individual, or the symptoms are so alarming 
that his services are at once sought; or it may be that the apo- 
plexy is so slight that there are no noticeable symptoms, except the 
expectoration of small blood-clots having a dark color. 
Symptoms.—When the apoplexy is of considerable size, or a 
number of small apoplexies occur at once, very decided symptoms 
are developed ; prominent among these is difficult breathing. For 
example, an individual has suffered for some time from chronic 
heart disease, he has become accustomed to the shortness of breath 
which accompanies the disease when, suddenly, he becomes aware 
that the difficulty of breathing from which he suffers is of a pecu- 
liar character, he feels as though some extensive damage had sud- 426 
DISEASES OF THE RESPIRATORY ORGANS. 
denly been done to his lungs; this sensation is immediately fol- 
lowed by a more or less free expectoration of dark blood. 
Treatment.—The treatment of this disease must necessarily be 
under the direction of a physician. 
Hemorrhage from the Lungs (Hemoptysis). 
It lias already been stated that the “ spitting of blood ” may oc- 
cur in pulmonary congestion or apoplexy. It also attends some of 
the severer forms of inflammation of the lungs and bronchial 
tubes, but in the majority of instances it is due to hemorrhage 
from the vessels of the mucous membrane of the bronchial 
tubes. 
Causes.—Bronchial hemorrhage is due to a weakness of the 
walls of the vessels of the bronchial mucous membrane. Such 
weakness may be a hereditary or an acquired condition. The 
tendency to bronchial hemorrhage from weakened capillaries is 
most marked between the ages of fourteen and thirty, especially 
in young and delicate persons born of consumptive parents. 
There is also a strong predisposition to this form of hemorrhage in 
persons who are suffering from developed consumption, or who 
have an acquired consumptive tendency. In such cases the direct 
cause of the hemorrhage is a sudden distention of the weakened 
bronchial capillary blood-vessels from violent physical exertion, or 
from certain peculiar atmospheric influences. In some instances 
it occurs without any appreciable cause. Occasionally, the con- 
gestion of the bronchial mucous membrane, occurring in that form 
of bronchial catarrh which often precedes the development of con- 
sumption, is the exciting cause of the hemorrhage. Hemorrhage 
from the bronchial mucous membrane may also be induced by the 
inhalation of irritating gases or vapors, and by the rarefied air 
of high elevations ; in both these instances the hemorrhage follows 
over-distention of the capillary vessels of the bronchial mucous 
membrane. 
Symptoms.—The symptoms which attend a hemorrhage from 
the bronchial tubes vary with the amount of hemorrhage. All 
bronchial hemorrhages are attended by the spitting of bright-red, 
frothy, arterial blood. If the quantity of blood is very small, this 
will be the only appreciable symptom. Rarely are the symptoms 
trivial which attend a bronchial hemorrhage, for, in most cases, 
it is profuse. 
A very profuse bronchial hemorrhage may come on suddenly, 
but usually, previous to its occurrence, the individual has had a 
sense of constriction at the upper portion of the chest, and, upon 427 
DISEASES OF THE RESPIRATORY ORGANS. 
respiration, a sense of uneasiness which he was unable to account 
for ; he may or may not have had a cough preceding the hemor- 
rhage. Suddenly, he feels as though some fluid had commenced 
trickling underneath the breast-bone, and he notices an unnatural 
sweetish taste ; he finds that this is due to blood in his mouth, 
although he may not have coughed immediately preceding the 
hemorrhage. Now, he feels more or less bronchial irritation, which 
is followed by cough and blood in expectoration, one mouthful fol- 
lowing another in quick succession. The coughing continues, 
interrupted only by short intervals, and blood may be expectorated 
for several days, sometimes only for a few hours. The quantity 
of blood expectorated varies ; it may be no more than one or two 
ounces, or it may be from sixteen to twenty ounces. 
The symptoms during an attack vary. Usually, as soon as the 
individual finds that he is expectorating blood, his countenance 
assumes a pale, anxious expression, he becomes tremulous and 
sometimes faints. These symptoms are not due to loss of blood, 
but are probably due to the shock given to the nervous system 
from the sight of blood, and the knowledge that a hemorrhage 
from the lungs is taking place. All these symptoms may be pres- 
ent when the individual has lost only a few ounces of blood. For 
a few days after a profuse hemorrhage, the coughing continues, 
and the individual expectorates small, dark, coagulated masses of 
blood, or blood-streaked sputa. Sometimes these hemorrhages are 
so profuse that the blood spurts out of the mouth and nose ; this is 
followed by nausea and vomiting of blood, and the nausea and 
blood-vomiting do not precede the bronchial hemorrhage, as would 
be the case did the blood come from the stomach. 
A single attack of bronchial hemorrhage is of rare occurrence. 
For a week or two following the first attack, the bleeding will recur 
at intervals. The individual becomes pale and feeble ; gradually 
recovery takes place, and in a few weeks he may feel better than 
before the accident. This is the most favorable termination 
that can be hoped for, except in those cases in which the hemor- 
rhage is comparatively insignificant. Attacks of haemoptysis, 
however profuse, are generally recovered from, in spite of the 
extreme prostration and tendency to fainting which sometimes 
attends their occurrence. In the majority of cases there is no 
occasion for sudden alarm. When the recovery from the hemor- 
rhage is delayed, inflammatory processes may develop in the 
lungs. 
There are certain bleedings which may be mistaken for hemor- 
rhage from the lungs. Bleeding from the nose has frequently been 
mistaken for it, but can readily be recognized, as the blood is of a 428 
DISEASES OF THE RESPIRATORY ORGANS. 
dark color and coagulates, and it can always be seen in the nos- 
trils and back of the throat; besides the bleeding is not necessarily 
attended or followed by a cough. Blood vomited from the stomach 
is not unfrequently supposed to be a hemorrhage from the lungs, 
but when blood comes from the stomach it is clotted and dark col- 
ored, and the vomiting precedes the hemorrhage. If nausea and 
vomiting are present with hemorrhage from the lungs, they follow 
the spitting of red, frothy blood, and the bleeding is not accom- 
panied by a cough. Frequently an individual, when he has a bron- 
chial hemorrhage, thinks the blood comes from the throat, and 
consequently regards the bleeding as of no serious import. Rarely 
is hemorrhage from the throat profuse, and the bleeding parts can 
be readily seen upon examination. 
It is the prevailing opinion that “spitting blood ” indicates that 
a person has consumption. In many instances this is true, but in 
a large proportion of cases, consumption does not attend or follow 
its occurrence. Nevertheless it should be regarded with suspicion 
and a physician should at once be consulted. Rarely does it im- 
mediately endanger life, but in many instances it is the precursor 
of consumption. 
Treatment.—In every case of bronchial hemorrhage the indi- 
vidual should be kept under the observation of a physician until 
all irritation produced by the hemorrhage has subsided. 
The most important element of treatment is absolute rest in a 
cool room. The individual should be placed in bed and not allowed 
to sit up, turn over, or even speak above a whisper. If the cough 
continues and is constant, or induces the hemorrhage, it must be 
quieted by a full dose of opium ; twenty-five drops of laudanum 
or one-fourth of a grain of morphine may be given for this purpose. 
There is no evidence that common salt has any controlling influ- 
ence over the bleeding, but if an individual or his friend thinks it 
will be of service, there is no objection to its use. The application 
of ice-bags to the surface of the chest may be resorted to in extreme 
cases, but these applications must be cautiously made, and not 
continued a sufficient length of time to chill the individual. The 
eating of ice and the taking of cold drinks is of service. 
These means are to be employed only until such time as the 
services of a physician can be obtained. 
Gangrene of the Lungs. 
This disease may only involve circumscribed spots in the lungs, 
it may be diffused through an entire lobe, or even an entire lung 
may be involved. The affected lung-tissue is more or less decom- DISEASES OF THE RESPIRATORY ORGANS. 
429 
posed and converted into a putrid mass, which is saturated with a 
grayish black fluid. 
Causes.—Gangrene of the lung occurs in connection with cer- 
tain nervous diseases, such as dementia, softening of the brain, 
epilepsy, chronic alcoholism, etc. It is also met with when the 
system is in a depressed condition, the result of acute or chronic 
blood-poisoning. It may be the result of local disease of the lungs, 
such as obstruction in the blood-vessels leading to the gangrenous 
part. 
Symptoms. —When gangrene of the lung commences, its symp- 
toms are frequently very obscure. Those which most positively 
declare its existence are an exceedingly fetid breath and the ex- 
pectoration of gangrenous material. 
An exceedingly fetid breath is also present in fetid bronchitis, 
and in very many cases it will be difficult to distinguish the one 
disease from the other. In gangrene of the lung, the material 
expectorated is usually of a dirty black or brown color, and con- 
tains small black masses ; by these it may be recognized. 
In some cases the gangrenous process may continue for weeks 
before there are any constitutional symptoms, and when they are 
present there is nothing characteristic about them; they are merely 
those which indicate great exhaustion. 
Recovery takes place only when the disease is small in amount 
and limited in extent Death may be caused by hemorrhage, or 
by the extension of the gangrenous process to other organs, or by 
the exhaustion which attends the general poisoning of the system. 
Treatment.—Sustain the individual in every possible way, by the 
administration of stimulants, tonics, and a most nutritious diet. 
Under the direction of a physician, antiseptic remedies may be 
employed, either by inhalation or in some other manner. For the 
most part the treatment must be palliative. 
Cancer of the Lungs. 
*This is a disease seldom met with, and it is in most instances 
secondary to cancerous developments in other parts of the body. 
Symptoms.—If difficult breathing, cough, hemorrhage from the 
lungs, pain in the chest, rapid emaciation, and a peculiar pale, 
dirty appearance of the skin should be present in one from whom 
a cancerous mass has been removed from some portion of the body 
by a surgical operation, there would be good reason to suspect the 
existence of cancer of the lung. 
Treatment.—The treatment is restricted to relieving symptoms. 430 
DISEASES OF TIIE RESPIRATORY ORGANS. 
Opium may be given in sufficiently large doses to relieve pain, and 
to alleviate the distressing cough which attends its development. 
If the disease is attended by hemorrhage, as is frequently the 
case, the same means may be resorted to to check the hemorrhage 
as would be employed in profuse bronchial hemorrhage. 
This disease always proves fatal. 
Pleurisy. 
A partial or general inflammation, of one or both pleura is termed 
pleurisy. There are three recognized varieties : Acute, sub-acute, 
and chronic—named from the course which the inflammation 
takes. 
In acute pleurisy the symptoms are well defined ; its course is 
rapid and the exudation which results from the inflammation is 
principally fibrous. 
Causation.—The cause of acute pleurisy is not always readily 
ascertained, exposure to wet and cold being regarded as one of 
the most frequent. I doubt if it occurs very frequently from this 
cause, unless some predisposing cause has previously existed, such 
as rheumatism, acute or chronic alcoholism, Bright’s disease, or 
some other chronic disease of the viscera. It may occur as the 
result of a blow or some other injury to the side, or as the result of 
an extension of inflammation from some adjacent tissue, as when 
it is secondary to pneumonia, or to inflammation of the covering 
of the heart. It may occur at any age, but is more frequently 
met with in adults than in children. 
Symptoms.—Acute pleurisy may be mild or severe, in either 
case it is ushered in by well-marked symptoms. At the onset a 
sharp, stitch-like pain is felt in some portion of the thoracic wall, 
increasing in severity from hour to hour, and is usually most 
marked under the nipple of the affected side. Each inspiration 
increases the pain, consequently the respirations become catching 
in character. To prevent motion of the affected side, the individ- 
ual assumes a peculiar position, leaning forward and toward the 
affected side. 
Neuralgic and muscular pains frequently affect the walls of the 
chest; in some instances these are very severe, and are sometimes 
mistaken for pleurisy, but they are not accompanied by any fe- 
brile movement, and the one can readily be distinguished from the 
other. In the early stage of pleurisy, chills are not usually pres- 
ent. At first, the countenance is pale and anxious, after a few 
hours it becomes flushed. In a case of average severity the pulse DISEASES OF THE RESPIRATORY ORGANS. 
431 
ranges between 90 and 120. The respiration is hurried and each 
inspiration is short and jerking in character. The temperature 
follows no regular course, rarely rising above 100° Fahr. in ordi- 
nary cases; occasionally I have seen it reach 104° Fahr. There is 
a constant hacking cough, either perfectly dry or accompanied by 
a moderate amount of thin mucous expectoration. Although there 
are few marked symptoms of acute pleurisy, yet these are such as 
direct attention to the seat of the disease. 
If no grave disease complicates it within a few weeks after its 
commencement, the chances for complete recovery are good; if 
there is such complication, it may destroy the life of the patient. 
Treatment.—The remedy which seems to have the greatest con- 
trolling influence in this disease is opium. It should be taken in 
sufficient quantity to relieve pain, say twenty drops of laudanum 
every two hours. The individual should be kept in bed in a room 
with a temperature of 67° Fahr. He should be allowed to assume 
the posture which he finds most comfortable, and should not be 
unnecessarily moved. An anodyne poultice, such as flaxseed and 
opium, should be applied to the affected side. The diet should be 
nutritious and non-stimulating. In mild cases, by the fourth or 
fifth day, the individual will be able to sit up and in two or three 
weeks can resume his ordinary business ; but he must keep his 
room and avoid all physical exercise until he is free from all pain 
in the side and difficulty of breathing. 
If a large amount of the inflammatory material be poured out 
upon the surfaces of the pleural membrane, the lung will be more 
or less crippled for a long time, and recovery will be followed by 
some retraction of the affected side which, for months after the 
acute stage of the disease has passed, will cause some difficulty of 
respiration. If there is great debility iron will be of service in the 
treatment. 
Subacute Pleurisy. 
This form of pleurisy is of much more frequent occurrence than 
is the acute, and may exist for weeks without any symptoms which 
will attract attention to the affected side. 
In this disease the pleural cavity may be partially or complete- 
ly filled with fluid, and the surface of the pleura be covered more 
or less extensively with a plastic exudation which may lead to ex- 
tensive adhesions between the pleural surfaces, and thus bind the 
lung firmly to the chest-walls. In nearly every case, if the fluid 
effusion disappears, extensive adhesions take place between the 
lung and the chest-wall, which sometimes cause retraction of 432 
DISEASES OF THE RESPIRATORY ORGANS. 
the affected side to such an extent, that the liver and heart are 
crowded out of their normal position. 
Causation.—Subacute pleurisy often depends upon the causes 
already mentioned as productive of acute pleurisy, although in a 
large proportion of cases it is secondary to some form of organic 
disease, as chronic Bright’s disease of the kidney, consumption, 
etc. Not unfrequently, it is the first step towards the develop- 
ment of consumption. The weak and enfeebled, rather than the 
strong and robust, are subject to attacks of this form of pleurisy. 
Symptoms.—Subacute pleurisy is frequently so insidious in its 
approach, that the individual is unable to tell when he commenced 
to be sick. For a period of five or six weeks he may not have 
Figure 126.—Diagram showing a pleural cavity completely filled with fluid, and the lung 
compressed into a solid mass. 
Figure 127.—Diagram showing roughening of the pleura from plastic exudation and a small 
quantity of fluid effusion in the bottom of the pleural cavity. 
been feeling quite strong and well, but he had not been really ill 
nor confined to his bed at any time, and if his accustomed avoca- 
tion required but little physical exertion, he may have attended to 
his daily business. He may have noticed that he was growing 
pale and losing flesh, and that upon physical exertion he had slight 
difficulty in breathing. He may also have noticed a slight febrile 
excitement at night, accompanied by dry hands and a sensation of 
thirst. He may have coughed, but the cough was accompanied by 
little or no expectoration. DISEASES OF THE RESPIRATORY ORGANS. 
433 
These symptoms go on increasing, until the countenance as- 
sumes a pale, anxious expression. The breathing becomes short 
and catching in character. The individual is scarcely able to 
walk ; when he attempts to speak, especially after moderate exer- 
cise, his sentences are uttered in a broken and interrupted man- 
ner. He is unable to lie down with any degree of comfort, except 
on his back, or on the affected side, with his head slightly ele- 
vated. 
The presence of the above symptoms is strong presumptive evi- 
dence that the individual has subacute pleurisy, and medical as- 
sistance should be sought. When this disease is not associated 
with consumption, or any other form of acute or chronic affection, 
it usually terminates in recovery. If an individual has a heredi- 
tary or an acquired tendency to consumption, and the fluid is per- 
mitted to remain a long time in the pleural cavity, it not only 
causes permanent crippling of the lung, but, in many cases, it will 
lead to the development of consumption. The adhesions between 
the surfaces of the pleura may become the seat of tubercular de- 
velopments. 
Treatment.—The rapid removal of the fluid effusion from the 
pleural cavity, and the sustaining of the vital powers of the indi- 
vidual are the principal things to be accomplished. 
Cathartics, diuretics, diaphoretics, and blisters applied in suc- 
cession over different portions of the affected side, are the means 
usually employed for the removal of the fluid. Those persons who 
are the subjects of this disease, are usually in such a debilitated 
condition, that these means should never be resorted to without 
the advice of a physician. 
In my own experience, I have found the remedial agent which 
has the greatest power in promoting the absorption of the fluid 
effusion to have been the iodide of iron. 
Chronic Pleurisy—Empyema. 
By this term is meant an inflammation of the pleural mem- 
brane in which pus is the product of the inflammatory action. 
The purulent accumulations may be so great as partially or com- 
pletely to fill the pleural cavity, and death may result from the 
depression and exhaustion induced by the pressure. These ac- 
cumulations may escape from the pleural cavity by spontaneous 
openings. The chest-wall may be perforated by an ulcerative 
process, and the pus be discharged externally ; or the lung may 
be perforated, and the discharge take place through a bronchial 
Vol. II.—28 434 
DISEASES OF THE RESPIRATORY ORGANS. 
tube ; or, in rare instances, the diaphragm may be perforated and 
the pus find its way into the abdominal cavity. If the individual 
survives the perforation and emptying of the pleural cavity, re- 
covery is possible. Occasionally, pus in the pleural cavity under- 
goes absorption. 
Causation.—The cause of chronic pleurisy cannot be ascer- 
tained in every case. It may originate in an injury. When it 
occurs spontaneously it is always associated with some vice of 
constitution, such as results from a protracted exhausting disease, 
or the debility which attends chronic alcoholism and follows ener- 
vating habits. Nearly all the pleurisies that are developed in 
advanced consumption are purulent in character. 
Symptoms.—The symptoms of chronic pleurisy are obscure. 
The individual rarely suffers local pain, there is simply a sense of 
uneasiness or weight in the affected side. The invalid gradu- 
ally loses flesh and strength, grows pale, and his countenance 
wears a peculiar, pale, anxious expression. There is an irregular 
daily fever preceded by a chill and followed by profuse sweating. 
His voice is weak, and ordinarily he has a cough with a not very 
abundant muco-purulent expectoration. As the disease advances, 
the patient gradually assumes the appearance of one in the last 
stages of consumption. 
If an empyema is about to open externally, it will make itself 
manifest by the appearance of a protrusion between the ribs; this 
gives a sense of fluctuation to the touch; after a time the top of 
the elevation grows red, and finally an opening is made and pus is 
discharged. 
Few recover from chronic pleurisy. Statistics show that of 
those in whom spontaneous openings occur, about one in five re- 
covers, while of those in whom artificial openings are made about 
one in eight recovers. 
Treatment.—In the treatment of this disease, it is useless to ex- 
pect the purulent accumulation to be absorbed. Its removal can 
only be accomplished by the establishment of spontaneous open- 
ings, or by mechanical means. In either case the individual must 
be under the care of a physician for a long time. 
Tonic remedies are of great service, and among these cod-liver 
oil and iron are the best, if the stomach will retain them without 
disturbance. 
Those who suffer from this disease should be kept in the open 
air as much as possible, and a change of climate is often followed 
by a marked improvement. DISEASES OF THE RESPIRATORY ORGANS. 
435 
Pneumo-hydrothorax. 
As the name indicates, this is a condition characterized by the 
presence of air and fluid in the pleural cavity ; as soon as air enters 
this cavity it excites an inflammation of the pleural membrane 
which gives pus as its product. 
Different views have been entertained in regard to the forma- 
tion in, or entrance of pus into the pleural cavity. Some have 
claimed that pus is formed under these circumstances as a secre- 
tion ; others, that it is the product of decomposition of fluid in the 
cavity, whereas fluid in cavities with a lining membrane resists 
decomposition in a remarkable manner. Both views are highly 
improbable. There is little doubt but that in the majority, if not 
in all cases of pneumo-hydrothorax, there is an opening from the 
lung outward through a bronchial tube to the surface of the lung, 
or from the surface of the lung inward to a bronchial tube. In the 
one case the ulcerative process commences within the lung-tissue, 
in the other it commences upon the surface of the lung. In rare 
instances air enters the pleural cavity through an opening in the 
chest-walls by a wound or a fracture of the ribs, etc. 
Symptoms.—In a few cases the symptoms which attend per- 
foration of the lung, and the escape of air into the pleural cavity, 
are well marked ; the individual is suddenly seized with great diffi- 
culty of breathing, becomes blue, and rapidly passes into a condi- 
tion of collapse. In the majority of cases, however, the symptoms 
are obscure and develop insidiously; the difficult breathing comes 
on slowly, and is not attended by any active symptoms. Under 
such circumstances, the diseased condition can only be determined 
positively by a physician after a careful examination of the chest. 
Very few recover from pneumo-hydrothorax. If perforation 
of the lung takes place in any stage, a fatal termination within a 
few weeks is almost a certainty. 
Treatment.—The treatment of this affection is almost necessa- 
rily palliative. At the very onset of the attack, when the indi- 
vidual is suffering from the shock of the perforation, a full dose of 
laudanum [twenty-five to thirty drops to an adult] with stimu- 
lants may be given. 
The further management of such a case requires the skill and 
judgment of a physician. 
Inflammation of the Lungs {Pneumonia). 
Pneumonia, or inflammation of the lung, is a disease which is 
grave in character and of frequent occurrence. 436 
DISEASES OF THE RESPIRATORY ORGANS. 
Strictly speaking, it is an inflammation of the vesicular structure 
of the lungs involving the intervesicular structure (the structure 
between the air-cells), the smaller bronchi, and the pleura. 
Three varieties of pneumonia have been described by medical 
writers : 1st. Croupous or lobar pneumonia, which is always 
acute. 2d. Catarrhal or lobular pneumonia, which may be acute 
or chronic. 3d. Interstitial pneumonia, or fibrous induration of 
the lung-tissue. I shall consider these varieties separately, com- 
mencing with croupous or lobar pneumonia, and when the un- 
qualified term pneumonia is used, reference is made to this 
variety. 
Croupous or Lobar Pneumonia 
Is one of the most common forms of acute disease met with in 
adult life. It occurs more frequently in males than in females, 
and between twenty and forty, and after sixty years of age, than 
during any other period, although no age is exempt. 
This disease has received the name of lobar pneumonia because 
in nearly every case the whole of an affected lobe is involved ; 
indeed the whole of one or a large portion of both lungs may be 
inflamed. It is sometimes called pleuro-pneumonia, for the reason 
that when the surface of the lung is involved, the pleura which 
covers that portion is also affected, but the pleurisy is secondary 
to the pneumonia. The term can only be properly employed when 
the pleurisy is the primary affection. 
Croupous pneumonia has been divided into three stages : First, 
a stage of engorgement or congestion. Second, a stage of con- 
solidation or red hepatization. Third, a stage of gray hepatization 
or resolution. 
In the first stage, or stage of engorgement or congestion, the 
blood-vessels which surround the air-cells of the affected portion 
of the lung are distended with blood, and the air-cells and their 
cavities are more or less filled with a fluid material. 
In the second stage, or stage of consolidation, the air-cells and 
the finest bronchial tubes become filled with a semi-solid inflamma- 
tory product, so that the affected lung-tissue is rendered solid, is 
impervious to air, and assumes a dark red color. 
In the third stage, or stage of gray consolidation, the color of 
the affected lung-tissue is changed from a red to a gray color, the 
contents of the air-cells and the small bronchi become liquefied, 
and the liquid is either coughed up or absorbed. When this change 
goes on in a regular manner and is completed, the affected portion 
of lung is rapidly restored to its normal condition. If this resolving 437 
DISEASES OF THE RESPIRATORY ORGANS. 
process is interfered with, or if it never takes place, the affected 
lung-tissue may undergo a purulent change which will result in 
the destruction of that portion of lung or in the death of the indi- 
vidual. Death may occur at any stage of the disease, although it 
is more usual during the second or third stages. Death may take 
place as the result of sudden development of congestion and oede- 
ma in that portion of the lung which is not the seat of the pneu- 
monic process. 
Causes.—Poverty, intemperance, and occupations requiring ex- 
posure to sudden changes of temperature predispose to pneumo- 
nia. It is most frequently met with in climates subject to sudden 
variations of temperature. The weak and feeble, rather than the 
strong and vigorous, are especially liable to an attack ; as also are 
those convalescing from any grave form of disease. Previous 
attacks increase the liability to its occurrence. Unknown atmo- 
spheric conditions undoubtedly act as exciting causes, and epide- 
mic pneumonia doubtless depends upon such conditions. 
This disease also occurs in connection with chronic maladies of 
the blood, as chronic alcoholism, and it is evident that this variety 
of pneumonia is rarely a primary affection. Nearly every case can 
be traced to some well-recognized exciting or predisposing cause. 
For instance, a man who is a hard drinker (the alcohol taken hav- 
ing had its effect upon every organ in his body), sits in a draught, 
or in some way the surface of the body becomes chilled, pneumo- 
nia follows, yet the pneumonia is not a spontaneous disease. 
Again, one may be charged with malarial, uraemic, or some 
other poison, and upon slight exposure pneumonia may be devel- 
oped, yet the pneumonia is a secondary disease. These facts in 
reference to its causation have an important bearing as regards 
the means to be used for its prevention or in its treatment. 
Symptoms.—Usually the invasion of acute pneumonia is sud- 
den. It is ushered in by a distinct chill, which lasts from half an 
hour to two or three hours ; the intensity and constancy of the 
chill being greater than in any other disease, except malarial or 
septic fevers. 
There are certain exceptions to this regular method of develop- 
ment which are worthy of special mention : In young children, 
pneumonia may be ushered in with convulsions, vomiting, and 
headache. Delirium may be a prominent symptom and cause 
attention to be directed to the head rather than to the lungs. 
When this disease occurs in persons more than seventy years 
of age, the chill is frequently absent. The pneumonia may come 
on insidiously, perhaps great prostration and stupor being the 
first noticeable symptoms. 438 
DISEASES OF THE RESPIRATORY ORGANS. 
When it is ushered in by a chill, in most cases there is after- 
wards pain underneath the nipple on the affected side. This is 
neither constant nor characteristic ; usually, it subsides within 
three or four days. When it continues beyond the eighth day it 
may be regarded as evidence of pleuro-pneumonia. 
The respirations are more markedly increased in frequency 
than in any other acute disease. They are rarely less than thirty, 
and often reach sixty to eighty per minute. 
The pulse is not usually accelerated in proportion to the fre- 
quency of the respirations. It may remain at 100, while the res- 
pirations are as frequent as 60 or 80 per minute. 
The difficulty in breathing does not seem to be in proportion to 
the amount of lung involved ; often there is less difficulty in 
breathing when an entire lung is involved, than when a small por- 
tion of lung is affected. This is a most troublesome symptom in 
those individuals who suffer from great nervous prostration, and is 
always a grave symptom. 
The rise in temperature is one of the most important and con- 
stant symptoms of this disease. In most cases it is sudden, and 
reaches 102° to 105° Fahr. In mild, uncomplicated cases, during 
the first week, it usually ranges from 102° to 104° Fahr. In fatal 
cases, and occasionally in those that recover, the temperature may 
reach 107° Fahr. 
The first indication of convalescence is a fall in temperature ; 
in ordinary cases this occurs on the fifth day. A high temperature 
after the tenth day is an unfavorable symptom. 
Usually, the severity of a case can be determined by these three 
symptoms : the frequency of the pulse, the rapidity of the respira- 
tions, and the height of the temperature. If the temperature is 
above 104° Fahr., the pulse more than 120 per minute, and the 
respirations more than 40 per minute, the case must be regarded 
as a severe one. 
In most cases cough is present. It usually comes on within a 
few hours after the accession of the disease. For the first twenty- 
four hours, if there is any expectoration, it is simply bronchial 
mucus. After this time the cough will be accompanied by an ex 
pectoration which is so peculiar that it has been called the charac- 
teristic expectoration of pneumonia. The material spat out is 
a semi-transparent, gelatinous, tenacious, viscid substance, which 
will adhere so closely to the walls of the vessel which may contain 
it that the latter may be inverted without displacing it. Its color 
varies ; sometimes it is of a cream-yellow, again it is of a brick-dust 
or prune-juice hue ; the latter color indicates that there is danger. 
If a case is tending to a fatal termination, the expectoration be- DISEASES OF THE RESPIRATORY ORGANS. 
439 
comes scanty, less tenacious, and of a greenish color ; if recovery 
is to take place, it becomes profuse, and assumes a creamy appear- 
ance. In pneumonia occurring in connection with acute articular 
rheumatism, as also in the pneumonia of old people, expectoration 
is frequently absent. Pneumonia may run its entire course with- 
out recognition if attention is paid only to the cough and expecto- 
ration. 
In the majority of cases, the aspect of the countenance is 
quite characteristic of the disease. It is more or less flushed and 
anxious, and assumes a dusky tint, in some cases approaching 
lividity ; this is usually circumscribed on the cheeks, and may be 
compared to color resembling mahogany. 
Not unfrequently, early in the disease, little watery blisters 
make their appearance on the face and lips. 
Head symptoms occurring in the early stage of this disease have 
no special significance ; in the latter stage they may be of very grave 
import. Headache may be present early, and continue throughout 
the entire progress of the malady. Delirium and convulsions rarely 
occur except in debilitated subjects and in persons of dissipated 
habits. Delirium is most frequently met with in connection with 
acute alcoholism when it assumes the character of delirium tre- 
mens. In children the head symptoms may resemble those attend- 
ing inflammation of the brain. 
Symptoms referable to the digestive organs are not very impor- 
tant. The tongue is usually covered with a creamy coating ; in 
severe cases it becomes brown and dry ; when recovery commences 
the tongue usually becomes clear and moist. 
Loss of strength is present earlier and is more marked in pneu- 
monia than in any other acute disease except typhus fever. Gen- 
erally, the individual becomes very weak within four or five days. 
During convalescence, the recovery of strength and flesh is very 
rapid. 
In most cases, acute, uncomplicated pneumonia runs a definite 
course : it is ushered in by a distinct chill; this is followed by a 
rapid rise in temperature and an acceleration of pulse. The char- 
acteristic symptoms of the disease, which have been described, go 
on developing and increasing in severity until the critical day— 
the fifth or sixth after the chill. At this time a striking change 
takes place in the whole phenomena of the disease ; the pulse and 
temperature fall, sometimes gradually, at other times rapidly, the 
difficulty in breathing is not noticeable, and often within twenty- 
four hours convalescence is fully established. If the case does not 
pursue the regular course, that is, if the temperature remains high, 
or is higher after the sixth day than it has been at any previous 440 
DISEASES OF THE RESPIRATORV ORGANS. 
time, if the pulse becomes small and rapid, if great prostration 
comes on, and there is a tendency to stupor and delirium, if the 
tongue becomes brown and dry, it is evident that the disease is as- 
suming a typhoid character ; under such circumstances it is called 
typhoid pneumonia. 
In the pneumonia of old people and persons of depraved con- 
stitution, typhoid symptoms may develop early in the disease, or 
they may be present at its commencement. Under such circum- 
stances recovery is possible, but in the majority of instances the 
disease proves fatal. The age of the patient has more to do with 
the result than any other single element. Pneumonia almost inva- 
riably proves fatal when it occurs in a very young child, or in a 
very old person. The lowest rate of mortality is between the ages 
of ten and thirty. When an entire lung is involved the disease is 
more dangerous than when only one lobe is affected. Most cases 
terminate fatally when both lungs are attacked. 
During some seasons, pneumonia is much more fatal than it is 
at others; probably this is due to the influence of certain atmos- 
pheric conditions not well understood. When pneumonia is devel- 
oped in a person who has serious disease of any internal organ, it 
generally destroys life. There is special danger when it occurs 
during pregnancy. 
Marked disturbance of the nervous system always indicates a 
serious form of the disease. Active delirium, coming on at the end 
of the first week in a person who has been addicted to the exces- 
sive use of alcoholic drinks, is always an indication of danger. In 
old persons, a tendency to stupor and tremulousness at any time 
during the progress of the disease indicates danger, as does ex- 
treme prostration when accompanied by a sunken pallid counte- 
nance, and followed by a cold and clammy perspiration. 
Treatment.—The successful management of the disease de- 
pends not so much upon the treatment of the diseased lung as upon 
that which is directed to the constitutional condition of the patient. 
There is little doubt that a large number of cases of pneumonia 
would terminate in recovery if left entirely to good nursing and a 
nutritious diet. It is equally certain that many lives can be saved 
by judicious medical treatment, as also the duration of a mild 
form of the disease can be shortened and convalescence hastened. 
To repeat what has already been mentioned, there are condi- 
tions and periods of life in which pneumonia is almost certain to 
terminate fatally, and on the other hand, there are other conditions 
and periods of life in which the disease is almost certain to termi- 
nate in recovery. The tendency of uncomplicated pneumonia is 
to terminate spontaneously in crisis between the fifth and seventh DISEASES OF THE RESPIRATORY ORGANS. 
441 
day. Age, sex, certain constitutional conditions and atmospheric 
influences so modify the course of the disease, that, however mild 
the form, its treatment should never be undertaken without the 
aid of a physician. 
My own observations have led me to this conclusion, that in or- 
der to intelligently treat the pneumonia we must take into account 
the circumstances and conditions under which the individual is 
placed. In the severer types of the disease, occurring in enfeebled 
subjects, there are two sources of danger—viz.: high temperature 
and feeble heart-poiver; the latter may have existed prior to the at- 
tack, or may have been developed during its progress. We should, 
therefore, aim to accomplish reduction of the temperature and sus- 
taining the power of the heart. The means employed to accom- 
plish these results can be safely used only under the immediate di- 
rection of a physician. 
During convalescence from pneumonia, great care should be 
exercised that the nutrition is maintained, and that the surface of 
the body is not exposed to changes of temperature. If three or 
four weeks elapse after the subsidence of the acute symptoms, 
and the individual is still feeble, with more or less cough and ex- 
pectoration, a change of climate and habits of life will be attended 
by the most markedly beneficial results. 
It is all-important that the sick-room of any one suffering from 
pneumonia should be large and well ventilated ; its temperature 
should range from 68° to 70° Fahr. Great care should also be taken 
in regard to the diet. Absolute rest in a recumbent posture should 
be insisted upon ; he should not be allowed to get out of bed, 
neither should he be permitted to converse with friends. As in 
other acute diseases, as much, perhaps even more, depends upon 
careful and judicious nursing, as upon medicinal treatment. 
Catarrhal Pneumonia. 
Catarrhal pneumonia may be either acute or chronic. In its 
acute form, it is almost exclusively confined to childhood ; in its 
chronic form it bears a close relation to consumption. In most 
cases its development is preceded by or associated with capillary 
bronchitis ; the small bronchi leading to the inflamed lobules be- 
coming more or less completely obstructed. 
Acute catarrhal pneumonia, like acute croupous pneumonia, 
has three stages : 
First.—The stage in which there is congestion and engorgement 
of the affected portion of lung. 442 
DISEASES OF THE RESPIRATORY ORGANS. 
Second.—The stage in which the affected portions are solid and 
impervious to air. 
Third.—The stage in which the changes take place in the in- 
flammatory material, which fills the air-cells and bronchial tubes, 
previous to its being coughed up or absorbed. 
Causation.—It is essentially a disease of childhood, occurring 
between one and six years of age. It is especially liable to be de- 
veloped in the bronchitis which attends Avliooping-cough, measles, 
diphtheria, and influenza. 
Debility, inhalation of impure air, and a long-continued recum- 
bent posture predispose to its development. When this disease oc- 
curs in the aged, in enfeebled adults, or in those suffering from 
acute infectious disease, it is generally of the chronic variety. 
Symptoms.—In most cases this form of pneumonia is second- 
ary to some other disease, it is therefore difficult to give a history 
of the phenomena which attend its development, as they are so 
frequently obscured by those of the disease which has preceded 
its development. If it occurs as a primary affection, these phe- 
nomena very closely resemble those which attend the development 
of croupous pneumonia. The symptoms which commonly attend 
its early stage may be the more readily appreciated if the history 
of its development is given in connection with that of the diseases 
with which it most frequently occurs. For instance, a child with 
an ordinary bronchial catarrh, or a bronchitis attending measles or 
whooping-cough, has a temperature ranging from 101° to 102° Falir.; 
if acute catarrhal pneumonia be developed, it rises within a few 
hours to 104° Fahr. The pulse and respirations are immediately ac- 
celerated, the respirations which before were labored, now become 
panting, the countenance becomes flushed and anxious, the nos- 
trils are distended, and there is great restlessness. The cough, 
which previously was loose, now becomes dry and hacking, and is 
attended with little expectoration ; there is nothing characteristic 
about it, as in croupous pneumonia. The course of this form of 
pneumonia may be exceedingly acute and rapid, or it may be sub- 
acute in character, and run a slow, lingering course. When it 
runs an acute course, it may prove fatal in a few days; especially 
is this the case in feeble children. 
The subacute form occurs in connection with the bronchitis of 
scrofulous children just recovering from measles or whooping- 
cough. In this form, the elevation of temperature is not so sud- 
den, and the accession of all the pneumonic symptoms is more 
gradual. The child loses flesh, becomes pale, has profuse sweat- 
ings and fits of exhaustion, his appetite becomes capricious or is 
entirely lost, his face becomes bloated, and death occurs as the DISEASES of the respiratory organs. 
443 
result of progressive exhaustion. In some cases, after a prolonged 
illness, when, apparently, death must ensue, a slow, but complete 
recovery is made. 
When catarrhal pneumonia occurs as a complication with 
measles it more frequently terminates fatally than when it occurs 
with whooping-cough. It is especially dangerous, when it occurs 
as a sequence to scarlet fever in which the kidneys are affected. 
The chances for recovery are always better in one who has no or- 
ganic disease at the time of the attack. When the hygienic sur- 
roundings are bad, the chances for recovery are diminished. When 
the temperature is above 105° Fahr., it is regarded as a specially 
unfavorable symptom. 
Treatment.—In the treatment of this form of pneumonia, it 
must be constantly borne in mind that it is a secondary affection, 
the child is already in a debilitated condition, and a supporting 
plan of treatment is indicated. In order to the successful manage- 
ment of this disease, it is of importance that the patient be kept in 
a well-ventilated room, with the temperature ranging between 65° 
and 70° Fahr. No sudden variations of temperature should be al- 
lowed. The body and extremities ought to be covered with flannel, 
and the child should be kept in bed until convalescence is fully es- 
tablished. During the entire course of the disease the food should 
be fluid, nutritious, and given in the most concentrated form. 
Great care must be exercised while the child is convalescing, all 
fatigue and exposure should be avoided, lest a fresh bronchial at- 
tack be induced. 
Interstitial Pneumonia. 
This form of pneumonia never occurs as a primary affection, 
and never runs a distinct course ; even its existence can be de- 
tected only by a careful physical examination of the chest, and 
this must be made by a skilful physician. The diseased processes 
have their seat in the intercellular structure of the lung. 
Symptoms.—The symptoms which attend its development are 
never well marked. There is no rise in temperature, nor accelera- 
tion of the pulse. Its existence is first indicated with any degree 
of positiveness by the retraction of the chest-walls over the affected 
portion of the lung. The constitutional symptoms are a gradual 
loss of flesh and strength, sometimes night-sweats ; there is no 
fever. When this form of pneumonia is once fully developed, it 
is incurable. This disease will be more fully considered in connec- 
tion with consumption. 444 
DISEASES OF THE RESPIRATORY ORGANS. 
Pulmonary Consumption—Phthisis Pulmonalis. 
In this country there are more deaths from pulmonary con- 
sumption than from any other chronic disease. Its symptoms, 
such as progressive emaciation, cough, night-sweats, hectic flush, 
and diarrhoea, are so characteristic, and the duration of the dis- 
ease is so protracted, that its existence is readily recognized by 
non-professional persons; at the same time, its occurrence is so 
common that nearly every person is familiar with its general fea- 
tures. 
There is great diversity of opinion among medical men in re- 
gard to the exact nature of consumption. One class of observers 
maintain that the changes which take place in the lungs in con- 
sumption are inflammatory ; another class hold the belief that they 
are due to the development and breaking down of tubercles in the 
lung-tissue. My own observations lead me to the opinion that 
these changes vary greatly in their nature in different cases, and 
that there are several varieties of consumption, which are marked 
by very different anatomical changes in the lung-tissue. I shall 
therefore describe the disease under three general heads : 
1st. Catarrhal Consumption. 
2d. Fibrous Consumption. 
3d. Tubercular Consumption. 
These different forms may occur separately, or they may all 
be developed in the same individual. Undoubtedly the most com- 
mon form is that in which there is a union of the catarrhal and 
fibrous processes. 
Catarrhal Consumption. 
At the commencement of the disease, there is usually a catarrh 
of the lining membrane of the air passages, more particularly of 
the lining membrane of the bronchial tubes which ramify in the 
upper lobes of the lungs. We do not always know what causes 
this catarrh. It differs from every other bronchial catarrh, in its 
persistency and in its tendency to recur. It first invades the lar- 
ger bronchi ; from them it passes to bronchial tubes of smaller size 
until it reaches the most minute branches of the bronchial tree, 
which become so completely obstructed by the products of the 
inflammatory process, and by the changes in the wall of the bron- 
chial tubes, that the passage of air to the air-cells beyond is en- 
tirely obstructed, and, as a result, the air-cells beyond the point of 
obstruction collapse. Following the collapse a peculiar form of 445 
diseases of the respiratory organs. 
inflammation is set up in the closed lobules, which ends in consoli- 
dation and degenerative changes, leading, finally, to the forma- 
tion of little cheesy masses. After two or three such attacks of 
bronchial catarrh and lobular consolidation a sufficient extent of 
lung-tissue becomes involved to lead to softening and the forma- 
tion of cavities in the lung. The length of time which a cheesy 
nodule thus formed may remain unchanged in the lung depends 
partly upon its size, and partly upon the rapidity of its formation ; 
the larger its size and the more rapid its formation, the greater 
the danger of softening and the formation of cavities. If the chan- 
ges which take place in the cheesy masses progress slowly, fibrous 
tissue maybe developed around them, and the destructive processes, 
for a time, will be arrested ; but if the changes take place rapidly, 
but little fibrous tissue is developed and the destructive process 
goes on rapidly, so that the development of fibrous pneumonia in 
connection with the pathological processes of catarrhal consump- 
tion must be regarded as a conservative process. 
Fibrous Consumption. 
The development of an excess of connective-tissue which occurs 
in this form of consumption, may commence in the intercellular 
tissue around the blood-vessels, or extend into the lung-tissue from 
the pleura, or it may commence in the walls of the air-cells, and in 
the connective-tissue sheaths of the minute bronchial tubes. It 
may or may not be associated with chronic catarrhal pneumonia. 
Sometimes the pleura over the hardened lung-tissue is thickened 
half an inch. When this indurating process has existed for some 
time, the apex, and in some instances the whole of the lung is con- 
verted into a tough, fibrous tissue, all trace of normal lung being 
obliterated. Within this fibrous mass the bronchial tubes present 
various conditions : at one point their walls are thickened and their 
calibre diminished, while at another point, they are thinned and 
dilated. 
Tubercular Consumption. 
In lungs which are the seat of this form of consumption, there 
are found scattered more or less abundantly throughout its sub- 
stance small, grayish, semi-transparent granules about the size of 
a millet-seed ; sometimes the entire lung is studded with these little 
bodies which are called tubercles. These little granules may unite 
and form nodules of greater or less size. In the lung-tissue adja- 
cent to these nodules, inflammation is usually set up. As the dis- 446 
DISEASES OF THE RESPIRATORY ORGANS. 
ease progresses these tubercles soften, break down, and cavities 
are formed in the lung substance. 
Tubercles may be formed in the fibrous tissue of the bronchial 
tubes, in the wall of the blood-vessels, in the connective-tissue of 
the lung, and in the walls of the air-cells. 
Causation.—Although consumption in its advanced stages must 
be regarded as an incurable disease, yet, with our present knowl- 
edge of its causes we may hope to be able to prevent its develop- 
ment in a large proportion of cases. Consequently the question of 
its causation becomes a very important element in its history. 
The causes of consumption may be classed under two general 
heads. 
1.—The general causes. 2.—The local causes. 
Under the head of general causes I shall make three sub-divi- 
sions. 
First.—Hereditary or acquired feebleness of constitution. 
Second.—Anti-hygienic influences. 
Third. —Climate. 
Under the head of local causes are the following : 
First, bronchitis. Second, pneumonia and pleurisy. Third, 
mechanical irritation. 
These two sets of causes may be associated, or they may ope- 
rate separately in the production of this disease. 
Hereditary influences.—There is no question that certain he- 
reditary influences have very much to do in preparing the way for 
the development of consumption. Some careful observers have 
maintained that consumption can never be developed in an indi- 
vidual who has no hereditary tendency to the disease. Every 
day’s experience disproves this statement. On the other hand 
equally competent observers have maintained that consumption is 
hereditary in comparatively few cases; this statement is also con- 
trary to the same experience. 
The statement that hereditary influences cause consumption is 
better understood and appreciated, when we take the position that 
it is not the consumption ivhich is transmitted f rom parent to off- 
spring, hut a feebleness or vice of constitution, which so affects the 
individual that consumption may readily be developed when he is 
subjected to certain local, exciting causes. Especially is this the 
case in the children of the aged, of drunkards, of those enervated 
by excesses of any kind, or those who at the time of the birth of 
their children were suffering from some form of constitutional dis- 
ease, such as cancer, syphilis, rheumatism, etc. Therefore, in 
order to fully appreciate the influence of hereditary taint, it is ne- DISEASES OF THE RESPIRATORY ORGANS. 
447 
eessary to know the physical condition of the parent at the time 
of the individual’s birth. 
Anti-hygienic influences.—So long as poverty and destitution, 
dissipation and enervating luxury shall exist, anti-hygienic influ- 
ences must be regarded as next in importance to hereditary influ- 
ences in the causation of consumption. Among these, are impure 
air, food of improper quality and in insufficient quantity, insuffi- 
cient clothing, damp and badly-ventilated apartments, intemper- 
ance in the use of alcoholic stimulants, prolonged lactation, want 
of cleanliness, and all those influences which arrest or lessen the 
function of the skin. 
It needs no argument to prove that the foundation for a strong 
and vigorous, or for a weak and feeble constitution, is to a great 
extent laid during the first two years of infantile life. 
Let a healthy child during its infancy and early childhood live 
in small and badly-ventilated apartments, with improper diet, and 
all the attendant anti-hygienic influences by which the tenement- 
house population of great cities is surrounded, and it will become a 
feeble child ; and though maturity may be reached, yet it will have 
stamped upon it such a vice of constitution, that consumption will 
be developed upon the least local exciting cause. 
The opinion prevails that sooner or later consumption is certain 
to develop in those who have a strong hereditary predisposition to 
the disease ; that because a father, mother, brother, or sister have 
died of consumption, the disease will develop in the other mem- 
bers of the same family. Whereas the antecedent hygienic influen- 
ces under which the childhood or adult life has been passed have 
much more to do with the development of the disease than has the 
hereditary tendency. 
How few infants are properly fed ! How few mothers, espe- 
cially among the wealthier class, are in a condition to properly 
nourish their offspring. The feeding of children until they are 
one, two, or even three years of age, upon barley-water, pap, 
sweetmeats, and indigestible articles of diet, has a most pernicious 
influence upon their future physical development, and if at the 
very entrance of adult life, some local inflammation of the lungs 
or bronchial tubes does not cause the development of consump- 
tion, the case will be an exception, and not the rule. The over- 
coming of such constitutional tendency should be aimed at in the 
physical training of such children during their infancy and child- 
hood. In the majority of cases this can be accomplished before 
the age of puberty is reached. A mother who has a consumptive 
history should never be allowed to nurse her own children; they 
should be nursed by a vigorous non-consumptive wet-nurse. 448 
DISEASES OE THE RESPIRATORY ORGANS. 
All of these predisposing influences, both in childhood and adult 
life, produce the one result, viz.: the arrest of physical develop- 
ment, and thus the power of resistance is lessened, and the indi- 
vidual is in such a condition as to be readily acted upon by the lo- 
cal causes which lead to the development of consumption. 
Climate.— It can hardly be said that there is any climate which 
prevents the development of consumption, or renders that develop- 
ment a necessity. There are, however, certain conditions of cli- 
mate which favor its development, and there are likewise certain 
conditions which, to a certain extent, are antagonistic to its devel- 
opment. For example :—a damp, cold climate, depending upon cer- 
tain conditions of soil, undoubtedly favors the development of con- 
sumption. On the other hand, consumption is rarely developed in 
a moderately high altitude; therefore, to a certain extent, high 
elevation is antagonistic to its development. There can be little 
question but that consumption occurs much more frequently in 
one latitude than in another, for instance, it is of much more fre- 
quent occurrence in the temperate, than in the torrid or frigid 
zone. 
Local Causes.—Under this head are included bronchitis, pneu- 
monia, pleurisy, and mechanical irritants. That repeated attacks 
of bronchitis may terminate in consumption has long been known. 
It is a well-established fact, that a large proportion of the cases of 
consumption begin with a catarrh, which gradually extends from 
the larger into the finer bronchial tubes, and finally involves the 
air-cells of the lungs. 
Why such catarrhs should lead to such results in one person 
and not in another, can readily be explained by referring to the 
general causes of consumption, to which allusion has already been 
made. When an individual is in a condition to resist an attack of 
bronchitis, it usually terminates speedily in complete recovery; if 
any or all of the predisposing causes of consumption, which have 
been detailed, are in operation, the bronchial catarrh progresses 
and consumption is the result ! 
The development of this disease from catarrhal pneumonia has 
already been sufficiently considered. The frequency with which 
it follows an attack of pleurisy leaves little doubt but that pleuritic 
inflammation is a very frequent local exciting cause. 
Mechanical irritation of the lining membrane of the respira- 
tory passages produced by the constant inhalation of air laden 
with dust and noxious gases, very frequently is the exciting cause 
of consumption. 
The causes of tubercular consumption are still undetermined. 
Many persons believe that the little tubercular granulations in the 449 
DISEASES OF T1IE RESPIRATORY ORGANS. 
lungs, which are the local cause of its development, are due to a 
specific infection. 
Symptoms.—Each variety of consumption has a few prominent 
characteristic symptoms; to these I will briefly refer, and will then 
consider those symptoms which are common to all varieties. 
Chronic Catarrhal Consumption.—This is the most common 
form, and generally begins as a common cold. No very active 
symptoms mark either its advent or development. After the 
cough has continued for some time, the expectoration becomes te- 
nacious, and is now and then streaked with blood. The individual 
gradually loses flesh and strength; is constantly, as is said, add- 
ing to his cold,” until after a variable time, he begins to have fe- 
ver and sweats, and becomes too feeble to continue his accus- 
tomed vocation, and is compelled to seek the advice of a physi- 
cian. Occasionally, this variety of consumption is developed from 
acute catarrhal pneumonia; then its advent is marked by active 
symptoms. 
Tubercular Consumption differs from catarrhal consumption in 
that the constitutional symptoms precede the local. Usually, for 
some time prior to the development of the local symptoms, the indi- 
vidual loses flesh and strength, has dyspeptic symptoms with com- 
plete loss of appetite, and more or less febrile disturbance. During 
this period the individual continues to go about, but constantly 
complains of physical weakness and an incapacity to do anything 
that requires mental application. At night there is more or less 
profuse sweating, and inability to sleep on account of a dry, hack- 
ing cough. A high range of temperature, rapid emaciation, and a 
dry, hacking-cough are the early and prominent symptoms of 
tubercular consumption. 
Fibrous Consumption is distinguished from all the other forms 
by its great chronicity. It comes on obscurely, and it is charac- 
terized by the signs of bronchitis, or of pleurisy limited to one side. 
After cough and expectoration have existed for some time, the in- 
dividual commences to lose flesh and strength, the cough increases, 
and the expectoration becomes more abundant. Gradually, the 
ordinary symptoms of consumption are developed, although at no 
time is there any very marked rise in temperature, or great accel- 
eration of the pulse. 
Increased frequency and difficulty of respiration is present in a 
greater or less degree in every variety of consumption. It is a 
marked symptom only after or during physical exertion ; an indi- 
vidual, even in the advanced stage of the disease, may not suffer 
from difficult breathing while lying quietly in bed. Pain in the 
chest is neither a very prominent nor a constant symptom, except 450 
DISEASES OF TIIE RESPIRATORY ORGANS. 
in connection with pleuritic changes. Dry pleurisies occur often 
during the course of the disease, and they cause intermittent attacks 
of pain ; these are usually located under the “ shoulder-blade.” 
Cough is usually present at the onset of the disease, and con- 
tinues through its entire course. Usually, at first it is dry and 
paroxysmal, or hacking in character, and is attended by slight-ex- 
pectoration ; if the latter is present, it is small in quantity, tena- 
cious in character, and gives the individual great trouble in its 
removal. 
Many persons cough but little, except in the morning after rising. 
Others have paroxysms throughout the twenty-four hours, with 
intervals of rest. In advanced cases the intervals of rest are short. 
As the disease progresses the cough has a rattling sound, is more 
or less hollow, and when cavities are formed, it assumes a peculiar 
sepulchral tone. 
Expectoration.—At first the expectoration may be composed of 
tenacious mucus. If fine yellow streaks are to be seen in it, it is 
an indication that the catarrh has extended into the fine bronchial 
tubes. If, with these yellow streaks, there are streaks of blood, it 
may be inferred that the inflammation has reached the lobules of 
the lung. When cavities are formed the expectoration changes ; 
then it appears in rounded masses of a grayish color, and when 
thrown into a cup, they remain separate. As the cavities increase 
in size, the rounded masses gradually disappear and purulent mat- 
ter in large masses, with small masses of cheesy matter mingled 
with it, are spat up. The quantity of matter expectorated varies, 
and depends upon the extent of the bronchial catarrh, and the 
number and size of the cavities. 
Fever.—A case of consumption is rarely seen, in which there is 
not a rise in temperature, and the variations which occur are very 
great. What is known as hectic fever may be present in each va- 
riety of consumption. The symptom by which it will be recog- 
nized is the “ night-sweats.” 
Hectic fever has three stages: a cold, a hot, and a sweating 
stage. These do not necessarily follow each other with any regu- 
larity. Sometimes in the course of the day the individual will have 
a creeping, chilly sensation, or a distinct chill lasting from a half- 
hour to an hour ; then there will be felt some dryness of the sur- 
face ; perhaps, in a short time, the temperature will rise to 103° or 
104° Fahr., and the fever will last a variable length of time, giving 
to the face that peculiar, brilliant hue, and to the cheeks that rose 
tint which is so characteristic and so well known. After a time 
the fever gradually subsides, and sometimes in the course of the 
night, perhaps towards morning, comes on the stage of sweating. DISEASES OF THE RESPIRATORY ORGANS. 
451 
These night sweats are usually very profuse and very exhausting. 
Hectic fever may occur during any stage of consumption ; usually, 
it is present during the stage of softening and the formation of 
cavities, but it is not necessarily confined to that stage. If it oc- 
curs early in the disease, it is an indication of tubercular phthisis. 
After hectic fever has occurred, it sometimes disappears without 
any apparent cause. 
Pulse.—The pulse is generally accelerated and corresponds to 
the variations in temperature. Any slight excitement will cause 
an increase in frequency of fifteen to twenty beats in a minute. 
In tubercular consumption it is accelerated for a greater length 
of time than in either of the other varieties. In fibrous consump- 
tion it rarely is more frequent than 100 beats per minute. 
Emaciation is a very constant attendant of consumption, but it 
is not always progressive. In the chronic forms of the disease it 
is usually, very slow, the individual will alternately lose and gain 
flesh. In tubercular consumption the emaciation is progressive and 
rapid. With the emaciation, the countenance assumes a peculiar 
pallor which is quite characteristic, and consumptives very early 
complain of great debility and loss of muscular power. 
Disturbance of the digestion is a common attendant of con- 
sumption, and often in the early stages of the disease there is great 
repugnance to food. 
Vomiting is frequently a troublesome symptom, and it is usual- 
ly reflex in character—caused by violent coughing. It may be 
due to a catarrh of the stomach, which is a frequent attendant of 
this disease. 
Diarrhoea.—Few consumptives escape diarrhoea. It may be 
due to irritation of the intestines produced by undigested food, or 
to ulceration of the intestinal mucous membrane, and it may come 
on during any stage of the disease. In some cases diarrhoea alter- 
nates with the hectic fever; one appearing as the other disappears. 
Unless it can readily be controlled it must always be regarded as 
an unfavorable symptom. 
Hemoptysis, or “spitting blood,” may occur in any stage or 
form of consumption. The quantity of blood expectorated varies ; 
there may be only a slight trace of blood, or the quantity expec- 
torated may be increased to even more than a pint. It makes its 
appearance with coughing, and is to be distinguished from all 
other bleedings from this region by the arterial-red color of the 
blood and the presence of more or less air-bubbles, giving it a 
frothy appearance. 
Bleeding from the lungs in the early stage of consumption may 
be profuse, but is rarely, if ever, dangerous or immediately fatal, 452 
DISEASES OF THE RESPIRATORY ORGANS. 
although in an advanced stage of consumption, it may be the 
direct cause of death. I have already considered the subject under 
the head of bronchial hemorrhage. [See page 426.] 
Changes in the voice, which occur during the course of con- 
sumption, are due to inflammation affecting the upper part of the 
wind-pipe (or larynx). In advanced consumption this laryngitis 
sometimes gives rise to the most distressing symptoms, such as per- 
manent loss of voice, burning pain in the upper part of the wind- 
pipe, and extreme difficulty of and pain during swallowing. La- 
ryngeal complications are always unfavorable. [See page 396.] 
CEdema or swelling of the feet and legs is always a grave symp- 
tom. Its occurrence usually indicates that a fatal issue is not far 
distant. 
There is a general impression that an individual with consump- 
tion is doomed to die within a limited period. Undoubtedly a 
large majority of cases will terminate fatally, yet improvement is 
possible in all stages of this disease ; approximate recovery may 
take place in more than half the cases, and complete recovery is 
not infrequent. In each case the result depends very much up- 
on the variety and stage of the disease. Cases of tubercular con- 
sumption are, as a rule, rapid in their development, and terminate 
fatally within a year. In the catarrhal variety, the condition of 
the individual at the time of the attack, the power of resisting the 
disease, and the stage of its development determines, to a great 
extent, the result of the case. In fibrous consumption, although 
complete recovery rarely takes place, the individual may live 
many years in comparative health. Complete recovery can be 
hoped for only in the catarrhal variety ; and in this variety only 
during its first stage. Many cases which seem to be recovering, 
suddenly assume an unfavorable aspect on account of the occur- 
rence of some complication. 
It should be remembered that a consumptive who has no symp- 
toms which are immediately alarming, may suddenly develop an 
emphysema, a pneumo-thorax, a peritonitis, intestinal ulceration, 
a profuse hemorrhage, a capillary bronchitis, or an acute pneumo- 
nia, and thus rapidly pass into a condition of great danger. 
Treatment.—One should be familiar with the causes which lead 
to the development of consumption, in order to properly under- 
stand what is required in its treatment. I have already stated 
that in a large proportion of cases, consumption is the result of a 
hereditary or an acquired vice of constitution. It is evident that 
it is of the greatest importance that this vice be removed, and thus 
the development of this disease be prevented. It is during the 
period when preventive measures can be employed, that we have DISEASES OF THE RESPIRATORY ORGANS. 
453 
the greatest power in controlling or preventing the development 
of this disease. 
To illustrate : suppose a person with a delicate constitution, 
with a tendency to consumption, either hereditary or acquired, be- 
gins to emaciate, to lose strength, and to furnish other evidences 
that there is a marked interference with the nutritive processes ; 
it is of the greatest importance that such an individual be immedi- 
ately placed under those influences which favor the arrest of this 
defective nutrition, and which have a tendency to invigorate the 
system and thus counteract this morbid tendency. 
If such a train of symptoms are developed in a person whose 
occupation or habits of life compel him to spend the greater part 
of his time within doors, his occupation and his sedentary habits 
must be changed. If an individual with such tendencies is living 
in a locality where he is subjected to depressing influences, a 
change of locality must be insisted upon. 
All those influences which tend to produce congestion and ca- 
tarrh of the bronchial tubes should be avoided. Individuals with 
consumptive tendencies should be careful not to breathe an atmos- 
phere laden with dust or charged with unwholesome vapors ; nor 
should they engage in occupations which compej. them to pass sud- 
denly from an atmosphere of extreme heat to one of extreme cold, 
or from one of extreme cold to one of extreme heat. Remaining 
in a crowded room for a few hours and then going into a cold, raw 
air should be avoided, as all such exposure for one with consump- 
tive tendencies is especially liable to lead to consumptive develop- 
ments. All extreme physical exertion should be avoided, for such 
exertion may be the cause of pulmonary hemorrhage. The surface 
of the body should be protected with the greatest care; flannel 
should be worn next the skin throughout the year. Persons with 
the tendencies described should sleep in large, well-ventilated apart- 
ments, and should engage in those pursuits which afford the great- 
est exposure to fresh air. Great care should be exercised in regard 
to the diet, which should be simple, of the most nutritious quality, 
and should be taken at regular intervals. The quantity of food 
taken should be limited only by the powers of digestion. Milk and 
cream are articles of diet especially adapted to this class of indi- 
viduals. 
Every catarrh, however slight, should be treated with the 
greatest care, and the treatment should be continued until all traces 
of the catarrh have disappeared. If the catarrh shall have reached 
the smallest bronchi, and the cough is persistent and accompanied 
by a tenacious expectoration, the necessity for its arrest or removal 
becomes imperative. A change of air is more certain to produce 454 
DISEASES OF THE RESPIRATORY ORGANS. 
this result than any other means which can be employed. If the 
individual lives in a mountainous region he should go to the sea- 
side ; if by the sea he should go to the mountains. The great ob- 
ject in the preventive treatment of consumption is to sustain the 
vital powers that the individual shall not become susceptible to 
the local causes of consumption. 
Medicinal Treatment.—This relates solely to the management of 
consumption already developed. There are a few remedial agents 
which are extensively employed in the treatment of this disease, 
but there are no specifics. Prominent among these is cod-liver oil. 
At one time this agent was thought to cure consumption, but it is 
very doubtful whether it has any direct curative power over the 
disease. Its beneficial influence is probably due to the fact that it 
furnishes some element which is essential to the digestion and 
assimilation of certain nutritive constituents of the food ; exactly 
what that element is, is not known. It always acts remedially 
with more certainty in young persons and in children than in the 
aged. As a rule, old persons are not very much benefited by its 
use. There are certain practical points relating to its administra- 
tion worthy of mention. 
If possible, it should be given in connection with some alkali, 
such as soda, lime, or magnesia. It should not be administered 
with stimulants, unless it cannot be taken in any other way. No 
special benefit is derived from the administration of large doses. 
A teaspoonful once or twice a day will produce decided beneficial 
results, and a tablespoonful three times a day is as large a quan- 
tity as can be taken with benefit. Most persons prefer to take it 
immediately after meals, others can take it best when ready to 
retire for the night. 
The inhalation of medicinal substances, vapors, and gases, has 
been very generally tried in the treatment of consumption, but 
there is no evidence that these substances, vapors, or gases have 
any power to control or arrest the progress of the disease. In 
many instances such inhalations do harm by exciting inflamma- 
tion of the bronchial mucous membrane. Experience is decidedly 
against their use. 
Alcohol.—Experience does not sustain the opinion that alcohol 
has power to arrest consumptive developments. For a time, its 
daily use may mask the consumptive symptoms, and the individ- 
ual, as well as his friends, may imagine that the progress of the 
disease is stayed, but a condition is soon reached when it is ap- 
parent that large doses do not arrest its progress. Alcohol is not of 
service, unless it increases the desire for food and assists in diges- 
tion, except, perhaps, in exceptional cases, when, from the influ- DISEASES OF THE RESPIRATORY ORGANS. 
455 
ence of some depressing cause, there is a physical demand for 
it, as after extreme fatigue or prolonged exposure to cold. It 
is exceedingly unfortunate for consumptives to become addicted to 
the daily use of stimulants. Malt liquors and wines are usually 
more serviceable than spirituous liquors. 
Cough Mixtures.—There is a universal demand for something 
to relieve the cough. All cough mixtures that afford relief contain 
some anodyne, usually opium. It should be borne in mind that 
the well-being of every consumptive depends upon his power of 
digesting and assimilating food; everything that interferes with 
this should be avoided. Cough mixtures may afford temporary 
relief from a distressing symptom, but they always interfere with 
the digestive functions, and consequently do harm. Their use 
should be delayed as long as possible, and they should only be 
used under the direction of a physician. 
The treatment of the diarrhoea, the night sweats, and the 
hemorrhage all require the personal attendance of a medical ad- 
viser. 
Climatic Treatment.—The question of climate is of great im- 
portance in the treatment of consumption, especially during its 
first stage, and it is only during this stage that any permanent ar- 
rest of its development can be expected. The individual peculiar- 
ities of each case of consumption will decide the question of local- 
ity. Let the consumptive invalid recall whether, when in health, 
he was most vigorous in warm or cold weather, in a damp or dry 
atmosphere, and his experience may be of service in his choice of 
locality. 
Nearly every variety of climate can be found in our own coun- 
try. Minnesota has a dry, cold climate. A dry, warm atmosphere, 
may be found in certain sections of California, and in the southern 
portion of Georgia. The Bermudas, some of the West India 
Islands, and the eastern portion of Florida have a warm, moist 
climate. To persons likely to be benefited by a cool and moder- 
ately moist climate, I know of no locality I can more heartily 
recommend than the Adirondack region in our own State. 
Some consumptive invalids do better among the mountains, 
others on or by the sea. In whatever locality a person with con- 
sumption improves, there he should remain, so long as the im- 
provement continues. 
Physical exercise is another essential element in the treatment 
of consumption. It should never be carried to over-fatigue, and 
it should be in the open air, or in a well-ventilated room. 456 
diseases of the respiratory organs. 
Peculiarities of Affections of the Respiratory Organs in 
Children. 
In the preceding history of the diseases affecting the respiratory 
organs, general reference has been made to their occurrence in 
adults, yet their nature and course is essentially the same when 
they occur in children. 
There are certain differences, some of which I will briefly notice. 
In children the nervous element greatly modifies the development 
and progress of all acute lung affections. In very young children 
the shock given to the nervous system by the onset of an acute 
bronchitis or pneumonia often causes convulsions. These are 
followed by brain symptoms, and, on this account, acute pulmo- 
nary affections are frequently mistaken for acute diseases of the 
brain. 
The Bronchitis of children is usually preceded by catarrh of the 
larynx. The child appears to have taken cold ; he is hoarse, and 
frequently has what is called “ false croup,” which, to a certain 
extent, is due to a spasm of the larynx. In the adult no such 
croupy symptoms are present in the early stage of a bronchitis. * 
Simple bronchitis more frequently extends to the small tubes in 
children than in adults, and is, therefore, much more dangerous. 
Spasmodic Asthma, in children, is always hereditary. I have 
seen a fully developed asthmatic paroxysm in a child three weeks 
old, born of an asthmatic mother. Atmospheric conditions seem 
to have little or no influence in developing asthmatic paroxysms 
in children, while in adults their effect is marked. 
Congestion of the Lungs in children is most frequently associated 
with the eruptive fevers, such as scarlet fever and measles ; while 
in adults it occurs most frequently in connection with heart dis- 
eases. 
Dropsy of the Lung—Pulmonary (Edema, or the passage of a 
watery fluid from the blood-vessels into the lung-tissue, and into 
the cavities of the air-cells, occurs much less frequently in chil- 
dren than in adults. In adults it often complicates acute pulmo- 
nary diseases, and is a frequent cause of death, while in children 
this rarely occurs, but it is occasionally met with in connection 
with diseases which obstruct the passage of air through the 
larynx. 
* [The larynx of a young child is relatively smaller than in an adult, and therefore, 
when the mucous membrane lining it becomes over-filled with blood and swollen, the 
space is considerably narrowed, and a croupy cough is apt to be produced.—Ed.] DISEASES OF THE RESPIRATORY ORGANS. 
457 
Collapse of the Air-Cells—Atelectasis. 
This disease is frequently met with in children, rarely in adults. 
It is a condition in which there is imperfect or entire absence of 
expansion of the lungs. Before birth this is the natural condition 
of the lungs, but if it continues after birth it becomes morbid and 
is then known as congenital atelectasis. It sometimes occurs that 
a portion of lung which has been perfectly expanded loses its ca- 
pacity for air, and collapses. This may take place as the result of 
complete obstruction of a bronchial tube, or as the result of exter- 
nal pressure, such as arises from tumors, rickets of the bones of 
the chest, or fluid accumulation in the chest, and is then called 
acquired atelectasis. Congenital atelectasis is the most common 
form. A circumscribed atelectasis is frequently met with in pneu- 
monia of the lobules of the lung. 
Symptoms.—When atelectasis involves only a small portion of 
lung, it does not give rise to symptoms. When large portions of a 
lung are involved, the breathing is superficial and rapid, the chest 
does not expand well, the ends of the fingers and the face are 
bluish, the voice is weak, nursing is imperfectly performed, and 
the surface of the body is paler and cooler than natural. Children 
in this condition are unusually inclined to sleep, and do not cry. 
In the new-born infant, if the atelectasis is extensive, it usually 
terminates fatally within a few days after birth. Occasionally life 
is prolonged two or three weeks ; then the child dies with all the 
symptoms of suffocation or in convulsions. 
In cases of slight congenital atelectasis, if the child is otherwise 
healthy, with favorable surroundings, the prospect of recovery is 
good. If the atelectasis is acquired, the prospect of ultimate 
recovery depends upon the condition causing it, and if that is 
removed entirely and rapidly (as, perhaps, it may be in fluid accu- 
mulations in the chest), the recovery will probably be complete. 
Treatment.—As atelectasis is more liable to occur in children 
whose bronchial tubes are partially or completely stopped by mu- 
cus or other substances, it is of the utmost importance that the 
mouth be thoroughly cleaned immediately after birth and that 
then the child be made to cry. Crying necessitates a preceding 
deep inspiration, and what is most needed is perfect expansion of 
every portion of the lungs. It is also important that those chil- 
dren be warmly clothed and kept thoroughly dry. The object is 
to protect them as far as possible from the danger of a catarrh. 
If the child is unable to nurse properly, it must be fed artifi- 
cially. The skin must be kept in a healthy condition, which can 458 
DISEASES OF THE RESPIRATORY ORGANS. 
be done by regular bathing with warm water. Respiration can 
be stimulated by irritating the skin, as by tickling the nose, or the 
soles of the feet, or by sprinkling with cold water. The strength 
of the child must be sustained by nourishing food, and, if neces- 
sary, by medicine and stimulants. 
In congenital atelectasis the condition of the child will be no- 
ticed soon after birth, and a physician’s aid should be sought. 
Pleurisy. 
Pleurisy in children is usually of the suppurative variety; the 
product of the inflammatory process is chiefly pus ; in adults the 
inflammatory product is usually fibrin and serum. For this rea- 
son pleurisy is a much more grave disease in the child than in the 
adult. Children with pleurisy usually complain of pain in the 
abdomen rather than in the affected side. 
Pulmonary Consumption. 
Pulmonary consumption in children, in the majority of cases, 
is of the catarrhal variety. Tubercular consumption rarely oc- 
curs in children unless there is general tuberculosis. 
Inflammation of the Lung. 
[A peculiar form of inflammation of the lung is apt to occur in 
very young infants who are either feeble from their birth, or who 
have become so in consequence of some severe and acute disease. 
When such children are allowed to lie too long in one position, it 
is found that, owing to the weak action of the heart, the blood stag- 
nates in the lowermost portions of the body, and especially in the 
lungs, and it is not uncommon for the congestion thus produced 
to develop into a condition closely resembling pneumonia. 
When this condition is added to the one previously existing, 
the chances for recovery are very much lessened. Care should 
always be taken, therefore, that children who are in this feeble 
state shall not lie too long without being turned over, or even taken 
in the arms, unless there are reasons for the contrary. 
The form of pneumonia common to adults, and called croupous 
pneumonia, is not often seen during the period of infancy. The 
kind which is most often met with is of a catarrhal nature, and 
instead of involving one or more of the anatomical divisions of 
the lungs—called lobes—it is confined to the lobules or smaller 
divisions comprising a group of air-cells. A number of these 459 
DISEASES OF THE RESPIRATORY ORGANS. 
lobules may be the seat of the disease, and they may either be 
close together, in which case a considerable mass of lung-tissue 
may be rendered solid, or they may be scattered about in a portion 
of the lung substance. 
Treatment.—None but a physician can detect the existence of 
these conditions, and it will be useless to mention any treatment 
beyond saying that a pure, warm air, kept moist by the presence 
of a vessel of boiling water in the room, favors the expulsion of 
mucus from the air-tubes. The chest may be entirely enveloped 
—front, sides, and rear—in a flax-seed-meal poultice, to which 
ground mustard has been added in the proportion of one part of 
the latter to fifteen of the former. 
In little children an emetic of syrup of ipecac (a teaspoonful in 
water) will oftentimes bring away mucus that has collected in the 
larger air-tubes when the little patient fails to expel it by cough- 
ing, as older children would do. 
If the infant is weak, its pulse feeble, and its surface cool, stim- 
ulants are essential; and for this purpose brandy may be given to 
a child one year old, in doses of twenty drops, in sweetened water, 
every hour. 
When an infant suffering with any trouble of the lungs or air- 
passages, is restless, has dusky lips and finger-ends, and when the 
openings of the nose are seen to enlarge with each inspiration, it 
is suffering for want of air, and no time should be lost in securing 
the services of a physician. Pending his arrival the treatment 
above recommended may be pursued.—Ed.] 
ALFRED L. LOOMS, M.D. The Kidneys in Health and 
Disease. 
BY 
A. BRAYTON BALL, M.D. 
OF NEW YORK CITY. THE KIDNEYS IN HEALTH AND 
DISEASE. 
The kidneys, two in number, are situated deep in the abdominal 
cavity, one on either side of the spine, between the eleventh rib 
and the crest of the hip-bone ; the right kidney being somewhat 
lower than the left, probably in consequence of its nearness to the 
liver. In the adult male the aver- 
age dimensions of the organ are : 
length, 4 inches ; breadth, 2% inch- 
es ; thickness, 1£ inches ; average 
weight, o£ ounces. The size and 
weight are both somewhat less in 
women, and its form is like that 
of the kidney of most domestic 
animals. 
The fundamental structure of 
the kidneys is the same in all 
orders of the animal kingdom 
which are provided with a uri- 
nary apparatus, and consists of a 
system of blood-vessels and uri- 
niferous canals, so related to each 
other as to favor the escape, 
from the former into the latter, 
of the surplus water and certain 
effete matters of the body. In 
insects and spiders the urinary 
apparatus is composed simply of 
long, delicate tubes, or groups 
of round vesicles, opening into a 
common canal, the dilated ex- 
tremity of which forms the blad- 
der. In the vertebrata—fishes, reptiles, birds, and mammals—the 
kidney presents a gradually increasing complexity of structure, 
but retains, in all, its character as an aggregation of distinct 
glands. 
Figure 128. (After Sappey.)— Section 
through a kidney. 1, 2, 3, 4, Pyramids of 
different degrees of complexity. 5. Papilla 
opening into the pelvis of the kidney. 6. Por- 
tions of the cortical substance intervening 
between the pyramids. 7. Pelvis of the kid- 
ney. 8. Commencement of the ureter. 464 
THE KIDNEYS IN HEALTH AND DISEASE. 
On laying open the human kidney by a longitudinal section the 
cut surface is seen to consist of two different portions : an exter- 
nal or cortical, and an internal or medullary substance (Fig. 128). 
The cortical substance, which constitutes about three-fourths of 
the gland, forms an outer rim about two lines (—) in diameter, and 
dips down between the pyramids of which the medullary substance 
is composed. The dotted granular appearance of the cortical sub- 
stance is due to prominent Malpighian corpuscles, which, as we 
shall see later, play an impor- 
tant part in the secretion of 
urine. The medullary substance 
consists of from eight to eighteen 
pyramids, the bases of which are 
directed towards the cortical sub- 
stance, and the apices (or points) 
towards the cavity occupying 
the interior of the organ. The 
pyramids are distinctly striated, 
owing to the mainly longitudinal 
direction of the blood-vessels and 
uriniferous tubes. At the points 
of the pyramids (papillae,) the 
uriniferous tubes discharge the 
urine into the cavity known as 
the pelvis of the kidney. Each 
pyramid, with its investment 
of cortical substance, represents 
one of the separate lobules seen 
in the kidneys of most of the 
lower animals, and in the human 
kidney itself during its foetal 
stage of development. 
Minute Anatomy. — Blood- 
vessels. Each kidney is supplied 
by a large branch of the abdomi- 
nal aorta, viz.—the renal artery. 
This artery enters the organ at the fissure on its concave border, 
and there divides into branches, which pass inwards on the out- 
side of the pyramids, forming arches over the bases of the lat- 
ter. From these arches are given off the interlobular arteries, 
which proceed directly into the cortical substance and there dis- 
tribute afferent vessels, each of which passes to a Malpighian 
body (Fig. 130). On entering the Malpighian body, the capsule of 
which is formed by the dilated extremity of a uriniferous tube, the 
Figure 129.—The kidneys and their appen- 
dages. A. The large artery of the abdomen. 
Ve. The large vein returning blood to the heart 
from the lower portion of the body. Ar. The 
artery supplying the left kidney. Vr. The left 
renal vein. K. The kidney. U. The ureter. 
Ve. The bladder. Ur. The commencement of 
the urethra. THE KIDNEYS IN HEALTH AND DISEASE. 
465 
afferent vessel breaks up into a tuft of capillaries, which are 
gathered together again to form the efferent vessel. This escapes 
from the capsule, alongside of the afferent vessel, and in its turn 
divides into capillaries, which surround the uriniferous tube in its 
further course. Since the total capacity of the capillaries in the 
Malpighian tuft far exceeds that of the afferent vessel, the current 
of blood becomes much retarded at this point; and as a sluggish 
current favors the escape of the watery portions of the blood 
through the walls of the vessels, it is probable that most, if not 
all, of the watery portion of the urine is separated in this part of 
the tube. The tuft probably fulfils, also, another function, viz., 
that of a “ breakwater ” against the sudden congestions to which 
the kidney is exposed even in health, and which, without some 
such provision, would be apt to rupture the delicate vessels sur- 
rounding the uriniferous tubes. Lying loosely 
within its capsule, the tuft readily expands 
under pressure from behind, and may thus 
serve as a “ governor” to the current beyond. 
The solid portions of the urine are separated 
by a special apparatus lining the uriniferous 
tubes. 
Uriniferous tubes.—Beginning with the 
capsule of the Malpighian tuft in the cortical 
substance, the uriniferous tube, after forming 
several convolutions, descends directly into 
the adjoining pyramid, where it turns upon 
itself, forming a loop, and then reascends to 
the cortical substance (Figs. 130,131). Here it 
empties into a collecting tube, which, starting 
just underneath the outer surface of the kid- 
ney, runs directly downwards, collecting on its way tubules from 
neighboring Malpighian bodies, and finally empties upon the papil- 
lary extremity of a pyramid. Throughout its entire extent, until it 
nearly reaches the papilla, the canal is lined with a layer of cells 
(epithelium). Many of these cells, especially those in the convolu- 
ted portion of the tubes, closely resemble the secreting cells of 
other glandular organs, and are therefore supposed to separate 
from the blood the solid ingredients of the urine. 
Ureters.—From the kidneys the urine is conducted to the blad- 
der by two tubes called ureters, from fourteen to sixteen inches in 
length, and of about the size of a goose-quill. Each ureter begins 
in the pelvis of the corresponding kidney, descends alongside of 
the spine, and on reaching the base of the bladder passes through 
its coats obliquely, opening upon the interior of the organ by a 
Figure 130. (After 
Gray. ) — The Malpighian 
tuft with the commencement 
of an uriniferous tubule and 
its blood-vessels. 466 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
narrow slit-like aperture, which acts as a valve, allowing the 
escape of urine from the ureter into the bladder, but preventing, 
under ordinary circumstances, a flow in the opposite direction. 
The narrowest portion of the ureter is that included within the 
coats of the bladder ; hence the pain occasioned by the passage of 
a stone from the kidney to the bladder 
is usually most intense just before the 
final relief is afforded. 
The Urine. 
Color.—Normal urine receives its 
color from the presence of a coloring 
matter called uro-hcematin, which is de- 
rived from the coloring matter of the 
blood. According to the degree of con- 
centration or dilution of the urine, the 
uro-haematin produces several shades 
of color, varying from a very pale straw- 
color to a brownish yellow. In disease 
the urine may be absolutely colorless— 
as in attacks of hysteria ; or may pre- 
sent deep red, olive, blue, green, or black 
hues. 
A deep red color is seen when there 
is fever, and is then produced by a mod- 
ification of the normal coloring matter, 
known as uro-erythrin. The olive color 
occurs in jaundice, and is due to the 
admixture of bile. When bile is present 
in large amount the urine has an olive 
yellow or olive brown color, which is 
best seen by tilting the fluid to the side 
of the chamber vessel. On shaking 
some of the urine in a bottle the foam 
is deep yellow. This olive-yellow color 
is produced by the coloring matter of 
the bile (biliver din), the same substance that occasions the yellow 
hue of the skin in jaundice. To detect biliverdin with certainty, 
pour a few drops of the urine on a plate or saucer, and add one 
drop of strong nitric acid. If bile is present a characteristic play 
of colors is produced, beginning with green and passing through 
olive, violet, blue, and red to yellow. The green color is essential 
Figure 131. (After Ludwig.)— 
Diagram showing the course of an 
uriniferous tubule, from the human 
kidney. M. Capsule of the Malpig- 
hian tuft, which is continuous by its 
neck with the convoluted portion of 
the canal (C). H. Henle’s loop—com- 
posed of a descending and an ascend- 
ing portion. D. Collecting tube. THE KIDNEYS IN HEALTH AND DISEASE. 
467 
to the test, as the other shades may be produced with other sub- 
stances besides bile. 
Blue and green colors in the urine are of rare occurrence. They 
are never present when the urine is voided, but develop only after 
the urine has been exposed to the air for some time, or has been 
treated with an oxidizing agent, such as a mineral acid. Their 
significance is not well understood ; they are sometimes noticed in 
the urine of Bright’s disease and organic affections of the liver, but 
may also occur without any apparent disturbance of health. 
A deep brown or black color varies in significance according as 
the urine is dark-colored when passed, or becomes so only after 
exposure to the air. In the former case the color depends upon the 
presence of altered coloring matter of the blood and broken down 
blood-corpuscles. This appearance of the urine in malignant 
typhoid and other fevers is usually a fatal omen, because it indi- 
cates a rapid dissolution of the blood. As a less serious symptom 
it occurs also in scurvy, purpura, and a singular affection called 
intermittent hsematinuria (see p. 493). A dark brown or black 
color, which does not develop until some time after the urine has 
been voided, may be caused either by oxidation of the normal col- 
oring matter (as occasionally happens in urine containing albu- 
men), or by melanine, a coloring matter derived from melanotic 
(black) cancer in some part of the body. 
It should be borne in mind that the abnormal colors may 
be produced in the urine by medicines as well as by disease. 
Thus rhubarb, santonine, and gamboge color the urine yellow; 
senna brown; turpentine, violet; and creosote and carbolic acid 
black. 
Odor.—Immediately after its discharge healthy urine has a 
characteristic, faintly aromatic odor, due to certain volatile organic 
acids. Abnormal odors are produced by certain articles of food 
(asparagus, garlic), and by certain medicines (copaiba, cubebs, tur- 
pentine). The urine in diabetes, when fresh, smells b lg new hay 
or ripe apples ; after fermentation, on standing for some time, like 
sour milk. In some cases of dyspepsia the urine smells like raw 
meat or decaying fish—probably from the presence of butyric acid. 
In inflammation of the bladder a pungent odor is sometimes devel- 
oped in the urine by the decomposition of urea into carbonate of 
ammonia. In animals, the cat, horse, cow, etc., the odor of the 
urine is characteristic of the species, and is said to resemble the 
odor of the fat of the animal; the urine of sheep, for instance, 
smelling like mutton suet. 
Reaction (acidity or alkalinity) of the urine.—The reaction 
is most readily tested by the change of color which the urine pro^ 468 
THE KIDNEYS IN HEALTH AND DISEASE. 
duces in strips of blue and red litmus papers. The blue paper is 
prepared by dipping white unsized paper into an infusion of litmus, 
a blue coloring matter, derived from certain lichens. For the pre- 
paration of the red paper, the infusion of litmus is reddened by the 
addition of a small amount of acid. As blue litmus is reddened by 
acids, and reddened litmus is restored to a blue color by alkalies, 
the blue paper tests the acidity, and the red paper the alkalescence 
of the urine. Healthy urine, when passed at ordinary intervals, 
has an acid reaction; if hourly specimens be obtained, the reaction 
is found to vary at different times of the day. Within an hour 
after each meal the urine becomes alkaline, and remains so for one 
or two hours, after which it again becomes acid. This alkaline 
tide seems to be due partly to the withdrawal of acids from the 
blood to the stomach during the process of digestion, and partly to 
the absorption of alkalies from the food. When the urine, how- 
ever, is discharged at the usual intervals, it remains continuously 
acid, because the effect of the alkaline tide is counteracted by the 
acid urine met with in the bladder. Temporary deviations from 
the normal reaction may be occasioned by various articles of diet, 
medicines, cold bathing, etc., and are usually entirely unimpor- 
tant ; but an habitual disposition, either to excessive acidity, or to 
alkalescence of the urine, is always a sign of ill-health, and by 
causing the precipitation of certain substances, which are soluble 
in urine of a proper degree of acidity, not infrequently gives rise 
to the formation of stone in the kidney or bladder. In the case of 
habitual excessive acidity, this danger arises from the deposition 
of uric acid crystals, of which gravel and stone are most fre- 
quently composed (see p. 472). The significance of alkaline urine 
depends entirely upon its cause, which may be either fixed alkali 
(potash, soda), or volatile alkali (ammonia). The distinction is 
extremely important, because the two varieties of alkalinity point 
to widely different morbid conditions, and consequently require 
different tr They may be readily distinguished by their 
different reactions to litmus paper. Fixed alkali restores a blue 
color to reddened litmus paper permanently, whereas, the blue 
color produced by volatile alkali disappears by evaporation on ex- 
posure to air, or the application of heat. Habitual alkalescence 
from fixed alkali is only very rarely connected with the formation 
of stone. It points rather to derangements in the digestive and 
nervous systems, and requires therefore to be treated by attention 
to the general health, out-door exercise if possible, the administra- 
tion of tonics, etc. Habitual alkalescence from volatile alkali, on 
the other hand, points to ammoniacal decomposition of the urine, 
a condition rarely seen except in connection with inflammation of THE KIDNEYS IN HEALTH AND DISEASE. 
469 
the urinary passages, particularly the bladder, and consequently 
requires local, as well as general treatment. 
Quantity.—The daily quantity of urine ordinarily passed in 
health, varies from thirty to sixty ounces (one to two quarts), and 
is regulated by a number of physiological conditions. Among 
these may be mentioned : 1. The quantity of liquids drank; 2. 
The nature of the food, a vegetable diet causing a greater forma- 
tion of urine than animal food ; 3. The amount of water discharged 
by the bowels ; 4. The amount of water escaping in the breath and 
perspiration. Active perspiration materially diminishes the se- 
cretion, hence much more urine is passed in winter than in sum- 
mer. The flow is more abundant also in a moist than in a dry 
atmosphere, since moisture of the air diminishes the amount of 
vapor given off by the lungs, 5. The influence of age and sex. 
Children pass more urine in proportion to their size than adults, 
and men pass larger quantities than women. The influence of 
various diseases will be considered later. 
Density or specific gravity of the urine.—This is commonly 
tested by the urinometer, an instrument composed of a graduated 
stem, a blown glass float, and a bulb loaded with mercury, or lead, 
at its lower extremity. The stem is graduated 
from 1000 (the level to which the instrument 
sinks in distilled water) to 1040 or 1060. Urin- 
ometers with very short stems are objection- 
able, as the graduations are so close to each 
other that mistakes of several degrees are read- 
ily made. In reading the registration, the top 
of the fluid should be brought to a level with 
the eye ; unless this is done, an optical illusion 
is produced by which the registration appears 
to be higher or lower than it actually is. Im- 
portant indications of disease are often afforded 
by the specific gravity of the urine, since the 
latter represents approximately the amount of 
solid ingredients, but as a means of diagnosis it 
requires to be used with great caution. Single 
observations are valueless. The entire urine 
for the twenty-four hours must be tested; or, 
when this is impracticable, the first urine pass- 
ed on rising in the morning may be used, 
as this usually represents the average daily specific gravity. 
These examinations should be frequently repeated to afford any 
reliable indication. In health the density generally ranges from 
1.015 to 1.025, but may exceed or fall below these limits tempora- 
Figure 132.—Urinom- 
eter. 470 
THE KIDNEYS IN HEALTH AND DISEASE. 
rily from accidental causes ; active exercise, copious drinking, 
prolonged fasting, etc. A 'permanent daily average below 1.008, in 
connection with a copious flow of urine, points to insipid diabetes ; 
a constant range between 1.008 and 1.015 commonly points to chron- 
ic Bright's disease, while a persistent elevation above 1.030 usually 
belongs to saccharine diabetes. Still these ranges are by no means 
distinctive, and are reliable guides only when taken in connection 
with other symptoms to be described later. 
Temperature.—The burning or scalding sensation sometimes 
felt in the urinary passages during the escape of urine, is often 
supposed to be due to a heated state of the secretion. As the urine 
derives its heat entirely from the body, its temperature can obvi- 
ously never exceed that of the channel through which it flows. 
The sensation referred to is in fact always due either to an acrid 
condition of the urine, or to morbid irritability of the passage itself. 
Composition.—Besides water, the urine contains numerous solid 
ingredients : urea, uric acid, hippuric acid, creatine, creatinine ; 
hydrochloric, sulphuric, and phosphoric acids, in combination with 
soda, potash, lime, and magnesia ; xanthine, hypoxanthine, sarcine, 
coloring matter, mucus, and traces of other less important substan- 
ces. Of the above constituents, urea is by far the most important, 
and nearly equals in amount all the others combined. This crys- 
talline nitrogenous substance forms the final product into which 
nearly all the nitrogenous food and waste material derived from 
the disintegration of the tissues are converted prior to their expul- 
sion from the body. In health, nearly nine-tenths of the nitrogen 
entering the body in the food ultimately escapes through the kid- 
neys, only about one-tenth being removed by the bowels, and 
merely a trace by the lungs and skin. As almost all the nitrogen 
discharged in the urine is represented by urea, it is clear that this 
substance must play a very important part in the process of nu- 
trition, and that serious danger to health must arise from failure 
of the kidneys to properly excrete it. The symptoms induced 
by its retention in the blood are seen in the form of blood-poison- 
ing known as uraemia, and will be considered under the head of 
Bright’s Disease. 
The average amount of urea excreted daily in health is about 
500 grains, or 3£ grains to each pound weight of the individual. 
In children, as might be expected from the marked activity of the 
vital processes in early life, the excretion of urea is proportionately 
greater than in adults, and for a similar reason is greater in mature 
than in advanced life. The chief physiological conditions, which 
regulate the excretion are the amount and nature of the food. 
Animal food increases the amount of urea to be excreted, while a THE KIDNEYS IN HEALTH AND DISEASE. 
471 
vegetable diet diminishes it; hence the great importance of cau- 
tion in the use of much animal food whenever the function of the 
kidneys is seriously impaired—for instance, during convalescence 
from dropsy following scarlet fever, as well as in all other forms 
of Bright’s disease. Owing to its ready solubility, urea never forms 
a deposit in the urine. 
Deposits in the Urine. 
After standing for a few hours in a glass vessel, even healthy 
urine presents a light cloudy sediment floating at a higher or lower 
level in the fluid. This fact is often taken advantage of by quacks 
to convince their dupes of the existence of serious disease. The 
deposit is composed simply of epithelial cells and particles of pig- 
ment, which are constantly shed by the urinary passages in health. 
When this shedding is excessive, as is often the case after an irri- 
tation of these parts, strings or flakes may appear in the urine, and 
excite much unnecessary anxiety. The appearance is usually en- 
tirely unimportant, and disappears after a time spontaneously. 
In abnormal states of the urine other substances are deposited, of 
which the most important are the following : 
Urates. 
The turbid appearance produced by a collection of this sedi- 
ment is more noticeable, and more frequently excites alarm, than 
any other deposit which occurs in the urine. It is readily distin- 
guished by redissolving on the application of heat. Even the ad- 
dition of fresh warm urine often suffices to redissolve it. It is usu- 
ally yellow, pink, or red in color, owing to its intense affinity for 
the coloring matter of the urine (brick-dust sediment). Occasion- 
ally, however, as in children and gouty subjects, the deposit is of 
a pure white or pale yellow color. Chemically the sediment is 
usually composed of uric acid in combination with soda, potash, 
and ammonia (mixed urates), and presents no crystalline structure 
(amorphous urates). As these urates are only sparingly soluble in 
cold urine of an acid reaction, the most common conditions of 
their precipitation are : low temperature, concentration, and un- 
usual acidity of the fluid. Deposit takes place, therefore, only after 
the urine has cooled, and may occur under a great variety of cir- 
cumstances, which either diminish the amount of urine or in- 
crease its acidity. Thus, active exercise, a night’s dissipation, a 
change or indiscretion in diet, an ordinary cold, and all feverish 
states of the body, may act as exciting causes. The transient ap- 472 
THE KIDNEYS IN HEALTH AND DISEASE. 
pearance of this sediment, although always an indication of an ab- 
normal condition of the urine, is usually entirely unimportant; but 
when it recurs frequently in the absence of fever, it demands at- 
tention as a possible indication of chronic disease in the stomach, 
liver, heart, or other important organ. 
Finally, it should be mentioned that occasionally the urates are 
crystallized, and are then liable to be deposited within the urinary 
passages, involving the risk of formation of stone. Under these 
circumstances the urine is often turbid ivhen passed, but becomes 
clear on heating. This form of turbid urine is especially common 
in infants and young children during febrile attacks, and it is 
probable that the great frequency of stone in the bladder in early 
life is largely owing to the repeated deposition of this material 
within the organ at such times. 
Treatment.—When due to temporary causes, the deposit needs 
no other treatment than a simple diet, abstinence from alcoholic 
stimulants, particularly beer and sweet wines, the use of Vichy 
or some other alkaline water at meals, and a tumblerful of plain 
water at bed-time. In chronic cases medical advice should be 
taken. 
Uric Acid. 
As we have already seen, uric acid is usually combined in the 
urine with alkaline bases, forming urates which are soluble in 
ordinary conditions of the secretion. In its free state, uric acid 
is very insoluble, and is precipitated in the form of minute brown 
crystals, which are often large enough to be seen by the naked 
eye, and then resemble a deposit of cayenne pepper. The red 
or brown color of the crystals distinguishes them from all other 
crystals which occur in the urine. The most delicate test for uric 
acid and its salts is the production of a bright violet color by 
treatment with nitric acid and ammonia (murexid test). Place a 
small quantity of the suspected substance upon a piece of glass 
or porcelain, add two drops of strong nitric acid, and apply heat 
over a spirit-lamp until the liquid is evaporated. If uric acid or 
its salts be present, the addition of a few drops of ammonia-water 
will develop the bright violet color of murexid (purpurate of am- 
monia). 
The significance of a sediment of uric acid depends mainly upon 
two circumstances : 1, whether the precipitation takes place be- 
fore or after the urine is voided ; 2, the frequency of the deposit. 
After standing for several hours, even healthy urine not unfre- 
quently deposits a small amount of uric acid, which has been liber- 
ated from its combination with alkaline bases subsequently to THE KIDNEYS IN HEALTH AND DISEASE. 
473 
the emission of urine. When, however, a deposit of red sand takes 
place before the urine has cooled or immediately afterwards, there 
is reason to suspect that these insoluble crystals may have been 
formed within the urinary passages; and since uric acid consti- 
tutes the most common basis of gravel and stone, the frequent 
repetition of a sediment of this character must always be regarded 
with apprehension. 
Treatment.—Occasional deposits due to transient causes, such 
as an attack of indigestion, or feverishness or other influences 
which increase the acidity of the urine only temporarily, are 
usually unimportant, and may be relieved by the same treatment 
which was recommended for the urate deposit. On the other 
hand, a persistent tendency to uric acid sediment is commonly 
connected with a gouty disposition or with chronic disease of the 
heart, liver, etc., and requires therefore the attention of a medical 
adviser. 
Phosphates. 
The three varieties of phosphatic deposit met with in the urine 
•—amorphous phosphate of lime, crystallized phosphate of lime, 
and ammoniaco-magnesian phosphate—possess certain characters 
in common which distinguish them from all other sediments. 
They occur only in urine which is nearly or quite alkaline, are 
white in color, remain unaffected by heat, and are redissolved by 
acids. 
Amorphous Phosphate of Lime is a normal ingredient of the 
urine, derived partly from the food and partly from the disintegra- 
tion of certain tissues and fluids of the body. It is soluble in acid 
urine, but may be precipitated whenever the urine becomes neu- 
tral or actually alkaline. Transient alkaline conditions of the 
urine, accompanied by this deposit, may be occasioned by several 
causes : an excessive indulgence in sweet or sub-acid fruits, alka- 
line medicines, a bout of smoking (possibly from the absorption of 
ammonia generated by burning of the tobacco), and occasionally 
by an overstrain of the mental faculties. In such cases the amis- 
sion of white, turbid urine, commonly during the morning hours, 
often excites great alarm ; but the symptoms will generally disap- 
pear on removal of the exciting cause. A frequent occurrence of 
this deposit, however, is always a sign of serious disturbance of 
the health, located generally in the nervous system, and requires 
careful attention. The Crystallized Phosphate is rare. Its signifi- 
cance varies ; sometimes it occurs in urine which is faulty only in 
a depressed acidity, but generally it is regarded as an indication of 
serious organic disease in one of the internal organs. Ammoniaco- 474 
THE KIDNEYS IN HEALTH AND DISEASE. 
magnesian Phosphate (or triple phosphate) is a crystalline sub- 
stance produced in decomposing urine by the generation of am- 
monia, which combines with phosphoric acid and the phosphate of 
magnesia to form a double salt. To the naked eye triple phos- 
phate presents much the same appearance as the amorphous phos- 
phate, and can be distinguished from the latter with certainty only 
by a microscopical examination, although the nature of the deposit 
may be suspected if the urine have an ammoniacal odor. When 
present in any such amount as to render the urine turbid when 
voided, this sediment almost invariably indicates ammoniacal de- 
composition of the urine within the urinary passages, particularly 
the bladder, and points therefore to the most common cause of 
urinary decomposition, viz., an inflammatory condition of these 
parts. It is necessary to bear in mind, however, that decomposi- 
tion may take place rapidly even in feebly acid healthy urine, if 
the latter be passed into a vessel containing urine that has already 
become decomposed. Triple phosphate, in connection with the 
amorphous phosphate of lime, is a common cause of calculus. 
Oxalate of Jaime. 
With very rare exceptions, oxalate of lime never forms a 
deposit sufficiently copious to be recognized by the naked eye 
in ordinary receptacles of urine; and even when the sediment 
is carefully collected by allowing the urine to stand for a few 
hours in a tapering glass, a microscopical examination is always 
necessary. Minute quantities of these insoluble crystals are oc- 
casionally seen in urine passed by persons who are to all appear- 
ance perfectly healthy. Such transient deposits are scarcely to 
be regarded as abnormal, but when large amounts of oxalate of 
lime are discharged persistently for weeks or months together, the 
symptom always demands serious attention. The chief danger 
lies in the formation of an oxalate of lime stone, this being one 
of the most common varieties of calculus (“mulberry” calculus). 
By many authorities, also, these deposits are supposed to indicate 
the existence of a special morbid condition known as the oxalic 
acid diathesis or oxaluria, which is said to be more frequent in 
men than in women, and to be characterized by the following 
symptoms, viz. : flatulent indigestion, palpitation, backache, fre- 
quent urination, loss of sexual desire, irritability of temper, de- 
spondency, and even profound melancholy. This group of symp- 
toms often occurs, however, without oxalate of lime in the urine; 
and, on the other hand, oxalate of lime may be continuously pres- 
ent in the urine in quantities sufficient to form a mulberry calcu- 
lus, without any of the above symptoms being manifested. It is 475 
THE KIDNEYS IN HEALTH AND DISEASE. 
highly probable, therefore, that when the symptoms and the de- 
posits in question occur together, they are both merely effects of 
a common cause residing primarily in the nervous or digestive 
systems. 
Treatment.—Whatever may be the correct explanation of such 
cases, there can be no doubt that tlieir successful treatment lies 
far more in attention to hygiene than in administration of drugs, 
useful as the latter unquestionably are as auxiliary means. 
Travel, if possible—at all events, an abundance of out-door exer- 
cise ; cold sponging of the skin, with friction ; moderation at meals, 
with exclusion of such articles of food or drink as contain oxalic 
acid or substances convertible into it, viz., rhubarb, apples, and all 
sweet fruits, effervescent wines and beer ; and finally, in districts 
where the water is impregnated with lime, the use of boiled or 
distilled drinking-water—these are the most important hygienic 
regulations. 
Pus or Matter. 
A collection of this sediment often resembles a deposit of phos- 
phates, but is distinguished from it by remaining undissolved 
after the application of heat and the addition of an acid, and by 
being converted, on treatment with a strong alkali (liquor potassee 
or aqua ammonise), into a ropy mass which can be drawn out into 
long strings. This ropy appearance is characteristic, and is not 
unfrequently seen in the highly ammoniacal urine discharged in 
some cases of inflammation of the bladder. Pus in large quantity 
renders the urine turbid or milky when passed, and produces a 
yellowish white deposit. As pus is always a product of inflamma- 
tion, its significance in the urine naturally depends upon its source. 
The direct sources are the kidneys and the passages through 
which the urine flows in its escape from the body ; the indirect 
are the generative organs in women, and an abscess external to 
the urinary passages. 
Blood. 
Urine containing blood may present a variety of colors, from a 
smoky tinge to a pink, or reddish, or even deep brown hue—the 
particular shade depending upon the amount of blood and the 
length of time it has been in contact with the urine. The smoky 
tinge due to minute quantities of blood is often seen during the 
course of Bright’s disease. When the color differs from that of 
ordinary bright red blood, a microscopical examination is neces- 
sary for the detection of the red blood-corpuscles. The sources of 
blood in the urine are in general the same as those of pus (see 
above). 476 
THE KIDNEYS IN HEALTH AND DISEASE. 
The preceding list includes all the deposits of common occur- 
rence in the urine, with the exception of casts of the uriniferous 
tubes. These will be considered under the head of Bright’s Dis- 
ease. It is to be particularly noted, in conclusion, that the sedi- 
ments which most frequently induce turbidity of the urine, viz., 
uric acid, urates, and phosphates, never indicate disease of the 
kidneys; and that the less frequent deposits of blood and pus, 
which occasionally occur in this connection, may arise from causes 
entirely independent of the kidneys. 
DISEASES OF THE KIDNEYS. 
Saccharine Diabetes. 
Saccharine Diabetes, or Diabetes Mellitus, is essentially a 
chronic affection, characterized by an excessive flow of urine con- 
taining sugar, and by certain well-marked disturbances of the 
general health. It is to be distinguished, therefore, from merely 
temporary conditions, in which sugar appears in the urine at times 
without inducing any of the symptoms to be presently described. 
Sugar is a normal constituent of the blood, derived partly from the 
sugars and starches present in food (starch being normally con- 
verted into sugar within the intestinal canal), and partly from the 
glycogen of the liver, a starchy substance manufactured in that 
organ from animal as well as vegetable materials, and trans- 
formed into sugar on absorption into the blood. In health this 
sugar is used within the body partly for its nourishment, and 
partly, also, for other purposes as yet but imperfectly understood. 
If the sugar, however, be formed in excess or fail to undergo its 
further changes, it accumulates in the blood, acts there as a 
foreign substance, and is expelled by the kidneys along with the 
large quantity of water necessary to hold it in solution. Strictly 
speaking, therefore, saccharine diabetes is not a disease of the 
kidneys, but is rather a blood-poisoning from excess of sugar. 
The causes which lead to this accumulation still remain unknown, 
although much study has been devoted to the subject. 
Symptoms.—The first symptoms noticed are usually intense 
thirst and a marked increase in the flow of urine. Sometimes at- 
tention is first drawn to the complaint by the deposit of sugar on 
the clothing, or by the fact that flies are attracted to the saccha- 
rine urine, or by the occurrence of distressing itching of the geni- 
tal organs; this symptom being due to the irritating lactic acid 
into which the sugar deposited on these parts is occasionally con- 
verted. The urine is clear, pale, of high specific gravity (1.030 to 
1.060 and upwards), contains sugar, and varies in quantity from THE KIDNEYS IN HEALTH AND DISEASE. 
477 
six to fifteen, or even thirty pints daily. Ir. severe cases the chief 
symptoms besides those mentioned are : emaciation in spite of a 
usually fair and often excessive appetite ; parched condition of the 
mouth ; a peculiar hay-like odor of the breath, resembling that of 
the urine ; decay and loss of the teeth ; marked dryness of the 
skin, with a disposition to boils, carbuncles, and eruptions ; obsti- 
nate constipation, sometimes alternating with diarrhoea ; impair- 
ment of vision, and in some cases blindness from cataract; depres- 
sion of spirits, and both mental and physical prostration. Death 
may occur suddenly from collapse after some unusual exertion ; 
more commonly the fatal result is due either to gradually progress- 
ing exhaustion or to the occurrence of dropsy, or to the super- 
vention of pulmonary disease resembling ordinary consumption. 
This grave type of the disease occurs most frequently in early and 
middle life. In old age, and sometimes in middle life, especially 
in corpulent persons, diabetes may be a comparatively mild disor- 
der, readily controlled by treatment, or perhaps disappearing after 
a time spontaneously. Between these two extremes, there are 
various degrees of intensity, and not unfrequently cases which are 
of a mild character at the outset ultimately assume the graver 
form. The following are unfavorable indications : youthful age, 
rapid loss of flesh, persistence of considerable sugar in the urine, 
even after withdrawal of saccharine and starchy substances from 
the food ; marked debility, loathing for food, excessive flow of 
urine of very high specific gravity, and the occurrence of lung dis- 
ease or dropsy. On the other hand, the prospect is encouraging 
when the individual is past middle life, when 
the sugar almost entirely or completely dis- 
appears from the urine on regulation of the 
diet, when the symptoms are of a mild grade, 
and finally, when the individual is able to 
incur the necessary expense of the dietary 
regulations mentioned below, and possesses 
the courage to give them a thorough trial. 
Tests for Sugar in the Urine.—Fermenta- 
tion test.—Fill a bottle or test-tube, contain- 
ing a little yeast, with the suspected urine, 
and carefully invert into a dish partly filled 
with the urine. Set aside in a warm place 
for twenty-four hours. If sugar be present, 
fermentation ensues, and the sugar is de- 
composed into alcohol and carbonic acid gas, 
the latter rising to the top of the inverted vessel and displacing a 
portion of the urine. The test is somewhat uncertain, and does 
Figure 133.—Fermentation 
test for sugar in saccharine dia- 
betes. 478 
THE KIDNEYS IN HEALTH AND DISEASE. 
not detect very small amounts of sugar ; therefore physicians are 
accustomed to rely upon others which are more delicate, hut which 
also are too difficult to be successfully used by those not practically 
familiar with them. 
Treatment.—The treatment of diabetes consists mainly in a 
careful regulation of the diet, so as to confine the amount of sugar 
in the blood within healthy limits. In many cases this result can 
be secured by a simple abstinence from all articles of food which 
contain sugar or starch. In other cases this measure fails, because 
the liver continues to form from the animal food an excessive 
amount of glycogen, which is converted into sugar on its absorp- 
tion into the blood. Still, in spite of the frequent failures of the 
dietetic treatment, and the frequent necessity of modifying it in 
certain particulars, it supplies, at present, the most reliable means 
of alleviation, if not for cure. Such an important alteration from 
ordinary diet should, of course, be undertaken only under the su- 
pervision of a medical adviser. The following table, taken, with 
some alterations, from Dickenson’s work on Diabetes, will supply 
general directions : 
Strict Diabetic Diet. 
What to Eat. 
What to Drink. 
What to Avoid. 
Fresh meat, without exclusion. 
Water. 
Sugar, treacle, honey. 
Meat, salted, smoked, cured, 
potted, or preserved in any 
Soda, and all mineral 
Common flour, bread. 
waters. 
Maccaroni, vermicelli. 
way except with honey or su- 
Tea, coffee, and cocoa 
Com flour, arrow-root, sago. 
Tapioca, oatmeal, barleymeal. 
Potatoes, beets, parsnips. 
gar. 
from the nibs. 
Poultry and game of all kinds. 
All unsweetened spir- 
Fish, fresh or preserved. 
its. Cognac, whis- 
Carrots, turnips, radishes. 
Soups made without common 
key. 
Onions, celery, sea-kale, rhubarb. 
flour or prohibited vegetables. 
Dutch Hollands. 
Peas and beans. 
Unsweetened jelly, isinglass. 
Unsweetened gin. 
Chestnuts. 
Oil, dripping, and suet. 
Rum. 
All sweet and preserved fruits. 
Butter, cheese, cream cheese. 
Claret. 
Milk, whey, skimmed milk. 
Cream, curds. 
Red Burgundy. 
Chocolate. 
Cooked green vegetables, cab- 
White Burgundy. 
All malt liquors, with specified 
bage, cauliflower, spinach, Chablis and Grave. 
exceptions. 
broccoli. 
Hock and still Moselle. 
Cider. 
Brussels sprouts, turnip tops, 
The driest pale sherry 
Champagne, and all sparkling 
French beans, the green ends 
Amontillado or Vino 
wines. 
of asparagus. 
Uncooked green herbs, lettuce, 
watercresses, mustard and 
cress. 
Gluten flour and bread. 
Bran flour and cakes. 
Almond flour and cakes. 
Almonds, filberts, walnuts, Bra- 
zil nuts, cocoa-nuts. 
Condiments, glycerin. 
de Pasto. 
Port, Madeira, and all sweet 
wines. 
Sherry, except the driest. 
Sweetened spirits. 
Liqueurs. THE KIDNEYS IN HEALTH AND DISEASE. 
479 
Modified Diabetic Diet. 
Add toasted bread. Add bitter ale. 
“ celery and sea-kale. “ milk. 
Among the forbidden articles in the above list, there is none 
whose deprivation is so seriously felt as bread. Several substi- 
tutes have been devised, the best of which are cakes made with 
bran, gluten, or almond flours. The bran cakes* are not un- 
palatable when well made, and tend to relieve constipation. Glu- 
ten bread is made from gluten which has been separated from 
common flour by frequent washings to remove the starch. It is 
more palatable and nutritious than bran bread, but is more apt to 
contain starch. Almond bread is an elegant, fairly digestible, but 
expensive preparation, made from the flour of sweet almonds, the 
sugar and gum being removed by boiling the flour in water slightly 
acidulated with tartaric acid. 
When these kinds of bread are not obtainable, ordinary bread 
toasted almost to a crisp, and thus deprived of most of its starch, 
may be tolerated in mild cases. Water may be drank as freely as 
inclination prompts. Out-door exercise is very important, but the 
strength should never be overtaxed. Long journeys have in nu- 
merous instances proved fatal. Warm clothing should be worn, as 
the temperature of diabetic persons is usually below the normal. 
* These may be made according' to the formula given by Dr. Camplin, in his work on 
Diabetes: “Take a sufficient quantity (say a quart) of wheat bran, boil it in two suc- 
cessive waters for a quarter of an hour, each time straining it through a sieve, then 
wash it well with cold water (on the sieve) until the water runs off perfectly clear; 
squeeze the bran in a cloth as dry as you can, then spread it thinly on a dish and place 
it in a slow oven ; if put in at night let it remain until the morning, when, if perfectly 
dry and crisp, it will be fit for grinding. The bran thus prepared must be ground in a 
fine mill and sifted through a wire sieve of such fineness as to require a brush to pass it 
through. That which remains in the sieve must be ground again until it becomes quite 
soft and fine. Take of this bran-powder three ounces (some patients use four ounces), 
three eggs, one and a half or two ounces of butter, and about half a pint of milk ; mix 
the eggs with a little of the milk, and warm the butter with the other portion ; then stir 
the whole well together, adding a little nutmeg and ginger, or any other agreeable spice. 
Bake in small tins, which must be well buttered, in a rather quick oven, for about half an 
hour. The cakes, when baked, should be a little thicker than a captain’s biscuit. They 
may be eaten with meat or cheese for breakfast, dinner and supper. At tea they require 
rather a free allowance of butter, or they may be eaten with curd or any of the soft 
cheeses.” Prepared bran flour in any quantity can be obtained from J. W. Shedden & 
Co., cor. Broadway and Thirty-fourth Street, New York. The same firm supplies also 
gluten flour. 480 
THE KIDNEYS IN HEALTH AND DISEASE. 
Insipid Diabetes. 
Insipid Diabetes, or Non-saccliarine Diabetes, is distinguished 
from the ordinary saccharine form by the absence of sugar from 
the urine, and by the low instead of high specific gravity of the 
secretion. That the two forms are, however, more or less related 
to each other, is proved by the fact that they sometimes alternate 
in different generations of the same family, as well as by the in- 
teresting experiments of the French physiologist, Bernard, which 
show that puncturing the floor of the fourth ventricle of the brain 
in animals will excite a temporary saccharine or a temporary in- 
sipid diabetes, according to the location of the puncture. The 
causes of insipid diabetes, so far as they are at present known, 
are : hereditary tendency, a bout of drunkenness, intense mental 
excitement or fright, severe muscular exertion, copious drinking 
of cold liquids during perspiration, syphilis, and inflammatory 
and febrile diseases. In many cases the origin of the disease is 
obscure. 
Symptoms.—The chief symptoms are excessive thirst and a very 
copious flow of urine of low specific gravity (1.002 to 1.006). Occa- 
sionally these are the only noticeable derangements, the general 
health remaining entirely unimpaired. As a rule, however, other 
disturbances are present: loss of flesh and strength, distressing 
dryness of mouth and throat, pains in the stomach and back, en- 
feeblement of the mind, and loss of sleep from the incessant desire 
to pass water. After weeks, months, or years of suffering, the 
individual finally succumbs to some disorder, such as consump- 
tion, inflammation of the lungs, or brain disease. The quantities 
of water drank by some of these persons is very remarkable. A 
French child, three years of age, drank two pails of water a day ; 
after her marriage, at the age of twenty-two, her daily allowance 
amounted to four pailfuls. A patient in the Hotel-Dieu drank, on 
an average, thirty-two pints of water every day. Sometimes a 
marked tolerance of alcoholic drinks is noticed. A patient of 
Trousseau, in Paris, repeatedly drank, for wagers, twenty bottles 
of wine at a single sitting, without manifesting any symptoms of 
intoxication. Until towards the end of the disease the appetite is 
usually excellent and sometimes enormous. Trousseau’s patient, 
just alluded to, is said to have inspired such terror among the res- 
taurant-keepers of Paris, where bread is allowed ad libitum at 
meals without extra charge, that one of them, after witnessing his 
inordinate capacity for bread, paid him money to dine elsewhere. 
The duration of the disease varies exceedingly in different cases. 481 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
Although usually a very chronic affection lasting for months or 
years, it occasionally runs a very rapid course, particularly when 
it depends on organic disease of the brain, and proves fatal within 
a few weeks. In some cases the symptoms disappear spontane- 
ously after an attack of fever or other severe disease. Insipid 
diabetes is more common in childhood and early life; saccharine 
diabetes in middle life and old age. 
Treatment.—Regulation of diet is unnecessary, as it has no 
influence upon the course of the disease. Water may be allowed 
in sufficient quantity to allay thirst, but should be drank slowly, 
and not gulped down in copious draughts. Any considerable re- 
striction in water is certain to produce great distress, and possibly 
serious prostration. Medical treatment generally fails to do more 
than keep the affection under control, but occasionally life may be 
preserved for years by such means, and by careful attention to 
the general health, until, finally, the disease seems to wear itself 
out spontaneously. It is not to be disguised, however, that with 
the exception of those comparatively rare instances in which the 
excessive thirst and profuse urination appear to be rather an idio- 
syncrasy than a disease, insipid diabetes is a very intractable and 
often a fatal affection. 
Congestion of the Kidneys. 
Experiments upon the lower animals have shown that by di- 
recting an increased flow of blood through the arteries of a kid- 
ney, or by impeding the escape of blood through the veins so as to 
considerably increase the pressure within the vessels, albumen and 
even blood may be made to appear in the urine. In a similar 
manner albuminuria (a condition in which albumen is present in 
the urine) may be produced in the human subject, either by a de- 
termination of blood to the kidneys in various inflammatory and 
febrile disorders of the body, or by an interference with the return- 
current of blood from the organ, such as occurs in certain affec- 
tions of the heart and lungs, as well as in pregnancy when the 
renal veins are compressed by the enlarged womb. These conges- 
tions of the kidneys do not as a rule interfere seriously with the 
excreting function of the organ, and are therefore to be distin- 
guished from the important structural changes which constitute 
true Bright’s disease. 
Bright’s Disease. 
This important disease, or rather class of diseases—for several 
distinct morbid processes are included under the general term— 482 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
received its name from Richard Bright, of London, who, in 1827, 
published a series of observations showing the dependence of cer- 
tain forms of dropsy with albuminous urine upon structural chan- 
ges in the kidneys. Before his time, although the occurrence of 
albuminous urine in connection with dropsy had been repeatedly 
recognized, and diseased kidneys had often been found at autop- 
sies, the true relation between the symptoms in question and the 
renal changes had escaped attention. “ Bright's disease ” is a gen- 
eric term applied to a class of acute and chronic affections of the 
kidney, characterized by the presence of albumen and fibrinous 
casts of the uriniferous tubes in the urine, usually, also, by more 
or less dropsy and accompanied by various secondary disorders due 
to deterioration of the blood. 
A.—Acute Bright’s Disease, 
or, acute inflammation of the kidneys, may be induced by sev- 
eral causes, the most frequent of which are exposure to cold and 
wet, and blood-poisoning from scarlet fever, measles, erysipelas, 
etc. In some cases the cause cannot be traced. The general course 
of the affection is similar to that seen in the form produced by 
exposure to cold, which is briefly as follows ( within a few hours, or 
a day or two after the exposure, a dull uneasiness or pain is felt in 
the back, with a frequent desire to void urine. The latter is scan- 
ty, of a dark bloody or smoky color, and on examination is found 
to contain a large amount of albumen, with fibrinous casts of the 
uriniferous tubes. The attack is generally ushered in by chilli- 
ness succeeded by fever, with perhaps nausea and vomiting. Soon 
dropsy takes place, the face becomes pale and puffy, and the limbs 
swollen. After a variable time, ranging from a few days to a few 
weeks, one of three results ensues : Either the dropsy subsides, the 
urine becomes more copious and clear, and convalescence is estab- 
lished ; or the dropsy persists, the urine remains scanty, and death 
takes place with coma, convulsions, or from some other result of 
blood-poisoning ; or the affection becomes chronic, and after a long 
illness protracted through months, or possibly two or three years, 
the patient finally either recovers, or, more frequently, succumbs to 
the disease. The prospect of complete recovery is much better 
when the disease is due to scarlet fever, measles, etc., than when 
it arises directly from exposure to cold. 
To return briefly to the individual symptoms : the amount of 
albumen usually corresponds to the degree of inflammation, and is 
therefore a fairly reliable guide as to the severity of the disease. 
To detect albumen, fill a test-tube half full of the suspected urine, 483 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
and apply heat over a spirit-lamp to the upper half of the fluid, 
leaving the lower half as a standard for comparison. After boil- 
ing add two or three drops of strong nitric acid. If albumen be 
present, a white cloud is formed, which falls to the bottom on 
standing. For the detection of small quantities of albumen, the 
following procedure is preferable : Fill a test-tube to the depth of 
an inch with the urine ; then, inclining the tube, pour nitric acid 
drop by drop slowly down the side, so as to allow the acid to sink 
to the bottom without mixing with the urine. If albumen be 
present, the following appearances 
are noticed: underneath, the color- 
less acid ; above, the urine ; and be- 
tween the two fluids, an opalescent 
zone of coagulated albumen. The 
only other cloud that resembles this 
white zone of albumen is a deposit 
of uric acid salts ; the latter, how- 
ever, forms, not at the point of con- 
tact between the urine and the acid, 
but higher up, and disappears on the 
application of heat. 
The casts of the uriniferous tubes 
found in the urine are moulds com- 
posed of coagulated fibrin, in which 
may be imbedded epithelial cells, blood-corpuscles, pus-cells, etc. 
The appearances thus produced afford important indications of 
the changes taking place in the kidneys, but their detection re- 
quires some experience and the use of a good microscope. 
Dropsy.—This symptom is due to the escape of the watery por- 
tion of the blood from the vessels, and is usually confined to the 
loose tissue underlying the skin. Not unfrequently, however, effu- 
sion takes place into more important localities : into the pleural 
cavity, producing pressure on the lungs ; into the pericardium or 
bag inclosing the heart, impeding the action of the organ; into 
the lungs, threatening death by suffocation ; and finally, into the 
cavities and tissue of the brain, inducing convulsions or profound 
stupor. 
Uraemia.—This term is given to a group of symptoms which 
are directly or indirectly excited by the urea and other excremen- 
titious substances retained in the blood. The so-called uraemic 
symptoms are : dyspepsia, vomiting, diarrhoea, muscular twitch- 
ings, defects of sight and hearing, headache, drowsiness, convul- 
sions, and profound stupor. 
Treatment.—This affection requires the most skilful manage- 
Figure 134.—Manner of holding a 
test-tube over a spirit-lamp so as to heat 
the upper portion of its contents. 484 
THE KIDNEYS IN HEALTH AND DISEASE. 
ment. The administration of drugs by irresponsible persons is to 
be severely condemned, and if the services of a physician cannot 
be obtained, the disease might better be left to the curative powers 
of nature and the observance of the following hygienic regula- 
tions : Exposure to cold should be avoided by wearing flannel next 
to the skin, and, at the outset of the attack, by rest in bed in a 
room of uniform temperature. Alcoholic stimulants are always 
injurious in this affection. Water may be drank freely, for the 
purpose of washing out the obstructed tubes of the kidneys. Meat 
should be excluded from the diet so long as the urine is scanty, 
and, even after the secretion is restored, nitrogenous food should 
be used with caution until convalescence is well established. 
B.—Chronic Bright’s Disease. 
Three distinct varieties of renal disease are included under this 
head : (1), chronic inflammation; (2), granular or cirrhotic dis- 
ease ; (3), waxy disease. Any two of these different forms may 
be associated in the same individual, so that it is not always pos- 
sible to refer the symptoms to a single type. The distinction is 
important, however, when it can be made, since the course of the 
affection varies considerably according to the nature of the mor- 
bid condition. 
1. Chronic Inflammation of the Kidneys. 
This form of Bright’s disease is generally the sequel of an acute 
attack, such as has just been described, and can therefore usually 
be traced to a definite cause : exposure to cold, or some preceding 
illness, viz., scarlet fever, measles, etc. Occasionally, however, it 
develops gradually without antecedent acute symptoms, and with- 
out an assignable cause. Dropsy and scantiness of urine are 
prominent features. Temporary amelioration of these symptoms 
is not infrequent, and even permanent recovery is by no means 
rare; in fact, Bright’s disease in this form is far from being as 
hopeless as is commonly supposed. In fatal cases the course of the 
affection is usually comparatively rapid, the common limit being 
from three months to a year, but occasionally extending to two or 
three years. THE KIDNEYS IN HEALTH AND DISEASE. 
485 
2. Granular or Cirrhotic Disease. 
This is the most common variety of Bright’s disease, though, 
on account of the usually less marked nature of its symptoms, it is 
not so frequently recognized as the other forms. Its access is al- 
ways insidious, and there are no means known at present for de- 
tecting its existence until it has reached a more or less advanced 
stage. The renal changes consist in a slow degeneration resulting 
in shrinking of the organ and destruction of more or less of its se- 
creting tissue. General dropsy occurs in some cases, especially 
towards the end of the disease, but usually this is not a prominent 
symptom. In most instances the dropsy is limited in amount, and 
is often absent altogether. The urine is excessive in quantity, 
compelling the person to rise at night one or more times. The 
specific gravity is low, varying from 1.007 to 1.015. Towards the 
end of the disease the urine may become scanty and of high 
specific gravity. Albumen is usually found in the urine in small 
quantities, and sometimes remains absent for considerable periods. 
If general dropsy occur, the amount of albumen increases. The 
general symptoms are those of constitutional rather than local dis- 
ease ; indeed, by the time the renal changes have become recog- 
nizable, they are commonly accompanied by structural alterations 
in other organs, particularly the heart and blood-vessels. The 
calibre of the smaller arteries is narrowed and their walls degen- 
erated—conditions which predispose to bleeding from the nose, 
stomach, and into the brain (apoplexy). In consequence of the in- 
creased work required to force the blood through the narrowed 
vessels, the heart becomes enlarged, and beats violently or irregu- 
larly on any unusual exertion (palpitation). Dyspeptic symptoms 
are rarely absent, and sometimes vomiting recurs with such obsti- 
nacy as to lead to suspicion of organic disease of the stomach. In 
other cases attention is first drawn to the disease by the occur- 
rence of gradual loss of eyesight. In still other instances the ex- 
istence of the renal affection is wholly unsuspected, until the indi- 
vidual is suddenly stricken down by apoplexy, or sinks into a 
comatose state. Granular disease of the kidneys is essentially a 
chronic affection, and though it is always difficult to fix the date 
of its commencement, numerous cases are reported where it has 
lasted for five, ten, or even twenty years. The result is always 
fatal, the immediate cause of death being usually ursemic poison- 
ing, apoplexy, dropsy of the lungs, or an attack of acute inflam- 
mation, particularly of the lungs (pneumonia). 
Causes.—Of the numerous influences which induce this degen- 
eration of the kidneys, the following are the most important: (1). 486 
THE KIDNEYS IN HEALTH AND DISEASE. 
Intemperance.—The habitual use of ardent spirits repeatedly during 
the day, in quantities that do not actually intoxicate, is more dan- 
gerous in this connection than occasional gross excesses, because 
it subjects the kidneys to a constant irritation from which it has no 
opportunity to recover. (2). Depressing emotions.—The influence 
of anxiety or distress of mind in inducing Bright’s disease is more 
potent than is commonly supposed. It is difficult to trace the chain 
of causation in these cases, but the fact that prolonged emotional 
disturbance can finally produce structural changes in important 
organs besides the brain is now well recognized. (3). Gout.—The 
gouty disposition, especially when inherited, is a very frequent 
cause of this affection, and occasionally manifests itself in this 
form of disease without at any time attacking the joints. (4). 
Lead-poisoning.—Plumbers, compositors, painters, and all persons 
habitually exposed to lead-poisoning, are specially subject to this 
form of Bright's disease ; in fact, it is estimated that among pain- 
ters fully one-half die from this cause. Dr. Dickenson even asserts 
that lead-poisoning is a more fertile source of this disease than any 
other external influence with which we are acquainted. (5). 
Heart disease.—The fact that valvular disease of the heart not 
unfrequently produces congestion of the kidneys with albuminuria, 
has already been noted (p. 481). When the congestion is long con- 
tinued, it occasionally induces structural changes which are simi- 
lar to, if not identical with, those of granular disease. Finally, 
this variety of Bright’s disease belongs especially to middle or ad- 
Aranced life, and is more frequent in men than in women, because 
the former are more exposed to the usual causes, viz., intemper- 
ance, mental anxiety, gout, and lead-poisoning. 
3. Waxy Disease. 
This form of Bright’s disease is commonly a secondary affec- 
tion arising in connection with consumption, syphilis, disease of 
the bones and joints, or chronic suppuration in some part of the 
body. The term “waxy ” refers to the appearance of the cut sur- 
face of the organ, which looks as if infiltrated with wax. The 
morbid process begins in the blood-vessels, which become abnor- 
mally pervious, and allow the escape of fibrin from the blood. 
Similar changes take place in the spleen and liver, producing 
enlargement of these organs, and in the arteries of the stomach 
and intestines, giving rise in many cases to obstinate vomiting and 
diarrhoea. Dropsy, profuse urination, and considerable albumen 
in the urine are also prominent symptoms. The duration of the 
disease varies with the cause. In most instances the downward 487 
THE KIDNEYS IN HEALTH AND DISEASE. 
course is continuous, death resulting within a few months from 
exhausting diarrhoea, coma, convulsions, or the consequences of 
the primary disease. At other times, especially when the cause 
has been removed, the ultimately fatal result may be delayed for 
several years. 
Treatment of Chronic Bright’s Disease.—It must be evident, from 
the variety of morbid conditions which are classed under the gen- 
eral name of “ Bright’s disease,” that there can be no uniform 
treatment for all cases, and that the so-called “ cures for Bright’s 
disease” are therefore open to the same objections that apply to all 
panaceas. Rational treatment consists not in prescribing some- 
thing that is “good for Bright’s disease,” but in intelligently adapt- 
ing the resources of medicine to the constantly varying conditions 
that constitute the disease, and to do this requires repeated and 
careful investigation of all the symptoms. As this task demands 
knowledge that the reader is not supposed to possess, we shall con- 
fine ourselves to a few important hygienic directions. 
Care of the skin is indispensable, since a sudden check to the 
perspiration may superadd acute inflammation to the already ex- 
isting disease. Flannel shirts should, therefore, be worn next to 
the skin, both in winter and summer, and all unnecessary exposure 
to cold carefully avoided. Perspiration may be encouraged by 
gentle exercise, when the strength permits, and by a hot-air or 
Turkish bath once or twice a week. These measures tend to relieve 
the blood of accumulated excrementitious matters, and often give 
great relief. The baths, however, should be used only under med- 
ical supervision, as they sometimes produce unpleasant symptoms 
when improperly employed. Removal to a warmer climate during 
the winter months is very desirable, when practicable. There is 
ample evidence that the sudden changes of temperature incident 
to this period of the year in temperate climates is a very important 
element in the causation and aggravation of Bright’s disease, since 
the affection is much less frequent in both high and low lati- 
tudes, where the daily variation in temperature is less marked. 
Even the uniform cold of northern latitudes is less dangerous than 
the constantly changing climate of temperate regions. Southern 
resorts of a uniformly mild temperature are, however, to be pre- 
ferred, viz. : the Bahamas (Nassau) Florida, the southern coast of 
California, the shores of the Mediterranean, etc. The diet should 
be simple, so as not to overtax the enfeebled digestive powers, and 
while a moderate allowance of meat is usually required for the 
maintenance of strength, an excess of animal food is objectionable, 
since the burden of removing nitrogenous substances from the 
body falls mainly upon the kidneys. As regards alcoholic stimu- 488 
THE KIDNEYS IN HEALTH AND DISEASE. 
lants, entire abstinence is doubtless the safer rule for the great 
majority of cases, especially for those of gouty origin ; in some in- 
stances, however, the moderate use of light wines acts favorably 
as a diuretic, and in emergencies the stronger stimulants may be 
absolutely demanded. When the disease has resulted from lead- 
poisoning, further exposure should be avoided if possible. If this be 
impracticable, as in the case of printers, plumbers, etc., who may 
be unable to abandon their occupation, the face and hands should 
be carefully washed before each meal, and the absorption of lead 
from the alimentary canal prevented by the free use during the day 
of sulphuric acid lemonade (five drops of sulphuric acid to a tum- 
blerful of water), which converts the lead into an insoluble sul- 
phate of lead. The lead already absorbed into the system is to be 
removed by a course of iodide of potassium and other measures 
best chosen by a physician. In the waxy form of Bright’s disease 
a surgical operation may be required for the removal of dead bone, 
or to check suppuration. 
Gravel, Calculi, Stone in the Kidney. 
Concretions are not unfrequently formed in the pelvis of the 
kidney by the deposition of certain ingredients of the urine, gen- 
erally uric acid or oxalate of lime. The smaller concretions are 
called gravel, the larger ones calculi. If the stone fail to escape 
through the ureter, it continues to grow, and may either remain as 
a harmless occupant of the cavity, or excite serious inflammation. 
The symptoms occasioned by the passage of a concretion from the 
kidneys to the bladder are commonly known as a “fit of gravel.” 
The attack usually begins suddenly, sometimes gradually, with a 
severe pain in one side of the loin, shooting downward along tho 
course of the ureter and inside of the thigh, and extending in 
males to the end of the penis, with retraction of the testicle on the 
affected side. The pain is accompanied by a frequent desire to 
void urine, which is passed in only a few drops at a time, and 
sometimes contains blood. Nausea and vomiting, and coldness of 
the surface of the body, are present in severe attacks. The pain 
ceases abruptly when the stone escapes into the bladder. Renal 
colic usually lasts but a few hours ; occasionally, however, it is 
prolonged for several days, with intermissions of relief, during 
which the progress of the concretion is temporarily arrested. 
After reaching the bladder the stone usually escapes through the 
urethra without serious difficulty in the course of a few hours or 
days, and every discharge of urine should be carefully examined. 
If the urine and faeces happen to be passed into the same vessel. THE KIDNEYS IN HEALTH AND DISEASE. 
489 
the entire contents should be thrown onto a fine sieve, and re- 
peatedly washed until only insoluble substances remain. The de- 
tection of the concretion is important, because occasionally the 
stone remains in the bladder, increases in size, and ultimately in- 
duces inflammation of the organ. The above symptoms are usu- 
ally characteristic, but may be simulated by other affections. 
Treatment.—In severe attacks, when medical advice cannot be 
obtained, the following palliative measures may be resorted to, 
viz.: a warm bath as hot as can be borne, the free use of drinking 
water, and in the case of an adult, the administration of from 
twenty-five to fifty drops of laudanum. 
Rarer Diseases of the Kidneys. 
Inflammation of the Pelvis (Pyelitis). 
Inflammation of this portion of the kidney (see Anatomy) is 
most frequently caused by exposure to cold, the presence of stone 
in the pelvis, obstruction of the lower urinary passages producing 
retention and decomposition of the urine within this cavity, and 
the extension of inflammation upward from the bladder. The 
symptoms are often disguised by the existence of chronic disease 
of the bladder, and may escape attention entirely. In marked 
cases they consist of backache, frequent micturition, daily chills 
followed by fever and sweating, emaciation, and gradual exhaus- 
tion. The course of the affection varies according as the products 
of inflammation (pus, etc.) escape freely, or are retained in the 
pelvis by obstruction below. In the former case pus (or matter) is 
discharged constantly with the urine; in the latter case the pel- 
vis becomes distended, so as to press upon and obliterate the kid- 
ney substance, and finally convert the organ into a bag of pus. 
One of three results now occurs : either the obstruction gives way 
and pus in large amount escapes with the urine, or the abscess 
bursts in some other direction, through the loin, or into the intes- 
tines or peritoneal cavity; or, in rare instances, a spontaneous 
cure is effected by the pus becoming inspissated and converted into 
an innocuous mortar-like, chalky, or even bony substance. Chronic 
pyelitis is a serious and often fatal affection, generally obscure in 
its symptoms, and very intractable to treatment. 
Cancer of the Kidney. 
Cancer occurs in the kidney in two forms : 1, as a primary af- 
fection, and 2, as an extension of malignant disease from some 490 
THE KIDNEYS IN HEALTH AND DISEASE. 
other part of the body. In the latter form the symptoms are very 
obscure, and are rarely recognized during life. Primary renal 
cancer is usually met with either in early childhood or in mature 
life, the period between the tenth and thirtieth years being singu- 
larly free from the disease. It commonly attacks but one kidney, 
and occurs much more frequently in males than in females. The 
characteristic symptoms are : a tumor in the region of the kidney, 
bloody urine, pain in the loin, emaciation, and final exhaustion. 
The tumor is usually large and may attain an enormous size ; in 
one case weighing thirty-one pounds. The duration of the disease 
in children is generally less than a year; in adults it averages 
about two years, and may extend even to seven or eight years. 
Recovery is unknown. 
Hydatids of the Kidney. 
These watery bladders or cysts, which are occasionally met 
with in man, in common with pigs, sheep, and oxen, are immature 
parasites which undergo their final de- 
velopment in the Tcenia echinococcus, a 
minute tape-worm scarcely longer than a 
millet-seed, found in the intestines of the 
dog (Fig. 135). The circle of development 
may be traced as follows : The mature 
worm in the dog consists of three seg- 
ments, the last of which, containing the 
generative organs, is cast off when fertil- 
ized, and escapes along with the excre- 
ment of the animal. The eggs, scattered by the bursting of this 
segment, become mixed with food or drinking water, and, pass- 
ing into the intestinal canal of man or one of the above-mentioned 
animals, develop there into embryos, which bore their way or are 
carried by blood-vessels into the internal organs or tissues. Hav- 
ing arrived at their 
destination, the em- 
bryos become encyst- 
ed, and develop into 
hydatids, or watery 
bags presenting the fol- 
lowing appearances: 
Externally, the cyst is 
composed of a firm, 
fibrous capsule, within which lies a gelatinous bladder, called the 
mother-bladder of the echinococcus. This is filled with a watery 
fluid, and usually contains also numerous large and small vesi- 
Figure 135.—(After Aiken).— 
Two echinococci. 
Figure 136.—(After Wilson).—Germinal membrane con- 
taining groups of echinococci. 491 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
cles, known as daughter-bladders, which in their turn may con- 
tain granddaughter-bladders. The mother-bladder is lined inter- 
nally with a very thin, delicate membrane, called the germinal 
membrane (Fig. 13G). This membrane is dotted with numerous 
white particles (echinococci), each of which1 represents the head 
of the mature tape-worm found in the dog (Fig. 
138). The echinococcus embryo measures from TV 
to °f a line in length, according as the head is 
extended beyond or retracted within the vesicle sit- 
uated beneath it. The head is supplied with a 
double row of hooklets (Fig. 
137), varying from 28 to 52 in 
number, which are less destruc- 
tible than other parts of the para- 
site, and therefore supply an im- 
portant means of diagnosis, when 
the parasite has been destroyed 
by suppuration in the cyst. 
Hydatid tumors in the human kidney vary in size 
from an egg to a child’s head, or larger. With very 
rare exceptions, only one kidney is affected. As 
compared with other organs, the kidney is a favor- 
able location for these tumors, because renal hyda- 
tids usually burst into the pelvis of the kidney and 
escape with the urine. The symptoms occasioned 
by such a rupture resemble those of an attack of 
gravel, and are followed by the discharge of several 
vesicles resembling a bunch of white grapes, and 
accompanied by shreds of membrane, and possi- 
bly some of the hooklets referred to above. These 
attacks commonly recur at shorter or longer inter- 
vals, and the emptied cyst finally shrinks into a 
harmless mass of dense tissue. Spontaneous cure 
occasionally takes place without rupture, as a result of death of the 
hydatid and absorption of the watery fluid. In less favorable cases 
the cyst either bursts in some other direction, especially through 
the lungs, or suppuration occurs within the cyst, producing the con- 
stitutional symptoms of a large abscess. The colic excited by the 
passage of the vesicles down the ureter may be relieved by the 
measures recommended for a fit of gravel (p. 489). When the 
tumor exerts serious pressure upon adjacent organs, or threatens 
to burst in an unfavorable direction, the cyst may require to be 
tapped for the purpose of drawing off the fluid, and thus causing 
the death of the parasite. This operation is less frequently neces- 
Figure 137. — (After 
Davidson).—Hooklets of 
the echinococcus. 
Figure 138.— 
(After Van Bene- 
DEN).—The mature 
tape-worm as it oc- 
curs in the dog. 492 
THE KIDNEYS IN HEALTH AND DISEASE. 
sary in hydatids of the kidney, than where the parasite locates 
itself in the liver or lungs. 
Hydatid disease in the human being is quite rare in America, 
more common on the European continent, and very prevalent in 
Iceland, where one-fifth of all deaths are stated to be caused by 
this affection. The excessive frequency of human hydatids in 
Iceland is accounted for by the extraordinary number of dogs on 
the island (a very large proportion of which are infested by the 
taenia echinococcus), and by the repulsively familiar relations 
which exist between these animals and the households of their 
masters. 
Movable or Migratory Kidney. 
Normally, the kidney is retained in a fixed position alongside of 
the spine in the lumbar region, by means of an investment of fatty 
tissue and a layer of peritoneum reflected over the anterior sur- 
face of the organ. Under certain circumstances, these attach- 
ments are loosened, and the kidney becomes more or less freely 
movable in the abdominal cavity. This dislocation may be unat- 
tended by any symptoms; in many cases, however, uncomfort- 
able or painful sensations are experienced, which are very apt to 
excite serious alarm, especially if a movable tumor happen to be 
discovered in the abdomen. Uneasiness, or a dragging sensation, 
or shooting neuralgic pains may be produced by the erect position, 
or sometimes even by turning in bed. Occasionally paroxysms of 
intense pain, resembling an attack of renal colic, and accompanied 
by enlargement and tenderness of the tumor, are observed. The 
cause of these attacks is not well understood ; the most plausible 
explanation is that at these times the kidney becomes twisted upon 
the ureter, thus producing an obstruction to the escape of urine 
and a consequent distention of the pelvis of the organ. The mov- 
able kidney is much more frequently met with in women than in 
men, and is very rare in children. The most common causes of 
dislocation are : relaxation of the fatty investment of the kidney, 
resulting from absorption of fat in wasting diseases ; severe mus- 
cular exertion ; falls or blows and, in women, repeated confine- 
ments or tight lacing. Relief from the above-mentioned disturb- 
ances may be obtained by wearing an abdominal bandage applied 
after replacement of the organ. Violent exercise and tight lacing 
should be strictly avoided, and the bowels should be kept regular, 
since constipation always increases the discomfort. THE KIDNEYS IN HEALTH AND DISEASE. 
493 
Rake Anomalies of the Urine. 
Chylous Urine (Chyluria). 
In this singular affection the urine has the appearance of milk, 
and usually coagulates into a trembling mass resembling blanc- 
mange. These appearances are due to the presence of chyle, the 
milky fluid formed in the intestinal canal by the digestion of fat, 
and absorbed therefrom by the lacteal vessels. Occasionally the 
chyle is replaced by lymph, and then the urine is clear when 
passed, but forms, on standing, a coagulum resembling calf’s-foot 
jelly. The affection is confined, ivith very rare exceptions, to the 
inhabitants of tropical climates, particularly India, Mauritius, the 
Isle of Bourbon, West Indies, and Brazil, or to individuals who 
have passed some time in these countries. Recent investigations 
by Dr. Lewis, of Calcutta, and others, have led to the discovery in 
many of these cases, of a 'minute nematoid worm, of an inch in 
length (the Filaria sanguinis hominis), which infests, in immense 
numbers, the blood-vessels, and probably also the lymphatics. 
Rupture of the lymphatic vessels, it is supposed, may be produced 
by the lashing movements of a mass of struggling worms, and 
allow the lymphy or chylous contents of the vessels to escape into 
the urinary passages. Chylous urine has, however, been repeat- 
edly noticed independently of parasitic disease, and in such cases 
the disorder still awaits explanation. 
Intermittent Haematinuria. 
This affection occurs almost exclusively in males. It is charac- 
terized by paroxysms lasting from three to twelve hours, and re- 
curring, sometimes, with marked regularity, but more frequently 
at irregular intervals. Each attack is ushered in by chilliness, or a 
marked rigor and general malaise, accompanied by pain in the 
back, and perhaps nausea and vomiting. The first urine voided is 
of a deep porter or port wine hue, and throws down, on standing, a 
chocolate-colored sediment which consists chiefly of broken-down 
blood-corpuscles. The symptoms now gradually subside, and the 
previous condition of health is restored until the next paroxysm. 
During the intervals the urine is perfectly normal. The appear- 
ance of the urine during the attack is probably due to an intense 
transient congestion of the kidneys, which in some cases can be 
traced to malarial poisoning, but more commonly seems to be oc- 
casioned simply by an abnormal sensitiveness to the influence of 494 
TIIE KIDNEYS IN HEALTH AND DISEASE. 
cold. The affection usually disappears spontaneously after a time 
or yields readily to treatment, but sometimes leads to a state of 
chronic invalidism. As regards treatment, by far the most impor- 
tant measure is careful protection against exposure to cold and 
wet. 
A. BRAYTON BALL, M.D. The Mate Genito - Urinary 
Organs. 
BY 
EDWARD L. KEYES, A.M., M.D., 
OF NEW YORK CITY, 
VISITING SURGEON TO BELLEVUE HOSPITAL; CONSULTING SURGEON TO CHARITY HOSPITAL; 
PROFESSOR OF DERMATOLOGY AND ADJUNCT TO THE CHAIR OF PRINCIPLES 
AND PRACTICE OF SURGERY IN BELLEVUE HOSPITAL MEDICAL 
COLLEGE, ETC., ETC. THE MALE GENITO-TTRINARY 
ORGANS. 
The genitourinary organs suffer more than other parts of 
the human body from neglect. This is largely due to ignorance, 
and is fostered by a strange false-modesty among English-speaking 
people which leads them to mention these organs only in a whis- 
per and to regard their maladies as a disgrace. 
Americans are peculiarly afflicted with this narrowness of mind. 
They shroud the whole subject, especially its sexual side, in unne- 
cessary mystery, and encourage among growing children a general 
ignorance on all such matters ; an ignorance which defeats its own 
ends, since it leads the active mind of the child to seek for infor- 
mation in bad quarters, often to its own serious injury. Parents 
magnify the importance and the significance of all allusions made 
by children to their genital organs, and the child grows up inclined 
to be morbidly over-sensitive about the whole subject, and careless 
in such simple attentions to his person as common-sense alone 
would naturally dictate. 
For fear of leading a boy into bad habits, his parents will not 
instruct him how to pull back his foreskin and wash away the 
accumulation of white, rancid material which the little glands of 
the region furnish. A boy whose face and hands are clean is often 
foully filthy under his foreskin, and the accumulation of this 
smegma, as it is called, gradually irritating the delicate mucous 
lining of the foreskin and creating an itching there, leads directly 
to masturbation, and produces the very vice which the fond pa- 
rent stupidly supposed he was helping the child to avoid. 
The absence of public urinals in American cities is another 
evidence of this weak-mindedness of the people, and another is the 
broken health and spirit of many a fine girl who has been ashamed 
to keep quiet and to be sick during her menstruation, lest some one 
should suspect her condition. 
The urinary and genital organs are as honorable as any, and 
their hygiene should be attended to with as much respect. Their 498 
TIIE MALE GENITO-URINARY ORGANS. 
derangement causes incalculable discomfort to the individual, and 
is the spark which kindles many a domestic tragedy. 
The Prepuce. 
The prepuce or foreskin is that fold of integument which en- 
sheaths the head of the penis. The Hebrews in the sacred rite 
of circumcision, when the child is named, upon the eighth day, 
cut off this redundant skin and thus save the boy from many 
annoyances and sources of possible disease to which his less fortu- 
nate Christian brother is exposed. For it is not doubtful that all 
mankind would be better without a foreskin than with it. What- 
ever function it served for primeval man, the prepuce is unneces- 
sary now and only attracts the attention of its possessor by its 
requirements for cleanliness, and of the physician by the diseases 
it occasions. 
Under the foreskin, behind the raised ridge (corona) of the 
head of the penis, a whitish material collects, composed of fatty 
matter and dead skin, which gathers into little rolls, has a rancid 
fishy odor, and calls for removal on pain of exciting, sooner or 
later, an inflammation of the membrane against which it lies. On 
this point mothers should be careful to instruct their children while 
young, teaching them, whenever they take a bath, to pull back the 
foreskin, rapidly wash the end of the penis with a handful of soap- 
suds, dry it immediately, and replace the foreskin at once as a 
matter of routine. 
Phimosis. 
When the foreskin cannot be pulled back over the head of the 
penis, phimosis exists. Most babies have this deformity, but for 
the first few years of life phimosis is not important unless it gives 
discomfort or produces symptoms to be named presently. The 
orifice of the prepuce often enlarges with the growth of the child, 
so that moderate phimosis in babyhood may cease to exist in boy- 
hood. When, however, the prepuce balloons during urination, 
showing that the preputial orifice is narrower than that of the ure- 
thra, then nothing can be hoped for from nature, and an operation 
is called for. 
Sometimes the tightness of the prepuce is due to inflammation. 
In such cases the end of the foreskin becomes red and more or less 
swollen. Slight inflammation is apt to occur from time to time in the 
case of all children with a narrow prepuce, and it may be only at 
such times that the little patient shows symptoms of disorder. If THE MALE GENITO-URINARY ORGANS. 
499 
unrelieved and repeated, these attacks of inflammation, which origi- 
nate on the inside of the prepuce, gradually cause adhesions to 
form between the latter and the head of the penis, and after these 
have been once formed a certain amount of inflammatory irrita- 
tion of the end of the penis is pretty sure to persist until the pre- 
puce has been removed or loosened and the adhesions broken 
away. 
As a result of the irritation caused by phimosis, inflamed or 
with adhesions, the most varied disorders may arise by a process 
termed reflex action. Thus the child may be peevish, fretful, 
pallid. He may look ill without being actually sick. He is apt to 
pull at his penis, attempting to relieve a discomfort he feels there. 
He passes water too often, especially at night. He is apt to wet 
the bed. He is found awake at night with the penis hard and 
erect, tossing about uneasily, ignorant of what distresses him. 
He will perhaps have erections during the day. His symptoms 
may reach the extent of mild inflammation of the bladder, accom- 
panied by much straining and more or less falling of the bowel. 
His reflex symptoms, indeed, may go to the extent of paralysis of 
groups of muscles ; to the simulation of joint disease, occasionally 
his mind becomes involved, and any or all of his functions may be 
more or less perverted as a result of this trifling local irritation at 
the end of the penis. 
So much for the young child. 
The growing boy is apt to be invited to self-abuse by the irrita- 
tion attending phimosis, while frequent urination and all the other 
symptoms of an irritable bladder are occasionally due to this con- 
dition. 
After middle life phimosis does not do so much harm, indeed 
one may have phimosis at any age and not suffer ; but a majority 
certainly do. Occasionally old men are met with who have never 
been seriously inconvenienced by phimosis, who have married and 
reared a family without ever in their lives having been able to 
draw back the foreskin. 
Whether a tight prepuce causes symptoms or not, it is always 
liable to become the seat of inflammation and to give trouble, and 
it is the part of wisdom to do away with the defect. 
Treatment.—Phimosis is cured by cutting away the foreskin or 
slitting it up, according to its length and tightness. The inflamed 
conditions which cause most of the symptoms, however, are met 
by the use of dilute lead-water, both externally and thrown into 
the cavity of the prepuce with a syringe. A lotion made of from 
half a grain to two grains of sulphate of zinc in an ounce of rose- 
water, may be used in the same manner, or a wash of three parts 500 
THE MALE GENITO-URINARY ORGANS. 
of water to one of aromatic wine. These lotions and injections 
under the prepuce should be often repeated, being always so mild 
as not to cause smarting; but no treatment of the irritation is so 
valuable as the surgical removal of the cause (the phimosis). 
Para-phimosis. 
This condition exists when the prepuce has been pushed behind 
the ridge of the head of the penis, and remains there. The parts 
quickly swell, and the whole member becomes distorted. If unre- 
lieved, the strangulated parts in front of the constriction may mor- 
tify after a time. 
Treatment.—Reduction may be readily effected if the mischief 
is detected early, by compressing the head of the penis side-ways 
with the thumb and fingers of one hand, while the other hand en- 
circles the penis and draws the skin forwards. If reduction can- 
not be accomplished after a few attempts, a physician must be 
summoned 
Cutaneous Affections of the Penis. 
Besides ordinary skin diseases and contagious venereal ulcers 
(described elsewhere), two common maladies of the integument of 
the penis call for a few words. 
Herpes Progenitalis consists of clusters of minute water blis- 
ters grouped together, much resembling “fever sores” on the 
mouth, tingling somewhat, drying up into a scab in a few days on 
the outside, and yielding distinct ulcers when occurring under the 
prepuce. They are often due to local irritation ; sometimes they 
appear spontaneously. They occur in youth and middle life. 
If these spots can be detected when first coming out, they may 
be modified in intensity by touching them with a drop of spirits of 
camphor or of strong tincture of aconite root. Once fully formed 
the lotions advised for inflamed states of the prepuce (see pre- 
ceding page) answer very well. Ulcers may be dusted with 
powdered oxide of zinc and calomel, or with powdered iodoform, 
where the odor of the latter is not objectionable. 
Warts upon and under the prepuce are very common in early 
life—especially in connection with uncleanly habits or inflamma- 
tions of the region. They generally yield to cleanliness and to 
dusting the parts freely with calomel. They may be radically 
treated by snipping them off with curved scissors and cauterizing 
the base from which they grow with nitrate of silver. Large 
crops of warts generally call for tonic internal treatment with cod- 
liver oil as one of its elements. Tincture of the leaves of Arbor 
Vitae (Thuja occidentalis) locally, is serviceable in such cases. THE MALE GENITOURINARY ORGANS. 
501 
Cancer of the Penis. 
The common variety (epithelioma) usually commences after 
middle life, as a warty looking, flat, more or less excoriated spot 
on the prepuce, or on the under side of the end of the head of the 
penis. The continuance of such a little rawish spot first attracts 
attention. Finally, an ulcer appears and eats its way backwards. 
The remedy is the surgeon s knife. 
Wounds and Contusions of the Penis. 
Wounds of the penis, if deep, are apt to bleed freely. The 
member should not be bandaged, but washed off with cold water, 
and when it becomes evident from what part of the wound the 
blood flows, that part should be firmly seized between the thumb 
and forefinger and held until the surgeon arrives. Much pressure 
is not necessary to arrest bleeding. 
Contusions of the penis are sometimes attended by pretty free 
effusion of blood under the skin, so that the member promptly be- 
comes black and swollen. Until medical aid is obtained, rest and 
ice-water compresses constitute the treatment. 
The Urethra. 
The urethra is the canal through which urine passes out from 
the bladder. It is about 
eight inches long in 
adult life. Its external 
orifice is called the mea- 
tus. Some notion of its 
different parts is desira- 
ble ; the following cut 
may help to make them 
comprehensible. 
The urethra is divid- 
ed into three portions : 
(1) pendulous urethra, 
which takes the direc- 
tion of that portion of 
the penis lying outside 
of the body; (2) mem- 
branous urethra, lying 
beneath the bone, and 
fixed in its position and 
shape. This is the part injured by falls upon the crotch with the 
legs apart; (3) the prostatic urethra surrounded by the prostate, 
Figure 139.—General view of the male organs of genera- 
tion : T, testicle, x, y, the larger and smaller extremities of 
the epididymis; vd, the vas deferens ; vs, vesicula seminalis ; 
p, the prostate; B, the bladder; nr, the urethra; b, the bulb; 
cs, the corpus spongiosum; cc, the corpus cavernosum; g, 
the glans ; p, the prepuce. 502 
THE MALE GENITO-URINARY ORGANS. 
receiving the ejaculatory ducts from the seminal vesicles, and ter- 
minating in the neck of the bladder. 
The urethra is surrounded with muscular fibres which keep its 
walls in contact. The membranous urethra has, also, a covering of 
muscles under control of the will: a group called, collectively, the 
cut-off muscle which any healthy person may cause to contract at 
will and arrest the stream of urine suddenly. It is in this group 
that spasmodic stricture is usually situated, and it is the refusal of 
this group of muscles to relax which makes it impossible, some- 
times, for an individual to urinate in another’s presence. 
The urethra is always moist. It is studded with numberless lit- 
tle glands which supply a translucent, sticky mucus. In conditions 
of excitement this natural mucus is thrown out in excess by the 
glands and appears at the meatus as a pellucid drop, often arous- 
ing the suspicion of disease in the minds of young people preoccu- 
pied about themselves. This is not a malady. A perfectly limpid 
sticky drop of fluid at the meatus after local excitement is natural. 
If it were not there it would indicate some disease of the glands 
whose function it is to supply this mucus upon call. 
Deformities of the Urethra. 
The urethra is sometimes deformed. It may be imperforate or 
congenitally strictured. This condition shows itself soon after 
birth by an inability on the part of the child to pass water. The 
urethra may open on the top of the penis, or underneath, or into 
the bowel. The penis may be variously contorted and the urethra 
with it, but none of these conditions can be mended by domestic 
surgery. 
One deformity, however, requires comment, since it bears such a 
direct causal relation to a number of the affections of the urethra 
and bladder ; it is an unnaturally small meatus. Just as phimosis 
may fail to cause its possessor any annoyance during a lifetime, 
so very much more often does a small mouth to the urethra pass 
unnoticed and give rise to no discomfort. Yet it is well to know 
that a small meatus may occasion considerable mischief ; pain in 
the urethra ; irritation of the bladder, leading to frequent micturi- 
tion, and to inflammation of the bladder ; reflex pains and dis- 
turbances of the most varied character, like those described for 
phimosis ; and all of this in so insidious a manner that the patient 
never suspects for a moment the true cause of his varied disorders. 
The mechanism of this action need not be described here. Most 
unquestionably cases occur where a small meatus alone is the cause 
of serious disorder, and there is no longer any doubt about them in THE MALE GENITO-URINAEY ORGANS. 
503 
the minds of practical observers. Even Civiale, years ago, refers 
to cases of this sort, and speaks of inflammation of the bladder 
due solely to a tight meatus; when the latter was cut the inflam- 
mation got well. 
A meatus which is too tight may be recognized by finding out 
whether there is a pocket behind its lower angle. The floor of the 
urethra should come out evenly at this point, and there should not 
be the slightest bridge of skin across it. If, therefore, a blunt 
probe drawn along the floor of the urethra—the instrument being 
held nearly at a right angle to the canal—can be made to catch in 
the lower angle of the meatus, the latter is too small and should 
be freely cut in all cases of obscure disease involving the urinary 
passages. This little operation can do no harm and may do an 
immense amount of good. If the patient suffer no inconvenience 
therefrom, mere smallness of the meatus is no reason for inter- 
ference on the part of the surgeon. 
Neuralgia of the Urethra. 
Pain of a neuralgic sort along the urethra is generally due to a 
contracted meatus, a stricture of large calibre or some congestion 
of the prostatic urethra or neck of the bladder. Its consideration 
and treatment fall to the surgeon. 
Inflammation of the Urethra {urethritis). 
This ailment is a very common one. It may be due to a vast 
number of different causes. Contact with the disease in another 
person is by no means the sole cause. Married men often come 
legitimately by urethritis. Excess in natural relations, contact 
of the urethra with a leucorrhoeal discharge, menstrual blood— 
any one of these is sufficient sometimes to occasion urethritis, 
especially in one who has previously suffered from this malady. 
Men differ very much in their susceptibility to being inflamed by 
contact with discharges not in themselves poisonous. 
Besides this set of causes, more or less urethritis follows all in- 
juries to the canal of any kind, mechanical or chemical. Highly 
acid states of the urine due to excess in drinking (particularly 
sweet and fermented liquors, champagne or beer), may alone cause 
urethritis, especially if the urethra has been already damaged by 
previous inflammation. The concentrated acid urine of gouty 
people may provoke in them a mild urethritis if the patient be run 
down or much fatigued, while stricture of the urethra, for the 
most part, is attended by some urethritis as one of its necessary 504 
THE MALE GENITO-URINARY ORGANS. 
symptoms. The most obvious symptom of urethritis is a creamy 
discharge of matter from the meatus. Attending this, according 
to the grade of the inflammation, is more or less redness and swell- 
ing of the orifice of the urethra and heat along the course of the 
canal, pain on urination and pain when the organ becomes rigid. 
This last pain is due to the stretching of certain portions of tissue 
outside of the mucous membrane, where the inflammation has 
penetrated beneath the surface. Such portions of the spongy tissue 
become inelastic, and do not distend with blood, as does the rest of 
the organ during erection. The portion which does not dilate is 
therefore shorter than the rest of the member, and the penis be- 
comes curved (generally downwards) during erection, in a condi- 
tion known popularly as chordee, great pain being felt along the 
shorter portion of the curve. 
When urethritis begins shortly after an exposure to contagion 
—within forty-eight hours—it is apt to run a mild course. If it 
commences on the sixth, seventh, or eighth day, it is pretty sure to 
be severe. The symptoms last from a few days in mild cases up 
to many months in severe ones—and indeed a slight discharge of 
mixed pus and mucus may continue for years after an attack. 
As complications of urethritis may be mentioned inflammation of 
the bladder due to an extension backward of the disease, inflam- 
mation of the testicle, abscess in the prostate, or around the urethra, 
a peculiar form of desperately chronic rheumatism which affects 
joints, tendons, muscles, and the eyes, and worse than all the others, 
a severe purulent inflammation of the eyes, gonorrhoeal conjunc- 
tivitis, very violent in character, always tending to destroy the 
eye, and always due to direct contact of some of the urethral pus 
with the eye. 
This fact just stated cannot be too seriously insisted upon. A 
general knowledge of it is most desirable. Ignorance of it has re- 
sulted more than once in total loss of sight. 
No portion of any discharge from the urethra should ever be 
allowed contact with a towel, lest it may afterwards reach the eye, 
and the patient should in all cases wash his hands after touching 
the penis. Another important fact in connection with inflamma- 
tion of the urethra is this : stricture is the legitimate consequence 
of prolonged urethritis. 
Treatment.—The treatment of an active urethritis generally il- 
lustrates the truth of the saying—the more haste the less speed. 
No patient should attempt to gain time in his own case by the 
active use of injections from the first. If injections are used in 
the beginning of an attack, some one besides the patient ought to 
bear the responsibility. In mild cases of urethritis, very weak in- TIIE MALE GENITO-URINARY ORGANS. 
505 
jections at first are serviceable, unquestionably, but in an active, 
virulent attack they cannot do good, and may do an immense deal 
of harm. 
The rules for a patient to follow during urethritis are these : 
Avoid activity of body of all sorts ; drink plenty of water and milk, 
but no strong drink, wine, liquor or beer, strong tea or coffee; 
avoid all spices and stimulating sauces, as well as rich and indi- 
gestible articles of food ; attend to the functions of the bowels, and 
avoid exposure to cold and local or general excitement. 
As for medical treatment, no patient can be made wise enough 
by any amount of written directions to bear the responsibility of 
conducting his own medical treatment during urethritis. Many 
persons do attend to themselves by the aid of suggestions from 
an apothecary, but such a course is unwise in view of the very 
serious complications which may arise, complications which some- 
times lead to the loss of important functions, sometimes even ter- 
minate in death. A surgeon is the proper person to be consulted. 
Stricture of the Urethra. 
A stricture of the urethra is a tightness of the canal, either con- 
genital (as of the meatus, already considered, p. 502) or acquired. 
The latter are (1) organic, due to inflammation (urethritis), or the 
result of injury (particularly of bruising injuries to the crotch) ; 
or (2) muscular, due to irritation somewhere along the canal, or 
to nervous causes. 
Vastly more common than all other causes in the production of 
organic stricture is inflammation of the urethra—urethritis. Stric- 
ture may follow a urethritis by the short interval of a few weeks, 
or it may be twenty years before it declares itself by obvious 
symptoms. 
The symptoms of stricture are a gleety discharge from the 
meatus (or clusters of matter, or shreds in the urine), sometimes 
pain and irritation of the bladder, and reflex symptoms of the most 
varied character. Finally, where a stricture becomes very tight, 
whether it be organic or muscular, a narrowing of the stream of 
urine, or at last even retention of urine comes on, with all its dis- 
astrous consequences to the bladder, the kidney, and possibly the 
life of the patient. When stricture is tight the urine starts slowly 
and dribbles away at the end of urination. There may be two or 
more curiously curved streams instead of one, or the stream may 
be very small, perhaps dropping down without force from the end 
of the penis. 
Spasmodic strictures may yield the same symptoms as organic 506 
TIIE MALE GENITO-URINARY ORGANS. 
obstructions, and, indeed, the line of symptoms covered by stric- 
ture includes nearly all the irregularities of function and conduct 
to which the urethra is liable. 
In no case of chronic or obscure disease even remotely involv- 
ing the urinary organs, should the surgeon omit to examine the 
urethra for stricture. 
Treatment.—The treatment of stricture cannot be carried on by 
the patient himself, but must be entrusted to some competent sur- 
geon. 
Strictures in the pendulous urethra may be radically cured by 
thorough division with the knife. Deep strictures are apt to re- 
contract after any operation, and should be kept open by the pa- 
tient himself by the occasional use of a full-sized steel sound after 
cure. 
The Prostate. 
The prostate gland, so called, is really a muscular body receiv- 
ing the neck of the bladder and surrounding the first portion of the 
urethra. An idea of its relative size and position may be ob- 
tained by a glance at the figure on page 501. It lies in contact 
with the end of the lower bowel, where it may be readily examined 
by the surgeon’s finger through the wall of the gut. A portion of 
the seminal vesicle lies enshrouded in it, and its substance is tun- 
nelled on either side by the ejaculatory duct which brings the sem- 
inal fluid from the vesicle during the orgasm into the sinus or 
cavity of the prostate, whence it is ejected in spasmodic jets by the 
involuntary contractions of the muscular tissue of which the pros- 
tate is mainly composed. The function of the prostate is therefore 
solely a sexual one. It is absent in the female. 
The prostate is composed of two symmetrical lateral portions 
called lobes. In disease a third (middle lobe) sometimes develops 
posteriorly and causes much trouble. In the nerves which termi- 
nate on the surface of the mucous membrane lining the sinus of 
the prostate lie the seat of the sixth special sense—the sexual 
sense—and it is the proximity of this region to the sensitive neck 
of the bladder which makes the prostatic sinus so important a 
factor, oftentimes, in the causation of diseases of the bladder as 
well as of the deep urethra. 
When a sensitive organ is abused it becomes more or less de- 
ranged. No one wonders at dyspepsia produced by irregularity 
and excess at table. An eye damaged by neglect, bad care and 
over-use does not occasion surprise, yet it is customary, with cer- 
tain people, to shamefully abuse the sexual function by over-use, THE MALE GENITO-URINARY ORGANS. 
507 
by irregularity, by stimulation without relief, and yet surprise is 
felt when this region goes wrong in a persistent, chronic way, and 
when disorder here lights up functional and even inflammatory 
distress in the bladder and neighboring urethra. The wonder is, 
on the other hand, that so many people remain as well as they do. 
Neuralgia of the Deep Urethra. 
Symptoms.—A certain sensitiveness deep in the crotch behind 
the scrotum, perhaps a throbbing in that region, or a sense of ful- 
ness on sitting down, made worse by constipation ; an uneasy feel- 
ing located in the rectum ; a pain on urinating, especially towards 
the close of the act; a lack of perfection in the marital function ; 
an uneasiness attending its performance—perhaps amounting to 
pain. These symptoms, added perhaps to some irritability of the 
bladder, with possibly phosphatic urine and a tendency to spas- 
modic stricture, constitute neuralgia of the deep and prostatic 
urethra. Hypochondria usually attends these symptoms. The 
patient is gloomy and apprehensive, and often believes that he 
has spermatorrhoea, or that impotence is imminent. 
The causes of this complaint are generally such as involve the 
sexual function, excess on the one hand, or, on the other and more 
often, stimulation by erotic thoughts and otherwise without natu- 
ral relief. These causes, which cannot be fully discussed here, are 
widespread in their action, and most often to blame in the produc- 
tion of this malady. They are more apt to occasion morbid 
symptoms in a patient who already has slight stricture, or has just 
had a urethritis. The prostate in this malady is sometimes tender 
and congested. There may be an oozing of a gleety fluid from the 
meatus. If the symptoms do not subside surface inflammation of 
the prostate comes on, becomes chronic, and a seriously rebellious 
malady (chronic prostatitis) is the result. 
Treatment.—The best treatment for neuralgia of the deep ure- 
thra is marriage, to insure a proper functional regularity of the 
parts involved. The gentle use of a steel sound, local applications 
of tannin and other stimulants, constitute the surgeon’s best wea- 
pons. The cold water sound is of service. Any tightness of the 
meatus should be divided, and strictures must receive proper 
attention. 
Prostatitis. 
Besides the neuralgic condition of the prostate with congestion 
just described, the organ suffers from inflammations, superficial 508 
TIIE MALE GENITO-URINART ORGANS. 
and deep. The former are due to the spreading backwards of a 
gonorrhoeal inflammation; to a prolonged continuance of local 
neuralgia with congestion ; to stricture of the urethra, etc. 
Old chronic cases of surface prostatitis furnish nearly all the 
symptoms characteristic of stone in the bladder. Gouty and rheu- 
matic, or tubercular, broken-down subjects are most apt to suffer 
from these obstinate forms of chronic inflammation. Inflammation 
of the prostate may reach beneath the surface, giving rise to ab- 
scess in the prostate, or within its capsule. 
Symptoms.—Such collections of matter occasion great pain, 
frequent calls to urinate, pain at stool, and often retention of urine. 
All these conditions of inflammation in and about the prostate are 
complicated by frequent and painful urination, and are attended 
by more or less fever and depression of spirits as characteristic 
features. 
Treatment.—Rest, heat to the perineum (crotch) and over the 
lower part of the abdomen, alkaline and demulcent drinks (see 
Formulas), an occasional sitz-bath in very hot water (of short du- 
ration)—these constitute about the only means a patient can 
readily employ for himself. Anodynes are usually necessary. If 
abscess forms, it should be evacuated by the surgeon promptly; if 
possible, through the rectum. It may, if left to itself, break into 
the rectum, bladder, or urethra. 
Tubercle and Cancer of the Prostate. 
Tubercle of the prostate comes on slowly like a chronic prosta- 
titis, with local pain and frequent micturition. The malady often 
appears in connection with the same disease in the kidneys or tes- 
ticles. It is very slow in its course and sometimes gets well by 
change of climate, cod-liver oil, etc. Local treatment is of no 
value. 
Cancer of the prostate gives all the signs of enlarged prostate 
at first. It generally occurs late in life. It is not a common mal- 
ady. The course of the disease, failure in general health, hemor- 
rhage from the urethra, the intensity of the bladder symptoms 
soon distinguish this malady from enlarged prostate. It is neces- 
sarily fatal. 
Enlarged Prostate. 
In round numbers one-third of all males after the age of fifty 
have enlarged prostate. Of this third a goodly number have prac- 
tically no symptoms, so that they live and die in happy ignorance THE MALE GEXITO-UEIJNTAEY OEGANS. 
509 
of their condition. Sometimes the prostate grows small with age. 
Sometimes it remains of natural size, so that not all men suffer 
from symptoms due to prostatic trouble. Prostatic enlargement 
is a malady, and not a normal degeneration due to age. The only 
certain cause of its appearance is inherited tendency. No amount 
of previous inflammation of the urinary passage will produce it. 
The false enlargement found in young people, due to congestion 
or chronic inflammation, is a totally different matter. When the 
prostate enlarges it does so by developing of new tissue like that of 
which it is naturally composed, and not by an inflammatory pro- 
cess. or by anything like it. The organ may grow outwardly in 
all directions by a symmetrical or unsymmetrical increase in the 
size of its two lobes, or by an enlargement of either, or finally, 
by the appearance of outgrowing prostatic masses, chiefly in the 
form of a projection upwards from the posterior wall towards the 
centre and into the urethral opening—the so-called third lobe. 
The general results of prostatic overgrowth is to offer an obsta- 
cle to the free escape of the urine. The muscular fibres of the 
bladder, enfeebled by age, are forced to perform extra duty. The 
return of blood from the substance of the walls of the bladder is 
interfered with by the increased size of the prostate, whereby the 
weakened, overworked muscle suffers the further indignity of 
constantly acting under the disadvantage of being in a state of 
congestion, and therefore with an enfeebled circulation. 
The natural result of enlarged prostate is, therefore (1), a weak 
bladder, tending to empty itself imperfectly, and (2) a certain 
amount of cystitis (inflammation of the bladder), tending to 
produce frequent calls to urinate. Nearly all the symptoms of 
enlarged prostate consist of disturbances in the function of the 
bladder, and are due to its weakness, to its congestion, and to the 
mechanical obstacle which it has to overcome in expelling the 
urine. The natural ultimate termination of prostatic obstruction, 
when unrelieved by treatment, is chronic inflammation of the kid- 
ney, culminating in one of the slow forms of Bright’s disease. 
Symptoms.—The symptoms of enlarged prostate vary greatly, 
as might be supposed, considering the different factors of their 
causation. If there is not much obstruction to urinary outflow, 
and if the bladder continues powerful, there may be no symptoms 
at all. The ordinary run of symptoms is as follows : An old man, 
otherwise hale, observes that it has become necessary to get up 
towards morning to urinate, then to get up once during the night. 
He thinks that this is natural at his time of life. Soon his calls at 
night become more frequent and he gets up several times. Mean- 
while he does not suffer much by day, perhaps not at all, but his 510 
THE MALE GENITO-URINARY ORGANS. 
stream of urine gradually diminishes in size and in the force with 
which it is expelled. The flow commences slowly and dribbles 
away at the end. 
Matters may rest here for an indefinite period, but the tendency 
of the symptoms is to take one of two courses. 
1. The irritability increases, the calls become more frequent, 
especially by night, more or less pain, throbbing, uneasiness, is 
felt deep in the crotch or in the rectum, increased by exercise or 
jolting ; the action of the bladder becomes spasmodic, crampy, and 
in this condition there may be more or less involuntary escape of 
urine. 
Here we have an irritable, thickened, contracted bladder, and 
sooner or later the bladder inflames more or less actively, and the 
symptoms of cystitis are complained of. 
2. In the other state, where the obstruction is great or the blad- 
der weak, the night-calls to urinate increase in frequency much 
more markedly than the day-calls, but the bladder gradually fills 
up, only discharging at each urinary effort the excess over a certain 
fixed residual quantity. There is less pain in these cases, not much 
spasm—perhaps none. The urine remains bright and clear, but 
there is a dull, dragging sense of uneasiness and weight about the 
belly and back, and the frequent calls to urinate sometimes become 
almost incessant, leading even to overflow and constant dribbling, 
forcing the patient to wear a urinal. In these cases the patient 
does not generally know, and will not believe, that he is carrying 
around a full bladder and only passing the excess above a certain 
fixed quantity. He complains that his bladder has become so 
small that it will hold little or no urine, and therefore demands 
frequent emptying. 
In either of these two conditions, positive inflammation may 
set in, or retention may occur (the latter generally from a chilling, 
especially of the legs), and then the urine goes through a series of 
ammoniacal changes due to fermentation within the bladder. 
Decomposing urine liberates ammonia, which is an active irritant, 
and serves to congest and irritate the bladder to a still greater de- 
gree, and catarrh of the bladder results. 
Prolonged catarrh of the bladder, of a mild grade, leads almost 
certainly to the formation of stone in the bladder, which, in its turn, 
serves still further to aggravate the symptoms. Hemorrhage into 
the bladder is sometimes met with. The straining at urination 
often brings on piles, or, perhaps, a slight prolapse of the rectum. 
Treatment.—The enlargement of the prostate itself is not influ- 
enced by treatment. The symptoms caused by it, however, may 
be greatly alleviated — perhaps practically overcome — and the THE MALE GENITOURINARY ORGANS. 
511 
secondary inflammatory changes in the kidney be prevented by 
appropriate means. Enlarged prostate causes its symptoms be- 
cause it obstructs the free outflow of urine, consequently the first 
aim of treatment is to make art supplement nature where the lat- 
ter is ineffective, and to insure thorough evacuation of the urine 
by means of a catheter. 
There are two kinds of catheters to be commended for use by 
the patient upon himself in obstructive prostatic disease : that of 
Mercier and that of Jaques. Sometimes the woven English or the 
bulbous pointed French instruments yield greater satisfaction; 
and occasionally nothing is so serviceable as a silver catheter with 
bevelled eyes. But, all things considered, there are few cases where 
a Mercier or a Jaques instrument does not give satisfaction. Of 
the two the Jaques soft-rubber catheter has the most merit. 
Mercier’s catheter, Fig. 140, is soft, made of woven material, 
covered with black varnish. Its advan- 
tage is a permanent elbow in the woven 
material which makes the instrument en- 
ter the bladder readily, since its point fol- 
lows the roof of the urethra, and easily 
rides over a posterior median overgrowth 
—the most common form of prostatic enlargement. 
Figure 140.—Tip of a Mer- 
rier Catheter, showing the 
bend. 
Figure 141.—A Jaques Catheter. 
The adjoining figure shows a Jaques catheter. It is represented 
as being bent and tied up to show its great flexibility. It is, in short, 
nothing but a fine quality of rubber tubing, closed at one end, and 
provided with an eye. Its advantages are, (1) the ease of its intro- 
duction, since it squirms around all obstructions in the urethra 
(except stricture), and (2) the fact that the patient cannot possibly 
injure himself with so soft an instrument. 
When a patient cannot pass his water at all, he at once recog- 512 
THE MALE GENIEO-UIIINARY ORGANS. 
nizes a need for the resort to a catheter, and calls loudly for its use, 
but generally for months or years before actual retention has oc- 
curred, such a patient has been suffering more or less from inabil- 
ity to empty his bladder properly, and would have been the better 
for the daily use of a catheter at least once. The rule is this : 
whenever, in prostatic disease, the bladder cannot empty itself en- 
tirely (though what remains over beyond the patient’s efforts be 
only a teaspoonful), the use of a catheter once a day is called for, 
and the bladder should be daily washed out. 
In commencing the use of a catheter the utmost care is required. 
Even with all possible care some inflammatory mischief is likely 
to be occasioned—such as an increase of inflammation of the blad- 
der already existing, or swelled testicle ; and during any such inva- 
sion the catheter must be omitted, if possible, and the inflamma- 
tion treated. On resuming the instrument, with care, there is less 
danger of lighting up inflammatory complications. 
When a catheter is used for the first time 
to relieve retention, the organ may recover 
its power of emptying itself entirely, but it 
is generally wiser for the patient to continue 
to pass an instrument occasionally, even if 
the bladder can empty itself, so as to be sure 
that all goes well. When the catheter is 
used to draw urine from a catarrhal bladder, 
the bladder ought to be washed out at least 
once a day, preferably in the evening. To 
do this a bag (Fig. 142) may be used. It is 
filled with water at blood heat (just under 
100° Fahr.), all air is driven out, and then the 
water is injected through the catheter (after 
the urine has all passed out) until a slight 
feeling of a desire to urinate tells the patient 
that the bladder is moderately distended. 
Then the nozzle of the syringe is withdrawn 
from the catheter, the water flows out of the 
bladder, carrying with it more or less mucus 
and pus, and the process may be indefinitely 
repeated until the water flows clear from the catheter, showing 
that the bladder is clean. 
A more convenient apparatus, and one which is more easily 
managed when it is understood, is the fountain syringe, with a two- 
way stopcock. (Fig. 143.) This bag injects simply by the weight 
of the column of water, the force of the current being increased 
by raising the bag, A. The cock C is only used when it is de- 
Figure 142.—India-rubber 
bag-syringe, used for injecting 
the bladder through a catheter. THE MALE GEN1TO-URINARY ORGANS. 
513 
sirable to throw a medicated injection into the bladder and retain 
it there for a time. F is a conical nozzle which is fitted into the 
catheter, G, before the latter is 
introduced into the bladder.* 
I, the end of the syringe, is a 
large smooth piece of metal, 
and fits so easily into E, that 
the clumsiest fingers of a trem- 
bling old man can make the 
coupling with ease. When D 
is turned as represented in the 
picture, water from the bag 
runs into the bladder. As soon 
as the latter feels slightly dis- 
tended the stop-cock is turned 
to a right angle with the tube 
(no uncoupling being neces- 
sary) and the contents of the 
bladder run out through H into 
a vessel placed to receive them. 
The use of this instrument 
is very simple. The coupling 
is made once for all while the 
urine is running through the 
catheter, and then by simply 
turning the stop-cock back and forth the bladder may be washed 
out as many times as desired, without any further manipulation, 
unless the pint of water in the bag A gives out and has to be re- 
plenished. The water placed in the bag A should have a temper- 
ature of at least 105° Fahrenheit, in order to be of a proper warmth 
on reaching the bladder. 
The object of washing the bladder is to get rid of the last drops 
of urine, mucus, and pus, and to leave the organ sweet and pure. 
If this washing process is carefully followed out, inflammation of 
the bladder is prevented, and the formation of stone (a not infre- 
quent consequence of obstructive prostatic disease) is averted. 
The washing should be repeated often enough to keep the bladder 
clean. Once a day is usually enough, but when pus forms rapidly 
it may be necessary to repeat the process several times. 
The methods of washing above detailed are the best. A 
double current catheter will not answer. In order to clean the 
bladder it is necessary to distend it somewhat, and this cannot 
Figure 143.—Fountain springe provided with a 
two-way stop-cock, for washing out the bladder. 
* F E is made of hard rubber so as to be very light. 514 
THE MALE GENITO-URINARY ORGANS. 
be done if the water escapes as rapidly as it runs into the bladder. 
Pure water is generally all that is required. In some instances, 
however, especially where there is much ca- 
tarrh, medicated injections are valuable. 
These are to be suggested by the surgeon. 
In some forms of prostatic enlargement 
more or less overflow will occur in spite of 
treatment, or the calls become so frequent as to 
interfere very seriously with the social comfort 
of the patient. Under these circumstances it 
becomes necessary to wear a urinal. The best 
urinal made is the one here represented. It 
is composed of soft rubber, is amply roomy, 
and buttons upon the suspenders. It takes in 
the scrotum as well as the penis, does not sweat 
the parts, and is perfectly safe. It should be 
washed out every night with a mild solution of 
permanganate of potash—just enough perman- 
ganate to give the water a rich purple tint. It 
is difficult to procure this urinal, as the rubber 
manufacturing companies prefer to supply 
smaller and cheaper patterns. They do not 
usually keep it in stock, but make it on order. * 
Any person who has worn this urinal is not 
likely to use any other style. 
Figure 144.—Soft rub- 
ber urinal. 
The Bladder. 
The bladder is a hollow muscle running into and attached to 
the prostate. Elsewhere it lies free in the abdominal cavity, cov- 
ered for the most part by the peritoneum, and capable of large dis- 
tention without materially interfering with the action of the intes- 
tines by which it is surrounded. (See chapter on Rectum and 
Anus.) It may be ruptured when weakened by ulceration, or 
when subjected to violence while distended, but this accident is 
exceedingly rare and usually fatal when it does occur. 
The bladder becomes paralyzed from injury to the spine, and then 
requires to be relieved by the catheter in the manner described on 
page 511, and washed out daily, or else it will certainly become 
seriously inflamed. The coats of the bladder may become feeble. 
They fail in muscular strength under certain circumstances, espe- 
cially with enlarged prostate. On the other hand they become 
* The Davidson Manufacturing Co., of Charlestown, Mass., does keep this urinal in 
stock. THE MALE GENITO-URINARY ORGANS. 
515 
overgrown and thickened in many conditions of chronic inflam- 
mation, and are then subject to violent painful spasm. There are 
certain tumors and unnatural growths, and cancerous and tuber- 
cular deposits found in the bladder, but these need not be described 
now. The conditions that call for notice here are neuralgia of the 
neck of the bladder, or irritability of the bladder, cystitis, or in- 
flammation of the bladder, and stone. 
Irritability of the Bladder. 
Irritability of the bladder simply means a frequent desire to 
urinate where there is no sufficient cause, such as diabetes, hys- 
teria, or local inflammation to produce the effect. This is the 
most common of all the maladies of the bladder. Something has 
been said of it under the head of neuralgia of the deep urethra. It 
is apt to complicate other maladies, such as stricture, enlarged 
prostate, neuralgia of the deep urethra, etc. In its mild form it is 
that condition known popularly as a “weakness,” but it may go 
on increasing in severity until it simulates the most intense form 
of chronic cystitis. Between these points its variations are simply 
infinite. 
Symptoms.—In a mild case the patient simply has a “ weakness.” 
If he sits straining at stool, he feels a desire to urinate upon aris- 
ing—although the bladder may be empty. He is inclined to strain 
at the end of the act of urination and not to have that full sense 
of comfort which naturally attends emptying the bladder. Soon 
he begins to pass water too frequently and to have some pain or 
smarting during the act—especially towards its close. A dull 
sense of discomfort or perhaps even pain is felt deep in the 
urethra, with more or less pain in the back—so that the patient 
often supposes he has kidney disease. The testicles may feel 
dragged upon or painful. The expulsive power of the bladder is 
generally weakened at first, later, it is sometimes greatly in- 
creased into a spasmodic, painful, crampy action. The patient 
may believe himself impotent, and is very apt to become mor- 
bidly despondent and hypochondriacal; perhaps complaining ex- 
travagantly about some red dust (uric acid) in his urine, which he 
believes to be blood ; perhaps equally uneasy about a white granu- 
lar sediment (phosphates), which he feels certain is seminal fluid. 
So long as the malady is pure irritability the symptoms are con- 
fined to the daytime. The patient may pass water hourly by day, 
but he sleeps through or nearly through the night. When he is 
pleasantly amused (in pleasant company) his symptoms lighten 516 
THE 31 ALE GENITO-URINARY ORGANS. 
up amazingly. He may be relieved for hours by a glass of beer. 
Bad weather, especially the east wind, makes him feel worse. 
If the malady continues long enough the congestion changes to 
inflammation, and the patient suffers by night as well as by day ; 
when amused as well as when brooding by himself. 
Irritability of the bladder is sometimes attended by more or 
less spasmodic stricture, inability to pass water at will, etc. 
The causes of the train of disorders above enumerated are 
varied. The most constant of all is erotic excitement, intense, 
prolonged, irregular, especially if unrelieved. Unmarried young 
men and widowers are the chief sufferers. Many other causes are, 
however, efficient in some cases to produce irritability : such as 
contracted meatus, strictures of large calibre, the congestion of the 
deep urethra left behind by an inflammation of the same region. 
Any of the above sets of causes are especially powerful when 
they act upon an individual in poor general health ; especially if he 
be overworked and the subject of mental anxiety and depression. 
Treatment.—Mild cases of irritability yield at once to treat- 
ment, but some forms of this malady cause despair to the patient 
and untold annoyance to the surgeon. In all cases the following 
rules hold good : The urine, if acid and heavy, must be modified 
by alkaline diluents (p. 517) ; if alkaline, pepsine, strychnine, nux 
vomica, and dilute phosphoric acid are called for. In all cases of 
debility, tonics, cod-liver oil, iron, quinine, vegetable bitters, are 
indicated, and sometimes entire change of climate and surround- 
ings, or a sea voyage. All worriment of mind and overtaxing the 
strength is to be avoided. Marriage will effect permanent cure in 
some cases, but irregular relations often aggravate the trouble. 
Ungratified stimulation is very harmful. A patient with a ten- 
dency to irritability should never strain at the end of urination. 
Let him be content to allow the urine to dribble away towards the 
close of the act and immediately turn his mind upon something 
else, forgetting his bladder. A smooth sound passed by the sur- 
geon at intervals of several days is often promptly curative. 
Cystitis. 
Cystitis, or inflammation of the bladder, may occur from a 
propagation backwards of urethral inflammation ; from large doses 
of cantharides, and sometimes from a fly-blister; from the use of 
instruments in the bladder ; from excessive potations, etc. ; but is 
most often due to some sudden increase of the symptoms in some 
other malady which is necessarily complicated by chronic cystitis, 
such as stone, enlarged prostate, stricture, etc. Acute cystitis, as THE MALE GENITO-URINARY ORGANS. 
517 
a spontaneous affection, does not occur. Sometimes it is the cul- 
mination of the purely functional disorder, irritability. It is met 
with during all periods of life. 
Symptoms.—The symptoms of cystitis are pain, heat, and 
smarting, felt in the region of the neck of the bladder, and often on 
the under side of the urethra near the head of the penis, an inces- 
sant and intolerable desire to urinate, and painful straining after 
passing a few drops of water tinged with blood. This pain some- 
times amounts almost to a convulsive spasm, so intense is it. No 
relief is felt on emptying the bladder, which feels to the patient 
as if it were constantly and painfully over-distended. All the 
above symptoms may be very mild, as in a bad case of irritabil- 
ity, or so intense as to keep the patient howling in agony. There 
is no remission by night. The urine loses its bright sparkle and 
becomes gruelly. Sometimes it is so full of pus as to lose its trans- 
parency entirely. Blood may appear in the urine in sufficient 
quantities to give it a red color, or in small quantities imparting a 
smoky look to the fluid. When blood and pus are together in 
urine, the latter settles to the bottom of the vessel containing it, 
then a film of blood settles upon the white purulent deposit while 
the clearer urine floats above. The urine of cystitis is alkaline, 
promptly becomes ammoniacal, and decomposes shortly after its 
emission. Then the odor becomes offensive as well as ammoniacal, 
the pus changes to a thick, gluey material called “ stringy or ropy 
mucus ” which adheres to the bottom of the vessel, and there is 
more or less deposit of earthy salts in an amorphous and crystalline 
form. 
Treatment.—Acute cystitis calls for three things imperatively: 
1. Rest in bed. 2. Something to make the urine abundant, dilute, 
and alkaline, and 3. Something to quiet pain and assist the patient 
in overcoming the constant desire to strain at urination. 
1. The patient with acute cystitis will go to bed without being 
asked to do so. He should have the hips raised so as to be slightly 
higher than the shoulders, since this keeps the pressure of the bow- 
els from the bladder and assists in relieving the congested state of 
the latter by draining away the blood from its neck. 
2. The urine should be made dilute and abundant, to render it 
less irritating to the inflamed surface in contact with which it lies, 
and alkaline for the same reason. It is alkaline with ammonia 
in cystitis, but if its natural acidity at the kidney be overcome by 
the use of an alkali in the stomach, it will be less acid and irrita- 
ting in the bladder, and the urine when voided will be less ammo- 
niacal ; so that the apparent absurdity of giving an alkali to over- 
come an alkaline condition of the urine is justified by the result. 518 
THE HALE GENITO-UKINAEY ORGANS. 
The alkali which is the most bland both for stomach and 
bladder is the citrate of potash. This substance is sold by the 
manufacturers in pound bottles. After the citrate has been ex- 
posed to the air for ten days or a fortnight it loses its peculiar odor, 
becomes changed to a carbonate, and ceases to be well borne by 
delicate stomachs, or very soothing to irritable bladders. Conse- 
quently if the citrate is bought from a druggist who does not sell 
his pound during, perhaps, a year, all those who are helped after 
the first consumer is supplied get an inferior article. Hence it is 
well when a patient is to take citrate of potash that he should get 
what he wants from a freshly opened bottle, and have his own 
supply put up dry in ounce bottles, wide-mouthed, and tightly 
corked. He uses his ounce in a week at the farthest, and the med- 
icine remains good to the end. When the citrate is taken in this 
manner the druggist puts up a twenty grain powder as a sample, 
and the patient takes a like amount from the bottle at each dose, 
dissolving it in a claret-glass of sweetened cold water, or of one of 
the diluents about to be mentioned. The dose should be taken 
about one hour before each meal and on going to bed. 
Diluents are very numerous. Among the best are teas made 
(one or two ounces to the j>int) from the leaves of the Bear’s foot 
(Alchemilla vulgaris), Buchu (Barosma crenata), Red Bearberry 
(Uva ursi), Pareira brava, the root of Dog’s-grass 
(Triticum Repens), or from the stems of cherries. 
These may be used freely, or teaspoonful doses of 
their fluid extracts in water may replace them. 
The uva ursi and pareira brava are most stimulat- 
ing. The balsam of copaiba is very soothing in 
some cases—where the stomach can retain it. 
Bethseda, Buffalo Spring, and Vichy mineral 
waters are serviceable. 
3. Anodynes are absolutely necessary in the 
treatment of acute cystitis. The man with an in- 
flamed bladder who urinates every few minutes 
and then strains violently, is in the same situa- 
tion as the man with an inflamed eye who rubs 
the tender organ constantly with his fist. The 
patient cannot help straining unless prevented by 
the soothing influence of an anodyne, and the 
empty bladder therefore squeezes itself, and does 
itself constantly increasing damage. The quality and quantity of 
the anodyne to be employed should be decided by the surgeon. 
The patient is not a proper judge. 
An excellent domestic anodyne applicable to all cases of acute 
Figure 145. —Hot- 
water bottle of India- 
rubber. Having a 
screw-cap, an India- 
rubber funnel at- 
tached to the neck, and 
a tag with islet-hole, 
by means of which and 
the handle, a cord can 
be used to keep the 
bottle in place. THE MALE GENITO-URINARY ORGANS. 
519 
and chronic cystitis, is heat. The best manner of app’ying heat 
is with the flat rubber bottle containing a thin film of very hot 
water. This is better than a poultice. It is dry and clean. It 
should be placed across the lower part of the belly and its action 
may be enhanced by placing upon the skin beneath the bottle a 
piece of moistened paper sprinkled with dry mustard. 
Catarrh of the Bladder. 
This is chronic inflammation, in which the discharge of stringy 
mucus forms a prominent feature, whence the popular name, 
Catarrh. The malady, catarrh, is never spontaneous, but depends 
upon obstructive disease of the urethra or of the prostate, stone in 
the bladder, muscular weakness, or upon prolonged neuralgia of 
the neck of the bladder, or degenerative disease in this region; 
upon irritative disease of the kidney acting in a reflex way, and 
occasionally upon irritative disease of the testicle. In other words 
essential chronic inflammation of the bladder does not occur as a 
special disease ; it is always a symptom of some other morbid state. 
The patient is rarely able, unaided, to decide what the particular 
malady is of which the catarrh is a symptom. For this diagnosis 
he seeks a surgeon. 
The natural termination of catarrh of the bladder is by the 
gradual development of chronic disease in the kidney.. 
Symptoms.—The symptoms of catarrh of the bladder are the 
same as those already set down for acute cystitis, except that they 
are more moderate in character. The urine is more or less am- 
moniacal, the stringy mucus, the pus, the pain, the frequent uri- 
nation, are all prominent in varying intensity, according to the 
grade of the inflammation. With stone in the bladder and stric- 
ture, the frequency of the calls to urinate is greater by day ; with 
enlarged prostate, by night. During catarrh of the bladder, on 
account of exposure to cold, violent exercise, or other cause, or it 
may be spontaneously, the symptoms may become suddenly inten- 
sified, and the whole attack becomes one of acute cystitis, which, 
subsiding, leaves the bladder in the same chronic state of inflam- 
mation as before. 
Treatment.—If the cause cannot be removed (as is often the 
case), palliative treatment may still afford the patient great com- 
fort. The symptoms of catarrh of the bladder are to be treated 
on the same general principles as those of acute cystitis, viz., by 
rest, alkaline diluents, and anodynes ; the strength of the reme- 
dies employed being proportionate to the intensity of the symp- 
toms. 520 
THE MALE GENITOURINARY ORGANS. 
Besides these means, medicated injections of the bladder and 
simply washing out the bladder, in the manner detailed on page 
512, are of immense service in keeping down the symptoms. The 
catheter must be employed with great gentleness, for fear of ex- 
citing acute symptoms, and simple warm water be used at first for 
washing until the bladder has become accustomed to manipula- 
tion. Then various medicines may be advantageously employed 
as injections, such as chlorate of potash, two drachms to the pint 
of water ; or borax, half an ounce to the pint of water, increasing 
the strength according to the effect. Stronger injections must be 
left to the surgeon, as well as the use of nitrate of silver, and the 
desperate remedy, cystotomy. 
Retention of Urine. 
This condition calls for the catheter, or for aspiration or punc- 
ture of the bladder, if a catheter will not enter by the natural route. 
The management of retention and suppression necessarily falls to 
the surgeon and does not need to be discussed here. It is well, 
however, to make this point: retention, when it once happens, is 
apt to recur, so that it is wise for a patient, liable to have retention, 
to understand clearly the cause of his inability to make water and 
the best means of relief, and to have such a form of catheter (pre- 
ferably of silver), among his effects as will suit his peculiar case. 
In this way, if caught with retention on a journey—a not infre- 
quent accident—he may escape much needless exploration (and 
possible damage) at the hands of a new surgeon. 
Gravel. 
As affecting the bladder there are two kinds of gravel: the red 
and the white. The former is the brick-dust deposit and red sand 
so common among gouty and rheumatic patients. This form of 
gravel tends to keep up irritation of the bladder and urethra, and 
leads directly to stone. Patients suffering from it should drink 
freely of water between meals and on retiring ; eat plenty of fruit, 
vegetables, and bread, avoiding much meat, and alcohol in all its 
forms. Considerable exercise and an out-door life are advisable, 
as are also great regularity of habits and attention to digestion. 
Vichy and other mineral waters, and alkaline diluents make the 
red sand disappear, but do not overcome the tendency to its 
re-formation. 
The white (or phosphatic) gravel is a mortar-like dust which 
appears in the urine, chiefly at the end of the stream (more espe- 521 
TIIE MALE GENITO-URINARY ORGANS. 
cially when the bladder is emptied at about two hours after break- 
fast). It is usually mistaken by the patient for seminal fluid or 
for pus. Urine containing it scums over with an iridescent pelli- 
cle soon after cooling, and goes rapidly into decomposition. Such 
urine has a peculiar chicken-broth odor. 
Phosphatic urine is often accompanied by a tendency on the 
part of the patient to melancholy, to despondency of disposition, 
pain in the back and in the head, to neuralgia and dyspepsia. 
Such patients are apt to be nervous, impressionable, easily upset, 
and of rather low vitality as a rule. Most of them bother them- 
selves incessantly about their urinary sediments, and magnify all 
their accidental urinary and other symptoms to a very unneces- 
sary extent. Yet phosphatic urine is compatible with perfect 
health. Many patients have it and are unconscious of its exist- 
ence. It is sometimes so considerable that the spatterings of the 
last drops of urine, charged with earthy phosphates, falling upon 
the shoes look, when they dry, like spots of whitewash. Overwork, 
especially worry of mind, decidedly increases the proportion of 
phosphates in the urine. Students who sit up all night preparing 
for an examination, are pretty sure to have their urine full of phos- 
phates in the morning. It settles like a white gruelly dirt in the 
chamber, while the characteristic, many-colored, oily scum quickly 
appears upon the surface of the fluid. [See page 488, for other 
references to this subject.] 
Treatment.—Great excess of acids, vegetable or mineral, will 
cause phosphates temporarily to disappear—but they return again. 
The best treatment is a regulation of all habits, attention to diges- 
tion, an animal diet, much air and exercise, avoidance of care, 
overwork, and worry, such tonic medicines as may be called for 
and found to agree, pepsin, iron, quinine, etc. Smoking and 
chewing tobacco are especially harmful for those having a ten- 
dency to phosphatic urine. 
Stone in the Bladder. 
Stone is large gravel. It forms in the bladder either by crystal- 
lization of urinary salts spontaneously (when the mother liquid is 
sufficiently dense and there is a rough surface on the bladder- 
walls), or more often upon a nucleus such as a few crystals or a 
small stone which has come down from the kidney and not escaped 
by the urethra, or upon a clot of blood or mucus, or a foreign body 
(pistol ball, piece of bone, etc.) which may have entered the blad- 
der from without. A great majority of all stones found in the 
bladder are composed of uric acid; others are phosphatic, mixed 522 
THE MALE GENITO-URINARY ORGANS. 
phosphates and urates, oxalate of lime, etc. They are encountered 
at all periods of life from the earliest childhood to extreme old age. 
The younger the subject the more certain is the stone to be hard 
and of uric acid ; the older the patient the more apt is the stone to 
be soft, composed of the phosphates, and secondary to preex- 
isting bladder disease. The tendency to stone is inherited. In 
some portions of the country stone is a common malady (Kentucky). 
In and around New York it is comparatively rare. The hardness 
of the water used for drinking purposes is not the cause of the fre- 
quency of stone. The real cause has not been determined. 
Symptoms.—The symptoms of stone in the bladder are those of 
chronic inflammation with occasional acute outbreaks (attacks of 
“ the stone ”). Besides the ordinary symptoms of inflamed bladder 
there are a few extra ones, rather characteristic of stone. Exercise 
increases the pain greatly. Blood in the urine is of frequent occur- 
rence. The stream of urine is apt to be cut off suddenly while 
flowing at full force (as the stone is washed up like a valve against 
the neck of the bladder), and this short, full stop is attended by 
great pain which runs down the penis and is most keenly felt near 
the end of the member, or at a point about three-quarters of an 
inch from the orifice of the urethra upon the under surface of the 
penis. The stream may flow on again in full force after such an 
interruption, but violent straining and pain are felt after the end 
of urination, the last drops of the fluid being often tinged with 
blood. The end of the penis feels itchy and irritated in some cases 
of stone, and there is a strong tendency, especially in the case of 
children, to pull at the end of the prepuce. In this way children 
often innocently acquire the habit of self-abuse. In many cases 
of stone, especially when the patient is an old man, the symptoms 
are simply and solely those of catarrh of the bladder, unmodified ; 
and in some cases of prostatic disease all the symptoms of stone 
are present, but no foreign body exists in the bladder. The most 
distinguished surgeons have cut patients for stone and found none, 
while other sufferers have been allowed to die with a diagnosis of 
cancer of the bladder (or some other disease), when a post-mortem 
examination has revealed stone to be the cause of all the symp- 
toms. The only certain diagnosis of stone is for the surgeon to 
strike the foreign body in the bladder with an instrument (sound) 
passed through the urethra. 
Treatment.—The treatment of stone is 1, Palliative—as for ca- 
tarrh of the bladder, where chronic disease of the kidneys makes 
an operation inadmissible, or 2, Radical, preferably by lithotrity— 
finally by lithotomy. In the former of these operations the sur- 
geon crushes the stone with an instrument passed through the THE MALE GENITO-URINARY ORGANS. 
523 
urethra, and either washes out the fragments through a catheter 
at once, or the patient passes them out while urinating. In lithot- 
omy a hole is cut into the bladder and the stone extracted with 
forceps. Lithotrity is by far the safer operation. In the case of 
elderly people the mortality of lithotrity is trifling as compared 
with that of lithotomy. The cutting operation is very safe and 
more applicable in the case of children. According to statistics of 
Sir H. Thompson, of England, which are the most reliable on rec- 
ord, the mortality for the crushing operation in old people is about 
1 in 13, while that for the cutting operation in patients of the same 
period of life is more than 1 in 3.* Where the age of the patient 
or the condition of the kidneys contraindicates any operation, the 
patient’s life may often be made very comfortable, but a cure is, of 
course, impossible. Rest, the free use of water, washing the blad- 
der (page 512), and the employment of the means advised in the 
treatment of chronic cystitis (page 514), constitute the best means 
for alleviating the patient’s sufferings. 
It is folly to attempt to dissolve stone in the bladder either by 
medicines thrown into it, or taken by the stomach. All such 
means have been patiently tested by the profession and discarded. 
Tumors in the Bladder. 
Tumors give rise to symptoms of irritability of the bladder at 
first, then to signs of chronic, and finally of acute cystitis. Vil- 
lous tumor, a soft vascular growth sometimes encountered in the 
bladder, is especially characterized by its tendency to produce re- 
current profuse hemorrhage. The palliative treatment for tumor 
of the bladder is that of cystitis—removal of the growth can only 
effect a cure. This is sometimes practicable, often not so. 
Diseases of the Testicle and Cord. 
Under this head it is necessary to consider briefly the question 
of masturbation. No subject requires to be dealt with more hon- 
estly or more boldly in a work intended for the general public. 
Mystery on such a topic is folly, and that sentimentality is false 
and criminal which induces a writer to roll up his eyes and mourn 
the weakness of fallen humanity, and to mouth out his regrets that 
some people can be so depraved and shameless as to pollute them- 
selves, and to yield to that perverted sexual instinct which leads to 
masturbation. It is this quality of false sympathy in writings and 
* Report before the Royal Medical and Chirurgical Society, in February, 1878. 524 
THE MALE GENITO-URINARY ORGANS. 
advice to the young which feeds the evil it assails, and leads to its 
continuance by attacking the patient as if he were a culprit, and 
were to blame in the matter, when really he is the victim of a 
natural instinct. The nastiness of the thing and its unmanliness 
are not brought out. The real issue is shirked. The father hangs 
his head, beats around the bush, and tries to intimate to the son 
what he is driving at in giving advice on these subjects. The son 
sulks and hangs his head, and although perfectly certain of the 
meaning of his father’s intimations, he pretends to an innocent 
ignorance of what his father is talking about, and when finally, by 
a heroic effort, an understanding between the two is reached as to 
what the subject under discussion really is, the innocent son lies 
about it and the simple father believes him—or perhaps, rather, 
persuades himself that he believes him—thanks heaven he has so 
good a son, and, dropping the subject, tries to feel satisfied. 
A very common method of attempting to prevent masturbation 
or to correct the habit where it exists, is through the instrumen- 
tality of fear. But this is stupid absurdity. Did fear of hell alone 
ever make a true Christian ? The body cannot conceive what it is 
to be ill while it is in good health. Sickness does not exist for the 
well man except as a name. Moreover, the picture which is paint- 
ed of the terrible weakness of body and mind so certain to be pro- 
duced by the secret vice is generally overdrawn. The boy cannot 
take it in and appreciate it. He is terribly frightened at first, 
struggles hard for a while, and then gives way; for the emotion 
of fear alone must yield, and cannot hold against a strong natural 
instinct. Then, after the fall, the boy finds that no harm comes to 
him, and he begins to think that he will be an exception to the rule. 
He goes on until he has been really injured, perhaps, to a very 
slight extent, and then he magnifies the possibilities of his misfor- 
tune by recalling all the terrors painted for him years before by 
some over-kind adviser, and he becomes a hopeless victim to melan- 
choly and hypochondria, not on account of his masturbation so 
much as from the terrible results of prolonged nervous apprehen- 
sion, due to brooding over what he remembers of the advice given 
to him when he was young, and to the books upon the subject 
which he has read since. 
A right-minded boy is capable of very noble sentiments, and 
generally possesses more reason than we give him credit for, while 
his perceptive faculties are vastly superior to those of his elders. 
It is better, therefore, to help him by assisting what is noble in his 
nature rather than to attempt to bully him by a base appeal to his 
fears. 
The same sexual instinct that will drive an animal through fire THE MALE GENITO-URINARY ORGANS. 
525 
and water to the death perhaps, and a man through folly to dis- 
grace, unless controlled by reason, will, as certainly as fate, lead a 
boy to masturbation by one means or another unless in his case also 
controlled by reason. Fear is powerless to hold a boy, blame urges 
him on, and sympathy destroys whatever resistance his own com- 
mon-sense might have furnished him with. 
The sexual instinct buds in a boy. He does not know why ; he 
cannot understand it at first. If much alone he stumbles by acci- 
dent upon some unnatural means of gratification; if with other 
children, some one teaches him, and the boy becomes a victim to 
accident or to vice. Babies and young children are sometimes 
abused by their nurses, and indeed there are so many routes leading 
to the same result, that it is wonderful how any one escapes, as 
some few certainly do. 
The only safe course in the management of male children is to 
assume that they all trifle more or less with themselves—or at least 
that they will do so unless precautions are used to guard against 
it. And what shall these precautions be ? Sleeping on hard beds, 
taking cold local baths, medicines, motherly sympathetic counsels, 
fatherly threats ? No, none of these. The child must be recognized 
as a reasonable human being. He must be taught to look his in- 
structor in the eye and to tell the truth. He must be encouraged to 
be manly and straightforward in his whole life. Out-door sports 
must occupy a large portion of his thoughts, and athletic exercises 
a reasonable amount of his time. He must go to bed at a regular 
hour when tired out with his daily duties, and he will sleep at once, 
and he should not be allowed to lie in bed in the morning. He 
should not be left much to himself or with older boys if it can be 
avoided, or with older girls. But particularly should he be encour- 
aged to free interchange of thought and opinion with his father, and 
no subject should be denied respectful consideration. The relation 
of the sexes, as sure to be observed by a boy among animals, should 
be discussed in the same way that the planting of trees is talked of, 
but in the general spirit that regulates discussion upon such physio- 
logical acts, for instance, as the movements of the bowels or the 
action of the kidneys. If, finally, there is reason to suspect that 
the boy is abusing himself, from any evidence offered by a tendency 
to slink away by himself, to lose his bold, boyish honesty of physical 
expression, to droop, to get morbid and have fancies, then he 
should be talked with plainly, not scolded, not sympathized with, 
not terrified, but shown the dirtiness of his tricks and shamed out 
of the unmanly nastiness of trifling with a noble function, which 
trifling may injure him, perhaps, to some extent in body, but cer- 
tainly will do so in his own self-respect. It is wrong for him to 526 
THE MALE GENITO-URINARY ORGANS. 
practise this habit, just as it is wrong for him to strain his eyes, to 
over-eat, to steal, or to lie. Decent people do not do these things, 
and this particular vice is peculiarly apt to do some harm, sooner 
or later, because it involves a shock to the nervous system—the 
most sensitive and delicate of all our structures. The morale of 
the patient, however, suffers more than anything else. 
Excess in masturbation, like excess in sexual intercourse, does 
lead to positive physical and intellectual decay, but the number of 
people who suffer from these causes is very small. Much evil 
resulting from other causes is ascribed to the excesses above men- 
tioned. They are blamed for what they never did. Therefore, 
while recognizing that excess in any direction is dangerous (especi- 
ally if it involves the nervous system), it is necessary to enter a 
protest here against the hypochondriacal complainings of nervous 
patients, chiefly with phosphatic urine, who ascribe to a certain 
amount of masturbation in early life untold imaginary evils from 
which they think they suffer in their later youth and early man- 
hood. Such patients are generally unbalanced in mind. They 
stimulate erotic fancies in various ways, and are really suffering 
from being in an unnatural state. Unappeased sexual needs, 
which they wilfully create, is the true name, very often, of their 
malady, and its cure is common-sense, hard work, and a respectable 
marriage. 
Varicocele. 
Varicocele is a dilated condition of the veins of the spermatic 
cord. It occurs nearly always on the left side and feels like a 
bunch of earth-worms in the scrotum. The left testicle naturally 
hangs lower than the right, and is a little larger than its fellow. 
The veins on the left side are longer, empty into the kidney-vein, 
and their circulation is influenced by constipation on account of 
their proximity to the end of the lower bowel. These causes are 
supposed to account, in the main, for the fact that varicocele of 
the left side is common, and of the right side very rare. Great num- 
bers of people—especially young unmarried men—have more or less 
varicocele in the left side. As a malady it is unimportant, and 
generally disappears for the most part after marriage. When it is 
attended by great pain in the testicle or by wasting of the testicle, 
it calls for treatment. 
Treatment.—Treatment is palliative or radical. The former is 
by far the better, and consists simply in the use of a well-fitting 
suspensory bandage. When matters get to such a pass that a, 
radical operation is called for, the case passes into the surgeon’s 
hands. THE MALE GENTTO-URINART ORGANS. 
527 
Operations are objectionable on two accounts :—1. If absolutely 
all the veins are cut away or tied, the testicle wastes away. 2. If 
too many of the veins are left, these may in their turn become 
varicose. A very good operation, in case of need, is to cut away a 
portion of the scrotum, thus forming a natural suspensory ban- 
dage, by shortening the bag. 
Swelled Testicle. 
This malady generally occurs in consequence of some inflamma- 
tory disturbance of the urethra (urethritis or stricture) or as a result 
of instrumentation (explorations and operations upon the urethra 
and bladder). It may occur as a direct result of cold, or injury— 
but very rarely. In ordinary swelled testicle the back part of the 
organ or epididymis is involved. The whole gland swells some- 
what, and some fluid is effused into the cavity of the tunica vagi- 
nalis—the little serous sac which surrounds the testicle in order to 
allow it to slip away easily from pressure and avoid injury. The 
greater amount of swelling and pain in these cases, however, is 
experienced at the back part of the testicle. 
Symptoms.—Generally the actual swelling of the testicle is 
preceded by a dragging pain in the groin for some hours. When 
the testicle actually begins to swell, this pain may cease or may 
become intensified. The testicle swells pretty rapidly. The scro- 
tum over it gets red and hot. The pain is often intolerable, of a 
sickening sort, sometimes culminating in positive faintness and 
nausea. Most patients are unable to walk about with an acutely 
swelled testicle, on account of the intensity of the pain. First 
attacks are the most intense. If there be any urethral discharge 
when swelled testicle commences it gets promptly better, but re- 
turns when the inflammation in the testicle begins to subside. 
The bowels become confined, the tongue gets coated, and the 
stomach upset during an acute attack of epididymitis. 
Treatment.—The treatment of this malady is very simple. The 
testicle should be slung up in a handkerchief attached to a bandage 
around the waist, so that all weight is taken off the cord. The 
patient must go to bed, and a poultice made of tobacco (one paper 
of fine-cut to the pint of water, with ground flax-seed enough to 
make a poultice) should be snugly applied from the start upon the 
elevated testicle until the latter becomes narcotized and the pain 
ceases. Cold applications are not generally applicable ; the poultice 
should be used from the commencement. It is very dirty, surely, 
but it is safe and effective, and a cleanly person can keep himself 
clean in spite of it. A plaster of opium and glycerine will do as 528 
THE MALE GEN1TO-URINARY ORGANS. 
well, but it is dangerous, which the tobacco is not—for adult men. 
Daily evacuations of the bowels are necessary, and rest in bed until 
the patient can stand up without pain in the testicle, when the 
latter is allowed to hang down unsupported. This takes from one 
or two to twelve days, according to the intensity of the attack. A 
mild anodyne may be necessary for a day or two, but afterwards 
no medicine is of any especial value. Puncturing the testicle is 
brilliantly effective, but sometimes dangerous, and the merits of 
tincture of pulsatilla, lately vaunted, have yet to be proved. 
This malady generally leaves the testicle perfectly healthy. 
Prolonged or recurrent attacks, however, or simple attacks in 
weakly persons, or those with a tubercular tendency, may lead to 
a permanent blocking up of the tube leading from the testicle, and 
to subsequent sterility (not impotence) if both sides be affected. 
The prospect of such a possibility gives the malady a respectability 
it would not otherwise have, and is the strongest argument to 
induce a sensible patient to go to bed at once when he gets any 
painful swelling of the testicle, so as to get well as quickly as pos- 
sible and be left a sound man. 
Orchitis. 
This malady is inflammation of the secreting structure proper 
of the testicle. It occurs sometimes spontaneously in an acute 
way. It is the malady of the testicle seen in connection with 
mumps, and is the kind of swelled testicle most apt to result from 
local injury. The pain in orchitis is intense, and often of a pecu- 
liarly sickening character. A chill may precede its outbreak. 
The natural terminations are in resolution, atrophy, or abscess. 
The first two occur in the spontaneous variety of orchitis, and in 
that seen with mumps. Abscess is not often seen except after 
local violence. 
Treatment.—Orchitis is to be treated on the same general prin- 
ciples as epididymitis, except that where the inflammation runs 
high, and strangulation of the testicle from lack of extensibility of 
its investing membrane seems imminent, incision of the tunica 
albuginea (investing sheath of the testicle) may be practised by the 
surgeon with good effect. 
Hydrocele. 
Hydrocele, or dropsy of the testicle, is a common malady. It is 
simply a distention with fluid of the sac which surrounds the tes- 
ticle (the tunica vaginalis). Hydrocele is due to a variety of THE MALE GENITO-URINARY ORGANS. 
529 
causes, but mainly occurs in connection with slight irritative in- 
flammatory states of the urethra (stricture, etc.) Hydrocele may 
be very small, not seriously incommoding its bearer, or may reach 
an enormous size. The historian Gibbon is reported to have had a 
hydrocele which contained six quarts of fluid. 
In hydrocele the testicle assumes a pear-like shape, larger below, 
and of a size proportionate to the amount of serum within the cavity 
of the tunica vaginalis. Little or no pain is felt in the swelling. 
There is no heat or redness of the skin over it, and the malady is 
only distressing, according to its size, by its weight, which drags 
upon the cord. A suspensory bandage generally relieves this dis- 
comfort until the patient is ready for operation. On pressing a hy- 
drocele the sensation of pressure upon the testicle is felt when the 
mass is squeezed about half way up posteriorly, where the testicle 
usually lies. The translucence of the swelling is the main diagnos- 
tic test. This is observed by letting strong sunlight fall upon one 
side of the swelling, or holding a candle there while that portion of 
the tumor nearest the observer is made tense and is shaded with 
the hand and the eye applied as if to look through the upper part 
of the swelling. If there be fluid in the tunica vaginalis, not pur- 
ulent or bloody, and the walls of the sac be reasonably thin, the 
swelling is noticed to be distinctively translucent. The extraction 
of a few drops of clear fluid with an exploring-needle completes 
the diagnosis. 
An old hydrocele is apt to have thickened walls, and may con- 
tain pus or blood. Encysted hydrocele is one of the special varie- 
ties. 
Treatment.—This malady is perfectly curable by puncture, in- 
jection, incision, seton, or other surgical means, which need not be 
detailed here. Medicine does not affect it. 
Tumors of the Testicle. 
The testicle is affected by tubercular and cancerous deposit, by 
cystic degeneration and syphilis, etc., making a variety of chronic 
swellings, some of them painless, others painful, difficult of diag- 
nosis, and not capable of thorough explanation in the brief limits 
of this article. 
The tubercular testicle may be perfectly cured, as may the 
syphilitic. Cancerous, non-malignant, and cystic tumors of the 
testicle do not get well under any treatment, and require a removal 
of the gland, an operation simple in its performance, and effective 
in its result if the disease does not return. 
E. L. KEYES, M.D. Diseases Peculiar to Women. 
BY 
A. REEVES JACKSON, A.M., M.D., 
OF CHICAGO, ILL., 
FORMERLY SURGEON-IN-CHIEF OF THE WOMEN’S HOSPITAL OF THE STATE OF ILLINOIS; 
LATE LECTURER ON THE DISEASES OF WOMEN IN RUSH MEDICAL COLLEGE, 
ETC., ETC. DISEASES PECULIAR TO WOMEN. 
INTRODUCTION. 
It is not intended or expected that, after reading this chapter, 
women will be qualified to attempt the treatment of the vari- 
ous maladies peculiar to their sex. On the contrary, it is rather 
designed to awaken in them a proper sense of the importance of 
these diseases—more frequently neglected than over-treated—and 
to call attention to the significance of certain symptoms of disor- 
dered health so pointedly as to show the necessity of timely resort 
to skilful medical aid. 
It will also be attempted to indicate such simple rules of pre- 
vention and management as a physician should impart to a patient 
who might not be able to obtain skilled services promptly when 
needed, or which are suitable for the domestic management of 
ailments which should be understood by all intelligent women. 
ANATOMY AND PHYSIOLOGY OP THE FEMALE 
ORGANS OF GENERATION. 
In order that the diseases of any organ of the human body may 
be understood, a knowledge of the location, structure, and use of 
such organ in a state of health is absolutely necessary. Hence, 
anatomy and physiology have always been properly regarded as 
the basis of all correct medical learning. In view of this fact, I 
will preface my remarks on the diseases of women with a brief 
account of the female organs of generation. 
The female generative organs are divided into the external and 
internal. The external consist of those which are chiefly con- 
cerned in coition, and the internal of those whose uses are the de- 
velopment, nutrition, and expulsion of the ovum. The external 
sexual organs comprise the mons veneris, labia majora and minora, 
clitoris, hymen, - carunculse myrtiformes, and perineum. These 
are known collectively as the vulva. 
The Mons Veneris is situated at the extreme lower portion of 534 
DISEASES PECULIAR TO WOMEN. 
the abdomen in front of the pubic bone. It consists of a prominent 
triangular cushion composed of fatty and connective tissue, cov- 
ered with a thick integument which, at maturity, becomes studded 
with a growth of short, crisp, curling hair. 
Of similar structure with the mons veneris, and extending 
downward from it on either side, are the Labia Majora, or larger 
lips of the vulva. At puberty they also are covered with hair, but 
more scantily than the mons veneris. These lips are full and large, 
and they lie in contact with each other at their upper part, but they 
become thinner and are separated as they pass downward and 
backward. Externally they are covered with skin, but their inner 
surface is lined with mucous membrane, which structure, com- 
mencing at this point, passes inward, lining all the genital and 
urinary organs. The internal surfaces of the labia majora are 
furnished with numerous little glands which secrete a fatty and 
odorous substance. The junction of the labia majora in front is 
called the anterior commissure j and that below, the posterior 
commissure, or fourchette. The posterior commissure forms the 
anterior boundary of the perineum. 
Situated between the labia majora, and about one inch below 
the anterior commissure is the clitoris, the analogue of the male 
organ, which it greatly resembles, although in miniature, being 
only about one inch in length. It differs also from the male mem- 
ber in being imperforate. It is capable of erection and is thought 
to be the principal seat of sexual sensibility. In some cases of dis- 
ease it remains constantly erect, giving rise to great suffering and 
making it difficult or even impossible to pass urine. The only 
part of the clitoris which is visible is its glans or head, the body of 
the organ lying behind the pubic bone and being covered with mu- 
cous membrane. A portion of this latter forms a small hood-like 
fold which partly covers the glans also, and which is called the 
prepuce of the clitoris. 
Arising from the prepuce of the clitoris, and sometimes from 
the glans, and extending downward on each side, are the labia 
minora, or lesser lips, sometimes called the nymphce. They each 
consist of a thin fold of mucous membrane, and are about an inch 
to an inch and a half long. On their inner surfaces are found the 
openings of numerous follicles which pour out mucus for the lubri- 
cation of the parts. 
Extending downward from the clitoris, between the labia mi- 
nora, is a smooth, grooved, triangular space called the vestibule, at 
the lower portion of which, about one inch from the clitoris, is the 
meatus urinarius, or external opening of the urethra, the passage 
leading to the bladder. DISEASES PECULIAR TO WOMEN. 
535 
The meatus consists of a puckered rim of mucous membrane, 
somewhat elevated above the surrounding parts. It is through 
this opening that the catheter is passed into the bladder in cases of 
retention of urine. 
Immediately below the meatus urinarius is the mouth of the va- 
Figure 146.—The female organs of generation seen from in front after removal from the ad- 
joining parts. The vagina has been laid open by an incision through its front wall, a, the body 
of the uterus ; 6, the divided edge of the peritoneum which has been removed from the organs on 
the left side (right side of the figure) ; c, the cervix, or neck of the uterus; d, the os or mouth 
of the uterus projecting into the vagina ; e, e, the broad ligaments which pass sidewise to the pel- 
vis and support the uterus laterally ; f, f, the round ligaments connecting the uterus with the 
pubis; g, g, the Fallopian tubes; h, the fimbriated or fringe-like extremity of the Fallopian tube 
of the right side ; i, on the right side, the ovary ; on the left side the fringed extremity of the 
Fallopian tube is closely applied to the surface of the ovary as occurs when an ovum is discharged; 
Jc, the vagina. 
gina, of an oval shape, and varying in size according to age, child- 
bearing, etc. In the maiden this opening is partly closed by the 
presence of a membranous fold of crescentic shape called the hymen. 
It was formerly thought that the existence of this portion of the 536 
DISEASES PECULIAR TO WOMEN. 
body was a proof of the chastity of the woman, but this notion is 
no longer entertained, since it is now well known that it is some- 
times entirely wanting, either from defective development or by 
accident. This membrane is usually ruptured at the first sexual 
approach, but not always ; for in some women it is so yielding in 
texture as to remain unbroken after frequent intercourse. On the 
other hand, it may be so thick and resisting as to afford an effect- 
ual bar to sexual congress, and require a surgical operation for its 
division. 
After rupture of the hymen, its place is occupied by a number 
of little bodies consisting of duplicatures of mucous membrane, 
which, from their supposed resemblance to myrtleberries, have 
been termed carunculce myrtiformes. 
Situated between the fourchette and the opening of the bowel 
is the perineum. In its ordinary state it is about an inch and a 
half in length, but is capable of great distention, and during the 
passage of the child’s head in labor it is elongated to the extent of 
four or five inches and widened almost as much. 
The internal organs of generation are the vagina, uterus. Fallo- 
pian tubes, and ovaries. 
The vagina is a curved canal leading from the vulva to the 
uterus. Its anterior wall is about three and a half or four inches 
long, and the posterior about one inch longer. It becomes shorter 
after childbirth. Its average diameter is about an inch or an inch 
and a half, being largest at the upper end and smallest at the out- 
let. Usually its walls are in contact and it thus prevents the ac- 
cess of air to the uterus. Its lining membrane is thrown into nu- 
merous transverse folds or rugse, which are much more distinct 
in virgins than in women who have borne children. The use of 
these rugae is to permit the distention of the canal during labor. 
The mucous membrane secretes a lubricating fluid having an acid 
reaction which, under some circumstances, constitutes the discharge 
known as leucorrhoea, or “whites.” 
The uterus, or womb, is situated in the centre of the pelvic 
cavity, between the bladder in front and the rectum, or lower por- 
tion of the intestine, behind, and having the vagina below and 
coils of intestine above. It is maintained in this position by vari- 
ous ligaments and attachments of cellular tissue to the other pel- 
vic organs. In shape, the uterus has been compared to a pear 
somewhat flattened from before backward. It is about two and 
three-quarters inches in length, one and a half inches wide at its 
broadest part, and one inch thick. Anatomically, it is divided in- 
to a body which constitutes its upper portion, and a cervix, or neck, 
which is the lower portion. The highest part of the body is called DISEASES PECULIAR TO WOMEN. 
537 
the fundus, and the extreme lower portion of the cervix opening 
into the vagina, is the os uteri, or mouth of the uterus. The body 
and cervix are traversed by a canal, which, in the former, is ex- 
panded into a cavity. The interior of the uterus is lined by mu- 
cous membrane, which is continuous with that of the vagina. 
The os uteri in the virgin is a transverse slit or fissure capable 
of admitting a small goose-quill. In women who have borne chil- 
dren it becomes more oval in form, and in old age it is circular 
and smaller, with sharp, hardened edges. The os is bounded by 
two lips, an interior and posterior. The anterior is the lowest, 
owing, chiefly, to the axis of the uterus being at a considerable 
angle with that of the body ; thus, a line drawn from the os uteri 
through the fundus of the organ, would strike the navel in front 
and the extreme lower part of the spine (the coccyx) behind. 
The canal of the neck of the womb is spindle-shaped, being 
narrowed at the os uteri, and still more so at the point where it 
connects with the cavity of the body, this point being called the 
internal os uteri. The mucous membrane which lines this portion 
of the womb, presents a very peculiar appearance when the canal 
is laid open. It is disposed in four columns of folds resembling 
the printed lines in a book. The spaces between these folds con- 
tain thousands of mucous follicles which secrete the mucus de- 
signed to lubricate the parts. In a state of disease this mucus is 
sometimes discharged in enormous quantity, constituting a fre- 
quent form of leucorrhoea. 
The cavity of the body of the uterus is triangular in shape, the 
base of the triangle being above, and the apex at the internal os 
uteri below. The two upper angles mark the points where the 
Fallopian tubes enter the uterus. The mucous membrane here has 
a very complex structure, is studded with glands, and is now gen- 
erally admitted to be the chief source of the menstrual discharge. 
The Fallopian tubes* are two in number. They are about four 
inches long, and extend from the upper angles of the womb out- 
ward on each side towards the brim of the pelvis. They vary in 
thickness from one-eighth to one-quarter of an inch. They are 
pervious throughout their entire length ; the canal being lined by 
an extension of the mucous membrane of the uterus. The abdom- 
inal end of each tube terminates in a curious structure called 
the fimbriated or fringe-like body, in the centre of which is the in- 
ternal opening of the tube. It is the function of the Fallopian 
tube to convey the ovum or germ from the ovary to the uterus. 
In order to do this, the fimbriated extremity of the tube, although 
* Named after the anatomist, Fallopius, of Italy. 538 
DISEASES PECULIAR TO WOMEN. 
to a certain extent floating loosely in the pelvic cavity, applies it- 
self accurately to that part of the ovary from which the ovum is 
about to emerge, and receives the latter into its opening, whence 
it is transmitted to the uterus. In case the ovum is impregnated, 
it remains in the uterus throughout the period of gestation ; other- 
wise, it passes on through that organ, and thence out of the 
body. 
The ovaries are two flattened ovoid bodies situated on either 
side of the uterus. They are developed between the layers or folds 
of the broad ligaments. * They are about an inch to an inch and 
a quarter long, three-quarters of an inch broad, and half an inch 
thick. In structure, they consist of a reddish-white substance con- 
taining numerous small bodies varying in size from a pin’s head 
to a small pea. These latter are called Graafian follicles, f It is 
in these follicles that the ovum is matured. In the ovary of a 
woman, after the age of puberty, there can usually be seen with 
the naked eye from ten to twenty of these follicles in different 
stages of development, the largest being found nearest the surface 
of the organ. The stroma, or proper substance of the ovary, is 
surrounded by a dense fibrous tissue, called the tunica albuginea 
(or white tunic). [See also chapter on Obstetrics.] 
Connected with the uterus and attaching it to the bladder, rec- 
tum, etc., are a number of ligaments, a description of which is 
hardly necessary here. 
Menstruation. 
About the age of fourteen to fifteen years—sometimes a year or 
two earlier, sometimes later—a remarkable change is observed to 
take place in the human female ; a change which affects her bodily, 
mentally, and morally. At this interesting and important period 
she ceases to be a child and becomes a woman. This change is 
designated by the term puberty. 
During the progress of this process the pelvis enlarges, the hips 
are expanded, the organs of generation are rapidly developed, the 
breasts become fuller, the limbs assume a plump and rounded 
form, the entire figure loses the angular and awkward outlines of 
girlhood and becomes graceful and beautiful. The girl’s manners 
and habits also undergo a marked change. She discards the doll 
that she played with but yesterday ; she feels that she is no lon- 
* A fold of the peritoneal membrane which covers the uterus, and passes outward on. 
either side to the walls of the pelvis. 
f After a Dutch anatomist, de Graaf. 539 
DISEASES PECULIAR TO WOMEN. 
ger a child, and that new duties and responsibilities devolve upon 
her. She is no longer wayward, romping, and careless, but be- 
comes reserved and modest in her deportment. In short, she is 
now a woman, prepared to love and be loved, and capable of per- 
forming the highest and most important functions of her sex. 
Simultaneous with these changes—sometimes at their very com- 
mencement—there occurs a most interesting and remarkable func- 
tion of the female economy, viz., menstruation. 
By the term menstruation is understood a discharge of blood 
from the female genital organs occurring at intervals of about 
twenty-eight days, lasting from three to five days, and continuing 
to return periodically, unless interrupted by pregnancy, suckling, 
or some disease, to the age of forty-five or fifty years. 
Owing to a variety of circumstances there is very great irreg- 
ularity as to the time at which menstruation commences and 
ceases. For example, it is hastened by a residence in a hot cli- 
mate, by the use of warm and stimulating food and drinks, fre- 
quent bathing in warm water, sleeping in warm, soft beds, luxuri- 
ous habits of living, etc. It is also accelerated by certain moral 
influences, as an early entrance into society, balls, theatres, music, 
painting, the reading of exciting romances, etc. The artificial 
maturity induced by these and similar agencies is always to be 
deprecated, for the result is very likely to be a lasting injury to 
the system. 
The approach of menstruation is commonly marked by various 
irregular nervous symptoms, as irritability of temper, fits of cry- 
ing, disturbed sleep, capricious appetite, headache, flushings of the 
face, palpitation of heart, pains in the back, loins, etc. These 
manifestations may disappear after two or three days to reappear 
at the end of a month, or, possibly, after some indefinite interval. 
Finally, they are followed by the appearance of a colorless mucous 
discharge from the genitals, which, in its turn, is succeeded by a 
flow of blood. The first menstrual flow usually lasts from one to 
three days. The function does not in most cases become regular at 
once : an interval of two or three months, or even more, elapsing 
sometimes between the first and second discharge. 
The quantity of blood lost at a menstrual period varies very 
greatly, so that it is impossible to fix a definite healthy standard. 
Some women do not lose more than two or three ounces, while others 
habitually lose eight or ten ounces; and these quantities may there- 
fore be regarded as within the limits of health. Nevertheless, 
the smaller quantity named would be regarded as scanty by the 
latter, and the larger quantity would be a profuse flow for the 
former. Indeed, in regard to the amount of the discharge, the 540 
DISEASES PECULIAR TO WOMEN. 
length of the periods, and the intervals between them, each woman 
is a law unto herself. 
At about the age of forty-five to fifty years the function of 
menstruation ceases ; and with it ceases also the reproductive 
power of women. This period has received the significant name, 
Change of Life. It is also known as the “ Turn of Life,” “ Cli- 
macteric,” etc. It is an extremely interesting and critical period 
of a woman’s existence, and one which is fraught with important 
consequences ; for, according as it is passed with safety or other- 
wise will her future health be. Sometimes, though rarely, the 
discharge ceases at once, to return without any preceding irregu- 
larity ; and when it does so, there is frequently much doubt as to 
whether the non-appearance of the flow at the customary time may 
not be due to pregnancy. Usually, however, the approaching 
change announces itself by a gradual diminution in the amount of 
discharge at successive periods, with the occasional occurrence of 
an uncommonly profuse flow. 
Again, a woman may pass one or two regular periods without 
any discharge, and then have one of great abundance. In short, all 
manner of irregularity, both as to amount of discharge and times of 
recurrence, may be expected. Several months, or even two or three 
years, may be marked by this variableness before the discharge 
fails to appear altogether. This is known as the “ dodging time.” 
Women usually regard the approach of the change of life with 
a good deal of anxiety, and not without reason ; for it is well 
known that certain diseases which may have lain dormant, as it 
were, in the system are. now likely to appear. More or less de- 
rangement of health is almost certain to occur. Thus, few women 
pass through the ordeal without experiencing headaches, frequent 
flushing of the face, nervous irritation, faintings, digestive disor- 
ders, etc. Existing gout, rheumatism, and consumption receive a 
fresh impulse ; while cancer, especially of the womb and breast, is 
more likely to appear than at any other time of life. 
But, on the other hand, many of the chronic diseases of the 
uterus and ovaries that have heretofore baffled all means of cure, 
now cease. And it is another hopeful fact that, if dangerous dis- 
eases should not be developed at this time, the woman’s chances 
for future good health and longevity are greater than those of the 
male who has reached the same age. Therefore, while women 
should not look upon this critical period with indifference, or ig- 
nore its possible dangers, neither should they entertain an exag- 
gerated notion of its perilous character. They should know what 
evils may occur, and, at the same time, they should know how to 
prepare for and meet them. 541 
DISEASES PECULIAK TO WOMEN. 
The change of life is especially dangerous to those whose health 
has already been impaired by previous and present disease ; and 
yet, with the single exception of cancer, the careful and persistent 
attention to the hygienic rules specified in the next section will 
usually be sufficient to carry a woman safely through, and prevent 
the more common diseases of the period. 
It is a great mistake to suppose that all the symptoms of disor- 
dered health occurring in women forty to fifty years of age are 
attributable to the change of life, and that hence they should not 
receive any special attention or treatment. And yet this error is 
constantly being committed both by physicians and patients. Thus, 
dropsy depending upon serious disease of the heart, liver, or kid- 
neys ; dangerous floodings produced by the presence of uterine 
polypus, ulceration, or cancer ; these and similar grave conditions 
have been referred, without local examination, to the change of 
life, and treatment, which possibly might have been effectual, if 
timely used, has been utterly withheld until too late ! If symp- 
toms such as the foregoing, or any others indicative of impaired 
health, should occur at this time of life, they require and should 
receive just as prompt and skilful treatment as though they ap- 
peared at any other time. 
FEMALE HYGIENE. 
It is quite as much the province of medical science to prevent 
disease as to cure it. If this fact were as fully realized by the pub- 
lic as it is by the medical profession, disease would be far less 
prevalent, and the efforts of physicians to prevent bodily suffering 
would be more heartily seconded than they now are, both by their 
patients and by legislators. Medical men may advise those with 
whom they come in contact how to avoid disease, but, as a rule, 
the advice is not acted upon. Persons who are in good health will 
not take any trouble to remain so; and, similarly, many who are 
sick are unwilling to incur any inconvenience in order to be cured. 
They are willing to continue in health and to be cured of disease 
so long as no effort on their part is required, but on no other terms. 
Now, the rules of hygiene contemplate, in regard to matters of 
health, self-help, and self-work ; and the directions which are given 
in this chapter are for the purpose of aiding those who place a suf- 
ficiently high value upon their health to be willing to do something 
themselves in order to preserve it. 
It is believed that at least two-thirds of the diseases of the re- 
productive organs of women are preventable complaints ; but in 
order that they may be prevented it is necessary not only that wo- 542 
DISEASES PECULIAR TO WOMEN. 
men should have a knowledge of the laws of health as pertaining 
to their sex, but that those laws should be obeyed. And so 
surely does the penalty follow any habitual infraction of those 
laws that it may be safely predicted that young women who neg- 
lect regular and sufficient exercise, who expose themselves to wet, 
fatigue, and excitement during the menstrual flow, or who reck- 
lessly interfere with the function in any way, will, sooner or later, 
have uterine disease. So, too, in the case of married women may 
a similar result be looked for among those who, by any means, 
induce miscarriages, or who are careless after their occurrence, 
who do not allow the generative organs sufficient time for physi- 
ological rest after pregnancy and parturition, or, in short, who in 
any manner abuse their sexual powers and privileges. 
When puberty appears at the proper time and pursues its usual 
course the condition needs but little, if any, treatment. Neverthe- 
less, when the headache, backache, flushings of the face, and other 
symptoms indicative of the attempt of the system to establish the 
monthly flow, are observed to be present, the girl should be relieved 
from her ordinary duties and permitted to rest on the bed or sofa 
two or three hours during the middle of the day. The diet should 
be simple and reduced in quantity. A warm hip-bath is frequently 
useful and is sometimes sufficient to determine the discharge. No 
stimulating drinks or “forcing” medicines should be given unless 
by the advice of a physician. 
Puberty may be premature; that is, it may occur at a much 
earlier age than usual. While we should not regard all the instan- 
ces of bloody discharge from the genitals of children as menstrua- 
tion—since such may take place from a great variety of causes 
wholly unconnected with that function—yet this latter has been 
known to appear and become regular in girls eight and nine years 
of age. Sometimes the general health is not affected in these 
cases, but in others the premature drain has been the cause of de- 
bility, dropsy, consumption, and other diseases of a wasting and 
fatal character. 
Under these circumstances, the patient should reside in the 
country and lead a quiet life ; she should have regular, moderate 
out-door exercise ; she should have a cold bath of short duration— 
say two to three minutes—every second day, followed by brisk 
friction of the skin ; she should avoid anything calculated to 
arouse the passions, such as going into gay company, reading ex- 
citing works of fiction, etc. The effects of loss of blood should be 
combated by nutritious food and the use of tonic medicines. 
The opposite condition, namely, that in which menstruation is 
tardy in its occurrence, is much more frequent. It not uncommonly DISEASES PECULIAR TO WOMEN. 
543 
happens that girls reach their seventeenth and eighteenth year 
without the appearance of the menstrual flow. This results from 
a great number of causes, both of a local and constitutional char- 
acter. 
The non-occurrence of menstruation at the usual time fre- 
quently gives rise to much anxiety on the part of the girl’s friends 
—especially of the mother, who is quite likely to use various do- 
mestic remedies of a stimulating sort for the purpose of inducing 
the flow. This course results from ignorance of the fact that 
something more than mere age is necessary for the performance 
of the menstrual function. Let it be understood that menstrua- 
tion is the result of the maturity of the organs engaged in its pro- 
duction, and it will then be apparent that it is useless to attempt 
by powerful medicines to hasten its occurrence. Indeed, not only 
will such means certainly fail to produce the desired result, but 
they are very likely to be productive of evil consequences. When 
the marks of puberty are absent and menstruation does not ap- 
pear, no means for coercing nature should be used, no matter what 
the age of the patient may be. If the latter be in general feeble 
health and lacking in physical development, such means should 
be employed as will give bodily vigor, and enable her, through the 
growth and maturity of her sexual organs, to perform the physio- 
logical offices of her sex. The diet should be of the most nutritious 
character ; she should spend a large part of her time in the open 
air, preferably in the country, and, if possible, at the sea-side. 
She should have few in-door employments, and none of a confin- 
ing nature. Flannel should be worn constantly next the skin, 
and exposure to dampness and chilliness carefully guarded against. 
Finally, she should use such gymnastic exercises as may be suit- 
able for her strength. 
It is a lamentable fact that, after menstruation has been estab- 
lished, most women, especially those who are in good health, give 
no attention to the menstrual periods, in so far as these latter may 
interfere with either their duties or their pleasures. They attend 
social gatherings, take long walks, ride on horseback, toil at the 
sewing machine, or perform other laborious duties, just as though 
the discharge were not present. This is most unfortunate; and, 
in many cases, deplorable consequences follow these imprudent 
practices. Women should know that, although menstruation is a 
natural process, in our state of civilization, where so many bane- 
ful influences are constantly in operation to impair health, the 
function is extremely liable to become disordered, sometimes from 
apparently slight causes. For several days prior to its appearance 
and during the time of its presence, the ovaries, uterus, and the 544 
DISEASES PECULIAR TO WOMEN. 
adjacent organs are in a state of intense congestion ; and this con- 
gestion needs for its relief the normal periodical discharge of 
blood. In order that the latter should proceed naturally, it is es- 
sential that the woman should have rest—rest for the body and for 
the engorged parts. Therefore it is that fatiguing walks, shop- 
ping, riding, dancing, theatres, etc., should be interdicted during 
the period ; for these things, by their stimulating effect, are likely 
to disturb and increase the flow, sometimes to a dangerous degree, 
and induce disease. Equally important is it that, at this time, 
women should avoid getting wet, sitting in currents of air, drink- 
ing large quantities of ice-water, putting on damp clothing, or 
bathing in cold water. These things are likely to suppress the 
flow and produce congestive and inflammatory diseases of the 
uterus and ovaries. 
It has been well suggested as a good practical rule that, in re- 
gard to exercise and labor, women should do less than usual during 
the menstrual period ; just how much less they ought to do must 
depend upon the conditions attending each individual case. 
When the change of life approaches, the sexual organs should 
have physiological rest. Intercourse should be abstained from or 
indulged in sparingly. For this reason marriages should not be 
contracted at this time. The utmost attention should be given to 
the digestive organs, and everything likely to impair their powers 
should be avoided. A full bath should be taken once a week in 
water at 92° to 94° Fahr., and continued one hour. If perspiration 
be profuse, a bath of shorter duration may be taken two or three 
times a week. In these latter cases flannel should be worn over 
the chemise, and in winter over the night-dress also, in order to 
avoid chilliness from change of posture. Exercise must he taken, 
not inordinately, but regularly. No other remedy is equal to this 
for the cure of the fidgets, hysteria, sleeplessness, and other evi- 
dences of disordered nervous action so characteristic of this pe- 
riod. Walking is the best form of exercise where the strength is 
sufficient to permit it. Carriage-riding, wTith other passive exer- 
cise, will answer for those who are more feeble; but horse-back 
riding must be prohibited until the “ dodging time ” is fairly passed. 
Balls, operas, and similar amusements should be likewise sus- 
pended. The plethoric should not indulge themselves with too 
much sleep, but those who are thin and nervous may take as much 
sleep as they can get. For this latter class sleep is the very best 
nerve-restorer attainable 545 
DISEASES PECULIAR TO WOMEN. 
SYMPTOMS OF PELVIC DISEASES IN WOMEN. 
The presence of disease in any part of the human body is known 
by certain manifestations which are termed symptoms. These are 
divided into two classes ; the first comprising those which are evi- 
dent to the patient’s own perceptions, as pain, the appearances of 
discharges, etc. These are called subjective symptoms. The sec- 
ond class consists of those which are only ascertainable by the 
investigation of another person, as the size, shape, color, and other 
conditions of organs beyond the view and reach of the patient; 
these are known as objective symptoms. It is the first of these 
classes only that will engage our attention here. 
Our principal objects in detailing these subjective symptoms 
indicative of pelvic disease in women are : 1. To call attention to 
the important fact that they are never sufficient to enable either 
patient or the physician to determine their real source. 2. To show 
that, in order to do this, a physical exploration of the pelvic organs 
is absolutely necessary ; and, 3. To explain why it is that, unless 
the symptoms are thus traced to their origin, all treatment must 
of necessity be vague, unsatisfactory, and ineffectual. 
These statements are made thus emphatically because there are 
many females who, having a natural repugnance to such physical 
examination of the genital organs being made, are apt to urge its 
omission. They think, or seem to think, that it can, and hence 
ought to be, dispensed with. This notion is an erroneous one, and 
the physician who undertakes the treatment of pelvic diseases in 
women without previously satisfying himself, so far as possible, of 
the nature and extent of the disease, is derelict in his duty both to 
his patient and himself. Far oftener than is supposed, the nervous 
and sick headaches of women, their backaches and indigestions, 
their troubles of bladder and rectum—treated as such for years 
possibly—are dependent upon some undiscovered uterine or ovari- 
an disease or displacement—undiscovered because unlooked for. 
Menstrual Derangements. 
Derangements of the menstrual function are frequent accom- 
paniments of disease of the uterus and ovaries. As stated in a 
previous chapter, the flow may not appear at the usual age. After 
its establishment the discharge may be scanty, it may be profuse, 
or it may be attended with pain. Any of these unnatural condi- 
tions ought to be regarded with anxiety by the patient, for they 546 
DISEASES PECULIAR TO WOMEN. 
are dependent upon some disorder either of a general or local char- 
acter. As we shall see when we come to their separate considera- 
tion, while they may depend upon certain constitutional conditions, 
more frequently some local disease will be found to be an impor- 
tant if not the sole factor of causation. Hence, in most cases, a 
physical examination of the pelvic organs should always precede 
treatment. 
So important are these menstrual irregularities, and so certainly 
indicative of organic disease—sometimes of very serious charac- 
ter—that no woman should permit them to continue without having 
the advice of an intelligent physician. Generally this course is 
not taken until after much loss of precious time and the failure of 
remedies prescribed by non-professional friends. Thus, many dis- 
eases which would yield readily to judicious treatment used in their 
early stages, become chronic and incurable by neglect, and the pa- 
tient is doomed to years, possibly a lifetime, of misery. 
Leucorrhcea. 
[Leucorrhoea, or Whites, is a discharge'from the genitals of fluid, 
sometimes thin and watery in character, at others containing a 
thick, sticky mucus from the neck of the uterus, or pus and blood 
from the uterine cavity. It may be so small in amount as to give 
little inconvenience, or be so profuse as to require almost constant 
attention. It may be without odor, or, on the other hand, its odor 
may be intensely disagreeable, according to the nature of its cause.] 
Of all the symptoms indicative of disease of the genital or- 
gans in women, this is the most frequent; and it is, perhaps, the 
most common ailment among them for which the physician is 
consulted. It is very rarely, if ever, a disease of itself. Nearly 
always it is merely a symptom of some disease of the pelvic 
organs. This is a highly important fact, and one which shows the 
necessity of investigating its antecedent causes before any means 
can be rationally adopted for its cure. What these causes spe- 
cially are will be fully pointed out in a subsequent chapter devoted 
to this subject, [see also, page 554.] 
Pain. 
The pain which is experienced by women suffering from 
uterine and ovarian disease is of two kinds—that which is con- 
nected with the menstrual flow, and that which is felt at other 
times and unconnected with the menstrual function. The first of 
these will be more appropriately considered under the head of pain- 
ful menstruation ; the second only will engage our attention here. 547 
DISEASES PECULIAR TO WOMEN. 
The various pains that occur independently of menstruation 
vary in their degree, character, and location. They are not al- 
ways felt in the particular organ which is the seat of disease. Fre- 
quently they attack parts of the body quite distant; that is, they 
are “ reflected.” A familiar example of this reflected pain is that 
which is felt at the top of the head, as a result of tipping or bend- 
ing of the uterus forward. 
Pain in the back is an extremely common symptom. Usually 
it is not acute, but rather of a heavy, aching character. 
Backache is not necessarily indicative of disease of the genera- 
tive organs ; but the connection between the two, when the symp- 
tom has been of long standing, is so frequent, that its presence 
furnishes strong presumptive evidence of disease of those parts, 
especially when the pain is habitually more severe just prior to or 
during the menstrual period. 
Pains in the lower portion of the abdomen are likewise very 
frequent. They may depend upon retention of menstrual blood or 
the products of conception within the uterine cavity, uterine tu- 
mors, displacements or abscess, distention of the bladder, disease 
of uterus or ovary, etc. 
Bearing-down pains are usually found in women who have suf- 
fered long from disease of the uterus, and in whom the general 
health has become impaired. Generally, in these cases the uterus 
is more or less completely prolapsed (situated lower down in the 
pelvis than is natural); although uterine tumors, polypi, etc., pro- 
duce the same kind of pain. 
Sometimes pelvic pains are clearly of a nervous or hysterical 
nature—very severe, possibly, but not connected with any percep- 
tible structural disease. 
Pains in the lower extremities are usually caused by pressure 
upon the nerves from enlargement of the abdominal or pelvic or- 
gans, as uterine or ovarian tumors. 
Itching of the Genitals. 
This sensation is closely allied to pain, and frequently is much 
more intolerable. The cause is not always readily ascertainable ; 
but very often it will be found to depend upon some local 
changes requiring actual inspection for their detection. Some- 
times it is produced by an irritating uterine or vaginal leucor- 
rhoea, and it is a very frequent accompaniment of the acrid, 
watery discharge present in cancer of the parts. Occasionally, 
however, the itching is very severe, extending even into the 
vagina, without any discharge. Frequently it is associated with 548 
DISEASES PECULIAR TO WOMEN. 
diabetes (or urine containing sugar). Various skin diseases affect- 
ing the external parts produce it. It is most common at the change 
of life, although young women are not exempt from it. It is usu- 
ally aggravated at the menstrual period. 
Treatment.—As we shall not recur to this subject, a few words 
in regard to the treatment of this distressing malady may not be 
amiss. 
A symptom depending upon so many different conditions clear- 
ly requires for its cure the removal of the existing cause ; and this, 
as already stated, necessitates an examination of the parts. Much, 
however, may be done in the way of palliation. 
Strict cleanliness is all-important, and in some cases great relief 
is obtained by simply bathing the parts in tepid water two or three 
times a day. Lotions of powdered borax in water (a drachm to a 
pint), or of the sulphite of soda, in the same proportions, are ex- 
tremely soothing and sometimes curative. So, likewise, is the 
frequent bathing of the parts with an infusion of poppy-heads, to 
which may be added sugar of lead (a half-teaspoonful to a pint). 
Where the parts are subject to rubbing or chafing against each 
other, strips of lint smeared with an ointment of lard and borax, 
bismuth or oxide of zinc, should be placed between them. 
Scratching the affected parts should be avoided as much as pos- 
sible, as this always aggravates the itching, and produces redness, 
heat, and swelling. The itching is also increased by acidity of the 
stomach, constipation, standing near a fire, warm bed-clothing, etc. 
Painful, Difficult, and Frequent Urination. 
Pain of a burning or scalding character during micturition 
(the act of urinating) is frequently complained of by women suf- 
fering from disease of pelvic organs. It may depend on an un- 
natural state of the urine, as from undue acidity or alkalinity, the 
presence of gravel or blood, disease of the bladder, Bright’s disease 
of the kidneys, etc. 
Again, it may be produced by inflammation or tumors of the 
urethra, or its outlet, and also by excoriation of the vulva and in- 
ner side of the thighs. Displacements and tumors of the uterus 
may cause both pain and difficulty in urination, either by pressure 
against the bladder and urethra, or by drawing the latter from its 
natural position. 
A frequent inclination to urinate is occasioned by almost any 
of the diseases and displacements of the uterus, vagina, and 
adjacent parts. To particularize, we may mention ovarian and 
other pelvic tumors, cancer, polypus and enlargement of the womb ; DISEASES PECULIAR TO WOMEN. 
549 
stone in the bladder, and inflammation or cancer of that organ; 
diseases of the rectum, as fissure, piles, fistula, etc. 
Treatment.—These symptoms, which are referable to the blad- 
der, cannot be treated without the aid of a phy- 
sician. The application of warmth externally, and the use of 
opium or hyoscyamus in some form internally,* may be used as 
palliative measures. These, with rest in the horizontal position, 
are frequently sufficient to give temporary relief ; but patients who 
suffer from the distressing symptoms named should always avail 
themselves of the earliest opportunity for obtaining competent 
advice. 
Amenorrhoea. 
The term amenorrhoea, although literally signifying absent 
menstruation, is likewise used to include cases in which the flow 
is defective or scanty. There are two forms of the disorder, 
namely : 1. That in which the discharge has never appeared ; and, 
2. That in which, having been established for some time, it has 
become suspended or suppressed. 
1.—The discharge has never appeared.—The menstrual discharge 
may not appear because of, 
a.—General debility and lack of development. 
h.—Congenital absence or imperfect development of the genera- 
tive organs. 
When the flow fails to appear in consequence of lack of growth 
and strength, the figure of the girl, instead of becoming full and 
rounded as it should at the age of puberty, remains delicate and 
angular. The breasts are undeveloped, the hips remain narrow, 
and the chest flat. Instead of becoming a woman, she is still a 
child. The absence of the menstrual function is but one of the re- 
sults of sluggish power and constitutional feebleness. 
The cases of amenorrhoea which result from absence or imper- 
fect development of the uterus, ovaries, Fallopian tubes, etc., are 
not frequent; a fortunate circumstance, inasmuch as they are but 
little amenable to treatment. 
Usually, in these cases, there is no deficiency of general devel- 
opment or strength ; but, as the age of puberty approaches, the 
form of the girl, instead of becoming plump and full, assumes a 
more muscular and masculine appearance. The shoulders are 
square and angular ; the feet and hands are large ; the breasts are 
generally and imperfectly developed, but not always so. If, 
* Fifteen drops of tincture of opium, or double that amount of tincture of hyoscy- 
amus, should be sufficient for one dose. 550 
DISEASES PECULIAR TO WOMEN. 
with these physical peculiarities, there appear none of the symp- 
toms pointing to the establishment of menstruation, we may rea- 
sonably suspect some organic defect. 
If an examination be made in these cases, the vagina is com- 
monly found to be short and narrow, ending, frequently, in a closed 
extremity with no trace of a uterus beyond ; or, possibly, a mere 
thickening or cord-like body occupying the place where that organ 
ought to be. The external organs may be fully developed, although 
they, too, are sometimes small and defective. 
Treatment.—There are all conceivable modifications of this class 
of cases, some of them admitting of successful treatment; but the 
propriety of remedial measures can only be determined by a skil- 
ful physician. 
In the second class of cases active treatment is not demanded, 
and would be improper. Pure air, plain, nutritious food, regular 
hours for meals and sleep, exercise, attention to the action of the 
bowels and skin, will, in time, produce the improvement in growth 
and vigor necessary to the establishment of the flow. 
2.—The discharge is suppressed.—After the menstrual flow has 
been fully established it may cease to appear. There are many 
causes capable of producing this result—exposure to cold and damp- 
ness during a menstrual period, attacks of fever or other acute 
diseases, violent mental emotion, as excessive anger, joy, fear, etc. 
The cessation of the flow happening suddenly during a period, 
is at once followed by severe pain in the back and pelvis, ex- 
tending, occasionally, to the abdomen ; the pulse becomes full and 
hard, the temples throb, there is headache, flushing of the face, 
and a dry and hot skin. The severity of these symptoms varies in 
different cases, being most intense in women of full, plethoric 
habit of body. 
Treatment.—This condition should receive prompt attention. 
The patient should put her feet and legs into hot mustard-water, 
and keep them in the bath half an hour. She should then be 
placed in a well-warmed bed, with vessels containing warm water 
to her feet. At the same time she should take freely of warm 
drinks with the view of inducing perspiration. Nothing is better 
for this latter purpose than a dessertspoonful of the syrup, or 
half a teaspoonful of the essence of ginger taken in a tumblerful 
of hot lemonade. This may be repeated every hour or two until 
the desired effect is attained. In the slighter cases these means 
will commonly succeed in. restoring the discharge in a few hours. 
Should they fail, however, and the symptoms of fever continue, a 
large poultice of flaxseed meal and mustard should be applied over 
the lower part of the abdomen : while, at the same time, flannels 551 
DISEASES PECULIAR TO WOMEN. 
wrung out of hot mustard-water may be wrapped about the feet 
and legs, and mustard-plasters applied to the inside of the thighs. 
The efficacy of these remedies will be greatly enhanced by the ad- 
ministration of a ten-grain dose of Dover’s powder. Should the 
discharge still fail to appear, a physician should be summoned. 
In some cases, from neglect of prompt treatment, or from gen- 
eral debility, the suppression of menstruation becomes chronic, 
and nature, thwarted in her efforts to restore the secretion in its 
normal form, seeks an outlet in other directions, and a periodical 
discharge of blood takes place from other parts of the body. This is 
called vicarious menstruation. Usually, this substitute discharge 
occurs from the lungs, giving rise to grave fears of consumption ; 
but it has been known to proceed from the bowels, ears, nostrils, 
gums, breasts, or any ulcerated surface. 
Such cases are not suitable for home treatment. The object is 
to restore the secretion to the uterus, and the means necessary for 
this purpose should only be used under the advice and supervision 
of a physician. 
C. The menstrual secretion is retained.—The menstrual fluid, al- 
though properly secreted, may be retained ; that is to say, may not 
appear externally. These cases, although considered here, should 
not be confounded with amenorrhoea, in which, as already defined, 
there is no secretion. Here the usual changes connected with 
puberty have taken place ; the ovaries and uterus have performed 
their work ; the menstrual fluid has been thrown out from the sur- 
face of the uterine cavity ; but, owing to a closure of some portion 
of the uterine or vaginal canal, it has no outlet, and is retained 
above the point of obstruction. 
In these unfortunate cases the patient suffers from periodical at- 
tacks of pain referred to the back, loins and pelvis ; from headache, 
and general disorder of health. With each returning period the 
symptoms increase in severity; the pains, at first amounting to 
little more than discomfort, become very intense and assume a 
paroxysmal character, owing to the contractile efforts made by the 
womb to discharge its contents ; the patient has a sense of ful- 
ness and weight in the pelvis ; there is frequent desire to urinate, 
and, sometimes, a difficulty in passing urine, amounting occasion- 
ally to complete retention. The bowels are also emptied with dif- 
ficulty ; the abdomen becomes enlarged and tender. After a time, 
pain is constant, aggravated, however, at the menstrual periods ; 
the general health fails ; the patient is dyspeptic, pallid, and suf- 
fers from all manner of nervous derangements. 
A most distressing feature of these cases is, that, owing to the 
absence of the menstrual flow and to the enlargement of the abdo- 552 
DISEASES PECULIAR TO WOMEN. 
men, the patient is likely to suffer from the suspicion of preg- 
nancy, and thus immeasurable mental anguish is added to her 
bodily pain. 
The impediment to the exit of the menstrual fluid may exist 
at any part of the genital tract below the cavity of the uterus. 
Where it consists in an imperforate state of the hymen, as it some- 
times does, that membrane becomes distended, thinned, and may 
protrude between the labia, presenting a smooth, reddish or pur- 
plish appearance. 
Treatment.—The only effective treatment is surgical. The op- 
erative procedures necessary for relief may be very simple, or of 
the most elaborate kind. Nothing but harm can result from the 
use of means to “bring on the discharge;” for such means not 
only certainly fail of their object, but they may be productive of 
great danger. 
Therefore, whenever a girl has reached the age of puberty, is 
well developed, and has periodically the symptoms enumerated as 
indicative of menstrual obstruction, an investigation by a physi- 
cian should always precede any but the simplest treatment. 
Dysmenorrhoea. 
By the term dysmenorrhoea is understood painful or difficult 
menstruation. Most women—even those who regard themselves 
as being healthy—experience some discomfort at the approach of, 
or during the monthly flow; but it is only when they suffer actual 
pain that they consider themselves proper subjects for medical ad- 
vice or treatment. 
Painful menstruation is extremely common, and arises from 
the most varied causes. Usually, the pain precedes the discharge 
by a few hours, or one or two days, reaching its height just before 
the flow appears, and subsiding after the latter has become free. 
In others, the discharge appears first, and the pain continues 
throughout the entire period. The pain may be constant or inter- 
mittent, sharp or dull, slight or severe. Sometimes it is so excru- 
ciating as to compel the patient to keep her bed, and even to scream 
with agony. 
The quantity of the discharge does not necessarily vary from 
that of health, although it is sometimes scanty, and at others pro- 
fuse. In some instances, after severe suffering, a quantity of 
membranous shreds or flakes are expelled, affording relief which 
may be temporary or permanent. Occasionally a large mass of 
fibrinous substance representing a cast of the uterine cavity, is 
thrown out. In still other cases, a severe attack of pain will be DISEASES PECULIAR TO WOMEN. 
553 
followed by the expulsion of coagulated blood; in these, the dis- 
charge is commonly abundant, and the patient is left much debili- 
tated at the end of the attack. 
As already stated, painful menstruation is associated with very 
many conditions of the pelvic organs, which, for our present pur- 
pose, it would be useless to enumerate. However, the cases may 
all be placed in two classes, namely : 
1. Those in which there is no impediment to the flow. 
2. Those in which there is some impediment. 
In the first class are to be placed all the cases which depend 
upon, or are produced by diseases of the ovary, by a gouty or rheu- 
matic tendency, neuralgia, digestive derangements, etc. 
The second class comprises all those in which some mechanical 
obstruction exists to the free outlet of the discharge. Such ob- 
struction may occur in the cervical canal, at the os uteri, or in any 
part of the vagina. If the passage be closed entirely, the effused 
blood will be retained, as explained in the foregoing section; but, 
if the closure be only partial, the fluid will be expelled with diffi- 
culty and pain. Such mechanical cause for the pain may be sus- 
pected whenever the pain precedes the discharge. In these cases 
the pain arises from the distention of the uterus and the contractile 
efforts of that organ to empty itself. 
Treatment.—The treatment of painful menstruation is either 
palliative or radical. 
The palliative treatment includes those means which have a 
tendency to lessen the pain; the radical, has reference to the remo- 
val of any existing cause. For the relief of pain the patient may 
do much; but for the detection and removal of the cause of the 
disorder—especially when this is of an obstructive character, gen- 
erally requiring surgical treatment—the services of a physician are 
indispensable. 
Pain is always more severe in persons whose general health has 
been impaired in any manner. Hence, every care should be taken 
by the patient to preserve or restore her constitutional vigor by all 
known hygienic means. She should carefully attend to the func- 
tions of the stomach and bowels. Such wholesome and nutritious 
articles of food should be used as past experience has proved to be 
easily digested, and a daily movement of the bowels should be 
secured,—by a daily attempt, aided, if necessary, by warm-water 
enemata, and an occasional mild laxative dose of medicine. For 
this latter purpose, a teaspoonful of Rochelle or Epsom salt, or a 
half-teaspoonful each of rhubarb and calcined magnesia will be 
suitable. Strict attention should also be given to keeping the body 
warmly dressed. Flannels should be worn next the skin except 554 
DISEASES PECULIAR TO WOMEN. 
during the summer, when they may be replaced by elastic merino 
or cotton underclothing. 
As the menstrual period approaches, the patient should take a 
full warm bath of twenty to thirty minutes’ duration, and then get 
into a warm bed, where she should remain during the continuance 
of the flow. When the pain commences, she should swallow a pill 
containing a half grain of opium and one grain of the extract of 
Indian hemp. This may be repeated every three or four hours, so 
long as necessary. If the opium should for any reason be objec- 
tionable, two grains of the extract of conium may be used in its 
stead. In case the patient has difficulty in swallowing a pill, as 
many have, the following mixture may be used with equally good 
effect: 
Laudanum One-half ounce. 
Tincture of hyoscyamus One ounce. 
Hoffman’s anodyne One ounce. 
Peppermint-water One ounce and a half. 
Of this, a teaspoonful may be taken every two hours until the 
pain is relieved. 
By the use of the foregoing means the pain may be greatly 
ameliorated, but the benefit is usually only temporary. In order 
to prevent the recurrence of the symptoms, their underlying cause 
must be removed. Chronic inflammation, flexion, displacement, 
a fibrous tumor of the uterus, ovarian disease, etc., cannot be abol- 
ished by the most skilful administration of medicines ; and, inas- 
much as dysmenorrhoea frequently depends upon these and similar 
conditions, it is evident that mechanical and surgical treatment 
must often be necessary in order to effect a permanent cure. 
Leucorrhcea. 
Leucorrhcea is, without doubt, the most frequent of all the symp- 
toms of pelvic disease in women; and, under the names “ whites,” 
“female weakness,” etc., there are few women who are not famil- 
iar with it. 
The term leucorrhoea is understood to include all the discharges 
from the female genital organs that are not of a bloody or mem- 
branous character—watery, mucous, purulent, etc. They are 
white, yellow, greenish, brownish, or colorless. They are some- 
times as thin as water, and at others as dense as boiled starch or 
the curd of milk. 
Leucorrhoea is not to be regarded as a disease of itself, but only DISEASES PECULIAR TO WOMEN. 
555 
as indicative of some disorder, either of the general system or of 
some of the pelvic organs, with this exception, viz. : during preg- 
nancy, more especially during the latter half of the term, a mu- 
cous discharge, sometimes very profuse, is always present, and is 
thought by many to be an essential accompaniment of that condi- 
tion. So, likewise, an increase of the normal mucous secretion 
from the parts takes place both before and after each menstrual 
period. These examples of white discharge are, therefore, to be 
regarded as natural, and any attempt to check them would be im- 
proper and likely to be followed by injurious results. 
It must not be understood from this, however, that pregnant 
women may not have a leucorrhoeal discharge in consequence of 
disease, and it becomes the duty of the physician always to ascer- 
tain, in any given case, whether it be the effect of disease or oth- 
erwise, before interfering with it, or ignoring it. 
Watery Discharges.—Watery discharges from the vagina in 
non-pregnant women may depend upon the presence of cancer, 
either of the womb or vagina. In these cases, it may be quite clear 
and transparent, but is more commonly mixed with small grayish 
particles, imparting to it a turbid appearance. Likewise, it is fre- 
quently mixed with blood, and then resembles brownish saliva; 
or, it may alternate with discharges of pure blood. It commonly 
has a characteristic and highly offensive odor. Sometimes it is 
very copious, necessitating the use of ten or twelve napkins daily. 
Polypus of the uterus is also frequently attended with a watery 
discharge. Here, it alternates with profuse menstruation, and 
discharges of blood between the menstrual periods. 
Mucous Discharges.—When the discharge is mucous, its ap- 
pearance will sometimes serve to indicate its source. Thus, when 
it is curdy and has an acid reaction, as indicated by its power to 
redden blue litmus-paper, it is from the vagina. If it be viscid, te- 
nacious, resembling soap-suds, and contain masses of curdled mu- 
cus, it is from the neck of the womb. When creamy and resem- 
bling pus, profuse and constant, it may come from both the neck 
and body of the womb. The mucous discharges, when dependent 
upon disease, are generally associated with inflammation of the 
uterus and vagina, and with displacements of the former. 
Discharges of Pus.—Purulent discharges from the genital canal 
may be from the inflamed mucous membrane of the vagina, the 
glands of the neck of the womb, an ulcerated surface, or the result 
of gonorrhoea. They may likewise proceed from an abscess ex- 
ternal to the uterus and vagina, opening into either of these organs. 
Bloody Discharges.—Discharges of a reddish color from admix- 
ture with blood may proceed from ulceration, morbid growths 556 
DISEASES PECULIAR TO WOMEN. 
within the uterus, as tumor, polypus, a fungoid condition of the 
lining membrane, cancer, etc. 
Offensive Discharges.—As heretofore stated, leucorrhoeal dis- 
charges are sometimes offensive in odor. When they are so, 
women are very likely to fear the presence of cancer. While it is 
true that a watery discharge, tinged with blood, and having a fe- 
tid odor, are sufficient to arouse the suspicion that malignant dis- 
ease is present, they may all exist as results of other less dreaded 
maladies. On the other hand, cancer may not be accompanied by 
offensive discharge at all. 
Retained products of conception, as a foetus or portions of pla- 
centa in a state of decomposition, give rise to a discharge very 
similar to that ordinarily caused by cancer. 
Treatment.—From what has been said, it will be seen that each 
of the varieties of leucorrhoea may depend upon a great variety 
of diseased conditions ; and hence, anything in the way of treat- 
ment can only be uncertain, unless the exact cause of the discharge 
be previously ascertained. 
Nevertheless, much good may be done in very many cases by 
the judicious employment of vaginal injections or douches. The 
best appliance for this purpose is that known as the “ Fountain” 
Syringe (see Index), or some of its modifications; and the best 
substances to be used are those of an astringent character. Among 
these may be mentioned, a solution of powdered alum (a teaspoon- 
ful to a half gallon of tepid water) ; a decoction of oak bark (half 
an ounce to the quart of water); a solution of tannin (a drachm to 
the quart of water), etc. If the discharge be offensive, carbolic 
acid or permanganate of potash may be added to either of the fore- 
going (to the extent of ten grains of the former, or five of the latter 
to the quart of water), or may be used separately. These means 
occasionally succeed in curing a vaginal discharge, but they are 
generally to be regarded rather as palliative than curative. 
But, whatever local means may be employed, it will commonly 
be found necessary to attend, also, to the state of the general health, 
which is nearly always more or less impaired. 
Menorrhagia and Metrorrhagia. 
A profuse flow of the menses is known by the term menorrha- 
gia, while a discharge of blood from the womb at other than the 
menstrual period is denoted by the term metrorrhagia, or uterine 
hemorrhage. It is convenient to consider these two conditions to- 
gether, for the reason that the causes which produce the one 
almost certainly, sooner or later, produce the other also. 557 
DISEASES PECULIAR TO WOMEN. 
It is not an easy matter to define just what should be consid- 
ered a profuse menstrual flow, estimated merely by the quantity of 
discharge ; for some women naturally lose much more than others. 
Speaking generally, however, it is safe to regard the discharge as 
excessive when the woman is obliged to use more than two or three 
napkins daily, and when the period continues more than six or 
seven days. But, as each woman has a standard of her own in 
this matter, she may regard the flow as inordinate whenever it is 
much, greater than usual with her j or, when it leaves her in a 
debilitated state. 
There are a great many conditions which produce excessive 
menstruation. Some of these are of a general and some of a local 
character. Among the former are the gouty and rheumatic pre- 
dispositions, scrofula, diseases of the heart, liver, and lungs, pleth- 
ora, general debility, etc. ; while the local causes include chronic 
inflammatory diseases of the uterus, uterine tumors and polypi, 
ulceration, displacement, cancer, etc. It will be seen, therefore, 
that, like amenorrhoea and dysmenorrhoea, profuse menstruation 
is not to be regarded as a disease of itself, but that it, likewise, is 
merely a symptom—the principal one, possibly—of a great many 
various disorders. Hence, the necessity in every case, of ascer- 
taining exactly what these underlying conditions are ; for, unless 
they are removable, treatment can only be of temporary benefit. 
There are two classes of persons in whom an excessive flow of 
blood may take place at the menstrual period. The first comprises 
those of full, plethoric habit of body, who live luxuriously, who 
habitually use rich, stimulating food, and who are indolent and 
sedentary. In these cases we find what is known as active menor- 
rhagia. At the onset of a period there is fulness of the vessels of 
the head, indicated by throbbing headache and flushings of the 
face ; the skin is hot, tongue dry, pulse full and hard. The patient 
has severe pain in the back, with a sense of heat, fulness, and 
weight in the pelvis. When the discharge appears it is in gushes 
of bright, red blood, with occasional clots of large size. The flow 
is somewhat paroxysmal, abating for a short time, and then 
returning as violently as before,—any movement of the body or 
any violent mental emotion being sufficient to cause its renewal. 
Finally, after continuing in this way for some days, the force of 
the circulation is lessened, the headache and heat of surface di- 
minish or disappear, and the patient is left weakened but other- 
wise relieved. 
If the periods be not too prolonged, the patient may not feel any 
evil effects for several months ; but usually each succeeding at- 
tack returns with increasing severity—the time of the flow length- 558 
DISEASES PECULIAR TO WOMEN. 
ening, and the intermenstrual period becoming shorter, until at 
last the system recovers its powers less and less perfectly, and the 
patient’s strength is exhausted. 
Treatment.—So long as the health of the patient shows no signs 
of impairment, the profuse discharge may be regarded as salu- 
tary. 
It is nature’s own method of relieving undue congestion of the 
pelvic organs and of the system at large; and the only proper 
treatment consists in the use of such means as are calculated to 
remove the necessity for the inordinate flow. 
The diet should be of the simplest and plainest sort; the bowels 
should be kept regularly open ; moderate but regular daily exer- 
cise should be taken, followed by rest for an hour or two on the 
sofa or bed. During the attack it is indispensable that the patient 
maintain the recumbent position, and she should lie upon a hard 
mattress. She should avoid all unnecessary movements of the 
body, and, so far as possible, all disturbing mental influences. 
She should be relieved of all household and domestic cares. Vis- 
itors should be excluded. Cloths wrung out of cold water, and 
changed frequently, should be applied about the vulva and lower 
part of the abdomen. Enemata of cold, or cool water, may also be 
thrown into the rectum. 
In case these means should not be sufficient to restrain the flow, 
and immediate danger threatens, the vagina should be plugged with 
a piece of sponge squeezed out of water and tightly rolled into a 
ball. This should then be pressed into the vagina, where, expand- 
ing with the filling of its interstices, it will effectually check the 
hemorrhage. In the absence of sponge, pieces of cotton, wool, 
strips of old muslin cloth, or even a cotton or silk pocket-handker- 
chief may be employed. Where a physician is not at hand, this 
may be done by any intelligent nurse, or even by the patient her- 
self. The vaginal plug should not be permitted to remain more 
than twenty-four hours. 
Menorrhagia never continues in the active form just described 
for a great length of time. The excessive loss of blood soon causes 
debility; the contractile power of the uterus is lessened, and the 
blood is poured out from the vessels of its lining membrane unre- 
strained. The blood itself becomes more watery, and loses, to a 
great extent, its power of coagulation ; the flow is almost con- 
stant, any brief intermissions being marked by the presence of 
profuse leucorrhoea. All the bodily functions are performed slug- 
gishly, and the patient is thoroughly prostrated. This form of the 
malady is termed passive menorrhagia. 
Treatment.—The patient should be surrounded, if possible, by DISEASES PECULIAR TO WOMEN. 
559 
everything fitted to improve the general health. Her residence 
should be in a dry, bracing climate ; her food should be plain and 
digestible, but of the most nourishing kind, consisting of beef, 
mutton, poultry, eggs, milk, etc., taken at regular times, and only 
in such quantities as the stomach can easily bear. It is frequent- 
ly difficult to carry out these dietetic directions, owing to the great 
feebleness of the patient’s digestive organs. Exercise should be 
moderate, always stopping short of fatigue, and followed by a 
period of rest. 
The treatment during the attack should be prompt and ener- 
getic. It must be borne in mind that in this class of cases the 
uterus is relaxed, flabby, and lacking in contractile power ; and 
that the object of first importance is to incite it to contraction. 
This is the aim of all treatment, and unless it can be accomplished 
the case is hopeless. 
The patient should be kept perfectly still in bed, and should not 
be permitted to leave the recumbent position for any purpose what- 
ever. Cloths wrung out of ice-water should be flapped upon the 
lower part of the abdomen, and, after remaining a few minutes, 
should be removed, and the part made dry by a warm napkin. 
The cold may then be applied as before, again to be followed by 
the drying and warming of the skin. The sudden injection of ice- 
water into the vagina or rectum may be resorted to when the ex- 
ternal applications fail. 
Cold applications in these cases are frequently mischievous 
rather than beneficial, because their mode of operation is not un- 
derstood, and they are hence used improperly. Cold is a powerful 
excitant of uterine contraction, when used in a sudden and tempo- 
rary manner ; but when it is applied continuously it soon loses its 
tonic power and becomes very depressing. 
Ergot is of great value in these cases. If obtainable, it should 
be given in doses of a half teaspoonful of the freshly-ground drug, 
mixed with water or table-syrup, every three hours ; or the fluid 
extract may be given in the same dose. If ergot be not at hand, 
or if the stomach should not retain it, gallic acid or tannin may be 
given in teaspoonful doses mixed with syrup. A strong infusion 
of cinnamon is also useful, although not so powerful as the other 
articles mentioned. If these remedies prove insufficient, the vagina 
should be plugged without further delay, in the manner already 
described. 
When contraction of the uterus has been effected by the fore- 
going means, it should be maintained, if possible, until the danger 
is past. For this purpose, firm pressure should be made over the 
enfeebled organ by placing a pad, made of a firmly-folded napkin, 560 
DISEASES PECULIAII TO WOMEN. 
above the pubic bone, and keeping it in position by means of a 
bandage pinned tightly around the body. 
The local causes of menorrhagia—when such exist—if not re- 
moved, soon produce hemorrhage from the uterus at times remote 
from the menstrual period and unconnected with it. This is called 
metrorrhagia. 
The treatment of these cases does not differ in any essential 
from that suitable for menorrhagia. In both classes of cases it 
is plain that, while the means mentioned may serve to moderate 
the flow during the attack, they can do no more than this ; and 
that, to prevent a recurrence, any existing local cause must be re- 
moved. Hence the necessity, in every case of persistent profuse 
bloody discharge from the uterus, of a thorough examination of 
the parts by a competent physician. 
Displacements of the Uterus. 
The womb is liable to be displaced from its natural position in 
a variety of directions. It may be pushed or drawn upward; it 
may descend ; its top may incline backward, forward, or later- 
ally ; it may be bent upon itself in any of these directions ; and, 
finally, it may be inverted, or, literally, turned “inside out.” 
Naturally, the womb has a considerable degree of mobility, and 
its upper portion may be pushed forward or backward by the vary- 
ing conditions of fulness or emptiness of the bladder and rec- 
tum. These temporary changes of position are not, however, 
what is meant by the term displacement. By it we understand a 
decided and comparatively permanent alteration of position. 
Prolapsus.—This term is used to denote that condition of the 
uterus in which it descends from its normal position in the pelvis. 
It is of very frequent occurrence, and is familiarly known as “fall- 
ing of the womb.” It is most common among women who have 
borne children, although the unmarried are occasionally subject 
to it. It varies in degree from the slightest appreciable depres- 
sion in the vagina to the complete protrusion of the organ from 
the vulva. 
The causes of the disorder comprise all the influences capable 
of increasing the weight of the uterus, weakening its natural sup- 
ports, or forcing or dragging it downward. 
The symptoms produced by it are usually proportionate in their 
severity to the degree of the displacement, but not always,—some 
women suffering more from a very slight degree of prolapse than 
others do with the womb dangling outside of the body. Women 
afflicted with falling of the womb suffer from a sense of weight DISEASES PECULIAIi TO WOMEN. 
561 
and dragging in the pelvis and back, tenderness in the groins and 
bladder, occasional swelling of the abdomen, an uncontrollable de- 
sire to strain unavailingly when emptying the bladder and rec- 
tum, pain extending from the groin to the lower limbs, leucorrhoea, 
etc. Together with these direct evidences of the displacement, 
there will usually be others of a sympathetic character, as lan- 
guor, depression of spirits, sleeplessness and other nervous symp- 
toms, pain in the side and back, dry cough, and derangement of 
stomach and bowels. 
In almost all the slighter grades of prolapsus, the uterus re- 
sumes its natural position so soon as the patient lies down and the 
weight of the abdominal contents is removed. 
Women frequently think 4‘the womb is coming down,” when, 
in reality, the sensation is due to the protrusion, in a greater or 
less degree, of the vaginal wall, dragging with it either the blad- 
der or rectum. When the uterus itself is the prolapsed organ, it 
may always be distinguished from other conditions by the pres- 
ence of the os uteri. 
Treatment.—Eelief may frequently be obtained in this affec- 
tion by the judicious use of astringents applied to the interior of 
the vagina, the walls of which being thus drawn together furnish 
increased support to the uterus. Injections of alum-water, or a 
solution of tannin, are among those most commonly used for this 
purpose. They should always be employed after the patient has 
lain upon the back for some hours, with the feet and hips elevated, 
for in this position the uterus is able to resume its normal place. 
In many cases the use of certain mechanical appliances, termed 
pessaries, is productive of the greatest comfort and benefit. If 
well selected and adapted to each particular case, they are some- 
times capable of effecting a perfect cure. The proper fitting of a 
pessary, is, however, a work of skill, and to do it requires a good 
deal of experience. When it is not skilfully done much injury 
may result to the patient, and a valuable means of treatment 
receive undeserved censure. 
In some very aggravated cases of complete protrusion of the 
womb, attended with loss of power in the vaginal walls and en- 
largement of its outlet, even pessaries are not adequate to retain 
the organ in position. In such cases various surgical procedures, 
having for their object the narrowing of the vaginal canal, have 
been employed, sometimes with gratifying success. These are 
especially indicated where the prolapsus is due to rupture of the 
perineum, an accident of frequent occurrence during difficult 
labors. 
Retroversion.—When the fundus of the uterus is turned back- 562 
DISEASES PECULIAR TO WOMEN. 
ward toward the lower portion of the spine, and the os uteri is 
thrown correspondingly forward and upward toward the pubic 
bone, the condition is known as retroversion. Like prolapsus, it 
is most commonly found among women who have borne children, 
or in whom the womb is enlarged from any cause. Hence, chronic 
inflammation and morbid growths connected with the womb—all 
of which produce increase of its size and weight—are likely to 
cause the displacement. Nevertheless, a retro verted womb is 
sometimes found to be even below the normal size. 
The symptoms of retroversion are frequently not referred by 
the patient to the uterus at all. Pain or difficulty in emptying the 
bladder and rectum, a dragging sensation in the groins and back, 
nausea and vomiting, and leucorrhoea, are among the most con- 
stant. 
Retroversion is generally complicated with inflammation or con- 
gestion of the uterus, and it is impossible in most cases to deter- 
mine whether these conditions are the cause or the effect of the 
displacement. But, whatever the relation may be of the one to 
the other, it is necessary in practice to consider both the disease 
and the malposition, otherwise all efforts to produce permanent 
relief fail. 
Treatment.—Rest, in the recumbent posture, together with in- 
jections of warm water, are likely to give relief from tho symptoms 
of pain and pressure; but most cases can only be satisfactorily 
treated by the replacement of the uterus and its retention in proper 
position by a suitable pessary. 
Anteversion.—This is the opposite of the condition just consid- 
ered. Here, the fundus falls forward toward the pubic bone, and 
the os uteri is carried up behind toward the upper part of the 
sacrum. 
The symptoms are such as are common to most of the diseases 
and displacements of the uterus:—pelvic pains, weight, sense of 
fulness, frequent micturition, etc.—and hence not at all distinc- 
tive. The displacement can only be determined by a vaginal ex- 
amination. 
Treatment.—This consists in removing all weight and pressure 
from above. The clothing should be worn loosely and supported 
from the shoulders ; the bowels should be kept in regular action 
by the use, if necessary, of mild laxative medicines. Rest on the 
back several hours in the day is beneficial, but should not be car- 
ried to the extent of impairing the general health. The congestion 
of the uterus, which is usually present, is best relieved by scarifi- 
cation of the cervix, a measure which can only be undertaken by 
a physician. DISEASES PECULIAR TO WOMEN. 
563 
Retroflexion and Anteflexion.—These terms signify, respective- 
ly, the bending backward and forward of the uterus upon itself; 
that is, the fundus only is displaced. These flexions differ from 
the versions of the womb in the fact that they imply, necessarily, 
some structural change in the organ. The same causes which 
might produce a retroversion or anteversion of a womb, with strong, 
healthy walls, would cause the organ to bend backward or for- 
ward if its walls were thinned or weakened,—the flexion being, of 
course, toward the weakest side. 
The symptoms are the same as are present in the versions of 
the womb — but with this addition, namely, that a flexion of the 
uterus, by narrowing the calibre of its canal, almost invariably 
causes pain during menstruation, and sterility. 
Treatment.—The treatment must usually be surgical. Certain 
forms of pessaries are capable, in some cases, of propping up 
the drooping fundus, and, acting as levers, of straightening the 
organ. But more commonly, when the fundus is thus raised in 
one direction, the os uteri follows ; that is, the bent ivomb is moved 
from its position, but remains bent. Intra-uterine stems of vari- 
ous kinds have been used for the purpose of correcting the deform- 
ity, and in many instances they have been successful. Their use 
requires great care, however, otherwise they may be productive of 
evil consequences. 
Other surgical means of cure, as dilatation, incisions, etc., have 
been employed, all having for their object the straightening of the 
organ and the enlarging of its canal. 
Polypus of the Womb. 
A polypus of the womb is an outgrowth of some portion of the 
uterine tissue, attached to the organs by means of a stalk or 
pedicle. 
Uterine polypi may occur at any time of life, from youth to ad- 
vanced age. They may be solitary, or several may exist in the 
same uterus at the same time. Their size varies from that of a 
pea to a large cocoanut. In structure they vary according to the 
portion of the uterine tissue which produces them; that is, they 
may be glandular, mucous, or fibrous. 
The symptoms are chiefly leucorrhcea, profuse periodical bleed- 
ing, and expulsive pain, aggravated at the menstrual period. 
These symptoms—especially the hemorrhage—bear no proportion 
to the size of the polypus, being sometimes greatest in connection 
with a growth quite insignificant in size. 
As a polypus increases in size, it has a tendency to pass out of 564 
DISEASES PECULIAR TO WOMEN. 
the uterus into the vagina ; and when it has done so it may be felt 
by the finger—being no larger perhaps than a filbert, or possibly 
sufficiently large to fill the vagina. In these cases the pedicle 
may be traced into or through the os uteri. The polypus is smooth, 
roundish, and insensible to pressure. If of large size, it may be 
confounded with prolapsus or inversion of the womb. But it may 
be distinguished from these conditions by remembering that, in 
prolapsus, the mouth of the womb may be felt at the lowest part of 
the mass, while in polypus, if felt at all, it is above, surrounding 
the pedicle, and that the inverted womb is sensitive to the prick- 
ing of a sharp instrument, while a polypus is not. 
When the polypus is still within the uterine cavity, its discovery 
and removal are much more difficult than when it has escaped into 
the vagina. If the mouth of the womb is sufficiently open, and 
the polypus descends low enough, as happens sometimes during a 
menstrual period, it may be felt by the finger introduced into the 
cervix ; but when this is not the case the os uteri must be dilated 
by artificial means,—preferably by the introduction of compressed 
sponge—and then the exploration can be made with great facility 
by passing a finger into the uterine cavity. And this should 
always be done when the cause of uterine pain, hemorrhage, and 
leucorrhoea cannot be otherwise clearly ascertained. 
Treatment.—When the presence of a polypus has been dis- 
covered, the proper treatment consists in its removal. This, of 
course, is an operation quite beyond the domain of domestic prac- 
tice, and need not here be described. 
Fibrous Tumors of the Womb. 
A fibrous tumor of the womb—called also uterine fibroid, fibro- 
ma, etc.—appears to be a local enlargement affecting some por- 
tion of the uterine wall, consisting of the proper tissue of the 
organ, and surrounded usually by an enveloping capsule of con- 
densed cellular substance or connective tissue. These tumors oc- 
cur during the period of greatest uterine activity,—that is, between 
the ages of fifteen and forty-five years. They vary in size, from 
the merest granule to enormous masses, weighing sixty pounds 
and upward. They occupy different portions of the uterine walls ; 
sometimes projecting externally, covered only by the peritoneum ; 
at others being immediately beneath the mucous membrane lining 
the interior of the uterus ; and, lastly, being imbedded deeply in the 
substance of the uterus. They may exist singly, or there may be 
several growing in different parts of the uterus at the same time. 
Fibrous tumors of the womb are of very frequent occurrence ; DISEASES PECULIAR TO WOMEN. 
565 
sometimes exist for years, and attain considerable size without 
their presence being suspected. 
Occasionally cysts or sacs containing fluid form in the substance 
of the tumor, usually when the latter has attained considerable 
size ; and to this form of the disease the term fibro-cystic has been 
applied. 
Symptoms.—The early symptoms are very obscure. The pa- 
tient, after suffering for some time from feelings of fulness and 
pressure in the pelvis, observes an enlargement or hard growth at 
the lower portion of the abdomen, movable, and more or less tender 
when pressed upon. The surface may be smooth or nodulated. 
The usual effect of fibrous tumors on menstruation is to increase 
the quantity of the flow; but this result is not invariable, and 
sometimes the amount is diminished. Another effect — and one 
which is constant—is to stimulate the uterus to increased growth, 
so that where a tumor, even of small size, is found, the uterus is 
elongated and enlarged. 
When the tumor has attained sufficient size, the patient suffers 
from pressure against the bladder and rectum, and, in addition to 
the distress attending the action of those organs, she is annoyed 
frequently with cramps, numbness, and swelling of the lower ex- 
tremities. When, as sometimes occurs, the tumor becomes too 
large to be accommodated in the pelvis, it rises into the abdomen 
and becomes prominent at the lowest part of the latter, and the 
symptoms of pressure to which the patient has been subjected are 
suddenly relieved. 
Treatment.—Many remedies have at different times come into 
vogue for the cure — that is, the removal — of these growths, and 
some of them with reputed success ; but it is now believed that 
they were powerless to produce any such result. Within a few 
years, however, a number of cases have been published in which 
a very great diminution in size, and, in some instances, the total 
disappearance of large fibroid tumors have occurred under the use 
of ergot administered by injection beneath the skin. Even when 
this desirable result was not attained, there was very generally a 
marked decrease in the amount of uterine hemorrhage, where this 
had been profuse, a lessening of pain, and an improvement of the 
general health. This mode of treatment should always be tried 
previous to the adoption of dangerous surgical measures. 
Sometimes relief may be obtained by elevating the uterus and 
propping it up by means of a pessary, and, when the tumor has as- 
cended above the pelvic brim, it may be supported by an abdomi- 
nal belt, and the symptoms dependent upon pressure thus greatly 
mitigated. 566 
DISEASES PECULIAR TO WOMEN. 
Under certain circumstances uterine fibroids may 
surgically; and, when other means have failed to relieve, and 
their removal can be effected without too great danger to life, such 
operations are justifiable. 
Ulceration of the Womb. 
By the term “ ulceration,” as applied to the womb, is properly 
understood a loss of some portion of the uterine tissue, especially 
of that portion of the organ which projects into the vagina. Judg- 
ing from the frequency with which the term is used, it would be 
reasonable to suppose that it was a disease of very common oc- 
currence. Such, however, is not the case; on the contrary, it is 
extremely rare. True ulceration of the womb is nearly always the 
result of either cancer or syphilis. Nevertheless, the conditions to 
which the name ulceration is commonly, though improperly, given, 
are quite frequent; and “ ulcers on the womb ” afford a lucrative 
field of practice for a host of illiterate and dishonest medical pre- 
tenders. These so-called ulcerations belong chiefly to three classes 
or conditions, namely : 
1. An Erosion or Abrasion of the Thin Delicate Covering of the 
Mucous Membrane around the Mouth of the Uterus.—This exposes 
the minute loops of blood-vessels, and they present a red and some- 
what granular appearance. This state of the parts usually results 
from, and is accompanied by chronic inflammation of the mucous 
lining of the interior of the womb ; and it bears a similar relation 
to the latter disease that a furred tongue does to a disordered 
stomach. Still, although not true ulceration, it is not without im- 
portance. If it be neglected or improperly treated, the erosion 
may extend into the cervical canal, or it may involve the greater 
part of the vaginal portion, besides being a frequent cause of leu- 
corrlioea, and occasionally of hemorrhage. 
2. Eversion of the Mucous Lining of the Cervix.—Where, from 
any cause, the os uteri is unusually open, the mucous membrane 
of the cervix becomes relaxed and congested, and protrudes from 
the os, presenting a red, pouting, wrinkled appearance. To any 
one not accustomed to the various changes of the parts produced 
by disease, this condition is extremely apt to be mistaken for 
ulceration. 
3. Laceration or Rupture of the Neck of the Womb.—This occurs 
as a result of child-bearing, and is much more frequent than is 
commonly supposed. It may be so slight in extent as to merely 
alter the shape of the os, or it may extend quite up to the vaginal 
attachment of the uterus. One or both sides may be involved. DISEASES PECULIAR TO WOMEN. 
567 
The effect of this accident is to permit the rolling away from each 
other of the anterior and posterior lips of the womb, thus allowing 
the mucous membrane within to become everted, as before men- 
tioned. 
Symptoms.—The sufferings of the patient afflicted with lacera- 
tion of the cervix are usually in direct proportion to the extent of 
the injury. 
The symptoms of this disorder commonly make their appear- 
ance shortly after the lying-in patient begins to walk about. They 
consist of a sense of weight and dragging about the pelvis and hips, 
a dull aching pain in the lower part of the spine, especially when the 
patient assumes the upright position, and leucorrhoea occasionally 
tinged with blood. In addition to these, there is frequently more 
or less pain in defecation, followed by a sensation as though the 
bowels were not entirely emptied. The bladder is also likely to 
become irritable through sympathy, and the patient is harassed 
with frequent desire to pass water. Soon the appetite fails, diges- 
tion becomes impaired, nutrition is imperfect, headache, sleep- 
lessness and other nervous symptoms supervene, and the patient 
becomes a wretched invalid. 
Treatment.—The abrasion of the os uteri, which constitutes the 
bulk of the cases of “ ulceration,” are treated more empirically 
perhaps than any other disorder of the womb. This results from 
the fact that the reddened, roughened surface is usually regarded 
as a disease of itself, whereas it is commonly an effect only of 
some antecedent condition. Thus, as already mentioned, it is often 
merely the sign of inflammatory disease of the canal of the uterus ; 
and, when this is the case, applications to the abrasion will be, if 
not useless, at least only temporarily beneficial. Again, it appears 
sometimes to be caused by the constant contact of irritating dis- 
charges which have either the uterus or the vagina for their source. 
Here, an essential part of the treatment consists in the frequent 
cleansing of the parts, and the protection of the raw surface from 
the further action of the irritant. But, usually, the treatment con- 
sists in exposing the os uteri with a speculum, and touching the 
eroded surface with lunar caustic—“ burning out the ulcer,” as it 
is termed. This process is repeated once, twice, or thrice a week, 
so long as the victim’s money and patience last. Occasionally this 
sort of treatment is successful; but much more commonly it fails, 
and the patient is left as miserable as before. 
In every case of this kind, the digestive organs should, if 
deranged, be restored to healthy action. Sufficient rest in the 
horizontal position should be enjoined to relieve the attendant 
congestion of the uterus. Vaginal injections should be used suffi- 568 
DISEASES PECULIAR TO WOMEN. 
ciently often to keep the parts cleansed from leucorrhoeal discharge. 
The uterus, if prolapsed or retroverted, should be supported in its 
normal position by a suitable pessary, which must not touch the 
diseased spot. Alterative applications of various sorts should be 
employed at intervals of five or six days. If inflammation of the 
cervical canal exist, this should be treated; and, if any other con- 
dition of disease, displacement, or anything calculated to produce 
or maintain uterine congestion, be present, it should be removed. 
Treatment based upon these principles will be found adequate to 
deal with all the usual forms of so-called “ ulceration but the 
particular means mentioned will be quite inefficient when applied 
to cases of eversion of the cervical mucous membrane, or lacera- 
tion of the neck of the womb. For both of these conditions surgi- 
cal treatment is indispensable. The operative procedures necessary 
for their cure are not at all dangerous, and should always be sub- 
mitted to by patients who are so unfortunate as to need them. 
Ovarian Tumors. 
The subject of ovarian tumors is too extensive to make it pos- 
sible to do more than merely allude to their more important fea- 
tures. They are divided into two classes : the solid and cystic. 
The former are quite rare, while the latter are very frequent. The 
cystic tumors are the only ones which we will consider. 
Cystic disease of the ovary, also known as ovarian dropsy, con- 
sists essentially in a degeneration of the ovarian tissue, and the 
formation within it of one or more cysts or sacs containing fluid. 
The tumors thus formed vary greatly in size, from that of a grape 
up to a mass weighing forty, fifty, and even one hundred pounds. 
They are not confined to any particular time of life, having been 
found in young children and in women past the climacteric. They 
occur most frequently, however, between the ages of twenty and 
forty years. 
The symptoms are at first extremely obscure. Commonly, the 
first indication the patient has of the existence of the disease is the 
discovery of a swelling at the lower part of the abdomen, gener- 
ally on one side. Pain, more or less marked, is usually felt in the 
tumor, or in the parts surrounding it, and there is sometimes diffi- 
culty in moving the leg of the affected side. The tumor may in- 
crease in size, either slowly or rapidly ; usually it is of rapid 
growth ; its surface may be smooth or lobulated. Its growth re- 
sults from the formation of new cysts, and also from the enlarge- 
ment of those already existing. 
The fluids contained in the cyst vary greatly in their physical DISEASES PECULIAR TO WOMEN. 
569 
characters, being sometimes thin and transparent as water, and 
at others thick and gelatinous as boiled starch or tar. In color 
they are white, yellow, green, brown, and all intermediate shades. 
The cysts may be no larger than a pea, or they may contain 
many pounds of fluid ; and their walls may be so thin and delicate 
as to rupture under the least pressure ; or they may be firm and 
dense, and half an inch or more in thickness. 
The general health of patients affected with ovarian tumors 
does not usually give way until the growth has attained consider- 
able size, although this is not always the case ; some seeming to 
suffer more from the presence of a tumor, the size of a child’s 
head, than others do when it has reached beyond the lower edge 
of the ribs. 
Occasionally there is much difficulty in distinguishing between 
ovarian tumors and other conditions which produce enlargement 
of the abdomen, as pregnancy, dropsy, tumors of the uterus, etc., 
and the highest degree of skill is required to determine between 
them. 
Treatment.—A great many remedies have at different times 
been employed for the purpose of causing the disappearance of 
ovarian tumors. They have all failed. The troublesome symptoms 
resulting from distention and pressure may be relieved by tapping 
the larger cysts and drawing off their contents; but the ameliora- 
tion is only temporary, and the operation is not unattended with 
danger. The only radical treatment consists in the removal of the 
tumor by surgical operation. 
Ovariotomy, although a dangerous operation, offers to the pa- 
tient whose life is threatened by advancing ovarian disease, the 
only chance of escape. Hence, so soon as the health begins appre- 
ciably to fail, the time for operation has arrived, whatever be the 
size of the tumor—provided that there be no other important organic 
disease present. An operation should not be delayed until the pa- 
tient's powers are well-nigh exhausted—an error frequently com- 
mitted both by the patient and the surgeon. Valuable time is lost 
in testing various remedies recommended by ignorant or inter- 
ested advisers, including drugs, liniments, plasters, bandages, 
mesmerism, electricity, and other inefficient means, some of which 
would not be injurious, but simply useless, if their employment did 
not involve dangerous delay. In the practice of experienced oper- 
ators fully two-thirds of the patients who undergo ovariotomy 
recover; and it is highly probable that even this favorable pro- 
portion would be increased if the operation were performed earlier, 
and not left, as it now too often is, as the last resort. 
A. REEVES JACKSON. Idiocy, and 
Nervous Diseases of Adult 
Life. 
BY 
ALLAN McLANE HAMILTON, A.M., M.D., 
OF NEW YORK CITY, 
CONSULTING NEUROLOGIST TO THE CITY INSANE ASYLUMS AND TO THE HOSPITAL FOR IDIOTS ; 
ATTENDING PHYSICIAN AT THE HOSPITAL POR EPILEPTICS AND PARALYTICS, 
ETC., ETC. IDIOCY. 
This term is quite inappropriately applied to a variety of mor- 
bid mental disorders which commence in early life, while, strictly 
speaking, its application should be limited to a condition which is 
congenital; that is to say, to a more or less undeveloped brain and 
a corresponding weakness or absence of the mind. Children, for 
instance, come into the world sometimes with three fingers in- 
stead of four, two heads instead of one, or without either arms or 
legs. When they are born with brains which are structurally defi- 
cient in parts or in quality, they are called idiots. It is true that 
there are conditions known as infantile dementia, or imbecility ; 
but these either follow other forms of disease, or are directly pro- 
duced by a variety of causes, to be alluded to hereafter. 
A weak-minded child may therefore be either an idiot, an im- 
becile, or may be simply the possessor of what has been called 
the insane neurosis ; consequently the shades of mental feebleness 
vary to a very great extent, and in some cases the child may 
present peculiarities which cause people to call it “queer,” “odd,” 
“ silly,” or weak-minded ; or its absence of intelligence will call 
forth still more expressive adjectives. An idiot, therefore, comes 
into the world with its unhappy heritage, while the imbecile or 
demented is unaffected until the onset of the nervous disease 
which destroys its brain and mind. 
The children with the insane neurosis are not necessarily idi- 
ots, but in many instances begin a life of misery with an inheri- 
tance of the most unfortunate character. In early life their lot 
is one of trouble, and in adult life they are quite likely to become 
insane. These are the children in whom lying, petty thieving, 
and cunning (which by some thoughtless and unprincipled persons 
are supposed to be evidence of “smartness”) are expressions of 
an inherited propensity for wrong-doing, and the perceptions of 
right and wrong are more or less blunted. Such children are 
highly emotional or irritable. They laugh and cry immoderately 574 
IDIOCY. 
under the most inconsiderable stimuli. They smile or laugh when 
they should be serious, and are very apt to take unreasonable pre- 
judices. At an exceedingly tender age they are able to perform 
certain mental feats which seem wonderful. They often display 
a precociousness which is striking; being able to master poetry, 
or recite long pieces. It will be found, however, that they are 
far behind other children of the same age in reasoning and think- 
ing ability, and they are usually devoid of judgment, or compre- 
hension of matter with which they should be reasonably familiar. 
They are unusually fond of music and rhythmical sounds, and learn 
to play and sing at an early age. Among such children convul- 
sions, chorea, or St. Vitus’ dance, and other nervous troubles are 
not uncommon. As they grow older there is a manifest disincli- 
nation to study or to apply the attention. Among other children 
there is a high degree of stupidity which is noticeable almost from 
the time of birth. If this is associated with certain malformations 
of the head, we have reason to suspect idiocy. 
The peculiarities in the shape of the head of the idiot are the 
following : an unusually small head, flattened anteriorly, so that 
it has an ape-like shape. Its average circumference is about thir- 
teen inches, while that of the normal head is never less than eigh- 
teen or twenty inches. This small development (microcephalus) 
is supposed to be due to premature union of the bones of the skull. 
There are other evidences of non-development which are 
striking and should be taken into account, and the first in impor- 
tance is the change in the appearance of the teeth, which are 
irregular both in shape and arrangement, and quite liable to de- 
cay. The gums are spongy and bleed readily, and the first set of 
teeth are shed at an unusually early period. The upper jaw pro- 
trudes, and, when the mouth is open, presents the appearance seen 
in the horse or other animals possessing a prehensile jaw. The 
lips are usually full and thick, especially the lower, and are clum- 
sily managed, so that saliva trickles from the corners of the 
mouth. The roof of the mouth will be found to be altered in 
shape, it being vaulted, quite narrow, and often containing fissures. 
The tongue is quite long and large, is furrowed, and, like the lips, 
is under imperfect mental control. The eye-balls, as a rule, aro 
prominent, fishy, and devoid of expression, and such ocular defects 
as strabismus (the condition known as cross-eye) are common. 
Various deformities—which, however, must not be confounded 
with those of paralysis occurring during early life—are met with. 
Children possessing these faults of configuration are sometimes 
unable to walk, but, when held up, scrape their toes over the floor 
in a spasmodic manner. The skin is usually of a “ muddy ” color 575 
IDIOCY. 
and very much wrinkled, so that a prematurely aged expression is 
presented, while the muscles lack power and are poorly nourished. 
Certain peculiarities of this kind have led students of anthropo- 
logy to divide idiots into certain ethnological groups, from their 
appearance, arguing that the idiot is but a type of a degenerate 
process, and that he bears a more or less close resemblance to 
some one of the lower great race divisions. There is always, ac- 
cording to Darwin and others, a retrocession toward the original 
type ; for instance, according to this observer, certain subjects 
present the Ethiopian type, for though they may be the children 
of white parents, they have high cheek-bones, puffy lips, crinky 
black hair, but the skin is not necessarily black. Others resemble 
the Malays, and have large mouths, prominent upper jaws, black 
curly hair, etc. In others are contained the elements which make 
up the Mongolian physiognomy, while a fourth class present the 
characteristics of the American Indian. Any one familiar with 
the appearance of idiots in large institutions can hardly help being 
amazed at the striking resemblances of this kind. 
So low is the development of some of these unfortunates, that 
they are little more than vegetables in their modes of life. They 
but eat, drink, and sleep ; are confined to their beds, and their hab- 
its are of the filthiest description; they are indeed little more than 
automata. In other subjects, and in adult idiots, this automatism 
is seen to perfection. Their childish amusement is of the most prim- 
itive kind ; a piece of bright tin and a button or two or piece of 
string affording perfect contentment. An idiot will sit for hours 
and days drawing the string through his hands, or arranging 
his buttons. Many idiots and imbeciles are totally blind, and in 
some cases deaf-mutism is associated with the other defects. 
The existence of a varying amount of intelligence is the rule, 
although such mental action may be of the lowest order, and 
hardly to be called forth by the effort of the physician or friends of 
the idiot. Certain forms of very high intellectual action may be 
displayed, while in other things the individual is little more than 
one of the lower animals. A case is related by Dixon, which 
illustrates this most perfectly: 
“ A lad, who had not sufficient power of reason to avoid danger, 
and who was usually listless, though at times mischievous, and 
always requiring surveillance, could yet calculate correctly any 
number of figures without the aid of memoranda. He was asked 
one day by a gentleman, who had made a calculation on paper, the 
number of days that had elapsed since the creation, calculating 
the date of the creation as 4000 years before the establishment of 
the Christian era. The lad almost instantaneously gave answer, 576 
IDIOCY. 
to which his questioner objected. The idiot then asked to see the 
memorandum, and pointed out that his examiner had omitted to 
enter the leap-years into his calculation ; and this extraordinary 
intelligence occurred in an individual who would hardly have been 
able to distinguish between sugar and sand, had they been put into 
his mouth.” 
Unusual Forms of Idiocy. 
Two peculiar forms of idiocy are mentioned by medical writers. 
One of these is Theroid Idiocy, in which the physiognomy and be- 
havior of the idiot resembles that of some of the lower animals. 
Children may resemble sheep or monkeys, and in manner and ap- 
pearance suggest this peculiar degeneration. 
Cretinism, in which there is goitre and bodily deformity in ad- 
dition to the intellectual impairment, is peculiar to some parts of 
Switzerland, and is supposed to be due to atmospheric or soil influ- 
ences, which, as yet, are shrouded in mystery. 
Imbecility of early origin is a condition dependent upon exten- 
sive primary brain disease. It may follow infantile convulsions, 
softening of the brain, and hydrocephalus (water on the brain). In 
the latter instance the size of the head is usually greatly increased. 
The intellectual condition and the capacity for development 
vary greatly. Many imbeciles are able to go about by themselves, 
but are nevertheless occasionally dangerous and homicidal, as 
they are totally lacking in moral sense. Such individuals are very 
often suicidal, or are disposed to be mischievous and troublesome. 
In large institutions they display destructive tendencies, tearing 
their clothing, breaking windows or furniture, and occasionally set- 
ting fire to their bedding. Like idiots, their personal habits are ex- 
tremely filthy. They eat voraciously, and sometimes choke them- 
selves by stuffing their mouths full of food. They may be taught a 
great deal, but it is not possible to carry the mental training so far 
as with the idiot. Basket and mat making, farm work and shoe- 
making are sometimes learned, while many imbeciles, who were 
supposed to be unteachable, have become really good musicians. 
Both idiots and imbeciles are found in whom the power of 
speech is lost, or very much limited, although this is more com- 
mon in idiocy. In such cases the power of communication by 
speech is limited to but a few words, though it is possible to teach 
many of them how to speak. A form of such disturbance, which 
is extremely interesting, is known as echolalia. The person, when 
spoken to, will invariably repeat the last two or three words of the 
sentence addressed to him. When asked, “ How do you do ? ” he IDIOCY. 
577 
replies, “ —do you do ; ” or, “ Did you have enough to eat to-day ? ” 
answers, “—enough to eat to-day.” Though asked numerous 
questions, he always replies in this manner, and does not talk of 
his own accord in any other way. 
The imbecile, as a rule, does not present any of the deformities 
of the teeth or jaw which are so conspicuous in the idiot. If the 
configuration of the skull is changed, it is, as I have said, larger 
than it should be. In a great many examples there are physical 
deformities which are the result of brain disease. In some cases 
the limbs are bent and twisted as a consequence of paralysis, and 
the face is paralyzed in others. Some imbeciles are stunted in 
growth ; though this, by no means, always happens. 
Infantile dementia, which is closely allied to imbecility, but in 
which there is usually a much lower grade of mental power, may 
follow exposure to the sun, drugging by narcotics, certain forms 
of wasting disease, and head injuries received in early infancy. 
Causes.—The two most important causes of idiocy are mar- 
riages among relatives and intemperance. Dr. Howe, of Massa- 
chusetts, Downs, of England, and others, have shown that the mar- 
riage of first cousins results very frequently in the production of 
degenerate progeny. At least eighteen per cent, of these children 
are idiotic, and the proportion is undoubtedly larger when the stock 
is bad, i. e., when there is nervous disease on both sides, or chronic 
alcoholism. Insane or weak-minded women are very apt to bring 
into the world feeble offspring ; and this transmission is more com- 
monly from the mother’s side than from the father’s—that is to say, 
the union of a weak-minded father and a healthy mother will not 
be so unfortunate as one of a father with normal mind and a 
weak-minded mother. Downs’ statistics are the following : 
“ Marriage of cousins : 20 marriages produced 138 children, i., e., 
6.9 each. Of the 138 children, 75 had health and intellect; 11 
were consumptive; 8 were still-born ; 4 died from convulsions or 
fits ; 2 were hydrocephalic ; 7 died young from infantile com- 
plaints ; 6 were puny and delicate ; 25 were idiots. Total 138.” 
The downward tendency which follows a combination of vice 
and inter-marriage is thus summed up by Morel, and quoted, as 
follows, by Dixon : 
“In the first period—the first generation—there is alcoholism 
and immorality. In the second, hereditary drunkenness, maniacal 
outbursts, and general paralysis. In the third, sobriety, homicidal 
mania, melancholia, confirmed mania, homicidal tendencies. In 
the fourth, feeble intelligence, stupidity, early mania, idiocy, and, 
finally, extinction of the stock.” 
The influence of intemperance in the production of idiocy is 578 
IDIOCY. 
too powerful to be disregarded. Prevost has proved that, in three 
generations of drunkards, a primarily healthy stock will run out, 
and that the children of the second generation will be, many of 
them, idiotic and insane. 
It is rare that idiotic or imbecilic parents bring into the world 
any issue, especially so in regard to idiots. Instances are, how- 
ever, related, one by Lucas, of a child born of idiotic parents. 
This “ child was left among the cows in the stable, and acquired 
the habit of ruminating like them.” (Bucknill & Tuke.) Esqui- 
rol has seen two cases of this kind, and another case is reported 
in which an idiot married a healthy woman who gave birth to an 
idiotic child as the fruit of the union. 
Treatment.—Idiots are good-tempered, and, as a rule, get along 
very well together, and the vicious subjects are chiefly imbeciles 
or idiots in whom epilepsy is a part of the trouble. 
Saegert, of Berlin, and Maxwell, of Earlswood Asylum, Eng- 
land, speak of the good results of the association system and the 
beneficial results of discipline. The latter says : “As to the cases 
we have in the asylum, I think I may say that they all have 
improved more or less. Kind treatment, good diet, and attention 
will improve the most helpless cases. Many that came in dirty, 
irritable, etc., not only become cleanly, but get to speak intelli- 
gently, to dress themselves perfectly, and make themselves useful. 
Other cases will do a great deal in the school; for instance, we 
have a case which came in spiteful, obstinate, and unable to read 
and write. Now he reads well, writes well, also writes from dic- 
tation, draws very nicely, can sing several songs, can play on the 
harmonium, and can drill, which has made him walk upright. 
He has latterly been in the mat-making shop, and can make the 
best part of a mat. Another boy has improved in all the above, 
and is learning mat-making. He possesses, perhaps, the most 
intellect of any of the boys, but I cannot say that I think he will 
ever be like an ordinary person. The cases most favorable are 
those between seven and twelve, which are healthy, can speak, 
and are free from fits and paralysis.” 
This is the experience of others. In the Idiot Asylum on Ran- 
dall’s Island, New York, there is a well-conducted schoolliouse 
where cleanly and well-dressed children may be found reciting, 
singing, and sewing. Many of them were apparently helpless 
idiots—the children of the streets—who were not only neglected 
by their drunken parents, but left to die in the gutters. Many 
may be raised to a condition which will enable them at least to 
support themselves. 
The management and improvement of weak-minded children IDIOCY. 
579 
must depend greatly upon the form of mental disease. Idiocy 
may in many instances be treated with some degree of success, 
and even imbeciles may be taught to do many things which at 
first seem impossible. These patients are better taken care of, 
and are more susceptible to good influences, when they are with 
others afflicted in a like way ; for this reason asylum treatment is 
better than any other. There seems to be a mutual dependence 
upon each other. It is most injudicious to neglect a child of this 
kind, to keep him shut up, or to deny medical treatment, simply 
because he has been pronounced idiotic. It is by far the more 
wise course to place him in a good institution. If this is not pos- 
sible, the parent must exercise the greatest patience and forbear- 
ance in home education. 
The teaching of gymnastic exercises should form a prominent 
part of the education of weak-minded children. In many idiots 
there is an inability to perform the simplest acts, and it is possible 
to teach them to use their arms and legs. Among the apparatus 
for gymnastics employed at institutions is the ladder, which the 
child is taught to climb. He is first suspended by his hands, but, 
by constant encouragement and the semi-involuntary use of the 
limbs, required to prevent himself from falling, he gradually learns 
to climb. 
Various other light forms of calisthenic exercises are in vogue. 
One of these, used at the New York State School, consists in hurl- 
ing a light’stick or ball from one to the other. This simple act is 
well arranged to engage their attention. Amusements which ne- 
cessitate rhythmical movements are strongly advised, for they call 
into play and develop an emotional and low grade of intellectual 
mental action which afterward becomes increased. Light Indian 
clubs, rings, or dumb-bells, used in company with a number of 
other children who go through certain exact movements, while 
time is kept to the piano, are recommended. 
A variety of methods of education are suggested. These vary 
from the simplest course of the Kindergarten school to those of 
an advanced character. Colored beads may be used in a variety 
of ways. The children are to be taught how to form patterns and 
figures with these, to put differently tinted beads alternately upon 
a string, to arrange colored bits of paper and straw. Size and 
comparison are taught by “dissected” maps, or, in the beginning, 
by a board full of different-sized holes, into which the children 
are taught to thrust plugs, which are also of varying sizes. 
In the same way it is possible to teach them the forms of let- 
ters and their appearance together in words. Object teaching is 
of the greatest importance, and articles which they use, or are 580 
IDIOCY. 
surrounded by, should be resorted to ; for instance, the weak- 
minded child is made to understand that its bread is white and 
soft. Other substances having the same physical properties are 
presented to them, and compared by the instructor, but the other 
points of difference are pointed out by him. 
Gentleness and patience, but earnestness of purpose, and sys- 
tematic treatment, are requisite for the teacher. He should stir 
up the slowly-working mind, and, as much as possible, supply the 
will needed by his weak subjects. 
It would hardly do to finish this chapter without some hints as to 
the management of children who are neither idiotic nor imbecile, but 
merely the possessors of the insane neurosis. A child of this kind 
is a care indeed, for, unlike the idiot, there is enough will, unbal- 
anced emotion, and perverted moral sense to give rise to constant 
annoyance. Strict discipline without violence and the formation 
of regular habits are the desiderati which must be accomplished 
before anything else can be done. The daily life of such a child 
should be characterized by the greatest regularity and system. 
He should eat, sleep, study, and play at stated times when it is 
possible, and nothing should be allowed to interfere with this mode 
of life. 
As to study, it will be found, if there is not a sufficient amount 
of brain-work and application, that various mental vices will be 
formed. The study, however, should be of the simplest kind and 
well arranged and graded. Such a child should not be sent to 
school until after the seventh or eighth year, and for three or four 
years or more it should not be permitted to devote its attention to 
more than three or four elementary branches. 
Its diet should be light and nutritious, and fatty foods, easy of 
digestion, are to be given in moderate quantity. Sleep to the 
amount of ten or twelve hours should be obtained if possible, and 
cold bathing and friction should be used in the morning. 
Above all, the child should be guarded against influences which 
might shock its highly sensitive nature. Rough and unthinking 
companions, and bad tempered or rude playmates, should be kept 
away from him, and, when the tender period of life which pre- 
cedes the tenth year has elapsed, he should be sent to some good 
school where there are not more than a dozen other scholars. 
ALLAN McL. HAMILTON. M.D. NERVOUS DISEASES OF ADULT 
LIFE. 
There is a strong predisposition to nervous diseases among 
certain individuals, especially those who are the descendants of 
persons who have been either insane, epileptic, or paralytic, or 
who have been the subjects of consumption. The possessors of 
the “nervous temperament,” or nervous diathesis, described in the 
article upon Idiocy, are especially subject to nervous disease, while 
the phlegmatic individual is more liable to other diseases, as a 
rule. Nervous disease is to be looked for among those who in- 
dulge to an excessive degree in mental labor, or who have con- 
tracted bad habits and vices. 
The diseases to which I shall allude are more common in the 
adult, though they may appear in early life. 
Cerebral Congestion. 
Cerebral congestion, or hypersemia, is a disease not entirely 
confined to any age, and is usually dependent upon general disease. 
As a rule, the patients are adults, and more often men than women. 
The special symptoms are fulness of the head, flushing of the face, 
a sensation as if the head were confined in a tight band. The suf- 
ferer complains of “ roaring,” or “noises in the ears,” and very often 
sees bright or dark specks, or motes. There is a sense of pressure 
behind the eyeballs, and the eyes are red and watery. Headache 
is a constant symptom, and the patients are troubled with loss of 
memory, irritability, and general restlessness. They are often 
low-spirited, and mental action is obscured and slow. Sleep is 
troubled, and disturbed by dreams. The skin, especially of the 
face, is puffed and red, and at times the vessels of the temples 
stand out prominently. 582 
NERVOUS DISEASES OF ADULT LIFE. 
In the course of cerebral congestion, there are sometimes at- 
tacks, which may be of three different kinds: 
1. The Congestive Apoplectic Attack.—The patient, after suf- 
fering in the way described above, may suddenly fall to the 
ground. His face is congested, and he breathes heavily. He be- 
comes unconscious, and so remains for a short time, but regains 
control over himself in a few minutes. He is confused and dazed 
after the attack, and speaks with difficulty. There may remain, 
for a short time, a slight paralysis of one side. 
2. The Maniacal Attack is characterized by a sudden seizure, 
during which the individual becomes excited and violent, and for 
a short time may be entirely insane. 
3. The Epileptiform Attack, which resembles very much an 
ordinary epileptic fit, only with its subsidence there is some mani- 
acal excitement. 
A form of congestion of the brain, known as passive hyperce- 
mia, is connected with an accumulation of venous blood in the 
vessels of the brain. The patient is heavy and stupid, falls asleep 
readily, and suffers from unusual torpidity of mind. 
The tendency of congestion of the brain is towards severe or- 
ganic disease, and such a condition is often followed by the rup- 
ture of a cerebral blood-vessel, and more or less permanent par- 
alysis. (See Hemiplegia.) 
Causes.—The disease may result from any cause preventing a 
return of blood from the head, or a determination thereto. Among 
these may be mentioned the bad habit of wearing tight neck-gear, 
the use of stimulants, exposure to the sun, or overwork of any 
kind. An enlarged heart often exists with congestion of this 
character, and the coexistence of liver troubles of various kinds 
is not uncommon, especially in middle-aged people. The stoppage 
of any natural flux will act as a cause ; for this reason, we find 
cerebral congestion in women who suffer from dysmenorrhoea. 
Malarial poisoning is responsible for much trouble of this kind. 
Treatment.—The removal of the exciting cause is of the first 
importance, and next to this the patient should be required to lead 
a quiet life. Stimulants are only good in passive congestion. 
Cold applications to the head, and the use of mustard foot-baths 
are useful in acute attacks. The constant use of moderate doses 
of the bromide of potassium (10 to 15 grains), three times a day 
upon an empty stomach, in a half-tumblerful of water, does much 
good, while the bowels should be kept open with saline purgatives, 
such as Rochelle salt or any of the bitter mineral waters. If 
the case is at all persistent, no time should be lost in consulting 
a physician. NERVOUS DISEASES OF ADULT LIFE. 
583 
Cerebral Anaemia. 
When the brain is deprived, to a greater or less extent, of its 
blood, a condition is produced which has received the above name. 
Acute cerebral anaemia is the form which accompanies shock, 
an ordinary fainting attack, or general loss of blood. The face 
then becomes pale, the pupils dilated, and there is partial or com- 
plete loss of consciousness. The pulse becomes small and thready 
as the heart’s action is markedly interfered with, while the sur- 
face of the body is cool, and sometimes clammy. Respiration is 
usually sighing; and if the shock be sufficient, it is stopped, and 
death results. 
The condition known as chronic cerebral anaemia, is, like cere- 
bral congestion, a symptomatic state. Certain losses of blood, 
such as result from bleeding piles, excessive flooding at the men- 
strual period, or other drains of the vital fluid, will be followed by 
improper supply and consequent failure in the nourishment of the 
brain. As a result, symptoms of headache, usually confined to the 
top of the head, with pressure, singing in the ears, sleepiness dur- 
ing the day, and insomnia or loss of sleep at night, weakness of 
vision, pallor, general lassitude and weakness, digestive disor- 
ders, constipation and palpitation, are quite common at some time 
or another. Women suffer more than men, and the trouble is 
usually aggravated at the menstrual period. 
Causes.—Any of the depleting causes already mentioned, as 
well as disease of the liver, overwork, and insufficient or improper 
food, will produce the disease, while gout and other constitutional 
diseases play no important part in its genesis. 
Treatment.—Medicines which tend to produce an improvement 
in the quantity and quality of blood and nerve-tissue, are used. 
Among these are iron, cod-liver oil, arsenic, and phosphorus, 
while nourishing, hearty food is to be given. Rare meat, game, 
poultry, with moderate quantities of red wine or beer, are abso~ 
lutely necessary. If the patient is sleepless, a glass of lager-beer 
may be given at night. If there be liver trouble or hemorrhoids, 
these conditions should be treated. Pills of podophyllum or man- 
drake are excellent when constipation attends the former, while 
bleeding piles should be treated by cold bathing of the parts, or 
by astringent applications, such as tannin. Uterine disorders 
often need attention which the patient herself cannot very well 
direct. 584 
NERVOUS DISEASES OF ADULT LIFE. 
Spinal Anaemia, or Spinal Irritation 
are conditions expressed by pain at the upper part of the spinal 
column, which is increased by pressure ; a sense of tightness or 
constriction about the body, feebleness of the limbs, neuralgic 
pains, weakened digestion, and indisposition to take exercise. To 
these are added constipation, and often the passage of large quan- 
tities of urine of a light color. Females suffer more than males, 
and there is usually a certain amount of associated hysterical 
trouble. 
Tonic treatment such as that suggested above, should be re- 
sorted to. Change of air and scene is important, and salt-water 
bathing is of valuable assistance. 
Headache. 
Headache is probably one of the most common symptoms of 
disease. It may appear in the course of nearly all of the fevers, 
eruptive and otherwise, in diseases of the brain or lungs, in diges- 
tive diseases, in disease of the heart or kidneys, or as a simple 
functional condition. In other parts of this book its symptomatic 
significance is alluded to where special organic affections are dis- 
cussed. We will here glance briefly at it in connection with some 
two or three of the diseases which give it origin. 
Sick headache, the most familiar form, and known to most of 
the readers of this work, is a species of neuralgic disturbance. It 
is ushered in by faintness, chilliness and pallor, general discom- 
fort, and pain of a paroxysmal character. One side of the head is 
usually involved, and when the pain becomes severe, the face be- 
comes flushed and anxious. After a variable time, extending 
from an hour or so to a day, the pain finally becomes associated 
with nausea, the individual makes attempts to vomit, but does 
not always do so, and the attack wears itself out. The pain is 
dull and throbbing, and every beat of the heart causes untold 
misery. Usually lying down increases the pain, and the patient 
assumes an upright position for relief. 
Disorders of the stomach are connected with this as well as 
other forms, but in this kind of headache the gastric trouble is a 
result, not a cause. In the so-called “bilious headache,” the 
pain is diffused over the head, and there is browache of an intense 
character, and vertigo. For some days before, constipation or in- 
digestion have existed, and the stools are either dry and contain 
hard balls, or are clay-colored through deficient supply of bile. 
Among delicate women there is a form of headache which is NERVOUS DISEASES OE ADULT LIFE. 
585 
worse on awaking, and seems most intense on top of the head. It 
is connected with general debility, backache, some uterine trouble 
as a rule, painful menstruation, etc. In hysterical women, there 
may be soreness of the scalp so that contact with the pillow is ex- 
cessively painful. In such cases, there is the feeling of a lump 
rising in the throat. Malarial headache, which may or may not 
be periodical, is usually dull, and connected with pain at the back 
part of the head. It is common among those who have lived for 
a short time in a malarious district, and with it there may or may 
not be a history of chills, vague pain in the bones, or gastric dis- 
turbances. Constipation will frequently give rise to a headache 
of severe character, and often it will be found in such cases that 
there are hemorrhoids or piles. 
The use of certain drugs, such as opium, chloral, or alcohol, 
will cause headache, usually of a congestive nature. 
Disease of the kidneys will often be attended by headache of 
an intense character, and is a dangerous symptom. There is, at 
some time or other, backache—the pain being just below the ribs, 
and not in the “ small of the back.” The urine, when heated, 
and treated with a few drops of nitric acid, will be found to 
contain a white cloud of albumen, though this is by no means a 
certain discovery. The skin has a white, puffy appearance, and 
pressure of the fingers over the skin leaves a dent in the tissues 
of the legs. This headache may be the precursor of convulsions. 
Organic disease of the brain, such as tumors or softening, is 
often expressed by pain confined to any part of the brain, but is 
limited. It may, in some cases, be localized, if the skull or the 
membranes of the brain are the seat of disease. With tumors, the 
pain is often paroxysmal, and very intense. Gout and rheuma- 
tism very often give rise to headache, and this may be connected 
with tenderness of the scalp. It is worse at night, and some- 
times is dependent upon rheumatic meningitis [inflammation of 
the membrane covering the brain], which is a serious disease, and 
should be looked upon with alarm. Last of all, may be mention- 
ed syphilis, which, during its tertiary stage, may give rise to great 
suffering. Such a headache is worse at night, and very obstinate. 
Treatment.—The management of sick-headache is a trouble- 
some matter, that is, so far as the patient himself is concerned. 
There are two or three excellent remedies, however, which relieve 
a certain number of cases. If these fail, the patient should con- 
sult his physician. Guarana powder, in doses of thirty to sixty 
grains, in water, given every hour, until five or six doses are taken, 
is the best of these agents. The muriate of ammonia is also of ser- 
vice in stopping an attack, and twenty grains may be administered 586 
NERVOUS DISEASES OF ADULT LIFE. 
in the same way. The bromide of potassium or sodium, in doses 
of fifteen or twenty grains, will often break up a light headache. 
The use of cold applications to the head often does good. 
For the morning headache of anaemic people, a cup of coffee or 
tea, taken on arising, is the best domestic remedy, while some form 
of iron should be administered regularly, with nourishing food and 
a moderate quantity of stimulants. When a suspicion of malaria 
exists, quinine should be resorted to. No time should be lost in 
consulting a physician, when one can be had, should there be any 
evidence of kidney trouble ; if none is within reach, hot-air baths, 
with sweating beneath blankets, and free action of the bowels 
obtained by the use of calomel and compound jalap-powder in 
twenty-grain doses, are recommended. In organic disease of the 
brain no domestic treatment will be of avail. In hysterical head- 
ache a dose of a teaspoonful of the ammoniated tincture of va- 
lerian in water will do much good. 
Above all things, the stomach should be rested, and never 
abused. Errors in diet may lie at the bottom of all the mischief. 
In nervous subjects this is especially the case, and with them ner- 
vous excitement of all kinds is to be guarded against. Emotional 
excitement, mental overwork, or fatiguing occupations are to be 
avoided. 
Giddiness. 
Giddiness or vertigo is always a symptomatic condition, and 
caused by digestive disturbance, altered conditions of the circula- 
tion in the brain, and a variety of other causes, such as malaria, 
exposure to the sun’s rays, hemorrhage, disease of the ear. or 
organic disease of the brain. 
Digestive disorders are most commonly the causes of vertigo, 
and the patient generally complains of his distress after a hearty 
meal. There is a sense of great fulness, sometimes eructations of 
wind, buzzing or other noises in the ears, and dizziness which lasts 
for a few moments, during which the patient may lose his balance 
and fall. The person may see bright specks or clouds during the 
continuance of the giddiness, but they do not occur when the head 
is lowered. Elderly people suffer more than do those of any other 
age, and persons fatigued by overwork, intellectual or physical, 
are quite subject to the disorder. Any stoppage of a natural flux, 
obstinate constipation, or exercise immediately after eating, may 
produce vertigo. When the giddiness is associated with conges- 
tion of the brain the face is flushed, and the arteries of the temples 
are distended. Giddiness of this latter kind has always a danger- "NERVOUS DISEASES OF ADULT LIFE. 
587 
ous significance, and no time should be lost in consulting a medical 
man. It is met with in women at the two critical periods of life, 
when it is of less importance as a symptom than when it occurs in 
the male subject, particularly if he has passed middle age. Giddi- 
ness dependent upon insufficient blood-supply of the brain, is asso- 
ciated with faintness, pallor of the face, sighing respiration, and 
weak pulse. The ordinary fainting attack is of this variety, and 
in women subject to such “ giddy turns ” there is usually backache, 
irritability, pain in the side, menstrual disorder, and disturbed and 
weakened digestion. 
Disease of the deeper portions of the cavity of the ear may be 
connected with a very serious form of giddiness or vertigo. There 
is often a discharge of matter from the ear, and more or less pain, 
or there may even be nothing of this kind. The individual sud- 
denly becomes very dizzy, and turns usually from left to right, 
while surrounding objects become hazy and indistinct. He may 
have many of these attacks, and the chance of getting well de- 
pends much upon the condition of his ear-disease. 
Certain grave diseases of the brain, such as tumor or softening, 
are not rarely symptomatized by giddiness. There are, however, 
other difficulties of a serious character, such as convulsions, head- 
ache of a severe character, disturbances of locomotion, paralysis 
or tremor, or other troubles of movement which may cause it. 
Besides the causes enumerated, tobacco, used in inordinate 
quantities, will give rise to serious giddiness, great prostration, 
fleeting pains in the chest, palpitation and irregular action of the 
heart, sleeplessness, and defective mental action, expressed by 
feebleness of thought, impaired memory, and restlessness. 
Numerous conditions enter into the production of the symp- 
tom besides those just mentioned, but it must be remembered that 
they all tend either to congestion or depletion of the brain; and 
powerful among these are malarial or other poisons, or exposure 
to the sun. 
The treatment of giddiness depends very much upon its origin. 
In many cases simple attention to the commonest laws of hygiene 
will be followed by relief. Regularity and moderation in diet, the 
avoidance of active exercise after eating, moderation in the use of 
tobacco, or abstinence when its use is attended by “ nervousness ” 
or uneasiness, are often followed by subsidence of this disagreeable 
symptom. If there be hemorrhage of any kind, either from hemor- 
rhoids or other diseases, medical aid should be promptly sought. 
If the person be of sedentary habit, there should be more exercise, 
sea-bathing, or walks in the open air. Overuse of the brain, through 
any kind of mental work, should be guarded against, and the neck 588 
NERVOUS DISEASES OF ADULT LIFE. 
should be unconfined by tight collars or neck-gear. It is unwise 
also to sit beneath a hot gas-jet, or to wear the hat too constantly, 
for, in fact, anything which tends to keep the head hot is very bad 
for the patient. 
If the trouble be connected with headache or paralysis, disturb- 
ance of vision, tremor, or other grave symptoms, the individual 
should lose no time in consulting his physician. 
Sleeplessness. 
No deprivation can possibly equal that of loss of sleep, so 
fraught is it with mental and physical exhaustion. Sleeplessness 
or insomnia is connected with a number of disorders, and may 
either be a symptom of disease well recognized, or a temporary 
disturbance, but in all cases there is more or less congestion, or 
other disturbance of the blood-circulation of the brain. In some 
forms of dyspepsia it is closely connected with hysteria and gen- 
eral nervousness. In such forms of wakefulness the patients are 
seized with sudden and voracious hunger, a sensation of gnawing 
at the pit of the stomach and faintness. In other cases the sleep 
may be of such a character as to cause the individual to awaken 
in the morning quite unrefreshed. It is heavy, almost amounting 
to stupor, and disturbed by dreams. In other cases the patient 
lies awake for a long time after he retires, his brain being preter- 
naturally active, and ideas are evolved with startling rapidity. 
The senses are all acutely alive. Every sound is exaggerated 
and distorted by the individual’s excited imagination. The head 
is hot, the heart beats violently, the feet are cold, and he tosses 
from side to side. This form depends usually upon overwork and 
mental excitement. The impression of some disagreeable idea, or 
some anxious care, will cause such a person great misery. He 
starts violently, or awakes again and again. The stupid, heavy 
sleep previously spoken of, depends usually upon a hearty meal 
taken just before going to bed. A close, badly-aired room, or one 
in which the plumbing arrangements are bad, will produce wake- 
fulness, and, as a result, a headache follows in the morning. 
The wakefulness of children has been before alluded to [see 
Yol. I.]. 
Various forms of troubled sleep, connected with somnambulism 
and nightmare, etc., are too familiar to need description. [See 
Yol. I.] Exposure to the sun during the daytime will often give 
rise to headache and sleeplessness, which are sometimes the pre- 
cursors of disease of the brain. In fact, if wakefulness is con- 
nected with other nervous symptoms which are manifested for NERVOUS DISEASES OF ADULT LIFE. 
589 
some time, we have reason for alarm. There is no rule which can 
be laid down as arbitrary regarding the amount of sleep required 
by any individual. Old persons do not require as much as those 
of younger years, so it is a natural consequence to find that people 
of advanced life awaken at an early hour in the morning, while 
children whose nervous system is being developed must have 
ten or twelve hours sound sleep. 
Treatment.—As sleeplessness so often depends upon a congested 
condition of the brain, it will be well to examine into the causes of 
such a condition. Mental labor has been spoken of as being a 
cause of this kind. In such cases work should be put aside an 
hour or two before bedtime and agreeable diversions resorted to. 
Sometimes when the individual has spent his time reading be- 
neath a glaring gas-jet which heats his head, it will be found that 
if he seeks a seat away from the light, or if he bathes his head in 
cold water, the evil consequences may be avoided. A brisk walk, 
or gymnastic exercises of a moderate kind before bedtime will so 
equalize the blood pressure as to relieve the excited and congested 
brain. In some cases where there is excessive sluggishness of ideas, 
and stupidity lasting through the evening, a glass of ale or beer 
before retiring will secure refreshing sleep. Bad ventilation is a 
very important cause of sleeplessness, and the windows of the bed- 
room should be opened even if the room becomes cold. Hearty 
meals taken late in the day or at night, cause, in some persons, a 
want of sleep, and therefore should be discontinued. In this con- 
nection I would call attention to the pernicious habit of drinking 
sweet beverages, or eating just before bedtime, so commonly and 
frequently indulged in by young persons and children. A cold 
bath is advised by Doctor Flint as a remedy which often accom- 
plishes much good, and may be tried in some cases. 
In old persons it will be found that a half-teaspoonful of Hoff- 
man's anodyne in a wineglassful of cold water will often bring 
refreshing sleep, but, as a rule, the use of anodynes is to be depre- 
cated. Tincture of lupulin, in teaspoonful doses, or the bromide 
of potassium in twenty-grain doses, are the least harmful of all 
drugs of this kind, but even these should not be habitually taken. 
In conclusion, a word of caution must be given to those who 
resort to opium or morphine for the production of sleep. The per- 
nicious effects which follow the habitual use of these drugs are 
deplorable. The “opium habit” is sure to be contracted in the 
majority of cases. Regulation of daily life, appetite, and diges- 
tion ; exercise in fresh air, and avoidance of excitement, are, after 
all, the best safeguards against sleeplessness. 590 
NERVOUS DISEASES OF ADULT LIFE. 
Alcoholism—Delirium Tremens—Chronic Alcoholism. 
The development of an immoderate appetite for alcoholic liquors 
is a most striking illustration of the facilis descensus, as the ap- 
proach to the point where the desire becomes a diseased manifesta- 
tion is so insensible and pleasant. The primary stimulation brings 
with it such a perfect intellectual sense of gratification: such a 
train of pleasant ideas ; such a play of lively fancy ; such a vivid- 
ness of imagination, that the resulting reaction makes a fresh 
resort to the agent of such great temporary happiness an easy 
matter indeed. Upon various individuals the action of alcohol 
differs greatly. In some cases there is an apparent exemption 
from its early stimulating effects, and the primary indication 
of poisonous influence is then profound stupor. This is due, in 
some measure, according to Richet and other writers, to the 
ability of the individual to exercise his will in preventing the mani- 
festation of morbid impulses founded upon disordered ideas. “ In 
those cases, will and attention, although diminished, have not en- 
tirely disappeared, and the will is even concentrated on the fear of 
intoxication.” 
Constant immoderate indulgence in alcoholic beverages is 
sure to bring about a condition of poisoning of the nervous sys- 
tem, which is shown by a variety of curious symptoms more or 
less grave. The first term is applied to an acute condition, but 
may be a feature of what is known as chronic alcoholism, which 
is a more serious disease, and continues, if the bad habit is fol- 
lowed, until softening of the brain or severe organic nervous affec- 
tions carry off the victim. Acute alcoholism, or delirium tremens, 
follows, generally, the excessive use of the stronger alcoholic 
liquors, but may appear after the sudden leaving off of spirits, and 
this form is common among sailors or soldiers deprived of stimu- 
lants, or it may occur in the midst of a debauch. In either case the 
outbreak of the disease is characterized by a period of excitement, 
hallucination, and excessive mental activity. The muscular system 
participates in the decline by expressions of feebleness. The hands 
shake tremulously, the patient is disinclined to take any exer- 
tion, and shuffles along in a demoralized manner. He is irritable 
and sleepless, and is at first dejected and sad. His face is pale and 
his eyes are red and bloodshot. Want of appetite, nausea, and 
constipation are complained of. and he finds it impossible to retain 
the simplest kind of food. The urine contains a heavy red sedi- 
ment which clings to the sides of the chamber-vessel, and if some 
of this urine is placed in a test-tube and heated it becomes clear. 
The first mental expression of the acute attack is deep depres- NERVOUS DISEASES OF ADULT LIFE. 
591 
sion. The individual believes that his friends have conceived a 
dislike and repugnance toward him, and he, in his own mind, is 
the most forlorn and wretched of his kind. Hallucinations and 
illusions are complained of. He sees imaginary reptiles and 
insects, vivid flashes of light, satanic imps, and hobgoblins. He 
has the morbid sensation that he is falling from a height; that ants 
are crawling over his skin, and that rats and mice are running over 
his arms and face. He becomes excited and maniacal, so that he 
can only be restrained by the greatest effort, and four or five strong 
men are required to hold him down. If he breaks away, he is 
liable to do himself and others personal violence through his de- 
lusions. He is destructive and tears his clothes, and breaks the 
furniture. Should he recover, he falls into a sound sleep, from 
which he awakes more or less refreshed, but is usually irritable 
and delirious. If a fatal termination follows the attack, he dies 
through exhaustion, for it is common to find that the patient 
neither eats nor sleeps for days, and his enfeebled strength is 
used up. 
A much more serious condition follows the constant use of alco- 
hol in quantities not sufficient to produce manifest drunkenness, 
but rather a depression of the nervous system, which, if continued, 
leads to all manner of organic changes. Tremor of the hands, 
more marked in the early morning, feebleness of both upper and 
lower extremities, entire numbness; or hypercesthesia, which is in- 
creased sensibility, in various parts of the body, are prominent motor 
and sensory troubles. To these may be added headache, confusion 
of ideas, loss of memory, and slowness of speech. He articulates 
clumsily, and substitutes wrong words. He becomes slovenly in 
his dress, neglects his business, his whole disposition changes, and 
he grows irritable if not brutal to those members of his family with 
whom he may be associated. This condition of affairs cannot last 
long. Softening of the brain, loss of mind, and gradual breaking 
down of the body and mind follow, and death comes as a relief to 
the poor shattered victim and his friends. 
This would hardly be the place to enter into the question of the 
physiological effects of alcohol; suffice it to say that the constant 
free stimulation of the brain is apt to lead to a pathological condi- 
tion due to continued contact of alcohol with the delicate tissues 
of the nervous system. In countries where beer or the light wines 
form a part of the dietary of the people, chronic alcoholism is 
quite rare, and drunkenness is equally so; but in England, the 
United States, and some of the colder countries, strong alcoholic 
compounds are much more plentifully consumed than the lighter 
beverages, and, as a result, alcoholic poisoning is far too common. 592 
NERVOUS DISEASES OF ADULT LIFE. 
This is especially true in England, where spirit-drinking is quite 
general. The use of alcohol at improper times seems to be fraught 
with danger. Early dram-drinking before breakfast, or between 
meals, or the taking of alcoholic spirits without water, are habits 
which all tend to the development of delirium tremens. The exces- 
sive use of alcohol in this way, of course, is connected with disturbed 
digestion and enfeeblement of the abdominal organs, and the mis- 
chief is increased by insufficient supply of nourishment and im- 
proper assimilation of food. 
Treatment.—It might be well to preface the suggestions in 
regard to special treatment by a word of caution to those persons 
liable to be abnormally excited by alcohol. Persons of weak judg- 
ment, with the hysterical tendency, in whom, according to Richet. 
the “ slightest access of fever brings delirium,” should eschew 
alcohol. In those whose fathers or grandfathers were drunkards, 
the same caution holds good. The habit of drinking before meals 
is a bad one to acquire as, the stomach being empty, there is not 
only direct action upon its mucous coat, but the alcohol is very 
rapidly taken up. Persons in warm climates should be exceed- 
ingly sparing in the use of stimulants, and confine themselves to 
light wines and beer, if they drink at all. 
For the relief of an acute attack of delirium tremens, sedative 
treatment is the most efficacious. Sleep should be procured if pos- 
sible, and for this purpose bromide of sodium [in doses of twenty 
grains, dissolved in a wineglassful of cold water], the mono- 
bromide of camphor, chloral hydrate, and other hypnotics are 
used. The two latter should never be given, except with the ad- 
vice of a physician. The patient should be made to eat, and if 
he will not partake of milk, beef-tea, and fluid nourishment, they 
should be given as enemata by the bowel, or through a stomach- 
tube. The digestive organs of the drunkard are in such a condi- 
tion, the stomach being usually the seat of inflammation, that the 
patient commonly abhors food, and has no appetite. In such cases, 
he may be given such alkaline waters as Vichy or Apollinaris, and 
these may be mixed with milk or, in lieu thereof, a pinch or two of 
bicarbonate of soda in a glass of cold water several times a day will 
afford relief. His bowels should be kept open with Rochelle salt, to 
favor elimination of the alcohol; should this remedy prove inef- 
ficient, any simple purgative or cathartic will be in order. The skin 
should be made to act by cold douches and shampooing, and abso- 
lute rest and quiet must be enjoined. The patient, should he be 
violent, must be tied down to the bed by a strap or strait-jacket ; 
and, disagreeable as such a measure must be, it is preferable to the 
use of such violence as must be required to keep the patient from NERVOUS DISEASES OF ADULT LIFE. 
593 
doing himself harm. The expenditure of muscular force in the 
struggle with his attendants must exhaust the patient to a very 
great extent. Quiet and a darkened room is to be provided. For 
the treatment of the condition which remains after the acute at- 
tack has subsided, tonics are to be administered, and the use of 
iron, quinine, and cod-liver oil is advocated. A change of air and 
scene is also advised. The use of substitutes for alcoholic liquors 
is strongly to be deprecated. There is no article which can take 
the place of liquor without the danger of contracting another 
habit equally bad. Various compounds containing opium have 
been sold as “ antidotes,” and nasty mixtures of a bitter character 
are offered by quacks and others. These, as a rule, contain alco- 
hol, and only derange the digestion, while they never do good. 
The use of “ pick-me-ups ” or “morningbitters,” is an evil practice, 
and results in no benefit; but should the craving for the morning 
dram be very strong, a teaspoonful of the compound tincture of 
gentian, in water, may be taken with good effect before break- 
fast. 
Hemiplegia. 
Hemiplegia is a term used to express a f;rrm of paralysis which 
involves one lateral half of the body, and it may be either com- 
plete or incomplete, in regard to the loss of motion and sensation, 
or of motion alone, when we have the latter form. Hemiplegia is 
usually the result of disease of a blood-vessel upon one side of the 
brain, such disease consisting perhaps in the plugging up of the 
vessel by a little blood-clot from the heart, when a condition 
remains which is known as embolism ; by the filling up of the 
vessel by local disease of its inner coat or sheath, or by clot- 
ting of blood in its interior, when the condition is known as throm- 
bosis ; or by disease of the vessel through fatty changes in its 
walls, and subsequent bursting—the condition being then known 
as cerebral hemorrhage or apoplexy. As a consequence of any of 
these accidents, the part of the brain supplied by, or in the neigh- 
borhood of the vessel, is subjected to dangerous pressure or loss of 
nourishment, so that its functions are impaired, and a paralysis 
takes place on the other side of the body. Such a paralysis is 
usually sudden, and except in the case of embolism, is attended by 
loss of consciousness. 
Symptoms.—Except in the occurrence of embolism, which is a 
sudden accident, the other forms of hemiplegia are followed by 
premonitory or warning symptoms. 
These are briefly—flushing of the face, headache, head discom- 594 
NERVOUS DISEASES OF ADULT LIFE. 
fort after eating, flashes before the eyes, absent-mindedness and 
forgetfulness, clumsiness of speech, tingling in the soles of the 
feet, and in the skin of the side of the body likely to be the seat of 
hemiplegia. The attack of apoplexy itself may come on quite 
suddenly, the individual, however, often making some violent ef- 
fort at the time, which tends to congestion of the brain. He falls 
to the ground unconscious, and if the apoplexy be serious, he 
breathes laboriously and violently, his cheeks being flabby, and 
blown in and out by each snoring respiration. His face is either 
livid, or purple and swollen, and his eyeballs are usually fixed, 
and look away from the paralyzed side of the body. The pupils 
will probably be found differing in size, and they do not act freely 
to bright light. The surface of the body is cold at first, then 
warmer; but if the patient is seriously ill, and likely to die, the 
temperature remains lowered. One side of the body, usually the 
left, will be found to be limp and powerless, and for some time 
there will be no indication of muscular strength. The paralysis 
may be of slower growth, and come on without loss of conscious- 
ness ; but this condition of affairs is not so common. 
In the case of embolism, the patient becomes suddenly paralyzed, 
but rarely loses his consciousness. There is, with these troubles, a 
loss of power of speech,-which is most serious when the right side of 
the body is paralyzed, and this condition is known as aphasia, the 
person substituting one word for another, and being utterly unable 
to say what he knows, but cannot express. A patient, for in- 
stance, desiring a cup of milk, may ask for a “ cup of cow.” But 
the mistakes are usually far more absurd than this, words being 
used in the most eccentric and improper manner. Loss of writing- 
power of the same kind is quite commonly associated with the 
speech disorder. Of course, the duration of the paralysis depends 
upon the extent of the part of the brain destroyed. In persons of 
middle life, there is usually a tendency to recovery, the uncon- 
sciousness lasting from a few minutes to twenty-four or forty- 
eight hours, and the remaining paralysis disappearing gradually, 
so that walking becomes possible, and finally there is an almost, or 
quite complete restoration of strength. In other cases the arm 
and leg become deformed and twisted, and although much of the 
original power may be restored, there are muscular contractions 
which interfere with the proper use of the limbs. 
There are persons who have other attacks, sometimes one, 
sometimes two or three, but it does not follow by any means, ac- 
cording to popular belief, that the third attack must necessarily 
be fatal. In old people, the occurrence of apoplexy is always 
serious and generally fatal. In young people, the hemiplegia is NERVOUS DISEASES OF ADULT LIFE. 
595 
due to plugging of the artery, or embolism, and very often the 
patient’s chances are very poor, because of the tendency to soften- 
ing of the brain, a diseased state which very commonly follows 
the deprivation of the brain of its usual amount of blood and nour- 
ishment. 
Sometimes hemiplegia is followed by trembling of the arm or 
leg, and this condition is a serious one, though sometimes greatly 
benefited by treatment. Mental trouble, headache, blindness, and 
a variety of serious symptoms, are disagreeable sequences of the 
condition which produces the hemiplegia. 
Causes.—In the case of embolism, and, in fact, of either of the 
brain troubles which produce the hemiplegia, heart disease plays 
an important part as a cause. Men are affected oftener than 
women, but it is a mistake to suppose that short-necked people 
are most subject to an “ apoplectic stroke.” Wiry, thin people of 
gouty temperament, are quite as often affected. Various constitu- 
tional diseases enter into the causation as well, as either exciting 
or remote causes. Intemperance and other dissipation, exposure 
to the sun, or violent muscular straining in any way, lead to, or di- 
rectly produce the trouble. 
Treatment.—The patient who has fallen after an apoplectic 
stroke should be carefully raised and placed upon a bed or in a 
chair, his head being elevated by pillows, while care should be 
taken to remove all tight neck-gear. The room should be cool and 
well ventilated, and crowding about the bed should be forbidden. 
Cool cloths may be laid upon the patient’s head, and a physician 
should be summoned at once. In the absence of a physician it is 
safer to avoid active treatment, and to a great extent let the suf- 
ferer alone. If the bowels are confined an injection should be 
given of warm water and soap-suds, or one or two drops (not more) 
of croton oil should be placed on the tongue. The surface of the 
body should be kept warm and the head cool, and quiet should be 
insisted upon. Do not give alcoholic drinks unless the patient 
remains cool and unconscious for a length of time, and then but 
a few drops. Mustard plasters may be placed upon the calves of 
the legs, and the feet may be placed in warm mustard-water. 
Do not attempt to feed the patient if he is unconscious, but give 
him injections of bullock’s blood from which the thick portion 
(fibrin) has been removed by a whisk-broom or whip of twigs. 
Use about a half-pint of this daily, upon two or more occasions. 
If he is conscious, he may take a little milk, but no solid food for 
several days, and it may be said that feeding of any kind must be 
carefully done. 
Do not use electricity for several weeks to the paralyzed limbs, 596 
NERVOUS DISEASES OF ADULT LIFE. 
but after this time it may occasionally do some good. It is advisa- 
ble, however, as soon as possible to seek medical advice. 
Paraplegia—Paralysis of the Lower Half of the Body. 
Paraplegia or paralysis, which begins, as a rule, in the lower 
extremities, is a result of a variety of spinal troubles, usually of 
an inflammatory kind. It may appear suddenly or come on grad- 
ually. In the ordinary form, at some time or other, sensation and 
motion are rather sure to be lost or lessened. If the inflammation 
involves the entire spinal cord transversely, there will be a loss of 
this kind, as well as wasting of the muscles and involuntary dis- 
charges from the bowels and bladder. Bed-sores are quite apt to 
occur, and may be very deep and troublesome. The result, in a 
large proportion of such cases, is permanent paralysis, with rigidity 
of the limbs, though some cases may be cured. The thighs and 
legs may be drawn up, and such a condition, of course, is attended 
with utter helplessness. In other forms of paraplegia the loss is not 
so extensive. There may be paralysis of muscular power, while 
sensation is left undisturbed, and this condition is connected with 
great wasting of the muscles, the functions of the bladder and 
bowel being normal. This disease is then called spinal paral- 
ysis of adults. 
Causes.—Disease of the coverings of the spinal cord, tumors in 
the spinal cord, and injury or disease of the bones of the vertebral 
column, may all give rise to various forms of paralysis of the 
lower extremities by pressure upon the spinal cord. 
Syphilitic disease, exposure to dampness and cold, dissipation, 
and hereditary predisposition, are fruitful causes of the disease. 
Treatment.—The administration of various constitutional reme- 
dies, such as cod-liver oil, phosphorus, and stimulating diet, is to be 
resorted to. Local treatment may consist of massage or rubbing, 
electricity, and baths of sulphur water, or cold water. The result- 
ing deformities in old cases may be treated by mechanical appara- 
tus with some hope of success. In the treatment of this, as well 
as many other forms of paralysis in which there is involuntary 
evacuation of the bowels and bladder, and a tendency to the forma- 
tion of bed-sores, cleanliness is of the first importance. If bed-sores 
exist, they may be best treated by alternate local applications of 
heat and cold, provided by sponges dipped in vessels of iced and 
hot water, and by applications of soft cloths greased with carbolic 
ointment. It may be necessary to use mixed flaxseed and char- 
coal poultices when there are masses of dead tissue. NERVOUS DISEASES OF ADULT LIFE. 
597 
Locomotor Ataxia—(Tabes Dorsalis.) 
When the posterior part of the spinal cord is affected, a peculiar 
form of trouble results. The patient first complains of “ stab- 
bing ” and shooting pains which run from the feet upward or down 
the back of the thigh, and are worse at night. He has also pain 
which is superficial, and appears in spots upon the inner side of 
the thighs, these spots being exquisitely sensitive. He also has a 
girdle of pain about the waist. After a time he loses sensibility 
in his lower extremities, being unable to appreciate surfaces with 
which his feet may come in contact. He says that there is a 
sensation comparable to that which might be experienced if sand 
were in his shoes, or if his stockings were down at heel; his feet 
are cold ; he complains of pain in his abdomen ; he loses the acute- 
ness of vision, and may become cross-eyed, but this latter is an 
early symptom. In the beginning, if he crosses his legs, and a 
tap be made with the side of the hand, just below the knee-cap of 
the hanging leg, the foot will not be thrown out as it is in health. 
His walk becomes peculiar, for he throws out his feet and comes 
down upon his heels, while his knees are stiff. He gradually be- 
comes more and more helpless, cannot walk in the dark, stand 
with his eyes closed, or use his hands. He becomes weaker and 
weaker, perhaps develops pulmonary disease, and finally dies 
after a period of from ten to twenty years from the beginning of 
the disease. Throughout the malady there is constipation. 
Causes.—Excessive dissipation has more to do with the causa- 
tion of the disease than anything else. Among sailors who have 
fallen overboard, and those whose clothing has remained wet for 
some time, this cause has preceded the malady. 
Treatment.—The treatment of this disease, which is a very 
hopeless one, can only be undertaken by a physician. Sulphur 
baths and galvanic electricity sometimes do good, and may safely 
be used by the patient. 
Paralysis from Pressure. 
Various transitory forms of paralysis may result from contin- 
ued pressure brought to bear upon some nerve-trunk. A variety 
is met with frequently in persons who have slept with their arms 
in some constrained position—for instance, on the back of a chair. 
Treatment.—Massage or rubbing, and electricity. 598 
NERVOUS DISEASES OF ADULT LIFE. 
Facial Paralysis. 
The muscles of the face are supplied by the seventh cranial 
nerve, which has two branches, one of which goes to the ear. 
Three forms of facial paralysis exist: one of a superficial nature 
and affecting the muscles of the face only, and usually produced 
by exposure to cold wind. This is commonly contracted by per- 
sons who sit by the open window of a railroad car. The next is 
accompanied by deafness, and is due to pressure made upon, or dis- 
ease of the nerve in the bone of the ear, or near thereto, and inside 
of the skull. This is a very'discouraging affection, because of its 
lasting character. It follows pain ovet and behind the ear, dis- 
charge therefrom of matter, etc. The third form is of much more 
serious import, and is connected with drooping of the eyelid, sug- 
gesting that the brain itself is affected at a point where the third 
and seventh cranial nerves originate. 
The appearance of a person with facial paralysis is decidedly 
peculiar, one side of the face being distorted by the healthy mus- 
cles of the other side, so that a peculiar grimace results. Owing to 
the paralysis of the lips the patient cannot whistle, or blow out a 
light, and when he spits, it is upon his clothing. The eyeball of the 
paralyzed side is usually exposed, and the individual cannot close 
his eye; the tears flow over his cheek and he suffers some dis- 
comfort from the lodgment of particles of dust on the front of the 
eye. 
Causes.—Exposure to cold draughts, and rheumatism—otitis or 
inflammation of the ear, diseased teeth, tumors in the brain, and 
disease of the brain, may give rise to facial paralysis, the former 
to the simple varieties, and the latter to grave and permanent 
paralysis. 
Treatment.—Faradic electricity to the face, used by itself, will 
cure most of the simple cases. A bent tin wire so contrived as to 
support the corner of the mouth on the paralyzed side, the other 
end being passed over the ear for support, may be used while the 
patient is in-doors, and often does much good. Medication should 
be left to a physician. 
Neuralgia. 
This term is used to express a condition of pain dependent upon 
impaired nutrition of the nerves, which is of so peculiar a charac- 
ter as hardly to be mistaken. While the pain of inflammation is 
usually at some time connected with heat of the affected parts, 
swelling, and the possible formation of matter or pus, that of neu- NERVOUS DISEASES OF ADULT LIFE. 
599 
ralgia is rarely associated with either of these, if we may except 
redness. This redness is, however, not limited. Neuralgic pain 
can scarcely be confounded with any other, and can never be for- 
gotten by one who has suffered. It is sharp, cutting, boring, or 
stabbing, generally paroxysmal, and usually obstinate. It is not 
increased by pressure, except in spots where a nerve has been its 
seat for some time, and then only when the nerve passes over some 
bony prominence, or when it leaves the opening or foramen from 
whence it emerges to supply the surface of the body. It is some- 
times associated with other nervous diseases, and quite commonly 
neuralgic subjects inherit it from nervous parents. It is, there- 
fore, anything but uncommon to find neuralgia connected with 
epilepsy, or various functional nervous disorders, or in individuals 
whose family history shows the taint of consumption. Neuralgia 
may be also the symptom of some organic disease of the brain or 
spinal cord, and then has peculiarities which distinguish it from 
the peripheral or surface varieties. In spinal disease, the nerves 
which start from the spinal cord and pass to the anterior part of the 
body, or the sciatic nerves which extend down the back of the thighs, 
are its seat, or, more rarely, the large nerves of the arms are affected. 
With organic disease of the brain it is not rare to meet with neu- 
ralgia of the trifacial or fifth nerve of the cranial group, which 
supplies the face and top of the head; but in both cases there are 
other symptoms which are treated of in another place under the 
head of Softening of the Brain, Tumor of the Brain, etc. 
The varieties of neuralgia are numerous, but the most common 
and familiar form is that which involves the great sensory nerve 
of the face and head. It may be confined to but one portion of 
this nerve, so that the upper or lower jaw is the painful site, or 
the pain may be general. In this variety but one side of the face 
and head is involved. The common form (see Headache) has al- 
ready been alluded to. The attack, for such it is, may come on sud- 
denly, but usually the pain is not so intense as it is after the par- 
oxysms have been repeated, as they usually are. The suffering 
incident to this kind of neuralgia is intense. Violent outbursts of 
pain of a shooting character dart down the various branches of the 
nerve, one of which leaves the skull just over, and another be- 
neath the eye, while the lowermost branch of the nerve (that sup- 
plying the teeth), is the seat of pain which gives rise to a violent 
toothache. The eyeballs feel as if they were being pressed from 
their sockets by some horrible pressure from behind, while the top 
and side of the head is sore to the touch, and the individual ex- 
presses his agony by saying that he “ feels as if his head would 
split.” Spots due to pressure remain, if the neuralgic attack has per- 600 
NERVOUS DISEASES OF ADULT LIFE. 
sisted, and these may be found at the sites spoken of above, where 
the nerves take a superficial course. Sometimes the pain is con- 
nected with a spasm of the facial muscles, and this variety is known 
as tic-douloureux. Such muscular spasms occur apparently from 
no adequate causes whatever, excepting, perhaps, that the stimu- 
lating effect of cold air may have something to do with them. The 
patient’s face is distorted and drawn upward on one side, so that 
he presents a lamentable, though extremely ridiculous appearance. 
When the nerve which passes to the back part of the head from 
below the ear is the seat of the disease, the affection is known as 
occipital neuralgia. The pain is not nearly so intense as in the 
preceding varieties, but is more dull and persistent, and does not 
possess the paroxysmal character to such a degree. It is com- 
monly of malarial origin. 
A somewhat rare variety is that which passes over the shoulder 
and down the arm (cervico-brachial), but it is most inveterate, and 
is accompanied very often by soreness and tenderness of the skin; 
not augmented by deep or firm pressure, but sometimes the slight- 
est touch upon the skin will give unutterable agony. It is usually 
found on both sides of the body, and, as a rule, exists as a symp- 
tom of spinal irritation, or deficient nourishment of the spinal 
cord. 
A form of neuralgia quite familiar to a great many people 
is confined to the spinal nerves which supply the upper half of 
the trunk, and called by a variety of names, such as, intercostal 
neuralgia, pleurodynia, etc. It is often mistaken for disease of 
the lungs, liver, or stomach, as the pain is complained of in the 
situation where these organs are located ; but its most common 
seat is at the lower edge of the ribs. It is, however, unconnected 
with cough or other symptoms suggestive of disease of the thora- 
cic or abdominal viscera, and lasts but a comparatively short time 
—a very short time if properly treated—but if not, is apt to recur 
constantly. 
Another form of neuralgia is, like the foregoing, liable to be 
mistaken for organic disease—notably for disease of the kidneys. 
I allude to lumbago. The difference, however, is, that the pain 
of lumbago is situated in the “ small of the back,” while that of 
kidney disease is much higher up. Lumbago is constant and 
rebellious, and occurs in persons apparently healthy in every 
other way. It is usually a gouty or rheumatic variety of neu- 
ralgia, and the pain is increased by bending the body forward. 
At times the pain is paroxysmal and intense, but in the greater num- 
ber of instances it has no such history, but is dull and persistent. 
A variety of neuralgia of an important nature is sciatica, in NERVOUS DISEASES OF ADULT LIFE. 
601 
which the pain runs down one or both thighs, and is sometimes 
so severe that the patient is confined to his bed, or he is obliged 
to resort to canes or crutches for support. In very rare instances 
the limbs are shrunken ; more frequently, in old cases, they are 
cold, and the circulation is defective. A painful spot may be 
found here and there down the back of the thigh, but most con- 
stantly above, where the nerve leaves the pelvis. This form, when 
it be due to malarial poison, is exceedingly obstinate. It occurs in 
middle life usually, though no age is exempt, but younger subjects 
are more easily cured, as the trouble is then, as a rule, only func- 
tional. 
Other forms of neuralgic disease are encountered. Neuralgia 
of gastric origin ; neuralgia of the heart; intestinal neuralgia, and 
various forms of trouble of internal organs of a painful nature are 
presented. As a rule, these painful affections depend upon some 
constitutional affection of the organ. It is sometimes gout, at 
others due to a degeneration or diseased condition of the blood- 
vessels. A form of the disease, excessively frequent, however, is 
ovarian neuralgia, which is either due to uterine or ovarian dis- 
ease, and is connected with irregular menstruation, or accompa- 
nies spinal mal-nutrition. Young women suffer much more than 
those of middle or advanced age, and it is in many instances an 
accompaniment of the earliest menstrual periods. 
Neuralgia is connected, in some cases, with changes in the skin ; 
sometimes with eruptions, and the familiar disease known as 
shingles, or herpes zoster, is an example of this kind. A circle of 
patches of eruption extends half way about the middle of the body, 
and is accompanied by some pain, not only about the spots, but 
radiating from the spine. Sometimes the hair changes color over 
the spot supplied by the affected nerve, so that a patch of gray 
hair in the midst of that of a darker hue is not an uncommon sight 
in inveterate cases of severe neuralgia. The nails and skin are 
occasionally the seat of changes, the former becoming horny and 
curved. 
Causes.—Any influence interfering with the proper nourish- 
ment of nerve-tissue is pretty sure fo give rise to neuralgia. This 
is especially true in nervous subjects. Insufficient food, bad air, 
dissipation, abuse of tobacco, of coffee, or of alcohol, exposure, late 
hours, want of sleep, intellectual fatigue, and malaria, are among 
these. Various special diseases play a part, and an important one, 
in the causation of the affection. The influence of gout is denied 
by some writers. Such a conclusion I believe to be unwarranted. 
Certainly rheumatism has much to do with the development of the 
disease, and very often the products of rheumatic inflammation 602 
NERVOUS DISEASES OF ADULT LIFE. 
make dangerous pressure upon some nerve trunk, and give rise to 
irritation and disturbance of its function. Syphilis is often a pow- 
erful cause. Other diseases which produce anaemia, or interfere 
in any way with the nourishment of the nervous system, have a 
decided influence, and their name is Legion. Neuralgia is pro- 
duced by a variety of other causes, some of them being often un- 
suspected. The existence of tumors, bad teeth, bony growths, 
broken or displaced bones, enlarged viscera, the presence of 
worms in the intestinal canal, uterine disease, will all favor the 
origination of various special forms of neuralgia. Malaria is 
probably one of the most fruitful causes, at least in this country, 
and an unsuspected exposure to the miasm will, very frequently, 
be the cause of a severe neuralgia, which may even follow it after 
an interval of many years. Neuralgia is rare before the fifteenth 
year, though children do suffer as well as adults. 
Treatment.—An inspection of the causes will enable the reader 
to judge for himself how varied must be the list of remedies and 
their application. In one case a large dose of quinine (ten to twenty 
grains) will break up the attack, or in fact the disease ; in others 
nothing will do good. In some facial neuralgias a bad tooth may 
be at the seat of the whole trouble, and relief follows extraction. 
Should malarial poisoning be suspected, a prompt and continued 
use of quinine will be the indication. If rheumatism is found to 
exist, the use of alkalies is suggested, and among these Rochelle 
salt in teaspoonful doses three times a day, may be tried. No 
special treatment can be laid down with any certain assurance of 
success. The patient should : 
1. Break off all bad habits, late hours, the immoderate use of 
tobacco or alcohol (if used in excess). Take exercise in the open 
air. Seek a warm, yet not an enervating climate. Bathe in mod- 
erately cold water, or, what is better, take salt-water baths, and in 
either event use the rough towel or the flesh-brush. Secure, if pos- 
sible, ten hours undisturbed sleep in the twenty-four. Take a brisk 
walk every day, and make your domestic life as different as possi- 
ble from that of your business. If suffering from sciatica, do not 
attempt too much use of the lower extremities, nor err in another 
way l>3r remaining in-doors. 
2. Make the diet as nourishing as possible and avoid pastry, the 
indigestible meats (pork, veal, corned beef, etc,). Avoid such ve- 
getables as cabbage, cauliflower, cucumbers, and others of the 
same class. Eschew condiments, hot cakes and hot bread; and 
if stimulants are needed, drink either a good light wine which is 
not sweet—such as claret, or if malt liquors are preferred, take 
lager beer or Scotch ale. 603 
NERVOUS DISEASES OF ADULT LIFE. 
A means of treatment which may be used in all cases with ben- 
efit, is electricity. The galvanic current is that which should be 
employed, and the positive pole should be placed upon the spine, 
while the negative pole is held upon the limb below or on the pain- 
ful part of the nerve. It is unwise to use this current except under 
a physician’s guidance, but the Faradic current, which is commonly 
known and quite generally in domestic use, may be employed, and 
sometimes does much good. This is especially the case in lum- 
bago and intercostal neuralgia or pleurodynia. 
Local applications sometimes do good, and blistering may be 
tried with the expectation of relief. A little chloroform may be 
dropped upon a small piece of cotton, and this, in turn, be placed in 
a wide-mouthed bottle which is held against the surface of the body 
over the painful spot. Warm applications do great good in some 
cases, or cold may be applied locally. This is especially true in 
ovarian neuralgia, the ice being placed in a rubber bag and laid 
over the seat of pain above the groin. If a limb be affected, it will 
be found advisable to swathe it in cotton batting on which a piece 
of oiled silk may be bound. Various lotions and liniments have 
been recommended, most of which, however, do little good. 
Epilepsy. 
This disease, as it appears in infancy, has been described in 
the first volume of this work. It may pursue an uninterrupted 
course, beginning before the tenth year of life, or more rarely 
afterwards, and is usually a lasting nervous disease, though not 
necessarily a fatal one. The worst results are mental decay, and 
the appearance of other diseases. The epileptic attack may be 
but a momentary and fleeting loss of consciousness, or one of a pro- 
found character, accompanied by much muscular action, frothing 
at the mouth, and tongue-biting, the escaping froth being blood- 
tinged. The first stage of a convulsive attack is a rigid spasm of 
most of the voluntary muscles of the body, succeeded by spasms 
broken by intervals of repose, though these intervals may be so 
short as to be scarcely recognizable. The face is at first livid, 
and afterwards congested and swollen ; the patient then falls 
usually into a deed sleep, lasting two or more hours, though this 
may be absent. In nearly every instance the attack is preceded 
by a cry, or a peculiar sensation complained of by the patient, 
proceeding either from the pit of the stomach or the fingers or 
toes. This is called an aura. There may, however, be no warn- 
ing whatever. 
What is known as petit mat is a form of attack of a transi- 604 
NERVOUS DISEASES OF ADULT LIFE. 
tory nature, which lasts but a moment or two. The patient may 
be seized at any time, as while walking across the floor, or while 
eating. His muscular trouble may be indicated simply by his 
dropping the fork or spoon in his hands, or his eyes may be 
rolled up and fixed. 
There are various phases of epilepsy which are so rare that a 
description would be out of place in this book ; I will refer only to 
the most conspicuous attacks of an irregular type, which consist 
of a kind of maniacal excitement following a fit or paroxysm. 
Epileptic fits may occur at all times, the light and severe at- 
tacks together or separately. The most common time for the at- 
tacks is the early morning, just on awaking. 
Causes.—Blows upon the head, hereditary transmission, in- 
temperance, and organic disease of the brain, may be mentioned 
as common causes. Digestive disorders have much to do with 
the origin and continuation of the disease, and a form known as 
gastric epilepsy is simply a variety of attack, precipitated by an 
overloaded stomach. Imprudence in diet or habits, therefore, 
cause paroxysms, and it befits the patient to abstain from indiges- 
tible food or alcoholic stimulants. Exposure to the sun’s rays has 
also much to do in exciting the paroxysms. 
Course.—Epilepsy is a notoriously chronic disease, except when 
it is symptomatic of some irritating cause which may be removed ; 
such as the presence of worms in the intestines, uterine disease, 
or accumulation of faeces in the lower bowel. When due to here- 
ditary transmission it is rarely curable, and the same holds good 
when it follows scarlatina or other fevers, or wounds or blows 
about the head. It may continue to old age. When it is a symp- 
tom of brain tumor, or other destructive brain trouble, the pa- 
tient’s life will of course be shortened. 
Treatment.—No one remedy has proved so successful as the 
bromide of potassium or sodium, given in from ten to twenty 
grain doses, three times daily in a half tumblerful of water. It 
is better, when the attacks occur in the early morning, to combine 
the doses, so that from forty to sixty grains are given at bedtime. 
The use of some simple bitter tonic is excellent. Tincture of ca- 
lumbo, for instance, in doses of a teaspoonful, in water, before 
each meal, does great good. It may be necessary to give cod-liver 
oil and nutritious fatty food. A vegetable diet has been found, as 
a rule, to be the best. Avoid pork, corned beef, cabbage, cauli- 
flower, carrots, turnips, cucumbers, pastry, and tea. 
Coffee in moderation does good instead of harm, but it should 
not be taken oftener than once a day. Moderately cold baths at 
night, and spongings with salt water, are useful. When an aura NERVOUS DISEASES OF ADULT LIFE. 
605 
or warning is recognized, the simple act of cramping or forcibly 
flexing the toes or fingers will often prevent the attack. The 
same result is attained occasionally by giving a glass of sherry as 
soon as the warning is recognized. 
Writer’s Cramp. 
This affection is one resulting from the overuse of one set of 
muscles in the act of writing, and is often complained of by clerks 
or others who do mechanical work;, such as copying. When the 
intellect enters actively into the work, there is not much danger 
of the development of writer’s cramp, for the affection is one of 
what has been called “hyper-automatism.” Certain actions are 
performed by all individuals, with difficulty at first, and require 
the cooperation of the mind for a long time before they become 
automatic. Writing, playing upon musical instruments, the exe- 
cution of various manual acts, are of this kind; but after a while 
the individual is enabled to perform them without much mental 
participation, so that to a certain extent they become unconscious 
efforts. Pianists can play and talk at the same time, and watch- 
makers, type-setters, or others, gain, after a time, wonderful 
ability to do two things at once, their hands doing one thing, while 
the mind may be engaged elsewhere. A very bad state of affairs 
may grow out of this development of faculty, and when writing 
especially is performed automatically, this serious condition of 
affairs may ensue. 
The first indication of writer’s cramp is a feeling of soreness 
and fatigue in the affected arm and hand. The fingers seem to 
lose their strength, so that the pen is managed clumsily, or in the 
other case, its point is with difficulty kept in contact with the 
paper, so that the words are formed slowly, and sometimes are but 
half written, when the hand is affected with a spasm or cramp, 
and flies upward and outward. If the act is persisted in, the 
trouble is very much increased, and sometimes even paralysis of 
the overworked muscles follows. If the individual learns to write 
with the other hand this, too, generally becomes the seat of the 
trouble, so that both hands are then affected. The disease is very- 
persistent, and continues for some time, and always as long as 
the particular act is persisted in, whether it be writing, piano-play- 
ing, and so forth. Its symptom is very often vague pains in the 
shoulders, back, and back of head, which is increased by damp 
weather, and is often accompanied by numbness of certain parts of 
the hands. Cessation of the particular work is of the utmost im- 
portance, and neither recovery nor improvement can be expected 606 
NERVOUS DISEASES OF ADULT LIFE. 
while the affected muscles are used. The use of the galvano- 
electric current, sea-bathing, change of scene and air, rest and 
quiet, moderate use of stimulants, and an animal diet, with free 
indulgence in milk, are recommended. 
Wasting Palsy. 
Wasting palsy, or progressive muscular atrophy, is a disease 
beginning usually in the hand of one extremity, though it may at 
first invade the legs and extend more or less, so that muscular 
groups of various parts of the body are finally involved. There 
are generally pains resembling those of rheumatism (and often 
mistaken therefor), which affect the arm and shoulder, and after 
a variable time, a commencing wasting of the muscles of the 
hands makes its appearance. After a period varying from a 
few months to a year or two, the palm of the hand loses so 
much of its muscular covering as to re- 
semble the claw of an animal, and ulti- 
.mately the arm, as well as the muscles 
of the forearm, are concerned in the 
atrophic or wasting process. The mus- 
cles of the shoulder are next involved, 
and, in turn, those of the back, neck, 
chest, and lower extremities, so that the 
miserable victim is reduced literally to 
a skeleton. It is only after some time 
that there is a loss of power. The mus- 
cles involved are the seat of little tre- 
mors, which somewhat resemble the ap- 
pearance one might observe if there 
were a number of worms wriggling be- 
neath the skin. The electrical current, 
after a while, fails to produce the slight- 
est contraction of the muscles when 
passed through them. 
The disease runs its course in from 
five to twenty years, and death takes 
place by an extension of the disease, 
which is spinal, to the medulla oblon- 
gata—that portion of the nervous tract situated between the spinal 
cord and brain. The general health is usually unaffected, except 
toward the end, when symptoms of exhaustion may show them- 
selves, or pulmonary consumption may become developed. 
Causes.—No cause is known, except that in some cases the dis- 
Figure 147.—A case of wasting 
palsy, where the disease has ex- 
tended to the muscles of the arms 
and shoulders. NERVOUS DISEASES OF ADULT LIFE. 
607 
ease has followed exposure to the elements, or has occurred in 
persons who have industriously and persistently used one set of 
muscles in the trade which they followed. It is found, for exam- 
ple, among tailors, dancers, telegraph operators, and blacksmiths. 
A remarkable feature of the disease lies in the fact that it is heredi- 
tary, and that families have been spoken of in whom several 
members were affected. The disease is luckily uncommon. The 
so-called “living skeletons” attached to “side shows” and public 
exhibitions, are striking examples of this disease in its advanced 
stages. 
Recovery, though rare, is by no means impossible under careful 
treatment. 
Treatment.—Nearly all good results, so far reported, have fol- 
lowed the use of electricity. No remedy of a medicinal character 
appears to have the least value. 
Shaking Palsy. 
Shaking palsy, as it is commonly called, or more properly, 
paralysis agitans, is exclusively a disease of old age, and rarely in 
any way shortens life. The first indication of trouble of any kind 
is a tremulousness of the hands, which becomes generally in- 
creased after a greater or less time, so that even the head bobs 
and shakes, and the whole body is agitated. When the patient is 
seated his body is bent over, his chin touching the chest, and his 
face wearing an intensely dejected expression. When he attempts 
to walk, his body pitches forward, so that he is obliged to run to 
keep his balance. In one form of the trouble (that due to harden- 
ing or sclerosis of the spinal cord and brain) the movements are 
increased with voluntary efforts, so that the more the will is ex- 
ercised to control them, the more disorderly will be the move- 
ment. If he carries a glass of water to his mouth, it is apt to be 
shaken so violently, that the contents is spilt. As a rule, the 
tremor ceases at night. In aggravated cases, a species of paraly- 
sis, with deformity through contracture or distortion of the limb, 
follows. 
Causes.—It has no apparent causes, except they be exposure, or 
hereditary tendency to nervous disease. 
Treatment.—No treatment has, so far, afforded relief. Conium, 
the bromide of potassium, and many other drugs, have been tried 
ineffectually. 608 
NERVOUS DISEASES OF ADULT LIFE. 
Catalepsy. 
This very rare disease is found almost exclusively among 
women, though occasional examples are met with in the other 
sex. It is marked by the recurrence of fits which may be repeated 
several times in the same day. The features of the fit or convul- 
sion are the following: The patient may experience headache, 
lassitude, dizziness, or trembling, and be suddenly stricken mo- 
tionless, so that, if he be engaged in walking, or using either the 
upper or lower extremities in any way, they become fixed, and 
remain in whatever position they may be in, no matter how con- 
strained. It is possible, however, for another person to bend the 
limb in a new position, in which it stays until the muscles become 
fatigued. The limbs feel semi-rigid, and as if made of wax or some 
half-resisting material, so peculiar is the contraction. The patient 
is utterly unconscious during the seizure, and remains so during 
its continuance, which lasts, perhaps, for an hour or two, or even 
for several days, but this is rare. The skin is numb and insen- 
sitive, so that pins may be thrust in to some distance without pro- 
ducing pain. 
Cases of trance usually come under this head, and religious his- 
tory is full of examples of what was simple ecstasy or catalepsy. 
Fright, malarial poisoning, anaemia, or other impoverished 
states of the blood, enter into the production of catalepsy, and it 
is commonly a disease of early life. The prospect of cure is dis- 
couraging unless it be of malarial or emotional origin, and not con- 
nected with hereditary nervous disease or insanity. Cold water 
douches may be used during the attack, and the patient must be 
kept perfectly quiet. Should there be more than one attack, a 
physician should be called. 
Ecstasy. 
Ecstasy is but a variety of catalepsy, or a symptom of certain 
forms of hysteria. (See Hysteria.) 
ALLAN McLANE HAMILTON, M.D. Insanity. 
BY 
JUDSON B. ANDREWS, A.M., M.D., 
OF UTICA, N. Y., 
FIRST ASSISTANT PHYSICIAN, NEW YORK STATE LUNATIC ASYLUM. INSANITY. 
The possession of reason is the distinctive mark of man’s posi- 
tion at the head of the animal creation, and renders him a free and 
responsible moral agent. The loss or perversion of reason, to the 
degree to which it extends, limits or destroys man's independence 
and responsibility, and, if continuous, reduces him to a condition 
of complete helplessness. 
At different periods in the world’s history the views regarding 
the nature, origin, and treatment of insanity have been very diverse 
in character. At times it has been considered as a punishment for 
sin, inflicted by Divine displeasure ; as a demoniacal possession ; 
as a simple moral state for which the person was accountable, and 
as a mental condition due to the malign influence of the moon. 
With these views of insanity, it naturally became a subject 
for the speculative discussions of philosophy. The insane were 
given over to the priests to be reasoned or prayed out of their 
unhappy state; or, still worse, they were punished for their per- 
verseness, or left to suffer from cruelty and neglect. At a later 
period, when medicine began to be crystallized into a science, and 
insanity came to be looked upon as a physical disease, the sufferers 
from it passed from the jurisdiction of the philosopher and priest to 
that of the physician. The insane man was then found to be a 
sick man. and his condition was entirely changed. The cruelty, 
inflicted under the plea of driving out an evil spirit, and the neglect 
of the physical system, gave way to the law of kindness and the 
medical care of the body, as the true mode of treating what was 
ascertained to be a disease. 
The theories which have gained standing in science regarding 
the nature of insanity may thus be formulated : 
1. “ Insanity is a disease both of the brain and mind.”—This is 
the materialistic view, which considers mind as a secretion from the 
brain, or a mere physical substance, and mental disorder a disease 
of this secretion, or, as has been differently stated, “ the mind is 
nothing more than the result of cerebral action.” “When the 
brain is quiescent there is no mind.” The tendency of this view is 612 
INSANITY. 
to make man only what the material organ, the brain, may develop, 
and to limit his existence to this life and to the vital action of the 
brain. 
2. “ Insanity is a disease of the mind only.”—This is the purely 
spiritual theory, according to which the mind is the immediate 
seat of the disease, and the mental disorder has its origin in error, 
sin, and passion. The belief in the power and presence of demons, 
in witchcraft and other superstitions, is a part of this view. It has 
been inculcated by the teachers of religion and philosophy, and re- 
tains the position, in the popular mind, of a traditionary opinion. 
Its influence is seen in the common use of the terms, “ disease of 
the mind” and “mental disease.” The logical conclusion of this 
theory is the complete annihilation of the mind, for disease implies 
destruction and death. 
3. “ Insanity is a disease of the brain only.”—This assumes the 
existence of a soul or spirit independent of bodily conditions, so 
far as disease is concerned. The brain is viewed as the organ or 
instrument of the mind. Insanity is a complex affair, consisting 
of disturbed mental manifestations caused by disease of the brain. 
This theory is fully sustained by the researches of science. Aided 
by the microscope and the tests of chemistry, changes, not only of 
gross but of the most minute character, in the brain and its mem- 
branes, are brought to light. These may be represented by photog- 
raphy and preserved for subsequent examination and comparison. 
This method of investigation is now pursued, both in this country 
and abroad, and is giving most satisfactory results. 
In every case of insanity in which a thorough microscopic ex- 
amination of the brain is made, evidences of diseased conditions 
are found. The belief long entertained and expressed by those 
conversant with the subject, and who devoted themselves to prac- 
tical investigation and study, that insanity exists only with disease 
of the brain, has been confirmed. It is not within the province of 
this article to describe the particular changes discovered. It is 
sufficient to say that in all cases of insanity some one or more of 
the tissues which compose the brain are involved ; the membranes, 
the blood-vessels, the connective tissue, the nerve-tubes, and the 
ganglionic, or nerve-cells. The success of the modern treatment, 
which is founded upon this theory of the nature of insanity, attests 
its correctness. 
Insanity may be defined, in a general way, as a more or less 
prolonged departure of the individual from the normal mode of 
feeling, thinking, and acting, the result of disease of the brain. 
This definition does not include mere delirium, which frequently 
accompanies acute diseases, such as fevers, inflammation of the INSANITY. 
613 
lungs, kidneys, etc., or injuries. The toxic effects of alcohol, and 
of narcotics, such as opium, hashish, belladonna, hyoscyamus, 
etc., must also be excluded. Mere eccentric, erratic, or other pecu- 
liar characteristics do not, of themselves, constitute insanity. 
Education, mental culture, the changes of social position, the ac- 
ceptance of new views of life and duty, are all capable of trans- 
forming individual character and of producing an entire revolu- 
tion of thought and action, but these cannot properly give rise to 
the suspicion of insanity. These variations of mental habit exist 
in health, with normal physiological action. 
In insanity the changes in character present a wide range and 
are graduated from the lightest variations to those of the most 
marked kind. They are usually gradual, and develop step by step. 
The individual, from being cheerful and hopeful, may become 
moody and despondent; from being trustful and confiding, may 
become suspicious of all around him, or treat with indifference or 
even hate, those whom he is bound to love and regard. From 
being assiduous in labor, he may come to neglect, or lose all inter- 
est in his daily vocation, or new pursuits may be entered upon 
without thought or preparation. The careful, prudent man may 
spend his means in the most careless and reckless manner, or he 
may form new associations which ordinarily would have been most 
distasteful to him. The religious man may become profane, in 
disregard of his previous professions, while the wicked and vicious 
may seem to lament their folly and set themselves up for reform- 
ers. The temperate may give himself over to excessive indul- 
gence, and the chaste and virtuous become lewd in speech and 
action. The honest may become dishonest, the truthful, untruth- 
ful, and the sta’id, quiet citizen may, by some criminal act, place 
himself in the hands of the law. Such transformations of charac- 
ter, when associated with, and dependent upon physical disorder 
within the cranium, mark the disease and clearly distinguish in- 
sanity from those moral perversities and personal idiosyncrasies 
which are perfectly compatible with normal mental operations. 
It is to be borne in mind that each individual is to be taken as 
his own standard in judging of mental states. Comparison is to be 
made between the former and the present condition of the person 
whose sanity is in question. In this way, only, can allowance be 
made for natural eccentricities, for the accidents of birth, nation- 
ality, education, and the surroundings of life. 
There are certain terms used in describing insane states which 
it is necessary to define. These are delusion, hallucination, and 
illusion. An insane delusion is a belief in that which does not 
exist, the offspring of disease of the brain, as when a man asserts 614 
INSANITY. 
that he is dead, or that he is the third person of the Trinity , and 
cannot be convinced to the contrary. 
A hallucination is a deception of one of the special senses ; one 
who believes that he hears voices or sounds where there is complete 
silence, or that he sees objects where there is impenetrable dark- 
ness, is subject to a hallucination of hearing or of sight. 
An illusion is an error or misinterpretation of one or more of 
the senses. A row of trees mistaken for a file of soldiers, or discor- 
dant sounds for the sweetest music, are instances of illusion of 
sight and hearing. That these sometimes occur when the reason 
is not affected is not denied. Delusions, which, in a general sense, 
are false beliefs, may arise from ignorance and superstition. Hal- 
lucinations and illusions may be due to a want of attention or to 
disorder of the special senses. The sane may correct them or be 
convinced of the deception or error, but the insane are not able to 
appreciate their true character, either by appeal to reason, to ex- 
perience, or by the clearest demonstrations of their falsity. 
Causes of Insanity. 
Predisposing Causes. 
Sex.—There are some causes of insanity which occur more fre- 
quently among men. These are exposure to extremes of heat and 
cold, the effects of intemperance and dissipation, bodily injuries, 
and certain forms of disease, such as rheumatism, apoplexy, par- 
alysis, and syphilis. Women are subject to maternity and to dis- 
eases incident to their sex. Statistics show that more men become 
insane than women, and that the mortality is greater among the 
former. The difference in the number of the insane in the sexes 
is so fully accounted for by diseases and conditions which have no 
relation to the question of sex, that it is not necessary to give it 
special consideration in treating of the liability to the occurrence 
of insanity. 
Age.—As regards age, the facts are very different. During the 
first ten years of life but few become insane. The diseases of in- 
fancy and early childhood that cause an arrest of mental develop- 
ment, result, usually, in imbecility. The changes accompanying 
puberty, which occur during the second period of ten years, are 
often causes of insanity, but the greatest number become insane 
between twenty and thirty years of age, and following closely in 
order, those between thirty and forty, and next those between forty INSANITY. 
615 
and fifty years. Attacks of insanity occur mostly during the years 
between twenty-five and fifty. This is the active period of life, 
when the energies of both mind and body are called into exer- 
cise, which often proves excessive, in the effort to succeed in the 
chosen fields of labor. It also includes the period of activity of the 
procreative functions, and of the climacteric in women with its 
changes in the physical system. 
Civilization.—Insanity has been called a disease of civilized 
life. There are a greater number of insane among civilized nations 
than among the savage and barbarous. There are also more in- 
sane in the nations of Europe and America than among the older 
civilizations of Asia. 
The liability to insanity among the former arises from two dif- 
ferent causes. The one is the severe intellectual and emotional 
strain in the struggle for subsistence, for the accumulation of 
wealth, and for the attainment of the honors and emoluments of 
civilized society. This affects the intelligent, industrious classes. 
The other cause is found largely at the opposite extremity of society 
in the vices, in the indulgence of the baser passions, and the ex- 
cessive use of stimulants, all of which may result in deterioration 
and disease of the system. 
There is a difference of opinion among those who have given 
attention to the subject as to whether insanity is on the increase. 
That there is an increase in the actual number of the insane would 
be expected from the rapid multiplication of the population. That 
there is a relative increase may well be doubted, for when compar- 
ison is made between the present and the past years, it will be 
found that from the advance of science and from the spread of 
knowledge, the boundary lines of the disease have been widely 
extended, and many cases are now called insane which formerly 
were not so recognized : such as the enfeebled mental conditions 
arising from age, from paralysis, and from epilepsy, mild states of 
mental depression, etc. Moreover, until a recent period there 
were no reliable statistics of the number of the insane, while now 
every effort is made to find out and to enumerate all of the 
cases. The lives of the insane are prolonged by superior care 
and treatment, which adds to the actual number at any given 
time. The demand upon public charity for increased accommo- 
dations does not prove a relative increase of the insane, as is often 
claimed. 
Social Condition.—The fact is fully established, by statistics of 
large numbers of the insane, that the family relation is conducive 
to health and sanity. More single than married of both sexes be- 
come insane, and of the widowed more women than men. 616 
INSANITY. 
Heredity is the most important of the predisposing causes of 
insanity. By a law of nature peculiarities of physical structure 
and of mental constitution are transmitted from parent to child. 
In some families the form, the features, the height, the color of 
the hair and eyes, and even certain traits of character, reappear 
with such frequency that they come to be recognized as distinctive 
family marks. With the general resemblances of form and of 
mental organization there may also be transmitted a resemblance 
of elemental structure, or of constitution, which renders the mem- 
bers of the same family susceptible to like influences, whether 
they tend to the promotion of health or to the production of dis- 
ease. Insanity is not directly communicated by inheritance. The 
heredity consists in a feebleness of constitution or in an instability 
of nerve element, which makes the individual liable to nervous 
disease or to insanity, when certain influences are brought into 
operation. The view that the disease itself is directly transmitted 
unfortunately holds a strong position in the public mind. The 
publication of occasional instances of families of which a number 
of members are afflicted tends to give currency and strength to this 
belief. The rule is that few are thus affected and the reverse is 
the rare exception. The popular idea is, that if insanity has once 
appeared in a family the descendants must become insane; and 
further, that where there is this heredity, it is such a taint that 
the disease is without remedy and the individual is hopelessly in- 
curable. There is no such fatality attending hereditary influence, 
and though it increases the liability to the occurrence of the disease, 
much can be done towards its prevention by judicious care of the 
general health, by attention to the laws of hygiene, by special 
education, and by avoiding the known causes of the disease. 
The chances of recovery from first attacks of insanity are not 
materially diminished by heredity, though the liability to their 
recurrence, under influences injurious to health, is somewhat in- 
creased. The probability of the inheritance of this infirmity of 
constitution in any case depends upon the number and nearness of 
kin of the relatives who have been insane. The liability is great- 
est when the disease has appeared in both branches of the parent 
stock ; next, when in only one branch ; and it is of less serious 
import when it occurs only in collateral branches, as among the 
uncles, aunts, or cousins. Sometimes the disease is strongly 
marked in one generation ; in the second it may not appear at 
all, while in the following it may recur either in the form of in- 
sanity, imbecility, epilepsy, or some other of the diseases of the 
nervous system. 
The frequency with which hereditary transmission is traceable 617 
INSANITY. 
is variously stated as high as ninety per cent, and as low as ten 
per cent, of the cases from which the estimates are made. In the 
Asylum at Utica, Y. Y., of more than eleven thousand cases, about 
twenty per cent, gave a history of heredity. 
Exciting Causes. 
Were it possible to enumerate all the assigned causes of insan- 
ity, the list would be found to include all the circumstances and 
conditions of the mental, moral, and physical life of man. It em- 
braces all the emotions and passions, all the exterior surround- 
ings, all the accidents and diseases to which the insane person 
may have been subjected. The closest scrutiny reveals nothing 
unusual, nothing which may not and does not often occur at one 
time or another to a large part of the human race. 
All mankind are subject to the emotions of grief, joy, anxiety, 
and the like, as they are a part of man’s nature. Many are bowed 
down under the disappointments of their hopes, the cares of fam- 
ily, and the perplexities of business. The excitements of religion 
and of politics permeate all strata of society. Changes in the con- 
ditions of life, from affluence to poverty, or the reverse, are so 
common as hardly to attract notice. Many receive bodily injuries, 
and still more suffer from some of the diseases which afflict man- 
kind. With every child the mother incurs the risk of diseases of 
the puerperal state. By their vices and excesses many court the 
dangers that threaten ruin of soul and body. 
It is not too much to say that all mankind are at some time sub- 
ject to influences which may become, and often are, the exciting 
causes of insanity, and yet comparatively few of the whole number 
become insane. There must still be another element or factor to 
complete the history of causation, and this is cerebral disease. It 
is not till the brain becomes involved, either primarily or second- 
arily, that insanity occurs. 
Causes are ordinarily divided into the two classes of moral and 
physical. The former includes all influences which act upon the 
body through the mind—as the emotions, passions, etc. : the latter 
such as act primarily upon the physical system—as diseases, inju- 
ries, etc. As moral causes are not operative till morbid physical 
conditions have been induced, these physical changes are by many 
considered as alone causative of insanity. The most prominent 
cause is ill-health, from overwork, grief, anxiety, fatigue, or loss 
of sleep. In this division is included a large number of cases, 
characterized by excessive mental action, emotional activity, or 
over-exertion of the physical system. These influences are thus 618 
INSANITY, 
classed together, since their operation as causes of insanity is 
similar. They result in deterioration of the general health, in 
lowering the nutrition of the body, and, through disturbance of 
the circulation, in setting up morbid processes in the brain itself. 
Other cases are traced to ill-health from fevers and acute disease— 
as of the stomach, lungs, kidneys, etc. ; to chronic constitutional 
diseases—as rheumatism, gout, syphilis, etc; to diseases of the 
circulatory apparatus — heart, arteries, etc. ; to diseases of the 
nervous system—as neuralgia, chorea, epilepsy, locomotor ataxia, 
tumors and softening of the brain, inflammation of the mem- 
branes or coverings of the brain, etc., to diseases of the puerperal 
state and the climacteric, uterine disorders, self-abuse, intemper- 
ance, narcotic poisons, etc. 
Classification of Insanity. 
Different classifications have been adopted by authors, accord- 
ing to the view held regarding the nature of the disease. Those 
which have attained the most prominent position in the literature 
of the subject are the following : 
1. The classification founded upon the supposed analysis of the 
mind which includes the various mental and moral faculties ; 
whence we have Intellectual, Perceptional, Emotional, and Voli- 
tional Insanity. From this arises what has been called moral 
insanity, and, as subdivisions of it, the different propensities 
which the insane sometimes manifest are elevated into classes, 
such as Pyromania, a mania for burning; Kleptomania, a mania 
for stealing ; Homicidal and Suicidal mania, etc. 
This is an outgrowth of the idea that the mind may be actually 
separated into different faculties, and further involves a belief that 
one portion of the mind can be insane and all the rest perfectly 
sane. 
2. A classification arranged according to causes of disease or 
peculiar physical states which underlie the insanity. From this 
system arises syphilitic, rheumatic, epileptic insanity, etc., or the 
insanity of pubescence, of pregnancy, of lactation, etc. 
This, though a rational method, is impracticable, in that it fails 
to cover the whole ground, as in many cases a variety of causes 
act consecutively or together, so that it is impossible to express 
them by any single term, however comprehensive. 
3. The classification founded on the type of the mental symp- 
toms. In well-marked cases this is most readily appreciated by 
the ordinary observer. This system is generally adopted in this 
country and abroad by both the medical and legal professions. 619 
INSANITY. 
Figure 148.—Mania. 
Figure 149.—Chronic Mania. 
Figure 150.—Melancholia. 
Figure 151.—Dementia. 
Figure 152.—Paresis. 620 
INSANITY. 
The principal divisions are Mania, a state of mental exaltation ; 
Melancholia, a state of depression ; and Dementia, enfeebled or di- 
minished mental activity. Mania and melancholia are both states 
of increased mental activity. They are produced by the same 
causes, present the same morbid conditions, but differ in the 
character of the mental symptoms. The one class of cases is 
marked by mental exaltation and expansive ideas, and the other 
by mental depression and circumscribed and painful ideas. 
Mania. 
This general term is subdivided, according to the duration and 
severity of the symptoms, into acute, subacute, and chronic forms ; 
and further into paroxysmal, periodic, and recurrent. 
Acute mania, or the raving madness of popular belief, is easily 
recognized. Most cases present disturbances of health as precursors 
of the attack. There is sleeplessness, variability of appetite, disturb- 
ance of the stomach or bowels, or of the secretions of the skin, kid- 
neys, or other parts of the physical organism. There is usually, pre- 
ceding the maniacal disturbance, a period of depression varying 
from a few days to several weeks, varying in degree in different 
individuals. He loses interest in his affairs, is inclined to avoid 
people, or to seclude himself. This is succeeded by a state of ex- 
citement and restlessness, and delusive ideas are formed. He is 
often suspicious, fearful, asserts that his friends are his enemies, 
and are trying to poison or injure him in some way, and for 
this reason turns against them. On the other hand, he may be 
cheerful, gay, and express himself as feeling well, better than ever 
before ; that he can undertake anything in the way of business or 
physical exertion. Soon these delusive impressions assume defi- 
nite form, usually regarding personal affairs : that he is possessed 
of great wealth or power, and he may form plans for using these 
for the benefit of friends or the community, or his enlarged views 
may include all mankind. He becomes restless, perhaps attempts 
to carry out his plans, and, if opposed, breaks out into threatening 
speech or open violence. 
Of the physical conditions at this period, it may be observed 
that there is usually inability to sleep, perhaps for days together ; 
the appetite may be good or impaired, and the muscular activity 
is marked by the rapid play of the features and the movements of 
the body. Occasionally there is increased temperature, dryness 
of the tongue, feebleness of the circulation, and such vital depres- 
sion as betokens danger to life. This state is not unfrequently mis- 
taken for one of fever. In the progress of the malady the mania INSANITY. 
621 
increases, and is indicated by noise, boisterous conduct, and vio- 
lence. The mental activity now reaches the point when ideas 
pass too rapidly for full expression, and there is incoherence in 
speech. 
Prominent among the symptoms is destruction of clothing and 
furniture, opposition to necessary care, profanity and obscenity, 
and even indifference to the calls of nature. Hallucinations and 
illusions frequently arise with the definite delusions, and imagi- 
nary voices are heard or conversations held, or objects are misin- 
terpreted. This condition may continue for weeks or months. 
The greatest liability to death is during the early stages, from sud- 
den exhaustion; but the tendency in simple acute mania is to- 
wards recovery. This occurs usually by gradual subsidence of the 
symptoms coincident with improvement of the physical health, as 
shown in the increase in appetite and flesh, with quiet rest at 
night. In this process the delusions are given up, and their true 
nature is for the first time appreciated by the patient. Convales- 
ence thus begun may, under proper care, result in complete re- 
covery. Should the disease continue, it may pass into the chronic 
form, or into a condition where there are periods of quiet alternat- 
ing with paroxysms of excitement, or, finally, into the mental en- 
feeblement of dementia. 
When it reaches the chronic stage, there is frequently the same 
incoherence of speech, the same violent, noisy, or boisterous con- 
duct, and the person may continue destructive, profane or ob- 
scene, and careless in habits. The term chronic refers to the dura- 
tion and fixed character of the disease, as well as to a change in 
the symptoms. In other cases there is a subsidence of symptoms 
both mental and physical. The person is quiet, coherent in speech, 
regular in habits, well behaved, in good flesh and fair general 
health, and, to the casual observer, may even seem sane, as the 
delusive ideas, though fully established, may be concealed. They 
often take the form of suspicions, of dislike to friends, of fears of 
conspiracy, of being poisoned or injured in reputation or person, of 
being affected by electricity, mesmerism, or some other influence 
exerted by one or more persons. Delusions of this character are 
liable to make the subjects of them dangerous to the life or prop- 
erty of those regarding whom they are entertained, and not un- 
frequently bring them under notice of the law for acts committed. 
The chronic maniac may hold delusions relating to his person- 
ality : that he is some noted individual, as an emperor, and under 
their influence he may decorate his person with colored rags, but- 
tons or paper, or in other ways indicate rank and assume authori- 
ty over and dictate to others. No refusal to obey, or incongruity 622 
INSANITY. 
in the assumption with the surroundings or position, for a moment 
disturbs the belief. There is a great variety of delusive ideas 
among the chronic insane, but the most common are in the direc- 
tion indicated. This form of disease is rarely recovered from, 
and the tendency is towards a gradual decline of mental power. 
The subacute form is characterized in the same general way in 
its inception and early history as the acute form, but it is not, 
however, in its progress so fully marked by violence, incoherence, 
and mental disturbance. The delusions generally control the per- 
son, but, being less noticeable in the conduct and more concealed. 
Cases of this kind are really more dangerous than the noisy, bois- 
terous maniacs, who are quickly put under charge. The duration 
and the results of treatment do not vary essentially from those of 
the acute form. Recovery from attacks of mania usually takes 
place within eighteen months from the commencement of the dis- 
ease, and comparatively few recover after two years or more. 
Melancholia. 
Melancholia, or the form of insanity characterized by mental 
depression, occurs next in frequency to mania, and in its inception 
closely resembles it. There is the same insomnia, loss of appetite, 
and physical disturbance. The person is despondent and appre- 
hensive, seeks to be alone, and is absorbed in gloomy contempla' 
tion. The thoughts are turned inward, and so concentrated on 
self that there is an inability for exertion and, following this, a 
loss of interest in business and affairs generally. 
The melancholic is unhappy and restless ; there is, to him, 
nothing cheerful or hopeful in his condition or prospects ; this 
gloomy view may be limited or extend over his whole life. He 
may consider his ordinary acts wicked or even criminal. All the 
misfortunes which occur, or of which he may hear or read in the 
papers, he may attribute to his own wickedness, and accuse him- 
self of the most heinous crimes. Remarks of persons which have 
no reference to him or his state, he may construe into accusations 
against himself. He often asserts that he is pursued by officers of 
justice for his crimes, or believes he has committed the unpardon- 
able sin, or that lie has lost all his property and has beggared his 
family ; that he is doomed to starvation or the poor-house, and 
has involved his friends in everlasting disgrace or ruin ; that his 
health has been undermined by some terrible disease ; that he con- 
taminates everything he touches ; that some dreadful fate awaits 
him, and he is to be arraigned, hacked in pieces, torn asunder upon INSANITY. 
623 
a rack, or burned in a furnace, or that he is dead and all the func- 
tions of life are suspended. 
Thoughts of suicide occur early, and often become intensified 
with the development of delusions. These may be openly ex- 
pressed or wholly concealed, and the suicidal attempt may be the 
first indication of their existence. About thirty-five per cent, of 
all cases of melancholia admitted to the Asylum at Utica had at- 
tempted suicide while with their friends, and a still larger per- 
centage had entertained thoughts or made threats of committing 
suicide. To avoid the dangers which, under such delusions, they 
believe threaten those near and dear to them, melancholics are 
sometimes led to commit the most fearful crimes : as the mother 
to take the life of her innocent offspring, or the father to destroy 
his wife or children, or both. 
Hallucinations of the special senses and delusions in regard to 
taking food are quite common : such as the belief that it does not 
nourish, but simply accumulates in the body, and that, therefore, 
it is impossible to eat; that the throat has grown up and food can- 
not be swallowed, or that it is wicked to prolong life, or that, by 
eating, one’s family will be starved; or that what is taken can 
never be paid for. Under such delusions all nourishment may 
be persistently refused, and if it is not administered, the strength 
fails rapidly and death soon closes the painful scene. 
In other cases the person walks to and fro, regardless of the de- 
mands of nature for repose, wringing the hands, moaning and 
lamenting. Sensation seems lessened, the nails are bitten off, or 
the skin is picked till the blood flows, or the hair of the head or 
the beard is pulled out. There is extreme restlessness and sleep- 
lessness, rapid emaciation and general disturbance of the secre- 
tions. The feet and limbs swell, the extremities are cold, and the 
circulation is languid and imperfect. 
In the course of the attack periods of frenzy sometimes occur, 
in which the person may abuse himself or injure others, and ex- 
hibit uncontrollable violence. Occasionally the melancholic passes 
into a condition of apparent stupor. He sits or stands in one posi- 
tion, with the head dropped on the chest and the hands hanging 
helplessly by the side. Food is only swallowed when placed in the 
mouth, and there is utter indifference to habits of cleanliness. ISTo 
response can be gained to questions, and no sign of recognition is 
given. The mind, however, is generally active, and everything 
said or done in the presence of the person may be understood and 
appreciated, though the influence of delusion seems profound and 
the mental abstraction apparently complete and controlling. This 
state may be mistaken for trance or ecstasy, or profound dementia. 624 
INSANITY. 
Sometimes, in the course of melancholia, paroxysms of mania 
alternate with periods of depression. Cases of simple melancholia, 
if placed under treatment in an early stage of the disease, usually 
recover. Where the result is not favorable, the termination, as in 
mania, is mental enfeeblement. 
Dementia. 
Dementia is the final stage of mental impairment, towards which 
all cases of insanity that do not recover tend. In this condition 
there may be coherence of speech and correct answers given to 
questions relating to the former life or present surroundings, but 
there is a loss of spontaneity and an inability for continuous men- 
tal effort. When compared with the normal state, the mental 
horizon is limited, the person drops to a lower plane of mental ac- 
tivity, whether relating to social duties, business affairs, or moral 
responsibility. 
Frequently the failure of memory, especially of passing events, 
from loss of the power of attention, is a prominent feature. The 
emotional nature is enfeebled and perverted, and the demented 
person becomes more or less insensible to any permanent senti- 
ment of love or hate, though there may be transitory exhibitions 
of feeling, as affection or jealousy, or sudden outbursts of laughter 
or passion, from the most trivial causes. The delusions, though 
still existing, are vague and often ill-defined. As the degeneration 
progresses, the ideas and conduct become silly and foolish ; there is a 
neglect of dress and habits, and a tendency to accumulate and 
secrete worthless articles and rubbish upon the person or else- 
where. This stage is often a protracted one, lasting for years, but 
with a steady decline towards the final state of complete mental 
obscuration, in which there is utter indifference and helplessness. 
In dementia the organic functions are not disturbed in propor- 
tion to the mental deterioration ; the appetite is usually good and 
even voracious, the sleep sufficient, and the flesh retained or in- 
creased. The sensibility to all outward impressions is diminished, 
as well as to the sensations of heat and cold. Care and treatment 
may ameliorate the condition, but will not effect recovery in con- 
firmed dementia. 
Paresis. 
There is another form of insanity, which is sufficiently distinct 
to merit separate notice. It is General Paresis, or Paralysis of 
the Insane. It is, compared with other forms, of infrequent occur- INSANITY. 
625 
rence, and is always fatal. As to sex, there are, in this country, 
about twenty cases among men to one among women. The par- 
alysis is of a progressive character, and is manifest in a tremor of 
the lips in speaking, of the tongue when protruded, and of the fin- 
gers when the hand is extended. The first indication to friends is 
generally in the change of conduct of the individual. This is 
manifested in extravagance of speech or action, or in the direction 
of unusual indulgence in drinking or other excesses. The careful 
man of business may talk extravagantly of his prospects, or plans, 
or make extraordinary or useless purchases without provision. 
The temperate man may begin to drink, or the one accustomed to 
the use of liquor may indulge more freely, or give himself up to 
the control of his appetite. The person affected in this manner is 
coherent in speech, complacent, and generous to friends and even 
strangers, though irritable if crossed in his purposes. Remon- 
strances against his conduct are unheeded, and suggestions that he 
is unwell, or overworked, are met by the assurance that he never 
was so well; that he is stronger and in better health than ever be- 
fore. The physical and mental symptoms increase in severity; 
light paralytic seizures, or “ fainting spells,” as they are often 
called, are followed by a slight change in speech, a tripping of the 
tongue, an elision of certain syllables or words, or a thickness of 
enunciation resembling that of intoxication. The gait is changed 
and becomes shuffling, the feet are set more widely apart to in- 
crease the base of support; the handwriting is noticeably altered, 
the letters are angular, syllables and words are left out, and the 
lines are irregular. 
Delusions are expressed of the most exalted character. The 
paretic claims to be worth millions or billions of dollars, to possess 
the most valuable gems in unlimited quantity, or to own the gold 
mines of the world. If the delusive ideas relate to his own person- 
ality he may assert himself to be the most successful merchant, or 
the most skilled artisan, or to be able to perform the most wonder- 
ful feats of strength, to move buildings or cities, to build railroads 
across continents or over oceans; he may imagine himself to be 
the President or an Emperor, the ruler of the world, or even God 
himself. 
The paretic seizures become more severe, and take the form of 
convulsions, with periods of unconsciousness lasting for hours ; and 
though the person may rally, he does not regain his former state, 
the mind is more feeble and the speech and gait more disturbed. 
Successive attacks occur, finally inducing coma, which may ter- 
minate in death ; or this may take place suddenly from hemor- 
rhage into the brain. The duration of the disease is usually from 626 
insanity. 
eighteen months to four years. It occurs most frequently among 
the intemperate and those who have freely indulged the baser pas- 
sions, but it may result from overwork, either mental or physical. 
From the insidiousness of its approach, the apparent insignifi- 
cance of the symptoms in the earlier stage, the character and grav- 
ity of the disease are seldom appreciated, and false hopes of speedy 
recovery are often entertained by friends. The individual who is 
thus afflicted is often thought to be under the influence of intoxi- 
cating liquor, and is held to a moral and sometimes legal responsi- 
bility when in an utterly irresponsible state from disease. 
In the foregoing, descriptions of well-defined cases of each 
form of insanity have been given, and some subdivisions, found 
useful in science, have been ignored as not having a place here. 
They are sufficient, however, to convey to the reader a correct 
idea of what insanity really is, and of the changes it produces in 
the individual. Absolute lines of demarcation cannot always be 
drawn, since the symptoms of different forms are sometimes so 
intermingled, or shade into each other, as to make the classifica- 
tion difficult except after a thorough examination of each case. 
Early Symptoms of Insanity. 
The outbreak of insanity may be sudden and entirely unlooked 
for; but there is usually a period of inception, during which such 
changes occur in the mental and physical condition, as, if properly 
interpreted, would indicate the danger which threatens. These are 
sufficiently common, in the great majority of cases, to be recog- 
nized as symptoms of an approaching attack. The first thing to 
be noticed, as an evidence of a disturbed condition of health, is the 
loss of the accustomed amount of sleep ; or there may be entire 
sleeplessness, continuing for several nights in succession. Head- 
ache is often present, either continuous or intermittent; general or 
limited to certain portions of the head. There may be a piercing 
or throbbing pain, a sense of weight, or of pressure, or of fulness, 
or a feeling as of a band drawn tightly about the head. There is, 
in some cases, great muscular restlessness; the person is almost 
continuously in motion, and unable to be quiet and ordinarily 
composed. In others there is a disinclination to muscular action, 
which is only overcome by strong effort and determination. 
There is either loss or variability of appetite, and disturbance of 
digestion, which soon affects nutrition. The natural functions of 
the system are sluggishly performed, and constipation of the bow- 
els and diminution of urinary secretion may follow. Disturbances 
of sensation are common, as flashes of heat or shivering, and 627 
INSANITY. 
coldness of the extremities. The countenance often loses the hue 
of health, and becomes sallow or pallid, and assumes a care-worn, 
haggard look. The skin is sometimes relaxed, and perspiration is 
profuse on slight exertion, or on the other hand it is dry and harsh 
and does not perspire. 
The first mental symptoms are manifest in the sphere of the 
feelings, by a departure from the normal emotional state to a con- 
dition of depression or excitement. A person becomes gloomy, 
unsociable, and inattentive in his domestic life ; seems absorbed in 
moody abstraction and loses interest in his affairs. Though he 
may continue regularly to attend to his ordinary duties, they are 
performed in a routine, listless, or anxious manner. He may have 
gloomy forebodings, or apprehensions of some vague danger that 
seems imminent. There is great indecision in forming judgments 
and in action. A decision made is regretted and recalled, and 
whatever action is taken the person is unhappy and unsettled and 
wishes he had done differently. Business may be distasteful and 
approached with dread, and yet the person cannot be induced to 
intrust it to another. 
At this stage there is frequently a realization of the true condi- 
tion, which is evident in the often-repeated remark : “ I do not 
know what is the matter with me ; I fear I am becoming insane.” 
In other cases the disease progresses without any declaration or 
recognition of the changed state. Restlessness and inability to 
apply the mind to external affairs increase, and the person is 
finally wholly taken up with his own unhappy state. After a longer 
or shorter period, suspicions and delusive ideas are openly ex- 
pressed, and then the melancholia is fully established. 
In another class of cases a stage of excitement follows, more 
or less closely, upon the first change to gloominess and depres- 
sion. The person becomes irritable, exacting, irascible, treats his 
friends and family with rudeness and harshness, is captious, un- 
reasonable, restless, and uneasy. As regards personal habits, there 
may be a loss of taste and care, or there may be over-nicety in 
dress, or an unusual indulgence in drinking, in the use of tobacco, 
or other excesses. Sometimes there is extravagant expenditure for 
the household or for personal adornment. In business relations 
the ideas are expansive, and transactions are made without ordi- 
nary care or caution. There is often an unnatural brilliancy and 
rapidity of thought, which, however, is neither logical nor con- 
trolled by judgment. Whatever is undertaken is either imper- 
fectly performed or left undone in the haste to attempt some new 
project. Confusion and irregularity take the place of order and 
system. Suspicions are often entertained of those who have been 628 
INSANITY. 
held in full confidence. This condition may continue for weeks or 
months before the friends appreciate the gravity of the case, and 
then, often, only when it terminates in an attack of acute mania. 
Treatment.—It is in the home-life of the individual that these 
changes occur, and it is during this period that treatment directed 
to the prevention of the attack must be employed. This can usu- 
ally be done only under the direction of a competent and judicious 
physician. Friends are generally powerless, as they fail to gain 
the confidence of the sick man and satisfy him that any action is 
necessary. If the physician is successful in this, an important 
point is already gained. A plain, truthful statement of the actual 
condition of the patient should be made to the friends, setting forth 
the changes in the mental and physical state, their import, and the 
danger which threatens. The patient should also be treated with 
candor and without deception, care being taken not to excite the 
fears unduly, so as to precipitate the trouble that it is desired to 
avert. There are certain requirements to be observed in the treat- 
ment, 
First : Diminish the hours of labor and responsibility ; increase 
the hours of repose. Sometimes it may be necessary to give up 
all business for a time and seek a change of all surroundings, or 
complete rest at home. In cases of depression, travel and an entire 
change of scene are often recommended, and in some instances 
are beneficial. They are not, however, to be advised indiscrimi- 
nately, as they are generally injurious when the patient is wearied 
by the annoyances of travel, or is too depressed to enter into the 
enjoyment of the incidents, and of the varied scenery of the jour- 
ney. It is only harmful to compel those who are in feeble health, 
and whose minds are so preoccupied with their own unhappy state 
as not to respond to the stimulus of active life around them, to 
leave the comforts of a well-regulated home and endure the dis- 
comforts of living in a hotel, and the irregularities inseparable 
from travelling. Such persons are more likely to be benefited by 
the care and nursing of friends at home, or, if any change is deemed 
advisable, it ought to be to some quiet place where ease and com- 
fort and proper treatment are assured. Change of residence is to 
be sought when depressing moral influences, unpleasant surround- 
ings, or unhealthy conditions exist at home. These will be readily 
appreciated both by the physician and friends. All efforts towards 
moral treatment should be tempered with judgment, avoiding such 
continuous effort to divert and amuse as annoy and weary the pa- 
tient, always remembering that notwithstanding there may be a 
semblance of health and vigor, the condition is one of debility and 
lowered vitality. 629 
INSANITY. 
Second : Sleep must be secured, if possible, in amount equal to 
that ordinarily demanded by the individual when in a state of 
health. Regular and early hours of retiring should be enforced ; 
these increase the probability of gaining repose and additional 
hours of sleep. Warm sponging of the body, and especially of the 
spine, allays muscular restlessness and is quieting to the nervous 
system. Bread and milk, warm gruel or beef-tea, or a glass of ale 
with bread or crackers, taken on retiring, often insure sleep. If 
these measures are ineffectual, the prescription of the physician 
should be employed. The remedies most commonly used are the 
elixir of the valerianate of ammonium, the bromides of ammonium 
or of potassium, opium in its various forms, hyoscyamus, cannabis 
indica, lupulin, sumbul, and chloral. The choice of the remedies, 
the amount and combination, depend so much upon conditions of 
the system, and the indications to be met in each individual case, 
that the medical adviser is the only one competent to direct. 
Third : The question of nutrition is one of vital importance. 
In most cases there is either a loss of appetite, a disinclination or 
a neglect to take sufficient food. This tendency on the part of the 
insane to neglect or to refuse to take a proper amount of food 
should be borne in mind, and also the additional fact that, to 
repair the constant and unusual waste of the system, nutritious 
food is absolutely demanded, and most frequently in quantity 
equal to that appropriated by the individual when in a state of 
health. It should be taken as a matter of duty, without reference 
to inclination or appetite. Much can be accomplished in this direc- 
tion by insisting, when practicable, that the patient continue the 
accustomed meals of the day and at the regular hours. Regularity 
in the habit of eating is too important an element of hygiene to be 
yielded to the desire of the patient or to his reiterated assurances 
that he cannot eat or does not need nourishment. 
If the supply of food taken at the regular meals is insufficient, 
additional varieties may be prepared, such as the patient is known 
to like, or such as will tempt the appetite. A full amount, of 
proper quality, without the restriction of dieting, is to be aimed at. 
Among the articles of nutriment, milk stands at the head. This is 
most readily obtained, the most universally acceptable, and the 
best; it can be given with the meal, or as a part of it, or the patient 
may be induced to take it between the regular meals of the day. 
If desired to increase the nutritive quality, eggs can be broken into 
it and sweetened to the taste. Gruel, soups of various kinds, or 
beef essence, all of which should be well seasoned and given warm, 
are eligible forms of nourishment. Fruits are valuable as acids ; 
they improve the secretions, act as laxatives, and often regulate 630 
INSANITY. 
the action of the bowels without the aid of medicines. By tact, 
persuasion, and by taking advantage of the moods of patients, 
sufficient nutritive material can usually be given, and it must not 
be neglected. 
Of the remedies to be employed to increase appetite and to meet 
the varying conditions presented in each case, the physician can be 
the only correct judge. The following are frequently prescribed : 
The preparations of iron, the vegetable tonics—as gentian, cin- 
chona and its alkaloids, quinia, etc.—columbo, quassia, nux vom- 
ica, strychnia, pepsin, lactic and hydrochloric acids, ale, wine, 
whiskey, cod-liver oil, phosphorus, ergot, the bromides, opiates, 
iodide of potassium, the various cathartic and laxative medicines, 
etc. There are few forms of disease in the proper treatment of 
which the skill of the physician and of the pharmacist are equally 
taxed. 
It is now left to consider what is to be done, when the early 
symptoms having passed unrecognized, or the efforts at preven- 
tion having proved unsuccessful, the disease has become fairly 
established, or where the outbreak has been sudden and severe in 
character. When there exists the ability to provide proper medi- 
cal attention, nurses, and care, certain classes of the insane may 
be retained at home : such as those with the mental enfeeblement 
of age, with paralysis, or general paresis without violence, cases 
of simple melancholia, of subacute mania, of chronic insanity 
and epilepsy without delusions tending to suicide or homicide or 
to the dislike of friends, and cases that are quiet and do not oppose 
care or the taking of food or medicine. On the other hand, forms 
of insanity characterized by delusions which may lead to destroy- 
ing life, or to resisting necessary care, or to the persistent re- 
fusal of food, or in which there is noise, violence, sleeplessness, 
destructiveness, exposure of person, obscenity or profanity, delu- 
sions of suspicion, of being poisoned or injured, or of dislike of 
friends, or where there are efforts to escape from the restraints im- 
posed at home, necessarily demand the means and mode of treat- 
ment which can only be found in the special care of a hospital. 
When the friends are unable to provide for the patient at home the 
public is usually called upon to assume the charge, and the insane 
person is then placed in an institution. Whatever the decision, 
whether the patient is to be kept at home or sent to an asylum, 
there should be no delay in placing him under proper medical 
care. The importance of this can hardly be overestimated, as 
statistics show conclusively that the shorter the duration of the 
disease the greater is the probability of recovery under appro- 
priate treatment. It is computed that of cases treated in asy- INSANITY. 
631 
Turns, where the insanity is of not more than three months’ 
duration, about seventy per cent, recover; while of those who 
have been insane for twelve months the percentage of recoveries 
is only about eighteen ; after a duration of two years the percent- 
age falls to an insignificant figure. Of those treated at home no 
statistics are available ; but it is considered a well-established fact 
that, considering all forms of insanity, the probability of recovery 
is largely increased by removal to an asylum. 
Insanity is essentially a chronic disease, and the morbid changes 
of the delicately organized nervous tissue are not recovered from 
until after a comparatively long period of continuous treatment. 
Under the most favorable conditions few recover in less than three 
months, more after six months, and a large number after one 
year. This should be taken into consideration in the decision as 
to place of treatment. Many would retain their friends at home 
if there was a favorable prospect of their recovery within a few 
weeks, as in many acute forms of disease, who would find it im- 
possible to care for them as many months. 
The annual death-rate among the insane in institutions, reck- 
oned upon the total population, varies from three to seven per cent., 
the general average being about five per cent. The highest rates 
are found in such as receive exclusively either the acute or chronic 
class in large numbers. The lowest percentage is in those which 
receive a mixed class in small numbers annually. The average 
duration of the insane life in those who do not recover is vari- 
ously given. The lowest estimate is eleven years and the highest 
twenty-one. The one quite generally accepted is about seventeen 
years. 
Asylums for the Insane. 
The manifestations peculiar to insanity led to the establish- 
ment of institutions for the care of the insane. For many cen- 
turies and till a comparatively recent period they were merely 
receptacles where the insane were imprisoned in cells, often loaded 
with chains, and at times left to die of starvation, in filth and 
squalor. The earliest asylum known existed at Jerusalem, in the 
fifth century. The insane colony at Gheel, in Belgium, was estab- 
lished in the eighth century, and still continues to receive patients, 
most of whom are quiet or chronic cases, who find homes among 
the surrounding peasantry. In the twelfth century there is said 
to have been an asylum at Bagdad. The Bethlem Hospital, of 
London, first received the insane at the close of the fourteenth 
century. After this period asylums were opened in France, Ger- 632 
INSANITY. 
many, and Holland. There was, however, little improvement in the 
care or the treatment of the insane in Europe down to the time 
of Pinel, in 1792. By the efforts and indomitable will of one man, 
the condition of the insane upon the Continent was greatly ameli- 
orated ; and the law of humanity and kindness received its first 
practical illustration there, when Pinel, in the Bicetre, one of the 
large asylums of Paris, released from their chains and brought 
into light and liberty fifty of the insane who had long been con- 
fined in a worse than penal imprisonment. 
In England, in 1794, the spirit of reform, instigated by the 
abuses of the asylum at York, induced the Friends to establish an 
institution of their own, the York Retreat, which, from the date of 
its origin, has been noted for the humane and enlightened princi- 
ples of its management. It was not, however, till some twenty 
years later, in 1815, that the investigation into the affairs of the 
Bethlem Hospital by a Parliamentary committee aroused the atten- 
tion of the people generally to the fearful condition and brutal 
treatment of the unfortunate lunatics, and brought about a series 
of changes which introduced the reign of humanity in the care of 
the insane in England. Progress thus begun, has, by successive 
steps, guided by the advance in medical science, raised the asy- 
lums of that country and of Europe to the position they now hold. 
In America, in 1750, or forty-three years before the movement 
of Pinel, the Pennsylvania Hospital at Philadelphia was organ- 
ized, and a department for the care and treatment of the insane 
was established, in which the system afterwards advocated by 
Pinel was anticipated, and the barbarous methods of treatment to 
which the insane were then exposed were abandoned. The act, 
as passed by the Provincial Assembly, provided “a hospital for 
the reception and relief of lunatics and other distempered and sick 
poor without partiality or preference.” This institution, the first 
projected on this side of the Atlantic, still exists as the insane 
department of the Pennsylvania Hospital, and during the whole 
period it has retained its position of prominence, and carried out 
the principles upon which it was founded. In 1773, the Eastern 
Lunatic Asylum, located at Williamsburg, Virginia, was organ- 
ized by legislative appropriation, and is therefore the oldest State 
Asylum in the United States. In 1797, the insane department of 
the Hew York Hospital, now known as the Bloomingdale Asylum, 
was opened for patients. During the same year the Maryland 
Hospital, at Baltimore, received a limited number of patients. This 
completes the list of asylums established in this country before 
the beginning of the present century. 
Institutions for the insane have been organized in nearly all 633 
INSANITY. 
the States, and in some of the Territories of the United States. 
They now number one hundred. Of these seventy-one are State 
Institutions ; ten are incorporated charitable institutions ; ten are 
city or county institutions, having a resident medical superinten- 
dent, and nine are private institutions. The latter have under 
care about two hundred and fifty patients. The total accommo- 
dations provided in organized institutions in this country are for 
about 30,000 patients. For the remainder, about 9,000, no ade- 
quate provision has been made. 
In the hospitals erected at the present time the intention and 
aim are to provide whatever can promote the recovery and the 
comfort of the inmates. The buildings are divided into wards, 
consisting of long halls or corridors, with rooms on the side. The 
wards are entirely separate, each having its own sitting, dining, 
and service rooms, thus practically making an asylum an aggre- 
gation of several communities, living under the same roof. This 
secures a classification, based on the power of self-control and 
upon the varying mental and physical condition of the patients, 
and promotes order and discipline. 
The best institutions, as now organized, are placed under the 
charge of a Board of Trustees, or Managers, who are responsible 
to the executive and legislative authorities of the State. The im- 
mediate control is vested in a Superintendent, or chief medical 
officer, who appoints his subordinate officers, subject to the ap- 
proval of the managers. Attendants are employed for their fitness 
and ability to perform the delicate and arduous duties of their 
position. In all their intercourse with the insane, kind and hu- 
mane treatment and attention to the wants of patients are en- 
forced by stringent printed rules and regulations, and by the con- 
stant and continuous supervision of the medical officers. This 
supervision extends to everything relating to the well-being and 
comfort of the insane—to the entire treatment which is divided 
into medical and moral. The former includes the hygienic and 
sanitary surroundings, the diet, and the administration of reme- 
dies ; the latter includes the exercise, occupation, amusements, 
recreation, and discipline, or the influence of mind over mind, 
which the sane exert over the insane, and the insane over each 
other. 
The special advantages of treatment in an asylum are : Re- 
moval from home and from the irritations of life there, with com- 
plete change of scene and of associations, which is often an impor- 
tant and necessary step in promoting recovery. It gives the patient 
the benefit of the skill and experience of those accustomed to care 
for the insane. It secures the advantages of moral treatment, 634 
INSANITY. 
directed to the wants of each individual case, and also of an insti- 
tution constructed and arranged with special reference to his vary- 
ing needs. It allows of more freedom than can be permitted else- 
where, especially in acute cases, and prevents the seclusion which 
is a necessity at home, and is usually only injurious. It protects 
the patient from injury to himself or others, and secures quiet, 
rest, and regularity of life. In the presentation of these advan- 
tages it largely enhances the prospect of recovery. 
Respecting the character of asylums, and the treatment of pa- 
tients therein, the knowledge of the people generally is quite lim- 
ited. Opinions are derived, for the most part, from sources that 
are not trustworthy or entitled to belief. They are formed largely 
upon the sensational reports of newspaper writers, or of novelists 
who sacrifice the truth to the plot of a story, or of patients who 
have been discharged uncured, and who delight to entertain the 
listener with marvellous accounts of their personal experience, and 
who misinterpret facts, or color them with the tint of their own 
delusive ideas. 
The strict seclusion of the insane, and the exclusion of visitors 
from asylums which has done so much to create suspicion and 
arouse prejudice, no longer exist. The personal visitation and in- 
spection which are now generally permitted are calculated to inspire 
confidence in their management, and to prove the advantages to 
be derived from care and treatment in hospitals for the insane. 
The quiet, neatness, system, and freedom from personal restraint 
characteristic of every well-conducted asylum, are in striking con- 
trast with the preconceived ideas of those who look for cells and 
chains, and expect to hear the noise and confusion of a veritable 
bedlam. 
Asylums of the present day are hospitals for the cure and care 
of the sick ; they are homes for the helpless and the incurable, who 
there receive skilled, considerate, and thoughtful care, which friends 
are often either unable or neglect to give them. They are not, as 
is sometimes thought and even asserted, places where sane people 
can be incarcerated by designing and interested persons. That 
some who are not insane are at times committed to them, simply 
shows the imperfection of human judgment, but does not reflect 
upon the intentions of those who commit them. A large number 
of those discharged as not insane, by officers of asylums, are sent 
thither after due examination, upon the order of a court or public 
official. Others, again, are cases of intemperance or vicious in- 
dulgence, in which the conduct of the individuals very naturally 
gives rise to the suspicion of insanity. Still another class of the 
not insane, are cases of delirium, or hysteria, which simulate in- 635 
INSANITY. 
sanity so closely as to deceive both the friends and medical prac- 
titioner. 
The law of commitment of the insane to asylums in most of the 
States creates a sufficient barrier against the improper confine- 
ment of the citizen. In some of the States a trial by jury is re- 
quired before a person can be sent to an asylum—an expensive and 
often injurious proceeding. In most of the States an examina- 
tion, under oath, by one or more, generally by two physicians, is 
required. In the State of New York the approval of a court to the 
medical certificates must be obtained before the commitment is 
legally made. 
Special attention was given to this subject, in this State, for 
some years, and in 1874 all the statutes relating to insanity were 
revised and codified. The provisions for the commitment of the 
insane, and for the visitation and supervision of institutions for 
their care, are as well guarded, efficient, and thorough as those of 
Great Britain, from whose statutes the various States have so 
largely copied in framing their laws. 
JUDSON B. ANDREWS, M.D. The Moijth and Teeth. 
BY 
FRANK ABBOTT, M.D., 
OF NEW YOBK CITY, 
PROFESSOR OF OPERATIVE DENTISTRY AND DENTAL THERAPEUTICS IN THE NEW YORK 
COLLEGE OF DENTISTRY, ETC., ETC. THE MOUTH AND TEETH. 
The mouth, properly speaking, comprises the greatest variety 
of separate organs of any portion of the body. Bones, teeth, 
muscles, mucous membrane, glands, nerves of common and special 
sensibility and of motor function, and blood-vessels, all enter into 
its construction. Its cavity serves not only as the receptacle for 
food undergoing mastication, but it also aids in the production of 
the voice, and, when the nasal passages are insufficient to allow 
the entrance and exit of the air needed in respiration, the opened 
mouth very greatly increases the available amount of air-supply. 
In infancy the movements of the tongue create a vacuum which 
draws milk from the breast, while in later year’s it serves to place 
the food so as to be best acted upon by the teeth, and in the playing 
of musical instruments it modulates the current of air and aids 
the lips in producing the vibrations in the current which cause 
musical tones. 
The bones which form its framework are rather appendages 
than integral portions of the case which holds the brain and which 
forms the great bulk of the skull, and they are peculiarly adapted 
not only to hold the teeth, but they also serve to protect the large 
blood-vessels which go to the brain, and to give prominence and 
expression to the lower part of the face. The teeth, which are 
firmly planted in bony sockets, are not only capable of seizing, 
cutting and grinding the articles used as food, but they also 
modify the voice in a very considerable degree. The upper jaw, 
being firmly attached to the under side of the skull, is immovable, 
but the lower jaw is so hinged that it moves quite freely in all di- 
rections. Several sets of muscles are provided which open the 
mouth and change its form, while others, which are among the 
most powerful, close the lower jaw and move it from side to side. 
Owing to peculiarities in their mode of development and to 
their complex character, the bones and other organs of the mouth 
are liable to a great variety of malformations and diseases, some 640 
THE MOUTH AND TEETH. 
of which are extremely painful or disfiguring in character. Some 
of these affections are unavoidable by any means yet known, 
while others by prudent forethought can be avoided, and their 
effects, with proper management, can be more or less relieved. 
The offices of the mouth are, the reception of food, taste, mas- 
tication, insalivation, and articulation, and it possesses organs for 
the fulfilment of these purposes. It is the beginning of the ali- 
mentary canal. Looking into the mouth we observe that it is an 
ovoid cavity, bounded behind by a veil or curtain (the soft palate). 
This falls obliquely downward and backward, having a central 
pendulous organ called the uvula, terminating laterally in arched 
curves. [See Fig. 115, p. 378.] Every part of the cavity is covered 
by a mucous membrane, which membrane we find associated ex- 
ternally on the lips with the common skin ; internally, we see it 
passing back of the soft palate down the throat. This mucous 
membrane, with some variation in its structure, lines the entire 
alimentary canal, as well as the air-passages. 
The Upper Jaw. 
The superior maxillary bone is one of the most important bones 
of the face. With its fellow 
of the opposite side, it consti- 
tutes the entire upper jaw. It 
is the largest bone of the face 
except the lower jaw. Each 
bone assists in the formation 
of three cavities: the roof of 
the mouth, the floor and outer 
wall of the nose, and the floor 
of the orbit. The superior 
teeth are inserted into it. The 
body of the bone is hollowed 
out in its interior, and forms 
a large cavity—the antrum of 
Highmore. This cavity is par- 
ticularly interesting from the 
fact that it is so often the seat 
of an abscess, produced by 
the death of the molar teeth, 
whose roots frequently either 
penetrate its floor, or are in such close proximity that an ab- 
scess produced by them will readily open into it. 
Figure 153.—Skull, showing the bones of the 
upper and lower jaws, and the teeth. THE MOUTH AND TEETH. 
641 
The Lower Jaw. 
The inferior maxillary bone is the largest and strongest bone 
of the face. It consists of a body, of horseshoe shape, and two 
branches joined to the body at nearly right angles. The branches, 
curved and angular at the base, terminate above in two processes : 
the condyloid, for articulation with the glenoid cavity of the tem- 
poral bone, and the coronoid, for the attachment of the large mus- 
cle of the temple which serves, with others, to close the jaw. 
The relation of the perpendicular to the horizontal portion of 
the bone varies in different ages. In early infancy the angle is 
very obtuse ; in fact the two portions are nearly on the same plane. 
In adult life a nearly right angle is acquired. As the teeth are 
lost, in old age, it again becomes obtuse. This accounts for the 
peculiar prominence of the lower jaw in old and toothless persons. 
The Teeth. 
The teeth, in the adult, are thirty-two in number, sixteen in 
each jaw, as follows : two central, and two lateral incisors, two 
Fig. 154. 
Figure 154.—The lower jaw of an infant. 
Figure 155.—Section of an incisor tooth, magnified, showing the pulp-cavity and the re- 
lation of the dentine and enamel. 
Figure 156.—Section through a molar tooth ; natural size. 
Fig. 155. 
Fig. 156. 
canines, four bicuspids, and six molars. They consist of three 
portions : a crown, which projects out of the gum. a neck to which 642 
THE MOUTII AND TEETH. 
the gum is attached, and a root, or roots, which set in the sock- 
ets formed in the alveolar processes of the jaw-bones. All the 
incisors and canines, both upper and lower, the second bicuspids 
in the upper, and all the bicuspids in the lower jaw, have but one 
root each. The first bicuspid in the upper, and the first and sec- 
ond molars of the lower jaw have each two roots. The first and 
second molars of the upper jaw have three roots each. The third 
molars, or wisdom teeth, both upper and lower, vary in their num- 
ber of roots from one to four, and sometimes they have even as 
many as five or six each. 
J'latarS 
JUeuspih 
Canine 
Frto'oDT* 
Wisdom too/h. 
-Fang 
- XeeJe 
—Crotvz. 
- Crown 
A!ar*± 
r*,.j 
’WVsrfom tooth. 
Molars 
JBf cuspids 
Cutiine 
Jncisrrs 
Figure 157.—Permanent teeth of the upper and lower jaws on the right side. 
Teeth are composed of three distinct structures : the enamel 
which covers the crown, and terminates at the neck ; the ce- 
mentum, which covers the roots, joining the enamel at the neck ; 
and the dentine, which forms the body of the tooth, in the centre 
of which the pulp is located, which is in shape very nearly the 
same as the tooth, and occupies in the crown about one-tliird of its 
diameter. 
The enamel is composed of about three parts in a hundred of 
organic material, which, besides forming a matrix, or frame-work, 
for the retention of the inorganic portion in position, consists, in 
part (very minutely of course), of living matter. The inorganic 
matter (ninety-seven parts in a hundred) is composed principally 
of phosphate of lime, with traces of fluerate of lime, carbonate THE MOUTH AND TEETH. 
643 
of lime, phosphate of magnesium, and other salts, rendering this 
portion of the tooth the hardest substance in the body. 
The dentine is composed of about twenty-eight parts, in a 
hundred of organic matter, and seventy-two of inorganic. The 
organic, as in the enamel, forms the matrix, into which the lime- 
salts are deposited, besides being composed in a greater degree, of 
lining matter. 
The cementum is composed of about thirty-three parts of or- 
ganic, and sixty-seven of inorganic material; and here the same 
condition of things exists as in the enamel and dentine : the organic 
portion forming the matrix for the deposition of the lime-salts, 
and sheaths for the protection of the living matter. 
At the junction of the enamel and cementum with the dentine, 
a more liberal distribution of the living matter takes place than is 
found in any other portion of the tooth structure, which accounts 
for the excessive sensitiveness experienced when they are cut in 
this locality. 
The pulp which occupies the central cavity in each tooth, is 
composed of capillary blood-vessels and filaments of nerve in 
great abundance, held together and in position by connective tis- 
sue. From this pulp the entire tooth is nourished and furnished 
with sensation, except the cementum, which receives its nourish- 
ment from the periosteum which lines the sockets in which they 
stand, and which is firmly attached to the roots. 
The teeth, thirty-two in number in the adult, are placed in ar- 
ticulating arches or curves upon either side, and are in shape and 
character midway between those characteristic of flesh-eating (or 
carnivorous), and vegetable eating (or herbivorous) animals. 
Certain of their number, the incisors, are so shaped and arranged 
as to cut, or incise ; the canines to tear, or more firmly hold upon 
substances ; the bicuspids and molars to comminute or grind. 
The teeth are intended to serve no less than four distinct pur- 
poses, viz., cutting or incising, masticating, to assist in the articu- 
lation of words, and to give a proper expression or contour to the 
mouth and face. The part they perform in the process of diges- 
tion is of incalculable importance to the health and comfort of 
every individual. The loss of teeth, particularly in front of the 
mouth, is detected in the pronunciation of many words, a sud- 
den loss of them often rendering the person incapable of speak- 
ing sufficiently distinct to be understood, and the changes in the 
expression of the mouth and face are so marked, that friends often 
fail to recognize. 
The roof of the cavity is a thin, bony wall between it and 
the cavity of the nose, and is covered by mucous membrane. 644 
THE MOUTH AND TEETH. 
If we continue to look into the mouth for a short period, we will 
observe that a fluid resembling water frequently flows up from be- 
neath the tongue just behind the incisor teeth. Also, by observing 
the inside of the cheek, we will see the same fluid flowing from a 
small orifice opposite the second molar tooth of the upper jaw. 
This fluid is saliva, and comes from glands situated in their respec- 
tive neighborhoods. The mucous membrane of the roof of the 
mouth, after it has been kept open a short time, is frequently seen 
to be covered by little drops. This is mucus, and is the product of 
the follicles or glands of the common membrane. 
The Tonsils are glandular organs, situated on either side of the 
opening from the cavity of the mouth into the pharynx. These 
bodies are almond-shaped in form, with many fissures lined by 
the common mucous membrane. They are quite frequently the 
seat of such chronic overgrowth as to necessitate their removal. 
In the fissures, particles of food are liable to lodge and become the 
source of foul breath. 
The Tongue is a complex structure, although it is made up 
principally of muscular tissue. It is attached to the inferior max- 
illary bone in front, and to the hyoid bone behind, and moves with 
the greatest facility in any direction. 
The tongue, a muscular body, rests within the lower dental 
arch. It evidently is fitted and suited to preside over the labor of 
the teeth; it receives or rejects articles to be masticated; places 
and retains such articles in position for that purpose, and, when 
they are ready to be swallowed, rolls them up into a bolus and 
passes them into the pharynx. 
First Dentition. 
The first or temporary set of teeth consists of twenty in num- 
ber, ten in each jaw, as follows : two central, and two lateral in- 
cisors, two canines, two first or small molars, and two second or 
large molars. They come into the mouth, or are cut, in the follow- 
ing order and age of the child : 
1st. The lower central incisors (a)— 5th to 7th month. 
2d. “ upper central “ — Gth to 9th “ 
3d. “ lower lateral “ (&)— 7th to 10th “ 
4th. “ upper lateral “ — 8th to 11th “ 
5th. “ first or small molars (c)—11th to 17th “ 
6th. “ canines (d)— 13th to 20th “ 
7th. “ second or large molars (e)— 20th to 30th “ 
It will be observed from the above table, that at the tender age THE MOUTH AND TEETH. 
645 
of five months, trouble with the teeth begins, which in too many 
instances never ceases, until they have all come and gone. 
The period of dentition is undoubtedly the most critical in the 
existence of children. It is during this period that the parents are 
in great anxiety concerning them, and the physician is often 
called in to examine the child’s mouth, to see if lancing the gums 
will not, in his judgment, afford some relief—an operation which 
should seldom be resorted to. When the case apparently demands 
such an operation, however, great care should be taken that the 
tooth or teeth are sufficiently advanced to readily make their 
way through the opening 
made by the lance before 
the gum heals over the 
cut. If it be done too 
early, a cicatrix forms, 
which is much harder for 
the tooth to penetrate 
than the gum would have 
been in its normal state. 
In lancing the gum over 
the front teeth, the cut 
should be made on a line 
with the edge of the 
tooth, over the back or 
molar teeth; a simple 
cut over the prominent point will generally afford the relief de- 
sired. In every instance the lance should penetrate deep enough 
to strike the tooth unmistakably, otherwise it will not relieve the 
child, but will heal over, thus increasing the difficulty and distress 
of the little one. 
In the great majority of cases, as soon as the teeth are all in 
place (cut), the services of a good dental-surgeon should be called 
into requisition. The molars often being imperfectly formed, im- 
mediately begin to decay, and should be filled before the decay 
progresses far enough to render the operation of filling painful. 
The dentist should be seen at least as frequently as once in 
every six months thereafter. By so doing, a great amount of 
pain for the child is avoided, and the teeth are kept in the mouth 
until it is time for them to be removed. The child is also taught 
to take proper care of the teeth, the benefits of which cannot be 
too highly estimated. 
The materials best adapted to the proper filling of children’s 
teeth, are amalgam and the preparations of gutta percha, on account 
of the ease and rapidity with which they can be placed into the 
Figure 158. —Primary or milk-teeth of the right side 
of the upper and lower jaws : a, the incisors ; &, the ca- 
nines ; c, the molar teeth. 646 
THE MOUTH AND TEETH. 
teeth. In most cases, gold or tin-foil requires too much force 
and too long a time to adapt them to the walls of the cavities 
perfect enough to prevent the tooth from further decay. A child 
should never sit in a dentist’s chair until it becomes fatigued; one- 
half to one hour being as long as they should be subjected to it. 
During the period from two and a half to six years of 
age, there is a marked 
change taking place in 
the front of the mouth. 
The teeth, which at the 
former age stood close 
to, and touching each 
other, have gradually 
separated, so that at 
the latter age they are 
frequently a sixteenth 
of an inch apart, and 
the jaws are nearly 
one-third larger than 
formerly. This change 
is due to the develop- 
ment of the perma- 
nent teeth in the jaws, 
and is indicative of 
regularity of the per- 
manent teeth when 
they come into the 
mouth. On the other 
hand, should it be ob- 
served that this sepa- 
ration does not take place, it is almost a sure indication that the 
permanent teeth will come in very irregularly. 
At the age of about six years, there is also a change taking 
place in the back of the mouth. The jaws have now grown suffi- 
ciently in that direction to accommodate another tooth on either 
side, which now present themselves behind the temporary molars ; 
they are the first, or sixth year molars of the permanent set. These 
teeth are often considered by parents as those of the first or tem- 
porary teeth, inasmuch as none of the first teeth have been taken 
out. Consequently, they are often neglected until hopelessly de- 
cayed. They are usually imperfect upon their grinding surfaces, 
thus forming lodgment for decomposing food, etc., and are conse- 
quently subject to early and rapid destruction by decay. They 
should be carefully examined as soon as they are through the 
Figure 159.—Set of milk teeth with the corresponding per- 
manent teeth still embedded within the jaw. The first perma- 
nent molars (a) have already emerged from the jaw both above 
and below, so that the second dentition has commenced. The 
somewhat inclined crowns of both permanent incisors are to be 
seen behind the roots of the milk incisors. The crown of the 
upper canine tooth (b), is quite sloping and is situated high up 
in its socket. The crowns of the permanent bicuspids are 
grasped by the roots of the milk molars. The crowns of the 
second permanent molars are still embedded in the jaws. THE MOUTII AND TEETH. 
647 
gums, and the slightest imperfections immediately filled. These 
are the largest and most powerful of the permanent teeth, and pre- 
senting as they do the greatest amount of chewing surface, it is 
very important that they should, in most cases, be permanently 
preserved. I say in most cases—occasionally a case presents itself 
where, by their removal at the age of from ten to twelve years, 
actual deformity of the face may be avoided; on account of the 
excessive size of all the permanent teeth, unless some of them 
be removed, the lower part of the face grows out of proportion 
to the upper. Again, these teeth may have become so badly de- 
cayed before any attention has been paid to them, that any effort 
to permanently keep them in the mouth would result in failure; 
in such case it would be best to have them removed. Under all 
circumstances, when thought advisable, from any cause, to re- 
move one of them, have its fellow on the opposite side removed 
also. Should this not be done (as is too often the case), quite a 
marked deformity of the face will be the result. As a rule, it is 
always the safest plan to have the entire four extracted, if any. 
Shedding- of Temporary Teeth. 
At this period, from the sixth to the seventh year, the shedding 
of the temporary teeth begins. Inasmuch as second dentition 
depends, in a great measure, for its proper accomplishment, upon 
the time at which the temporary teeth are removed from the 
mouth, I propose to give the proper time for such removal, and 
allow the permanent teeth in coming in, to take care of themselves, 
or rather let Nature take care of them. This I consider of much 
more importance than a discussion of second dentition proper. 
As in coming in, each tooth or pair of teeth (for they usually 
come in pairs, and should be removed in the same manner) of the 
temporary set has its time at which it should be removed from the 
mouth, in order that it shall not remain as an obstruction to the 
progress of the permanent tooth, which is to take its place, and 
which will almost immediately present itself through the gum. 
The time for their removal is usually indicated by their becoming 
loose; the loosening is occasioned by the absorption of then- 
roots, which is caused by the growth and progress of the perma- 
nent tooth beneath. See Fig. 159. 
The first to become loose and require extraction, are the central 
incisors of the lower jaw, which occurs between the sixth and 
seventh year. From six months to a year later, or between the 
seventh and eighth year, the central incisors of the upper jaw 
will become loose and should be removed. A few months later 648 
THE MOUTH AND TEETH. 
(during the eighth year) the four lateral incisors, two upper and 
two lower (the lower preceding the upper), present the same condi- 
tions and should be taken out. 
At this period the mouth often presents a very interesting and 
sometimes, to parents, an alarming condition. The four perma- 
nent incisors are so much larger, and occupy so much more space 
than the temporary ones which have been removed, that they are 
frequently very much crowded and irregular, so much so that the 
anxiety on the part of the parents becomes very great for fear of 
permanent irregularity, and the little one is taken to the dentist 
for the purpose of consulting him in reference to the advisability 
of removing the temporary canines in order to give room for the 
incisors to become regular. Of course the dentist advises that 
they should not be removed. Should he do otherwise, and take 
them out, the immediate result would undoubtedly be pleasing, 
but eventually the effect would be very unpleasant indeed, as it 
would produce a most unsightly irregularity. The root of the tem- 
porary canine having been so little absorbed, the permanent tooth 
being still so deep in the jaw, and requiring so long a time for its 
development and growth into its proper place, the permanent in- 
cisors, in regulating themselves, readily occupy the places of the 
temporary canine, if they have been removed. Should they not 
succeed entirely in doing so, the molars become pushed forward 
by the growth of the permanent molars behind, and thus, in the 
course of a year or two, no place Avhatever is left for the perma- 
nent canine tooth, and it presents itself some years later than it 
ought, usually in front and entirely outside the line of the other 
teeth. Such teeth are then called “tusks,” and, in too many in- 
stances, these most valuable teeth are sacrificed through the 
ignorance of the parents and attending dentist. 
The temporary canines should never be extracted to make room 
for the permanent incisors. Should the incisors come in irregu- 
larly, the effort of nature to regulate them will often result in the 
growth of the jaw and alveolar process, sufficiently to accomplish 
the desired end. 
There is usually a lapse of about two years after the removal 
of the lateral incisors before any other of the temporary teeth should 
require removal. We then (about the tenth year) find the first 
molars loosening, and they should be removed ; in their places 
will come the first bicuspids of the permanent set. About a year 
later (or the eleventh year) the canines will require removal, and 
the permanent teeth will soon make their appearance. These teeth 
are considerably larger than the temporary ones, and will, of course, 
require more room, which nature has provided in the case of the THE MOUTH AND TEETH. 
649 
second molars, which will require removal about the twelfth year, 
and which occupy much more room than is required for the second 
bicuspids which take their places. By a process which Nature 
usually takes care of, the first bicuspid is pushed back by the ca- 
nine, which in turn falls into its proper place. 
Recapitulation. 
1st. Lower central incisors should be extracted between the 6th and 7th years. 
2d. Upper “ “ “ “ about “ 7th year. 
3d. Four lateral “ “ “ “ “ 8th “ 
4th. First molars “ “ “ “ 10th “ 
5th. Canines “ “ “ “ 11th “ 
6th. Second molars “ “ “ “ 12th “ 
At about the latter period (at twelve years of age), the second 
permanent molar presents itself through the gum, and from eigh- 
teen to thirty the generally unwelcome 
Wisdom Teeth 
make their appearance. Sometimes, however, these teeth come 
into the mouth much later in life. I have a patient who cut the two 
upper wisdom teeth after the age of sixty years. It is not an un- 
usual thing for people to suffer very severe and protracted pains 
during the cutting, or rather on account of these teeth, particularly 
those of the lower jaw. There is frequently so little room between 
the second molar and the angle of the jaw, that, in their endeavor 
to take their proper places, they are tipped forward, and the crown 
is forced against the root of the second molar; its progress is then 
stopped, and an irritation is set up which often for months, perhaps 
for years, is the seat of most excruciating neuralgic pains, over 
the face, head, neck, and shoulder, causing, perhaps, deafness 
upon the affected side, loss of sight, etc., etc. Eventually, unless 
relief is obtained, an abscess will form, which will probably re- 
lieve the acute diffusive neuralgic pains, which then become local- 
ized in the neighborhood of the angle of the jaw. As pus begins 
to accumulate, the neck and face swell, sometimes out of recog- 
nizable shape. Should the abscess “ point ” into the pharynx, the 
patient’s life may be in great danger ; it is then that prompt action 
is necessary to prevent the patient from choking to death before 
the swelling is stopped by the discharge of the accumulated pus. 
When the dangerous position of these teeth above described is 
recognized, either by patient or dentist, undoubtedly the best treat- 
ment would be their immediate removal. It is, however, very 
often that they come in without very much trouble, except, that 650 
TIIE MOUTH AND TEETH. 
from the relation of surrounding parts, a portion of their crowns 
are sometimes kept for months under a flap of gum, which holds 
more or less decomposing food directly in contact with them, often 
resulting in quite extensive decay before the whole grinding sur- 
face is visible. 
DISEASES OF THE TEETH. 
Decay or Caries of the Teeth. 
Caries and tartar are said to be the two grand agents that give 
business to the dentists. At the head of these is caries, the most 
common and formidable disease to which these organs are sub- 
ject. Until within the past two years this disease was very 
little understood. Every writer upon the teeth from the time of 
John Hunter, of England, had, however, a theory as to its causes 
and progress, some claiming that it is altogether chemical in its 
operations, others that it is an inflammatory process, and others 
still, that it is produced and carried on by vegetable organisms, 
which are found in great numbers in the mouth, particularly where 
food is allowed to remain around and between the teeth until it 
undergoes decomposition. These organisms are also found in de- 
cayed cavities in the teeth in great quantities. That they play 
any important part in the origin or progress of the decay of teeth, 
however, is considered very improbable by educated dentists. 
After much labor and study with the microscope, it has pretty 
clearly been settled that caries first begins by the action of an 
acid, which, in a chemical way, dissolves out the lime-salts from 
the enamel. It would be quite natural to suppose that it would 
require a strong acid for the decalcification of so solid a tissue as 
the enamel of a tooth, and the question often arises, where does 
this acid come from ? First let us consider the starting-points of 
the morbid process. It is a fact that caries never begins upon the 
smooth surfaces of teeth which are exposed to the friction of mas- 
tication, but it always starts at points which, owing to their ana- 
tomical structure, form receptacles for food, etc., or between the 
teeth where, owing to want of cleanliness, decaying material can 
accumulate. The friction produced by the teeth coming in con- 
tact with each other does not produce caries, but it is to the acid 
generated from the decaying material retained between the two 
flat or concave surfaces which the teeth present to each other that 
the beginning of the destruction of the enamel is due. That this 
decaying material is food will hardly admit of a doubt; and in 
such kinds of food as, through their decomposition, produce an THE MOUTH AND TEETH. 
651 
acid, not very strong it is true, but which possesses a high degree 
of affinity for lime-salts, viz., lactic acid. 
First among the varieties of food ranks meat, which, by putre- 
faction, may produce free lactic acid; next are the saccharine ma- 
terials ; and last the amylaceous, which, being converted into 
glucose by the action of the saliva, may be transformed, if brought 
in contact with putrefying meat, into lactic acid. There is no 
doubt that the organic portion of teeth, as it advances to the stage 
of decomposition in the process of caries, plays a very important 
part in the formation of this acid. 
As soon as the lime-salts are dissolved out sufficiently to expose 
the living matter of the tooth, an inflammatory reaction takes 
place, which, in acute caries, penetrates the substance of the tooth 
to a considerable extent, producing a melting down of the organic 
portion (matrix), which then returns to its original or medullary 
condition. 
It is well known that the teeth of some persons decay much 
more rapidly than others ; this is due to the fact that they con- 
tain less lime-salts and more of organic material. Why this should 
be so is a question not easy to answer. We are told that such 
people inherited poor teeth from their parents ; then the question 
arises, why did the parents have such teeth ? Many teeth come 
into the mouth in an imperfect state ; more particularly is this the 
case with the molars and bicuspids, which predisposes them to 
decay; consequently they should always be examined as soon as 
they are through the gums, and the smallest possible imperfection 
thoroughly cleansed and filled. Imperfections of the enamel, 
occasioned by a severe and protracted illness of a child (such as 
scarlet fever, measles, etc.) during the development of the teeth, 
are quite frequently seen. In such cases the surfaces of the teeth 
should be made as smooth as possible by a dentist, and kept scru- 
pulously clean to prevent them from decay. 
There are certain physiological conditions which seem to pre- 
dispose teeth to decay, such as pregnancy, when there is an ex- 
cessively strong acidity of the fluids (not the saliva in its pure 
state) of the mouth, which acid readily acts upon the teeth. It is 
a very common experience with mothers to “lose a tooth with 
each child.” During this period the teeth should be examined 
often, and any carious places found should be filled temporarily 
with gutta-percha. * Asa preventive against caries at such times 
—or, in fact, at any time—it is wTell to rinse the mouth several 
* Severe operations upon the teeth during1 pregnancy are not only excessively pain- 
ful, but are attended with more or less danger, both to mother and child. 652 
THE MOUTH AND TEETH. 
times a day with a strong solution of bicarbonate of soda in water. 
This should always be done after taking any acid medicines, and 
also when the teeth are very sensitive, as it will, in a few days, 
render them almost painless to dental operations. 
Caries, when slight, will often produce toothache, and some- 
times severe facial neuralgia; more particularly is this the case 
when the decay is located at the necks of the teeth, and during 
pregnancy. Such pains, however, are more frequently caused by 
an irritated or inflamed pulp due to caries having penetrated the 
substance of the tooth until it has become exposed, or to perios- 
titis (inflammation of the periosteum surrounding the roots of the 
tooth), a condition liable to occur with any tooth, the pulp of 
which has been destroyed. By neutralizing the acid (which is 
always present in the cavities of decay) by rinsing the mouth 
every three or four hours with a solution of bicarbonate of soda 
in water (two teaspoonfuls of the soda to a glass of water), the 
pain arising from teeth when the pulps are not exposed will, in 
most cases, be readily allayed. When the pain is produced by an 
irritation of an exposed pulp, an application of oil of cloves, laud- 
anum, ether, or chloroform, on a small pellet of cotton, and covered 
over with a pellet of cotton dipped into a solution of gum mastich, 
or Canada balsam, in chloroform, will often quiet the pain tem- 
porarily. Creasote should never be used, except by a professional 
man, on account of the danger of doing severe injury to the sur- 
rounding parts. For further treatment the dentist should be con- 
sulted. 
Gum-boil—Alveolar Abscess. 
This is a very common disease, liable to occur in the mouth of 
any person; it is always caused by the decomposition in a tooth 
of a dead pulp, either entire, or of portions left, which, from the 
tortuousness or narrowness of the canals, it has been impossible 
to remove, or similar decomposition of the organic portion of the 
tooth structure, when the gases from it are allowed to exude into 
the pulp canal which has been imperfectly filled. 
Symptoms.—The first symptoms of an alveolar abscess are 
soreness of a tooth on closing the jaws, or to the touch. This sore- 
ness continues some ten or twelve hours before actual pain begins. 
If allowed to take its own course, the pain will continue for four 
or five days, increasing in intensity each day and hour, when it 
will gradually subside, and the face then begins to swell. The 
matter is commonly discharged through an opening, which occurs 
just outside the tooth in the gum at the point Avhere the swelling 
of the gum has been greatest. There afterward continues to be an 653 
THE MOUTH AND TEETII. 
opening at this point, unless the amount of matter discharged is 
small, when it closes for a time. In this case, a little pouting, 
nipple-shaped growth forms in most cases, as the matter accumu- 
lates ; the tooth again becomes sensitive, the little nipple rup- 
tures, and another escape of matter takes place, and so on in- 
definitely, until properly treated. 
Treatment.—During the period of swelling of the face, the com- 
mon and very bad practice is to poultice it. While this may pos- 
sibly allay the pain in a measure, it, at the same time, occasions 
the destruction of an unnecessary amount of tissue, besides tend- 
ing to bring the pus to the surface, where it will discharge, leav- 
ing, when cured, an unsightly scar and depression upon the face. 
The only treatment, after the swelling begins, that can he recom- 
mended before consulting a dentist, is the application to the face 
of ice, or iced-water. Professional treatment is always necessary 
as soon as the first soreness of the tooth is observed. 
Tartar, or Salivary Calculus. 
The fluid (saliva) which is almost constantly poured into the 
mouxh during the daytime, or wakeful hours, is, as before ex- 
plained, the product of various glands. It holds in solution inor- 
ganic or earthy matter (carbonate of lime), in varying quantities in 
different persons, which is liable, when thorough cleanliness of the 
teeth is not observed, to deposit upon them. During the process of 
deposition, mucus and particles of food are lodged in the intersti- 
ces, making it a concrete substance, from which fact the name tar- 
tar is given to it. The quantity of tartar deposited, as stated above, 
varies in different persons, as do also its chemical and physical 
characteristics. It is sometimes composed almost entirely of 
inorganic material (when it deposits very rapidly); sometimes the 
organic matter will be found to predominate. It is frequently 
found extremely hard, then again so soft that it may readily be 
removed with an ordinary toothpick. The various colors of tartar 
to be found in the mouth, are yellowish-white, light brown, dark 
brown, black and green. That which deposits the most readily, 
in the greatest quantities, and is the least injurious to the sur- 
rounding tissues, is the lightest in color. This is usually found on 
the lower front teeth, and on the upper molars, opposite the open- 
ings of the salivary ducts. It seldom lodges under the gum, but 
is attached to the enamel upon the crowns of the teeth, sometimes 
covering them almost entirely. The dark brown and black de- 
posits occur much more slowly and densely, but more universally, 
as all the teeth, both upper and lower, are liable to its visitation. 654 
THE MOUTH AND TEETH. 
It is usually found under the edges of the gum, firmly attached to 
the necks of the teeth, and presenting to the gum a rough surface 
which produces congestion, swelling, sponginess, and ulceration 
of this tissue, and absorption of the alveola. Unless interfered 
with, the accumulation increases, and the process of absorption 
goes on until the entire sockets of the teeth are destroyed, and they 
fall out, or are picked out by the patient. I presume that, after 
the age of thirty years, more teeth are lost from this cause than 
from all others combined. 
Aside from the danger of losing the teeth, there are other dis- 
agreeable features which accompany this condition, such as a 
had breath, soreness of the teeth in masticating, neuralgic pains 
through the face and head, and, often, impairment of the sight 
and hearing. If taken in season this can all be easily prevented. 
No amount of care one may bestow upon their own teeth, how- 
ever, will prevent this accumulation altogether, or remove it after 
it has accumulated. It is a condition which requires, and must 
have, the best of professional attention. 
The green tartar or, perhaps more properly called, “ stain,” is 
usually found upon the outer surfaces of the upper front teeth, 
more frequently of young persons. Unlike all other forms of tar- 
tar, it is of an acid nature, and usually produces caries of the teeth. 
Its presence is, in all cases, attributable to a want of proper clean- 
liness on the part of the patient, for when the teeth are kept clean 
by brushing, the green tartar or stain is never to be found. When 
once deposited, however, the services of a dentist should be sought 
at once, and its removal, and a most perfect polishing of the ena- 
mel, should be accomplished. 
Artificial Teeth. 
It is, unfortunately, a fact that notwithstanding the univer- 
sally acknowledged skill of American dentists in preserving natu- 
ral teeth, and the knowledge of the community in general, in the 
matter of proper care of, and attention to these organs, many 
people are obliged to submit to the disagreeable necessity of wear- 
ing artificial substitutes. The practice is altogether too common, 
among many dentists, to remove from two to six, perhaps eight or 
ten good teeth, which, with comparatively little trouble and ex- 
pense, might be kept and made to do good service for years, and 
to replace them with an artificial set, which possibly may look 
better than the old ones, but, for service, are a very poor substi- 
tute indeed. Very few plates, either partial or entire, are worn 
Avith absolute comfort. They are either loose and in danger of THE MOUTH AND TEETH. 
655 
falling, or rest against other teetli for support, which they soon 
render sensitive and cause to decay. Should the wearer experi- 
ence no real pain, there is a constant fear of some accident, such 
as the teeth coming off at most inopportune times, when in com- 
pany, at dinner, for instance, or the plates being thrown from the 
mouth when coughing, sneezing, or when seasick, and so forth. 
Recognizing the fact, however, that the necessity exists for 
the wearing of plates of some kind, the questions most people are 
interested in, more than any others, are, what are the best ma- 
terials, and how should they be fitted to and worn in the mouth to 
insure the greatest amount of comfort to the wearer ? 
For full sets, either upper or lower, the best materials are gold, 
platinum (continuous gum), or porcelain, for the reason that they 
contain no poisonous ingredients, and are good conductors of heat 
and cold. The mucous membrane covered by the plate is kept in 
a much more healthy condition than it is under rubber or celluloid, 
each of which contains more or less poison (red oxide of mercury); 
and they are both non-conductors of heat and cold, consequently 
the mucous membrane covered by them is kept at a high degree 
of temperature constantly, which often results in a very severe 
congestion of the parts, which may, and often does, extend to the 
throat and air-passages. It has recently been ascertained, that 
through this constant irritation produced by wearing these plates, 
the hearing is often very seriously affected, and I have no doubt 
that the eyes may suffer just as much, although this particular 
branch of the subject has not been carefully investigated as yet. 
Partial plates are, if anything, more distressing to the wearer 
than even entire dentures. The habit of too many dentists is, in 
putting a few teeth in the front of the mouth, for example, to carry 
the plate back on either side, to the extreme back molars, and for 
its support it is braced against each tooth, covering one-lialf or 
two-thirds of their inner surfaces, thus holding decomposing food 
constantly against them. This sooner or later produces an irrita- 
tion and absorption of the gums, exposing the necks of the teeth, 
which soon decay and become extremely painful and annoying, 
besides forming an opening for the lodgment of tartar which, if 
allowed to go on, soon loosens the teeth, and eventually makes 
them sore to bite upon, and finally they are lost altogether. 
For partial plates, the best material, and the most comfortable 
to wear, is undoubtedly gold or iridio-platinum, for, with either of 
these, much less room is taken up in the mouth than with any 
other material. They are good conductors of heat and cold, and 
can be so adjusted as to be held in place, either by atmospheric 
pressure, or by clasping to two or three teeth. If by the former, 656 
THE MOUTH AND TEETH. 
they should stand away from the insides of the teeth, at least three- 
sixteenths of an inch ; if by the latter, the plate should stand the 
same distance away from all teeth, except those clasped. With 
care (taking them out, and thoroughly cleaning them two or three 
times a day, and at the same time carefully cleansing the teeth 
clasped), such partial plates may be worn with comparative com- 
fort, and with very little or no injury to the other teeth for many 
years. 
All plates should be removed from the mouth at night, so that 
any irritation produced by them may, in a measure, be allayed. 
No person should ever go to sleep with a partial plate in the mouth, 
as there is great danger of its becoming dislodged, and carried 
into the throat. 
Individual Care of the Teeth. 
The proper care of the teeth is a subject very little understood 
by people in general, although it is claimed by those who pretend 
to take any care of them at all, that they follow the directions of 
their “ professional adviser,” notwithstanding nearly all they do 
is in the wrong direction. 
As soon as a child cuts its first teeth the cleansing process 
should begin by rubbing them with a bit of linen, and, as soon 
as it is old enough to allow a brush in the mouth, it should be 
used at least twice a day. This should be kept up through its 
after-life. The proper time for brushing the teeth is in the morn- 
ing after breakfast, and before retiring at night. A very narrow 
brush should be used, so that an up and down or rotary motion 
may readily be produced. Brushing the teeth across is productive 
of irritation and absorption of the gums and alveolar processes, ex- 
posing and cutting the necks of the teeth, which are liable, sooner or 
later, to decay. After brushing, and also after each intervening 
meal, a toothpick (quill) and floss silk should be passed between the 
teeth to remove any particles of food not dislodged by the brush. 
The necessity of these precautions will readily be seen, when the 
fact is taken into consideration that acids generated from decom- 
posing food, left around and between the teeth, is the primary 
cause of decay. 
Use of Tooth-powders and Mouth-wash. 
Once each day a proper dentifrice should be used, for the rea- 
son that with this the teetli can be kept clean with much less 
brushing than with water alone ; the least amount of friction pro- THE MOUTH AND TEETH. 
657 
duced upon the teeth and gums, which will clean them from parti- 
cles of food and mucus, is always preferable. A powder consisting 
of one part of precipitated chalk, one part of powdered castile soap, 
and one part of powdered orris-root, flavored wuth rose, winter- 
green, sassafras, etc., to suit the taste, is as good as can be made. 
No dentifrice should ever be used with acid in it, nor any sub- 
stance so coarse or sharp-cutting as to injure the enamel of the 
teeth, such as pulverized cuttle-fish, pumice-stone, or charcoal. 
Washes, so far as cleansing the teeth proper is concerned, are 
of no use whatever. The most of them, I am aware, are recom- 
mended and used, on account of their astringent properties, which, 
if the teeth are kept free from accumulations of tartar and food, is 
never needed. Bleeding and spongy gums are caused by tartar, 
etc., which must be carefully removed. The gums will then as- 
sume, and remain, in a healthy condition, provided proper cleanli- 
ness is observed. 
Action of Medicines upon the Teeth. 
The impression is widespread, that medicines of any descrip- 
tion, if taken in large quantities for a long time, produce very in- 
jurious effects upon the teeth. That those impressions are well 
founded, so far as some medicines are concerned, there can be no 
doubt; but the great majority of drugs are as harmless to the 
teeth as cold water. Unfortunately, however, those which do harm 
to these organs, are needed, and are prescribed more frequently 
perhaps, than any others. They are the preparations of mercury, 
iron, quinine, and the mineral acids. Mercury, while it retains 
the liquid metallic state, is inert, but when taken internally, as in 
blue pill, for instance, it is thought to combine with the chlorine 
of the hydrochloric acid in the gastric juice of the stomach, form- 
ing a chloride, and thus becomes active. The vapor of this metal 
frequently proves injurious, in some instances exciting saliva- 
tion, ulceration of the mucous membrane of the mouth, etc. Some 
of its compounds are violent caustic poisons. It is, however, more 
frequently administered in the form of blue pill, or the mild chlo- 
ride of mercury (calomel). When given in large doses, the mucous 
membrane of the mouth, and the salivary glands take on increased 
secretory action, and become irritated and inflamed. The gums 
first show the mercurial influence by tenderness and swelling. 
The whole mouth soon becomes sore, the tongue is swollen and 
protruded, the saliva and mucus flows excessively, sometimes to 
the extent of several pints a day. At the same time the breath 
acquires a peculiar fetid odor, and the patient perceives a metallic 658 
THE MOUTH AND TEETH. 
(coppery) taste in the mouth. When it is pushed too far, or ad- 
ministered to persons peculiarly susceptible to its action, a train 
of very serious symptoms, such as excessive salivation, ulcera- 
tion of the gums, loosening, and perhaps loss of the teeth, and 
sometimes death of the alveolar processes and jaw-bones, follow. 
Should the teeth retain their positions in the mouth through the 
above described disturbances, the injury to them will be very 
serious notwithstanding. From the excessive inflammation of the 
gums, their proper nutritive supply is interfered with to such an 
extent that they become detached from the necks of the teeth, 
thus forming receptacles for tartar, which collects so suddenly, 
and to such an extent, that it requires all the skill of a dentist to 
prevent their ultimate loss from this cause. 
Treatment.—In cases of salivation, the best and most simple 
remedy to use is chlorate of potash—a half-teaspoonful to a glass 
of water, or the same amount of common salt in a glass of water, 
to rinse the mouth and gargle the throat with, every hour or 
two. 
The preparations of iron are some thirty in number ; there are 
only two, however, which exert any marked effect upon the teeth, 
except to discolor them, viz.: the tincture of the chloride of iron 
(muriated tincture of iron), and the solution of the nitrate of iron; 
this last, however, is very little used. The first of these is proba- 
bly more frequently prescribed than any other, if not all other 
preparations of this metal, on account of its astringent as well as 
restorative effect. It contains muriatic and nitric acids, which 
are employed in its manufacture. Both muriatic and nitric acids, 
even when very much diluted, have a great affinity for the lime- 
salts of the teeth ; and it is no uncommon thing to see teeth very 
badly decayed from the effects of this preparation of iron. 
Quinine, if taken in a dry state, or in the form of pills, can pro- 
duce no injurious effects upon the teeth, but in order to make a 
solution (the form in which it is often prescribed, for the purpose 
of obtaining a more ready action), it must be dissolved in water 
acidulated with sulphuric acid. The acid reaction of the mixture 
is quite enough, however, if proper care is not taken, to produce 
destruction of the teeth in a comparatively short time. 
In malarial districts teeth decay more rapidly than in other 
localities, because iron and quinine are taken in large quantities 
in the form of liquids, as described above, and I have no doubt 
that the bad teeth of Americans may, in a great measure, be ac- 
counted for, by the fact, that malaria is always much more preva- 
lent in new countries, and that these acid preparations of iron 
and quinine are taken in such enormous quantities. Diluted sul- THE MOUTH AND TEETH. 
659 
phuric acid, diluted nitric acid, diluted muriatic acid, and diluted 
nitro-muriatic acid, are all administered, more or less frequently, 
as tonics. They all have a decided affinity for the lime-salts of 
the teeth, and dissolve them away very rapidly, unless great pre- 
caution is exercised. During the time any medicine containing 
a mineral acid is being taken, the mouth should be rinsed with a 
solution of bicarbonate of soda in water (a heaping teaspoonful to 
a glass of water), four or five times a day, in order that the acid 
may be so neutralized that the teeth cannot be injured by it. 
Some Peculiarities of Dentition. 
It has been prophesied that the time may come when the human 
race will become altogether toothless. As far as my observations 
have gone, however, the present indications are not particularly 
flattering for the immediate fulfilment of such a prophecy, but 
such cases do occur, now and then. The writer knows of two 
well authenticated cases : one, a gentleman who formerly lived in 
Rochester, and the other a lady residing a few miles out of Albany, 
in this State. Whether these two isolated cases point to a like 
condition of things throughout the entire human family, at some 
far distant day, I should hardly venture to suggest. 
On the other hand, there are frequently found old people who 
say they have their third set of teeth, and I believe there are cases 
on record where it is believed such a thing has occurred. I never 
have seen such a case myself, however, and conclude that the teeth 
coming into the mouth so late in life, are either supernumerary 
teeth—so called—or are those of the second set, which have been 
kept from taking proper positions on account of the crowded and 
irregular condition of the teeth, or from malposition in the jaws. 
FRANK ABBOTT, M.D. Diseases of the Digestive 
Organs. 
BY 
FREDERICK A. CASTLE, M.D., 
OP NEW YORK CITY, 
VISITING PHYSICIAN AT THE PRESBYTERIAN HOSPITAL; ATTENDING PHYSICIAN IN THE OUT- 
DOOR DEPARTMENT AT BELLEVUE HOSPITAL; LECTURER ON PHARMACOLOGY 
IN BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC., ETC. DISEASES OF THE DIGESTIVE 
ORGANS. 
An English writer, I think it was, said that John Milton would 
never have written Paradise Lost, had he not suffered from dys- 
pepsia ; and Thackeray, in his “Roundabout Papers” remarks: 
“ Ah ! what a poet Byron would have been had he taken his meals 
properly, and allowed himself to grow fat—if nature intended him 
to grow fat ”— . . . . “If that man had respected his dinner, 
he would never have written ‘ Don Juan. ’ ” 
Without doubt much of the incapacity for mental and physical 
labor which does not absolutely put a stop to active exertion; 
much of the worry and low spirits which are out of proportion 
to their tangible causes, and much of the suffering which may not 
always attain to positive illness, are to be traced to derange- 
ment in the function of one or more of the digestive organs. 
While other causes may lead to these derangements, imprudence 
in eating, or improper articles of diet, are doubtless to blame in the 
majority of cases. Individual peculiarities exist, it is true, in 
many instances, and render such persons more than ordinarily 
liable to stomach and intestinal disturbances ; but even in these 
cases experience should soon teach what habits of eating and 
kinds of food ought to be avoided. 
Popular writers on medical topics often assert that inhabitants 
of the United States are more troubled with digestive derange- 
ments than the people of other countries, and claim that this is 
because of the general use of improper modes of cooking. It is 
doubtful, however, if such causes are more active here than 
elsewhere, since the forms in which food is taken, as well as the 
substances used, are largely the result of experience as to what 
things are best adapted to the climate, modes of life, and circum- 
stances of those who are chiefly concerned. It is not unreason- 
able to presume that all communities would be the better for in- 
creased knowledge upon this, as well as upon most other subjects. 664 
DISEASES OF THE DIGESTIVE ORGANS. 
If any exception were to be made to tlie above in the case of 
our own people, it would apply to the farming population. Many of 
this class are well able to afford a better dietary than that to which 
they accustom themselves, but they often lack either the knowl- 
edge or inclination to obtain it, and, as compared with the middle 
. classes of large cities, are much the poorer fed. With abundant 
opportunities for procuring fresh and wholesome food, they often 
depend largely upon salted, smoked, and otherwise preserved 
meats; forego the use of farm-products that have a marketable 
value ; neglect the making of a kitchen-garden in time to secure 
an early supply of fresh vegetables, and resort to modes of cooking 
which, while involving the least amount of labor, are calculated to 
produce disturbance of health and more or less permanent impair- 
ment of the digestive functions. 
Hot only is the food appropriate for different ages various in 
kind, but it should, within certain limits, be adapted to different 
climates and modes of life. Speaking generally, however, it is de- 
sirable that as much variety as possible should be aimed at in the 
selection of food, since too monotonous a diet is apt to lessen the 
appetite and throw an excess of labor upon particular portions of 
the digestive apparatus. During infancy, food which requires the 
action of teeth, will, if taken, fail to meet, at other points in the 
alimentary canal, with the fluids which are also needed for its dis- 
integration. So, also, in old age, the stomach and intestines may 
fail to provide the means for digesting food, the structure of which 
makes mastication essential, but which the toothless jaws are 
incapable of performing. 
So much has been said and written about the harmful effects of 
over-feeding that most people have failed to appreciate that under- 
feeding may be even worse. In most cases of indigestion from 
over-feeding the trouble is chiefly limited to disturbance of the 
digestive organs, and, unless too frequently repeated, is often of 
temporary duration. When, however, persons, and especially 
children, become habituated to too a diet, however well diges- 
tion may be performed at first, it will ultimately suffer in many 
cases, because the blood fails to contain the material out of which 
the digestive fluids are formed, just as it also fails to provide the 
elements needed for the growth of the body. Instances are not 
uncommon in which the health of children becomes seriously im- 
paired, and future development is rendered imperfect, owing to ex- 
cessive solicitude on the part of parents and others that they 
should not eat too much. In schools for girls, especially, too re- 
stricted or monotonous a diet (united with too strict an adherence 
to routine work and amusement) may lead to greater impairment DISEASES OF THE DIGESTIVE ORGAN'S. 
665 
of health than could ever come from occasional over-feeding. It 
seems in some such cases, that, owing to the fact that the stom- 
ach is never fairly put upon the stretch, it fails to hold as much 
food as the nourishment of the system requires, and whenever 
food is taken, a feeling of satiety is reached which puts an end to 
further eating, even before a sufficient amount has been taken to 
nourish the body. In the days when tight lacing was fashionable 
and compression of the waist about the stomach and liver was often 
so great as to leave a permanent notch in the latter, the inability to 
take a full meal was quite explainable, and it is, perhaps, not sur- 
prising that in time it came to be considered unlady-like for a girl 
to eat as much as her brothers. 
DERANGED DIGESTION, OR DYSPEPSIA. 
There are few diseases affecting the body generally which are 
not attended with more or less disturbance of the functions of 
digestion. Indeed, many persons are accustomed to attribute to 
some trouble of this sort every attack of illness from which they 
suffer, and the majority, perhaps, of domestic remedies are of 
a nature to affect the digestive organs in one way or another. 
In many acute diseases the prospect of recovery depends largely 
upon the ability of these organs to accomplish their work, while in 
other maladies of a more chronic nature, it is an incomplete per- 
formance of digestion, and, consequently, imperfect assimilation 
of food, which greatly complicates the symptoms caused by the 
disease. 
None of the symptoms connected with indigestion are ex- 
clusively characteristic of affections of the stomach and intes- 
tine, but the same symptom may sometimes be the result of quite 
dissimilar causes, so that persons not experienced in such matters 
may quite easily be misled. This fact makes it the more difficult 
to popularize the knowledge of this class of affections, or to give 
more than an outline of their nature and treatment, such as may 
serve to place the reader on his guard against allowing them to 
occur, or attempting to do that which had better be left to the 
judgment of a physician. 
The symptoms which are most commonly referable to diseases 
of the digestive organs are : difficulty of swallowing, loss of appe- 
tite, inordinate or unnatural appetite, nausea, vomiting, hiccough, 
foul breath, belching up or eructation of gases, water-brash, heart- 
burn, discomfort located between the shoulder-blades or in the 
abdomen, swelling of the belly, perceptible movements and noises 666 
DISEASES OF THE DIGESTIVE ORGANS. 
in the belly, infrequent or too frequent movements of the bowels, 
and unnatural character of the evacuations. In addition to these 
are certain other derangements which arise from disturbed diges- 
tion or disease of the digestive organs, which will be considered 
later. (See page 679.) 
Solid food should always be well chewed before it is swallowed. 
This is necessary not only because it is thus rendered more easily 
acted upon by the gastric and intestinal juices, but it also is then 
mixed with saliva and bubbles of air. The former is of service in 
digesting starch, and stimulates the mucous membrane of the 
stomach to secrete gastric juice; the latter, by its admixture with 
the morsel of food, renders it porous and more capable of being 
digested. When food is “bolted” in unchewed masses, it fre- 
quently irritates the mucous membrane too powerfully and causes 
dyspepsia. Moreover, the fluid taken with it is not thoroughly 
mixed with the contents of the stomach so as to render the latter 
a soft, pulpy mass on which the gastric juice acts freely, and it 
is not until the excess of fluid has been absorbed that digestion 
takes place. 
Although, as mentioned in the chapter on Anatomy, the quan- 
tity of gastric juice secreted during digestion is very considerable 
—amounting, it may be, to several pints—at no time is the quan- 
tity actually present very great, since, as rapidly as food is di- 
gested, it is dissolved in the gastric juice, and both together are 
absorbed into the circulation. The stomach continues to pour out 
fresh portions of the juice, and so the process goes on until 
stomach-digestion is ended. If, however, such absorption is in- 
terfered with, digestion is rendered difficult, and the contents of 
the stomach become unnatural. The active element in gastric 
juice is called pepsin. In order that it may act upon the contents of 
the stomach, the presence of an acid is necessary. Such an acid is 
formed in the stomach, and is now commonly believed to be hy- 
drochloric. Certain other acids are capable of aiding this change 
in the food, but none are so efficient as the one named. When- 
ever the proportion of acid during the course of digestion falls 
below a certain limit, the process is retarded or altogether ar- 
rested, and thus fermentative changes may take place. In some 
cases there may be a deficiency of pepsin, but this is not so often 
a cause of tardy digestion as want of acidity. 
The contractions which the walls of the stomach undergo during 
the presence of food have the effect of keeping its contents in con- 
tinual motion, so that fresh portions are constantly brought into 
contact with the mucous membrane, moistened with gastric juice, 
and then mixed with other portions of the mass. These contrac- 667 
DISEASES OF THE DIGESTIVE ORGANS. 
tions have, however, none of the force of those which occur in 
the thick and powerful gizzard of fowls, and exert no such grind- 
ing influence upon the food as is there observed. When they 
are arrested, as during powerful mental emotion, or as a result of 
paralysis, the rapidity of stomach digestion is very considerably 
retarded. 
Stomach digestion ordinarily occupies two to three hours, and 
is not only unaccompanied with any feeling of discomfort, but, on 
the contrary, most healthy persons, after taking a full meal, ex- 
perience feelings of contentment and pleasurable emotions which, 
in themselves, favor rapid digestion. When, however, on account 
of ill-health, or the sudden occurrence of business or disturbing 
emotions, digestion is rendered tardy or altogether arrested, the 
contents of the stomach cause irritation of its walls, and there 
follows a sense of weight and discomfort. After a time, owing to 
the stoppage of digestion, and the presence of conditions capable 
of causing fermentation, decomposition takes place, unnatural 
acids and gases are formed, and the person suffers from heart- 
burn, belching up of gas, bloating of the stomach, and increase of 
the sense of weight and discomfort, occasionally amounting to 
pain at the lower end of the breast-bone and between the shoul- 
der-blades. Sometimes vomiting occurs and the stomach is 
emptied, but more often the contents escape into the intestine 
and there produce further trouble. 
When the starchy elements of vegetables are not acted upon 
by saliva, the mucus of the stomach and the intestinal fluids effect 
their digestion, but it is probable that this is not so thoroughly 
accomplished as it would have been with the aid of the saliva. 
Moreover, when they have not been properly soaked with water 
in cooking or in the stomach, so as to swell and soften their 
grains, and they are passed into the intestine without such 
change having occurred, their digestion by the intestinal fluids is 
apt to be correspondingly slow, and they undergo decomposition. 
The effect of this is to render the fluids of the intestine acid in- 
stead of alkaline; to distend the bowel with gases, and, by the 
irritation produced, to lead to colic and diarrhoea. 
Fat, still held in the connective tissue which encloses it as it is 
deposited about the muscles and in other parts of animals used as 
food, is sometimes not set free in the stomach, but escapes 
while still solid into the intestine. The pancreatic juice and bile 
which have the property of emulsifying it, or separating it into 
minute drops (such as exist in milk) fail, then, to fit it for absorp- 
tion, and it either escapes unchanged from the body, or is only 
partly digested. Both in the stomach and intestines it may un- 668 
DISEASES OF THE DIGESTIVE OEGANS. 
dergo changes which convert it into substances unfit for absorp- 
tion, and irritating to the mucous membrane of the bowel. 
The nature of intestinal digestion is less understood than that 
which takes place in the stomach. It consists mainly, however, 
in the continuation of the process commenced in the latter and the 
conversion of fats, starch, and sugar into substances capable of 
being absorbed. The agents which accomplish these changes are 
the pancreatic juice, the bile, and the fluid secreted in the upper 
portion of the small intestine. It is here that many of the products 
of digestion are absorbed by the blood-vessels and lymphatics with 
which the mucous membrane is abundantly provided. 
Feeble persons who are badly nourished, in whom digestion 
as well as other functions are sluggish, often derive marked bene- 
fit from taking one or another of the malt preparations. What- 
ever quickens moderately the contractions of the muscular coats 
of the intestine, and increases the secretion of fluids poured out by 
its glands, helps to improve the digestion of its contents. Rhu- 
barb, in small doses frequently repeated, and nux vomica given 
in a similar manner, are classed among these agents. 
Loss of Appetite. 
This symptom is common to most diseases which are attended 
with fever, or which alter, in any considerable degree, the char- 
acter of the blood. Anything which stimulates the secretion of 
gastric juice commonly increases the appetite—such as the thought 
of inviting food, and the effects of bitter, alkaline, or pungent sub- 
stances upon the mucous membrane lining the stomach. In this 
way the various vegetable bitters, alcoholic drinks—especially ale 
and beer—red pepper, mustard, hot sauces, etc., produce their ef- 
fects. Active exercise in open air, by quickening the circulation, 
hastens the flow of blood in the mucous membrane of the stomach, 
as well as in other parts of the body, and in this, as well as other 
ways, leads to an increase of appetite. 
Unnatural Appetite. 
In convalescence from acute diseases, and in cases of anaemia 
and chlorosis, in which the blood is lacking in the elements out of 
which gastric juice is formed, the capacity of the stomach to per- 
form its office may be, for a time, quite limited, and although the 
appetite may be craving, food should be taken in less amount than 
in health and at shorter intervals. It is the irritation of the mu- 
cous membrane in such cases by undigested food which sometimes DISEASES OF THE DIGESTIVE ORGANS. 
669 
causes relapses in typhoid, typho-malarial, remittent, and other 
fevers. In such cases the food taken during the first weeks of 
convalescence should be of the most easily digestible character. 
When the mucous membrane of the stomach is subjected to 
prolonged irritation ; when worms or masses of undigested food 
are in the small intestine ; in certain diseases of the nervous sys- 
tem ; in some chronic diseases of the stomach and bowels, and 
sometimes during pregnancy, or in the disease known as chloro- 
sis, we observe an unnatural appetite. Such persons not uncom- 
monly prefer unwholesome things to those which they formerly 
preferred. 
The Treatment of this symptom varies with the cause that pro- 
duces it. In disease of the nervous system the diet of the patient 
needs to be regulated by some one whose judgment is more relia- 
ble than that of the patient. The freaks of appetite of pregnant 
women will pass away in time of themselves, and no hesitation 
need be felt about denying them the gratification of their wishes 
in this respect, for fear of harm to the infant. 
Persons who are in feeble health have often a certain degree of 
derangement of the mucous membrane of the stomach, which ac- 
counts for their perverted appetites, and the use of subnitrate or 
subcarbonate of bismuth, in doses of a scruple, thrice daily, when 
the stomach is empty, may be of service. 
When irritation by worms is the cause, their expulsion by such 
remedies as are mentioned under the head of Intestinal Worms 
(see Yol. I.), will be all that is required. When the morbid appe- 
tite follows prolonged fasting, food should be allowed at first only 
in very small quantities and at short intervals. 
Nausea. 
This may be a result of unpleasant emotions, or disagreeable 
smells or flavors. It very commonly follows the presence of irri- 
tating substances in the stomach, and is also caused by unnatural 
movements of the body—as in whirling, swinging, riding back- 
ward, the movements of a boat, etc. When carried to an extreme, 
nausea is followed by a feeble pulse, paleness and coldness of the 
surface, perspiration of the face, sighing, respiration, and, finally, 
by 
Vomiting-. 
When the movements of vomiting-, or the retching as it is 
called, are continued, the lower opening of the stomach is re- 
laxed and admits the contents of the first portion of the small in- 670 
DISEASES OF THE DIGESTIVE ORGANS. 
testine. This is said to be owing to the peristaltic or “ worm-like ” 
movements of the intestine becoming reversed, but it is quite as 
likely that it is the result of the squeezing to which the small in- 
testine is subjected by the abdominal muscles. 
With the first portion of the intestinal contents which thus en- 
ters the stomach, we commonly have a quantity of bile which had 
already been in the intestine, or is expelled from the gall-bladder 
during the efforts of retching. It is supposed by many people 
that it is the presence of bile in the stomach which gives rise to 
retching, whereas, in fact, the reverse is usually the case. 
When the vomited matter contains blood, there is reason to 
suspect the presence of ulcer of the stomach, cancer of the stomach, 
or some equally serious affection. The occurrence of this symp- 
tom should lead to the immediate procurement of the services of 
a physician. 
Vomiting is sometimes a symptom following blows on the head 
or obstruction of the intestine, and is often seen in the commence- 
ment of scarlatina. Pregnant women are often much troubled 
by it. 
Treatment.—Simple nausea may be relieved sometimes by a 
stimulant, such as five drops of camphor, or a teaspoonful of com- 
pound spirit of ammonia, or of compound spirit of lavender in a 
half-wineglassful of cold water; going into the open air ; rest on 
the back ; the application of a mustard poultice to the pit of the 
stomach ; two drops of tincture of ipecac in a tablespoonful of cold 
water, repeated at intervals of ten to fifteen minutes ; ten drops of 
chloroform in two tablespoonfuls of water—any one of these may 
be resorted to with a fair prospect of relief. 
Should vomiting occur, it is often well to aid, at first, the thor- 
ough emptying of the stomach by drinking warm salted water, but 
when this is accomplished, continued retching serves only to render 
the muscles of the abdomen painful, to cause congestion of the mu- 
cous membrane of the stomach, and to force the contents of the 
upper portion of the intestine into the stomach, and thus add to 
the trouble. In such case the remedies above named may be re- 
sorted to, and small lumps of ice may be swallowed without chew- 
ing them. 
When blood is vomited the patient should be kept absolutely 
quiet in bed, and on the back. Iced water, if it is available, 
should be applied over the stomach by means of cloths, or enclosed 
in a bladder or India-rubber bag. Small lumps of ice may be 
swallowed from time to time. The temperature of the legs and 
arms should be kept up with the aid of bottles filled with hot 
water. A doctor should be sent for at the earliest opportunity, DISEASES OF TIIE DIGESTIVE ORGANS. 
671 
and the messenger should be instructed to explain the nature of 
the accident. For several days after a hemorrhage of this kind 
has occurred, only the very mildest form of food should be taken. 
Indeed, it is better for a day or two to take food by the bowel ex- 
clusively, and for a considerable period thereafter to subsist upon 
milk. 
When the vomiting occurs in a case of intussusception or rup- 
ture, or when it is a symptom of gastric ulcer, or cancer of the 
stomach, it should be arrested as soon as possible and without 
resorting to the salt and water. When it is owing to a blow upon 
the head, or when it occurs during pregnancy, a dose of twenty to 
thirty grains of bromide of potassium or bromide of sodium in 
a wineglassful of water will often prove serviceable. Other reme- 
dies appropriate for the latter condition will be found in the chap- 
ter on Obstetrics. 
Hiccough. 
This is commonly the result of eating too rapidly or too abund- 
antly, or is caused by irritating articles of food and drink. Drink- 
ing rapidly a considerable amount of cold water will produce it, 
and it is also seen in the last stages of some exhausting diseases. 
Treatment.—The quickest way to relieve hiccough caused by 
over-eating or by alcoholic drinks, is to give an emetic. When 
it is caused by eating too rapidly, it will, ordinarily, soon pass off 
of itself. At such times it may also be of service to take a single 
swallow of cold water or a small lump of ice. Taking a full breath 
and holding it for a time, will sometimes stop the spasm. 
Foul Breath 
may be caused by escape from the stomach of gases which result 
from decomposition of food, but it may also be due to the presence 
of decomposing food in cavities in the teeth or tonsils, disease of 
the nasal passages, consumption, chronic bronchitis, or other dis- 
eases of the chest, or it may be owing to the escape through the 
lungs of the odor of substances in the blood. When gas escapes 
from the stomach, it is usually a couple of hours or more after 
eating. 
Treatment.—Coarsely powdered charcoal is often of service as 
a temporary corrective. A tablespoonful may be taken in a half- 
glass of water. When it is of frequent occurrence, digestion 
should be aided by doses of ten drops of dilute hydrochloric acid, 
taken shortly after eating, in a wineglassful of hot water. 672 
DISEASES OF THE DIGESTIVE ORGANS. 
Water-brash or Pyrosis 
is the raising of an alkaline or brackish fluid, sometimes in con- 
siderable quantity, but more often to the extent of a few mouth- 
fuls only. It occurs when the stomach is empty of food, and the 
fluid bears no resemblance in taste to gastric juice, which is de- 
cidedly sour. 
Treatment.—The remedy most resorted to is subnitrate or sub- 
carbonate of bismuth in scruple-doses, taken when the stomach 
is empty, say about one hour before meals. When the water- 
brash is of frequent occurrence, the use of all alcoholic drinks 
should be avoided. 
Heart-Burn or Sour Stomach. 
This is often owing to some product of faulty digestion of fats, 
and is liable to occur after eating pastry and other articles con- 
taining fat that has been overheated in cooking. 
Treatment.—When the character of the food is not the cause, 
but there appears to be an excess of gastric juice, one of the 
simplest remedies is a piece of bread or a cracker. It is customary 
to take, also, a half-teaspoonful of baking-soda in water, or soda- 
mint, or a glass of carbonic acid water to which a little bicarbonate 
of soda has been added. The soda in these cases neutralizes the 
acidity of the gastric juice, but is apt to stimulate the secretion of 
more. When the fatty food is the cause, the best remedy is an 
emetic, unless there are reasons which make it undesirable to pro- 
duce vomiting. Bicarbonate of soda, as above recommended, or 
a teaspoonful or two of calcined magnesia in a little water, are 
likewise serviceable. 
Discomfort in the Stomach and Bowels. 
This symptom has many degrees of severity; from the uncom- 
fortable fulness caused by flatulence or by over-eating, to the 
burning, stabbing pain of inflammation of the belly, the acute 
pain of neuralgia of the stomach, or the passage of a gall-stone 
along the bile-duct. The discomfort is not always greatest at the 
seat of the trouble causing it. 
A feeling of weight is often felt at the lower end of the breast- 
bone, or at the “pit of the stomach” in chronic dyspepsia and in 
ulceration, and cancer of the stomach. In the former it is not 
unusual to meet also with pain in the back, just between or a 
little below the points of the shoulder-blades. DISEASES OF THE DIGESTIVE ORGANS. 
673 
In diseases of the spinal column, and in the one known as acute 
dropsy of the brain, there is often pain in the belly. In some forms 
of uterine disease there is pain and tenderness on one or the other 
side, low down in the belly, or along the lower margin of the ribs 
on the left side. When the bladder is over-distended, pain is felt in 
the lower part of the belly, and extends into the genitals. Enlarge- 
ment of the spleen, and congestion or inflammation of the liver 
may be attended with pain or discomfort in their respective regions. 
In colic of the large intestine, the pain is situated midway between 
the breast-bone and the navel, and is spasmodic in character. 
Pain on the right side, and about opposite the point of the hip- 
bone, may be a symptom of over-distention or inflammation of 
the commencement of the large intestine. In diarrhoea there is 
usually a feeling of bearing down, and of dragging, griping pains 
in the entire belly. During the passage of gravel from the kid- 
neys to the bladder the pain is intense; it is greatest about the 
navel, and shoots downward into the genitals. 
Swelling of the Belly. 
When this is sudden and variable in amount, it is com- 
monly due to distention of the bowel with gas. In hysterical 
women this sometimes occurs with great rapidity, but it is ordi- 
narily owing to fermentation or decomposition of the contents of 
the intestine, and is accompanied with a rumbling and movement 
of wind from one part of the bowel to another. It is a not unusual 
effect of an ordinary cold, or of other causes which arrest di- 
gestion, and may continue to give trouble for several days. At 
intervals temporary relief follows the escape of gas. When the 
bloating is considerable, it prevents descent of the diaphragm dur- 
ing respiration, and the movements of breathing are proportion- 
ately quickened, especially in men, while women, who uniformly 
breathe with the upper part of the chest, suffer comparatively 
little inconvenience in this respect. Tympanitis, or flatulence, as 
this condition is called, is a prominent and painful complication of 
inflammation of the peritoneum. 
Among the accidents which may result from flatulence, one of 
the most important is rupture or hernia. This most often occurs 
in the groins, where large blood-vessels pass into the thighs, or 
where the spermatic cords in the male, and round ligaments in 
the female, enter the abdomen. It may occur at the navel in 
women whose abdominal walls have been over-stretched by 
dropsy, pregnancy, etc., but it is most often seen in this situation 
in babies whose navels have not entirely healed ; who have been 674 
DISEASES OP' THE DIGEST1VP; ORGANS. 
too tightly bandaged, and who, together with flatulent bowels, 
have prolonged fits of crying.* 
It is not uncommon for women who have borne children to 
mistake the movement of gas in the intestine for the motions of a 
child in the uterus, and to persist in their belief in spite of the as- 
surance of their physician that pregnancy does not exist. 
Enlargement of the belly is also caused by dropsy; by tumors; 
by excessive fatness ; by enlargement of the liver or spleen; by 
dilatation of the stomach; by accumulatian of faeces in the large 
intestine, and by pregnancy. The proper distinction between 
these conditions will usually require some skill. 
Enlargements due to the liver, stomach, or spleen, commence 
above, and gradually extend downward. Ovarian tumors are first 
noticed below, and to one side (usually). The enlargement due to 
pregnancy is attended with signs described in the chapter on Ob- 
stetrics (see Vol. I.). Accumulations of faeces are most often 
noticed on the left side, and are firm to the sense of touch. A cor- 
responding enlargement on the right side, opposite the point of 
the hip-bone, occurs in over-distention or inflammation of the com- 
mencement of the large intestine (see page 692). Sometimes the 
bladder becomes so enormously distended as to simulate the condi- 
tions just described, and require skilful observation for a recog- 
nition of its true character. 
Treatment.—When flatulence is due to fermentation of food, a 
dose of two to four teaspoonfuls of Rochelle or Epsom salt in warm 
water, with the addition of a few drops of essence of peppermint, 
will clear out the intestine. When it has existed for some time, 
and the bowel has become over-distended, ten drops of tincture of 
nux vomica (for an adult) in water, every two hours, until four or 
five doses are taken, or a pill of three to five grains of assafoetida, 
followed by a saline purgative such as just mentioned, will be ser- 
viceable. In these latter cases, relief will follow the wearing of a 
flannel bandage constantly about the belly, provided it be pinned 
snugly. The treatment appropriate to the other forms of enlarge- 
ment is mentioned elsewhere. 
Diarrhoea. 
This is not a disease in itself, but is merely a symptom that ac- 
companies very many conditions of ill-health. Speaking1 gener- 
ally, it consists of excessive frequency of stools, the matter passed 
being greater in quantity and more fluid than is natural. It may 
* See also, Chapter on Obstetrics and Section on Hernia. DISEASES OF THE DIGESTIVE ORGANS. 
675 
be caused by such mental emotions as anxiety or fear, and is, 
from this cause, seen among soldiers in the commencement of a 
battle; among students about to appear for examination, or in 
the case of persons in court awaiting a summons to the witness- 
box. It may be owing to excessive irritability or inflammation of 
the intestine, the peristaltic or worm-like movements of the gut 
becoming so increased in frequency as to expel its contents before 
the fluid portion has time to be absorbed. Or it may be the result 
of stimulation of the mucous membrane by the presence of irri- 
tating substances, like undigested, fermenting, or putrid food, or 
the presence of an excess of food or fluids, etc. It is ordinarily 
attended with feelings of discomfort or pain in the belly in pro- 
portion to the activity with which the intestine contracts upon its 
contents. 
Diarrhoea is most common in hot weather, when the nervous 
system is exhausted by long-continued heat. When it is very 
prevalent in any particular locality there is reason to suspect the 
contamination of the drinking water with filth from sewers, 
drains, cesspools, and barn-yards. 
The Treatment of diarrhoea depends largely upon the nature of 
its cause, but whatever that may be, its arrest is favored by re- 
maining quiet in bed ; by warm applications to the belly, and by 
the use of some form of opium in small doses repeated after each 
stool. 
Specific directions will be found further on in this chapter in 
connection with the section relating to diseases of the intestine. 
Constipation and Costiveness. 
These terms are often used in the same sense, but really they 
have different meanings. In constipation, the amount of matter 
discharged from the bowel does not vary much from what is nat- 
ural, but it is evacuated at too long intervals; whereas in the con- 
dition known as costiveness, not only may the evacuations be less 
frequent than natural, but the actual amount is considerably les- 
sened. It is, without doubt, owing to their diminished quantity 
that the discharge in some instances is so infrequent. 
Constipation has a great variety* of causes. For example, in 
certain diseases of the nervous system the muscular coat of the 
intestine is rendered more or less inactive, and fails to propel its 
contents toward the rectum. In others these muscular fibres are 
in a state of spasm, and by rendering the canal too small for the 
ready passage of its contents, favor its accumulation and reten- 
tion. During some forms of inflammation of the intestine the dis- 676 
DISEASES OF THE DIGESTIVE ORGANS. 
charge of fsecal matter ceases for a time. In some instances, pres- 
sure by a pregnant uterus or by a tumor narrows the cavity of the 
bowel so as to arrest its contents. Strictures, such as are men- 
tioned in the sections upon Hernia and Intussusception, collec- 
tions of worms and undigested food, have the same effect. Inflam- 
mation of some portion of the abdominal contents may bind down 
the intestine so as to lead to stricture, but, more frequently than 
to all of these, is constipation due to habit. 
Ordinarily, the rectum in adults becomes filled with faeces in 
about twenty-four hours, and when a condition of moderate dis- 
tention is reached—as is likely to be the case after a night’s rest— 
the first meal taken in the day stimulates the muscles of the intes- 
tinal canal to more active contraction. The rapid addition to the 
contents of the rectum causes it to react, and they are expelled. 
If, however, the desire to empty the rectum is resisted, it grows 
tolerant of its contents and so, in time, becomes accustomed to 
retain a larger amount of matter. When once overstretched in 
this manner it is some time before it recovers its tone, and it be- 
comes again and again over-filled, until the condition of over-dis- 
tention and corresponding weakness of its muscular coat are more 
or less permanent. 
The collection of masses of hardened fseces in the rectum leads 
not only to over-distention of its walls, but by interfering with the 
return of blood from the lower portion (which is commonly empty), 
the large veins of the mucous membrane become stretched, and 
form knots or swellings called hemorrhoids or piles. In the case 
of females, the uterus is crowded out of place, and the free circu- 
lation of blood in it is interfered with—producing derangement of its 
functions. Pressure upon the nerves which pass out at the deep 
notch in the rear of the pelvis, gives rise to neuralgia of the lower 
extremities. 
When faecal matter is too long retained in the higher parts of 
the large intestine, it undergoes absorption of its fluid portion, 
which is taken up by the blood. With the latter phenomenon 
there is not infrequently absorption, also, of so-called excremen- 
titious substances which poison the blood and thereby affect the 
whole body. It is not uncommon to meet cases of the latter descrip- 
tion in which the persons liaTO headache, loss of appetite, disturb- 
ance of digestion, and some fever—symptoms usually attributed to 
“ biliousness ”— all of which are completely relieved by the action 
of a purgative which clears out the lower portion of the bowel. 
The relief which has followed the use of a cathartic at such times 
has, without doubt, led to the very common resort to such a practice 
by people who are slightly out of health from any cause. Such 677 
DISEASES OF THE DIGESTIVE OllGANS. 
symptoms as those just mentioned may, however, be due to very 
many other causes, and not infrequently the action of a brisk 
purgative when the bowel was not in need of it, has had most un- 
fortunate results. 
I well remember a gentleman who suffered from fatty disease 
of the heart, and who, thinking to relieve his feelings of ill-health, 
took three cathartic pills. The weakness which followed the ac- 
tion of the medicine was so great that he had barely strength 
enough to get from the water-closet to his room, and by the time 
a physician could be summoned from his house—next door—the 
feeble heart had stopped beating, and the man was dead. 
Costiveness is owing, in most cases, to deficiency in the amount 
of fluids secreted by the intestinal tract or excreted from the 
blood ; to deficiency of food, or to the fact that the food taken con- 
sists largely of substances which are capable of being absorbed into 
the blood, leaving little residue to pass out by the rectum. 
This condition is very often met with in growing girls, who are 
tall for their age, badly nourished, hysterical, have a sluggish cir- 
culation, cold extremities, and a variable appetite. The latter 
symptom is not always present, however, since cases occur in 
which the appetite appears to be good, and the usual amount of 
food is taken, but in which the actual amount of faeces passed is 
lessened, and generally is in the form of small, firm lumps, coated 
with mucus. 
In nearly all acute diseases attended by fever, costiveness is a 
notable symptom, and it is not infrequent, in pneumonia for ex- 
ample, for a week or more to go by without a movement of the 
bowel having occurred unless as the effect of medicine. 
Treatment.—When neglect to empty the rectum is the cause, 
regularity in going to the water-closet, or drinking, on rising, a 
glass of cold water to which a teaspoonful of salt has been added, 
will ordinarily be quite sufficient if it is continued for a few days. 
The custom of eating fruit, such as an apple, or an orange, imme- 
diately after rising, is often sufficient to secure a movement of the 
bowel at the usual time. When the rectum has been over-distended 
it should be emptied with the aid of an enema of soap-water, and 
thereafter an injection of a small amount of cool water may be 
taken twice a day for several days, so as to cause the bowel to 
contract and prevent any accumulation of matter. 
Among the laxative medicines which it may sometimes be de- 
sirable to take, there are few better than the compound licorice 
powder, of which senna and sulphur are the chief ingredients, or 
the elixir of buckthorn bark. Either of the above may be taken in 
doses of one to two teaspoonfuls mixed with water. 678 
DISEASES OF THE DIGESTIVE ORGANS. 
When the bowel fails to be emptied regularly during an attack 
of acute disease, the necessity for resorting to the use of cathartic 
medicine had better be left to a physician. 
Constipation caused by spasm of the intestine commonly yields 
to the use of extract of belladonna, in doses of a quarter of a grain 
every four or five hours. When it is caused by pressure on the 
gut, and such pressure can be relieved, this should be done in 
preference to using purgatives. When the intestine is sluggish 
in its action, kneading and shaking the belly will often afford 
relief. When it is a result of stricture, enemas of salt and water 
(a tablespoonful to a quart) or soap-water is the only safe thing 
to be recommended here. When due to an intussusception or a 
hernia, the only remedies to be thought of are those which will 
relieve the obstruction. 
When persons in comparatively good health suffer from cos- 
tiveness, it is always safer and better to increase the quantity of 
food taken, or to add to the regular diet articles which increase 
the bulk of the faeces, such as coarse and raw vegetables, fruit, 
wheaten grits, oatmeal, rye bread, corn-meal puddings, etc., than 
to resort to the habitual use of medicines. 
Changes in the Appearance of Faecal Matter. 
During adult life, changes in the character of matter discharged 
from the bowel in health are mainly due to the nature of the food 
and drinks taken. When the food contains undigestible particles, 
like seeds, husks, woody-fibre, etc., the irritation which they create 
increases the activity of the bowel and causes loose stools. An 
excess of drinks will have a similar effect upon their consistence. 
During illness attended with fever, the odor of the faeces be- 
comes unnatural, and sometimes exceedingly offensive. When 
the liver is inactive, or the bile is retained in the gall-bladder, 
the faeces become light in color, resembling clay, and have an un- 
usually offensive odor. In some rare cases the duct of the pan- 
creas becomes obstructed, and the pancreatic juice is not poured 
into the intestine during digestion. In such cases the fatty matter 
of the food is not absorbed, but passes out of the bowel. Then, 
also, is the faecal matter extremely offensive, and the fat some- 
times hardens, as the motions cool, into a waxy mass. 
When blood escapes into the intestine from the rupture of a 
blood-vessel, or is discharged from the stomach, into which bleed- 
ing has taken place, the motions become tar-like, as during the 
first hours after birth, and they may also have a very offensive 
odor. The same effect follows the employment of enemas of fresh DISEASES OF THE DIGESTIVE ORGANS. 
679 
blood, when the quantity used is greater than can be absorbed 
through the intestine. 
Congestion of the mucous membrane of the bowel gives rise to 
loose and watery stools, whether the congestion be due to the 
presence of irritating food or other substances, or to inflammation of 
the mucous membrane, as in the inflammatory diarrhoea of sum- 
mer, or the ulceration of the intestine • following extensive burns 
of the skin, or as one of the conditions present in typhoid fever. 
In epidemic cholera and in cholera morbus, the stools lose en- 
tirely their natural character, and consist of an acid fluid, having 
a slippery feeling when rubbed between the fingers, and holding a 
large quantity of flaky bodies in suspension, giving it the appear- 
ance of rice-water. The cause of this condition is sufficiently ex- 
plained in the section on Cholera. 
Worms of different kinds inhabiting the intestine, as well as 
their eggs, are occasionally found in the stools. (See Intestinal 
Worms.) 
There is a form of inflammation of the bowel in which mem- 
branous casts of its inner surface are discharged with the stools. 
In other cases portions of the mucous membrane itself appear. In 
cases of intussusception (see Vol. I.), portions of the bowel may 
become separated, and come away. Gall-stones, matter from ul- 
cerating surfaces, and foreign bodies that have been swallowed, 
are also occasionally found in the frnces. 
In dysentery, blood and mucus are expelled, and there may be, 
for a time, an arrest of natural stools. Piles, too, give rise to 
bloody stools. In dysentery, the stools have commonly quite a char- 
acteristic odor. 
Other Symptoms of Dyspepsia. 
There are a number of symptoms which may have their origin 
in derangement of the digestive apparatus, but which, on account 
of their apparent lack of such connection, frequently mislead 
the sufferer and cause unnecessary anxiety. Among these the 
most common are dizziness, headache, loss of memory or inability 
to use the mind continuously, irritable temper, low spirits, short- 
ness of breath, palpitation or irregular action of the heart, trem- 
bling and weakness of the muscles, change in the color of the skin, 
and pains in the back and sides. 
The occurrence of the first group of symptoms connected with 
the brain, sometimes leads to the belief that softening of the brain, 
apoplexy, paralysis, or some other disease of the nervous system 680 
DISEASES OF THE DIGESTIVE ORGANS. 
is threatened. A little attention to the digestive function will 
show, however, that the latter is in some way deranged, and fol- 
lowing its restoration the head symptoms will disappear. 
Palpitation and shortness of breath likewise cause some persons 
to believe that they have disease of the heart or lungs. 
Muscular weakness and trembling may not only attend dis- 
turbed digestion, but they also are due to too prolonged abstinence 
from food. Women who have no appetite for breakfast, and who 
are attacked with fits of “ weakness ” about the middle of the day; 
persons who are addicted to the immoderate use of alcoholic 
drinks, and who therefore take too little food ; business men, who 
neglect to take a lunch in the middle of the day, and who, it may 
be, have taken but a light breakfast, owing to the diversion of 
their minds by reading a morning paper or being called away to 
other affairs while they were eating, are among the number who 
suffer from this symptom. Not unfrequently, their coffee or morn- 
ing cigar have been blamed for the trouble, and in the case of ine- 
briates it has been counted among the effects of alcohol upon the 
nervous system. In numbers of such instances, however, a plate 
of hot soup, a glass of milk, or a cup of chocolate and milk, will 
speedily relieve the trembling, and a resort to an alcoholic stimu- 
lant, as a “ pick-me-up,” is entirely uncalled for. Indeed, it is like 
the spur used on a jaded horse, and adds none of the strength 
which comes from taking some form of quickly digestible nourish- 
ment. 
To recapitulate :—Dyspepsia, indigestion, or painful digestion, 
is not in itself a disease, but is a symptom that may attend various 
conditions of ill-health. 
It may temporarily follow some indiscretion in eating or drink- 
ing, especially at a time when, from fatigue or ill-health, the stom- 
ach fails to perform its office, or : 
It may be owing to actual disease of some one or more of the 
organs of digestion resulting from prolonged misuse of them, or 
coming on in the course of other diseases. 
When following temporary causes, in a person otherwise 
healthy, no medicine is usually needed, but rest, abstinence in 
eating and drinking for two or three days, will restore health. 
When the trouble is more constant, the habits of life may re- 
quire to be altered, and remedies may be used for the various 
symptoms, as before enumerated. When these do not prove soon 
efficacious, a physician should be consulted. DISEASES OF THE DIGESTIVE OIIGANS. 
681 
DISEASES OF THE DIGESTIVE ORGANS, 
Stricture of the Gullet or CEsophagus. 
A constriction or narrowing of the gullet may be owing to 
spasm of its muscular coat at some portion of its length—as in 
hysterical persons, or when something irritates the nerve going to 
these muscles. It may be caused by the pressure of a tumor—such 
as an aneurism or dropsy of the heart-sack. When corrosive poi- 
sons are swallowed or when, in other ways, ulceration of the 
mucous membrane lining this tube is produced, a narrowing of its 
calibre is pretty certain to follow if the patient survive for any 
length of time. 
Even a moderate constriction causes difficulty in swallowing, 
and is apt to lead to dilatation of that portion of the tube above the 
narrowed part. Cases occur in which this pouch-like dilatation 
retains for a time a large portion of the food swallowed, until, 
finally, it is expelled from the throat without having ever entered 
the stomach. 
Symptoms and Results.—In these cases the difficulty of swal- 
lowing, and the discomfort which attends the act are among the 
most prominent symptoms. Hysterical cases ultimately recover. 
Those caused by the action of corrosive poisons, ulcerations, can- 
cer, etc., may after a time cause such obstruction to the passage 
of food, as to reduce the sufferer to a process of slow starvation. 
Treatment.—Fluid or very soft food should be the only form 
taken, and enemas of nutritious substances should be used as 
freely as possible, in order to avoid the irritation caused by the 
passage of food through the strictured portion of the gullet. A 
smooth bougie should be passed through the stricture at regular 
intervals by a physician, so as to dilate it. 
Inflammation of the Stomach—Gastritis. 
This is a quite common disease, if we limit the meaning of the 
term to an inflammation of the mucous membrane, or catarrh of 
the stomach as it is sometimes called. On the other hand, an in- 
flammation of the entire thickness of the walls of the stomach is 
rare unless produced by irritant poisons or injuries. A large pro- 
portion of those who suffer f rom dyspepsia have the simple variety, 
either as acute attacks from which they recover more or less com- 
pletely, or in a chronic form. 
The Cause of inflammation of the stomach may be exposure to 682 
DISEASES OE THE DIGESTIVE ORGANS. 
cold; the presence of irritating, imperfectly chewed, or spoiled 
food ; over-fatigue, followed by hearty eating ; excessive use of al- 
coholic drinks, and especially the habit of drinking strong liquor 
when the stomach is empty ; immoderate use of condiments, etc. 
Those who are convalescing from acute disease are liable to at- 
tacks, and so, especially, are infants. 
There are other causes than those originating in the stom- 
ach itself, or in faulty habits of eating, such as diseases of the 
lungs, heart, liver, and kidney, and ansemia or impoverished 
blood. The first three commonly act by interfering, in some 
way, with the natural flow of blood from the veins of the 
stomach, whereby the small blood-vessels are over-distended, the 
mucous membrane is congested, and inflammation is more easily 
awakened than it otherwise would be. 
In certain forms of disease of the kidneys the stomach, intes- 
tine, and skin, supplement, to some extent, the function of the dis- 
eased organs, and, in such cases, chronic derangement of the whole 
alimentary tract is liable to take place. The vomiting and diar- 
rhoea which then occur, serve to remove the poisonous urea from 
the body. 
Symptoms.—When poisonous substances are the cause, there 
is violent burning and stabbing pain in the stomach and between 
the shoulders, with tenderness on pressure over the former. The 
breathing is rapid and short, and efforts at vomiting continue 
long after the stomach has been emptied. Thirst is excessive. 
After a time the pulse grows feeble, the surface cold, there is 
faintness, hiccough, and, perhaps, diarrhoea. The matter vom- 
ited after the stomach has first been emptied, consists of stringy 
mucus containing blood, bile, and sometimes shreds of mucous 
membrane. 
In the form which follows an alcoholic debauch, aggravated, it 
may be, by exposure to cold and improper or immoderate feeding, 
the symptoms may be somewhat less severe than the foregoing, so 
far as relates to the faintness, collapse and the vomiting of por- 
tions of the mucous membrane, but there are still pain and tender- 
ness at the pit of the stomach, the tongue is coated, the breath foul, 
the stomach refuses to retain anything unless occasionally it be 
small lumps of ice and very cold drinks; but the latter, as they be- 
come warm, are also ejected, together with ropy mucus, and per- 
haps a little blood. Appetite is entirely lost, there is some fever, 
and there may be headache and restlessness. 
In cases of chronic inflammation of the stomach, the prominent 
symptoms are those of dyspepsia ; and it is safe to say, that in 
nearly all cases of prolonged indigestion, this kind of inflamma- 683 
DISEASES OF THE DIGESTIVE ORGANS. 
tion will be found to be present. While such persons may, at 
times, be comparatively comfortable, and digestion may be fairly 
performed, any of the causes which have been mentioned as likely 
to produce an acute attack will aggravate their trouble for the 
time. Such cases are sometimes called ‘‘gastric fever/’ 
Those who suffer from inflammation of the stomach have occa- 
sional attacks of headache, terminating in vomiting. The appetite 
is either poor, or, when the irritation is considerable, there may be 
a constant craving for food or drink, but taking even a moderate 
amount of either causes a sensation of discomfort or pain which 
continues until it has been vomited or has passed into the intes- 
tine. When vomiting occurs, the matter will sometimes be found 
to contain undigested food taken many hours previously. Some- 
times, in the intervals of digestion, and especially after a night’s 
rest, a clear brackish fluid will be spat up, having no sour taste 
like gastric juice, but being composed largely of saliva that has 
been swallowed. Low spirits, bad breath, belching up of gas, 
heartburn, pain between the shoulder-blades, palpitation of the 
heart, bloating of the belly, and constipation, are among the 
other symptoms which, more or less constantly, torment the suf- 
ferer. 
Treatment.—The treatment of the severe form, following the 
swallowing of irritating substances, demands that the stomach 
should be first emptied of its contents (if this has not already taken 
place) and rinsed out with draughts of warm water. After this 
has been once and speedily accomplished, the stomach should 
be put absolutely at rest. A hot flaxseed poultice should be applied 
over the upper belly, or cloths wrung out of cold water, or a bladder 
partly filled with pounded ice should be similarly applied, which- 
ever may give the most comfort. Small bits of ice may be swal- 
lowed whole from time to time, being careful not to allow so much 
as will fill the stomach with water and encourage vomiting. All 
foods and drinks should be given by the bowel with the aid of a 
syringe. If coldness of the skin and faintness occur, cold applica- 
tions should be removed and bottles of hot water be placed about 
the body and limbs. At the same time a tablespoonful of brandy 
added to a half-cupful of quite warm gruel or starch-water, may be 
thrown into the bowel with a syringe. Opium may be added to the 
enemas in doses (for an adult) of twenty-five to thirty drops, re- 
lated, in very severe cases, every hour or two ; but great discre- 
tion is required in repeating the dose more than three or four 
times, or after there is a tendency to drowsiness. 
If recovery follows, no food or drink should be taken into 
the stomach for several days, but nourishment should be entirely 684 
DISEASES OF TIIE DIGESTIVE OKGAES. 
by the bowel. For this purpose, milk, beef-tea, and fresh blood 
which has been deprived of its clot by beating with a stick and 
straining, are the most available. 
Inflammation of the stomach following a debauch must be 
treated in much the same manner as above indicated, but it is 
sometimes possible to administer by the mouth, doses of a half- to 
one grain of powdered opium, and a half-drachm of subnitrate of 
bismuth, at intervals of two or three hours. In such cases it is 
safer to restrict the opium to two or three doses, except when ad- 
vised by a physician, while the bismuth may be continued. 
Mustard and flaxseed meal poultices to the pit of the stomach; 
covering the patient with hot blankets so as to cause free perspira- 
tion ; occasionally swallowing ice to relieve thirst, are all service- 
able and safe procedures. 
The only successful mode of relieving chronic dyspepsia due 
to disease of the heart, lungs, liver, etc., is by improving the con- 
dition of the diseased organs—often a matter of extreme difficulty. 
Persons who suffer from dyspepsia due to chronic inflammation 
of the stomach, need to exercise much care in order to effect a 
cure, and they are constantly liable to bring about a temporary 
increase of their troubles by indiscretions in diet and habits of life. 
When food is not easily digested, but remains for hours in the 
stomach, it is well to take, before each meal, a half teaspoonful of 
bicarbonate of soda (baking soda) in iced water, or to take a glass 
of cold Vichy, Selters, or Apollinaris water, since alkalies and 
moderate stimulation, like that caused by a small quantity of very 
cold water, increase the flow of gastric juice. 
Great care should be taken to thoroughly chew all solid articles 
of food, not only in order to render their digestion easier, but also 
because the alkaline saliva which is thus mixed with them serves 
to cause a greater flow of gastric juice. It is the relief which 
follows the swallowing of saliva in certain cases, which leads 
some people to acquire the habit of chewing spruce gum or 
paraffin after eating. So, too, the practice of smoking tobacco 
after meals, stimulates the salivary glands and indirectly in- 
creases the flow of gastric juice. 
One of the most valuable aids to slow stomach-digestion is a 
dose of five to fifteen drops of dilute hydrochloric acid in a 
wineglassful of hot water, taken about an hour after eating. This, 
and all other acid medicines, should be taken through a straw or 
glass tube, and the teeth should be rinsed immediately afterward 
with a solution of baking soda and water. 
Pepsin is another aid to slow stomach-digestion. If it is fresh 
and of good quality, the dose does not need to be large, since its DISEASES OF THE DIGESTIVE ORGANS. 
685 
action in digestion is that of a ferment, and not a chemical one. 
It should always be given with dilute hydrochloric acid, in the 
manner above mentioned. 
When bloating of the stomach is a pretty constant source 
of trouble, doses of sulphite of soda, from one to two scruples 
in a little cold water, will arrest the fermentation temporarily. 
Creosote is another remedy used for a similar purpose. It may be 
taken in doses of two to five drops in pill form, or mixed with 
some kind of mucilage. Coarsely powdered charcoal may also be 
taken in doses of a tablespoonful in water. 
Acidity and heart-burn occurring to any extent during diges- 
tion may be relieved by a half-teaspoonful of bicarbonate of soda 
in water, or a teaspoonful of calcined magnesia may be similarly 
used. If the irritation be considerable, it will be better to take 
an emetic of warm water, or twenty grains of powdered ipe- 
cac in water, and by the free use of draughts of tepid salt-water 
to thoroughly empty the stomach of its contents. 
When heart-burn occurs with an empty stomach, it is some- 
times owing to the presence of gastric juice secreted in conse- 
quence of some irritation of its mucous membrane, and a cracker 
or some similar article of food will absorb it and put a stop to 
the trouble. If it does not, a doctor should be consulted. 
When attacks of acute inflammation occur, the stomach should 
be allowed to rest as long as possible without the presence of food, 
since the latter not only aggravates the trouble, but often fails to 
be digested, and it would have been better not to have taken it at 
all. In cases occurring among delicate persons in which prolonged 
abstinence may be harmful, it is better to give necessary nourish- 
ment by enemas during the first forty-eight hours. 
Every person who suffers from chronic indigestion, or indeed 
from any prolonged disturbance of the digestive organs, should 
wear at all times a bandage of flannel, pinned or tied snugly 
about the bowels, and wide enough to extend from the pit of the 
stomach nearly to the pubis. He should eat regularly of easily 
digestible food, avoiding only such as his experience shows to be 
slow of digestion, and when the amount that the stomach will 
tolerate at any one time is small, meals should be taken more of- 
ten than thrice daily. The interval between meals should, how- 
ever, never be so short as to allow the introduction of fresh food 
into the stomach while that which is partly digested still remains. 
Spices, very hot drinks, and all alcoholic beverages should be care- 
fully avoided, and the discomfort occasionally caused by the irri- 
tation of wholesome food may be relieved with doses of twenty 
grains of bismuth subnitrate. It is serviceable to resort at intervals 686 
DISEASES OF THE DIGESTIVE ORGANS. 
to the use of mineral waters containing salt, bicarbonate of soda, 
and sulphate of soda. (See chapter in Yol. I. on Mineral Springs.) 
Those whose occupations are sedentary, should daily take a cer- 
tain amount of walking, riding, or rowing exercise, and men 
should so arrange their clothing that pressure by waist-bands 
may not come across the region of the stomach. The habit of 
going without suspenders, and depending upon a tight waist-band 
for the support of pantaloons is decidedly harmful. 
Neuralgia of the Stomach—Gastralgia. 
Women are more liable than men to a nervous affection of the 
stomach, characterized by intense pain, but the cause of which is 
little understood. In men it sometimes occurs during an attack of 
gout, and during its continuance the pain in the joints may disap- 
pear. The pain is of a griping, “ clawing” character, most severe 
at the lower end of the breast-bone, and may cause the patient to 
become unconscious. 
The Treatment most effectual is the administration of opium in 
doses of twenty drops of the tincture, repeated every half-hour 
until the pain becomes easier ; and the use, at the same time, of hot 
foot-baths, and hot poultices over the stomach. 
A physician should be summoned as soon as possible, since his 
judgment will be necessary in regulating the amount of opium 
that may be used with safety. 
Inflammation of the Bowel. 
This occurs in several forms, viz.: a simple inflammation of 
the mucous membrane, similar to that which affects the stomach 
and which depends upon the same causes ; a more acute form, 
common among infants and known as “cholera infantum that 
which is characterized by ulceration of the mucous membrane ; 
still another, which most often occurs about the commencement 
of the large intestine, and is the result of accumulation of fasces, 
or the impaction of some foreign substance into the vermiform ap- 
pendix to the large intestine ; another form occurring in disease of 
the kidneys, spleen, or liver; the inflammation of the large intes- 
tine, known as dysentery or bloody-flux, and in inflammation of 
the peritoneum—the smooth, serous membrane which covers the 
intestines and lines the walls of the abdomen. 
The first variety often accompanies a similar condition of the 
stomach, or is caused independently by exposure to cold or the 
irritation of worms, etc. DISEASES OE THE DIGESTIVE ORGANS. 
687 
Symptoms.—The most prominent of these is diarrhoea, or loose 
and frequent stools ; the others resemble closely those which char- 
acterize acute dyspepsia (see page (581), when the upper portion of 
the small intestine is affected; and dysentery, when the lower 
portion of the small intestine or the large intestine are its seat. 
There is discomfort, and griping, perhaps, a coated tongue, some 
fever, loss of appetite, and headache. When the trouble becomes 
chronic, the sense of discomfort is more constant, although less 
severe ; there is bloating of the belly and loose stools, which may 
contain mucus, or yeasty and bad-smelling matter. When the dis- 
ease lasts for some time, it interferes with nutrition and the patient 
loses flesh, owing to the degree of interference with the absorption 
of food through the mucous membrane. 
The form which affects infants has already been considered 
in Vol. I. 
The Treatment of inflammation of the bowel demands rest on 
the back, in bed. If the trouble arise from the presence of irri- 
tating food, a saline purgative such as two teaspoonfuls of Ro- 
chelle salt in water ; a similar amount of Epsom salt; or a pint of 
solution of citrate of magnesia; or two teaspoonfuls of elixir of 
buckthorn, will clear the bowel; after that, laudanum may be 
given (to an adult) in doses of ten drops, in water, after each move- 
ment of the bowel, or a teaspoonful, or two, of paregoric elixir 
may be given at similar intervals in a lialf-wineglassful of hot 
water. A light but hot poultice of flaxseed or corn meal, or a 
bag of flannel filled with hops and wet with hot water or hot 
vinegar, may be laid across the belly. Many of the attacks of 
“loose bowels” occurring during warm weather or following 
exposure to cold or wet, etc., may be relieved by Squibb’s Diar- 
rhoea Mixture, mentioned among the formulas at the end of this 
volume. 
Nausea and thirst may be relieved by acid drinks, like lemon- 
ade or a solution of cream of tartar in water, but should be taken 
in small quantities when cold, if their use is found to increase the 
griping. Flaxseed tea with lemon-juice is a good drink, and teas 
of sage and catmint are especially suited to cases attended with 
flatulence. For some days after the patient begins to improve, 
mild and easily digested food should be the only kind taken. 
In all these cases the wearing of a flannel bandage snugly 
fastened about the bowels should be attended to for some days 
after the attack, and those who are liable to this disturbance will 
often avoid such attacks by making such use of flannel con- 
stantly. 688 
DISEASES OE THE DIGESTIVE ORGANS. 
Colic. 
An affection of the bowel which is extremely painful, which 
is usually unattended with inflammation, and which is liable to 
be confounded with other diseases of a more serious character, is 
intestinal colic. 
Colic is often a spasm, or a series of spasms of the muscular coat 
of the large intestine or colon, and may commonly be traced to 
the presence of irritating substances. The chronic lead-poisoning 
of painters and others, is another form, and some people suffer an 
attack of colic from taking small doses of opium—such as are used 
in cough-mixtures and the like. Over-distention of the intestine 
with gas, also may cause it. 
There are other painful troubles liable to be mistaken for colic, 
viz.: the passage of a gall-stone from the gall-bladder into the in- 
testine ; neuralgia of the stomach ; the pain attending ulcer of 
the stomach; sudden perforation of some organ which allows an 
escape of its contents into the abdominal cavity; strangulation of 
a hernia ; the passage of a calculus from a kidney through its 
ureter to the bladder, etc. 
Symptoms.—In true intestinal colic the pain is greatest (usu- 
ally) about midway between the end of the breast-bone and the 
navel; extends across the belly; commences with a feeling of dis- 
comfort, and finally increases to acute pain, which recurs in par- 
oxysms, with intervals of comparative comfort. The pain is ordi- 
narily relieved by pressure, and does not often cause vomiting or 
faintness, although these may occur. It is most apt to come on 
during the night, in which respect it resembles most other bowel 
complaints. 
Treatment.—When caused by gas, the adoption of a position 
which raises the hips as high as possible above the level of the 
stomach will sometimes cause quite rapid relief with the escape of 
the flatus. Ordinarily, however, it is necessary to give a dose of 
fifteen to thirty drops of laudanum (to an adult), which may be 
followed in an hour, if needed, with twenty drops more. A hot 
poultice of flaxseed meal may be applied. After the pain has 
ceased, a purgative of some kind should be taken to clear away 
whatever may have caused the trouble. 
Dysentery—Bloody Flux. 
This disease has two varieties, viz.: the sporadic form, or that 
which is caused by exposure to cold and similar special causes, DISEASES OF THE DIGESTIVE ORGANS. 
689 
ancl the epidemic form, which afflicts armies, and which prevails 
during periods of famine.* It is most common in hot countries, 
where the land is low and wet. It has, however, no connection 
with malaria, so far as has yet been proven. Hunger, overwork, 
and bad air favor its development; but the exciting cause, of the 
epidemic form especially, is presumed to be foul drinking-water. 
In the course of the disease, the mucous membrane of the large 
intestine becomes intensely congested and inflamed, the solitary 
glands become swollen, and afterwards ulcerate ; the folds of mu- 
cous membrane become covered with patches of false membrane, 
similar, somewhat, to those which occur in the throat during diph- 
theria ; the whole thickness of the intestine is swollen and boggy, 
and the mucous membrane becomes detached in places, so as to 
leave raw, ulcerating surfaces. 
Sometimes the inflammation may extend upward into the small 
intestine, though this is not common. 
Symptoms.—At first the patient may be only feverish, and 
have occasional chilly sensations and griping pains in the belly. 
By and by there comes a sudden desire to empty the bowel, fol- 
lowed by a large and natural movement unattended with any dif- 
ficulty. In a short time, however, the desire recurs, and presently 
becomes constant. The stools become small in quantity, lose their 
natural character, and consist mainly of slimy mucus, with, per- 
haps, a little fsecal matter in small, hard lumps. The griping pain 
in the belly increases, blood makes its appearance with the mu- 
cus, and the stools acquire a very offensive odor, which is quite 
characteristic of the disease. Each movement from the bowels is 
attended with violent spasms of the intestine ; the fever increases, 
the tongue becomes coated ; the skin is dry and harsh, and the 
belly bloated and tender. 
After the disease has continued for a little time the stools lose 
their gray or colorless, jelly-like appearance, and become watery, 
resembling in color the washings of meat. Sometimes the dis- 
charges resemble matter (or pus) after the disease has continued 
for a few days. When the disease is at its height, the urine be- 
comes scanty, high-colored, and its passage painful. There is loss 
of appetite, and, perhaps, vomiting. The pulse becomes feeble, 
and, when the disease is likely to end fatally, the extremities grow 
cold, there is hiccough, the pain in the belly becomes less, or quite 
ceases, and the patient gradually sinks into a stupid state just 
before death occurs. 
Generally, recovery takes place when the disease has lasted from 
* See also the chapter on Acute Infectious Diseases. 690 
DISEASES OF THE DIGESTIVE ORGANS. 
one day to a week or ten days, but not uncommonly the severity 
of the symptoms abate and the disease becomes chronic, and may 
then last for years, giving the patient more or less discomfort from 
pain in the bowels and frequency of movements. 
Treatment.—It is the custom of many physicians to give a sin- 
gle purgative at the outset of the attack to clear the large intes- 
tine of faecal matter. For this purpose a full dose of Epsom salt 
(a tablespoonful), or castor oil, or a dose of eight to ten grains of 
calomel, is preferred. After that, opium is administered in the 
form of laudanum (ten to fifteen drops after each stool), or Dover’s 
powder (eight to twelve grains at similar intervals), or by the 
hypodermic injections of morphia. In India it has become cus- 
tomary to give, from the outset, large doses of ipecac—twenty to 
thirty grains combined with a grain of powdered opium, and re- 
peated every six to ten hours. 
An enema of a wineglassful of cold water will often relieve, for 
a time, the sense of discomfort in the rectum. So, too, fifteen 
drops of laudanum may be mixed with four tablespoonfuls of 
boiled starch (such as is used for starching linen), and injected, 
while warm, into the bowel. Cloths wrung out of cold water may 
be applied to the belly and will sometimes relieve the burning sen- 
sation. At other times hot poultices, or hot water applied with 
flannel, will give most comfort. 
During the attack, gruels, milk, jellies of tapioca, sago, etc., 
are the most appropriate food. After recovery from the acute 
symptoms, the diet should be carefully regulated for some time, 
all irritating substances and food which is difficult of digestion 
being avoided. 
When the disease occurs in hot, low countries, a removal as 
soon as possible to a cool, dry climate and to high land, will aid in 
complete recovery, and will oftentimes prevent the disease con- 
tinuing in a chronic form. As mentioned in a preceding section, 
a flannel bandage should be worn about the belly after convales- 
cence has commenced. 
Inflammations, Unnatural Growths, etc. 
Besides the foregoing affections, the stomach and intestines 
are liable to certain general and local inflammations and morbid 
growths, such as peritonitis or inflammation of the interior of the 
belly, ulceration of the stomach and intestine, inflammation of 
the pouch-like commencement of the large intestine (called typhli- 
tis), cancer, tubercle, etc. Most of these are attended with symp- 
toms of indigestion which complicate those properly belonging to DISEASES OF THE DIGESTIVE ORGANS. 
691 
the disease, and a detection of the true character of the malady 
requires the skill of a physician. 
Peritonitis. 
This is one of the gravest forms of inflammation of the bowels 
when caused by the presence of foreign matter in the peritoneal 
cavity, as occurs with perforation of the intestine or stomach, 
rupture of an abscess internally, or when the abdomen is penetrated 
by some foreign body. When the peritoneum is injured, as in the 
case of operations when it becomes necessary to open the abdo- 
men, it is less liable to be followed by fatal results ; and the forms 
of local peritonitis which are developed in inflammation of the 
organs in the pelvis, or in adhesions of the intestine or stomach 
caused by ulceration, are still less dangerous to life, although fatal 
results occasionally are observed. 
Symptoms.—The patient who suffers a rupture of intestine or 
of an abscess, has a sudden attack of pain, faintness, shortness of 
breath, a cold skin, clammy perspiration, great restlessness—in 
fact, the usual symptoms of a shock to the nervous system. 
The pain which soon follows is of a burning, stabbing char- 
acter, extending more or less over the whole belly, except in 
cases where it occurs in the pelvic cavity. The patient is forced 
to lie quietly on the back, with the shoulders raised and the knees 
drawn up to relax the muscles of the abdominal wall and to re- 
lieve the belly from the pressure of the bed-clothing. Owing to 
the pain caused by a deep breath, the diaphragm is not used in 
breathing, and the respirations are therefore short and hurried. 
There is fever, thirst, and, it may be, vomiting. The bowel and 
bladder cease to act, and gas collects in the intestine until the 
belly may be bloated and drum-like. 
The inflammation may terminate in death within a few hours, 
when caused by rupture of the intestine or of an abscess, or it may 
continue for several days, and end either in recovery or in death 
by exhaustion, consciousness continuing until life has nearly 
ended. In the latter case it is not infrequent for the pain to cease 
entirely toward the close, to be followed by hiccough and all the 
symptoms of intense prostration. 
Treatment.—Opium, in some form, is absolutely essential, and 
the use of cathartic medicines is, on the other hand, to be posi- 
tively forbidden. Opium or morphia act by stopping the con- 
tractions of the intestine, and by relieving the intense pain. 
Very large doses are sometimes requisite to produce this effect, 
and are much better borne than would be possible during health. 692 
DISEASES OF THE DIGESTIVE ORGANS. 
Cloths wet with iced water, or a large bladder or india-rubber bag 
lightly filled with pounded ice, may relieve the burning pain in the 
abdomen if their weight can be borne. If the lower bowel contains 
faeces to such an extent as to cause trouble, enemas of warm salted 
water may be used with caution, to wash it out. Ice may be swal- 
lowed in lumps to arrest vomiting and relieve thirst. 
There is hardly an affection which demands such constant 
attendance of a physician, or which, even then, is so liable to 
end fatally. 
Typhlitis. 
This term is employed to indicate inflammation of the caecum, 
or commencement of the large intestine. At this point the intes- 
tine forms a pouch-like enlargement, into one side of which the 
small intestine discharges its contents. 
Opening into this pouch or caecum, is 
also a short “appendix,” as it is called, 
about the size of a goose-quill, and from 
one to three inches in length.* Into 
this worm-like appendix, seeds, bits of 
bone, gall-stones, faecal matter, and 
even intestinal worms sometimes enter, 
and by their presence produce inflam- 
mation. Faeces become impacted in the 
caecum itself, so as to over-distend it, 
and cause inflammation. Ulcers may 
also be located here, and give origin to 
inflammation of the parts surrounding 
them. 
The accident most liable to follow 
inflammation of the appendix is the 
formation of an abscess, which dis- 
charges either into the cavity of the 
abdomen, and causes fatal peritonitis, 
or into other cavities, such as the bowel or bladder. In some cases 
the inflammation subsides with the escape of the impacted faeces, 
or, if an abscess form, its contents are discharged through the walls 
of the abdomen, or through some of the channels just mentioned. 
The Symptoms of typhlitis are pain and tenderness in the 
right side of the belly, near the point of the hip-bone. Pressure 
with the ends of the fingers will detect a firm body when the dis- 
ease is caused by impaction of faeces. Fever follows, and the oc- 
Figure 160.—The shaded region 
on the right side is the seat of the 
pain and swelling in inflammation of 
the commencement of the large in- 
testine. (See chapter on Anatomy 
in Vol. I. for the arrangement of 
the intestine in this locality.) 
* For anatomy of the large intestine see Vol. I., pages 87 and 96. DISEASES OF THE DIGESTIVE ORGANS. 
693 
currence of chilly sensations may be taken as an indication that 
matter has formed. 
There is not usually much disturbance of the stomach, but con- 
stipation generally exists from the outset. 
Treatment.—Do not give purgatives, but resort at once to hot 
and light poultices, and the use of opium to quiet pain and arrest 
the contractions of the intestine. If hot applications do not afford 
relief, resort may be had to a bladder filled with pounded ice. 
Enemas of soap-water to empty the lower bowel, may be desirable, 
but had better be repeated than used in too large a quantity at 
once. Absolute quiet must be maintained, owing to the danger of 
rupture of an abscess—if one have formed—into the cavity of the 
belly. 
Those who have recovered from the disease are very liable to 
be subsequently attacked, and need to exercise constantly great 
care respecting their diet and the condition of their bowels. 
It hardly needs to be said that the treatment of a disease of 
such severe character should not be attempted without profes- 
sional aid. 
Ulceration of the Stomach and Bowel. 
In some cases the causes of this condition are not understood, 
and not unfrequently the symptoms are so complicated with those 
of indigestion or with loose bowels that they can only be appreci- 
ated by a physician. 
When ulceration of the stomach occurs, vomiting of blood, and 
pain coming on shortly after eating and ceasing when the stomach 
is empty, are the most notable symptoms. The course to pursue 
when blood is vomited has already been referred to on page 670. 
Ulceration of the bowels generally gives rise to diarrhoea of a 
more or less persistent character, sometimes resembling dys- 
entery. 
Neither of these affections can be treated without professional 
advice. 
Cancer of the Stomach. 
This is a disease that rarely appears before middle life. It is 
attended with pain at the “pit” of the stomach, which is in- 
creased about an hour or two after food is taken, at which time 
the contents of the stomach are passing into the intestine. 
Food is sometimes vomited, and may occasionally be streaked 
with blood. Besides these local signs, the patient presents the 
general appearance of those who suffer from cancer of other por- 
tions of the body. (See Cancer.) 694 
diseases of the digestive organs. 
Any prolonged duration of these signs of disease should lead 
to consultation of a physician. 
Other Diseases of the Digestive Organs. 
There are certain other diseases of the stomach and intestines 
besides those above mentioned. Their symptoms are, however, too 
obscure or complicated, and their occurrence too infrequent, to 
make their description in these pages desirable. Those, however, 
connected with the rectum, are of such importance that they are 
embraced in a separate chapter. 
Diseases of the Liver. 
The anatomy and physiology of the liver have been so suffi- 
ciently well described in Vol. I., that what follows here will relate 
mainly to the common derangements of this organ. 
Of all the causes which lead to liver derangements, it is prob- 
able that none are more important than the habitual use of alco- 
holic drinks. Next to this may be reckoned syphilis (either in- 
herited or acquired), long-continued malarial poisoning, or resi- 
dence in hot and low-lying regions, and diseases of other organs 
which interfere with the circulation of blood in the liver. 
The last might, perhaps, be counted as second in frequency in 
the greater part of the United States. Some diseases of the organs 
in the abdomen, particularly those of a malignant character, give 
rise to similar affections in the liver, owing to the transfer of the 
elements of the disease through the medium of the blood-vessels. 
It has been customary to attribute to over-eating, or to the eating 
of too large a proportion of fats and sugars, conjoined with a sed- 
entary life, the cause of some of these diseases. It is doubtful, 
however, whether this is the case as often as has been commonly 
supposed. 
Ignorant and unscrupulous physicians have long made “liver 
complaint ” and “ biliousness ” a cover for their lack of knowledge ; 
and many diseases, of quite another nature, have often been 
classed under one or the other of these heads. So fixed have the 
minds of many people become of the truth of such statements as 
these persons find it in their interests to make, that there are few 
nostrums, or secret and patented remedies which find so large 
a popular sale as “Liver Pills,” “Liver Invigorators,” “Liver 
Pads,” and similar preparations that are presumed to regulate the 
action of this gland. 
Many of the symptoms which attend derangements of the liver DISEASES OF THE DIGESTIVE ORGANS. 
695 
are also more or less characteristic of other maladies. Indigestion, 
for example, is not uncommonly present for some time before the 
attention is directed to the liver as its primary cause ; diarrhoea or 
constipation may likewise exist, and piles or hemorrhoids may 
give more or less trouble. It is desirable, therefore, in all cases in 
which derangements of the digestive organs are pretty constant, 
to examine with care into the condition of the liver. 
The symptom which, more than any other, is characteristic of 
liver derangement, is jaundice ; but it is true also, that some of the 
most incurable of liver diseases may exist from first to last with- 
out its presence, while, on the other hand, cases of intense jaun- 
dice may occur, in consequence of violent mental emotion, with- 
out there being any considerable alteration noticeable in the struc- 
ture of the liver itself. 
Pain in the region of the liver, increased by pressure, or by 
lying on either side, especially the right, pain in the right shoulder, 
and enlargement or irregular shape of the liver, as determined by 
feeling its margins through the walls of the abdomen, are all more 
definite evidences of its being diseased than are disturbances of 
the nervous system and of digestion. 
Not an uncommon condition which is often attributed to “ bil- 
iousness,” is the effect of constipation. The blood becomes pois- 
oned with the substances which should be cast out from the 
bowels, giving rise to feverishness, loss of appetite, bad breath, a 
“ muddy ” skin, bad taste in the mouth in the morning, diminished 
capacity for work, etc. All of these disappear after the action of 
one or two brisk purges, which are very likely to bring away bile 
in the movements ; but there is little ground for believing that 
arrest of function of the liver had much, if anything, to do with 
the trouble. 
Jaundice. 
This is not a disease in itself, but is due to the circulation 
in the blood of elements of the bile, which have been absorbed. 
The coloring matter of the bile penetrates all the tissues of the 
body, staining them various shades of color, from a faint yellow 
to a bronzed or greenish brown. The color is always most per- 
ceptible in the white of the eye, but is liable to be masked in the 
yellow light of lamps or gas. 
In most cases of jaundice, the urine becomes yellow, the per- 
spiration stains the linen of the same hue, and sometimes the 
saliva, tea.rs, and milk are similarly affected. When the condi- 
tion is owing to retention of bile in the gall-bladder, the fseces 
lose their natural color, becoming pale, clay-colored, or slate- 696 
DISEASES OF TIIE DIGESTIVE ORGANS. 
colored, hard or lumpy, and acquire a very offensive odor. At 
the same time, owing to the absence of bile in the intestines, the 
latter become sluggish in their contractions, and constipation re- 
sults. 
An intense and pernicious form of jaundice attends one of the 
diseases of the liver, known as “acute yellow atrophy,” and is 
also seen occasionally, following intense passion, such as anger, 
jealousy, fear, etc. 
During pregnancy, the displacement of the intestines by the 
large uterus, may cause pressure against the gall-duct, so as to 
obstruct the flow of bile, and so may tumors of other organs, or of 
the liver itself, produce over-filling of the gall-passages, and thus 
cause jaundice. 
It is questionable whether the so-called jaundice, with which 
most babies are affected for a few days after birth, is really a 
staining of the tissues by bile, or a discoloration following the in- 
tense congestion of the skin during labor, and which, in a mild 
way, resembles a bruise of the entire surface of the body. 
Usually, persons affected with jaundice are low-spirited and 
irritable, lose their appetite, and have a slower pulse than natural. 
Troublesome itching of the skin, without any apparent cause, is 
also sometimes noticed. A feeling of exhaustion, and inability to 
work, exists pretty constantly. 
Unless the jaundice is caused by some incurable disease of the 
liver, or occurs in persons who are enfeebled by sickness or age, 
the prospects of recovery are favorable. An exception to this may 
be in cases where it follows mental shock. 
Treatment.—Many cases of jaundice recover without any treat- 
ment whatever, after an interval of two to fourteen days. Others 
continue for a longer time, especially when due to disease of the 
liver. In the simpler form a brisk cathartic, like a tablespoonful 
or two of castor-oil; a tablespoonful of elixir of buckthorn ; eight 
grains of rhubarb with twice as much powdered jalap and five 
grains of powdered ginger ; or a tablespoonful of Epsom salt dis- 
solved in a glass of warm water, will favor recovery. 
When the gall-duct is obstructed by a gall-stone or plug of 
thickened bile, the jaundice will disappear when the obstacle to 
the flow of bile is removed. A remedy occasionally resorted to at 
such times is chloride of ammonium, in doses of twenty grains in 
water, every four hours. Nausea and vomiting may be controlled 
by abstinence from food for a few hours ; the use of ice swal- 
lowed in small lumps ; mustard plasters or hot poultices applied 
over the stomach; or milk and lime-water, in the proportion of 
one part of lime-water to two, three, or four parts of milk. DISEASES OF THE DIGESTIVE ORGANS. 
697 
Improvement in the condition of the patient will be attended 
with lessening of the bile in the urine, and darkening of the color 
of the faeces, which, at the same time, become less firm in con- 
sistence and lose their unnatural odor. Owing to the slowness 
with which the coloring matter of the bile is absorbed from the 
tissues, the skin and whites of the eyes may continue stained for 
some days after the function of the liver is restored. Convales- 
cence may be aided by the use of doses of two teaspoonfuls of 
tincture of gentian with a little cold water, taken before meals, 
and by restricting the diet for a few days to easily digestible food. 
The jaundice caused by diseases of the liver require the services 
of a physician, and it is best to send for one in any case. 
Gall-Stone—Biliary Colic. 
When speaking of Colie, reference was made to the pain attend- 
ing the passage of bile-gravel through the gall-duct. This trouble 
is not often met with before middle life, and is rather more fre- 
quent in women than men, and in those who take but little exer- 
cise. The gall-stone may be single, or there may be a large 
number of various sizes. In the latter case, they are apt to pre- 
sent flattened surfaces caused by wearing against each other. 
They vary in color according to the amount of bile-pigment con- 
tained in them, from nearly white to reddish-brown, dark brown, 
or black. 
An attack of biliary colic is most apt to follow a meal or some 
unusual muscular effort. It commonly commences with a sense 
of discomfort at the pit of the stomach, which increases to pain of 
a steady character. At intervals the pain increases in severity, 
and then as gradually diminishes. Nearly always there are dart- 
ing pains in the direction of the right shoulder. Nausea and 
vomiting come on, the fluids thrown up being sour. There is 
flatulence, and, it may be, some looseness of the bowels. 
When the spasms of pain are at their height, they are intensely 
agonizing, sometimes so severe as to cause convulsions, and they 
leave the patient, in the intervals when less acute, with a cold, 
clammy skin, weak and slow pulse, and great prostration. When 
the gall-stone escapes from the gall-duct into the intestine, or 
drops back into the gall-bladder again, the relief is instantaneous, 
and all the trouble is soon over. 
The attack may last for a few moments only, or, when the gall- 
stone is large, it may continue for many hours. When once a 
stone of considerable size has passed through the gall-duct, the 698 
DISEASES OF TIIE DIGESTIVE ORGANS. 
latter remains larger than before, and smaller masses may after- 
ward escape without making trouble. 
Treatment.—When the nature of the malady is recognized, it 
is well to send for a physician. In the meantime, take twenty 
drops of laudanum and a teaspoonful of the compound spirit of 
ether in a wineglassful of water, and repeat it in about an hour 
if the first dose does not suffice. If vomiting and retching are 
troublesome, an eighth of a grain of morphia may be taken dry on 
the tongue, and, if needful, may also be repeated once after an 
hour. 
Pressure across the pit of the stomach often gives some relief, 
and still more may he derived from a hot poultice of flaxseed and 
mustard, strong enough to redden the skin. Chloroform applied 
to the pit of the stomach and covered with a folded napkin, towel, 
or a piece of oiled silk, is also of service. 
If sulphuric ether is at hand, a teaspoonful may from time to 
time be poured into a folded napkin and held an inch or two 
above the mouth and nose, so as to be inhaled. It is not necessary 
to produce entire insensibility, but merely to “take the edge ” off 
the suffering. No harm whatever can follow this mode of using 
ether, where the suffering is intense, and it serves to tide over the 
period occupied by the passage of the calculus. 
Relief sometimes follows the taking of a hot bath, but ordina- 
rily the sufferer is too restless to make it practicable. 
For several days after a, fit of gall-stone, the stools should be 
thoroughly mixed with water and passed through a sieve so as to 
secure the concretions that have given origin to the trouble. This 
is desirable on account of the knowledge derived respecting the 
probability of there being another attack—since the discovery of a 
calculus having smooth, flattened sides, is evidence that others 
have accompanied it, while a calculus which lacks such facets is 
probably the solitary cause of the trouble. 
Gin-Drinker’s Liver—Cirrhosis of the Liver. 
This is not always to be traced' to the use of alcoholic drinks, al- 
although this cause exists in the large majority of cases. Occa- 
sionally it affects young children and persons who have never been 
addicted to drinking, but it is mostly found among people who 
have been subjected to the privations of poverty, hard work, and 
depressing emotions, and who have been accustomed to the drink- 
ing of undiluted liquors. Although liquor in any form is liable to 
cause this trouble, it is particularly harmful if taken without water, 
and most persons suffer sooner or later from its habitual use in this DISEASES OF THE DIGESTIVE ORGANS. 
699 
way. Certain persons who are especially susceptible to the effects 
of alcohol suffer derangements of the liver from drinking even 
the light wines, while others appear to be able to drink whiskey, 
brandy, gin, etc., with daily regularity, without such harmful 
results. Those of the latter class are few in number, however. 
The Symptoms which characterize the early stage of the dis- 
ease are not easily distinguished from those of ordinary indiges- 
tion, and are almost always overlooked. When, however, there 
is loss of flesh and strength, frequent loss of appetite, pain or dis- 
comfort on the right side about the region of the li ver, with, per- 
haps, occasional pains about the right shoulder, some tenderness 
on pressure, and when the liver is found on examination to pro- 
ject below the margins of the lower ribs in front, in a person who 
is pretty regularly in the habit of drinking, there is little occasion 
for doubting the nature of the trouble, but it is hardly probable 
that abstinence from the use of liquor will now prevent the further 
progress of the disease. 
A little later the material which has been deposited, and thus 
caused the general enlargement of the organ, begins to contract, 
and, in time, the whole liver commences to grow smaller, and 
have a lumpy form and an irregular margin, even when felt 
through the wall of the abdomen, and it is this condition which 
has given to it the name “hob-nail liver.” This contraction 
leads to narrowing of the blood-vessels which pass through 
the gland, and so causes the veins coming from the other organs 
of the abdomen to be over-distended. Piles or hemorrhoids 
result, and give constant trouble. Indeed, they are so uniformly 
present as to lead physicians to suspect some such liver de- 
rangement when piles are persistently troublesome in persons 
past middle life. The fluid portion of the blood oozes through the 
walls of the intestinal veins and gives rise to dropsy of the belly. 
The veins of the stomach are over-filled with blood in consequence 
of the impediment offered to its passage through the vessels of the 
liver to reach the large vein of the trunk, and the mucous mem- 
brane of the stomach becomes, therefore, congested and inflamed. 
The patient grows irritable and dyspeptic, loses flesh and strength, 
has bleeding from the bowel; the accumulation of fluid in the 
belly increases and interferes with the action of the lungs, heart, 
kidneys, and other organs of the trunk, and, finally, the patient 
dies in a state of exhaustion, after suffering, perhaps, from an un- 
controllable diarrhoea. 
Treatment.—There is no cure for the trouble. When it is 
caused by the use of alcoholic drinks, these should be entirely 
stopped, and every means be taken—such as the improvement of 700 
DISEASES OF TIIE DIGESTIVE ORGANS. 
digestion, the use of nourishing food, and the provision of fresh 
air—to sustain the strength. 
Anodynes, in some form, and under the advice of a physician, 
together with the wearing of flannel, the use of salt baths, and the 
application, to painful spots, of hot poultices, may serve to make 
the patient more comfortable. 
There is another form of Cirrhosis or hardening of the liver, in 
which it becomes much enlarged, and does not afterwards contract 
in a manner to render its surface irregular, as in the affection just 
described. The cause of the disease is not well understood, but 
there is no evidence to show that it is caused by the use of alcohol. 
Symptoms.—As in the foregoing malady, the early symptoms 
are obscure, dyspepsia, and loss of strength and flesh being also 
present. But, whereas in “hob-nail” liver, dropsy of the belly, 
diarrhoea, intestinal hemorrhage, and piles, are uniformly present 
in the advanced stages, in this form they rarely occur. Jaundice, 
however, occurs early, is very persistent, and, as a consequence, 
the person suffers from its poisonous effect upon the structure of 
the brain and nervous system. 
Syphilis sometimes causes an overgrowth of the liver, which 
may resemble the foregoing in its early stage. In other cases, 
the deposits of unhealthy material are limited to isolated portions 
of the organ ; in still others, the liver acquires an irregular form. 
Congestion of the Liver. 
This is sometimes caused by over-eating, conjoined with sed- 
entary life and the use of stimulants ; residence in a hot climate, 
and in malarious localities ; certain fevers and inflammatory affec- 
tions ; but more often it is caused by diseases of the heart and 
lungs which obstruct the current of blood, and cause the vessels 
of the liver to be overfilled. 
The symptoms are enlargement of the liver, pain and tender- 
ness in the right side on pressure and while lying on either side, 
pain during a deep breath or coughing, and some shortness of 
breath when the enlargement is considerable. There is apt to be 
some jaundice. Late in the disease, if the congestion has led to 
inflammation, the liver contracts, and such symptoms follow as 
were noted when speaking of “ gin-drinker’s liver.” 
Abscesses may also form in the substance of the gland and be 
discharged through the lungs, stomach, into the belly, through the 
walls of the abdomen, etc., etc. 
Treatment.—When caused by diseases of the heart or lungs, 
these must first be removed if possible. When due to climatic or 701 
DISEASES OE THE DIGESTIVE ORGANS. 
malarial causes, change of residence is requisite. When it follows 
improper modes of eating and drinking, the course to adopt will 
be evident. Temporary benefit will follow a dose of Rochelle or 
Epsom salt, but a physician should be consulted, owing to the 
probable dependence of the congestion upon lung or heart affec- 
tions. 
Waxy Liver. 
This is a condition which often follows long-continued and ex- 
hausting discharges, such as diseases of the lungs, chronic dysen- 
tery, diseases of the bones and kidneys, chronic abscesses which 
keep up a constant discharge of matter, etc. The liver in such 
cases becomes enlarged and causes disturbance of the health. It 
is usually complicated with disease of the kidneys, and, owing to 
the nature of the original cause, is not likely to escape the attention 
of a medical adviser, whose services can hardly have been dis- 
pensed with in some stage or another of the trouble. 
Fatty Liver, etc. 
People who live well, and lead at the same time a sedentary 
life, sometimes acquire an enlargement of the liver due to a de- 
posit of fat in its structure. This is by no means always the case, 
nor is the condition restricted to those who are high-livers and 
who indulge regularly in alcoholic drinks. In fact, in the majority 
of cases, perhaps, its fatty condition is not recognized during life 
unless it undergoes considerable enlargement. In cases of chronic 
lead-poisoning, in poisoning by phosphorus, and sometimes, dur- 
ing continued fevers, the liver becomes fatty, but the symptoms 
of the causative disease are the ones which attract most attention, 
and are the most amenable to treatment. 
Besides the foregoing, there are derangements due to cancer, 
parasites, etc. Their consideration, however, can hardly be at- 
tempted with profit in a work of this character. 
E. A. CASTLE, M.D. Diseases of the Rectum and 
Anus. 
BY 
WILLIAM H. VAN BUREU, M.D., 
OP NEW YOBK, 
CONSULTING SURGEON TO THE NEW YORK HOSPITAL, BELLEVUE HOSPITAL, PRESBYTERIAN HOS- 
PITAL, WOMAN’S HOSPITAL, AND THE HOSPITAL FOR THE RUPTURED AND CRIPPLED; 
PROFESSOR OF THE PRINCIPLES AND PRACTICE OF SURGERY, WITH DISEASES OF 
THE GENITO-URINARY SYSTEM, AND CLINICAL SURGERY, IN BELLEVUE 
HOSPITAL MEDICAL COLLEGE. MALFORMATIONS AND DISEASES 
OF THE RECTUM AND ANUS. 
ANATOMY. 
The lowermost division of the intestinal canal is called the rec- 
tum. It occupies the cavity of the pelvis, being continuous with 
the sigmoid flexure * of the colon 
above, and ending below at the 
anus. The rectum is about ten 
inches in length, and is divided, 
for convenience of description, 
into three portions : the upper, 
five to six inches in length, cov- 
ered outside b j peritoneum ; the 
middle, about three inches long, 
usually dilated into an ovoid 
pouch ; and the lower, about an 
inch in length, which is con- 
stricted by the grasp of the sphinc- 
ter muscle. Seen from the front, 
the course of the rectum is nearly 
straight, as its name implies ; but 
in profile it presents three well- 
marked curves : the upper or peri- 
toneal portion bends forward over 
the brim of the pelvis and then 
passes backwards, so that the 
second portion, or pouch, occupies 
the lower part of the concavity 
of the sacrum ; the latter then 
curves forward along the coccyx 
below, and finally turns sharply backward, to end at the anus. 
The walls of the rectum consist mainly of strong muscular 
fibres, in two layers : the outer running in the direction of the 
length of the bowel, whilst the inner layer encircles it, and, tow- 
Figure 161.—Section from the front back- 
ward through the organs lying in the male pel- 
vis : 1, The pouch or middle portion of the 
rectum ; 2, the lower portion of the rectum; 
4, the pubic bone ; 5, the inner sphincter mus- 
cle ; 6, the bladder; 7, the prostate ; 8, portions 
of the large and small intestine which have 
been cut across in making the section ; 10, the 
spinal canal; 11, the coccyx; 12, the urethra; 
15, the outer sphincter muscle ; 16, the mem- 
branous portion of the urethra ; 17, the promon- 
tory of the sacrum. 
* Shaped like the Greek letter q {sigma). 706 
DISEASES OF TIIE RECTUM AND ANUS. 
ards the anus, grows thicker and stronger, so as to form what is 
called the “internal sphincter.” Invested with peritoneum exter- 
nally on its upper two-tliirds, its longitudinal muscular fibres are 
bare below. Within the bowel, its mucous membrane, which seems 
too long for the other coats, and is consequently thrown into 
transverse folds which tend to obstruct the passage of instru- 
ments through the cavity, is attached to the internal or circular 
muscular fibres by a loose but strong layer of fibrous tissue. This 
latter is extensible, for, in prolapse, the lower portion of the mu- 
cous membrane is dragged away from the muscular coat and pro- 
truded, alone, through the orifice of the anus. 
The mucous membrane of the rectum is studded with numerous 
minute glands, which furnish a quantity of thick, ropy mucus for 
its lubrication and protection ; the necessity for this constant and 
large supply of mucus accounts for the size and number of blood- 
vessels, especially at the lower end of the gut. 
In front, the peritoneal portion of the rectum is in relation, in 
the male, with the bladder, and its pouch is closely connected with 
the prostate and urethra; in the female, the rectum is in relation 
with the uterus above, and the vagina below, a fold of peritoneum 
separating them. This latter relation is important, for displace- 
ment of the uterus may obstruct the rectum. Behind, the rectum, 
throughout its course, is in relation with the bony walls of the 
pelvis. 
The pouch of the rectum varies in its capacity ; it is increased 
by overdistention from neglect of the calls of nature. A small 
hand can be introduced safely through the sphincter and along 
the rectum, even beyond its upper limit, where its diameter is less 
than in the pouch. This measure has been found useful in detect- 
ing disease. The rectum usually contains some faeces, but it is im- 
properly regarded as a reservoir. Its function is to receive and 
extrude faecal matters ; hence the increase of muscular fibres in 
its walls, and the provision for lubrication. Moderate distention 
of the rectum provokes the desire to expel its contents, and this 
natural call should not be habitually ignored. The nerves of the 
rectum, and especially of the anus, are very numerous, hence the 
exquisite sensibility of these parts. 
MALFORMATIONS OF THE ANUS AND RECTUM. 
Although rare in the experience of individuals, the aggregate 
number of infants annually born with these deformities is large ; 
and of this number a majority are relievable by the resources of 
art. Such cases very frequently pass unrecognized, until it is too DISEASES OF THE RECTUM AND ANUS. 
707 
late for successful operation, and they are too often regarded as 
hopeless, and allowed to die, when, in fact, skilful surgery could 
save them. 
Of the almost endless variety of congenital malformations the 
following are the principal : 
A child may be born with partial closure, or simple narrowing 
of the orifice of the anus, to such a degree that it will hardly ad- 
mit a probe or bodkin. This deformity is not immediately mortal; 
it causes gradual distention of the rectal pouch, with great diffi- 
culty in defecation, and grave consequences sooner or later. It 
should be entirely and permanently relieved by an operation. 
Figure 162.—Malformations. A, the usual position of the anus; B, the bladder; R, the 
rectum ; U, the uterus ; V, the vagina. 
In 1 a thin membrane closes the opening of the anus. In the next instance (2) the partition 
is higher up and apparent, only, on careful examination. In 3 no attempt has been made on the 
part of nature to form an anal opening. In I the rectum opens into the bladder, and in 5 the 
vagina communicates with the rectal pouch. 
In complete imperf oration there is often entire absence of any 
trace of an opening, or there may be a dimple or minute depres- 
sion marking the spot, or the boundaries of the natural opening 
may be covered in by a film of skin of more or less density. The 
latter is the most common of all these deformities, and it is always 
promptly relievable. 
When the anus is entirely leanting, the rectum may lie just be- 
neath the skin, so as to be reached at once by an incision, or it 
may terminate higher up, at a distance of half an inch to two 
inches, or so high as to be entirely out of reach ; or, in a certain 
proportion of cases, the rectum ends by a narrow opening into the 
bladder, or vagina. 
Symptoms.—An infant born with occlusion of the rectum soon 
becomes fretful, refuses the breast, and looks pinched ; there is 
absence of stools, gradual distention of the abdomen with difficult 
breathing, and a short peculiar cry, great restlessness and general 
distress, with colicky pains, vomiting, and sometimes convulsions. 
When unrelieved by a surgical operation, death generally occurs 
within ten days, from peritonitis, sometimes preceded by actual 
rupture of the large intestine. Where there is an escape of me- 
conium with the urine, or from the vagina, a fatal result is de- 
ferred, in rare instances indefinitely ; but such cases have been 708 
DISEASES OF THE RECTUM AND ANUS. 
remedied by art, and nothing is to be expected from the efforts of 
nature. 
Treatment.—Whenever a new-born infant goes over the first 
day without a natural passage, the fundament should be carefully 
scrutinized in search of a possible malformation. Even when the 
opening is perfectly natural in appearance, the little finger should 
be well greased and inserted to feel if the passage is free internally, 
for there may be entire occlusion within an inch ; in case of doubt, 
surgical aid should be sought at once, for delay rapidly diminishes 
the chances of successful interference. The object of an opera- 
tion in these malformations should be not only to give relief at the 
moment, but to secure permanent use of the part. Puncture by a 
trocar may secure a full escape of faeces, but afterwards, except 
in the simplest cases, constant effort will be required to keep the 
artificial passage open. Advancing surgery discards the trocar in 
these cases, except for exploration, and strives for permanent es- 
tablishment of function ; where there is deficiency in the rectum 
this can only be accomplished by bringing what there is of the gut 
down and attaching it to the margins of the new opening. When 
the bowel cannot be thus reached and brought down, there is still 
a possibility of relief by making an opening in the abdomen, or in 
the loins. A woman reached the age of forty-nine whose abdomen 
was thus opened shortly after birth. 
DISEASES OF THE ANUS AND RECTUM. 
These affections are exceedingly common, and, although hut few 
of them are dangerous to life, they are remarkable for the extreme 
pain which they are capable of producing. For reasons not credit- 
able to either patient or physician, they receive less attention than 
other maladies, and this is to be regretted, for there are no dis- 
eases which, as a class, are so promptly and certainly remediable 
by art. 
Painful Itching of the Anus. 
This distressing and often obstinate affection is, in most instan- 
ces, the local expression of some general disorder of the system, 
but occasionally it arises from causes which are entirely local. It 
is usually worse at night. The anus often presents a water-soaked 
appearance, with evidences of violence from scratching. 
Causes.—Derangement or failure of nerve-force ; the gouty dia- 
thesis, in which the perspiration is acid and irritating ; high living, 
with immoderate use of strong drink, tea, coffee, or tobacco ; over- DISEASES OF THE RECTUM AND ANUS. 
709 
work, and anxiety of mind ; too sedentary habits ; salt-rheum and 
other eruptions ; piles ; fistula; thread-worms ; a parasitic vege- 
table growth. 
Treatment.—This depends upon the cause of the affection, 
which must be ascertained. In the sedentary and high-livers, ex- 
ercise and abstinence are necessary remedies. In the gouty and 
costive, the laxative salts of magnesia and soda, Pullna water, 
colchicum. In the weak and nervous, cod-liver oil, arsenic, quin- 
ine. Locally, for thread-worms, injections of lime-water, diluted 
tincture of iron, decoction of pink-root. For an eruption with a 
curved and well-defined margin, indicating a parasitic growth, 
sulphur ointment with chloroform. Where there are abrasions, 
benzoated zinc ointment, with or without chloroform. For ecze- 
ma or salt-rheum, add calomel to the preceding, or apply yellow- 
wash. An application of tincture of iodine, diluted at first, before 
going to bed. Wearing a wad of prepared oakum pressed well 
against or into the anus. Daily washing with soap, and subse- 
quent application of alcohol in some form, to harden the part. 
Hemorrhoids or Piles 
Are the most common disease of this region. They are small, 
rounded tumors, generally of a red or purplish color, which form 
either just without or just within the orifice of the anus ; hence 
the distinction into external and internal piles. They take their 
origin in overdistended and varicose blood-vessels, principally 
veins, modified by the mechanical violence to which their position 
exposes them. 
Causes.—Hereditary tendency ; neglect of regularity in attend- 
ing to the calls of nature ; straining, and sitting too long at stool; 
sedentary habits and high living ; obstruction to the venous circu- 
lation within the abdomen, as by pregnancy or tumors. 
Symptoms.—An external pile is first recognized as a little pain- 
ful excrescence at the margin of the anus, which usually subsides 
after a few days, leaving a shrivelled flap of integument, which is 
permanent; or, it may go on to suppuration, and if not opened 
early, there is a possibility of fistula. 
Internal piles are liable to bleed at stool, and, as they grow, are 
extruded during defecation, and drag down with them the mucous 
membrane to which they are attached. At first they go back into 
the bowel spontaneously after the stool, but as they increase in 
size it becomes necessary to put them back. In advanced cases 
they come down at other times than at stool, and, if there is delay 
in returning them, they become engorged and excessively tender 710 
DISEASES OF TIIE RECTUM AND ANUS. 
in consequence of prolonged strangulation by the sphincter, so 
that they cannot be put back, in which case they are liable to 
slough. The danger of this occurrence, and the injury to the gen- 
eral health by the constant loss of blood, and inability for active 
exercise which the disease entails, necessitate treatment for its 
radical cure. In many cases the loss of blood is excessive, and it 
may take place so insidiously as to affect the patient’s complexion, 
as a consequence of actual bloodlessness, before its existence is 
suspected. 
Treatment.—For external piles, rest and cold ; or, greasy appli- 
cations to prevent friction, preferably Goulard's cerate, which is 
also sedative and astringent, together with means to secure easy 
defecation, of which the most certain is to inject from half a pint 
to a pint of tepid water into the bowel just before the act. If the 
pain is very acute and persistent, a poultice with laudanum may 
be tried; and, finally, an incision may be necessary. 
For internal piles, the safest and surest remedy is the applica- 
tion of a ligature to each tumor, by an expert; this is best done 
under the influence of ether, and at one operation, which, if prop- 
erly managed, will be free from serious pain. Nitric acid is only 
a palliative of limited application, and, unless used with great 
care, may cause stricture. The actual cautery, which has been 
highly praised, is liable to be followed by hemorrhage as well as 
stricture. 
The sudden stoppage of a hemorrhoidal flux is popularly as- 
sumed to be attended by some danger. In a long experience the 
writer has seen nothing to warrant this apprehension, and he be- 
lieves it to be unfounded; he knows of no operation in surgery 
more uniformly satisfactory in its results, and more certainly fol- 
lowed by improved health, than the ligature for internal piles. As 
a preventive of increase, and a palliative where a radical cure 
cannot be attempted, the daily use of an enema of tepid water 
before stool, and the injection of a gill of cold water immediately 
afterwards, with cold douche to the anus, when feasible, are the 
most useful means, together with attention to diet, and avoidance 
of the causes of the disease already mentioned. 
Fissure of the Anus. 
This is the name usually applied to a small ulcer, long and nar- 
row in shape, situated just within the orifice of the anus in a cleft 
between two of the wrinkles into which the membrane lining this 
portion of the rectum is thrown by the constriction of the sphincter 
muscle. The little ulcer is, therefore, entirely within the grasp of 711 
DISEASES OE THE RECTUM AND ANUS. 
the muscle, and this circumstance accounts for its characteristic 
features, viz., the peculiar and intolerable pain which always 
accompanies it. The lesion itself is insignificant, but its unfortu- 
nate position subjects it to the unceasing action of the bundles of 
fibres which compose the sphincter, and this, in the first place, pre- 
vents it from healing, and afterwards keeps it in a condition of 
painful irritability by incessant pinching. This affection is known, 
also, as the “ irritable ulcer of the anus.” 
Symptoms.—The pain of fissure is not very considerable at the 
moment of defecation—in fact, it is sometimes hardly noticeable ; 
but, after a short interval, it commences with a smarting, teasing 
sensation, remarkable for its unremitting persistence, and which 
sufferers describe as harder to bear than much more severe pain. 
After a variable period it ceases, but only to be renewed with in- 
evitable certainty the next time the bowels act. To avoid its re- 
currence patients defer their stools, often habitually, and, in con- 
sequence of this irregularity, and the use of anodynes to control 
the pain, the complexion becomes sallow, the expression unhappy, 
and the general health suffers. It is not a matter of surprise, then, 
that this malady, so trifling in extent, should have been mistaken 
for cancer. The disease may be recognized by the symptoms just 
detailed; but, by inspection of the anus in a good lighi, on carefully 
pulling apart its margins and unfolding the wrinkles, the lower 
end of an angry-looking sore, with elevated edges—an unhealthy, 
irritable ulcer, in short, is brought into view. 
Causes.—In the act of straining to extrude a hard stool, the 
thin integument at the anus is cracked or fissured, and healing 
being prevented by the constant motion and mechanical violence 
to which it is subjected, the lesion gradually takes on the charac- 
ter of an irritable ulcer. The presence of internal piles favors the 
occurrence of fissure, and the two diseases are frequently associ- 
ated. Any wound of this part, if its healing is delayed, may as- 
sume the characteristics of “fissure.” 
Treatment.—Any measure capable of arresting the action of 
that portion of the sphincter muscle in immediate contact with the 
little ulcer, for four or five days, will at once stop the pain in this 
disease and bring about a cure. The ulcer assumes a healthy 
character as soon as it is placed at rest, and it forthwith begins to 
heal. Boyer, who first discovered this fact, divided the whole 
muscle by the knife; Copeland found that division of the ulcer it- 
self, and of the muscular fibres immediately beneath it, was suffi- 
cient ; and it has since been fully demonstrated that gentle stretch- 
ing of the anus, so as to produce a condition of temporary atony 
of the sphincter, if thoroughly and properly done, will cure the 712 
DISEASES OF THE RECTUM AND ANUS. 
affection at once, without confining the patient to the bed. No 
other remedies possess any value. Infants, who are very liable 
to fissure, usually get well promptly by the use of zinc ointment 
alone, and securing soft stools ; and the same result may be at- 
tained in the adult, if the remedies are applied promptly on the 
occurrence of the lesion. Where ocular inspection has been neg- 
lected, this readily curable disease has been often treated for a 
long time, unsuccessfully, under the vague name of “neuralgia,” 
or of “ spasm of the sphincter.” 
Ulcer of the Rectum. 
The disease last described, although strictly an ulcer of the 
rectum, owes its characteristic features entirely to the spasmodic 
action it provokes in the sphincter muscle, in contact with which 
it is situated. In the disease now in question, the ulceration is 
seated higher up in the bowel, out of the reach of the sphincter, but 
usually within three or four inches of the anus, and it gives rise to 
symptoms which are readily distinguished from those of fissure. 
Symptoms.—Ulcer of the rectum occurs mainly in middle life ; 
it sometimes gives little evidence of its presence, but generally 
causes more or less uneasiness in the rectum, with desire for stool, 
especially in the morning, after rising from the recumbent posi- 
tion—what has been called “morning diarrhoea”—the dejections 
showing streaks of blood, or pus, or a material like coffee-grounds, 
which is rectal mucus mixed with blood. Pain may also be re- 
ferred to the back between the hips, sometimes extending down 
the thighs ; and there is, usually, more or less desire to strain at 
stool. 
In consequence of its exposure to the contact of irritating faeces, 
and of constant lack of rest, ulceration in the rectum tends to 
persist and to increase ; and it is noticeably slow in healing under 
treatment. Perforation of the coats of the bowel is liable to take 
place, giving rise to escape of faeces and consequent abscess and 
fistula. Or, the ulceration extending around and involving more 
or less of the circumference of the mucous membrane of the bowel, 
when there is an effort at healing, it produces thickening and 
puckering, by contraction, resulting in stricture. Besides the lia- 
bility to these complications, persistent ulceration of the rectum is 
usually accompanied by loss of flesh and failure in the general 
health. 
Causes.—Ulcer of the rectum may follow abrasion from con- 
tact of hard faeces, or of some rough foreign substance which has 
been swallowed, or it may come from a wound or laceration re- DISEASES OF THE RECTUM AND ANUS. 
713 
ceived in some other way. It may be left behind after a dysen- 
tery, may take its origin in tubercular deposit in the rectal glands, 
or in a tendency to ulceration from a vice in the system, such as 
scrofula, or syphilis, or it may result from the contact of other 
local poison. 
Treatment.—When the symptoms above detailed are present, 
an exploration of the rectum should be made, preferably under 
the influence of ether, as the only sure mode of determining the 
exact seat and character of the ulceration ; this may show the ne- 
cessity of a local application, as of caustic, to alter the character 
of the sore and make it heal. Local applications, however, are 
painful and difficult to make, and alone are rarely effective. The 
best medical treatment is as follows.; a full dose of castor oil to 
clear out the bowel entirely, and then the recumbent position 
rigidly persevered in for a month at least, with a diet confined 
absolutely to unskimmed milk, of which from two to three quarts 
may be taken, by an adult, daily. The milk may be coagulated by 
rennet. When the general condition is poor, koumyss, or cod- 
liver oil may be added. If at the end of six weeks an examination 
shows that the ulcer is not healed, or rapidly healing, experience 
has proved that division of the ulcer and the sphincter at the same 
time will be necessary. 
Stricture of the Rectum. 
In its simple or benign form,* stricture of the rectum is a rather 
rare disease. It consists in a narrowing or constriction of the 
calibre of the bowel, so as to obstruct the passage of it contents. 
It is almost always situated within three and a half or four inches 
from the opening of the anus, and in the great majority of cases 
even nearer, and therefore within reach of the finger. In the very 
rare instances in which an ordinary stricture forms so high up the 
bowel as to be beyond the touch, its presence can only be ascer- 
tained with certainty by the fullest exploration under ether, by an 
expert, with all the most recent means at hand to insure success. 
Exploration by bougies, however perfectly constructed, or by 
tubes, even aided by simultaneous injection with water, cannot 
be relied upon with absolute certainty ; the contact of the advan- 
cing extremity of the instrument with the transverse folds of the 
gut, or with the projection of the sacrum, has constantly deceived 
even experienced physicians ; and, strange to say, the majority of 
* These terms are used to distinguish simple stricture from cancerous disease, 
which in this locality is also attended by narrowing and obstruction of the bowel. 714 
DISEASES OF TIIE RECTUM AND ANUS. 
cases of so-called strictures of the rectum beyond the reach of the 
finger are purely imaginary, the symptoms of stricture being 
simulated by certain not uncommon forms of constipation. 
Symptoms.—A necessity for straining, in order to extrude the 
contents of the rectum, even when of moderately soft consistence— 
(this symptom is also present where the walls of the bowel have 
lost their contractile power) ; the habitual presence of wind in the 
large intestine, which rolls from one part of the bowel to another 
in unsuccessful efforts to escape externally, with frequent colicky 
pain, and more or less constant general distress ; the alternation 
of periods of costiveness with looseness of the bowels, large quan- 
tities of semi-liquid material being voided during the latter; the 
duration of the periods of costiveness steadily increasing. The 
narrow, tape-like form of solid matter passed at stool is a symptom 
of little value, for this shape must come from the orifice of the 
anus—unless, indeed, the stricture itself is forcibly protruded 
through the anal orifice by straining during defecation, and thus 
gives its impress to the matters extruded—and this not unfre- 
quently happens ; but in this case the stricture can be pretty cer- 
tainly felt by the finger. A stricture beyond the reach of the 
finger could not cause tape-like stools, unless complicated with 
invagination. 
Causes.—Previous ulceration, which in healing has been at- 
tended by contraction ; continued mechanical bruising — as by 
hardened faeces, long retained, or by the child’s head in the act of 
parturition ; congenital malformation, in which the rectum re- 
mained pervious, but undeveloped to its full proportions. 
Treatment.—The only method that promises a permanently 
satisfactory result is an operation by which a complete linear 
division of the strictured portion of the gut is effected in the direc- 
tion of its length, including the sphincter and the intervening 
portion of the bowel. With proper management afterwards in 
the way of dilatation during the healing of the wound, this 
operation will limit the tendency to contraction, and confer per- 
manent relief. When this cannot be done, the stricture may be 
nicked by the knife and rectum bougies systematically introduced, 
in the hope of securing dilatation ; or bougies may be used without 
any previous cutting, beginning with the size that will pass through 
the stricture and following it, if the parts are not too tender, at 
once, or if much pain is produced, on the next day, by the instru- 
ment of next larger size. If a dilating bougie is left in a stric- 
ture more than five or ten minutes, it is liable to cause irritation, 
and to be followed by an increase of thickening of the substance 
of the stricture. Force should never be employed in introducing DISEASES OF THE RECTUM AND ANUS. 
715 
rectum bougies, as fatal results have followed. Dilatation cannot 
be relied upon to effect a cure of stricture. Judiciously employed, 
it may palliate indefinitely, but if the regular use of the dilating 
instrument is suspended, recontraction will inevitably recur. 
Fistula in Ano. 
After piles, fistula is the most common disease of this region. 
It consists in the presence of an unnatural track of the nature of a 
hollow, tubular ulcer, with an outer opening near the anus, and, 
generally, an inner opening which communicates with the rectum 
at a point just within its orifice. The fistulous track may be sin- 
gle, and lie immediately beneath the integument; or, its outer 
opening may be distant from the anus, sometimes several inches, 
and the track crooked, or branched, and communicating, possibly, 
with the cavities of unhealed abscesses, in which case there may 
be several external openings. Fistula in ano very rarely gets well 
spontaneously ; its general tendency is to increase in extent by 
thickening of surrounding parts, or by forming new abscesses 
with additional openings, and to continue indefinitely. Besides 
the pain and annoyance which it causes, the disease is damaging 
to the system by the wasting discharge which attends it, and the 
arrest of this unnatural discharge is always an advantage to the 
patient. The popular idea that cutting off the discharge of a 
fistula in a person with “weak lungs” aggravates the phthisical 
tendency, is not in accordance with modern experience. On the 
contrary, it removes a source of waste, and an impediment to 
exercise and out-door life. A fistula may have continued many 
years, and yet be safely cured. 
Symptoms.—A sense of uneasiness, itching, and not unfre- 
quently pain, at the lower end of the bowel, with a more or less 
constant moisture, which generally soils the clothing, and is some- 
times offensive in odor through admixture of material which has 
entered the fistula from the bowel. Now and then gas from the 
bowel also escapes externally through the fistula. Temporary 
closure of the external opening, with arrest of discharge, followed 
afterwards by increased pain and re-ulceration, destroying the hope 
that had arisen of spontaneous cure, constitute a not unfrequent 
group of symptoms in fistula. Sometimes a new abscess forms, 
attended by greater swelling and pain. The discharge of a fistula 
often provokes irritation and soreness of the skin around its outer 
opening ; this is liable to be increased, especially in hot weather, by 
the dressings which it is necessary to employ for the sake of clean- 
liness. In women, fistula sometimes escapes detection when the 716 
DISEASES OF TIIE EECTUM AND ANUS. 
outer opening is very minute, which is often the case, the slight 
discharge being ascribed to leucorrhoea. There is a variety of 
fistula known as “blind internal,” in which the outer opening is 
wanting, and a painful lump exists in its place. 
Causes.—Fistula always takes its origin in abscess which has 
formed near the lower'end of the bowel, and which, in this locality, 
failing, as a rule, to heal entirely, shrinks down to the dimensions 
of a hollow canal, and persists indefinitely. An abscess may pos- 
sibly form in such a slow and painless manner as to escape notice, 
the subsequent discharge being the first symptom to attract atten- 
tion. There is generally, however, a lump recognized beforehand, 
and in most cases this becomes hot and tender, often excessively 
painful before it discharges. [See Abscess.] 
Treatment.—Fistula may be palliated in some degree by fre- 
quently bathing the part in cold water, by strict attention to 
cleanliness, and by using as light dressing as possible to receive 
the discharge. An excellent material for dressing is prepared 
oakum, which usually remains in place, in consequence of its 
adhesiveness, without any retentive bandage; or a piece of fine 
sponge squeezed out of a very weak solution of permanganate of 
potash and kept in contact with the anus by forcing the buttocks 
together and retaining them in contact by a broad, transverse strip 
of adhesive plaster. 
A radical cure is most certainly secured by a surgical opera- 
tion in which the fistulous track is incised throughout its entire 
length ; the lost tendency to heal is thus renewed in full force, and 
the fibres of the sphincter muscle which kept the part in constant 
motion being placed at rest, the wound heals forthwith, soundly, 
from its deepest portions. Since the American discovery of ether, 
by which it is rendered entirely painless—and this is a sensible 
resource, and perfectly safe in competent hands—there is very little 
to be desired in the way of entire efficiency for this operation. 
There is no danger from hemorrhage, and the subsequent dress- 
ings, in the improved practice of the present day, are light, pain- 
less, and not very frequent. The condition of health of the pa- 
tient should be determined beforehand, by careful examination of 
the internal organs, to ascertain if there be sufficient vital force to 
heal the wound made in operating. The ability to digest food, 
and to increase in weight under tonic treatment and appropriate 
diet, will determine this question in doubtful cases. Whilst 
there is no remedy so rapid and sure, and at the same time so 
safe as the knife in the hands of a skilful surgeon, there are 
substitutes for it which might be employed for patients with a 
natural tendency to bleed too freely (subjects of the hemorrhagic DISEASES OF THE RECTUM AND ANUS. 
717 
diathesis), or whose aversion to the knife is excessive. Of these, 
the elastic ligature inserted through the fistula and tied tightly 
enough to cut its way out, is, perhaps, the best; and injection of 
strong tincture of iodine has some advocates. Both are more 
tedious and painful than the regular operation, and are liable to 
provoke abscess. The ecraseur * has also its advocates. In bad 
cases of fistula, a second or even a third operation may be required 
to accomplish a cure, safely, without too free incision. The heal- 
ing of the wound when slow, is hastened by change of air, or a 
sea-voyage. 
Abscess Near the Anus or Rectum. 
Abscesses in this region are of frequent occurrence. They 
have this peculiarity, that, as a rule, they refuse to heal, and 
gradually assume the characteristics of fistula. This tendency to 
assume the form of a chronic disease instead of getting well, like 
most abscesses in other localities, has suggested much inquiry as 
to its cause, in the hope of discovering the means of preventing 
fistula. In some instances these abscesses assume an extent and 
a degree of gravity leading to a destruction of parts around the 
lower end of the rectum, which is beyond the power of nature to 
repair, and may involve life. 
Symptoms.—Abscess presents itself in different forms, accord- 
ing to its cause, its size, and exact position. A very common 
form is that of a minute globular tumor, situated just at the mar- 
gin of the anus, and remarkable for its excessive painfulness, 
which is due to the fact that it is within the grasp of the sphincter 
muscle. It may last five or six days, and in exceptional instances 
only, may subside without suppurating. An abscess arising farther 
from the anal margin, although out of the grasp of the sphincter, 
is nevertheless liable to be attended by great pain and some degree 
of feverish reaction, and to continue for some days longer. It al- 
ways suppurates. A third variety takes its origin more deeply in 
the fat alongside of the rectum, and is slow in coming to the sur- 
face ; occasionally it assumes a spreading character like the more 
serious forms of erysipelas, is attended by a low form of fever, 
and requires prompt surgical interference to prevent serious con- 
sequences. Slowly-growing, indolent abscesses not unfrequently 
form with little or no pain, and even ulcerate and discharge, in 
* An instrument in which a loop of wire or smooth-jointed chain is gradually tight- 
ened by means of a screw and nut, so as to crush through the soft parts inclosed within 
it. 718 
DISEASES OF THE RECTUM AND ANUS. 
some instances without the patient's knowledge ; but they almost 
always leave fistulse. 
Causes.—Piles, both external and internal, which have become 
the seat of irritation; straining at stool to void hard faecal matter; 
ulcer of the rectum, from whatever cause, which may perforate 
the wall of the bowel and permit escape of its contents. A tem- 
porary derangement of health in sedentary persons, especially if 
high livers, often culminates in a rectal abscess ; and, in emacia- 
tion complicated by a bad cough, the lack of support to the lower 
rectum of the usual fatty cushion, often leads to rupture of the 
isolated veins, and consequent abscess. 
Treatment.—In case of a lump near the anus, painful or other- 
wise, which threatens to culminate as an abscess, there is little 
use in seeking for remedies to put it back, for the simple reason 
that suppuration is the almost inevitable rule. The speediest relief 
is to be got from means employed to hasten this result; and it is 
undoubtedly the best course to take ether, and submit to an in- 
cision without delay, which will arrest the morbid process at once, 
by giving free issue to pus which has formed, or to the foreign 
matter which is provoking the effort at pus-formation. After this, 
a poultice or a moist sponge to the part, and absolute rest until the 
wound heals, will be most likely to prevent the formation of a 
fistula. If the operation is preceded by a dose of castor oil, the 
bowels can be kept at rest, after it, with propriety, for a few days, 
and the result rendered more certain. When this course is not 
adopted, rest, as perfect as possible, with a pig's bladder two- 
thirds full of finely cracked ice, and accurately moulded to the 
part, may prevent a painful external pile from suppurating, and, 
in any event, is an excellent remedy for the pain, which is often 
excruciating. A warm poultice, with laudanum, stands next in 
order, and ointments of stramonium, or belladonna, may be ap- 
plied directly to the part. The use of opium internally is liable to 
render the stools hard, and to produce flatulence. If employed at 
all, it should be given in combination with castor oil. 
Polypus. 
This name belongs to a class of tumors which grow from the 
inner surface of cavities lined by mucous membrane. They are 
small in size, globular in shape, and composed of one of the simpler 
tissues of the body; in some cases hard, but most frequently sott- 
ish in consistence, they always tend to protrude themselves into 
the cavity, from the walls of which they grow by forming a neck 
or pedicle which gradually becomes more slender as it increases in DISEASES OE THE KECTUAf AND ANUS. 
719 
length; hence, when fully formed, a polypus is pear-shaped, and 
attached by its stem. In the rectum the point of attachment of a 
polypus is almost always within a few inches from the lower end 
of the bowel, and the tendency of its pedicle to elongate is aided 
by the action of the muscular coat of the gut in extruding its con- 
tents. Thus it happens that sooner or later the little tumor escapes 
with the contents of the bowel at stool, usually returning at first 
spontaneously, but after a time requiring to be put back. Polypus 
of the rectum is not a common disease ; it occurs most frequently 
in children, but also in adults and occasionally even in old age. 
Symptoms.—This disease presents itself as a smooth, rounded 
tumor of a scarlet color, which protrudes from the anus, accompa- 
nied by pain, and a desire to strain, and also by escape of blood. 
In a child the occurrence of the latter symptoms leads to an ex- 
amination of the part; as soon as the crying and straining are 
controlled, the polypus usually returns again within the cavity of 
the bowel, or can be put hack with very slight pressure. In an 
adult such a protrusion at stool is usually mistaken for an internal 
hemorrhoid; but it is, as a rule, harder to the touch, and more 
uniformly smooth of surface, than an internal pile, and a polypus 
is almost always solitary. 
The constant recurrence of these symptoms with each move- 
ment of the bowels, especially the loss of blood, which is badly 
borne by children, renders a prompt cure necessary. 
Causes.—As is the case with all tumors, the cause of a polypus 
growth in the rectum is obscure ; and there are, consequently, no 
rational means of prevention to suggest. 
Treatment.—A simple surgical operation will cure the disease 
promptly, and it rarely, if ever, returns. If, when the tumor is 
down, a sufficiently strong ligature of twisted silk, or hempen 
thread, be tied very tightly around its pedicle, the polypus will 
turn dark in color, die, and separate, spontaneously, in from one 
to three days, according to its size ; the ligature will also take care 
of itself, and the pedicle will shrink away and disappear. The 
pedicle of a polypus consists of mucous membrane and the blood- 
vessels which nourish it; it must, therefore, be tied tightly enough 
to arrest completely the circulation in these vessels. If it were 
to be cut instead of tied, bleeding might follow. 
Tumors of a more serious nature sometimes show themselves 
first in the form of simple polypi. 
Palling of the Bowel. 
The terms prolapse and procidentia are applied to a protrusion 
from the anus of the mucous coat of the bowel. Its mucous mem* 720 
DISEASES OF THE RECTUM AND ANUS. 
brane is the longest of the coats which form the walls of the rec- 
tum, and therefore, when the cavity of the gut is empty, its mu- 
cous lining lies in folds. It is also somewhat loosely attached to 
the middle or muscular coat by fibrous tissue, which is readily 
elongated. It is easy to understand, then, how it may be carried 
along with a costive passage, and dragged upon, so as to be pro- 
truded externally. This accident is especially liable to happen to 
young children, who strain violently and recklessly, and who are 
often left sitting for a long time upon the chamber, and to old 
people, in whom the feecal matter is often dry and hard, and the 
mucous secretion deficient. Such a protrusion presents the ap- 
pearance of a soft, scarlet-colored mass, with a number of deep 
transverse folds on its surface. It usually retires of itself, or may 
be readily pushed back. In a person of middle age, with internal 
piles, the tumors which grow from this part of the mucous mem- 
brane, assist greatly by their presence and bulk in provoking its 
prolapse, for they stand in the way of the faecal mass, and in the 
act of defecation are pushed out before it. Hence such a protru- 
sion consists largely of prolapsed mucous membrane of the gut, 
but the livid and patchy looking piles can be readily distinguished 
on inspection from the smoother and more uniform mucous mem- 
brane. The causes and symptoms of this simple malady are thus 
plain, and its treatment is equally so, but it should consist mainly 
in prevention. If the protrusion should resist gentle efforts to 
push it back by the fingers, aided by a greased rag, in the horizon- 
tal position of the body, or with the hips elevated, then surgical 
aid should be secured. In a young child a tendency to protrusion 
must be promptly met, or the reckless straining which is so hard 
to control in infancy will bring on a more serious affection—pro- 
cidentia, or falling of the whole bowel. The two conditions are 
thus distinguished : in the milder form (prolapse) the mucous lin- 
ing membrane only, forms the protrusion ; whilst in the more 
serious form (procidentia) the whole gut doubles upon itself and is 
forced outside to a greater or less extent. Except by the greater 
bulk and firmness of the latter and its usually occurring suddenly, 
like a rupture, it is not easy to distinguish the two affections ; 
their mode of production is very similar, and they are generally 
treated under the same head. A procidentia of the rectum some- 
times attains a very large size when neglected. 
Treatment.—A change of diet or other means to secure soft 
passages, and compelling the child to defecate in the horizontal 
position, with a diaper or a thin-edged bed-pan beneath the but- 
tocks, assisting the act, if necessary, by an injection of warm milk 
and water, will certainly prevent any protrusion. If a child can DISEASES OE THE RECTUM AND AHUS. 
721 
be made to defecate in the upright position, in a bath, with the 
lower limbs slightly straddled, or if, whilst half squatting, the 
mother will drag the orifice of the anus a little out of position— 
say to one side, by the hand upon the buttock, the protrusion can- 
not take place. If thus prevented for a few days, the parts will 
recover from their stretching, and the tendency to recurrence will 
be cured. But the squatting position, and sitting long at stool, are 
powerful provocatives. In weak-minded children the difficulty in 
effecting a cure is sometimes insuperable, and the protrusion be- 
comes chronic, and its surface ulcerated; but even in the most 
aggravated cases there are surgical operations which are both safe 
and effectual. 
Cancer of the Rectum. 
This is happily a rare disease, for which many other affections 
of this region are liable to be mistaken. It is a painful malady, 
which usually terminates life, but modern surgery has made great 
advances by which its pain is alleviated, and in some instances 
life has been saved, in others prolonged for many years. Cancer 
in this locality is thought to be less malignant, and consequently 
more likely to be cured by an early and thorough operation, than 
when developed elsewhere. 
Symptoms.—A dull wearing pain between the hips and in the 
lower bowel, with frequent desire for relief by stool; pain, and, 
generally, difficulty, in the act, with strong tendency to strain, and 
a discharge of coffee-colored mucus. Later, costiveness, sometimes 
amounting to entire obstruction, with alternations of diarrhoea; 
distress and colicky pain of the abdomen; a sallow complexion, 
failure of strength—more rapidly through loss of blood—and going 
on, finally, to fatal exhaustion. In rare cases pain is absent. In 
a certain proportion, the disease involves the anus, and is to be 
seen externally. The disease is liable to complications ; in some 
instances by abscess and fistula ; in others, by incontinence of 
fseces ; in men by troubles on the part of the bladder, and in women 
by ulceration into, and discharge of fseces through, the vagina. 
Causes.—The causes of cancer of the rectum are obscure. Long 
continued rectal ailments of a minor sort have been supposed to 
induce it; and hereditary tendency is often suspected. 
Treatment.—Early and entire removal, when feasible—an opera- 
tion which modern surgery has succeeded in safely accomplishing 
—affords the only chance of radical cure, and it offers, in most 
cases, a fair prospect of benefit. But the disease must be detected, 
and the operation undertaken, early. When it is too late for treat- 722 
DISEASES OF THE RECTUM AND ANUS. 
ment in this way, great, and generally certain, relief from the daily 
distress and difficulty in securing evacuations, is to be had by 
establishing an artificial outlet, which accumulating experience 
has demonstrated to be undeserving of the prejudice heretofore 
entertained against it. Years of comparatively comfortable life, 
with ability to attend to business in some instances, have been 
attained by a resort, for this purpose, to an operation which, in 
itself, is not attended by serious danger. Amongst other pallia- 
tive measures, the most important are : The use of concentrated 
nutritive materials for food, those which leave the least faecal resid- 
uum ; occupying the horizontal position as much as possible, with 
the hips raised ; having the stools only in the horizontal position, 
by which the straining and loss of blood are both materially les- 
sened ; the free use of tepid water, milk and water, and of mucila- 
ginous or oily injections, to facilitate the escape of faecal matters, 
and, subsequently, of anodyne injections and suppositories ; pre- 
pared oakum to the anus to prevent involuntary escape of dis- 
charge, or of faeces ; deodorizers, of which a weak solution of 
permanganate of potash is the best; cleanliness and protectives to 
prevent soreness of the skin near the anus; and, finally, opium. 
Sometimes the use of a rectum bougie, or of the finger, may possi- 
bly aid in palliating the obstruction so often present, but great 
care is necessary, inasmuch as fatal injury has been done in this 
way. 
Impaction of Faeces. 
This condition occurs in old age, in paralytics, and in women 
who, through sedentary habits and neglect of the calls of nature, 
have allowed the pouch of the rectum to become habitually over- 
distended, and thus to lose its natural sensibility and, finally, its 
contractile power. 
Symptoms.—Uneasiness in the lower bowel and desire to defe- 
cate, with inability to extrude the contents of the rectum, which 
the sufferer recognizes is distended, for he can often touch a hard, 
dry faecal mass with the finger ; in some cases there is diarrhoea. 
Causes.—In addition to those stated above, there is frequently 
a deficiency of rectal mucus—the natural lubricating material. 
Certain kinds of food seem to promote this condition. 
Treatment.—Strong cathartics are injudicious ; they cannot 
break up the impacted mass, and may excite violent straining, 
which is to be avoided, for it has caused laceration and rupture. 
If castor oil in moderate doses has failed, resort must be had to 
manual interference by means of a strong iron spoon-handle, an 723 
DISEASES OF THE RECTUM AND ANUS. 
instrument for injection, and a good supply of warm flaxseed tea 
and oil, with which, by patient perseverance and repeated wash- 
ings out, the mass may be gradually broken down and got away. 
It may be necessary to gently dilate the sphincter. To prevent 
recurrence, the best means are the use of bran, or crushed wheat 
as food, or of an aloetic dinner-pill, or a daily injection of tepid 
water, with out-door life. 
Foreign Bodies in the Rectum. 
Under this head are included concretions which have formed 
in the bowels and which sometimes reach an almost stony hard- 
ness, indigestible substances which have been accidentally swal- 
lowed—as in the case of the lady who bolted her false teeth—and 
articles introduced from without—as in the case of the old gentle- 
man who was in the habit of sitting upon a cone-shaped cob- 
ble-stone after stool, to press back a large protrusion of internal 
piles and prolapse, and one day the stone slipped through the over- 
stretched sphincter into the bowel, from which it was removed by 
the late Dr. Valentine Mott with obstetrical forceps. 
The Symptoms caused by a foreign mass in the lower bowel 
are the same as those described under ther last head. Where it has 
a rough or angular surface there is more local irritation. The 
symptoms may, moreover, resemble those of diarrhoea or dysen- 
tery, and cases have occurred in which the foreign body long es- 
caped recognition, much medicine having been swallowed to no 
purpose. 
Treatment.—The services of a judicious surgeon are indispen- 
sable. 
Relaxation of the Sphincter. 
In persons who have suffered from internal piles, or from falling 
of the bowel, the sphincter muscle, in consequence of frequent and 
long continued over-stretching, is liable to lose its power of con- 
tractility, and to cease to be a trustworthy sentinel. The anus be- 
comes habitually relaxed through muscular atony, the condition 
resembling, although less in degree, the loss of power which at- 
tends paralysis. 
Symptoms.—This is simply, in most cases, an unpleasant in- 
firmity which shows itself by the involuntary escape of gas from 
the bowel, or, in diarrhoea, or under the action of laxative medi- 
cine, there may be, also, lack of power of retaining faecal mat- 
ter. 724 
DISEASES OF THE RECTUM AND ANUS. 
Treatment.—A simple and safe surgical operation, in which it 
is not necessary to use the knife, will promptly and satisfactorily 
improve the tone of the muscle and remove the disability. Neither 
strychnia nor ergot are reliable. As palliatives, avoidance of flat- 
ulent food and laxative medicine, local cold-water bathing, and in- 
jections may be tried. 
Neuralgia of the Anus. 
The existence of this distressing affection is undoubted, although 
in a large proportion of instances a careful inspection of the seat 
of pain will result in the discovery of a local and removable cause 
—most commonly a minute “ irritable ulcer ” or fissure. When 
this is not the case, the pain is most probably reflex, arising from 
some source of disturbance in the genital organs, which must be 
sought for and remedied. It has occurred as a sign of pregnancy, 
of dysmenorrhoea, and of prostatic nervous disorder. 
Wounds and Contusions of the Anus and Rectum. 
These injuries are as various in their character as to details, as 
the casualties which produce them. In some cases necessarily 
mortal, as where the vicious cow impaled the milkmaid with her 
horn, or the child sat down upon the leg of an upturned stool, yet 
the recoveries which often take place in apparently desperate 
cases make it a duty to secure the best aid as soon as possible. 
The most common, perhaps, are punctures received in squatting 
suddenly in the dark to relieve a call of nature, lacerated wounds 
from the breaking of a chamber utensil under the weight of the 
body, ruptures made in efforts to relieve obstinate constipation, 
and contusions from kicks, or falls astride a beam. 
Symptoms. — Shock, fainting from internal bleeding, pain, 
bleeding externally, presence of foreign matter—perhaps of faeces, 
subsequently fever, heat, swelling, discharge of pus. Complica- 
tions with injury of urinary organs, or the vagina, may cause 
symptoms of their own. As later consequences, abscess, fistula, 
and contraction, or stricture of the anus, or of the bowel, are not 
uncommon. 
Treatment.—Stop bleeding, if necessary, by tying vessels; wash 
out dirt with syringe and tepid water; bring edges of wound to- 
gether with sutures and plaster, and await symptoms and compli- 
cations. In case of contusion, poultices, with the addition of lead- 
water, and rest on the back. Secure soft stools by castor oil, or 
warm-water injections. In case of persistent bleeding from within DISEASES OF THE RECTUM AND ANUS. 
725 
the rectum, pieces of ice may be inserted. Where faecal matter 
escapes into the tissues around the rectum, free incisions for ex- 
ternal escape, washings with antiseptic solutions, and drainage 
tubes, with surgical aid, will be required. 
The lacerations of these parts, which occur in childbed, are un- 
wisely left to nature ; much suffering and subsequent regret may 
be saved by transferring the responsibility to the surgeon, for his 
art can remedy them. 
Specific Ulcers and Eruptions. 
There are certain sores and eruptions liable to affect the anus 
and its immediate neighborhood, especially in infants, which take 
their origin in poison inoculable from one individual to another— 
as from a nurse to her nursling. Whilst it is very desirable that 
the true nature of such symptoms should be ascertained at once, 
in the interest of the child, by appealing to the best professional 
advice, there are certain points to be always borne in mind: first, 
that personal fault is not necessarily involved in these cases—they 
may be, and often are, the result of simple ignorance or misfor- 
tune ; second, contrary to popular belief, they are often easily and 
entirely curable, if wisely managed; third, in view of their ob- 
scure nature, and the general absence of exact knowledge concern- 
ing them, it is well to be slow in arriving at conclusions 
General Remarks. 
There is no class of diseases, so many of which are entirely pre- 
ventable by obedience to the laws of hygiene, especially in refer- 
ence to personal habits, as that considered in this chapter. 
As to children, there are no diseases in which prevention re- 
quires more care and wisdom on the part of parents. 
There are no preventable ailments so certain to assume a seri- 
ous character, in consequence of failure to recognize them early; 
and failure is the rule, for these simple reasons : ignorance of the 
serious consequences which follow neglect, and hesitation, through 
false delicacy, in applying for relief. 
It is to be remembered that none of the functions which the 
Creator has made conditional to life in man can be safely ignored, 
or regarded as ignoble; and that no physician, worthy of the 
name, considers them beneath his studious care. 
WILLIAM H. VAN BUREN, M.D. Diseases of the Organs of 
Circulation. 
BY 
EDWARD G. JANE WAY, A.M., M.D., 
OF NEW YORK CITY, 
PROFESSOR OF PATHOLOGICAL ANATOMY AND HISTOLOGY, DISEASES OF THE NERVOUS SYSTEM, 
AND OF CLINICAL MEDICINE IN BELLEVUE HOSPITAL MEDICAL COLLEGE, 
VISITING PHYSICIAN TO BELLEVUE HOSPITAL, ETC., ETC. DISEASES OF THE ORGANS OF 
CIRCULATION* 
Inflammation of the Sac Covering the Heart—Pericarditis. 
This term is employed to indicate an inflammation of the thin 
membrane which covers the heart and lines the sac which sur- 
rounds the heart. 
The membrane becomes opaque, thickened, congested, and 
covered by a layer of what is termed fibrinous exudation. At the 
same time more or less fluid accumulates in the sac, and contains 
little particles of fibrinous matter like that covering the surface. 
More rarely pus (matter) is formed. If the inflammation lasts a 
long time, the sac becomes much thickened. Sooner or later, as a 
rule, the fluid is absorbed or removed, and the surfaces coming 
together may adhere, and, becoming united, obliterate the pericar- 
dium or heart-sac, or leave bands which unite the heart and the 
opposed surface of the sac. The amount of fluid formed is usu- 
ally small, though cases are recorded in which pints were found. 
More rarely there is an accumulation of fibrinous matter, with 
but little fluid. 
According to duration and intensity, the disease is named acute, 
subacute, or chronic. According to the nature of the material 
which accumulates in the sac, it is denominated simple, where 
serum occurs; purulent, when matter is formed; fibrinous, where 
only fibrin exists, and hemorrhagic, when blood is present. 
Causes.—This disease is usually an accompaniment of some 
general disease, or of a local inflammation in the neighborhood; 
and is very rarely independent of other conditions, or, as physi- 
cians say, idiopathic. 
The diseases with which it is most frequently associated are 
* [See Vol. L, Chapter on Anatomy, for a description of the Organs of Circulation.— 
Ed.] 730 
DISEASES OF TIIE ORGANS OF CIRCULATION. 
acute inflammatory rheumatism, Bright’s disease of the kidney, 
the eruptive fevers (scarlet fever, measles, etc.), cerebro-spinal 
meningitis (spotted fever), pyaemia (blood-poisoning by matter), 
and scurvy on the one hand; and on the other, pleurisy, pneu- 
monia, peritonitis, or a local inflammation in the neighborhood. 
It is at times due to an injury, as a stab or gun-shot wound, and is 
then termed traumatic. 
The first two of the above list and pleurisy are the causes in a 
large majority of cases. 
Symptoms.—This disease may be developed insidiously, and the 
patient be made worse by its existence, without drawing attention 
to his heart as the site of pain or distress. In other cases he suffers 
from pain and tenderness in the region of the heart, at times sharp, 
cutting, though usually not very severe. The fever of the causa- 
tive disease becomes increased when pericarditis is developed ; but 
it is rarely high in the simple form of the disease. The breath be- 
comes short, either from the accumulation of fluid in the heart-sac, 
or from weakness of the muscular fibre of the heart. The pulse 
varies considerably ; at first it is, perhaps, full and strong, but it 
becomes weak and small as the fluid accumulates or the muscular 
fibre becomes degenerated. A dry, suppressed cough also occurs 
without the existence of any lung trouble. Pain or difficulty in 
swallowing may exist, because the food, as it passes along the 
tube (oesophagus) from the mouth to the stomach, behind the heart, 
presses on the inflamed sac, or meets with obstruction from the 
pressure of the full sac. 
Delirium is occasionally present. At first the heart throbs, 
palpitates, and later becomes feeble in its action. Faintness, too, 
is apt to be felt on exertion in the severe cases. 
Difficult as it is to distinguish the disease by the symptoms 
alone, it becomes very easy when auscultation, percussion, and 
palpation of the region of the heart are employed. The roughened 
surfaces cause rubbing sounds to be heard during the movements 
of the heart. The eye notes and the hand feels that the beat of 
the heart is feeble or lost, and percussion maps out a large, dull 
space in the region of the heart, when fluid exists in the sac. 
The Prospects of a patient (the prognosis) with pericarditis de- 
pend much upon its cause. Where it is due to acute inflamma- 
tory rheumatism or simple pleurisy, the patient may, as a rule, be 
expected to recover. Bright’s disease and the eruptive fevers 
give a more unfavorable outlook ; and with pyaemia (or blood- 
poisoning) it is part of an almost invariably fatal disease. 
The disease may end in complete recovery, or the heart, be- 
coming agglutinated by the new tissue to the pericardial sac 731 
DISEASES OF THE ORGANS OF CIRCULATION. 
may later become enlarged by overgrowth or dilatation. This 
is, fortunately, an infrequent result. More rarely still the sac 
becomes thickened and is distended with fluid, or occupied by the 
fibrinous material before spoken of, the acute terminating in the 
chronic disease with but little hopes of improvement. The disease 
may terminate in sudden death, owing to arrest of the action of 
the heart produced by the compression by the surrounding fluid, 
or by a change in its muscular fibres. This is most apt to happen 
during some exertion. 
Treatment.—This must be in the main general, and directed 
against the disease which produces the inflammation. At the out- 
set, agents which quiet the excited heart’s action are useful, as aco- 
nite, digitalis, etc. Later, these remedies may be harmful. Exter- 
nally, especially when fluid is present, counter-irritation by blisters 
or the tincture of iodine is useful. For the pain, poultices may be 
applied. The only remedy which it would be wise to use without a 
physician’s direction is some stimulant, as brandy or the aromatic 
spirit of ammonia. Of the latter a teaspoonful in a wineglassful 
of sweetened water may be employed, and may be repeated as 
often as every one, two, or three hours. These are available in 
case faintness occurs and the physician has left no directions. 
The patient with this disease, especially if it is associated with 
pleurisy or pneumonia, should be very careful about exertion. The 
safe rule is that he should keep perfectly quiet. At times it is 
necessary to draw off the fluid by means of an aspirator or syringe, 
or by tapping. Of the necessity for and the advisability of this 
measure, a physician must be the judge. During convalescence, 
tonics, careful exercise in the open air, and good, nourishing food, 
must be relied on. 
Inflammation of the Interior of the Heart—Endocarditis. 
This term—endocarditis—signifies an inflammation of the lining 
membrane of the heart. The left side of the heart is much more 
frequently affected than the right. The valves, also, are much 
more subject to the disease than the rest of the membrane. 
These valves, it should be remembered, are double folds of the 
lining membrane, strengthened by a small amount of firmer tissue. 
In the earlier part of the disease the valves become swollen, 
often looking as though they contained a little water. Sometimes 
they are slightly reddened. They not infrequently become coated, 
especially on the side over which the blood rushes, with little, soft 
masses called vegetations, which are derived from the blood^—a 
material in it, termed fibrin, having the tendency to accumulate 732 
DISEASES OF THE ORGANS OF CIRCULATION. 
on a rough or inflamed surface. At times little outgrowths, which 
are like warts, spring from the valve, and on these vegetations 
may form. This is more apt to happen in the chronic forms of 
the malady. 
A more severe and dangerous form is denominated ulcerative, 
and is characterized by large masses of soft material on the valve, 
and the ulceration and perforation of the valve. This material is 
composed, to a greater or less extent, of those minute organisms 
called bacteria. (See chapter on The Acute Infectious Diseases.) 
The late changes in the ordinary form are more serious than the 
immediate ones, and lead to thickening, which constitutes a part 
of chronic valvular disease of the heart. Fortunately every case 
does not so terminate. 
Causes.—Endocarditis, like pericarditis, is rarely an indepen- 
dent or idiopathic disease. The ordinary form is due to rheumatism, 
Bright’s disease, the eruptive fevers (especially scarlet fever), to 
pericarditis, pleurisy, and pneumonia. Acute rheumatism is the 
most frequent cause. The ulcerative variety is due to septic dis- 
eases (blood-poisoning), including puerperal or child-bed fever. 
Symptoms.—Endocarditis, of itself, produces but few symp- 
toms. Palpitation of the heart, slight pain or distress in its vicinity, 
a little increase in the symptoms, fever, restlessness, etc., of the 
causative disease, are the most marked events. It is generally 
made out by the physician, who, in listening to the heart, hears a 
murmur accompany or take the place of the proper sounds of the 
heart, more especially of the first sound. Many of the cases are 
discovered in this way rather than by the symptoms. When the 
little vegetations have formed on the valves, and more especially 
in the severe ulcerative variety, these may be swept away with 
the blood-current, and, coming to an artery through which they 
are too large to pass, block it up. This affection is called embolism 
(see Embolism). A sudden paralysis of one side of the body, es- 
pecially of the right side, or the sudden development of aphasia 
(i. e., loss of the memory of words, or of the method of pronoun- 
cing them, the tongue being movable in all directions), indicates 
that embolism has occurred in the brain. 
In the rheumatic and acute forms, other than the ulcerative, 
the prospect of recovery (prognosis) is good. The great danger is 
not immediate, but that in the future it may lead to chronic val- 
vular disease with its attendant troubles. (See Valvular Disease.) 
Treatment.—This consists in quieting the action of the heart if 
excited, and in avoiding the excitation of the organ by exertion or 
in any other way. The main treatment must be directed against 
the disease causing the endocarditis. DISEASES OF TIIE ORGANS OF CIRCULATION. 
733 
Inflammation of the Substance of the Heart—Myocarditis,, 
This term is used to designate an inflammation of the muscular 
structure of the heart. It is not a disease of frequent occurrence, 
and several varieties are included under this common head: 
I. A swelling of, and a granular change in the muscular fibres 
may develop during the course of febrile diseases, especially if 
protracted. 
II. During the course of typhoid fever the muscular fibres at 
times lose their striated appearance and become translucent, uni- 
form, glassy-looking. This is spoken of as “ myositis typhosa,” or 
glassy swelling. 
III. During the progress of pyaemia (a form of blood-poisoning), 
small abscesses, or abscess-like spots, may form in the heart. 
This is designated by some as acute myocarditis. 
IV. There is still a form which occurs in the left side, and es- 
pecially in the wall of the large cavity—the ventricle. It is more 
generally developed in connection with thickened endocardium; 
or less frequently with thickened pericardium. There is an in- 
crease of that connective substance which binds the muscular 
fibres together, and hence a compression or destruction of these 
fibres. The first two classes are, perhaps, more properly degener- 
ations than inflammations. 
Symptoms.—They produce the weakened heart’s action and the 
feeble pulse which characterize continued fevers, and are among the 
dangerous influences of the febrile processes. Beyond the indica- 
tions above mentioned, a feebleness or an absence of the first sound 
of the heart discloses to the physician the existence of the disease. 
Treatment.—A tonic, supporting, and stimulant treatment is 
indicated, as preventive of paralysis of the heart, which may 
ensue, and a treatment which, by the use of packing, sponging 
with cool water, and baths, or by the administration of quinine 
in large doses, aims to prevent the fever from becoming exces- 
sive, and is rational as a preventive (prophylactic) measure. Pa- 
tients in whom the degeneration exists should avoid sudden 
exertion. 
The third form is not readily recognized. 
The fourth form is chronic, and may allow of dilatation of the 
left large cavity—the ventricle—locally or generally,, 
Chronic Valvular Disease. 
This term is used to signify a number of different conditions 
which produce similar results, viz.: thickening, or else insuffi- 734 
DISEASES OF THE ORGANS OF CIRCULATION. 
ciency of the valves. The importance of any change in the valves 
may, in the main, he said to be equivalent to the amount of obstruc- 
tion it offers to the current of blood, or of the amount of blood 
which it permits to flow back into the cavity from which it has 
come. This latter condition is called regurgitation. 
These diseases are of far greater frequency on the left than on 
the right side of the heart. The valves, instead of being thin, del- 
icate, pliable folds, may become firmer and thicker by development 
of connective tissue, or by a deposit of lime salts, when they are fre- 
quently said to be ossified; or the edges of the segments of the 
valves may become united so as to prevent their closure, and only 
leave a small opening for the blood ; or one or more segments may 
become adherent to the wall of the artery or heart-cavity; or 
again, a rupture may take place through the valve, or a tendinous 
chord may be torn from the valve, and in this way regurgitation 
(flowing back) of blood allowed. The effect upon the heart is no- 
ticeable in the increased size of its walls and of its cavities. The 
former is called hypertrophy, the latter dilatation. The site of the 
hypertrophy and dilatation will vary with the valve affected, so that 
at times one side of the heart may be normal, while the other is 
greatly enlarged. If, however, two sets of valves are affected, as 
the aortic and the mitral, both sides of the heart will usually be 
greatly enlarged. The rule is that the walls of that cavity at 
whose outlet obstruction or regurgitation occurs are first thick- 
ened, and later the cavity itself dilates. 
Causes.—The most frequent cause of chronic valvular disease 
is acute articular rheumatism, the acute inflammation of the 
valves becoming chronic. Cases, too, occur in which a recurrence 
of the rheumatism excites additional change in the valve. Other 
cases may be referred to an attack of scarlet fever. Advancing 
age induces certain changes in the inner coat of the arteries, and, 
in the aortic valves more especially, atheroma and calcification. 
It is supposed, also, that work attended with severe strain may 
induce chronic inflammation in the arteries and valves. The wri- 
ter, however, believes that syphilis is the cause of not a few of 
these cases. The difficulty of elucidating the cause is due to the 
fact that, in many cases, years elapse between the time of primary 
injury in the valve and the development of the secondary effects 
which induce the patient to apply to a physician with reference to 
the heart disease. It is on this account that a difference of opin- 
ion exists as to whether certain forms are present at birth (con- 
genital), or are due to some disease of early infancy. 
In the examination of a person who has died of chronic val- 
vular disease, it is customary to find congestion of the lungs, liver, DISEASES OF TIIE ORGANS OF CIRCULATION. 
735 
kidneys, stomach, etc.; and, not infrequently, dropsical accumu- 
lations of fluid in different positions, such as the pleural cavities, 
around the bowels, and so forth. 
The brain, also, though less markedly, may show congestion of 
its veins, and some increase of the fluid normally present. Usu- 
ally the limbs are swollen from accumulation of fluid beneath the 
skin. 
Symptoms.—From the sketch of the changes which are found 
on examination, it is apparent that not the valvular disease only, 
but its results also, are of importance. The increase in the mus- 
cular structure of the heart, at the outset presents the effects 
which would otherwise manifest themselves. Later, dilatation, 
with or without fibre-degeneration, occurs, and then the effects of 
lack of blood, or of the congestion of the various parts, produce 
symptoms. So, also, symptoms may be developed when, from 
some cause, the heart has been weakened by degeneration of its 
fibres, general debility, or a watery state of the blood, which will 
disappear under proper treatment. The following are most no- 
ticeable among the symptoms : 
First. Palpitation, or a forcible heaving of the heart. This is 
more apt to be developed by some exertion in the earlier stages of 
the malady. Palpitation may disappear under conditions noted 
above, being dependent upon causes which would induce it in 
otherwise healthy persons. 
Second. Shortness of breath, after exercise, frequently exists 
with the palpitation. As the disease progresses, the patient feels 
the desire for fresh air, even when quiet; and when dropsy de- 
velops, such a condition of distress obtains that he is only com- 
fortable in a sitting posture. This is an earlier and more promi- 
nent event in disease of the mitral than in disease of the aortic 
valves. 
Third. Bronchitis, spitting of frothy serum, or even of blood, 
are events more especially of mitral troubles, being dependent 
upon the congestion of the lungs. 
Fourth. Slight jaundice is apt to appear when the liver becomes 
congested, and at the same time a sense of fulness is experienced 
under the right lower ribs. 
Fifth. Over-distention of the vessels of the stomach and intes- 
tine may cause dyspeptic symptoms, vomiting, perhaps with some 
blood. 
Sixth. The urine becomes scanty, high-colored, at times con- 
taining blood, owing to the fulness of the vessels of the kidney. 
Seventh. Dropsical swellings, as a rule, make their appearance 
late in the disease. Exceptionally, however, a watery state of the 736 
DISEASES OE THE ORGANS OF CIRCULATION. 
blood permits the temporary occurrence of dropsy at an earlier 
period. 
Eighth. Pain and a sense of distress in the region of the heart 
are complained of by some. The pain may have those character- 
istics which constitute what physicians term angina pectoris, 
especially in diseases of the aortic valves. 
Ninth. Owing to gravity, the brain does not suffer from con- 
gestion as much as the other organs ; yet sleeping with the head 
raised, disturbed sleep, mental dulness, and other evidences of 
imperfect mental action, may indicate its occurrence. Paralysis 
of one side of the body may occur in the course of heart disease, 
owing either to an embolus obstructing an artery of the brain (see 
Endocarditis), or to hemorrhage in the brain. Physicians are en- 
abled to distinguish the disease, and to decide which set of valves 
are affected, by listening to the heart (auscultation). 
Pain in the region of the heart is frequently supposed to indi- 
cate heart disease, when really it proceeds from indigestion. Pal- 
pitation is also popularly supposed to imply organic heart disease, 
when really it may depend upon the use of tobacco, coffee, etc. 
The best methods of discriminating between these and organic 
heart trouble, are those offered by listening to the heart, and by 
the evidence of enlargement of the heart. Yet the reader must be 
warned that a murmur may be due to other causes than disease 
of the valves or of the heart. A watery state of the blood, slight 
pressure on an artery, sounds made in respiration, pressure exer- 
cised on the artery in the neck of the examining physician, may 
each cause a murmur to be heard, which may be mistaken for a 
sign of organic heart disease. These are discussed because of 
their importance with reference to the procurement of a policy of 
life insurance. A murmur due to an aneurism (a poucli-like dila- 
tation of the walls of an artery), or other disease of the aorta (the 
large artery of the heart), may likewise be mistaken for a heart 
murmur. 
The Prospect of a patient (prognosis) with valvular disease de- 
pends upon the amount of obstruction or leakage; whether only 
one or more than one set of valves is affected, and upon the degree 
of heart-stretching or overgrowth of the heart. Many persons 
with valvular disease live for a long time, and suffer but little 
from its effects ; being able to conduct a large business, etc. Sud- 
den death in chronic valvular disease is by no means so frequent 
as is generally supposed. It is most likely to happen when closure 
of the valve at the commencement of the aorta is imperfect; yet 
only a small proportion of those affected with this disease die in 
this manner. The supervention of Bright’s disease is dangerous. 737 
DISEASES OF THE ORGANS OF CIRCULATION. 
The symptoms caused by congestion of the kidneys, however, may 
be mistaken for those of this disease. 
Treatment.—A person with chronic valvular disease should 
lead such a life as prevents undue excitement of the heart. He 
should not engage in any business requiring heavy lifting or for- 
cible exertion. He should avoid a house which requires him to 
frequently mount numerous stairs, or a home where he would be 
obliged to ascend hills regularly. He should be clothed in flannel 
during summer and winter, and should carefully avoid what is 
popularly termed 44 catching cold.” He should not allow his blood 
to become watery, so that the lips look pale, as thereby dropsical 
affections and irregular heart-action are produced more readily than 
in people with sound hearts. He should avoid over-eating, and such 
quantities of tea, coffee, and tobacco as cause irritability of the 
heart. In a word, he should lead as calm, equable, and temperate a 
life as his disposition will admit of. Boat-racing, running-matches, 
ball-playing, rope-jumping, should be abjured by the young having 
this affection. The least sign of rheumatism should be instantly 
attended to, for fear that an increase in the disease of the heart 
might be brought about. As far as medicines are concerned, they 
should be taken under the direction of a physician. He will bo 
able to decide whether digitalis or a heart-sedative are requisite. 
It may, however, be stated that digitalis is the main reliance in 
cases of feeble or irregular heart-action. In case a fainting-fit 
should occur, ammonia (hartshorn) should be inhaled, the bottle 
being held near the nostrils, though not for a longer period than a 
few seconds at a time. Or 10 to 15 drops of water of ammonia, or 
a teaspoonful of the aromatic spirit of ammonia, may be taken in 
sweetened water (a wineglassful). 
The dropsies require, at times when remedial measures will not 
afford relief, puncture of the limbs with a needle, or tapping of the 
abdomen or chest. 
Overgrowth or Hypertrophy of the Heart. 
This consists is an enlargement of the heart, due to an increase 
of its muscular tissue. This increased thickness may affect the 
wall of one, or that of each cavity, according to the position and 
the nature of the exciting cause. As a rule, it may be termed a 
compensative affection, without which the patient would die, or 
survive with extreme discomfort. It may exist with or without 
dilatation or stretching of the affected cavity. 
Causes.—Any obstruction to the circulation—as valvular dis- 
ease, narrowing of the aorta (the large artery,) or of the pulmo- 738 
DISEASES OF THE ORGANS OF CIRCULATION. 
nary artery (the artery leading from the right side of the heart to 
the lungs),Bright’s disease of the kidney, or emphysema (dilatation 
of the air-vesicles), chronic thickening or firm compression of the 
lungs—may produce this complaint. In addition to this category 
we have another, in which over-action of the heart, as in soldiers 
marching with heavy knapsacks and tight dress, in brakemen on 
cars, or in persons engaged in and training for boat-races, run- 
ning-matches, or, still more rarely, excessive and long-continued 
rapidity of the heart’s action, brings about some enlargement. 
Of all these, continued palpitation is least efficient, in many 
cases not inducing any noticeable enlargement. The philosophy 
of the process is similar to that which leads to overgrowth of 
other muscles. Formulated into a law, it may be said that when 
increase of function will result from an increase of size, over- 
growth results from increase of work. There is a limit, however, 
in the heart as in the muscles, varying in different individuals, be- 
yond which excessive work ceases to cause increased growth, but 
leads to over-stretcliing of the cavities, or perhaps degeneration of 
its substance. The special effects on the ventricles, according to 
the seat of obstruction at the valves, has been referred to under 
the head of Valvular Diseases. Bright’s disease leads to simple 
enlargement of the left side of the heart—the ventricle. Narrowing 
of the aorta, or obstruction in the smaller arteries, produces the 
same result. Trouble in the circulation in the lung induces en- 
largement of the right side of the heart—the ventricle. Over-action 
of the heart, also, especially affects the left side—the ventricle. 
Symptoms.—The principal symptoms of the disease consist in 
the more evident and palpable force of the heart-beat, and in its 
greater lifting or heaving character. As in most cases, the en- 
largement is compensative ; much of the associated feelings and 
distress is owing to the exciting cause. At times, however, the 
head may throb, or the patient be troubled with ringing in the ears, 
or spots before the eyes, owing to the greater force with which the 
blood is sent to the brain. 
The prospect is, in the main, dependent upon the cause of the 
enlargement. In cases of simple enlargement of the left side of the 
heart from Bright’s disease, or where it is more than sufficient to 
overcome the obstacle, a rupture of a vessel in the brain may oc- 
cur, and apoplexy result. The enlargement may, if it is slight and 
the cause is removed, be recovered from. If the cause continues 
in operation, dilatation is sooner or later associated with the en- 
largement. Of many hearts we have to say that either the hyper- 
trophy or the dilatation is predominant. 
Treatment.—Treatment for hypertrophy will be requisite in DISEASES OF THE ORGANS OF CIRCULATION. 
739 
those cases only in which it is due to removable causes, or where, 
owing to excited action, it is greater than is required to overcome 
the obstruction. All causes of undue excitement of the heart must 
be avoided, such as mental excitement, overloading of the stom- 
ach, and severe exertion. Coffee, tobacco, tea and alcoholic drinks 
should be given up if found to be injurious, and should be taken 
only in moderation, in any event. Palpitation of the heart should 
lead the sufferer to seek a physician’s advice, as he is the best 
judge of the most appropriate treatment. Such persons as have 
acquired somewhat enlarged hearts, from too great or protracted 
physical exertion, should abstain from this in the future. 
Dilatation or Over-stretching of the Heart. 
Sometimes as the result of previous disease, the cavities of the 
heart become distended so that they are capable of containing 
more blood than natural. Dilatation is usually associated with 
more or less increased thickness of the wall of the affected cavity. 
It may implicate each, several, or all of the cavities. Naturally, 
each cavity will hold about two ounces of blood, though capable, 
when distended, of considerably exceeding this. Usually the in- 
crease is once, twice, or more times the natural amount. In cases 
where the walls appear thinned, the muscular structure may be 
normal in amount, but stretched. 
Causes.—This condition is produced by processes which either 
diminish the resistance of the muscular tissue, or increase the 
pressure within the heart, or prevent or render difficult the com- 
plete emptying of the cavities. In some cases these methods may 
unite to bring about the result. Hence, valvular disease, inflam- 
mation of the substance of the heart, adhesions of the heart, ob- 
struction to the blood in the great arteries near the heart, degen- 
eration of the muscular tissues, or advancing age, may occasion it. 
On the right side it may be brought about by such diseases of the 
lung as render the pulmonary circulation difficult. It should be 
remembered that the more rapidly the cause operates, especially 
if at the same time the heart by exertion is forced to work ac- 
tively, the greater is the probability that dilatation will occur. 
Though the lung-tissue, and hence a part of the blood-vessels in 
the lung, are destroyed in consumption, the heart neither becomes 
enlarged nor dilated. The weakness which the disease causes, 
and the diminution of the amount of blood, account for this. 
Symptoms.—A person with a dilated heart has usually the 
primary cause as well as the secondary dilatation to contend with. 
When dilatation becomes marked, or predominates over enlarge- 740 
DISEASES OF THE ORGAN'S OF CIRCULATION. 
ment {hypertrophy), the person will suffer with over-distention of 
the veins of the parts back of the dilated cavity (back with refer- 
ence to position in the circulatory circuit), and from a diminished 
amount of blood in the arteries. The brain, as before mentioned, 
will suffer less than the other organs, because gravity will pre- 
vent some of the evil effects. The pulse is apt to be small, be- 
coming frequent on exertion, feeble; occasionally, however, slow. 
The veins of the neck, when the right side of the heart is dilated, 
become prominent and may pulsate. The congestion of the lungs, 
liver, kidneys, etc., and the dropsies mentioned under the head of 
Valvular Diseases, make their appearance, for, when valvular 
disease exists, dilatation is often a cause of these phenomena. 
Where there is no such disease, the dilated cavity, not emptying 
itself, is unable to receive a full charge of blood, and is unable to 
propel the blood with proper force, and, as a result, the capillaries 
and small vessels become overfilled. 
These patients have a sense of distress in the region of the 
heart, and attacks resembling those which physicians call angina 
pectoris. They also get out of breath easily, or have attacks of 
difficult breathing independent of exertion, which, as in valvular 
disease, may prevent them from lying down. An inspection shows 
the heart-region to be more or less prominent according to the 
amount of dilatation. The beat of the heart is enfeebled, diffused, 
perhaps replaced by a sort of wave-like sensation over the space 
occupied by the heart. 
Where the dilatation has been produced by a cause which has 
ceased to operate or is removable, then recovery may be possible, 
provided the disease is not far advanced. But, where it is due to 
marked valvular disease, pericarditis (inflammation of the lieart- 
sac), myocarditis (inflammation of the muscular fibre), or is far 
advanced, it proceeds steadily to a fatal issue. 
Treatment.—The treatment must in the first place be directed 
toward removing or diminishing the effect of the cause, or of any 
secondary conditions which aid it. In the majority of cases the 
cause will be a persistent one, and we shall be obliged to be con- 
tent with modifying its effects. Hence, if the heart be irri- 
table, palpitating under slight excitement or exertion, rest and 
cardiac medicines which quiet the heart’s action, will be ad- 
visable, with such other medication and advice as the history 
and symptoms warrant. Anaemia and all debilitating conditions 
should be removed quickly. Where also the disease has produced 
its effects rapidly, the heart should be allowed, as it were, to 
become accustomed to it, and all violent and protracted exer- 
tion should be avoided. The hope is, that under these circum- DISEASES OF THE ORGANS OF CIRCULATION. 
741 
stances we may favor enlargement or hypertrophy, rather than 
dilatation. 
When dilatation is established, we have to be guided by the 
same rules as were laid down under the head of Valvular Diseases; 
using digitalis, ether, stimulants, and the different methods for 
the removal of dropsy. 
Fatty Degeneration. 
This disease is usually divided into two classes. The first 
comprises those cases in which an extra amount of fat tissue ex- 
ists upon and between the muscular fibres; the second, those in 
which the muscular fibres are themselves the seat of the morbid 
change. In this variety oil-globules and granules are observed in 
the fibres by microscopic examination, and obscure, to a greater or 
less degree, the normal striations. In the former class the muscu- 
lar tissue is often less than normal, and the fibres work at a dis- 
advantage. In the latter the power of the affected fibres is weak- 
ened. The walls of the large cavities (the ventricles) are more 
affected than the walls of the small cavities (the auricles). The 
second variety is not infrequently associated with the first. 
Causes.—The form in which fat is present in excess is infre- 
quent under twenty years of age, and whatever tends to increase 
of fat in the body, as hereditary disposition, indolent life, excess 
of fat-producing food, alcoholic drinks, may predispose to or cause 
the complaint. The second form may occur at any age, but is 
most frequent after forty years. It may result from febrile dis- 
eases, poor blood (anaemia), the abuse of alcoholic drinks, the 
changes of advancing age, Bright’s disease of the kidney, obstruc- 
tion of the nourishing artery (coronary) of the heart, or phos- 
phorus taken as a poison. 
Symptoms.—In cases of moderate change, there are few eviden- 
ces of the disease. An unnaturally slow, feeble pulse, or an irreg- 
ular, frequent one, provided other conditions liable to cause it 
have been excluded, is an important symptom. Attacks of faint- 
ness and of temporary loss of consciousness, called pseudo-apo- 
plectic attacks, may occur. Shortness of breath, on exertion, is 
apt to be complained of; at times this distress is independent of 
exertion, and occasionally severe chest-pain is felt (angina pec- 
toris). The circulation is poor, the extremities, perhaps, cold, and 
slight dropsical swelling may appear. The presence of a white 
ring (arcus senilis) around the transparent portion of the eye (cor- 
nea) has no great signification. The visible area and the palpable 
force of the heart’s action are diminished or lost, and the heart is 742 
DISEASES OF THE ORGANS OF CIRCULATION. 
found normal or nearly so in size ; or, at all events, whatever other 
changes may be noted, are not sufficient to account for the con- 
dition. 
The Prospect of the patient (the prognosis) is unfavorable in 
advanced steps of the malady. Where the disease has been due 
to some recent and removable cause, as excess of alcohol, or febrile 
disease, providing these have ceased to act, a cure may be ob- 
tained. On the other hand, when a part of the senile change is due 
to obstruction of the nourishing artery of the heart, no hope of a 
favorable event can be entertained. 
The disease, as above stated, may be cured in some cases. 
Rupture of the heart, or sudden cessation of its action, are the 
great dangers to be apprehended. Again, if an acute febrile dis- 
ease should occur to a person with fatty heart, his prospects of 
recovery would be less than if he had a normal heart. So, also, it 
should be recollected that persons with fatty heart have died from 
the inhalation of a small quantity of chloroform, or after the ad- 
ministration of hydrate of chloral in doses which were not exces- 
sive. 
Treatment.—In the first case, the cause, if possible, must be 
removed. If excess in eating or abuse of alcohol have led to it, 
the person should stop the excess. Ansemia (poor blood) should 
be cured by ascertaining and, if possible, removing its cause, as well 
as by the administration of iron, and remedies which help diges- 
tion, etc. In all cases the patient should avoid sudden severe exer- 
tion, such as lifting, pulling on tight boots, or straining in order to 
procure a passage from the bowels. He should see that the bowels 
are kept open. He should not take chloroform under any circum- 
stances, nor chloral without a physician’s direction. All medicines 
which enfeeble the heart’s action, as aconite, should be avoided. 
He ought not to allow himself to become angry or excited. With 
care he may avoid a fatal issue for a considerable period. In diet 
he should take comparatively less of the starchy, saccharine, and 
fatty, and more of the nitrogenous articles (animal food). 
Embolism and Thrombosis. 
These terms, though used together, have a different significa- 
tion. An embolus is a plug, not in each instance of the same com- 
position, which may be found in a vessel, artery, heart, vein, or 
capillary, to which it may have been carried by the blood-current 
from some other part of the vascular system than that in which it 
was formed or entered the circulation. A thrombus, however, is 
composed of a clot or mass of blood or lymph, situated in the DISEASES OF TIIE ORGANS OF CIRCULATION. 
743 
heart, artery, vein, capillary, or lymphatic vessel, which has been 
formed at the place where it is found. 
Emboli are most frequently little pieces which have broken off 
from a thrombus, or one of the little vegetations which have been 
mentioned as forming on the heart-valves when inflamed. They 
may, however, be composed of little pieces of calcareous matter 
which have been derived from a calcified artery or heart-valve, or a 
portion of a torn valve ; oil-globules which have found entrance to 
the circulation by an open vein, as in fracture of a bone ; pigment, 
which has formed in the spleen in severe malarial fevers ; part of 
a tumor which has grown into a vein ; hydatids (a parasite), 
which have gained access in a similar manner; or bacteria in sep- 
tic diseases. In the lower animals the effects of the disease have 
been produced by forcing little pellets of paper, pith, or the pow- 
der of lycopodium into the circulation. The plug (embolus) is 
generally found in an artery, because the cause producing it is 
usually situated in the heart, or at the commencement of the large 
artery going from the heart (the aorta) ; or, if in the veins, the 
plug will be carried from smaller to larger vessels till it reaches 
the right side of the heart, and thence it passes into the branches 
of the artery going to the lung (the pulmonary). The liver forms 
an exception to this ; for, as the blood returning from the stomach 
and bowels goes to the liver, it passes through veins (portal) that 
become smaller and smaller till they break into capillaries. Hence, 
any clot in the veins of the stomach or bowels may furnish an 
embolus for the veins in the liver, which is not a very infrequent 
occurrence. 
The effects produced by an embolus vary: 
First. With the nature of the process which has existed at the 
point from which it was derived. 
Second. With the amount of obstruction produced by it. 
Third. With the nature of the circulation beyond the obstructed 
point. 
As a rule, it may be stated that, if the embolus has come from 
a portion of the body at which there was gangrene or suppuration, 
these will be excited in the part to which it is carrried. This con- 
stitutes a part of the process called pysemia. Where the artery 
which is occluded does not communicate with another artery be- 
yond the obstruction, or its capillaries do not communicate with 
the capillaries of another artery, a complete obstruction will de- 
stroy the function and the life of the part supplied by it. At the 
same time, if there are no valves in the vein between the part and 
the heart, a hemorrhage into the tissues is apt to take place, owing 
to the blood being forced back in the vessels of the part weakened 744 
DISEASES OF TIIE ORGANS OF CIRCULATION. 
by lack of nutrition. This is called “ hemorrhagic infarction.” The 
arteries of the brain on the left side, more especially, of the spleen, 
kidneys, and of the lungs, are the most liable to receive an embo- 
lus. The large artery of the leg may become obstructed, and death 
of the limb ensue ; so also, but more rarely, an arm may be simi- 
larly affected. 
The embolus, after producing obstruction, may become broken, 
so as to allow a return of the circulation. It may increase in size, 
owing to a clot forming on the plug, and hence an increase in the 
original trouble result. Rarely an inflammation is excited around 
the plugged vessel, when it has come from a spot where no inflam- 
mation, gangrene, or suppuration exists. Embolism of the pul- 
monary artery may cause sudden death. 
Treatment.—Persons who have clots of recent origin in a vein 
in any situation, more especially in the veins of the legs, should 
be warned to keep quiet, lest a piece may become detached ; so 
also, rubbing or forcible pressure should be avoided for a similar 
reason. 
Thrombosis, as already stated, may occur in the heart, arteries, 
veins, or capillaries. The causes which produce it may be ranged 
under several heads: 
First. A diminished force of the circulation, due either to weak- 
ness of the body or to a change in the heart-muscle, or to a diminu- 
tion of the elasticity of the arteries near the heart. 
Second. A dilatation of the heart, or artery near the heart, by 
inducing a slower circulation in this part. 
Third. An altered condition of the walls of the heart or vessels, 
so as to make them rough, or present obstacles to the circulation. 
Fourth. Pressure upon the vessel. 
Fifth. Injury of the vessel, as in rupture or ligature. 
Sixth. The blood is more liable to form a clot when an inflam- 
mation exists, than during a continued fever or in health. 
The clot may form either quickly or slowly. In the latter case 
it will be made up of layers, or, as physicians say, “ laminated.” 
They may either fill up the vessel, totally obstructing it, or 
simply form a layer of varying thickness on the wall. After the 
clot has formed, it may soften and disintegrate, constituting em- 
boli; or a piece may become detached to form an embolus. In 
other cases they become organized, or have a channel formed in 
them, or, becoming filled with the salts of lime, undergo calcifica- 
tion. 
The Result in thrombosis will vary, as in embolism, with the 
site of the process. If in the veins of an extremity, which have a 
freer communication with one another than arteries, they may DISEASES OF THE ORGANS OF CIRCULATION. 
745 
simply occasion a swelling of the limb, and a corded feeling along 
the course of the vessel. 
Only when all the veins coming from a part are completely ob- 
structed, is death of the part likely to occur. Where an artery is 
affected, similar effects may be expected as those described in em- 
bolism, with the exception that, if the clot forms slowly, more time 
will be given for circulation to be established in communicating 
vessels, if such exist. 
Blue Disease—Cyanosis. 
By this term is meant a blue color of the skin, due to the circu- 
lation of imperfectly purified or oxygenated blood. The cause of 
this condition is some congenital (present at birth) malformation 
of the heart, or of its principal branches, which allows a mixture 
of venous and arterial blood. It is not uncommon, however, for 
physicians to use the term cyanosed, when they intend to describe 
the condition which exists as a result of any cause that consider- 
ably interferes with the proper aeration of the blood. The bluish, 
dusky tint to the lips, under the nails, and perhaps of the skin 
more generally, which is seen in croup, pneumonia, pleurisy, etc., 
is frequently spoken of in this way. 
Some of the infants born with this condition are either unable 
to live, or survive for only a short period. Others, however, with 
a less serious malformation, may attain a considerable age. The 
dusky hue may be present to some extent all the time, or become 
manifest on exertion, or during fits of crying or of coughing. At 
all events, these latter circumstances markedly increase the col- 
oration of the skin. It ought to be understood that the color of 
the skin is due to the natural coloration of its parts, in addition 
to that of the blood in its vessels, more especially in the capil- 
laries. The reader may recall some person, the pale color of 
whose skin was due to a watery state of the blood, or followed a 
severe hemorrhage, the skin then showing its color with but little 
blood. 
The conditions which are found on the examination of those dead 
with cyanosis, vary. There may be a large opening between the 
two auricles. This is normal before death, but is closed within a 
week after birth, except that a very small opening, which is of no 
importance, may remain. Sometimes a deficiency is found in the 
wall which separates the two ventricles ; or again, the position of 
the arteries may be reversed, so that the artery which sends blood 
to the body comes from the ventricle, which receives the blood 
from the body, and not from the lungs, as it should. In these cases 746 
DISEASES OF THE ORGANS OF CIRCULATION. 
an opening in the partition between the two auricles, and an ex- 
istence of an artery called the “ductus arteriosus,” situated be- 
tween the aorta and pulmonary artery, may allow sufficient 
aerated blood to reach the body, life being thus retained. Again, 
a narrowing of the trunk of the pulmonary artery, or of the aorta, 
may exist, and be compensated for, as mentioned under the head 
of transposition of these vessels. 
Treatment.—No medicine is of any avail as curative of this 
condition. Such children should be carefully watched, restrained 
from crying (if it is possible), and kept with more than ordinary 
care from the risk of whooping-cough, bronchitis, and colds. 
Angina Pectoris. 
By this term is meant a peculiar nervous affection of the heart, 
associated with pain and a sense of impending death. The exam- 
ination of the body of a patient who has died of angina pectoris 
discloses varied derangements of the heart or large artery leading 
from the heart—the aorta. These have been fatty degeneration 
of the muscular fibre; valvular disease, aortic particularly; ob- 
struction of the nourishing arteries (coronary), and aneurism 
(local dilatation) of the aorta. 
Symptoms.—The phenomena of the disease occur in paroxysms, 
with intervals, which progressively shorten. They consist of a 
peculiar sense of weight, burning or pressure over the heart, ex- 
tending at times from the heart to the chest and back, or down 
the left arm to the elbow or fingers, or into the right arm ; or, 
more rarely still, into the legs, and of the feeling that the heart is 
about to cease beating, and that death is impending. The face is 
usually pale, and the pulse is either natural, or small, feeble, and 
perhaps irregular. 
The first attacks usually occur as the result of some exertion, 
which the patient instantly ceases from with the feeling that, if con- 
tinued, death would at once result. Later, they may be developed 
independent of any exertion. 
The result of true angina pectoris is death from cessation of 
the action of the heart in one of the attacks. Yet persons who 
have died of the affection, have had long intervals, sometimes of 
years’ duration of comparative comfort and health, between the 
attacks. 
There is a peculiar affection which simulates angina pectoris, 
and is sometimes described as neuralgia of the heart. Such attacks 
may be due to accumulation of gas in the stomach, or to neuralgia 
in this organ. The latter is distinguished from the former by the 747 
DISEASES OF TIIE ORGANS OF CIRCULATION. 
absence of any evidence of structural change in the heart or aorta; 
also, as a rule, by the absence of that vivid sense of impending 
death, and by the presence of a regular action of the heart during 
the paroxysm. There is a possibility that obstruction of the cor- 
onary artery might be overlooked and too favorable an opinion 
be given. The mistake in the other direction is the rule, the neu- 
ralgic or stomach affection being supposed, by the patient, to be 
the true disease. 
Treatment.—The treatment during the paroxysm must be di- 
rected to the relief of the painful symptoms. The medicine which, 
of late years, has found the most favor, has been the nitrite of 
amyl—three to five drops being placed on a piece of cotton or a 
handkerchief and cautiously inhaled. Ether, also, may be inhaled, 
putting a tablespoonful or more on a handkerchief. Chloroform 
should be avoided, except under careful medical direction. Mor- 
phia in one-eightli or one-quarter grain doses may be injected 
under the skin. Aromatic spirit of ammonia may be adminis- 
tered in half-teaspoonful or teaspoonful doses diluted with a wine- 
glassful or more of water. Hoffman's anodyne may be given in 
teaspoonful doses similarly diluted with water. 
In the intervals between the attacks, the patient should lead a 
quiet life, avoiding severe muscular effort, or violent mental emo- 
tion. He should also secure as favorable action of the stomach 
and bowels as possible, avoiding excess in eating or drinking. 
Palpitation. 
This is a functional disease or action, and usually exists with- 
out any organic change either in the valves or in the structure of 
the heart. It may, however, exist in people with diseased hearts, 
and be due to the same causes that produce it with the healthy. 
What is meant by the term is, that the heart beats more frequently 
than natural, and also makes its beating manifest to the person. 
One form exists with enlargement of the gland in the middle of 
the neck, called the thyroid and protrusion of the eyes, named 
Exophthalmic Goitre, or Graves’s Disease, or Basedow's Disease. 
The palpitation in this affection is a marked feature. 
Causes.—The heart, like the rest of the muscular, and also the 
nervous system, does its work most quietly and regularly when 
properly nourished, and, as it is excited and controlled by two dif- 
ferent sets of nerves, the one hurrying, the other slowing its 
action, those agencies which produce what is denominated ner- 
vousness, have a strong influence upon, and tend to produce, this 
condition. All are probably aware, from personal observation, of 748 
DISEASES OF THE ORGANS OF CIRCULATION. 
the effect of mental excitement upon the heart. Weakness, due 
to whatever cause, tobacco, coffee, tea, indigestion, and secret 
indulgences, are among the most prominent causes. The female 
sex, owing to the less power of nervous control, is especially sub- 
ject to this affection. 
Symptoms.—The distinguishing feature consists in the occur- 
rence of attacks of violent or rapid beating of the heart under cir- 
cumstances which, in the normal state, would not be capable of 
developing them. These are followed, in some cases, by copious 
discharges of urine. 
The prospect (prognosis) in these cases is good, providing there 
is no actual disease of the heart. The usual result is recovery. 
In some few cases, continued palpitation is the first evidence of 
the disease called exophthalmic goitre. The enlargement of the 
heart which ensues from continued palpitation is, at most, slight. 
Treatment.—First remove the cause. People with a tendency 
to palpitation should use coffee, tea, tobacco, sparingly, or not at 
all. They should strengthen the nervous system by exercise in 
the open air, cool sponge baths and salt-water bathing, and by giv- 
ing up any injurious habit in which they may have indulged. 
When severe or continued, aconite, veratrum, or digitalis, and 
the proper application of electricity (galvanism) to the nerves in 
the neck, furnish the best means of combating the malady. These 
measures should not be resorted to except under the direction of a 
physician. 
Rupture of the Heart. 
Rupture of the heart is, fortunately, a rare affection, and never 
occurs when the organ is sound. It may occur in either of the 
auricles—the small cavities, or in the ventricles—the large cavi- 
ties—though the ventricles, and of these the left one, is most fre- 
quently the site of the rupture. Either the fibres will be found 
degenerated, or disease will exist at the point of rupture, as an 
aneurism, softening, abscess, etc. The result of the rupture is the 
penetration of the blood into the heart-sac, death happening very 
quickly, as a rule. Where the rupture has been small, it is pos- 
sible that life may be prolonged some little time. 
Aneurism of the Heart. 
This term signifies a localized sac or pouch in the heart-wall, 
and communicating with the cavity of the heart. The size of the 
sac is variable. Some only attain the dimensions of a small nut, 
while others are as large as the heart itself. The left side of the DISEASES OF THE ORGANS OF CIRCULATION. 
749 
heart is alone affected, the left ventricle, with a few exceptions, 
being the site of the disease. As a rule, the lining membrane of 
the heart (endocardium), and the membrane covering the heart 
(pericardium), present evidences of old inflammation; and it is 
not uncommon to find the surfaces of the heart-sac grown together. 
The valves of the heart, also, are frequently diseased. 
Symptoms.—This disease is not readily recognized during life, 
and is frequently mistaken for disease of the valves with its at- 
tendant evils, or for an aneurism of the artery coming from the 
heart (aorta). In some of the cases, particularly when the pouch 
is of small size, the fatal rupture has been the first evidence of the 
disease. In others, in which the sac is larger and more marked, 
the interference with the action of the heart and with the circula- 
tion is similar to what obtains in valvular disease. However, the 
sense of pain and distress in the heart is apt to be greater in aneu- 
rism of the heart than in valvular disease. 
It has occurred that the blood has coagulated in the sac and 
and thus worked a cure. Death, however, is the general termina- 
tion, either owing to a rupture of the sac and fatal hemorrhage, or 
to compression of the heart; or in the same manner as obtains in 
valvular diseases. 
Causes.—It is more frequent in males than in females, and oc- 
curs especially between twenty and fifty years of age, though it is 
possible at an earlier or a later date. Articular rheumatism and the 
attendant inflammation of the heart are chief among the causes. 
Treatment.—This must be directed against the symptoms, and 
demands professional skill. 
Diseases of the Arteries. 
The arteries, fortunately, have but few diseases. Of these the 
most prominent are aneurism and the condition known as deform- 
ing inflammation (endarteriitis deformans). Inflammation of 
the inner coat of the arteries is characterized by the appearance of 
small, hard, rather transparent-looking patches, which are raised 
above the surrounding parts, and on section best show the increase 
in thickness. It is found to be due to an increase of cells in this 
portion. Later, these cells become fatty, sometimes even forming 
a little mushy spot, which finally opens into the artery. This 
at times leaves a little ulcer which may heal, or it may allow the 
formation of a variety of aneurism called dissecting, because the 
blood getting between the coats of the artery, tears them apart, 
and finally returns to the cavity of the vessel at another point, or, 
more frequently, bursts externally. 750 
DISEASES OF TIIE ORGANS OF CIRCULATION. 
At other times, instead of the softening process in these trans- 
parent-looking patches, calcification may occur, and the inner coat 
of the artery become coated with bone-like plates. On these and 
on the ulcers, fibrin may be deposited, forming thrombi, which 
shall later furnish emboli (see Embolism and Thrombosis). The 
artery, in this disease, when advanced, is dilated, and its walls 
are more or less thin. This process is also one of the frequent 
causes of aneurism,* owing to the resulting diminution of the elas- 
ticity of the middle coat. In the smaller arteries of the brain, 
especially in syphilis, it may lead to more complete obstruction, 
and thus occasion symptoms of impaired function, usually con- 
sidered as softening of the brain. In the extremities it may either 
directly, or as a result of the formation of a clot in the vessel 
(thrombosis), cause gangrene (death) of the limb. 
Fatty degeneration of the small arteries may happen, inde- 
pendent of inflammation, and occasion such weakness of the ves- 
sel, as to allow its rupture, for example, in the brain. In the 
larger vessel it produces yellow or whitish patches on the inner 
surface. At other times there may be calcification of the arteries 
independent of any preceding inflammation. This is best seen in 
the middle coat of the arteries of medium size. In this trouble 
the arteries may be converted into rigid tubes which may be rec- 
ognized by the presence of hard bone-like rings. This is due to 
the infiltration of the middle or muscular coat with certain salts, 
phosphate and carbonate of lime especially. It is a disease of ad- 
vanced life, and may lead to imperfect circulation. 
Waxy degeneration of the different organs of the body is usu- 
ally due to a change of the blood-vessels as the starting-point, es- 
pecially of the small arteries and capillaries. For a description of 
this change see Waxy Degeneration of Kidney and Spleen. 
Diseases of the Lymphatics. 
There is but little to be said of this class of diseases in a work 
of this kind. In the description of the diseases of the different 
organs, under the head of Tumors and of Inflammation, most 
that has any interest may be said. The finer lymphatics forming 
spaces in the tissues, take part in inflammations. The acute in- 
flammation of the larger vessels of the skin is probably familiar 
to many readers. As a result of some irritation, such as a small 
boil, a slight wound somewhat inflamed, etc., there is seen a red 
line or lines running from this point to the bend of the elbow or 
[* See Chapter on General Surgical Affections for a description of Aneurism.—Ed.] DISEASES OF THE ORGANS OF CIRCULATION. 
751 
to the armpit in the upper extremity, or to the back of the knee or 
the groin in the lower extremity. These lines are a little raised, 
have a slight corded feeling, and at the inner side of the elbow 
or back of the knee, or in the armpit or groin, a painful swelling 
or lump can be felt. At times a small abscess may form in their 
course, or the painful tumor or swelling may have matter formed 
in it, and will finally burst, or it may be opened by the surgeon. 
This is one of the annoyances to which medical students and phy- 
sicians who make post-mortem examinations are particularly sub- 
ject, and constitutes a part of what are called dissecting wounds. 
This disease is inflammation of the lymphatic vessels, and is 
technically called lymphangitis, or angeioleucitis. 
Treatment.—Remove, as far as possible, all source of irritation 
from the causative wound or sore. It is a good plan, if some slight 
scratch or fester is becoming red or inflamed, to paint it with the 
tincture of iodine, or with a solution of nitrate of silver, of the 
strength of five grains to an ounce of water. If red lines extend 
from the sore or wound in the directions mentioned, coat them and 
the surrounding parts with tincture of iodine, and just above the 
termination of the red line paint a circle around the limb. Where 
a sore on the foot, as a fester from tight shoes, etc., has led to the 
development of this disease, rest, with the foot elevated, is neces- 
sary. In some forms of puerperal (childbed) fever, the lymphatics 
of the womb become inflamed, and may contain those little disease- 
producing organisms called bacteria. These bacteria may be pres- 
ent in the lymphatics in other erysipelatous inflammations. The 
description of these events falls under the head of Pyaemia and 
Erysipelas. 
The disease called hypertrophy of the tongue (makroglossie) is 
largely made up by dilatations of lymphatic vessels. In elephan- 
tiasis, there is also a considerable enlargement of these vessels. 
So, also, in some enlargements of the privates, dilatation of the 
lymphatics may form a marked feature. At times an opening on 
the skin communicates with a lymph vessel which has been dila- 
ted, leading to a flow of the lymph—lymphorrhcea is the scien- 
tific term. Tubercles may be found in the lymphatics in connec- 
tion with ulcers, preferably in phthisis (consumption of the lungs, 
bowels, etc.). The reader has previously been referred to the ar- 
ticle on Tumors for a statement of the method of propagation of 
malignant disease. 
Diseases of the Veins. 
Inflammation of the veins was formerly considered a much 
more frequent event than it is at the present time. In each in- 752 
DISEASES OF THE ORGANS OF CIRCULATION. 
stance that a clot (thrombus) was found in a vein, it was supposed 
that its formation had been preceded by inflammation. Physi- 
cians, at the present time, generally hold the view that, in many 
cases, the clot is the cause and not the result of the inflammation. 
The truth lies, to a certain extent, between these extremes. An 
inflammation outside of a vein (periphlebitis) may produce a clot 
in the interior of the vessel, and that in turn give rise to inflam- 
mation of the vein itself. We have already considered this under 
the head of Thrombosis and Embolism. 
The veins are liable to become varicose. This is seen in the 
veins of the leg and thigh. Large blue trunks variously twisted 
are seen raising the skin, and, where markedly developed, the tis- 
sues covering them are much thinned. This disease consists 
in a dilatation of the coat of the veins, first on one side, then on 
the other of the affected vessels, so that, in its course, it looks 
knotty. 
The three things which may result are, swelling, ulceration of 
the limb, and hemorrhage. 
Causes.—Varicose veins occur especially in women and in those 
people engaged in occupations which require them to stand most 
of the time. Constipation aids in producing the disease. Child- 
bearing is, however, the most prominent cause. The enlarged 
womb pressing on the veins in the abdomen, and thus obstructing 
the circulation, the blood sets hack and dilates the veins in the 
lower extremities. 
Treatment.—An elastic stocking or bandage should be worn to 
give support to the veins. People who notice the disease com- 
mencing might prevent its increase by adopting this measure. 
The bowels should he kept open daily. The affected limb should 
be elevated frequently so as to prevent, as far as possible, over- 
distention of the blood-vessels. This is readily done by occasion- 
ally lying down and raising the limb above the head. If a vein 
ruptures, the person should instantly lie on his back, raise the limb 
above the head, and then press with the fingers, or a folded cloth 
of any kind on the vessel at the point of opening. This will stop 
the flow of blood. Constriction of the limb above the opening is 
not proper, for that tends to produce a flow of blood from a vein, 
though it may stop that from an artery. 
Leueoeythaemia or Leukaemia. 
The first of these terms means white-cell blood, the second, 
white blood ; they both refer to the same disease, the names 
having been given by different observers. 753 
DISEASES OF THE ORGANS OF CIRCULATION. 
An examination shows that either the spleen or the lymphatic 
glands are enlarged, or else that the bone marrow has become 
altered. Hence we have a splenic, a glandular, and a myelo- 
genic (marrow) type of the disease, or all these varieties may co- 
exist. The spleen, instead of having its usual weight (less than 
half a pound), may be so increased in size as to weigh five, seven, 
ten, or even eighteen pounds. The lymphatic glands, in different 
situations, as in the neck or armpit, instead of being little ker- 
nels, scarcely perceptible, or feeling like little peas, may attain the 
size of a marble, a pigeon's egg, or even larger, and, when a group 
of glands becomes enlarged, they may be connected together in a 
large, uneven mass. The liver is often found enlarged, and, at 
times, glandular growths appear in this organ, as well as in the 
lungs, kidneys, etc. At the same time the blood may become so 
white, as in the case where an observer, when the heart was 
opened after death, thought that an abscess had been cut; usu- 
ally, however, the change in color is not so great. 
Symptoms.—The marked symptoms are pallor, debility, gradu- 
ally increasing, perhaps attended with bleeding from the nose, 
stomach, or bowels, the hemorrhage from the nose being by far 
the most frequent. At the outset of certain cases a pain has 
been present in the left side, or the spleen has been found en- 
larged, forming a tumor, projecting from under the left ribs. In 
other cases lumps have been noticed in the neck, armpit, or groin, 
in connection with the symptoms above mentioned. The distin- 
guishing feature, however, is afforded by a microscopic examina- 
tion of the blood. This disease is characterized by an increase of 
the white blood-globules and a diminution of the red. Normally, 
there should be about one white blood-globule to three hundred 
red, though this is a matter subject to variations. In leucocythm- 
mia the white blood-globules may be equally as numerous as the 
red, or as one to two ; or somewhat in excess of one to twenty. 
In the latter part of the disease the pallor becomes more marked, 
the bleedings, perhaps, are more frequent, the sight, possibly, is 
affected from changes in the sensitive membrane of the eye, fever 
develops, dropsy may occur, and frequently, by the addition of 
some intercurrent disease, death results. 
Causes.—The disease may occur at any time of life ; most fre- 
quently between the ages of twenty and fifty years ; and is more 
often observed in males than in females. Malarial fever has pre- 
ceded it in a certain number of cases ; injury to bone has also 
happened in others, but we are unable to say why, in one case, 
this disease should occur, while so many in similar circumstances 
escape unaffected. 754 
DISEASES OF TIIE ORGANS OF CIRCULATION. 
Very few recover from the complaint. The disease may end 
within a year, or extend its march over several years— five, or 
even more. Death may result from an intercurrent affection, as 
pneumonia, or pleurisy; or be due to hemorrhage in the brain, or 
from the nose or stomach, etc. Generally, however, the debility 
entailed by the malady is the occasion of the fatal termination. 
The disease is to be distinguished from other enlargements of 
the spleen, as malarial, etc., attended with pallor and general 
debility. Enlarged lymphatic glands also may occur from scrof- 
ula, from another condition like leucocytliaemia, and called 
pseudo-leukaemia, from syphilis, and also in the course of a ma- 
lignant disease, such as cancer. An examination of the blood 
with the microscope is the best method, and the only one by 
means of which the presence of the disease can positively be as- 
certained. The only trouble is, that red blood globules may be 
mistaken for white ones, or, a slight increase of white blood- 
globules, which occurs in a number of other conditions, may be 
supposed to indicate this complaint. 
Treatment.—This disease is best treated by maintaining the 
nutrition and strength of the patient. The medicines which have 
been supposed to be effective are phosphorus, quinine, and, in one 
case where it coincided with syphilis, a mercurial. Transfusion 
of blood has also succeeded in some cases, according to published 
accounts. 
E. G. JANEWAY, M.D. Diseases of the Bones and 
J OINTS. 
BY 
BENJ. LEE, A.M., M.D.. 
OF PHILADELPHIA, PA. DISEASES OF BONES AND JOINTS. 
Entirely apart from their often fatal and usually exquisitely 
painful nature, this class of diseases possesses an importance of its 
own, from the fact that its victims are, even if life is spared and 
health restored, apt to be left deformed and helpless, unable to 
earn their daily bread, an encumbrance on their friends or society, 
and a constant mortification to themselves. 
The attempt to treat these affections without the aid of a physi- 
cian should never be made unless unavoidable. And indeed they 
are, for the most part, so gradual in their invasion, and so slow in 
their progress, that they rarely present those sudden emergencies 
which call for immediate domestic interference. There is, therefore, 
little room, in a treatise like the present, for detailed instructions 
in regard to treatment. But, notwithstanding this, such affections 
have a most important place here, from the fact that so much de- 
pends upon their early recognition. Premature death, or life-long 
deformity, with weary years of bodily anguish, and still sharper 
agony of mind, are the penalties of the failure to discover their 
existence wh ile they are still susceptible of complete cure ; by which 
is meant restoration of health without deformity. It will, there- 
fore, be the special aim of the following pages to present their distinc- 
tive symptoms in so plain and intelligible a manner that any parent 
who will take the trouble to read the descriptions attentively, will 
be able to arrive at a tolerably correct conclusion in regard to the 
condition of a child who repeatedly manifests pain or discomfort 
on moving or being moved. This may be set down as the first and 
most general symptom of commencing trouble in a joint or bone, 
and should always lead to careful examination. And as such 
affections commonly depend for their immediate cause upon a 
hurt, careful inquiry should first be made of the sufferer (if of an 
age to give information), and of his friends or playmates,* of any 
* The statements of a nurse are, for obvious reasons, not always to be depended on. 758 
DISEASES OF HONES AND JOINTS. 
possible source of injury, such as a blow, a fall, a wrench, or a 
jar. No accident of this kind should be deemed too trifling to be 
considered, and it would be well to make a written memorandum 
of any such circumstance for the use of a surgeon in forming his 
own judgment of the case. 
If we except cancer, which we shall not consider, and tubercle, 
the existence of which, in bone, is doubtful, we may say that there 
are but two diseased conditions to which bone is liable, namely: 
Inflammation and Defective Nutrition. 
Inflammation may be either acute or chronic. 
Acute inflammation of a bone, whether seated in its covering 
membrane (the periosteum), or in the hard portion of the shaft, or 
the spongy portion of the joint end, or the marrow of its canal, is 
always an alarming affection, coming on suddenly, with chills, 
high fever, headache, often with delirium, frightful pain, and, usu- 
ally, tenderness at the seat of disease. A physician will al ways 
be summoned at once, and active operative measures are often 
demanded to save life. 
Chronic inflammation is either the result of an attack of acute 
inflammation, imperfectly recovered from, or conies on slowly, 
with slight occasional or daily recurring fever of a hectic charac- 
ter (see Glossary), pain more or less severe (often not in the part 
affected), lassitude, loss of appetite, emaciation, night-sweats, and 
disorders of the digestive system; in short, all the symptoms which 
characterize consumption of the lungs except the cough. Hence 
many physicians have been led to look upon it as being necessarily 
strumous (scrofulous) or tubercular in its origin and nature. Mod- 
ern experience in the employment of improved mechanical modes 
of treatment, however, demonstrating that with relief of the local 
disease, the general health is restored, has given a severe shock to 
this theory, and places this class of cases in a much more hopeful 
light. 
Chronic inflammation of bony tissue may result in hardening, 
a peculiar and rather rare termination, which is simply mentioned : 
in softening or ulceration, technically called cariesj or in gangrene 
or death of the portion attacked, to which surgeons give the name 
of necrosis. The process of ulceration may be dry, when the soft- 
ened bone-tissue is simply absorbed and carried away in the 
blood : or moist or suppurative, when matter or pus is formed. 
This matter collecting in any quantity constitutes what is called 
an abscess. If it pushes its way to the surface and is discharged 
either spontaneously or artificially, it usually establishes a running 
sore. 759 
DISEASES OF BONES AND JOINTS. 
General Description of Joints. 
A joint is the place where two or more bones are naturally 
joined together, for the purpose of allowing motion between the 
different parts of the body. The bones are tied firmly together 
by excessively strong cords and bands called ligaments. But al- 
though held together so tightly, the ends of the bones do not 
touch each other. If they did, they would soon wear off. The 
joint end of each bone is covered with an elastic cushion or spring 
of gristle, called by anatomists cartilage, which forms a complete 
protection to the bone. But for these springs, of which there are 
not less than thirty between the sole of the foot and the head, 
Fig. 163. 
Fig. 164. 
Figure 163.—Section through a knee-joint which has previously been distended with air and 
dried, so as to show the limits of its cavities. 
Figure 164.—A section through the hind and upper part of the shaft of a thigh-bone ( femur) 
and through its socket on the side of a hip-bone. The illustration shows the spongy character of 
the extremity of the bone and the arrangement of the bony fibres, so that the greatest strength is 
secured with the least amount of material. The capsule, or sac in which the joint is enclosed, is 
also shown as it passes from the margin of the acetabulum to be attached about the neek of the 
thigh-bone ( femur). 
every step that we take would communicate such a shock to the 
brain, that we should all very quickly suffer injury. But no 
tissue could stand the wear and tear to which a joint is subjected, 
without a lubricating fluid, like the oil for the axle of a wheel. 
This is furnished by a delicate membrane, which lines the sides of 
the joint all around, and is constantly pouring out, in just such 760 
DISEASES OF BONES AND JOINTS. 
quantities as are required by the work which is being done, a clear 
oily fluid, called synovia. This membrane is called the synovial 
membrane. The essential parts of every joint, therefore, are bone, 
cartilage, ligament, and synovial membrane. 
But notwithstanding these admirable precautions, the amount 
of wear and tear on joints is still great. To diminish it yet more, 
the bone is spread out at the end, in order to afford as large a sur- 
face of contact as possible, thus, of course, lessening the pressure 
and friction at any one point. In thus spreading out, its tissue nat- 
urally becomes looser, and its fibres more separate ; and into the 
spaces between the bone-fibres and bone-cells penetrate the blood- 
vessels, always on the alert for work. Provision is thus made for 
a supply of blood amply adequate to the complete repair of the 
constantly wearing-out cartilage, and the steady manufacture of 
fresh synovia. Those portions of a bone which are thus loose in 
texture, and full of blood, we call spongy. It will readily be under- 
stood that bone of this kind is more easily injured, and more lia- 
ble to inflame when injured than is the hard, ivory-like structure 
which forms the shaft or principal portion of the length of the bone. 
To these two facts, namely, the soft, spongy character of the 
bones, constituting a joint, and their exposure to wear and to 
shock, it is owing that bones are vastly more liable to become dis- 
eased at their joint ends than elsewhere. 
The joints most liable to disease, and to which, as types, we 
shall confine our attention, are the spine (which is simply a long 
compound joint), the hip, the knee, and the ankle. 
Anatomy of the Spine. 
The spine differs from the other joints in having, in its most 
essential part, and that in which disease almost invariably com- 
mences, no synovial membrane. Hence, in considering its dis- 
eases, we may leave that element out of the question. It is com- 
posed of twenty-four rounded blocks of spongy bone, called verte- 
bras, the cartilage on the under surface of each of which is at- 
tached to the upper surface of the one next below. These carti- 
laginous discs are from one-eighth to five-eighths of an inch in 
thickness. Instead of being firm and hard all the way through, 
like the cartilages of other joints, they are, in their interior, quite 
soft and pulpy ; a fact which adds greatly to their elasticity. 
Taken together, they form about one-fourtli of the entire column. 
The motion between any two of the bones, thus united, must of 
course be very limited, but their large number makes the entire 
joint capable of a great range of motion in all directions. 761 
DISEASES OF BONES AND JOINTS. 
Each vertebral body opens out behind into a strong, hard ring 
of bone, which, in combination with its fellows, forms a continu- 
ous canal, giving passage and affording protection to that prolon- 
gation of the brain which is called, from its position, the spinal 
Figure 165.—The bones of the spinal column as seen from the left side. The numbers refer 
to the vertebrae of the different regions. 
Figure 166.—The bones of the spinal column as seen from behind. 
Fig. 165. 
Fig. 166. 
cord. From both sides of this ring, close to the body, project little 
branches, a short one upward, and a longer one downward, which 
form true joints with similar projections on the vertebras next 
above and below, and act both as auxiliary supports, and as stops 
to prevent too great motion backward. Behind these joint- 762 
DISEASES OF BONES AND JOINTS. 
branches, on each side, the ring carries a long, stout arm which 
stands out backwards at an angle of about 45°, for the attachment 
of the muscles of the spine. Finally, from the back of this ring 
Fig. 167. 
Fig. 168. 
Figure 107.—A vertebra of the neck, seen from above (A) and from the right side (B). 
Figure 168.—The tenth, eleventh, and twelfth (and last) dorsal vertebrae as seen from the left 
side. The numbers are placed on the bodies of the bones. To the right are seen the smooth sur- 
faces giving attachment to the heads of the ribs. The bones are represented as being stripped of 
the ligaments, cartilages, and all other soft parts. The spaces between the bodies of the bones 
are those filled by the intervertebral cartilages. 
projects a long, slender branch or spine, also designed to give at- 
tachment to muscles and ligaments. The points of these spines 
are what we feel in passing the hand down the back, and they 
give its name to the whole column. 
Diseases of the Spine 
are usually called, in consequence of the results which they inva- 
riably lead to if not arrested in their earliest stage, spinal curva- 
tures. They are divided, in accordance with the form and direction 
of the curve, into Angular or Posterior curvatures, Anterior curva- 
tures, and Lateral curvatures. Angular curvature is also known 
as Pott's Disease, from Dr. Percival Pott, an English surgeon, who 
first described it as a distinct affection ; and as Caries of the Spine, 
a descriptive title indicating the condition of the bone when the 
disease has made considerable progress. Lateral curvature is 
sometimes more distinctively denominated as Rotary Lateral Cur- 
vature. owing to the fact that the spine turns on its axis as well DISEASES OF BONES AND JOINTS. 
763 
as bends sidewise ; and as Double or Sigmoid Curvature, because 
it curves in two directions, assuming a fancied resemblance to an 
inverted letter S, the Greek name for this letter being sigma. An- 
gular and lateral curvatures are sufficiently distinctive and intel- 
ligible terms, and we shall confine ourselves to their use. 
The essential distinction between the two diseases consists in 
this : In angular curvature the bones and cartilages are being 
destroyed,, eaten away, melted down, by a process of active in- 
flammation and ulceration taking place at one point. At this point 
Fig. 169. 
Fig. 170. 
Fig. 171 
Figure 169.—Diagram of lateral curvature. 
Figure 170.—Bones of the spinal column in a case of lateral curvature. 
Figure 171.—Vertebra? showing the results of caries of two of their number. 
an abrupt change of form ensues, properly enough described as 
angular', and as this usually projects backward, it is also naturally 
called posterior. In lateral curvature, on the contrary, there is no 
such destructive process going on. There is simply a condition of 
debility, in which the spine yields, in long gradual curves, to a 
force exerted along its entire length, either the weight of the head 
and body, or muscular contraction. The former is, therefore, es- 
sentially much the more dangerous and painful disease, although 
in its earliest stage not less amenable to treatment. It will readily 764 
DISEASES OF BONES AND JOINTS. 
be understood of what paramount importance it is to recognize the 
existence of this terrible malady at the very outset, before any dis- 
integration of tissue has occurred. With this object we proceed to 
consider the diagnosis, or, in simpler phrase, 
The Detection of Angular Curvature. 
We assume, as is usually, though by no means invariably, the 
case, that the patient is a child between four and twelve years old. 
He has, in nine cases out of ten, either recently recovered from 
whooping-cough of unusual severity, or has had an injury of more 
or less gravity, or, as frequently happens, the latter following the 
former. The first thing which the parents notice as being out of 
the usual way is a certain squareness and stiffness of the shoul- 
ders, and general awkwardness of carriage and gait. Taking the 
place of his previous perfect freedom and recklessness of motion, 
is a careful, constrained mode of walking, like that of a decrepit 
old man. He gives up jumping, and even avoids stepping quickly 
down. Every sudden jar evidently causes him discomfort if not 
absolute pain. He chooses the smoothest ways, and walks around 
obstacles. • His feet are held rather far apart, and one or both toes 
are turned in. The head is probably tilted slightly backward. 
The motive for this carriage is preservation of equilibrium and 
avoidance of shock. 
He soon begins to complain of sudden attacks of pain in the 
side, stomach, or bowels, most commonly centred about the navel. 
These are often of the most excruciating character, causing him 
to double up, or even to fall as if shot, and eliciting piercing cries, 
but lasting only a short time, and often ceasing as abruptly as they 
began. They are usually caused by an unguarded movement on 
the part of the patient, or shock communicated from outside, as 
by being suddenly lifted, or from the jolting of a vehicle. Being 
situated in or near the stomach, they are commonly supposed to be 
produced by worms or indigestion, or inflammation of the stomach 
or colon, and much valuable time is wasted in experimental treat- 
ment for their relief, based upon these ideas. 
Another symptom makes its appearance about the same time, 
which, taken in connection with those already described, should, 
however, prevent any such unfortunate and fatal error. This is 
morning rigidity. The child on first waking in the morning 
is greatly disinclined to stand erect and bear his weight on his 
feet; sitting in a stooping posture on the side of the bed; ap- 
pearing very fretful and irritable, and especially averse to put- 
ting on his stockings and shoes, as the effort to stoop forward is 765 
DISEASES OF BONES AND JOINTS. 
painful. In other words, the spine is rigid in a slightly stooping 
attitude, and will not bend either forward or backward without 
discomfort. This gradually wears off later in the day, but it will 
still be found that the patient avoids stooping, and if directed to 
pick up an object from the floor, will approach it sideways, bend- 
ing the knees only, and holding the back quite stiff. Many a little 
sufferer is punished for what is ignorantly supposed to be lazi- 
ness or crossness on waking up in the morning, who is, in reality, 
in the incipient stages of this distressing malady. 
There are other symptoms which are more or less peculiar to 
the disease in certain parts of the spinal column. When in the 
neck, the head is apt to be thrown back, unless paralysis has taken 
place, which it sometimes does very early, and then the patient 
will be powerless to hold the head up. It will fall forward or upon 
the shoulder, and at the same time he may be entirely deprived 
of the use of his limbs. When situated in either the neck or the 
upper part of the back, the breathing is short, jerky, and often ac- 
companied with a slight grunt; and persistent and distressing hic- 
cough is of frequent occurrence. When in the lower part of the 
back, the pain often travels around the crest of the hip, or down 
into one of the legs ; and there is not infrequently a contraction 
or drawing up of an important muscle which runs from the front 
of the spine, about opposite the small of the back, down to the 
upper part of the thigh, and which is known as the psoas muscle. 
This contraction inclines the child to keep the knee of that side 
somewhat drawn up when lying in bed, but when standing, it draws 
the spine inward, making him hollow-backed, and also may draw 
it to one side, so that a careless observer will mistake the case for 
one of lateral curvature. The attendant symptoms are so differ- 
ent, however, that this error is unpardonable. 
We must be on our guard against the universally prevalent 
error, that true spinal disease is accompanied by pain in the spine 
or back. This is never significant of its early stage, and indeed 
scarcely ever accompanies it. Hence, if we delay our decision for 
this supposed sign to make its appearance, we shall lose time 
which can never be made up. Nor is tenderness on pressure any 
more to be depended on. So far from its occurrence being a sign 
of this disease, firm pressure actually relieves the discomfort, and 
produces a sense of great relief. Let the child be laid, face down- 
ward, on the lap of the examiner, and let the latter slowly separ- 
ate his knees, and at the same time make gentle pressure upon the 
spine. All signs of previous discomfort—and prominent among 
them, the distressed breathing—will, if they are dependent upon 
spinal disease, cease as if by magic. The reason of this will 766 
DISEASES OF BONES AND JOINTS. 
readily be comprehended by glancing at the annexed diagrams. 
The point at which the disease almost invariably commences is 
the front part of the upper or under surface of the body of a verte- 
bra, or the connecting cartilage. Any force which brings these 
Fig. 172. 
Fig. 173. 
Figure 172.—Two lumbar vertebrae, showing the position of the bodies of the bones when the 
spine is bent forward. 
Figure 173.—Two dorsal vertebrae, showing their position when the spine is erect. 
bodies closer together, therefore, will evidently produce pain, 
while any force which separates them will give relief. It needs 
no mathematical demonstration to prove that pressure on the 
points of the spinous projections (which form the portion of the 
spine felt in passing the hand down the 
back) will open rather than close the 
space in which, like a finger caught in 
the hinge of a door, the inflamed por- 
tion is being compressed and crushed. 
This fact of relief being afforded by 
extension and pressure upon the spine, 
as indicated by improved breathing, is 
of very great value in enabling us to 
come to a conclusion as to the nature 
of the disease in the case of infants who 
can afford no assistance themselves to 
our diagnosis. 
When these symptoms, or some of 
them, have continued a varying time, 
from a month to a year, or even two or 
three years, the destruction of tissue in the front of the spine 
allows it to tilt forward, and causes the spinous projection at that 
point to become prominent behind. This shows itself at first as 
a mere little knuckle of bone ; but no matter how small it is, 
it possesses the gravest significance, as indicating that an amount 
of tissue has been destroyed which can never be wholly replaced. 
Figure 174.—An aggravated case 
of angular curvature of the spine. DISEASES OF BONES AND JOINTS. 
767 
There is one spinous projection, on a level with the top of the 
shoulders, which is naturally so much more prominent than the 
others, that its vertebra is known as the prominent vertebra. A 
similar projection anywhere else along the spine, is an indication 
either of original malformation, which is rare, or of serious dis- 
ease. A slight lateral curvature of the spine 
may, especially in women, be consistent with 
health : an abrupt projection backward, how- 
ever trilling, never is. But, if parents and 
physician are properly alert, the disease will 
have been arrested before any such tell-tale 
of its ravages appears. And this leads us 
to consider the 
Treatment to be adopted to procure this 
very desirable result—a result which would 
make the sad spectacles of gibbous defor- 
mity, which now so constantly pain the eye, 
almost a thing of the past. One of the old 
names for this affection, in its aggravated 
stages, was “broken back” Now it is in 
considering it as this—and nothing else or 
more than this—and treating it as such, no 
matter what its cause may have been, that 
the secret of its successful management con- 
sists. 
The indications for the care of a fractured 
limb, with bruising and crushing of the bone, 
are the indications for the treatment of a 
spine in which ulcerative inflammation has 
its seat. What are these indications ? First, 
to restore the part, as nearly as possible, to 
its natural relations of form and position ; 
secondly, to maintain it in that position ; 
thirdly, to prevent all motion, friction, and 
irritative pressure between the fractured 
ends of the bone ; fourthly, to make such 
local applications as will tend to diminish 
inflammation and promote a healthy circulation in the diseased 
tissues ; and lastly, and of least importance, although not to be 
neglected, to administer such internal remedies as the general 
condition of the patient seems to call for. To make this last ob- 
ject the first, either in point of time or of value, is to commit an 
error which cannot be too seriously deprecated. 
Mere rest in bed, although useful in partially fulfilling the me- 
Figure 175. — Mode of 
using the spinal swing. 768 
DISEASES OF BONES AND .JOINTS. 
chanical indications, is by no means sufficient; and its effects upon 
the general health, from the deprivation of fresh air, sunlight, and 
exercise, the three great factors in the renewal as well as the 
preservation of health, 
may be disastrous. Its 
proposal, save as a tempo- 
rary expedient, must be at 
once rejected. 
In accomplishing our 
first proposed end, namely, 
placing the spine in its nat- 
ural form and relations, we 
cannot fully carry out the 
analogy with the fractured 
limb, from the fact that we 
cannot produce the rectifi- 
cation all at once. Both 
on account of the charac- 
ter of the tissues involved, 
and for fear of injuring 
the spinal cord, which runs 
the whole length of the 
spinal canal, and whose in- 
tegrity is essential to life, 
locomotion, and sensation, we must proceed by degrees. The 
most efficient appliance for this purpose, that is, direct extension 
or straightening of the spine by traction, is the spinal swing, in 
which the patient draws himself up by the head, while the weight 
of the body and of the limbs, below the seat of disease, acts as 
an extending force. The whole movement being under the pa- 
tient's own control, he uses no more force than is entirely agree- 
able to him. It is necessary to check rather than to urge him in 
its use, so great is the sense of relief which it gives. 
The best splint for maintaining the parts in position, and pre- 
venting hurtful motion and pressure, is that of Dr. Charles F. 
Taylor, of New York. It consists simply of two steel bars, pass- 
ing up and down the spine, one on each side, hinged and padded 
opposite the seat of disease, and held in position by shoulder straps 
above, and a hip-band below. Its action is that of a lever, with 
the fulcrum at the point of deformity, actual or threatened, and 
it results in lifting apart the diseased vertebrae, by throwing the 
weight upon the oblique projections shown in the figure of the ver- 
tebra on a foregoing page. 
Where it seems necessary to confine the motion of the ribs to 
Figure 176.—Taylor’s splint applied in a case 
where the disease is in the upper part of the spine. DISEASES OF HONES AND JOINTS. 
769 
a considerable degree, or to make use of an elevating action from 
the hips, the raw hide jacket of Mr. S. A. Darrach, of Newark, 
N. J., leaves little to be desired. All of these objects are very per- 
fectly attained by the method recently advocated by Prof. L. A. 
Fig. 177. 
Fig. 178. 
Figure 177.—The arrangement of hinges, levers, pads, and screws by means of which pres- 
sure is made over the transverse processes of the vertebrae in Taylor’s splint. 
Figure 178.—Diagram showing the mode by which the splint brings the distorted spine into 
a correct position. Tne broken stick represents the diseased spine, and the straight stick a splint 
applied for its support. The string tied about their lower ends holds them together, and by 
tightening the loop surrounding the upper ends, the angle at the point of fracture will be made 
to disappear. 
Sayre, of New York, of surrounding the body with a plaster-of- 
Paris bandage reinforced with light tin splints, exactly as a frac- 
tured limb would be put up, extension being maintained during 
its application by the spinal swing. This plan has in its favor 
extreme economy, facility for everywhere obtaining the neces- 
sary materials, and great efficiency. There are objections to it 
on the score of retention of the excretions of the skin, interfer- 
ence with respiration and the action of the heart, together with 
its weight, and liability to crumble. 
These objections are met, to a great extent, in the adaptable 
porous spinal jacket, of Mr. Johnstone, of Philadelphia. The 
material of which this appliance is composed is felt stiffened with 
gum. It has the advantage of allowing the air to pass freely 
through it, thus permitting the exhalations from the surface to 
escape, and is at the same time sufficiently rigid to afford adequate 
support. The jacket is laced up the front like a corset, and can 
therefore be removed to meet the demands of cleanliness. In 
order to have such a jacket made, a plaster jacket or cast must 
first be taken, the patient being stretched either by the spinal 
swing or in the horizontal posture, the latter being less painful. 
From this cast, which is sent to the manufacturer, a solid plaster 
mould is made. This is the exact counterpart of the patient’s 770 
DISEASES OF BONES AND JOINTS. 
body in its improved position ; and on this plaster body the felt is 
accurately adapted while softened by steam. This appliance is 
very much lighter than the plaster jacket, and is usually worn 
with much comfort. 
A very useful apparatus for aiding locomotion and promoting 
extension in these cases is Darrach’s wheel crutch, with head 
suspensory. Extension may also be kept up by means of ap- 
paratus attached to a chair, and worked with a ratchet and 
key. 
The best local remedy for reducing inflammatory action is dry 
Fig. 179. 
Fig. 180. 
Figure 179.—Darrach’s patent wheel-crutch. 
Figure 180.—A simple form of wheel-crutch in which the rests for the arms can be adjusted 
to varying heights, and in which the ring surrounding the body is made to open for the admission 
of the patient. 
cold, applied by means of the spinal ice-bag, followed by a very 
brief application of beat. 
To improve the circulation and nutrition of the part affected, 
nothing is more effective than gentle and long-continued friction 
and kneading of the back, with vaseline, cosmoline, camphor- 
ated oil, or other lubricant. 
The general medicinal treatment must be determined by the 
patient’s condition. It may, however, be suggested that tonics 
soon lose their effect in these cases, unless the mucous membrane 
of the alimentary canal is freshened by occasional mild purga- 
tion. DISEASES OF BONES AND JOINTS. 
771 
To sum up: Angular curvature of the spine is a destructive or 
ulcerative inflammation of the bodies of one or more vertebrae, 
usually resulting from external injury on whooping-cough, char- 
acterized in its earlier stages by a stiff, awkward gait and car- 
riage, by impossibility of bending the back, by morning rigidity, 
by frequent attacks of severe spasmodic pain in the abdomen in- 
Fig. 181. 
Fig. 182. 
Figure 181.—India-rubber bag, made in three compartments, for applying pounded ice to the 
back. 
Figure 182.—Apparatus attached to a chair, for making extension in a case of angular curva- 
ture of the spine. 
duced by motion, by short, jerking respiration and protracted 
and painful hiccough, by the turning in of the toes of one or both 
feet, and sometimes by loss of power in the limbs and impaired 
digestion. It is to be treated by mechanical appliances, which 
will extend and straighten the spine, and diminish the pressure 
between the diseased surfaces until new bone can be made, and 
by attention to the general health, and the administration of the 
lime phosphates. 772 
DISEASES OF BONES AND JOINTS. 
Lateral Curvature of the Spine. 
The detection of this affection in its incipient stage is also of the 
greatest importance. It usually occurs in girls between the ages 
of twelve and sixteen years, during the period of womanly devel- 
opment and rapid growth. It begins with lassitude, disinclination 
to vigorous exertion, and a tendency to stoop, the spinal muscles 
seeming too weak to support the frame erect. Its characteristic 
pain is one of a dull aching or burning character, quite constant, 
not paroxysmal or spasmodic like that 
of angular curvature, situated under the 
point of one shoulder-blade, usually the 
right. But this is often not developed 
at the very outset. The general health 
is rarely seriously impaired. A slight 
difference in the height or size of the 
shoulders or hips, or both, is early 
noticed by the mother or the dress- 
maker. (See Figure 183.) These are 
often made light of, as dependent upon 
a “bad habit” in standing or sitting, 
especially in sitting at the desk in 
school. In point of fact the habit is the 
result, not the cause of the loss of symme- 
try ; and, instead of making the child's 
life a burden by constantly nagging 
and reproving her for it, appropriate 
means should at once be taken to remedy 
the deformity. They cannot be initi- 
ated too early. When such a condi- 
tion as above described exists, it becomes important to determine 
its exact nature. To this end let the entire back be exposed to 
view in a strong light. If there be a true /-shaped curvature 
commencing, but not yet arrived at that characteristic stage 
when the eye recognizes it, at a glance, from the sinuous double 
curve, rotation or twisting of the spine will already have begun. 
To test this, pass the two forefingers down the spine, one on either 
side, half an inch outside of the line of the spinous projections. If 
they move along, side by side, exactly upon the same level from 
the top of the spine to the bottom, there is no rotation, and true 
lateral curvature does not exist. Rest from brain-work, open-air 
exercise—if possible, in the country—and attention to the general 
health, are probably all that will be required in such a case. But 
Figure 183.—Lateral curvature 
toward the right. DISEASES OF BONES AND .JOINTS. 
773 
if . when the fingers reach the point on a line with the middle of the 
shoulder-blades, one of them, usually the right, is found to be rising 
above the level of the other toward the examiner, this elevation 
continuing for two or three inches, and if, as they reach a point 
about opposite the crest of the hips, the other finger begins to rise 
Figure 184.—Effect of rotary lateral curvature upon the form of the trunk: A, views from 
above and one side of a case of curvature; B, views from above and one side of a healthy spine. 
in the same way while the first recedes, we may make up our 
minds that rotation has commenced, and may feel sure that the 
sigmoid curve will follow, unless prompt and vigorous measures 
are taken to prevent it. 
Treatment.—These measures are essentially the same in princi- 
ple as those recommended for angular curvature, namely, correc- 
tion of the improper position of the vertebrse by extension, and 
maintenance of this improved position by strong mechanical ap- 
pliances : but with these differences in detail: First. Owing to the 
compound nature of the deformity, suspension must be made, not 
simply in the direct axis of the spine, but also both laterally and 
obliquely. Secondly. As we have no disease present in the bone- 
tissue, we can use much greater force without fear of injury, and 
do not need to guard' against occasional relaxation. And Thirdly. 
Certain of the muscles of the trunk and spine being in a weak, re- 
laxed condition, we must, by appropriate exercise, by manipula- 774 
DISEASES OF BONES AND JOINTS. 
tion, and perhaps by the use of electricity, endeavor to restore their 
tone and strength. In the early stage just described, the employ- 
ment of the spinal swing and the application of an antero-posterior 
splint will generally be all that is demanded. The ladder and 
the trapeze, both of which can easily be put up in any house, are 
of the greatest service in this stage, and form valuable means of 
exercise for all growing youth. When the double curve is 
once well developed, so that one shoulder projects noticeably 
Fig. 185. 
Fig. 186. 
Figure 185.—Vertical suspension by the hands, by means of the trapeze, as used in lateral 
curvature. 
Figure 186.—Vertical suspension by the hands, by means of the ladder, as employed in the 
treatment of lateral curvature. 
backward and the front of the chest is advanced on the opposite 
side, as shown in the diagram, complete restoration of symme- 
try is rare, and the treatment becomes laborious and complica- 
ted, demanding the employment of powerful fixed machinery, and 
the devotion of several hours daily to its use. The time and 
labor are well spent, however, if the increasing deformity can be 
checked before the internal organs have suffered irreparable injury 
from compression. 
In most of our large cities, educated physicians are to be found 775 
DISEASES OF BONES AND JOINTS. 
wno have provided themselves with the mechanical facilities 
essential to the successful management of this and other distor- 
tions of the frame, and who devote their attention more particu- 
larly to this department of medical art. In the great centres of 
European civilization, so much importance is attached to this 
matter, that institutions of the kind are usually under government 
patronage. 
The employment of exercise in the correction of deformity was 
first worked up systematically and scientifically by a Swede named 
Peter Henry Ling, and is somewhat extensively practised as the 
System of Ling, or the Swedish Movement Cure. It has been 
largely developed since his day, and much ingenious and valuable 
apparatus has been introduced to take the place of manual assist- 
ance, but the principles are essentially those first enunciated by 
him. * 
To sum up: lateral curvature of the spine is a loss of sym- 
metry of the trunk, with lateral deviation of the spine from its 
normal upright position, and rotation upon its axis, unaccompanied 
by inflammation or ulceration, but gradually producing a change 
of shape in the bodies of the vertebrse bjr absorption from mere 
unequal pressure ; both the lateral deviation and the rotation being 
double, and the former assuming the shape of a reversed letter S- 
It is characterized by dull aching or burning pain in the back, usu- 
ally under the point of the right shoulder-blade, and by debility. 
Its most significant early sign is a bulging outward of the surface 
on one side of the spine, usually the right, in its middle third or 
chest portion, and on the opposite side, though to a less degree, 
in its lower third or loin region. 
Its treatment is extension—direct, oblique, and lateral—pres- 
sure against the curves, exercise for the development of the mus- 
cles, alternating with rest, and powerful instrumental support. 
Diseases of the Hip-Joint—Coxalgia.f 
Next to the spine, the hip-joint is that portion of the skeleton 
which is most liable to injury, and hence to disease. Affections of 
this joint are even more serious and intractable than those of the 
vertebrae. The invaluable improvements, however, which have 
been introduced in their treatment by American surgeons during 
* A most interesting exhibit of machinery for this purpose was made at the Interna- 
tional Exhibition held at Philadelphia in 1876, by Dr. Gustaf Zander, of Stockholm, 
founder of the Mechanico-Therapeutic Institution in that city. Dr. Charles F. Taylor, 
of New York, also exhibited miniature models of such apparatus, 
t Painful affection of the hip. 776 
DISEASES OF BONES AND JOINTS. 
the past quarter of a century, have done much to remove them 
from the category of almost hopeless cases, to which the older 
writers consigned them. According as one tissue of the joint 
or another is the first seat of injury or inflammation—the bone, 
the cartilage, or the synovial membrane—different names are at- 
tached to its diseased conditions ; hut as they all have one natural 
termination—destruction of the joint, and are amenable to but 
one mode of treatment—mechanical protection of the joint, noth- 
ing will be gained by going into nice distinctions; and we proceed 
to give the prominent points in the detection of the disease. 
Symptoms.—The first thing to attract attention is usually a 
slight, but persistent limp. The child inclines to walk and stand 
with one heel raised from the ground, the knee of the same side 
Figure 187.—Effect of stretching out the limb in a case of disease of the hip-joint: A, with 
the thigh raised, the back lies flat upon the floor; B, bringing the knee to the level with the 
other, causes the back to arch upward. 
slightly bent forward, and the toe turned out. For some months 
nothing more than this may be noticed. Gradually sleep begins to 
be disturbed during the earlier hours of the night. At first the 
patient is simply restless, giving little starts like an over-fatigued 
and nervously excited child ; but soon the start is accompanied by 
a piercing scream, almost like the cry of a dumb animal in pain. 
He does not, as a rule, awake with the scream, and, if aroused, 
says that there is nothing the matter with him, and sinks into a 
quiet slumber, again in a few moments to utter the same inarticu- 
late cry of terror and pain. At the end of about four hours these 
“ starting” pains become less frequent, and the latter part of the 
night is spent in profound and undisturbed sleep. 
Up to this time, the general health may not have suffered ma- 
terially, and the child may be actually free from pain during the 
day, and inclined to active exercise. If pain is complained of, it 
will be in the knee, or in a line running upward from the inside of 
the knee, obliquely across the front of the thigh. But we must 
not allow ourselves to be thrown off our guard by the situation of DISEASES OF BONES AND JOINTS. 
777 
the pain. The coexistence of these two conditions points unmis- 
takably to serious mischief going on in the liip-joint, and demands 
immediate interference and persistent attention for at least a year, 
if we would obviate permanent deformity or lingering death. On 
stripping the patient, the following additional signs will confirm 
our suspicions : placing him flat on the back, on a firm, level sur- 
face (not a soft bed), we notice that the knee of the affected side 
is slightly drawn up, or, if he 
makes an effort to stretch it out 
beside its fellow, the small of the 
back is at once arched up. (See 
Fig. 187, B.) Slipping one hand 
under this arch, and moving 
first the sound limb, and then 
the affected limb up and down 
with the other hand, we shall find 
that in the first case the spine re- 
mains perfectly quiet, while in 
the second it is bresse(l down 
strongly on the hand when the 
limb is raised. This is a most 
important point, as showing 
that motion does not take place 
through the hip-joint; the same 
fact is occasionally noticed in 
psoas abscess, already mention- 
ed in treating of angular curva- 
ture of the spine, for which we 
must be careful not to mistake 
it. On comparing the limbs laid 
carefully side by side, we shall 
find that the lame one is a little 
longer than its fellow. Both 
knees being drawn up, it will be 
impossible to move the affected limb in or out to any extent, with- 
out moving the entire body with it. Turning the child upon 
his face, we shall find that he cannot lie quite as flat upon the 
affected side as on the other, the leg being slightly drawn up 
and thrown outward. The buttock, instead of presenting like 
the opposite one a well-rounded mass of elastic muscle, will be 
flattened and broadened, as if a heavy weight had pressed it out, 
and the crease below it will have disappeared. On making pressure 
with one or two fingers directly behind the head of the thigh-bone, 
where the flattening is most apparent, the depression which exists 
Figure 188.—A, a child free from disease of 
the hip-joint; B, a case of disease of the riirht 
hip-joint (early stage) in which the fold of the 
buttock on the diseased side has became raised 
and the buttock is smaller than the one on the 
opposite side. 778 
DISEASES OF BONES AND JOINTS. 
on the sound side will be found to be more or less completely filled 
up, and the head of the bone will appear to be somewhat higher than 
that of the opj)osite side. The attempt to produce pain by striking 
upward against the sole of the foot, as a confirmatory sign, is an 
unnecessary infliction of suffering, as the symptoms already de- 
tailed are quite adequate to a decision. 
Treatment.—The only treatment for this distressing and often 
fatal affection consists in drawing down the limb, so that the pres- 
sure of the head of the thigh-bone against the socket of the hip 
may be diminished as much as possible, and the spasmodic con- 
traction of the muscles, which produces the starting pains at 
night and the excessive deformity, may be completely overcome. 
This may be accomplished in two ways : First. By attaching a 
weight to the foot by means of adhesive plasters, carried spirally 
up the limb to the middle of the thigh, 
the patient lying on his back, with the 
lower end of the bed raised to prevent 
him from sliding down, and the cord, by 
which the weight is fastened to the plas- 
ters, passing over a pulley. Less than ten 
pounds is of little use. The weight must 
be kept on night and day, and the patient 
must be confined to his back most of the 
time. [See page 678, Fig. 280, Yol. I.] 
This mode of treatment is open to the 
grave objection of interfering with the en- 
joyment of fresh air and exercise, and thus 
seriously impairing the general health. 
Second. By the use of an extension 
splint. Several such instruments, known 
as ‘‘hip-splints,” are used by surgeons— 
all. modifications of that originally devised 
by Dr. H. G. Davis, of New York : among 
which we may mention Davis’s, which 
reaches down to the ankle ; Sayre’s, which 
reaches only to the knee ; Taylor's, which 
comes down below the foot; and Pan- 
coast’s, which is fastened to the shoe. 
The first two have been very successful in 
the hands of their inventors. The third 
affords the largest space for the applica- 
tion of plasters, and, acting as a crutch, protects the joint from 
shock more effectually than the others. It is necessary, however, 
to watch the knee carefully in using it, and see that it does not 
Figure 189. — Taylor’s hip- 
splint. DISEASES OF BONES AND JOINTS. 
779 
become stiff. The fourth is hinged at the knee, which deprives it 
of much of its power as an extending apparatus, while its attach- 
ment to the foot is very imperfect. It is usually applied by the 
instrument-maker, which fact alone is sufficient to condemn it, as 
no surgical apparatus should ever be applied in the first instance 
except by the physician or surgeon. 
The local application of ice around the joint, especially just be- 
hind it and over the groin, followed by dry heat, as recommended 
in speaking of spinal caries, will give great relief, and contribute 
to a cure. The general treatment differs in no respect from that 
for the disease just mentioned. 
To sum up: hip disease is a destructive or ulcerative inflam- 
mation of the socket of the hip, or the head of the thigh-bone, or 
both, usually resulting from external injury, and therefore not 
necessarily indicating an inherited taint of constitution, charac- 
terized in its earlier stages by a limping gait, confined to one limb, 
the knee of the affected limb being slightly bent forward, the heel 
raised and the toe turned slightly outward ; by attacks of acute, 
spasmodic pain during sleep, called “ starting pains,” which cause 
the patient to shriek out suddenly without necessarily waking; by 
pain in the knee or along the front of the thigh ; by stiffness of 
the hip-joint, as determined by various tests ; by flattening of the 
buttock and wasting and lengthening of the limb. 
It is to be treated by maintaining the limb in a condition of 
permanent extension, either by weight and pulley, or by a ratchet 
splint. The latter is greatly preferable, but the former should al- 
ways be resorted to at once, when there is good reason to suspect 
the existence of the disease, until a proper instrument can be ob- 
tained. Such instrument should be applied only by a physician, 
and worn under his direct supervision. The local application of 
dry cold followed by that of heat; the use of the lactophosphate 
of lime and cod-liver-oil, or malt extract ; exercise in the open air 
and sunlight, with the aid of the wheel-crutch if necessary, consti- 
tute the accessory measures, which should be scrupulously carried 
out, but must never be depended on to the neglect of the me- 
chanical treatment, even in the very earliest s1;age. 
Diseases of other Joints. 
All the other true joints are liable to precisely the same dis- 
eased conditions which we find in hip-disease. Lying near the 
surface there is comparatively little difficulty in their detection, 
and their treatment is to be conducted on the same principles. 780 
DISEASES OF BONES AND JOINTS. 
The affection to which the knee is most liable, and to which it 
is far more liable than any other joint, is 
Inflammation of the Synovial Membrane. 
In its acute form this disease is characterized by heat, swelling, 
redness, and excruciating pain through the joint, greatly aggra- 
vated by motion. It is accompanied by fever and general dis- 
turbance of the system. Its best-known form is rheumatic fever, 
in which more than one joint is usually affected; but, wherever 
else it may appear, the knee is rarely spared. The swelling is 
partly in the tissues about the joint, but is principally due to an 
increase in the synovial fluid, which is also much altered in qual- 
ity, in accordance with the nature of the irritant or poison which 
has produced the inflammation. Under the influence of the irri- 
tation, the muscles contract, bending the knee, often to a right 
angle. The symptoms are always 
so grave that professional aid will 
at once be sought. 
Chronic inflammation may be 
the result of an acute attack, or 
it may come on gradually and 
spontaneously. When of rheu- 
matic origin, it produces great 
stiffness and swelling, due to fibri- 
nous deposits about the joints. 
When gouty, it leads to deposits 
of lime, called chalky concretions, sometimes so extensive that all 
the natural tissues are absorbed, and the sufferer can write his 
name on a blackboard with his knuckle—the preference of gout 
being for the fingers and toes. If of a simple and very sluggish 
character, it causes the effusion of an immense quantity of watery 
synovia, constituting Dropsy of the Joints. This condition is rec- 
ognized by the great enlargement of the joint in certain directions, 
its elastic feeling under pressure, and the absence of pain or heat. 
A similar collection of fluid in the sheath of a tendon close to a 
joint is called a ganglion, and is mentioned farther on in this chap- 
ter. One chronic form, however, comes on often so insidiously that 
its serious nature may remain unsuspected until very sad mischief 
has been wrought. It is supposed to be scrofulous in its origin, 
but it is by no means necessary to its occurrence that the sufferer 
should have before exhibited any of the signs of scrofulh. It is 
commonly known as white swelling, and is to be recognized by the 
following signs : 
Figure 190.—Deformity of fingers caused 
by rheumatism of their joints. DISEASES OF BONES AND JOINTS. 
781 
Symptoms.—The beginning of this disease is almost painless, 
and it may continue to present neither decided pain nor tender- 
ness on pressure for many months. The joint is enlarged and 
shapeless, with an inelastic, boggy feeling under the touch, but, 
instead of being red, is unnaturally white, having a sort of pearly, 
translucent hue. There is often a sense of weakness in the knee, 
and the limb becomes fatigued sooner than its fellow. When pain 
is present, it is of a dull, aching character, with a sense of fulness. 
Sometimes the patient complains of intense coldness in the joint. 
After a time, however, the unhealthy fluid in the joint eats away 
the cartilages covering the ends of the bones, and the superficial 
layer of the latter begins to be inflamed and ulcerated. When 
this happens, we very soon have suffering as a result. The “ start- 
ing pains,” spoken of in treating of hip-disease, come on, the swell- 
ing increases, abscesses form, and the joint is often rendered stiff 
and useless, even if the limb is saved. The general health, of 
course, sympathizes with the local disturbance, in the same way as 
in the disease just alluded to. 
Treatment.—Whether the inflammation be acute or chronic in 
its progress, gouty, rheumatic, scrofulous, or purulent in its na- 
ture, however caused, in whatever joint developed, demanding 
what remedies soever, either generally or locally, one means 
should never be neglected, namely, fixation of the affected joint 
or joints by means of splints, as nearly as possible in the straight 
position of the limb. In some cases, a stiff splint of wood or 
metal, carefully padded to fill up irregularities of the surface, as, 
for instance, the space under the knee-joint—in other cases, an ex- 
tension splint, like that advised for disease of the hip, will best 
fulfil the indications ; but one form or other is essential. When 
all motion and friction between the joint-surfaces is thus pre- 
vented, the pain begins to diminish, as if by magic, in acute cases; 
and the whole system to show signs of healthy reaction, in chronic 
cases. 
Rickets 
is retarded or imperfect development of tlie bones. Under its in- 
fluence they remain soft and cartilaginous much longer than is 
natural. It is therefore a disease of earliest infancy—in fact, may 
be said to exist from birth—although often unrecognized until 
some time after the child begins to walk. Owing to their soft, 
yielding condition, the bones bend both under pressure and from 
muscular action. Those of the limbs are thus shortened and curved. 
The points at which bony tissue is in the natural process of growth 
most rapidly deposited, become enlarged out of proportion to the 782 
DISEASES OF BONES AND JOINTS. 
rest of the bone, and indeed actually enlarged. These points are 
near the joints. Hence the joints appear thickened, especially those 
of the knee, ankle and wrist. This is, perhaps, most noticeable at 
the wrist. To this enlarged condition of the ends of both bones 
forming a joint, the term “double-jointed” is commonly applied. 
The ribs sink in at the sides, straighten, and project in front, 
thus forcing out the breast-bone, and producing what is known as 
“chicken-breast.” Where they join the cartilages which connect 
them with the breast-bone in front, they swell out into little round 
knobs. The soft spot in the top of the head continues much 
later than usual, and is often larger than is natural. On the 
skull, the deposit of bone tissue takes place in irregular patches, 
leaving depressions or holes in and between them, which some- 
times actually perforate the bone. The child is usually very late in 
getting its teeth. When it begins to walk, the legs curve rapidly, 
generally forward and outward, producing bow-legs. The spine 
yields under the weight of the head and arms, bending backward, 
forward, or, rarely, toward one side, producing a lateral distor- 
tion, which, however, exhibits the rotation of true lateral curva- 
ture. Occasionally the bones of the limbs not only bend, but 
break; and, reuniting irregularly, produce very great deformity. 
One of the most serious results in the female is distortion and 
narrowing of the pelvis, rendering child-bearing dangerous, if 
not impossible. Probably owing to the fact that the muscles 
elongate more rapidly than the bones in such cases, and are thus 
relaxed and necessarily lose tone, a kind of false paralysis often 
shows itself. They contract sluggishly and feebly, and those of 
the lower limbs are not able to support, much less to carry, the 
body. The deformities resulting from this disease are therefore 
of the most serious and appalling nature. Hence the 
Detection of Rickets, at the earliest possible moment, is of 
the utmost importance. It is probable that the first thing which 
will attract the attention of the mother or nurse, beyond the fact 
that the child is peevish and that its food does not appear to do it 
as much good as it ought, will be excessive sweating of the head. 
The pillow will be soaked in an hour or two, night after night, 
while the perspiration elsewhere will not be unusual. The large 
size and noticeable pulsation of the soft spot on the top of the 
head will be observed. The child will roll its head from side to 
side, often making a bald spot on the back of the head. Its flesh 
will become painfully sensitive, so that it will dread to be touched 
and lifted. It will emaciate generally, but its abdomen will be- 
come prominent. If these conditions exist, let the fingers be 
passed carefully over the back of the head. If irregular holes, with DISEASES OF BONES AND JOINTS. 
783 
rather clearly defined edges (as if made with a gouge) are found, 
the child is rachitic or rickety. Let the fingers be passed care- 
fully down the front of the chest on either side of the breast-hone. 
If two rows of little bony knobs or “beads ” are felt, running up 
and down the chest, the child is rachitic. Let the wrists and 
ankles then be examined. If they appear as if a broad ring of 
bone surrounded the joint immediately above the hand and foot, 
the child is certainly rachitic, but this should have been found out 
before. 
The existence of the disease being detected, how shall the im- 
pending deformity be averted ? By supplying in excess those 
elements of nutrition in which the blood is poor. 
The treatment of rickets will therefore be mainly hygienic. 
Undiluted milk with lime-water, eggs, strong broths, and, as soon 
as it can be digested, oatmeal, must be given as frequently and 
in as large quantities as the stomach will tolerate. In addition to 
this, the salts of lime must be administered medicinally. Of these, 
none is more readily absorbed into the system than the lacto- 
phosphate, which may be administered in the form of syrup, or in 
emulsion with cod-liver oil, or with malt extract. 
The child should not be allowed to walk unless in a wheel- 
crutch, nor should it be permitted to lie long or habitually in one 
position ; that on the face is the best. It should be much in the 
open air, should be clad in flannel, and should have a daily bath 
of salt water. Its muscles should be worked and kneaded, and 
its limbs exercised regularly, twice a day. Mechanical appliances, 
worn upon the person, are rarely needed or useful, unless in an 
advanced stage of the disease. Under such a regimen as that 
just described, very serious distortions will often disappear with- 
out mechanical support, the nutrition of the skeleton having been 
put upon a firm basis. 
To sum up:—Rickets is a disease of nutrition in infancy, pro- 
ducing softening, or rather interfering with the natural hardening, 
of the bones. It results in loss of stature and in deformity of all 
the parts of the frame. It is characterized by sweating of the 
scalp, depressions in the back of the skull, openness of the top 
of the head, late dentition, shortening and curving of the limbs, 
and enlargement of the joints. It is to be treated by generous 
diet, hygienic measures, and administration of lime salts. 
Dropsy of the Joints. 
This disease was spoken of as one result of inflammation. The 
inflammation, however, may be of so low a grade, as never to 784 
DISEASES OF BONES AND JOINTS. 
have attracted attention by the usual symptoms of pain, swelling, 
or heat. A sense of weakness in the part may be the first thing 
noticed. This will be followed, as the accumulation of fluid in the 
joint accumulates, by slight stiffness gradually increasing, and by 
pain on making certain movements. When the swelling becomes 
very considerable, motion is correspondingly difficult, and when 
the knee is affected, walking is often impossible. 
Symptoms.—The most noticeable feature of this affection is, of 
course, the swelling. It is distinguished from that of inflamma- 
tion by the absence of heat, of redness, and of any decided degree 
of tenderness, and by the absence of feverish symptoms in the pa- 
tient. The character of the swelling is peculiar. It is soft and 
elastic. It appears in rounded, bulging prominences on different 
sides of the joint; and when the fingers of one hand are rested on 
one of these bulging prominences, and sudden pressure is made 
upon another, even if on the opposite side of the joint, motion will 
be directly felt by the former, showing that there is free communi- 
cation between them, with fluid enough to transmit a wave. This 
is called a “ sense of fluctuation.” When the knee is affected, if 
the knee-cap be tapped smartly with the end of the finger, it will 
be felt, unless the distention is excessive, to strike against the 
joint beneath. The swelling shows itself along the sides of the 
knee-cap, but more along the sides of the strong sinew which at- 
taches the lower edge of the knee-cap to the head of the shinbone, 
and very noticeably above the joint, often for a considerable dis- 
tance. 
Treatment.—Blisters are positively injurious. Powerful coun- 
ter-irritants, such as iodine and tartar-emetic not less so. Pres- 
sure, either by an elastic knee-cap or a rubber bandage, or by adhe- 
sive straps carefully applied, is very useful. Rubbing with oil or 
unguent, such as cosmoline or vaseline, and massage or kneading, 
not only of the joint itself, but of the whole limb, are efficacious 
agents in producing absorption of the fluid. Putting the joint at 
rest bv means of a splint is also often attended by good results. 
The diet should be generous. Iron and cod-liver oil are often very 
beneficial, and any drain upon the resources of the system, in the 
shape of an exhausting discharge, should be sought after and 
promptly checked. Operative measures should, of course, not he 
attempted by any but a surgeon. 
Hysterical Joints. 
Very frequently in women, comparatively rarely in men, cer- 
tain symptoms of joint disease will manifest themselves, such as DISEASES OF HONES AND JOINTS. 
785 
pain, tenderness, stiffness, and difficulty or impossibility of mo- 
tion, while certain other symptoms which ought to appear if the 
joints were actually in a state of inflammation or structural 
change, are entirely absent. Such affections are called hysterical 
—by which it is meant—not that they are not real, as is often sup- 
posed. but that the irritation which exists in the joint is confined 
to the nerves of the joint, not extending to its blood-vessels, and 
therefore not accompanied by inflammation or any of its de- 
structive results ; and further, that this irritation does not neces- 
sarily or usually indicate any disease in the nerves of the joint, 
but a diseased condition of some remote organ, generally connected 
with the generative function. The nerves of this organ convey an 
irritation to the nerves on their way to the affected joint, or to the 
spinal cord at a point where those nerves are given off, and it is 
then reflected along the latter to the joint. Hence, although dis- 
ease exists in the system, it does not exist where it appears to be, 
and where the patient is firmly convinced that it is—in the joint. 
Formerly, when confinement in bed for long periods, and the ex- 
cessive use of powerful counter-irritants was the only treatment 
for joint diseases, to mistake a hysterical joint for a diseased joint 
was, it can readily be understood, a blunder of the most terrible 
character. Now, when mechanical extension has so generally 
taken the place of the severer mode, the error is not so serious in 
its results, and, indeed, a hysterical joint may often be very suc- 
cessfully treated in this manner. Nevertheless, it is still very im- 
portant that the distinction should be made, and made early. The 
following rules are therefore given for the detection of hysterical 
or simulated disease of the joints: 
It is not necessary that the subject of this disease should have 
been what is ordinarily called hysterical, that is, subject to fits of 
hysterical laughing and weeping, convulsions, unconsciousness, 
and so on. And in fact, if previously liable to such attacks, they 
very often cease when the apparent joint affection commences. 
The symptoms rather resemble those which exist in acute and se- 
vere inflammatory affections. Hence it is from those, and not 
from the milder and more chronic affections, that we must en- 
deavor to distinguish it. We say, therefore, that the hysteric joint 
is neither swollen, hot, nor red. All of these conditions may have 
been produced in it by blisters, poultices, and so on, but they do 
not belong to it, and will quickly disappear if these applications be 
dispensed with. The patient does not emaciate, grow pale, and 
lose appetite in the mock disease, nor is there that haggard, anx- 
ious expression on the countenance which is so characteristic an 
index of the suffering arising from inflammation and ulceration of 786 
DISEASES OE BONES AND JOINTS. 
a joint. Sleep is usually not seriously interfered with, and the 
starting pains at night are unknown. The pain complained of is 
inordinately great as compared with the healthy appearance of 
the joint. The tenderness on pressure is as great or greater when 
the pressure is slight than when it is severe. And, indeed, the 
anticipation of being touched seems almost worse than the touch 
itself. 
The joints most liable to become hysterical are the hip and the 
knee.. In the case of the hip, the characteristic pain in the knee 
will be wanting ; there will be no flattening of the buttock, and no 
filling up of the depression behind the hip-joint. The leg will, if 
differing in length from its fellow, be shorter, while in the first 
stage of hip disease, it ought to be longer. Pain and swelling in 
the groin will be absent. Striking the sole of the foot will not pro- 
duce pain, as it does in the true disease. 
In regard to the knee, the only point to be observed is, that the 
pain is usually referred to a point just below the knee-cap, which, 
if seized above, can be moved freely from side to side without 
causing pain. In the case of the knee especially, etherization will 
at once remove all stiffness, thus showing the mock character of 
the disease. 
Treatment.—The offending organ must first be sought out and 
subjected to appropriate treatment if discovered. In the second 
place, while on the one hand the patient must not be accused of a 
deception which, in nine cases out of ten, she does not consciously 
practise, she must be made to understand the true nature of her 
disease, and her conscience and will must be enlisted on the side 
of active effort, and resolute endurance of pain. Petting, coddling, 
and making-much of, must be most carefully avoided. The love 
of “ petting ” grows by what it feeds on, and the appetite will soon 
become so imperative that actual deception will be resorted to in 
order to secure the longed-for attentions on the part of loved ones. 
An extension splint serves a good purpose in obstinate cases, in 
enabling the patient to take exercise, and be out in the fresh air. 
Change of air, and especially of scene, often works wonders. All 
direct treatment of the joint, as by leeches, blisters, cauteries, and 
so on, is injurious to the last degree; but the moral effect of an ap- 
plication of a slightly painful nature at a distance from the joint 
may be good. On the same principle, the application of galvanism, 
to such an extent as to produce pain, may be recommended. Cold 
baths and douches, and all other measures which will invigorate 
the system, are advisable. DISEASES OF BONES AND JOINTS. 
787 
Softening, or Fragility of the Bones 
is, like rickets, a disease of nutrition. But unlike that affection, 
it comes on in advanced life, is accompanied by excessive pain in 
the limbs, and fever, and is very rapid in its progress, which is 
usually to a fatal termination. It is characterized by the tendency 
to frequent fracture of the bones. 
The Treatment is the same as that for rickets, but is rarely of 
any use. Cod-liver oil is here especially indicated. 
[House-Maid’s Knee. 
A disease which may be mistaken for an affection of the knee- 
joint, but which, in reality, is an enlargement of a bursa or sac, 
which is interposed between the knee-cap and the skin which cov- 
ers it, is the so-called housemaid's knee, 
shown in the adjoining figure. This is 
presumed to be caused by the habit of 
kneeling during the work of scrubbing. 
The pressure and motion to-and-fro, to 
which the knee is subjected, causes the 
sac to enlarge and become filled with 
fluid. 
Similar enlargements are found on 
the elbows of miners who work in a 
partly reclining posture ; on the but- 
tocks (under the ends of the seat-bones 
or tuberosities of the ischia) in weavers 
and boatmen, etc. Such enlarged bursse 
are liable to become inflamed by injury, 
and their cavities be filled with matter 
or pus. 
Treatment.—When these swellings 
first occur, the avoidance of all press- 
ure and the repeated application of very 
small blisters at different places about the seat of trouble, will 
often make a cure, but when they are of longer duration, they will 
require treatment such as only a surgeon can administer. When 
they become inflamed, as before mentioned, the limb should be 
kept at rest, and a cloth wet with cold water, or with a solution of 
a drachm of sugar of lead to the pint of cold water should be 
applied until the redness and soreness subside; or a decoction 
of oak-bark (half an ounce to a quart of boiling water, cool 
Figure 191.—House-maid’s knee. 788 
DISEASES OF BONES AND JOINTS. 
and strain) may be used instead. If matter collects it must be 
let out. 
Ganglion. 
This is a name given to enlargements which often occur on the 
wrist in laboring men, mechanics, oarsmen, gymnasts, and such 
others as are accustomed to raise heavy weights, or in other ways 
strain the tendons of the forearm and hand. They may occur 
wherever a tendon plays through a serous sheath, but the back of 
the wrist is the most common situation. They are liable to be in- 
flamed by overstraining or injury, and cause excruciating pain. 
At times they are soft and “ boggy” to the touch, and at others 
are tense and resisting. About the wrist they are liable to spread 
to the sheaths of several of the tendons going to the hand, where 
they may largely interfere with its usefulness. 
Treatment.—When of recent occurrence, placing the hand on 
a splint, and keeping it at rest for several days, together with the 
use of small blisters, as advised in the foregoing section, will be 
serviceable. 
When the ganglion is of the last-mentioned variety, the ser- 
vices of a surgeon are essential. It is sometimes customary, when 
the swelling is small, to attempt the rupture of the sac by strik- 
ing it with the back of a book or something similar, or by pres- 
sure with the thumbs, and afterward, by keeping the hand at 
rest, and applying pressure with a pad and bandage, to prevent it 
from refilling with fluid. This is not. however, free from danger, 
and should be left to a surgeon.—Ed.] 
BENJAMIN LEE, M.D. General Surgery. 
BY 
GEORGE F. SHRADY, A.M., M.D., 
OF NEW YOBK CITY, 
VISITING SURGEON TO THE PRESBYTERIAN AND ST. FRANCIS’S HOSPITALS, ETC., ETC. GENERAL SURGERY. 
TUMORS. 
Tumor, in the strictest signification of the term, is a mere swell- 
ing {turnere, to swell), but in a surgical sense is understood to be 
a more or less circumscribed prominence in any part of the body, 
lion-inflammatory in character, and due to an unnatural growth of 
tissue. In the popular mind the word tumor is associated with a 
condition of things desperate in the extreme, if not past help. 
The reason for this is probably in part due to the fact that these 
growths are generally supposed to be of a cancerous character, 
and are, therefore, necessarily fatal in their tendencies. Again, 
their importance is greatly magnified because some cutting opera- 
tion is usually required in their treatment. In truth, however, 
very many tumors are entirely innocent in character, and occasion 
no inconvenience to the patient except those which are purely me- 
chanical in character. For instance, a growth may be so situated 
as to create great deformity; may be of such size as to be an 
actual burden, or it may, directly or indirectly, embarrass the ac- 
tion of an organ. Otherwise these tumors do no harm, grow very 
slowly, and may be carried for a long lifetime without material in- 
jury to the health. On this account the adjective benign is chosen 
to designate this class of growth. The simple, innocent, or be- 
nign tumors are composed of fat, bone, and cartilage ; fibrinous, 
mucous and vascular tissues, and may occupy any part of the 
body. They increase in size independently of the surrounding tis- 
sues, from which they are usually separated by a dense wall of 
membrane, called a cyst. The composition of these growths is 
simple and uniform for each variety, being entirely of fat in one 
case, entirely of fibrous tissue in another, and so on. The only 
manner in which the surrounding organs suffer is by displacement, 
or pressure, or both. The overlying skin is, as a rule, healthy, 
non-adherent, and supple. 792 
GENERAL SURGERY. 
Fatty Tumors. 
The fatty tumor is not only the most common variety, but may 
be taken as the type of the innocent, or benign growths. It is 
usually situated upon the trunk, or the extremities near the trunk, 
although it is met with in any other situations which are supplied 
with fatty or adipose tissue. Although growing very slowly, it 
sometimes attains an enormous size. In one instance on record, 
such a tumor weighed nearly seventy pounds. 
Not unfrequently it becomes pendulous, or hanging in charac- 
ter, and when of considerable size, and attached, as it sometimes 
is, to the root of the 
neck, gives the patient 
the appearance of the 
extra flesh being an 
actual burden. Some- 
times these hanging tu- 
mors have their attach- 
ments to the extremi- 
ties, and give rise to 
much inconvenience in 
impeding free and ne- 
cessary movements. 
The fatty tumor 
may be said to be a 
mere circumscribed in- 
crease of the fatty tissue of a given locality. This departure from 
the natural appearance of a part is sometimes so slight as scarcely 
to be noticed, appearing as a mere increase of plumpness. The 
large double chin is an instance of this condition. As soon, how- 
ever, as the enlargement has a shape of its own, distinct from the 
surrounding tissue, it presents the characters of a tumor. As 
might be expected from its composition, this growth has a semi- 
elastic doughy feel. Sometimes the surface is lobulated or lumpy, 
but generally it is smooth, the skin covering it being healthy and 
freely movable. The attachments, as a rule, are neither very firm 
nor very deep. The tumor itself is, save in exceptional cases, en- 
veloped in a sac. 
Figure 192.—Fatty tumor of elbow. 
Fibrous Tumors. 
The fibrous tumor resembles, in general character, the fatty 
tumor, except that it is harder and firmer to the feel, is more 
firmly attached, and is even slower in its growth. Its favorite seat GENERAL SURGERY. 
793 
is the uterus, but it is also commonly found on the skin, nerves, 
bones, throat, lobe of the ear, and lower bowel. Generally, it is*' 
Figure 193. —Hanging fibrous tumor of leg. 
Figure 194.—Fibrous tumor of neck. 
Figure 196.—Fibrous tumor of ear. 
Figure 195.—Fibrous tumor of ear. 
surrounded by a cell-wall. Sometimes these growths contain 
closed sacs of fluid, giving rise to irregularities upon the sur- 794 
GENERAL SURGERY. 
face, and to differences in the feel when compared witli the more 
solid parts. Like the fatty tumor it occasions inconvenience, 
principally in a mechanical way. A type of this tumor is often 
seen connected with the lobe or tip of the ear, and appears to be 
caused by the irritation of earrings. These growths are apt to be 
of irregular shape, to attain a considerable size, and occasion great 
deformity. For some unexplained reason, such varieties of this 
tumor are most frequently seen in mulatto females. 
The fibrous tumors, as a class, are more apt to be hanging than 
the fatty, and are chiefly distinguished from the latter by their 
hard and firm feel. 
Vascular Tumors. 
The tumors formed by vascular tissue are those known as 
bloody tumors, and in a less degree as “mother’s marks.” They 
are most frequently situated about the face, occasion great defor- 
mity, and appear with birth. Their substance is spongy in charac- 
ter, and is composed of blood-vessels of greater or less size. Gen- 
erally, the skin covering them is of a purplish or bluish color, and 
contains numerous small branch- 
ing vessels highly injected. Pres- 
sure upon such tumors will partly 
or wholly empty them of the blood. 
When pressure is renewed they will 
quickly refill. The summits, and 
often the surroundings, of these 
tumors are covered with hair, in 
which case the overlying skin is of 
a brownish color. 
The ordinary “port-wine mark” 
is a mere irregular purple blotch, but 
there is, in reality, a difference only 
in the degree of growth as compared 
with the vascular tumor itself. 
The supposed causes for these defects are maternal impressions 
before the birth of the child. Some very curious stories are told 
of the relations between the so-called cause and elfect in these 
cases, but in the present state of science they can be considered 
little else than striking coincidences. 
The treatment of these tumors is peculiar as compared with 
others. We refer to it now, in passing. It consists in killing the 
substance of the growth by means of a red-hot needle thrust in 
Figure 197.—Vascular or bloody tumor 
of face. GENERAL SURGERY. 
795 
different directions from its circumference to its centre. But such 
a proceeding, for very obvious reasons, is not to be entrusted to a 
novice. Sometimes galvanism is used for the same purpose. 
Horny Tumors. 
Horny tumors are of very 
unfrequent occurrence. They 
spring from the skin, are of 
very slow growth, and are easily 
removed by operation. Their 
frequent location is upon the 
head, although they have been 
seen upon the tip of the nose and 
chin. The growths are always 
of an innocent character, and 
are, consequently, not apt to re- 
turn after removal. 
Figure 198.—Horny tumors of head. 
Figure 199.—Horny tumor of head, with accompanying u wens.” 
Cartilaginous Tumors 
The cartilaginous tumors 
may occur singly or in groups. 
They are seen most frequently 
connected with the joints of 
the fingers or toes, are very 
hard, slightly elastic, and 
never of themselves give rise to pain. They are quite apt, especial- 
ly if much irritated, to degenerate into malignant tumors, when 
they grow with considerable rapidity. 
Figure 200.—Cartilaginous tumors of fingers. 796 
GENERAL SURGERY. 
Bony Tumors. 
Bony tumors—or, to use the term in a wider sense, tumors con- 
nected with bone—may occur during almost any period of life. 
They may be composed entirely of bone and cartilage, or of bone 
and more or less dense fibrous tissue. 
The pure bony tumor is a simple localized increase of the bone 
affected, and varies greatly in shape. Under some circumstances 
it is an ill-defined and flattened swelling, extending over a com- 
paratively large surface. Occasionally it is distinctly globular, 
and very rarely its base is narrower than the growth itself. When 
composed of pure bone it sometimes becomes of ivory hardness. 
As a rule, it is of slow growth and seldom attains a large size. 
Fibrous tumors of bone constitute a distinct variety of growths. 
As they take all their peculiarities from the situation in which 
they are developed, they are considered under the present division 
rather than under that of simple fibrous growths. Although in 
other parts of the body fibrous tumors, so called, as a rule are sim- 
ple in character and not liable to return, when connected with the 
bone that are almost always open to the suspicion of malignancy. 
Especially is this true of a variety of fibrous tumor of uneven con- 
sistency and of rapid growth. This is called sarcoma. It springs 
from the membrane covering the bone, and is liable to involve the 
neighboring soft parts. Such growths are almost always sure to 
return and to act in many respects like true cancer. That is to 
say, even when the disease is removed it may return in the same 
locality, or, if not, make its appearance in some of the internal 
organs, such as the lungs, liver, or kidney. 
This variety of fibrous tumor of the bone which, unfortunately, 
is more common than the simple form, is usually circumscribed, 
and not infrequently follows an injury to the bone or bone-mem- 
brane from which it springs. Its most common seat is at or near 
the end of one of the long bones, and its outline is more or less 
regular. On handling, it gives the impression of being somewhat 
softer in some places than in others. This condition is explained 
by the fact that a cartilaginous or bony tissue is found mixed with 
the growth, or the fibrous tissue itself is of different density and 
firmness. 
The bases of these tumors are always firmly attached to the 
bone, while the tumors themselves, during their growth, push the 
overlying muscles and other soft tissues before them. The growth 
of these tumors is usually quite slow, and is not attended with 
much pain. Adult age is the time of life during which they oc- 
cur most frequently. 
When the existence of this disease is certain, amputation of the GENERAL SURGERY. 
797 
affected limb at the farthest possible point from the disease is the 
only safe procedure ; otherwise the growth, through the medium of 
the blood-vessels, is apt to propagate itself to the internal organs. 
When so situated as to forbid amputation, thorough extirpation 
is usually advisable. In either event, it is necessary to exercise 
the greatest possible precautions against the return of the disease. 
The degree of malignancy of this form of tumor of bone can be 
measured by the rapidity of its growth, the comparative softness 
and irregular consistency of its texture, and the degree of consti- 
tutional disturbance which it occasions. 
A bony tumor may be cancerous in character, and may give 
rise to many of the symptoms named. Generally bone cancer is 
more rapid in its course, is liable to involve the skin, and may 
cause fracture. As regards the necessity for prompt and radical 
treatment, there is no practical difference between the two forms 
of disease. 
Cystic Tumors. 
Very often, outgrowths in the shape of tumors consist of little 
more than closed sacs, containing a fluid or semi-solid material. This 
variety is called cystic. The feel is semi-elastic, but, contrary to that 
of the fatty tumor, gives an idea of a fluid or semi-fluid contents. 
The tumor connected with the ovary 
is an example of the class, as well 
as similar outgrowths which are 
connected with the under-surface of 
the tongue, the anterior portion of 
the throat, and over the knee-pan. 
The most common variety of the 
semi-solid cyst is that seen on the 
scalp, which contains a cheesy-like, 
fatty material, and which is popu- 
larly known as a “wen.” These 
“ wens ” vary in size, are apt to oc- 
cur in groups, and sometimes oc- 
casion much annoying interference 
with the proper combing and brush- 
ing of the hair. Unless of unusual 
dimensions these growths can be very effectually hidden by the 
hair. They are apt, as the result of injury, to inflame and ulcer- 
ate, giving vent to an offensive discharge. Sometimes the tumor 
disappears in this way. 
The benign or innocent tumors only become the subjects of 
special treatment, when, by their position, great deformity re- 
Figure 201.—-Cystic tumor of scalp. 798 
GENERAL SURGERY. 
suits, or, by their pressure upon adjacent organs, an interference 
of function is produced. As all local applications are useless, and 
as internal medication is of no avail, the treatment is narrowed 
down to removal of the growths by surgical operation. 
It may be well to state here that many of these tumors are 
christened “cancerous” by the quacks, and are treated by them 
accordingly. Consequently, what at first was an innocent growth, 
becomes converted, by the use of caustics, into a ragged and formid- 
able-looking sore. When this sore heals, as it will when no more 
irritating applications are made, the so-called cancer is said to 
have been cured. With the great majority of even intelligent 
people, it has never occurred to them to ask the question whether 
or no their disease was really a cancer, or some one of the many 
varieties of innocent tumors. As no patient, however learned in 
other things, is able to come to a definite conclusion regarding the 
nature of any tumor, and, as it is not likely that the quack, with 
his patent salve or never-failing caustic, will give impartial ad- 
vice, it is always safe and proper first to obtain the opinion of the 
family physician. He will be competent to state the true nature 
of the growth and advise as to the proper treatment in each indi- 
vidual case. In regard to this method of so-called cure of cancer 
by caustics, more will be said under the head of the treatment of 
that disease. 
Cancer. 
Distinguished from the simple, innocent, or benign tumors, are 
those which are called malignant. Benign tumors are circum- 
scribed, are not liable to spread, are covered by healthy skin ; do 
not involve neighboring organs, do not compromise the life of 
the patient, and are not inclined to return after removal. On 
the contrary, malignant tumors always, sooner or later, invade 
the skin and neighboring tissues, have no tendency to limitation, 
involve other parts of the body by means of absorption of the 
tumor elements, if left to themselves invariably kill the patient, 
and are always liable to return after removal. 
Although there are several distinct varieties of growths which 
are said by surgeons to be malignant, practically speaking the de- 
scription of such varieties can be most intelligently made from a 
popular standpoint under the general heading of Cancer. 
Cancer is, as a rule, a condition of tumor, but generally it is a 
term which can be applied to mere malignant ulcerations. The 
word cancer, signifying a crab, was given to this disease by the 
ancients, although it is difficult to see for what reason. Some- 
times the form of ulceration can, by an active imagination, be GENERAL SURGERY. 
799 
made to resemble that of the crab, so also can the twisted condi- 
tion of the large veins in the neighborhood of the tumor. 
Cancer may occur in any part of the body, but its most frequent 
seat is the female breast. The period of life most liable to the 
invasion of the disease is between thirty-two and fort}r-five. Its 
occurrence is not, however, impossible in the infant at birth, or in 
the patient of “three-score years and ten.” 
Let us, for the sake of describing the general character of can- 
Figure 202.—Ulcerated or rose 
cancer of breast. 
Figure 203.—Cancer of breast. 
cer, give its history as occurring in its favorite locality already 
named. 
Its first appearance is usually as a small, hard lump under the 
skin and near the nipple. It is attached, by its base, to the substance 
of the breast itself. So seldom is pain present at this time that the 
growth is most frequently discovered by accident. As the tumor— 
for, small as it is, it is nothing more nor less—increases in size, pain 
of a peculiar darting character manifests itself, and generally ra- 
diates from the disease toward the armpit. Enlarging still more, 
the mass involves the surrounding tissues, infiltrating them with 
the cancerous material, and creating an irregular belt of hardness. 
This hardening is an evidence of the matting of the tissues in a 800 
GENERAL SURGERY. 
common disease, and extends until the breast becomes firmly ad- 
herent to the chest-wall, and of almost stony hardness. While 
this is going on, the diseased material is carried by the absorbent 
vessels to the armpit, and, as a result, new cancerous tumors form 
in that locality. In the same manner, similar growths appear at 
the root of the neck. About this time the general health begins 
to suffer, the patient presenting a peculiar sallow complexion and 
careworn look. Also, sooner or later, small hard bodies appear 
underneath the skin, over the tumor, enlarge and run together. 
The skin itself, in its turn, becomes brawny, gives way, and an 
irregular ulcer with raised and turned out edges, of greater or 
less size, is the result. This ulcer never heals, but, on the contrary, 
enlarges, and is the source of a protracted, exhausting, and foul- 
smelling discharge. It is this condition of ulceration which is 
indicated by the popular term “rose cancer.” The patient may be 
worn out by this extra drain upon the system, fatal bleeding may 
occur by the ulceration opening a blood-vessel, or life may be ter- 
minated by the secondary invasion of some internal organ, such 
as the liver, lung, kidney, or uterus. 
Notwithstanding the frequency of cancerous tumors of the 
breast, it does not by any means follow that all growths in that lo- 
cality are necessarily of that character. A great number of tumors 
of the breast are entirely innocent. An injury of the organ is suf- 
fered, some pain is occasioned, and then a localized swelling may 
appear. This may be nothing more than a hardening of a portion 
of the substance of the breast, a swelling which will disappear of 
itself if let alone. Or, it may be a temporary enlargement of a por- 
tion of the gland which may remain an indifferent period without 
causing any trouble. Such cases, if submitted to the active treat- 
ment of stimulating plasters, irritating liniments, or caustics, are 
apt, in the end, to become actually cancerous, especially if there be 
present in the individual any hereditary tendency to the disease. 
But in regard to the matter of mistakes regarding the presence of 
cancer, what may appear stranger than all is, that cases are not 
unfrequently seen in which the lobulated, knotty feel of the per- 
fectly healthy breast, is supposed, by the patient, to be due to a ma- 
lignant tumor. These cases tend to show, as do all cases of tumor, 
actual or supposed, that it is always safer to trust to the opinion 
of an educated physician. 
The general history of cancer in the breast is similar to that of 
the disease in other parts of the body. As in that organ, cancer 
commences by forming a firm attachment for its base, and this 
attached base widens as the disease progresses. Figuratively 
speaking, its growth may be likened to that of a tree—the larger GENERAL SURGERY. 
801 
the top the deeper do the roots penetrate. Other characteristics 
of malignancy in a tumor are an extension of disease to the over- 
lying skin, of the neighboring glands, and the disposition to ulcer- 
ate. Taken separately, these symptoms are suspicious ; grouped 
together and properly weighed they are almost, if not quite, con- 
clusive. It must be confessed, however, that there is oftentimes 
a doubt among the most experienced surgeons concerning the 
existence of cancer in a given case. Under such circumstances, 
however, a microscopical examination of the tumor settles the 
question as to its precise character. 
The most common variety of the disease is that known as 
scirrhus, or “hard cancer,” popularly called “stone cancer ” and 
“ crab cancer.'” “Rose cancer ” is nothing more than the ulcerating 
process of any of the varieties. But the growth is sometimes so 
soft in consistency as to merit the name of soft or medullary can- 
cer. Not infrequently this variety is stained by a black pigment, 
and is usually spoken of as “black cancer.” The most frequent 
seat of the latter is in the eye. A third form is the so-called 
“ skin cancer,” or epithelioma. Each of these has a history which 
varies with the part of the body affected, and with the character 
of the growth itself. In some localities the pain occasioned by the 
disease is greater than in others, and the disturbance of the func- 
tion is more marked in one organ than in another. The soft can- 
cers grow more rapidly than the hard, and the hard more rapidly 
than the skin cancers. The rapidity of the growth is also gov- 
erned by the degree of moisture in the locality affected, or by the 
degree of the activity of the organ invaded. Thus, the disease is 
more active when it attacks the tongue, the lower bowel, the 
bladder, and the uterus, than when it invades the bone or the 
skin. As before stated, cancer may occur in any part of the 
body, but it is only necessary to refer to it in those localities which 
are accessible to the surgeon. 
When the disease occurs in the eye, as already remarked, it com- 
monly takes on the black form. Sometimes it appears in the sub- 
stance of the eye, making its way externally, sometimes in the 
socket of the eye, and at other times on the surface of the eyeball 
itself. Generally, the eyesight is affected early, deep-seated pain 
is quite constant from the beginning, and not infrequently the eye 
protrudes, sometimes to such an extent as scarcely to be covered by 
the lids. When ulceration occurs, the granulations are, of course, 
blackened, and in some cases give the appearance of having been 
sprinkled with charcoal or stained with writing-ink. 
Cancer of the tongue first shows itself as a hard, angry ulcera- 
tion on the side or tip of the organ, and is quite painful when 802 
GENERAL SURGERY. 
touched by articles of food, or by the teeth. Sometimes the act of 
swallowing is intolerable. The patient generally supposes that 
the ulcer was caused by the irritation of an adjoining decayed 
tooth. As the disease progresses, the floor of 
the mouth becomes involved, also the glands 
under the lower jaw, and in some cases it ex- 
tends into the throat. Pain in the ear is quite 
a common sy mptom. 
Cancer of the lower lip belongs to the skin 
variety of the disease. This occurs at first as 
a circumscribed hardness of the margin of the 
lower lip, becomes ulcerated, presenting a more 
or less gouged appearance upon its surface, with 
hardened edges, and may destroy the whole sub- 
stance of the lip, and in fact, the greater part 
of the face itself. The upper lip is very rarely 
involved, save by extension of the disease from 
the lower lip. 
Causes.—The precise cause of cancer is not 
known. There is a general belief that the dis- 
ease is a constitutional one, and that certain in- 
dividuals have a hereditary predisposition to it. 
On the contrary, a large number of cases have 
no hereditary history whatever, the disease appearing to com- 
mence as a local one in a perfectly independent way. Some sur- 
geons are inclined to believe that in the majority of cases the 
disease has a purely local origin, due to some persistent irritation 
of the part. Certain it is, that constant irritation is very often 
followed by cancerous disease of that part. For instance, the 
prevalence of cancer of the lip among smokers of clay pipes, is 
well proven ; the irritation of a decayed tooth is so often present 
in cancer of the tongue, that there seems to be a relation which is 
similar to that between cause and effect. It is fair to suppose that 
there must be some predisposition in the system to cancer, in those 
individuals affected, and that irritation possibly determines the 
deposit of the diseased matter in a particular organ. Bearing 
upon the latter supposition is the fact that irritation of a cancer 
causes it to grow with great rapidity, when before it was in a 
comparatively quiescent state. 
Treatment.—Cancer is a disease which is very naturalty looked 
upon with dread by every one. Its malignant tendency, the suf- 
fering which it occasions, the acknowledged difficulties in the wray 
of arresting its progress, make the chances for life desperate even 
to the most hopeful. Hence it is that the quack, always ready to 
Figure 204.—Can- 
cer of the tongue. GENERAL SURGERY. 
803 
take advantage of such a state of things, has more so-called reme- 
dies for this disease than for any other. 
It is safe to say that no medicine has yet been found which will 
cure cancer. This is a fact which it is well to take into account 
in connection with the boasted efficacy of the patent elixirs, of the 
secret powders, and of the miraculous pills so extensively adver- 
tised as cancer-cures. No wash 
or liniment is sufficiently pow- 
erful to cause a malignant tu- 
mor to disappear, and no salve 
has been discovered which can 
heal over an ulcerated surface 
caused by the disease. All the 
hopes for relief are centred in 
the removal of the growth. The 
sooner this is done the better. 
In the earlier periods of invasion 
the disease is localized within a 
small compass, and can easily be 
removed without the sacrifice of 
much of the adjoining healthy 
tissue. 
The best w*ay to do this is by 
means of an operation with the 
knife, the patient having been 
previously made insensible by 
chloroform or ether. This is a general principle of treatment 
which, however, can only be made to apply to a particular case 
by the opinion of the physician in charge. The responsibility of 
deciding belongs entirely with him, or with those whom he may 
call in consultation, and should not be assumed by the patient. 
There are many circumstances that may militate against an oper- 
ation, and which can never be appreciated by any save a medical 
man. These are, for instance, the extent of the disease, the con- 
stitution of the patient, his age and surroundings, the rapidity of 
the growth, and the locality of the body affected. There is such 
a general repugnance to a surgical operation that few, if any, 
submit to it willingly. To the ordinary popular mind there is an 
aversion to being made insensible, and in being cut while in such 
a state. Then, again, the idea that a large quantity of blood may 
be lost, and also the fear that the patient may, perhaps, never 
survive the shock of the operation, are too prevalent to require 
reference. 
In most cases, the operations are not of a formidable character, 
Figure 205.—Cancer of lip. 804 
GENERAL SURGERY. 
very little blood is lost, and the patient suffers no pain. The re- 
sulting wound is a clean and healthy one, and is usually rapidly 
healed. 
The popular prejudice, however, is in favor of burning out the 
cancers with caustics. This is a method which is always second 
best, and is applicable only to such cases of superficial cancers as 
are spread over large surfaces, and the removal of which, by the 
knife, is inadvisable. By this means the least amount of surround- 
ing healthy tissue is removed, but this is by no means an advantage, 
considering the necessity of working as wide of the mark of the 
disease as possible. No suspicious tissue should ever be left after 
an operation for cancer, whether that operation be performed by 
the knife, the hot iron, or caustic. Hence it follows that no oper- 
ation should be undertaken unless such a result can be guaranteed. 
Otherwise, the disease is not only sure to return, but reappears 
with great rapidity and increased malignancy. 
Various methods are resorted to for burning out cancers. A 
popular one with the quacks and so-called cancer-curers, is the 
employment of a caustic paste, the essential ingredient of which 
is arsenic. Occasionally chloride of zinc, chloride of ammonium, 
and similar caustics are employed, mixed with poke-root or some 
other vegetable. The paste is smeared over the tumor or the ul- 
ceration, and is allowed to remain there until the underlying tissue 
is killed. The application causes great pain, but this is said to be 
merely the preliminary treatment. When a slough or dead tissue 
is produced, there is then, of course, no pain, and the so-called 
“cancer” is apparently removed from the bed of the wound, root 
and branch. The appearance of the “roots” of the disease is 
simply due to the irregular action of the caustic in different parts. 
In some places it penetrates deeper than others, and a string of 
dead tissue is the result. The same thing occurs when caustics are 
applied to perfectly healthy tissues. This is, perhaps, the reason 
why so many persons suppose they have been cured of cancer by 
cancer doctors, when, in reality, they have only had simple ulcers, 
or some one of the varieties of innocent tumors. 
As these caustics have no power of searching out cancerous 
material and leaving sound tissue, it naturally follows, especially 
in the case of deep-seated tumors, that some of the disease may 
still be left, in which case, for reasons already stated, the patient 
is in a worse condition than before the operation. 
When the caustic is thoroughly applied to a superficial cancer- 
ous ulceration by an intelligent practitioner, the disease may be 
eradicated, but such a result can never be guaranteed when the 
paste is used on a tumor of any ordinary size. The caustic can GENERAL SURGERY. 
805 
only burn to a certain depth, and after the separation of the slough 
a foul cancerous ulcer is apt to be left, and the disease stimulated 
to an increased activity, which is oftentimes terrible to contem- 
plate. Numerous cases of this sort frequently find their way into 
the hospitals, when their chances for help are gone, and long after 
their cures have been advertised in the newspapers. Aside from 
the want of reliability of the caustic treatment, and the tendency 
of increasing the activity of the disease, there are positive dangers 
in the shape of arsenical poisoning from the paste used, and from 
the occasional alarming bleeding when the dead tissue is ready to 
separate. 
Although it is impossible for those not educated as physicians 
to treat successfully the various kinds of tumors by removing them, 
they can do something toward alleviating symptoms and meeting 
certain emergencies. It should be borne in mind that an inflam- 
mation of any growth is always to be avoided. Hence, any tumor 
should be guarded against injury as much as possible. When, 
however, inflammation does occur, everything should be done to 
reduce it as soon as possible. Cooling applications should be 
made by cloths dipped in cold water, or by an evaporating lotion 
made of one part alcohol and six or eight parts of water. 
The discharge which takes place when the cancer passes into 
the stage of ulceration, is oftentimes so foul-smelling as to be in- 
tolerable to the patient and to others in the house. In such cases 
everything should be done to correct the odor. In the first 
place the parts should be kept clean, and the dressings should be 
changed frequently. A very good disinfecting wash is made by 
adding one part of carbolic acid to forty parts of water. This lo- 
tion may be kept constantly applied to the ulcerating surface. 
To some patients the smell of carbolic acid is quite disagreeable, 
and is not used on that account. This is an unfortunate circum- 
stance, as no other disinfectant is superior to it. 
The next choice of a deodorizer is the solution of the perman- 
ganate of potash in the proportion of four to eight grains to the 
ounce of water. 
A very good application for the same purpose is that of simple 
dry or baked clay, finely powdered, and dusted over the part. 
The earth adheres to the moist surface, absorbs the discharges, 
protects the ulcer, and does not produce irritation. As soon as 
any part of the application becomes saturated, it may be allowed 
to fall off or be gently removed, and fresh earth dusted on as before. 
In the progress of ulceration a blood-vessel of some size may be 
opened. According to the extent of the opening and the size of 
the vessel, the bleeding may be more or less alarming. Ordinary 806 
GENERAL SURGERY. 
oozing of blood may be stopped by the application of small pieces 
of ice to the bleeding part. When the flow is more considerable, 
pressure with the finger, or with a pad of muslin secured by a 
bandage will arrest it. If, despite this, the blood soaks through 
the bandages, the compress should be reapplied with more firm- 
ness, and this failing, pressure should be made upon the main 
artery between the bleeding point and the heart. Such cases, 
though happily of rare occurrence, require the immediate attend- 
ance of a medical man. 
Aneurism or Ruptured Blood-Vessel. 
Aneurism or “ ruptured blood-vessel,” as it is popularly termed, 
is, in a general sense, a pulsating or beating swelling or tumor con- 
taining blood and connected with an artery. It is situated in the 
course of the large blood-vessels either inside or outside the body. 
The condition of aneurism may be defined as an expansion of one 
or more coats of the vessel. In order to understand how this may 
occur it is necessary to recollect that there are three coats to an 
artery—the inner, middle, and outer coats. All of these coats 
may expand together, forming a uniform 
enlargement of the vessel, but more fre- 
quently the inner and middle coats are torn 
and the outer coat only is expanded. This 
enlargement of the artery is generally 
limited in extent, and is occasioned by the 
pressure of the blood-current. Sometimes 
the three coats of the artery are ruptured 
at one time. In that case the blood escapes 
directly into the surrounding tissues. Na- 
ture limits the escape of the blood by form- 
ing a clot on the margin of the effusion, 
which clot helps to make a firm wall or sac 
for the swelling. Although the latter is 
outside of the artery, it generally maintains its connection with 
that vessel through the original rupture, and is, to all intents and 
purposes, just as much an aneurism as any of the other varieties. 
Aneurism generally occurs during and after middle life, for the 
reason that the inner coats of the arteries are then more brittle, 
and, consequently, more liable to rupture than during youth. 
The exciting cause of the trouble is usually an extra and sudden 
strain of one or more parts of the body. Not only is the blood- 
pressure increased thereby, but the artery itself may be torn by 
direct or indirect violence. For instance, aneurism has been 
Figure 206.—Aneurism of 
artery (sub-clavian) at root of 
the neck. 807 
GENERAL SURGERY. 
known to occur as the result of lifting unusually heavy weights, 
of running rapidly, of jumping, and unduly testing the strength. 
When the arteries are elastic and can sustain extra strain, as dur- 
ing early life, there is not so much danger, hut the contrary is 
always the rule with persons advanced in years. 
The ways in which the artery may be torn or injured by direct 
violence are numerous. It is true the main vessels are situated 
in those parts of the body least exposed to external injury, but 
they are not always out of harm’s way. Nature has guarded 
against any stretching of an artery during forced straightening 
of the limbs by limiting such action of the limbs and by placing 
the vessels on the bending sides and as far as possible from ex- 
posed situations. Thus we notice that the main arteries of the 
arms are tucked away under the arm- 
pit and on the inner part of the arm, 
and the same is true of the thigh. The 
arteries of the forearm and leg are 
covered by thick muscles, except at 
the wrist and ankle where they are 
necessarily near the surface. The 
main vessels of the neck are also in 
the line of flexion, and are protected 
by the chin, angle of the jaw, large 
muscles of the neck, collar- and breast- 
bones. As examples of direct injury 
or violence producing aneurism, we 
may mention the following cases : One 
man suffered from aneurism of the 
groin by falling backward while row- 
ing in a boat, the sudden stretch upon the artery causing its rup- 
ture ; another man brought about the same condition by stumbling 
forward while carrying a large and heavy kettle ; another caused 
an aneurism between his hamstrings, back of his knee, by violently 
kicking a door ; another by jumping on a spring-board in a gym- 
nasium, and another by being thrown by a horse. Not infrequently 
the vessel is wounded by some sharp instrument or by a bullet. 
Under such circumstances, of course all the coats of the artery are 
involved in the injury. To illustrate how easily the accident may 
occur it is necessary only to refer to the case of a boy who accident- 
ally dropped an ordinary jack-knife in his lap. The point happened 
to strike the main artery on the inner side of the thigh, an aneu- 
rism was the result, and the patient came very near losing his leg. 
Blood-vessels are often wounded by pistol-balls, but in general 
results such injuries do not differ from those already mentioned. 
Figttre 207. —Aneurism of artery 
(brachial) at bend of elbow. 808 
GENERAL SURGERY. 
When an aneurism is formed from any cause, and when 
situated on the external part of the body, the attention of the 
patient is first directed to a limited swelling, which is of pulsating 
or beating character. The beatings correspond with those of the 
heart and with the pulse at the wrist, and being due to the blood- 
current are constant in character. Sometimes the patient suffers 
from great pain on account of the pressure of the swelling upon 
some of the more important nerves in the neighborhood. 
The sudden appearance of an aneurism is generally marked by 
a sensation as if something had snapped or broken, and is usually 
likened to that of a smart blow on the part. When the condition 
can be recognized early it is well for the patient to maintain the 
most absolute quiet, to avoid handling the swelling, and to control 
the force of the blood-current by pressing upon the main artery be- 
tween the tumor and the heart. 
Cooling applications are gener- 
ally grateful, as is also an ele- 
vated and bent position of the 
limb. The latter places the limb 
in the most favorable position 
for the formation of a clot in the 
sac. 
The general principle of treat- 
ment of aneurism is centred in 
the obliteration of the sac by the 
formation of a clot in its interior 
and the diversion of the main 
blood-current into a different 
channel. 
Various means are used to 
bring about these results, such, 
for instance, as forced bending of the limb, keeping it in such posi- 
tion for a long period, and by the finger or some mechanical appa- 
ratus upon the artery supplying the aneurism, but the most trust- 
worthy is the arrest of the blood-current, by tying the supplying 
artery. In this way the inner coats of the vessel are torn across 
and retract, a clot plugs the vessel on both sides of the ligature or 
string, the contents of the sac also become solidified, and the 
current of blood takes a new course determined by such branches 
above and below the point of stoppage as communicate with each 
other. The branches thus changing the course of the blood-flow 
become enlarged and virtually form a new main artery. 
The operation of tying the artery is one which varies in risk 
according to the vessel involved, but is ordinarily a safe procedure. 
Figure 208.—Aneurism of main artery (fe- 
moral) of thigh. GENERAL SURGERY. 
809 
It should not, of course, be attempted by any save an experienced 
medical attendant. Fortunately the necessity for prompt treat- 
ment is not, as a rule, very urgent, and the patient can have plenty 
of time in which to obtain the required assistance. Although an- 
eurisms may he carried for indefinite periods, the patient is never 
secure against accident; and, all other things being equal, the 
sooner he submits to treatment the better. The swelling often 
being of the same size for a long period, may become enlarged 
suddenly, endangering neighboring parts by direct pressure; or 
ulceration of the sac may occur, or the tumor may burst in either 
of the latter cases and sudden death may result from profuse bleed- 
ing. It must be borne in mind that the growth is more or less 
liable to direct injury according to its position. Nature, however, 
does her best to guard against the accidents of rupture and en- 
largement of the aneurism by depositing on the inside and outside 
of the sac layers of fibrine, which thicken and strengthen the 
original walls. 
If by any accident the aneurism should become ruptured, or 
should suffer such injury as would cause bleeding, firm pressure 
should be promptly made above the swelling, upon the supplying 
artery, until help arrives. This can best be done in the case of a 
limb by tying a handkerchief tightly around it and twisting it 
by means of a stick, as shown in another part of this work. 
Hare-Lip or Split-Lip. 
Hare-lip is a deformity in the human being resembling the 
natural condition in the hare and rabbit. For this reason it re- 
ceives its particular name. It is due to an arrest of the natural 
development of the upper lip before the child is born. The bony 
and soft parts of the upper jaw are originally formed of two halves 
joined together in the middle line of the roof of the mouth. In 
the front part of the upper jaw, under the nose, there is a defici- 
ency which is filled up with a triangular wedge-shaped bone also 
divided in the middle line. The soft parts correspond in their 
mode of development with the bony formations to which they are 
attached. Thus there is originally a separate and central portion 
of lip which belongs to the wedge-shaped hone, and like it, is sepa- 
rated from the portions of the upper lip at either side. 
When the upper portions of the face are naturally developed 
all the different parts are joined together, making the central and 
two side portions of the jaw one piece, as also the central and side 
portions of the upper lip. If, however, the growth is arrested at 810 
GENERAL SURGERY. 
any period, any one or more of these portions may fail to unite 
and a deficiency will be left. In the case of hare-lip, when the 
wedge-shaped bone unites only on one side, there is a split of the lip 
on the other side; and when neither side of the central lip becomes 
attached there is, of course, a double split. Very often these con- 
ditions of the lips are associated with those of the upper jaw, and 
there is not only a deficiency of the upper lip on both sides, but 
the splits may extend on one or both sides of the wedge bone en- 
tirely through the hard and soft palate. 
When the wedge-shaped bone is not 
united with its corresponding sides of 
the jaw, it is apt to project forward at 
the upper portion of the cleft and give 
the little patient the appearance of hav- 
ing a double nose. 
The deformity, even in cases of sim- 
ple liare-lip—those in which there is a 
single split—is always considerable. It 
varies in degree according to the amount 
of deficiency present. When the split is 
very wide or double, or extends through 
the upper jaw, the corresponding nostril 
is flattened, the point of the nose is drawn down, the child pre- 
sents a hideous expression, and even its mother turns from it in 
disgust. When the deformity is associated with cleft palate, the 
cavity of the nose is exposed and food very often overflows 
through the nostrils. So marked is this latter trouble that it is 
often very difficult to feed such children properly. It is, of course, 
unnecessary to say that in the majority of such instances suckling 
is out of the question. 
The most complicated cases of liare-lip are those in which there 
is a projecting wedge-shaped bone with the accompanying condi- 
tion of split-palate. The deformity in such is very great, and 
transforms what otherwise might have been a beautiful, lovable 
child into a repulsive monster. Not infrequently some rudimen- 
tary teeth are found growing from the central projection and in- 
crease, not a little, the general hideous effect. 
It is very commonly believed that this deformity is the result of 
fright or other impression of the mother previous to the birth of 
the child. But, as has been said on a previous occasion in regard 
to another congenital deformity, there is no relation between the 
supposed cause and effect. In fact, if fright of the mother has 
anything directly to do with this and other deformities said to de- 
pend upon like causes, a well-formed child would be exceedingly 
Fig. 209.—Roof of mouth of in- 
fant, showing the formation of the 
upper jaw. GENERAL SURGERY. 
811 
rare. That it is the exception, however, to have anything but 
perfect babies, every loving mother knows. Then, again, this de- 
formity sometimes descends from one generation to another in a 
particular family. One case has been related in which liare-lip 
was thus hereditary for over one hundred years, scarcely a male 
Figure 210. 
Figure 211. 
Figure 212. 
member escaping. It is not a very uncommon circumstance to 
see two or more members of a family similarly deformed with one 
or other of the varieties of the split-lip. Generally about one in 
ten of all children affected have the complicated variety of hare- 
lip. It occurs most frequently in males, and upon 
the left side of the upper lip. 
There is no treatment for this deformity save 
that by a surgical operation. The latter consists 
in paring the edges of the cleft on one or both 
sides and accurately bringing them together by 
means of pins and stitches. When the central 
wedge of bone projects, it may either be removed 
or pressed backward into the opening. Any un- 
evenness of the arching gums is corrected by 
pressing the bulging jKtrtion into line. Under 
ordinary circumstances, and when everything 
progresses favorably, the wounds usually heal 
within a week. The operation is not attended with any special 
danger, and the patient, being under the influence of chloroform, 
need not suffer any pain. 
The time for operating may vary according to the urgency 
of the case. Under some circumstances it may be necessary to 
operate as early as the fourth or fifth week. Usually surgeons 
when they can make a choice prefer any period from the third 
month to that of commencing dentition. The results of treatment 
are, as a rule, extremely gratifying. In the majority of cases the 
cleft is perfectly closed and the attending deformity entirely re- 
moved. The flattening and expansion of the nose are corrected 
Figure 213. 812 
GENERAL SURGERY. 
and the whole configuration of the face is entirely changed. The 
child is given perfect command over its lip, and can use it with 
ease in the performance of all its complicated functions ; in fact, 
may be transformed from a pitiable, hideous monster to a lovely 
child, with expressive mouth and intelligent countenance. 
Cleft Palate. 
Although split-palate may be associated with hare-lip, it is 
often an independent condition. Like hare-lip, it is due to lack of 
proper development of the part, or rather to the want of union be- 
tween the two halves of the upper jaw. The cleft may be limited 
to the hanging teat of the soft palate, may extend through the 
middle line of the palate curtain as far as the bony roof of the 
mouth, or may involve the whole of the latter, causing a direct 
communication between the nose and mouth. In cases in which 
the cleft is complete there is little or no roof for the mouth, and 
the cavities of the nose can be plainly seen from below, presenting 
a large, irregular opening lined with mucous membrane. 
Cleft palate by itself—that is, not associated with hare-lip, is 
Figure 214.—Complete cleft of bony and 
soft palate. 
Figure 215.—Cleft involving hanging tip 
of palate- 
not noticeable as a deformity when the patient's mouth is closed. 
It is only when he or she talks that the malformation is apparent. 
In all these cases there is always a peculiar nasal intonation of the 
voice. The patient appears to talk almost entirely through the 
nose, and articulation is sometimes so indistinct as to be scarcely 
intelligible. This state of things is easily explained on ana- 
tomical grounds. The soft curtain of the palate is an indispens- 
able organ for perfect speech. It is so situated in the back part of 
the mouth as to be capable of shutting off communication either 
between the throat and nose or between the throat and mouth. 813 
GENERAL SURGERY. 
According to one or other of these motions of the palate, the sound 
of the voice can be made to go entirely through the nose or entirely 
through the mouth. When it is recollected that language is made 
up of distinct interruptions of sound, and that such interruptions 
can only be made by a perfect valve, the association of indistinct 
and imperfect speech, with a deficient or absent palate, can he 
easily understood. For instance, in pronouncing the consonant 
D, the column of sound should be entirely shut off from the nose, 
but when there is no palate to do this the nasal modification gives 
the sound of N. So, instead of the sound B we have that of M, 
while the articulation of K, G, and Ch become almost impossible. 
There is some imitation of this condition in an 
ordinary cold, when the palatal curtain becomes 
swollen, loses its pliability, and is unable, with 
promptness and accuracy, to effect a complete 
closure between the cavity of the throat and 
that of the nostrils. 
The treatment of cleft palate consists in the 
closure of the opening. How this is best ac- 
complished is still a question. Many surgeons 
prefer to pare the edges of the split and unite 
them by suture. But even when this is success- 
ful there is still great difficulty with, the palate 
thus formed in completely closing the opening 
between the throat and nose during articula- 
tion. The consequence is, that the patient, although much im- 
proved as regards the power of distinct articulation, still has 
much of the characteristic nasal tone. The operation requires 
great skill for its performance, and has been advocated* and prac- 
tised by the most experienced and accomplished surgeons in the 
world, but with indifferent success. The time for operation is 
generally selected when the patient is old enough to intelligently 
assist the surgeon. 
Of late years the dentist’s art has been brought into requisition 
in the treatment of these deformities. A plate is fitted to the roof 
of the mouth, thus closing any opening, be it more or less exten- 
sive. To this plate is attached a soft and exceedingly flexible 
rubber palate, which is acted upon by the muscles of the throat in 
such a manner as to cut off all communication between the cavities 
of the nose and those of the mouth, when such is required during 
articulation. It is quite possible, with these artificial palates and 
with proper education, not only to speak with perfect distinctness, 
but with little or none of the nasal tone. 
FiGUiiE 216.—Partial 
cleft of palate. 814 
GENERAL SURGERY. 
Abscess. 
An abscess is a collection of pus, or what is popularly called 
“matter,” in any part of the body. It may be the result of an in- 
jury, or may appear without apparent cause. When the latter is 
the case, the abscess is generally supposed to be due to a so-called 
bad state of the blood. Whether the latter can be proven or not, 
it is certain that some changes in the general system are almost 
always associated with the appearance of collections of pus. The 
first symptoms of abscess are those which belong to any inflam- 
matory action. They can be summed up under three heads— 
pain, heat, and swelling in the part affected. The pain is usually 
of an aching character, due to distention, is attended with throb- 
bing, and is much aggravated by pressure. The heat is quite per- 
ceptible, and is limited to the extent of the inflammatory action. 
The swelling is somewhat circumscribed, but its edges are hard 
and inclined to leave sunken spots after pressure. In the centre 
of the swelling, “ matter ” forms after a while. The presence of 
pus is detected by placing one finger on one side of the abscess, 
while a slight tap is made by another finger on the opposite side. 
To the first finger a distinct wavy feel or impulse is communicated 
through the fluid. This is called fluctuation, and, when recog- 
nized, is a sign of fluid in a cavity. 
Under favorable circumstances an abscess “ breaks ” and dis- 
charges itself. The natural tendency of the pus is in the direction 
of least resistance. At a given point the tissues become thin, 
the swelling becomes unduly prominent, and, finally, an opening 
forms, when there is a relief to all the symptoms. The color of 
healthy pus—that is, the discharge from a so-called healthy ab- 
scess—is of a yellowish color, of the thickness of ordinary cream, 
and of a slightly sweetish, musty odor. After the discharge has 
taken place the swelling decreases, the hardness of the surround- 
ing tissue fades away, the redness disappears, the sac contracts, 
and the parts soon resume their natural shape, the opening being, 
of course, the last to heal. 
But such a fortunate termination of an abscess does not alwa}Ts 
occur. Sometimes, the pus being deeply seated, the overlying tis- 
sues are too resistant to permit of its natural escape. Under such 
circumstances it burrows in different directions, causing a great 
deal of damage. A familiar example of this is the ordinary felon. 
In that case the abscess is formed next the bone, under the dense 
and tough tissues of the finger, and, if a timely escape is not made 
by a suitable incision, the “matter” finds its way into the palm GENERAL SURGERY. 
815 
and back of the hand. The cutting of these binding tissues is the 
only safe course. In fact, it is always a good rule, so soon as pus 
is found, to open the abscess at once. It is well to remember, how- 
ever, that this is a procedure which is not always a safe one in the 
hands of the novice. Although in superficial abscess matter over- 
lies the large blood-vessels, there are sometimes exceptions to this 
rule which it is well to bear in mind. 
When an abscess is situated in the neighborhood of large arte- 
ries or veins—for instance, on the front part of the neck, behind 
the jaw and under the ear, inside of the thigh, groin, armpit, or 
inside of the arm—it is safer, in the absence of a competent medi- 
cal attendant, to allow nature to take her course, than run a 
risk of inviting dangerous bleeding by ignorant and unskilful 
handling of the lancet. Even cutting parallel with these vessels— 
as is the surgical rule—is an operation attended with the danger 
of wounding some of the larger branches which are united to the 
main trunk by different angles. 
When an inflammatory swelling commences, an attempt may 
be made to arrest its progress by the application of cooling washes, 
or even by ice; but generally, when the symptoms are sufficiently 
urgent to claim the attention of the patient or to call for treatment, 
the period for the employment of such measures is past. Hence 
it is that the application of a poultice comes first in order. The 
latter may be made of bread and milk, flaxseed meal, or powdered 
slippery elm. The object of such treatment is the maintenance 
of heat and moisture. Consequently, so long as a poultice is warm 
and moist it is accomplishing all that can be expected of it. 
The proper way to prepare a poultice is to mix the material 
thoroughly with hot water, and fold the mass in a cloth, so that 
no part of the material comes in direct contact with the skin. 
Sometimes a piece of ordinary mosquito netting is placed over the 
part of the poultice next the skin, and appropriately folded with 
the margins of the outer cloth. 
As previously stated, abscess may occur in any part of the body; 
but its particular situation has a great deal to do with the symp- 
toms which may be presented, or the mischief which may be pro- 
duced. Generally, the more superficial the abscess and the more 
rapid its course, the greater is the heat and the more abrupt is the 
swelling. When deeply seated underneath a tough membrane, or 
fascia, pain is usually the symptom which claims most attention. 
Hence the great pain in the “felon,” in “quinsy” sore throat, so- 
called “ulcerated” tooth, and other painful troubles. 
The mischief done by an abscess is usually due to the confine- 
ment of the pus, and to the burrowing which is commonly an 816 
GENERAL SURGERY. 
associated condition. When the “ matter ” collects bet ween the 
bone and the membrane, covering the latter, not only is there apt 
to be burrowing in the surrounding tissues, but the bone itself is 
liable to die at that point. Not only does this happen in the 
true felon, but in that condition of the leg which terminates in 
what is popularly called “fever-sores,” but which is, in reality, 
nothing more than dead bone which keeps the ulcers open. Just 
so long as the dead bone is present will a discharge of matter con- 
tinue. In this connection reference may be made to the occasional 
occurrence of persistent discharge of matter after the abscess has 
either opened itself, or has been lanced. When this is the case, 
either the abscess has not a free escape for its contents, or there is 
some irritating substance in its interior—such for instance as dead 
bone which prevents closure. The channel for escape of the pus 
is, under such circumstances, comparatively long and narrow, 
and is called a sinus. The latter is more apt to occur when 
there has been a delay in the evacuation of deep-seated pus, and 
when there has been extensive burrowing in consequence. If, 
after a reasonable time, the parts fail to heal, the sinus can be 
cured by removing the irritating substance at its bottom, and by 
slitting up its entire length, thus allowing it to heal as an ordinary 
ulceration. 
While the majority of abscesses run an acute or rapid course, 
there are some that are exceedingly slow in their progress, give 
rise to very little redness, heat, or pain, the main symptom being 
the accumulation of pus. These are called chronic or cold ab- 
scesses, and are very often connected with disease of the spine. 
They show themselves most frequently in the back, in the region 
of the kidneys, or they burrow their way forward under the dense 
tissues inside the pelvis, and point in front in the fold of one or 
other groin. This condition of abscess is usually associated with 
a feeble state of the system, and requires the patient and persistent 
attention of a well qualified practitioner of medicine. 
GEORGE F. SHRADY, M.D. Diseases of the General 
System, Etc. 
BY 
FREDERICK A. CASTLE, M.D., 
OF NEW YORK CITY, 
VISITING PHYSICIAN AT THE PRESBYTERIAN HOSPITAL; ATTENDING PHY'SICIAN IN THE OUT- 
DOOR DEPARTMENT AT BELLEVUE HOSPITAL; LECTURER ON PHARMACOLOGY 
IN BELLEVUE HOSPITAL MEDICAL COLLEGE, ETC., ETC. DISEASES OF THE GENERAL 
SYSTEM, ETC. 
Scurvy—Scorbutus. 
This disease is caused by deprivation of vegetable food. Sail- 
ors, soldiers and prisoners are most liable to it, and it lias been 
known to occur in countries where—as in Ireland—the failure of 
a potato crop deprived the inhabitants of the principal source of 
their food-supply. Scurvy is always apt to break out in armies 
encamped in large masses, and among the garrisons of fortified 
towns during their besiegement, and no amount of food of other 
kinds can be made to take the place of the missing vegetables. 
The constant use of salted meats, and a monotonous diet have 
wrongly been claimed to produce the disease. 
Symptoms.—The skin becomes pale, sallow, or muddy in color; 
there is increasing listlessness and disinclination to exercise or use 
the mind. Pains resembling rheumatism occur in the limbs ; the 
face becomes puffy and the expression listless. The bowels are 
constipated but digestion is fairly well performed, and the appe- 
tite continues good for a time. Presently, reddish-brown spots, 
like flea-bites, appear on the skin of the arms and legs; vary 
in size ; are not raised above the level of the adjoining skin, and 
cause no sense of discomfort. By and by their color changes so 
that they resemble bruises, and, indeed, are liable to be mistaken 
for them. The skin, generally, is dry and scales off readily. 
The gums become swollen and soft or spongy, and in advanced 
stages of the disease the teeth become so loose as to be easily 
pulled out, being, apparently, held in place only by the puffy 
gums which swell up so as nearly to cover them, and which bleed 
upon the slightest injury. 
The breath is extremely offensive, the flow of saliva profuse, 
and eating, even of soft foods, becomes almost impossible, owing to 
soreness of the mouth. 820 
DISEASES OF THE GENERAL SYSTEM, ETC. 
The slightest blow upon the skin causes a black-and-blue mark, 
and injuries which would at other times be trivial in importance, 
now cause open, ragged, burrowing sores, which may lead to ex- 
haustive bleeding, owing to destruction of the walls of blood-ves- 
sels. There is difficulty of breathing and great prostration, during 
which attacks of faintness are easily produced, and are liable to 
end fatally. 
Treatment.—Fresh vegetables—especially potatoes, onions, sal- 
ads, and fresh fruits—should be given in as large quantities and 
in such forms as the patient can digest. Lemonade, oranges, 
and limes are of great value. Medicines are, by comparison, almost 
useless, although the citrate or tartrate of potash, and vinegar are 
sometimes found to ameliorate the symptoms. 
In the English marine service, all ship-captains are required 
to provide lime-juice preserved by means of a small amount of 
brandy or rum (ten per cent, of the whole), and sealing it tightly 
in bottles. This they are required to issue to their crews to the 
amount of four tablespoonfuls for each man, twice a week during 
the voyage, and to increase the quantity if signs of scurvy appear. 
During the war of 1861-65 in this country, a considerable amount 
of sickness was caused by scurvy, although in the Southern States 
when fresh vegetables failed, the fruit of the prickly pear—a 
variety of cactus—sometimes served, when roasted, to take the 
place of accustomed vegetables and fruits. Potatoes have been 
known to replace money in bartering for the commodities of 
camps, and their fortunate possessors have often scraped and eaten 
them raw as morsels of the greatest delicacy. 
Anaemi a—Chlorosis. 
These conditions are due to a deficiency in some elements of the 
blood, and their causes are various. Among physicians, a dis- 
tinction is made between them, but for most practical purposes 
they are the same. 
There may be actual deficiency of blood—as when there is 
bleeding from a wound, from piles, from excessive menstruation, 
nose-bleed, vomiting of blood, etc., or there may be a profuse dis- 
charge of matter from some sore which exhausts the system. On 
the other hand, while there may be no excessive waste, there may 
be deficiency of food, or indigestion of that which is taken, so that 
the elements of the blood fail to be renewed as they are consumed 
by the tissues. Deprivation of sunlight, chronic disease of vital 
organs, overwork, excessive use of alcoholic drinks, and a number 
of other causes may lead to these conditions. 821 
DISEASES OF THE GENERAL SYSTEM, ETC. 
The variety of blood-impoverishment known as chlorosis is es- 
pecially liable to occur among girls at the age of puberty, and wo- 
men suffering from menstrual derangements. 
Symptoms.—These are headache—not very severe, but pretty 
constant and relieved by lying down ; shortness of breath ; palpi- 
tation of the heart after even slight exertion—such as going up- 
stairs ; a feeling of constant weariness and inclination to sleep ; 
inability to do manual or mental work ; loss of appetite ; cos- 
tiveness ; thick, muddy-looking and scanty urine; cold extrem- 
ities and paleness of the skin in parts that are not tanned by 
exposure to sunlight. There is usually an appearance of floating 
spots before the eyes, and a sensation of noises like a distant rum- 
ble of carriages, or the roar of a waterfall. The feet are fre- 
quently swollen. Most of these symptoms are relieved, for a time, 
after eating or after taking an alcoholic stimulant. 
Treatment.—A sufficiency of good and digestible food, warm 
clothing, exposure to sunlight, change of air and relief from worry 
and overwork will generally accomplish a cure in many cases if 
combined with the internal use of iron. When the trouble is, how- 
ever, owing to loss of blood or to excessive discharges, these must 
be stopped before recovery can take place. 
Among the preparations of iron, the following are to be recom- 
mended : 
Solution of dialyzed iron, fifteen drops for an adult, taken 
at intervals of five or six hours and when the stomach is empty, 
in a half-wineglassful of water. Tincture of the muriate of iron, 
in similar doses, but after meals, and with the additional precau- 
tion to use a glass tube through which to suck it, and rinsing the 
mouth afterward. Pills of the sulphate of iron containing about 
two to four grains each, taken after eating, or, when there is loss 
of appetite, pills of three or four grains of citrate of iron and qui- 
nia. These can be made by any apothecary. 
Rheumatism. 
The essential nature and causes of this disease are but little un- 
derstood. A liability to its attacks is characteristic of the members 
of certain families, while others never suffer from it. In some 
instances it has been presumed to be owing to the presence in the 
blood of certain products of indigestion, or of nutritive changes in 
the tissues of the body. In other instances it follows attacks of 
gonorrhoea or scarlet fever. Those who are liable to have it are 
often attacked after exposure to wet or cold. Prolonged residence 
in damp situations and changeable climates may lead to its devel- 822 
DISEASES OF THE GENERAL SYSTEM, ETC. 
opment in those who might otherwise have escaped. The disease 
occurs in several forms; besides gonorrhoeal or scarlatinal rheu- 
matism, there are acute rheumatism or rheumatic fever, subacute 
rheumatism, chronic rheumatism, muscular rheumatism, deform- 
ing rheumatism or rheumatic arthritis, and rheumatic gout. 
Acute Rheumatism. 
This variety is most common between the ages of fifteen and 
twenty, although it is rarely found in infants and more often in 
middle life, and it affects males more commonly than females. 
Causes.—The most common exciting causes are getting wet or 
cold, and delaying to change the clothing and secure warmth. 
Persons who are liable to it do not tolerate damp surroundings, and 
it has often been observed that with such persons even the use of 
ordinary baths sometimes causes trouble. In many cases the out- 
break can be traced to no apparent cause unless it be an attack of 
indigestion or some disturbance of the general health. 
Few persons die of the immediate effects of the disease, al- 
though it may cause high fever and excruciating pain. The chief 
danger lies in the liability to inflammation of the membranes 
which line or cover the heart, or of the muscular substance of 
the heart. Another of the results sometimes attributed to it in 
the case of young children, is the production of St. Vitus’s dance, 
or chorea. 
Symptoms.—An attack of rheumatic fever commonly begins 
with chilliness. After a few hours or a day or two, there is fever, 
throbbing headache, thirst, and high-colored urine. About this 
time one of the large joints—most often it is the knee—becomes 
swollen, painful, red, hot to the touch, and stiff, and the patient 
loses completely the use of the limb. Confinement in bed becomes 
imperative ; the fever increases and the skin becomes covered 
with a profuse and peculiar, sour-smelling sweat. The slightest 
movement—even jarring of the bed by some one who walks across 
the floor—causes pain ; the tongue is covered with a thick, white 
fur; appetite is lost; the bowels are constipated ; the urine be- 
comes scanty and deposits a “brick-dust” sediment, and sleep is 
rendered short and difficult to obtain in consequence of parox- 
ysms of pain. 
Not unfrequently, in the midst of an attack, the pain and swell- 
ing of the joint disappear, to reappear soon after in some other 
joint, and so the seat of the disease may change from one to an- 
other until a number of them have been affected. DISEASES OF THE GENERAL SYSTEM, ETC. 
823 
An attack of acute rheumatism may last almost any length of 
time from five or six days to as many weeks, but three weeks is 
about the usual period, and a person who has once been attacked 
is more and more liable to subsequent seizures. 
Treatment.—The patient should be wrapped in the softest and 
most “fluffy” woollen blanket obtainable, and this must be 
changed, should it become wet, with care against leaving the skin 
uncovered. Milk, broths, gruels, and various starchy foods in 
fluid forms, are the best diet during the height of an attack. 
Iced water, or carbonated alkaline waters, lemonade, and cream- 
of-tartar water, may be used to allay thirst. 
Lemon-juice, in as large quantities as can be taken with com- 
fort, has long been resorted to as a remedy, and so, also, have 
alkalies—like the acetate of potash, in doses of thirty grains given 
every four hours in a half-glass of water, or Rochelle salt, in doses 
of a half-teaspoonful in water, every two or three hours. 
Of all the remedies that have been used for the relief of acute 
rheumatism, none approach so nearly to being a specific as sali- 
cine and its compounds, such as salicylic acid and salicylate of 
soda. The former is most agreeable to take ; the latter is cheap- 
est, and is less irritant to the stomach than salicylic acid. Fif- 
teen grains of salicylate of soda may be taken every two hours 
until the fever and pain in the joint subside, which will commonly 
be within twenty-four hours. Its use then needs to be continued 
in similar doses, but at intervals of four to six hours. Salicylate 
of soda is best given in capsules, or wrapped in wafer or tissue 
paper. 
Tincture of aconite, in doses of a half-drop every fifteen or 
twenty minutes (for an adult), will sometimes prove useful at the 
commencement of an attack. 
When the pain is severe, tincture of opium may be cautiously 
used, in doses of ten to fifteen drops in water, every hour or two, 
until it causes drowsiness or relieves the pain. 
When the fever is high, the body—so far as its surface can be 
reached without disturbing the patient—may be sponged every 
hour with tepid water. 
No case of acute rheumatism should be treated without the aid 
of a physician, if one can be obtained. 
After recovery, the patient can render the chances of subse- 
quent attacks less by wearing always woollen undergarments and 
avoiding exposure to wet and cold. 
The rheumatism following gonorrhoea and scarlet fever had 
better be treated by a physician, if one is to be had. 824 
DISEASES OF THE GENERAL SYSTEM, ETC. 
Subacute Rheumatism. 
This variety is liable to occur in those who have previously 
suffered from acute attacks. While there may be considerable 
soreness of joints or muscles, there is rarely much fever. 
Its Treatment resembles, in a general way, that of the acute 
variety. 
Chronic Rheumatism. 
This is the form most commonly met with in old people, and 
not unfrequently it has never been preceded by a well-marked 
acute attack, but as age increases, pains in the joints and muscles, 
especially at night, become more and more troublesome. The 
joints are rarely red or tender, as in the acute form, but are swollen 
and stiff. The stiffness is especially noticeable when the joints 
have long remained in one position. Owing to the fact that the 
pain is usually worse at night it is sometimes confounded with 
syphilitic disease of the bones and periosteum. It affects chiefly 
the large joints at various times, and gives most trouble to people 
who are liable to exposure in stormy weather; whose dwellings 
are damp; whose clothing is scanty and during sudden changes 
from warm to cold and damp winds. 
Treatment.—Little can be accomplished unless the patient se- 
cures warm clothing and a dry habitation, although cases occur 
among those who are abundantly provided in these respects. Hot 
flannels, or hot-water bags, and wrapping the affected joints in 
oiled silk or gutta-percha tissue, usually palliate the local symp- 
toms. When the pains are worst at night, iodide of potassium, in 
doses of seven to fifteen grains, three times daily, in water, will 
often give relief. Salicylate of soda, given as directed on the pre- 
ceeding page, will occasionally be serviceable. Tincture of rhus 
toxicodendron, in doses of a drop or two in water every couple of 
hours, is recommended when the lower limbs are affected and are 
painful while at rest, and the tincture of black cohosh, in doses of 
three to five drops in water, every two or three hours, is another 
remedy which often proves serviceable. Ammoniated tincture of 
guaiacum, given in half-teaspoonful doses in milk, every four to 
six hours, is an old remedy. 
Liniments of any kind, which, together with rubbing, render the 
skin red at the seat of chronic rheumatic pain, will frequently give 
some relief. Small blisters—not more than an inch square—ap- 
plied successively at different places about a tender joint, are some- 
times useful. DISEASES OE THE GENERAL SYSTEM, ETC. 
825 
Many persons find great relief to follow an annual visit to some 
sulphur spring, where they drink the water and take a series of 
baths. 
The Turkish bath is among the most valuable remedies when 
it is obtainable. 
Crick in the Back—Lumbago. 
This is considered to be a rheumatic affection of the muscles of 
the back, but it is quite as likely, in many cases, to be a neuralgia. 
The same may be said of many cases of so-called muscular rheu- 
matism of other localities. 
When the muscles of the back are the parts affected, there is a 
dull, dragging pain and some soreness, at times, and efforts to 
move the spinal column in any direction cause sharp paroxysms 
of pain. The patient, on standing, is obliged to bend forward, 
and efforts to stand upright, or to pick objects from the ground, 
are rendered almost impossible on account of the suffering which 
they cause. 
Treatment.—The remedies useful for neuralgia are usually ser- 
viceable in this affection. Much comfort follows the application 
of a hot poultice to the back, or the wearing of a broad bandage of 
stout flannel pinned tightly about the loins after placing a piece 
of oiled-silk next to the skin. Galvanism is often serviceable. 
The best remedy that has yet been discovered is the insertion, 
for a moment, of a sharp needle—like a shawl or bonnet-pin—to 
the depth of about an inch, into the skin and muscles at the points 
that are most painful. The relief which usually follows this little 
operation is immediate and almost miraculous. • 
Crick in the Neck. 
This is, to all intents, similar to the foregoing, the muscles of 
the neck, instead of those of the back, being the seat of the trouble. 
The use of stimulating liniments (see Formulas), the applica- 
tion of oiled silk, flannel, hot poultices, and capsicum plasters, 
with rest, are the best remedies. Owing to the presence in the 
neck of large blood-vessels and nerves, the puncture-treatment 
should only be undertaken by a doctor. 
Deforming Rheumatism. 
There is a peculiar affection known as “ deforming- rheuma- 
tism,” “rheumatic arthritis,” or “rheumatic gout,” which is ob- 
served among persons of all ages, though most often among 826 
DISEASES OF THE GENERAL SYSTEM, ETC. 
adults. Females, and more particularly women who suffer from 
menstrual disturbances, are said to be most frequently attacked. 
It is not hereditary, and is not apparently caused by alcoholic 
drinks, or excessive feeding. It rarely presents the inflammatory 
symptoms and disturbance of general health noticeable in rheu- 
matic fever, but when once a joint is affected by it, the swelling, 
tenderness and stiffness continue, and joint after joint becomes 
involved. Not unfrequently it is mistaken for gout, but it is to be 
noted that the great toes, which so often are the seat of gouty 
trouble, are among the least frequent seats of the disease in this 
malady. Moreover, gout most often attacks small joints, while 
rheumatic arthritis attacks large and small alike. While none 
of the other forms of rheumatism are ordinarily followed by per- 
manent deformity, this is a leading symptom of the variety in 
question, and the joints attacked become more and more distorted 
and surrounded with bony outgrowths, until the patient is ren- 
dered a helpless cripple. 
Treatment.—This is at best a very intractable malady, and 
very many cases are not influenced, apparently, by anything that 
can be done. The measures mentioned under the head of chronic 
rheumatism may be resorted to for temporary comfort, and a 
course of life should be adopted which will aid in the preservation 
of the general health. All else should be left to a physician. 
Gout. 
Gout is almost entirely a disease of adult life, and is most com- 
mon among men, women being but very infrequently attacked. 
It is decidedly hereditary, but it can be developed by over-eating, 
by the constant use of sweet wines and malt liquors, sedentary 
occupations, and a deficiency of muscular exercise. Its attacks 
are often sudden, or preceded only by disturbance of the stomach 
and notable irritability of temper. Persons liable to it may have 
an attack brought on by over-indulgence of the appetite, by over- 
fatigue—especially too much walking—and by mental depression 
from any cause. The first attacks are usually confined to the 
small joints, and of these, the joints of the great toes are most 
liable, but in chronic cases all joints may become implicated. 
Symptoms.—As before mentioned, the onset is sudden and very 
frequently occurs during the night, when the patient is awakened 
with pain. In the case of the great toe, the joint becomes swollen, 
red, hot, and so tender as to endure no pressure whatever, and 
prevent the foot being placed on the floor. The pain is usually of DISEASES OF THE GENERAL SYSTEM, ETC. 
827 
a burning or crushing character; the veins above the joint are 
swollen ; the patient is restless and irritable, and sometimes— 
though not invariably—there may be feverishness, loss of appetite, 
a coated tongue, and constipated bowels. The pain is commonly 
worse toward evening and through the night. The usual duration 
of an acute attack is from five to ten days, according to the care 
taken. At the end of the attack the pain and swelling subside, 
and the outer layer of the overstretched skin peels off. By and 
by the joint can be used, and the patient feels generally better than 
he did for some time before the attack. 
Unless proper precautions are taken, one attack of gout is 
pretty sure to be followed by another. The intervals may, at first, 
extend over two or three years, but in time they become shorter, 
and recur at about the same time each year. As the attacks be- 
come more frequent, their duration increases, until the patient 
suffers almost constantly, excepting a short period during the hot 
weather of summer. 
Matter very rarely forms in gouty joints, but there is deposited 
in them a substance known as urate of soda, which at first is soft 
and creamy, but afterward grows hard and chalky, until, in cases 
of oft-repeated gout, the joints, especially of the fingers and toes, 
present hard lumps, over which the skin is stretched, and may 
finally ulcerate, leaving these “chalk-stones,” as they are wrongly 
termed, exposed. 
During an attack, the urine becomes scanty, high-colored, and 
has a pink or red sediment. 
Treatment.—The patient should remain as quiet as possible in 
a warm room. The joint should be closely wrapped in oiled silk 
and cotton-wool or flannel, and when the foot or hand is the part 
affected, it should be kept in a horizontal position on a soft pillow. 
The diet should be rather spare and consist largely of fluids. 
The medicine which usually affords relief is the tincture or wine 
of colcliicum, either of which may be taken in doses of a half-tea- 
spoonful, in water, every two hours, until the pain is relieved. 
Colchicum usually acts best when it is preceded by a dose of Ep- 
som salt, or some similar saline laxative. 
In cases that are somewhat chronic, iodide of potassium may 
be of service in doses of seven to fourteen grains taken in a half- 
wineglassful of water every six hours. 
A physician should be consulted in regard to the treatment of 
individual cases, and he should lay out a course of diet, exercise, 
etc. , which should be closely adhered to during the intervals be- 
tween attacks. 828 
DISEASES OF THE GENERAL SYSTEM, ETC. 
Dropsy. 
The general characteristics of this condition have already been 
mentioned in other parts of this work, and we shall here consider 
some of the causes and varieties of dropsy in greater detail. 
All the blood which has passed through the capillary circulation 
of the intestines—stomach, spleen and pancreas—is collected by 
venous trunks which empty into the portal vein. After entering 
the liver, this again subdivides so as to form a second capillary 
network, which surrounds each of the lobules, or small divisions 
of the liver-substance. From this area the blood is again collected 
into branches of the hepatic veins, and is then discharged into one 
of the great veins which empty into the right side of the heart. 
Any impediment to the passage of blood through the capillary 
vessels of the liver naturally leads to an overfulness of the blood- 
vessels which empty into the portal vein, and a natural conse- 
quence is an oozing out of the fluid portion of the blood, which 
fluid collects in the cavity of the belly and gives rise to the form 
of dropsy called ascites. 
When the obstruction to the blood-current exists in the heart 
or lungs, and over-distention of the veins takes place, the oozing out 
of the blood-serum is more general, and is likely to take place at 
points where the pressure against the walls of the vessels is greatest. 
This, of course, is the case in the lower extremities and in places 
where the connective tissue is loose in texture and offers little sup- 
port to the vessels contained in it. In heart-diseases, therefore, 
swelling of the feet, ankles, and hands occurs during the day, and 
disappears more or less completely during the night when the 
limbs are on a level with other portions of the body. 
In certain varieties of kidney-disease, a diminution in the quan- 
tity of fluid excreted by these glands leads to overfulness of the 
blood-vessels, while, at the same time, the blood-vessels them- 
selves may be the seat of disease, which renders them less able to 
retain their contents. 
In pregnant women, the pressure of the enlarged uterus against 
the veins passing through the pelvis, causes obstruction to the 
passage of blood, and the lower limbs swell in consequence. 
Not uncommonly, the watery state of the blood in anaemia, 
and the deficient nourishment of the blood-vessels, as well as other 
parts of the body, leads to an escape of serous fluid into various 
localities in the body. 
Embolism, or other cause arresting the flow of blood in an ar- 
tery, leads to oedema or dropsy of the parts beyond, in consequence DISEASES OF THE GENERAL SYSTEM, ETC. 
829 
of the weakening of the coats of the vessels whose supply of fresh 
blood has thus been cut off. 
Certain affections of the nervous system which paralyze the 
muscular coats of the arteries, favor an over-supply of blood to 
corresponding portions of the capillary vessels, and thus dropsy 
of the adjoining tissues is produced. 
The serous sacs—like the pleura, pericardium, and peritoneum 
— are liable to accumulations of fluid as a result of inflammation. 
The Symptoms of dropsy or oedema are commonly very appa- 
rent. When it takes place in the connective tissue of the limbs, 
pressure with the end of a finger over some firm point—like the 
shin—squeezes the fluid out of the connective tissue underlying 
the skin, and a pit or hollow remains for a time. 
When dropsy of the belly takes place, the swelling may be- 
come extremely great, and the descent of the diaphragm during 
breathing be interfered with. When lying on the back the fluid 
causes the sides of the belly to bulge, and by placing a hand on 
one side, while a gentle tap is struck with the fingers on the other 
side, a wave-like impulse of the contained fluid may readily be felt. 
Treatment.—When the cause of the dropsy can be removed (as 
in pregnancy, by supporting the womb with a bandage slung from 
the shoulders, or by lying on the face), no other treatment is needed. 
When the swelling is due to disease of the liver or kidneys, how- 
ever, the removal of the cause is not always possible. The same is 
true in some heart affections; although not unfrequently, when 
the action of the heart is feeble, the use of digitalis, tonics, and 
other means which increase its power, will lessen the amount of 
dropsical fluid. 
In anaemia, iron, fresh air, nourishing food, and the moderate 
use of stimulants, will greatly help to put an end to the trouble. 
When in dropsy of the extremities, or anasarca, the skin is so 
overstretched as to become painful, and even when the swelling 
is less in degree, much relief follows the wearing of a well-fitting 
roller-bandage, or an elastic bandage will afford great comfort. 
Occasionally it is thought necessary to puncture the skin with 
a needle or lancet at various points, to permit an escape of the 
fluid. Owing to the bloodless state of the skin from over-stretch- 
ing and narrowing of its vessels, this is liable to be followed by the 
formation of sores. 
When fluid accumulates in the abdominal cavity to such an ex- 
tent as to interfere with the action of the lungs, heart, stomach, 
intestine, or kidneys, it becomes necessary to draw it off through a 
tube—an operation which gives but trifling pain, and is unat- 
tended with much risk if properly performed. 830 
DISEASES OF THE GENERAL SYSTEM, ETC. 
A moderate amount of fluid may be carried off when the 
over-distention of the blood-vessels is lessened by means of purga- 
tives and production of sweating. To accomplish these, elaterium, 
croton-oil, compound jalap-powder, and jaborandi, and hot-air 
baths are administered, but should not be undertaken without 
the direction of a physician. Remedies which act upon the kid- 
neys are not often successful in lessening dropsy. 
Sunstroke. 
Sunstroke, or heat-stroke, as it would be more proper to call it, 
is not due to exposure to the sun's rays alone, but follows the pro- 
longed effect of heat from any cause, when this is combined with 
exhaustion from overwork or sickness, bad air, a sultry atmos- 
phere, an inactive skin, and the use of alcoholic drinks ; laborers, 
soldiers, emigrants on crowded vessels, those who are exposed to 
intense heat in their occupations—such as glass-blowers, smelters, 
moulders of metal, laundresses, bakers, &c., are among the persons 
most liable. The attack does not always occur during the day- 
time, but may come on at night. Preceding it the person has 
usually suffered more or less from loss of appetite or nausea, ex- 
haustion, inability to hold the urine for any considerable length of 
time, headache, dizziness or confusion of ideas, a dry skin; and 
the use of a thermometer in the arm-pit will show the existence of 
fever. 
Symptoms.—The onset may be quite sudden and take the form 
of an active delirium, during which the patient rushes about and 
may even attack those who would restrain him, or he becomes 
suddenly weak and sinks to the ground in a condition of stupor. 
At this time the temperature in the armpit will be found to have 
risen to 106° or 107° Fahr. and the pulse will have become feeble. 
Other cases are not attended with loss of consciousness, but 
there is great weakness, a feeble pulse, and cold, clammy face and 
extremities. 
Persons who have once suffered from sunstroke rarely ever 
recover entirely from its effect on the brain, but suffer from head- 
ache and loss of memory. Those who are liable to epilepsy, not 
unfrequently have the disease developed by it. 
Treatment.—Those who are not in good health, and who feel 
the early symptoms of the attack coming on, should immediately 
retire to a cool, airy, darkened room, apply cold water to the head, 
lie quietly in bed, take thirty grains of bromide of potassium in 
cold water, to relieve headache, and put mustard drafts on the 
insides of the thighs, or have a hot foot-bath. DISEASES OF THE GENERAL SYSTEM, ETC. 
831 
When a person is attacked suddenly, carry him at once to a 
cool place in the shade, and after taking off the outer clothing, 
pour cold water on the head and over the entire body. If the skin 
is very hot and dry, ice may be put into the water, and an ordi- 
nary garden sprinkling-pot may be used. 
Do not allow blood to be drawn under any circumstances. If 
there is much delirium, a long mustard plaster may be put on the 
back over the spine. Convulsions, which are apt to occur in se- 
vere cases, may ordinarily be arrested by giving inhalations of 
chloroform. For this purpose a teaspoonful may be put on a folded 
handkerchief or napkin, and held a short distance above the nose 
and mouth. If the pulse is feeble, use smelling-salts with care. 
Send for a physician in any case. 
Sea-Sickness. 
This is commonly considered to be a disturbance of the diges- 
tive organs, owing to vertigo, nausea, and vomiting being promi- 
nent symptoms, but it is probably due to some derangement of the 
nervous system ; the nausea and dizziness being attendant upon 
the disturbance of the brain, such as occurs in riding backward, 
swinging, whirling, blows upon the head, etc. Most persons are 
liable to it, and even old sailors suffer at times when the sea is 
rough. Not unfrequently, when a ship, an iceberg, or some novel 
sight attract attention ; when imminent shipwreck, or a man 
overboard cause intense excitement, or when land appears in 
sight, even those who have suffered most, often lose at once the 
sense of utter wretchedness which a moment before rendered 
mere existence intolerable. 
Sea-sickness has a number of varieties. At times there is no 
nausea, but a feeling of constant dizziness, confusion of ideas, 
and, perhaps, a dull headache take its place. Even in such cases 
there is more or less loss of appetite, and in nearly all there is ob- 
stinate constipation. Without doubt the close and unsavory at- 
mosphere of a vessel plays an important part in the production 
of the nausea, since even those who are not, ordinarily, much 
affected, may lose control of their stomachs if they venture into 
the neighborhood of the cook’s galley. 
Intense as the suffering may often be, it is rarely that the mal- 
ady ends fatally. The prolonged absence from food and the 
prostration which follows the nausea and retching, frequently 
weaken those who do not soon become accustomed to the move- 
ments of the vessel, and persons who are already weakened by 
disease may sometimes suffer fatal injury. For some reason con- 832 
DISEASES OF TIIE GENERAL SYSTEM, ETC. 
sumptive persons appear to be less subject to sea-sickness than 
most others. 
Treatment.—The long list of remedies at one time or another 
recommended for sea-sickness is sufficient evidence that there 
are no specifics. Almost every traveller has tried a number of them 
without benefit, and has at last settled down in a condition of 
mental apathy, to await the deliverance which comes with reach- 
ing land. 
When an ocean voyage is to be made, arrange your affairs so 
that nothing shall need to be done for twenty-four hours previous 
to going on board. Take a dose of some purgative that will empty 
the bowel, and when the time for going to the vessel comes, do it 
without excitement. Take a farewell of friends before going on 
board, and make use of the time that precedes starting, by ar- 
ranging clothing, toilet articles, knick-knacks, etc., where they 
can be reached without fumbling, and fix them securely to pre- 
vent their being dislodged by the motions of the ship. Leave all 
flowers in the saloon, and try to keep the air of the stateroom dry 
and entirely free from all odors, agreeable or otherwise. 
Provide extra wraps that will keep out wind and cold ; they 
will never be too warm, even in mid-summer, when going to and 
from European ports, and, with their protection, stay on deck, as 
near the centre of the vessel as possible, even if you are obliged to 
lie on the deck and have meals brought to you. When you go 
below, go directly to your stateroom and lie down with as little 
delay as possible. Have your pillow toward the forward end of 
the vessel, and fix all curtains, garments, etc. , so that they cannot 
swing. Eat sparingly at first, and have the food either hot or ice- 
cold, and well seasoned. Those articles which have a decided fla- 
vor are best retained. A cracker spread with butter, sprinkled 
with cayenne pepper, and eaten with a piece of smoked herring or 
sardines and lemon-juice, pickled oysters, a thin slice of cold 
boiled ham, or smoked tongue with spiced mustard, are often 
dainty bits on shipboard. 
When walking on deck, keep on the side toward the wind, or 
along the middle ; don’t look at the rigging, but keep the eyes fixed 
on the horizon, which is about the only object that does not appear 
to be in constant motion ; and do not walk too near the after-end 
of the vessel. The up-and-down motion is there sometimes very 
great, and will pretty certainly cause vomiting in those who are 
“ squalmish.” 
The headache and dizziness can sometimes be relieved by bro- 
mide of sodium or of potassium, in doses of twenty to thirty 
grains for an adult, taken in water, and repeated at intervals of DISEASES OF THE GENERAL SYSTEM, ETC, 
833 
four to six hours. Chloral hydrate sometimes proves serviceable in 
short trips by putting the sufferer to sleep, but should be used only 
with the advice of a physician. Nitrite of amyl can now be had 
in most large seaports, put up in little thin glass capsules con- 
taining three to five drops each. One of these may be crushed in 
a handkerchief or napkin and its vapor inhaled. This remedy acts 
best in cases where there is not flushing of the face and headache, 
but where there is pallor, nausea, and a cold surface. The dose 
should not be repeated oftener than every two or three hours, and 
it is better to consult a physician before using it. With some per- 
sons, lumps of ice swallowed whole are grateful. Others use a 
small quantity at a time of iced dry champagne—that is, cham- 
pagne having but little sugar in it. And for this purpose one of 
the forms of bottle-tap will economize the champagne, and facili- 
tate its being drawn as needed. 
Those who are able to be on deck often derive much comfort 
from a stout, broad, flannel bandage, made with buckles and straps, 
so that it can be secured firmly about the abdomen. This should 
be put on next to the outer garments ordinarily worn, so that it 
can easily be taken off while lying down, and put on before rising. 
Swinging berths are from time to time recommended, but unless 
they are suspended at the point in the vessel where the up-and- 
down motion is the least, viz., a little behind the centre, they are 
practically useless to prevent sea-sickness, although they avoid 
the uncomfortable rolling from side to side in the berth during 
rough weather. 
Whooping-Cough—Pertussis. 
This affection properly belongs among the Acute Infectious 
Diseases. It is a disease of the general system, and is not con- 
fined to the respiratory organs. Its most characteristic symp- 
tom (from which it gets its name) is a “whoop ” or crowing sound 
made when the breath is drawn after an attack of coughing. The 
cough itself is peculiar, as it consists of a number of expulsive ef- 
forts without intermediate inspiration, and when it is long con- 
tinued the face becomes swollen and red, the lips bluish, and some- 
times the nose bleeds in consequence of the congestion of the head. 
The disease is rather more infectious than measles, and is most 
common among children, for the reason, probably, that all persons 
are liable to have it once, and are usually exposed to its influence 
before they have lived many years. It is sometimes observed to 
follow measles in epidemics of the latter disease. The period 
which intervenes between exposure to infection and the develop- 834 
DISEASES OF THE GENERAL SYSTEM, ETC. 
ment of the cough, is usually about four days. The first stage of 
the disease or the simple cough, lasts ordinarily from one to two 
weeks, the second stage, characterized by spasmodic cough, may 
continue 'from two to three weeks, even longer, and not unfre- 
quently it is three to six months before the cough has quite disap- 
peared. 
The infectiousness of the disease is probably greatest during 
its early stages ; toward the end the whoop appears to be con- 
tinued in consequence of an acquired disturbance of the nervous 
system. 
Simple cases of whooping-cough rarely end fatally, but there is 
liability to complications, such as inflammation of the small air- 
tubes, pneumonia, convulsions, diarrhoea, etc., which render some 
cases much more serious. Not unfrequently, tubercle of the brain 
and disease of the spinal column are to be traced to an attack of 
whooping-cough as their starting-point. 
Symptoms.—The disease almost always commences with a 
cough which is not distinguishable from that of a common cold or 
a bronchitis, and after this has continued a week or two, it ac- 
quires the spasmodic character above described; a little later the 
whooping inspiration is developed, and any excitement, such as 
violent or quick movements, or disturbance of the emotions, is apt 
to bring about a paroxysm. When the disease has reached this 
stage, the child instinctively grasps some steady object for sup- 
port when it feels a paroxysm coming on, or it drops at once to the 
floor. At the height of this stage, the paroxysms may be as fre- 
quent as once an hour, and may prevent sufficient sleep. Each 
paroxysm is usually terminated with the spitting out (or swallow- 
ing) of a quantity of tough, stringy mucus that has been expelled 
from the air-tubes, and not unfrequently it also causes vomiting 
to such an extent, that the child suffers for want of nourishment. 
After the second stage has lasted for the period mentioned, the 
frequency and severity of the paroxysms decline, and the matter 
coughed up more nearly resembles that which belongs to the last 
stage of an ordinary cold. During this stage the whoop may re- 
main, although the spasmodic cough has disappeared. 
Treatment.—In the early stages the same treatment may be 
pursued that has been recommended in other portions of this 
work when speaking of bronchitis and common cold. It is ad- 
visable to cover the chest with a jacket of cotton-wadding or oiled 
silk, and once or twice a day, especially at night, on going to bed, 
to give an emetic of a teaspoonful or two of syrup of ipecac to 
small children who do not readily cough up the mucus in their air- 
tubes. DISEASES OE THE GENERAL SYSTEM, ETC. 
835 
Opium should not be given in any stage of the disease, and 
the only remedy which will here be recommended is the bromide 
of ammonium, or of sodium, given with water and in doses of five 
grains to a child one year old. This may be repeated at intervals 
of three hours. 
Belladonna, sulphate of zinc, black cohosh, and numerous other 
remedies have been recommended for the relief of the second 
stage ; but it is better to leave the directions respecting their em- 
ployment to a physician. 
When the disease is prolonged, and the child’s health has 
suffered, a change of air is among the most valuable measures. 
In addition to this, such tonics as a physician can best prescribe 
will hasten a return to health. It has become customary for those 
who live in cities or towns where gas-works are established, to 
send their children, during the last stage of whooping-cough, to 
breathe the air of the rooms in which the “purifying apparatus” 
is located. In many cases this appears to be serviceable in stop- 
ping the whoop. 
F. A. CASTLE, M.D. Nursing, and Diet for the 
Sick. NURSING. 
The kind of care which is taken of an invalid during most at- 
tacks of severe illness, may have a very decided influence upon 
the favorable or unfavorable course of the sickness. In most cases 
the exercise of proper attention will prevent many of the annoy- 
ances and discomforts which are suffered both by the patient and 
the family. It is a common belief that the nursing of those who 
are strongly attached to an invalid by ties of affection is more 
valuable and agreeable than services rendered by a stranger. This 
may be very true when the stranger lacks both skill and a friendly 
interest. As a rule, however, the worst kind of nursing is that 
received from friends and relatives, and in many instances the 
recovery of the patient depends, in a large degree, upon his being 
separated from those who are unable to conceal their solicitude, 
whose sympathies prevent the exercise of their judgment, or whose 
inability to properly perform their labor causes the patient to suf- 
fer mental distress, as well as bodily discomfort, and leads to the 
suppression of wishes that might better be gratified. Another 
evil effect of amateur nursing is often seen in the injury to the 
health of those who undertake it without the capacity for enduring 
the anxiety and fatigue which come from their constant presence 
with the invalid. In most cases of illness among children, the 
mother or some other member of the family make the best nurses, 
for reasons that are apparent. 
The number of those who are able to avail themselves of trained 
nursing in all cases of sickness, is, however, comparatively few, 
nor is it every case that demands the constant exercise of the best 
skill and judgment. In cases of prolonged illness, such as fevers, 
brain, lung, heart, and kidney affections, and following severe 
injuries or surgical operations, the choice of a person who is to 
take the sole charge of the nursing is a matter of great importance. 
In such cases there should always be but one person who receives 
the directions of the doctor, and who is responsible to him for the 840 
NURSING. 
manner in which they are carried out. When it becomes neces- 
sary for this person to be absent, whether to sleep, eat, or secure 
a change of air and exercise out of doors, some one should be left 
with the patient who can be trusted to carry out instructions until 
the nurse returns. 
As a rule, women make better nurses than do men, and strong, 
healthy women, between the ages of twenty-five and thirty-five, 
are usually the best. No one is a “born nurse,” but those who 
possess good judgment, a fair degree, at least, of education, a 
cheerful manner, tidy habits, dexterity in doing their work, good 
digestion, and the habit of thinking beforehand and to themselves, 
are capable of becoming good nurses if they have the proper train- 
ing. There is hardly a profession 
in which there are so many occa- 
sions for exercising all of these qual- 
ities as in that of nursing, and the 
actual number of those who possess 
them is very few indeed. 
While physical strength may 
be very desirable, its possession 
is not always essential, since, for 
its exercise, the services of oth- 
ers can ordinarily be depended up- 
on when needed, and there are 
those who, though muscularly fee- 
ble, are strong in constitution, and 
capable, in other ways, of making 
excellent nurses. In a number of 
our large cities, training-schools for 
nurses have been established in 
connection with hospitals, and the 
opportunities for thus acquiring a 
knowledge of the details of good 
nursing are becoming much better 
than formerly. 
A few words in regard to the 
clothing and habits of a nurse may 
not be amiss here. 
Nurses’ Dress.—This should be 
of some material that does not 
rustle, is not easily injured, that has no pronounced pattern or 
color, and that will bear frequent and thorough washing ; without 
doubt a dark calico is best. Black dresses, and garments so made 
as to interfere with free motion of the wearer, or likely to catch the 
Figure 217.—Nurse’s dress as adopted 
by most training-schools. NURSING. 
841 
furniture, trail on the floor, or overturn objects placed on tables or 
stands, are to be avoided. In hospitals it is customary for nurses 
to wear broad linen wristbands that fit the arms closely, a plain 
collar, a white muslin cap to confine the hair, and a large apron. 
Jewelry of all kinds should be avoided ; shoes should be free from 
noise, stout, and firmly fixed to the feet, and when night-work is 
demanded, a closely-fitting woollen sack, and not a shawl, should 
be put on to prevent catching cold when getting out of bed to at- 
tend to a patient’s wants. 
Every one who undertakes nursing will find it useful to hang a 
pair of scissors and a pin-ball from her apron-string, and to have a 
watch with a minute-hand, a clinical thermometer, and a box of 
matches in her pocket. 
Talking.—Never talk unnecessarily to a sick person, nor “think 
aloud.” When it is time to give food or medicine, never ask a 
patient if he does not think he ought to take this or that, or if he 
would like something or another, but get it ready, take it to him 
and say “ Here is your medicine,” “Now let us see how much of 
this you can eat,” or some other expression that will attract atten- 
tion, and require as little exercise as possible of judgment on his 
part. Don't, as a rule, ask sympathizing questions, or such as “Do 
you feel comfortable ?” “ Are your pillows right ?” “I hope your 
head doesn’t ache as badly? ” “Is not the room a little cold?” But, 
so far as you are able, use your own wits and quietly put the pil- 
lows so that they afford rest, look at the thermometer, judge from 
the expression of the face and the motions of the patient whether 
the head aches, and say something else, if anything. 
When a patient is able to bear conversation, and when a little, 
now and then, will serve to distract the mind from present trou- 
bles, never tell of other cases that you have seen, nor of the va- 
rious persons whom you have known to be sick in similar ways, 
nor gossip, nor recount your own troubles, nor encourage the 
patient to talk of family affairs or of matters that will be liable to 
cause excitement. Moreover, never tell to others the things which, 
in feebleness of judgment, a patient may sometimes say respecting 
the affairs of himself or others, if there is the slightest reason for 
thinking that they may better be kept private. Never praise the 
superior skill of other medical advisers than the one in charge, nor 
recommend to the patient or friends measures or remedies that 
may be very excellent, perhaps ; but remember that a nurse’s duty 
is to carry out the doctor’s orders. If you have any suggestion 
to offer, make it to the doctor himself, and privately. If it is a 
reasonable suggestion, he will appreciate your discretion and be 
obliged to you for it. Never ask the doctor, in the presence of a 842 
NURSING. 
patient, respecting the nature of any symptom, or for an expres- 
sion of his opinion on any subject connected with the patient’s 
condition. Never whisper in the patient’s presence, nor talk in 
a low tone just outside the door, or where the voice and not 
the words can be distinguished by the sick person. Talking in 
an ordinary tone about matters that are essential rarely causes 
disturbance. 
Noise in or about the sick room is always objectionable, and is 
particularly aggravating when the patient feels that a little fore- 
thought might have avoided it. Outside noises that result from 
necessary pursuits and occupations, rarely cause as much annoy- 
ance as those which come from boisterous children, pianoforte 
practising, rocking-chairs, carpet-nailing, and the like. Squeak- 
ing shoes, rattling the tongs and poker, squeaking and slamming 
doors and shutters, rattling windows and noisy chimney cowls 
and ventilators should always be prevented. 
Never allow a rocking-chair in the room of a sick person, unless 
it be for his or her exclusive use. At other times keep it where 
people cannot sit in it nor stumble over its feet. 
Visitors should not be allowed in cases of severe illness, with- 
out the doctor’s permission, and the patient should be asked 
whether he will see them before they are admitted. Tell such vis- 
itors, before they go into the room, that they must not sit on nor 
lean against the bed, nor stand about the room, but take a sub- 
stantial chair and sit quietly near the bed, in a position where they 
can easily be seen and heard. They should also be told how many 
minutes they may stay, and sometimes it may be advisable to say 
pleasantly to them, that there must be no relation of distressing ex- 
periences in similar cases, unpleasant or startling news of any kind, 
or recommendation of remedies, food, or doctors. Whatever they 
may have to say on such topics, can be said to other members of 
the family and elsewhere. The only excuse there can be for mak- 
ing the visit at all, is that it may relieve anxiety, or cheer and en- 
courage the patient, and persons who do not exert such an influence, 
had better communicate with the patient through a third person. 
It is very common for friends to “ run in” and sit awhile with 
a sick person, when the nurse is obliged to be away to get rest or 
out-of-door exercise. Unless you are reasonably certain that the 
person so left in charge is likely to refrain from gossip, long 
stories, and injudicious remarks, it will, for some reasons, be bet- 
ter to leave many invalids entirely alone, particularly if they can 
be got to sleep in the meanwhile. 
Rest and Exercise.—A nurse owes it to herself as well as to her 
patient, that she should secure a proper amount of rest, and when 843 
NURSING. 
one nurse only is in charge of a patient, the afternoon will usually 
be found the most convenient time for sleep if there is much night- 
watcliing to be done. Before returning to the patient, it will be 
advisable to take a brisk walk out of doors when the weather will 
permit it. 
Sick-Room.—In choosing a room for the reception of a sick per- 
son, take as large an one as can conveniently be used. It is well to 
have it located so that the sun shines into it. Have it in a quiet 
part of the house, and, if possible, provided with some means for a 
separate fire when the weather is cold—an open grate is best. It 
is an advantage in severe cases to have another room adjoining 
for the nurse’s bed, and where medicines, changes of clothing, etc., 
can be kept, so as to be readily at hand. If the case is one of fever, 
have the room cleared of all draperies and carpets, and in the place 
of the latter, spread on the floor, at places where a covering is de- 
sirable, pieces of carpeting that can be easily taken up and aired. 
Agreeable pictures, if not too numerous, are rather a relief to bare 
walls and, when dusted occasionally, can do no harm. Before the 
patient is admitted have the room dry and clean, and as long as 
he remains in it let it be kept as clean and dry as it is possible. 
The ventilation of a sick-room requires judgment to insure 
that the air shall at all times be of proper temperature (65° Fahr., 
is right in most cases) and pure. The only way to secure pure air 
is to let it in from outside, and this should be done in such manner 
as to avoid drafts. One of the best modes of accomplishing this is 
to have a board, from one-half to one inch thick, six to eight inches 
wide, and as long as the window sash is wide. Raise the lower 
sash, place the board in under it, so as to rest on one edge and 
reach from side to side of the window-casing, and then shut the 
sash down on to it. This leaves an opening between the rails of 
the upper and lower sashes, and the air which enters is directed 
toward the ceiling, where it is mixed with the warmest portion of 
the air in the room before coming in contact with the patient. 
When more thorough airing is demanded, the patient may, in the 
meantime, be taken into an adjoining room, or, if that is not feas- 
ible, cover him up snugly in bed, open the doors and windows, 
air the room quickly, close them again, and when the temperature 
is raised sufficiently, uncover the patient. 
Much can be accomplished in the way of keeping the air pure, 
by removing all discharges, soiled clothing and dressings as rapidly 
as possible. 
Thermometer.—All sick-rooms should be provided with a good 
thermometer, hung out of the way of accidents, and not against a 
warm chimney-flue. 844 
NURSING. 
Flowers in the sick-room, so long as they are fresh and grow- 
ing, are by no means objectionable. The idea that they exert an 
unhealthy influence at night, has no foundation in fact, while, on 
the other hand, those which have a decided perfume, give off 
ozone under the influence of sunlight, and thus serve to destroy 
the organic matter floating in the air of the room. Faded flowers 
should always be excluded. 
Beds.—The bedstead used for a sick person should be low and 
not more than three and a half feet wide. This will make it easy 
to lift or turn him, change the clothing, and do such other things 
as are necessary. It is sometimes also desirable to have two beds 
side by side, one of which can be used during the day, the other at 
night. Rest will thus be more refreshing, and the unused bedding 
can meanwhile be thoroughly aired. 
The best bed-bottom is of woven wire, with an arrangement 
for tightening it when it sags from overstretching. On this a hair- 
Figure 218.—Bedstead with woven wire bottom. 
mattress may be placed, and in order that the latter may be worn 
evenly, and not become packed in certain places so as to form 
hollows, it should be made in two pieces—one square, the other 
oblong. Either can then be turned over and changed about, so as 
to present a fresh surface daily. 
Feather beds should not be used about an invalid. 
When a wire bed-bottom is not to be had, and other arrange- 
ments must be made use of. the essential thing is to have a smooth, 
level surface, that is soft and yielding, but which does not allow 
the patient to settle into a hollow. Except in cases of fever, and 
in certain injuries that require a firm, level bed. it may sometimes 845 
NURSING. 
be better to allow the invalid to use the bed he has become accus- 
tomed to, especially when the illness is not likely to be prolonged, 
and the bed is not positively a bad one. 
A valance, or anything else that interferes with a free circu- 
lation of air under or about a bed, should be removed. 
In a case of prolonged illness, the mattress should be protected 
FlGUHE 219.—Mattress made in two portions. 
from becoming soiled, or from the odor which comes from the pa- 
tient, by covering it with a square of India-rubber cloth. A small 
blanket folded once may be placed between this and the sheet, to 
avoid the uncomfortable feel of the rubber. When a sheet of rub- 
ber cannot be had, a folded blanket or quilt may be used, but it 
should be changed daily and aired or washed, and none but a 
clean one should be allowed to remain. 
When there is a liability to escape of matter from the bowel 
or bladder, without the invalid being conscious of it, a draw-sheet 
may be placed under the hips—that is, a sheet folded several times, 
so as to absorb the discharges before they reach the lower sheet. 
This may be slipped out when necessary, and another put in its 
place. It is also a practice in some cases to apply a pad of oakum 
to the bowel, and hold it in place with a diaper, but this increases 
very greatly the liability to bed-sores, and requires quite as much 
attention to avoid this accident as does the use of a draw-sheet. 
Woollen blankets are the best coverings, and coverlids and 
down quilts should be dispensed wTith. 
Cotton-sheets are better than linen, and a fresh sheet should be 
put on the bed every day, if possible. When the supply of bed- 
ding is scanty, a change of sheets can be used, so long as they are 
not soiled, by airing one set out of doors or in an adjoining room 
while the others are in use. Soiled sheets should be removed and 
washed as soon as possible. 
Water-beds are of great service in preventing bed-sores in pa- 
tients who are unable, from weakness, to change their position, 846 
NURSING. 
since pressure is thereby distributed over the entire surface of the 
body in contact with the bed. They are made of various sizes, 
and the largest are quite expensive. They require to be carefully 
protected from oil or grease of any kind, as this renders them 
sticky, and so soft as to tear with the greatest ease. They should 
be supported by a strong bedstead provided with a board bottom, 
and should be covered with two folds of a woollen blanket or a 
quilt. A small bed, of the length of the body, will answer in most 
cases, pillows or folded blankets being used to cover the remain- 
der of the bed-floor. If they contain water alone, the beating of 
the heart and other movements of the body are apt to create a 
wavy motion of the contents, which disturbs rest. This may be 
prevented by filling them partly with water, and then blowing in 
enough of air to put the rubber moderately on the stretch. 
Figure 220.—Dr. Kibbe’s fever-cot, with foot-board removed. 
Occasionally, it is desirable, in the treatment of cases of high 
fever, to bathe the patient freely with cold or tepid water. For 
this purpose, nothing lessens the labor of doing so as much as the 
cot invented by Dr. Kibbe. The bottom of the cot is made of 
coarsely woven cloth of cotton twine, and below it is placed a false 
bottom of India-rubber cloth, sloping toward the foot. When oc- 
casion demands, water of the proper temperature can be poured 
over the patient, and thence it runs through into the false bottom, 
which conducts it to a bucket placed at the foot of the cot. In- 
deed, when a proper mattress is not obtainable, the ordinary cot is 847 
NURSING. 
to be preferred to most other beds, and this may be readily con- 
verted into a “ Kibbe cot” by making a few small holes in its 
canvas bottom, and adding the false bottom of rubber cloth. 
For treating sick persons on ship-board, where the motion of 
the vessel keeps the invalid in more or less constant motion, owing 
to his inability to hold himself steady in his berth, and when the 
cramped attitude of the body in the ordinary hammock interferes 
with rest, a hospital cot may be constructed of canvas, in the shape 
of an oblong box, laced at the corners and provided with a frame- 
work of wood to keep the sides and ends stretched to their proper 
form. This frame-work must be the exact size of the bottom of the 
cot, and be held in place by means of a false bottom made of two 
strips of canvas, which are laced together by their adjoining edges, 
after the frame has been placed on the bottom proper. The end' 
pieces of the cot are made higher than the sides, and terminate in 
a point, where eyelet-holes are formed for the reception of the two 
cords with which the cot is slung. 
' Bed-sores come from long-continued lying in one position; ex- 
coriation of the skin by matter from the bowel and bladder ; the 
presence in the bed of crumbs, plaster-of-Paris, salt, etc., and gen- 
eral want of care and cleanliness. The amount of pressure needed 
is not very great so long as it is continuous. It makes little differ- 
ence whether a person be thin or fat, as this serious condition is 
liable to occur in either case during a long illness in which proper 
care has not been taken. It is not safe to wait until the patient 
complains of discomfort, since it will probably then be too late, but 
the back, hips, heels, shoulders, and elbows, should often be ex- 
amined for evidences of redness, a raw appearance, or creases 
made by wrinkled clothing; and the bed should always be kept 
scrupulously clean, aired, and smooth. 
When there is any evidence of redness, such an air-cushion as 
is shown in the illustration on page 851 should be so placed as to 
relieve the prominent part; or a cushion can be made by stuffing a 
ring of soft muslin with cotton, tow, or curled hair. The rubber 
air-cushion is preferable, however, owing to the greater ease with 
which it can be kept clean. Conjoined with relief from pressure 
it is useful to apply mildly stimulating washes, such as one part 
of alcohol to three or four parts of water. With this the part 
which threatens to ulcerate may be bathed frequently during the 
day, and will serve to increase the flow of blood, and thus avoid 
death of the skin. 
Before an ulcer forms, the skin becomes pale and often sodden 
with fluid, and instead of being inflamed it shows a want of vital- 
ity. When an ulcer has actually formed, it is absolutely neces- 848 
NURSING. 
sary to support the body so that no pressure can come upon this 
part, and such an apparatus as here shown is sometimes resorted 
to. It may be useful, likewise, as a temporary rest in the absence 
of a water-bed. The formation of a bed-sore is, however,quite un- 
likely when care has been taken in season to prevent it. 
It is sometimes customary to apply a piece of adhesive plaster 
over the place where a bed-sore is threatened. This usually serves 
Figure 221.—Arrangement for supporting a patient so as to prevent pressure on a bed-sore. 
to hasten its formation, and to prevent any observation of what is 
going on. When a bed-sore is established, make sure that no pres- 
sure whatever comes upon it. Apply a poultice made by mixing 
flax-seed meal with yeast; or of equal parts of bread-crumb (wet 
with hot water), linseed meal, and charcoal powder. This may 
be dusted over with powdered charcoal before it is applied, and 
should be changed frequently. It will also be necessary to in- 
crease in every way the strength of the patient. 
Clothing.—The best clothing for most invalids is an ordinary 
night-gown over a thin merino undershirt. In the case of patients 
who are able to be propped up in bed, alight dressing-sack may be 
added, and sometimes it is well, for the sake of extra warmth, 
that this should he made of wool. 
Patients who have a feeble circulation, with cold extremities, 
are often rendered more comfortable by wearing a long flannel 
bed-gown. When this is used, however, it should be shaken and 
aired for several hours daily, being, meanwhile, replaced by 
another. Underclothing should be changed, likewise, every twen- 
ty-four hours, if possible, and to accomplish this with little effort 
on the part of the patient, the under-vest may be opened entirely 
down the front and fastened with tapes or ribbons. 
In cases of fracture or other injuries of the upper extremities, 
the bed-gown may be made to open on one side of the body, and NURSING. 
849 
down the inside of the sleeve on the same side, instead of in front, 
so that it can be slipped on and off without trouble. By a little 
skill it can be made so as to be turned either side out, and thus 
fasten on either the left or right side. 
Restless children often require close watching at night to pre- 
vent their becoming uncovered and chilled. When their unrest is 
the result of fever, and the room is properly warmed, no harm is 
likely to result; but this can be entirely avoided by dressing them 
in a gown made with the waist and drawers connected, and hav- 
ing the legs of the latter long and closed at the bottoms. 
Undressing an injured person often requires some tact in order 
to avoid doing further injury. 
In cases of injury of the foot or leg, the boot should be removed 
by ripping one of the side seams. Laced shoes should have the 
lacing entirely removed. Congress-gaiters may have the elastics 
cut. Pantaloons should be carefully ripped through the outer 
seam, from waistband to bottom, on the side injured. A coat may 
be ripped through the shoulder-seam of the injured side, and the 
sleeve detached at the arm-hole. There is seldom occasion for 
mutilating garments so that they cannot be resewed, and the ex- 
penditure of a few minutes of time in this manner, will be well 
compensated by the avoidance of unnecessary injury from rough 
handling. Many fractures may be converted from a simple to a 
compound one—that is when the broken fragments perforate the 
skin—by a little mismanagement in removing clothing. 
Appliances. 
Certain articles are almost indispensable in the care of the sick, 
and there are many others that can add greatly to their comfort 
and lessen the labor of nursing. 
Bed-pans are essential when a patient is unable, for any reason, 
to rise. They should be made of earthenware, and before being 
placed in the bed should be warmed by allowing hot water to run 
into them, after which the outside should be wiped dry. A warm 
towel should be folded over the edge of the pan to catch any 
moisture, and when there is difficulty in evacuating the bowel, 
owing to the unnatural position, the shoulders should be well 
raised upon pillows, the knees drawn up, and something should be 
placed on the bed against which the feet may be pressed. 
Sickness may occur under circumstances when it is not pos- 
sible to obtain a bed-pan, or, in cases of fracture of a lower 
extremity, it may not be possible to use one. In‘ such cases an 
arrangement such as is described on page 684, of Yol. I., can easily 
be made, and will be found extremely useful. 850 
NURSING. 
Urinals may be of either glass or earthenware. The former 
are most easily kept clean but are most liable to be broken. Be- 
fore using them they should be dipped into warm water and wiped 
dry. Either urinal or bed-pan should be immediately emptied and 
washed after use, and kept in a convenient place out of the room. 
Never leave a patient resting for any length of time on a bed- 
pan, and, except by a doctor’s orders, never leave a urinal con- 
stantly in the bed. 
Whep. it is desirable to preserve the evacuations for the doctor’s 
inspection, the vessel should be covered and placed out of doors. 
Never allow an invalid to sit upon a chamber-vessel that is not 
strong, or that is in the least cracked. Terrible wounds of the 
buttocks have not infrequently resulted from the sudden breaking 
of a chamber while in use. 
Back-rest.—When patients are able to be propped up in bed to 
take their meals or to change their position, a back-rest made so 
that it can be fixed at any angle, will be found very serviceable, 
and especially when provided with arm-rests; but, in the absence 
of such a contrivance, a flat-backed chair can be reversed so as to 
rest on its forward edge and top of the back, and pillows can be 
adjusted against the inclined surface so as to support the back and 
shoulders. 
Support for Bedding.—When the weight of bed-clothing is ob- 
jectionable—as during inflammation of the bowels and in some 
Figure 222.—Urinal for males. 
Figure 223.—Urinal for females. 
Figure 224.—Convenient mode of suspending a leg after an amputation of a foot or ankle. 
The same arrangement will serve to prevent contact of the bedding with a tender limb or with 
the belly. • 
surgical affections—two halves of a barrel-hoop can be wrapped 
with strips of flannel and tied together so as to cross each other NURSING. 
851 
at right angles. These may then be placed astride the body or limb 
to be protected. When the presence of such an apparatus in bed 
is irksome, a smooth stick can be placed under the clothing, and 
two stout dress-holders, suspended by cords from the ceiling, can be 
made to grasp its ends together with the clothing which covers it. 
Cushions.—In addition to the feather pillows ordinarily used, 
air-cushions of India-rubber and cotton-drilling, or small pillows 
Figure 225.—Varieties of air and water pillows. The round one is adapted to be used also as 
a bed-pan when the ring is inflated, but should be so used only when travelling or in emergencies 
when an earthenware pan is not available. 
of various sizes stuffed firmly with curled hair, will prove service- 
able as supports for various parts of the body. In warm weather 
the latter are far more comfortable as supports for the head than 
are pillows of feathers. 
In fractures of limbs, long cushions of strong muslin, half-filled 
with sand that has been washed free from dirt and carefully dried 
in an oven, are often of service. Smaller cushions of the same 
character can be made use of to support splints, or to relieve pres- 
sure at various points. 
Water- and Ice-bags and Tins.—For applying heat or cold, 
nothing can be more convenient than the India-rubber bags now 
made in various sizes, and shaped like Fig. 226. These may be 
filled with hot or cold water by means of the funnel-shaped 
mouth, and then closed with the screw-cap. In their absence, 
stoneware mineral-water jugs are useful, but the corks used for 
stopping them should be securely tied in. When these water- 
bags leak, as they sometimes do, about the neck, where they 
become broken, the holes may be covered with pieces of rubber 
cloth and a cement made by dissolving bits of gutta-percha, or 
pure India-rubber, in chloroform, until it is syrupy. A can made 852 
NURSING. 
of tin, in the shape of Fig. 227, may be constructed by any tin- 
smith, and is particularly useful for applying heat to the belly. 
Figuke 227.—A tin vessel for applying heat to the belly. 
Figube 226.—Water-bag. 
Invalid-Lifts.—With the aid of a strong cord or a strip of web- 
bing attached to the foot-posts or rail of a bedstead, or to a ring 
in the ceiling, an invalid can with greater ease help himself to a 
sitting posture, or turn from side to side. Such a contrivance as 
shown in Fig. 228 may be of service. Its centre is made of cro- 
Figure 228. - Invalid-lift. 
cheted worsted, and the ends are attached to long strips of web- 
bing which pass around the foot-rail, and return, so as to be 
grasped by the hands of the patient. A support made of elastic 
webbing and a cross-bar, in the form shown in Fig. 229, is of 
service to those who suffer with difficult breathing, due to asthma, 
heart disease, dropsy, etc. 
Invalid Chairs.—For carrying an invalid about the house, a 
chair such as shown in Fig. 230 will be a great convenience, but 
the methods referred to in the Chapter on Accidents and Emer- 
gencies, will serve when such removals are not often demanded. 
With the exception of carrying up or down stairs, nothing is bet- NURSING. 
853 
ter adapted for the moving about of an invalid than the wheeled 
chairs, such as are shown in Figs. 231 and 232, made by the Hew 
Figure 229.—Sling for patients 
who suffer with difficult breathing. 
Figure 230.—Chair with handles, for carrying an 
invalid. 
Haven (Conn.) Folding Chair Company. Their use enables many 
convalescents and cripples to dispense largely with assistance 
from others. 
Figures 231 and 232.—Wheel-chairs for invalids. The first is intended to be pushed from 
behind, and is best adapted for convalescents who are too feeble to roll themselves; the second 
is propelled by means of the circles of wood attached to the spokes of the wheels. Either will 
easily pass through an ordinary doorway. 854 
NURSING. 
Night-Chair.—The use of a night-chair adds to the comfort of 
invalids who are able to leave their beds, but unless they are care- 
fully aired after use they are apt to be- 
come nuisances. They should be made 
with arms that can be removed, so that 
there may be none on the side next the 
bed, or they may be without arms, but 
provided with a low back on two adjoin- 
ing sides of the chair. When it does not 
require too much exertion, it is better to 
place the patient in a wlieel-chair, and so 
roll him, carefully wrapped in a blanket, 
to the cabinet. 
Bed-tables.—When an invalid becomes 
sufficiently strong to feed himself, or to 
read, it is of service to have a table made 
with short legs, that will rest on the bed, 
or one in the form of Fig. 235, which is 
supported by a column that will adapt it 
to various heights. 
Mosquito netting is generally objection- 
able, on account of its liability to interfere 
with a free supply of air. During convalescence, however, when 
the constant presence of a nurse is not necessary, the use of 
netting as a protection against the annoyance of flies may enable 
Figure 333.—Frame-work 
of a night-chair of simple con- 
struction, without arms. This 
may be covered with calico, 
with a valance to inclose the 
lower part and a cushion made 
on a false bottom of wood to 
cover the seat when not in use. 
Figures 334. and 335—Bed-tables. 
the patient to prolong the morning nap which is usually so re- 
freshing. Whenever a netting is used, it should be taken down 
during the daytime, and thoroughly aired out of doors, or in 
another room. NURSING. 
855 
Bandages.—Theoretically, there are many varieties of bandage, 
but the roller—a long strip of muslin or flannel, formed closely 
into a cylinder—is the only one much used, and with skilful 
management it can be made of great service in many cases. 
Roller-bandages are made of loose-textured muslin or flannel 
torn lengthwise with the cloth, and vary in size from an inch to 
four or five inches in width, to as many or more yards in length. 
Figure 236.—A roller-bandage, show- 
ing the method of uniting its pieces. 
Figure 238.—Machine for rolling bandages, 
to be fastened to the edge of a shelf or table. 
When the bandage is rolled it is held while the 
spindle is turned backward two or three times to 
loosen it and then drawn out. 
Figure 237.—A T -bandage. 
The ordinary size is two and a half inches in width and five or six 
yards in length. The edges should be without selvage or hem, so 
that the bandage may stretch evenly, and when additional lengths 
are added, the adjoining ends should be overlapped about half to 
three-fourths of an inch, and sewed through and through all 
around. Similar bandages may be made of India-rubber, when it 
is necessary to exert pressure or to confine the perspiration to the 
part covered. 
To roll a bandage snugly, a machine is useful, but when there 
are but few to be prepared, it may be done as follows : Take one 
end of the strip a few inches above the right knee, allowing the 
remainder to rest on the floor in front of the foot. Fold and refold 
the end, so as to make a small compact roll, and then place the 
palm of the right hand on it and roll it toward the knee, the left 
hand being used meanwhile to keep the bandage tightly drawn. 
Draw up the roll again on to the front of the thigh, and repeat the 856 
NURSING, 
manoeuvre, and so on until the whole is firmly rolled. The edges 
should be kept true and even, and when the whole has been rolled 
the loose threads may be pulled off. Sew or pin the free end to 
keep it in place. Another mode of rolling a bandage is shown in 
the adjoining figure; but although more elegant, it requires dex- 
terity, and does not lead to any better results. 
A T-bandage, as its name suggests, is made by sewing one end 
of a strip of bandage to the edge of another one, so that they will 
be at right angles. This is commonly used to retain dressings on 
the groin, on the lower end of the back, or between the thighs. 
Figure 239.—Double-tailed T-bandage. 
Figure 240.—Manner of rolling a bandage 
with the hands. 
The horizontal portion is first fastened about the waist, and the 
other end, being carried between the thighs, is fastened to the 
first portion in front or behind, as the case may be. 
Plaster-rollers are made of the loosest textured muslin, crino- 
line, or cheese-cloth. They are usually not more than two inches 
wide, as they can then be better applied without “ reverses.” In 
making them, a shallow dish, like the top of a long envelope box, 
a quantity of fine, recently prepared plaster-of-Paris, and a large 
spoon are to be provided. Laying one end of the bandage length- 
wise in the box, a few spoonfuls of plaster are put on it, and 
scraped back and forth until the meshes of the cloth are filled. 
All superfluous plaster having been scraped off, the end is rolled 
up, with care not to shake out the plaster in its meshes, a fresh 
portion of bandage is drawn along into the box and similarly 
treated, and so on until the whole is rolled. 
Plaster-rollers should not be made very firm, as they require to 
be immersed in water for a few moments before being used, and firm 
rolling interferes with wetting the plaster in their folds. When NURSING. 
857 
they are not needed for immediate use, they should be wrapped 
in tin-foil or waxed paper, or placed in a fruit-jar with a tight-fit- 
ting cap, to exclude moisture which prevents the plaster setting 
when they are used. 
Starch-bandage is made by applying thin, boiled starch as a 
roller-bandage is put on. Previous to putting on the bandage the 
Figure 241. —Many-tailed bandage 
made from a single piece of muslin. 
Figure 242. 
limb must be enveloped in a thick layer of soft cotton-wadding, 
with which, also, all hollows in the surface must be evenly filled. 
The limb needs to be kept at rest for several hours afterward, and 
the drying of the starch may be hastened by placing bags of hot 
sand about the limb, or ironing it with a moderately hot smooth- 
ing-iron. 
A many-tailed bandage is made by overlapping half an inch 
the edges of a number of short strips of two-inch bandage, and 
then sewing a similar strip at right angles down their middle, to 
keep them in place. Another mode is to tear a square of muslin 
into the shape shown in the above figure. 
Figure 243. 
Figure 244. 858 
NURSING. 
This is used when it is not desirable to disturb an injured limb 
in order to remove the dressing, and is applied by commencing at 
the end farthest from the body, and laying, alternately, the strips 
of both sides smoothly into place across the front of the limb. As 
the ends are overlapped by this method, the dressing is rendered 
firm. The bandage is more smoothly applied if it be first wet 
with water. • 
In applying a bandage to the arm, thigh, or leg, it is usually 
necessary to begin with the hand or foot in order to prevent their 
becoming swollen with blood as a result of the pressure of the 
bandage above. Commence the turns 
as shown in the adjoining illustrations, 
and after fixing the extremity of the 
roller, make a few turns about the foot 
or hand, as shown in Fig. 242, and then 
carry the turns of the bandage upward 
on to the limb, allowing each turn to 
cover about half of the turn preceding 
it, taking care that each edge of the 
bandage is drawn equally tight. When 
the calf of the leg or the tapering part 
of the fore-arm are reached, it will be 
found that the edges of the bandage 
cannot be kept evenly strained when it 
is applied so as to overlap the turn be- 
low, the lower edge being loose, as 
shown in Fig. 248. To avoid this and to cover the limb evenly, 
reverse the bandage at each turn as shown in Fig. 244. The 
turn just made must be held with the tip of a finger or thumb; 
the tension on the bandage is then to be relaxed and the- roller 
turned over. On drawing the bandage tight again, its surface 
will adjust itself smoothly. 
Figure 245.—Bandage for a foot 
and leg. 
Figure 240.—Mode of bandaging the 
large joint of a thumb. 
Figure 247.—Arrangement of a roller 
bandage for a finger. 
It is only by practice that skill can be acquired in applying the 
roller-bandage. The adjoining figures will, however, show the ap- 
pearance of a bandage when properly applied to certain localities. 859 
NURSING. 
When the end of an amputated limb is to be covered, a piece of 
lint shaped like Fig. 249 is sometimes applied; the ends being 
smoothly folded over each 
other, are retained in place 
by a few turns of a roller- 
bandage. 
Sticking-Plaster is of va- 
rious kinds. That made with 
resin, oil, and litharge, needs 
to be heated over the flame 
of an alcohol lamp (to avoid 
smoking it), or by applying 
its back to a can of hot wa- 
ter, hot stove-pipe, the glass 
chimney of a kerosene lamp, 
or to a hot-air register. The practice of using turpentine to 
soften it is wrong, since it is apt to cause inflammation of the 
skin. 
Adhesive plasters are now made with India-rubber as an ingre- 
dient, and are so adhesive as to require no heating. When either 
of these plasters is applied, the skin must first be perfectly dry to 
insure their adhesion. 
Isinglass plaster is made to adhere by moistening it. To do 
this, a damp sponge may be brushed once only 
across its adhesive surface. 
For small cuts and for covering small, 
tender surfaces, “goldbeater’s skin” or the 
prepared intestine of cattle is serviceable. In 
applying it, the skin and not the plaster must 
be wet, since the latter is apt to curl up and 
become unmanageable when it is dampened. 
When adhesive strips are to be removed, 
pull them from the ends toward the sore or 
cut, and before reapplying them, clean the skin 
by softening any remaining plaster with tur- 
pentine. This must afterward be entirely re- 
moved with hot soap-suds to prevent its in- 
flaming the skin. 
When the ordinary sticking-plaster is in contact with discharg- 
ing sores, it often becomes blackened. This need cause no alarm, 
as it is only the effect of the discharges upon the litharge with 
which the plaster is made, and is no indication of “mortifica- 
tion.” 
One of the modes of treating ulcers of the leg is by the use of 
Figure 248 A fore-arm that is not properly band- 
aged. At a, o, and c, the lower edge of the turns are 
looser than the upper edge, causing the pressure to 
be uneven and enabling the bandage to slip down- 
ward. 
Figure 249.—Maltese 
cross, such as is formed of 
a sheet of lint for covering 
the end of a stump after 
amputation. The central 
hole should be smaller in 
proportion than is here 
shown. 860 
NURSING. 
strips of sticking-plaster, which prevents the edges of the sore be- 
ing pulled apart by the elasticity of the skin adjoining. To insure 
this effect the plaster should not encircle the 
limb, but should extend only far enough to 
hold on the skin. The manner of arranging 
them most effectually is shown in the adjoin- 
ing figure, in which the ulcer has been but 
partly covered. 
Leeches.—The head of a leech is at the 
smaller extremity. When not wanted for 
immediate use they may be kept in a small 
bottle, over the mouth of which a piece of 
paper or cloth has been securely tied, and, in 
the case of the former, pierced with a few 
holes. Before applying them the surface of 
the skin should be washed with warm water, 
to which a little baking-soda has been added, 
in order to remove entirely the fatty matter 
on the skin (the presence of which will gen- 
erally prevent a leech from taking hold) after 
which the skin should be dried. It is well to 
put each leech into water, and then to wipe it 
dry with a soft napkin in order to remove 
the slime covering its skin. All the leeches to be applied to the 
part should be placed in a glass of proper size, which may be cov- 
ered with paper, and the whole can then be inverted and placed 
in position. The pa- 
per can then be with- 
drawn. Leeches can- 
not bite upon surfaces 
covered with hairs. 
When a leech is to 
be applied within the 
mouth, or it is desired 
to make it bite at any 
particular point, it 
may be inclosed in a 
test-tube, or in a leech-tube made for the purpose. A vial with a 
narrow neck will serve quite as well. A large tube should be 
chosen, so that there may be room for the leech to fill itself with 
blood. 
Never pull off a leech, but when it fails to let go, put a few 
grains of salt on it and it will then drop off. After leeches loosen 
their hold they should be put into a basin of water. It will be 
Figure 250— Mode of 
applying strips of sticking- 
plaster to an ulcer of the 
leg. 
Figure 251.—1, a leech—natural size; 2, its mouth, a, b, c, 
its jaws ; 3, the markings on the surface of its hinder extremity. 861 
NURSING. 
some time before they can be induced to bite again, and when salt 
is used to make them drop off, they are usually never good for 
much afterward. 
To stop the 
bleeding from 
leech-bites, put a 
pad of lint or bits 
of muslin over the 
bite and make 
pressure for a few 
minutes with a finger. If this does not suffice, put on a pinch of 
powdered alum and again apply a pad as before. 
When it is desired to prolong the flow of blood, cupping may be 
used, or a warm poultice may be applied to the bites. The condi- 
tion of affairs should be examined occasionally, to make sure that 
too much blood is not being lost, and this is especially necessary 
in the case of infants and children. 
Cups of glass and tin are made purposely for cupping, but 
small tumblers will answer. To use them, 
take a bit of blotting-paper or cotton- 
wool, wet it with alcohol, place it in the 
glass and light it. Then, after a moment, 
turn the glass quickly over and apply its 
mouth to the skin. The flame, having 
exhausted the air in the cup, will almost 
immediately go out, and the skin under 
the cup will rise up and become red. 
When the cup has remained from five to 
thirty minutes—as need may be—it can 
be loosened by inserting a thumb-nail un- 
der its edge, so as to admit air. Wet 
cupping consists in pricking with the point of a lancet the raised 
surface from which a cup has been taken, and reapplying the cup 
again, whereby a little blood is drawn. 
Poultices.—These should be large enough to reach some dis- 
tance about the part which is the seat of pain or inflammation, 
and at least a half to one inch thick at the edges as well as at the 
centre. An exception to the foregoing is the poultice of mustard 
flour. This should be spread evenly, but thinly, and should be no 
larger than the surface which it is desired to irritate. Always 
have a poultice as light as possible, and as hot as can be borne by 
the cheek or inside of an elbow of the person who makes it. 
To make a poultice, have ready a piece of muslin, somewhat 
larger than the poultice is to be ; a piece of mosquito-netting, or 
Figure 252.—A glass leech-tube. 
Figure 253.—A cupping-glass 
applied, showing the twisted pa- 
per-cone wet with alcohol, and the 
surface of the skin underneath, 
rising up into the cup. 862 
NURSING. 
similar coarse lace ; a good-sized bowl in which to mix the poultice ; 
a knife to stir and spread it with ; some vaseline, cosmoline, or 
suet, to grease its surface with (especially when it is to be applied 
to a part which has hair) ; a quantity of boiling hot water, and 
whatever is to form the basis of the poultice. 
If linseed meal is to be used (this makes the best of all poul- 
tices), put rather more than will be needed into the bowl, and pour 
in little by little the boiling water, stirring it meanwhile with the 
knife or spoon. Mix thoroughly, and do not have it too stiff, nor 
so soft that it will not keep 
its place when applied. Have 
the muslin spread on a wood- 
en table or a board (not on the 
cold marble top of a dressing- 
stand) and put the greater 
part of the poultice mass into 
its middle, working it quickly 
out into the shape it is to have 
when finished. Add (quickly) 
any that may be needed to 
make the poultice evenly thick 
all over ; lay on the lace ; fold 
the edges of the muslin over the margins, so that the poultice will 
not ooze out ; spread on a little of the vaseline, or whatever is used 
to grease the surface ; double the entire poultice in half, so that its 
face shall be kept moist and hot; slide it off into a hot plate, cover 
the whole with a piece of warm flannel, and then take it to the 
patient, whose clothing should have been loosened at the outset. 
Open the poultice, try it as above directed, to see that it is not too 
hot, and put it lightly in place. Cover it first with oiled silk, thin 
rubber, or waxed paper, and then with the hot flannel in which it 
and the plate were wrapped, and bind the whole in place with a 
folded towel or strip of muslin snugly pinned, so that it cannot 
shift about. Then clean up the litter, and get everything ready 
for making another poultice when the first has become cool. Do 
not allow a cold poultice to remain on the skin. 
When small poultices are used, such an apparatus may be 
used as is described in the chapter on The Ear, for re-warming 
them, but after this has been done two or three times they become 
dry and irritating instead of soothing, and fresh ones should be 
made. 
A very convenient mode of making a flaxseed-meal poultice, is 
to put the poultice-mass into a flannel bag of proper size, and fold 
over and sew the mouth to prevent its escape. 
Figure 254.—A poultice with the cloth con- 
taining it, folded over to prevent the poultice 
from escaping at the edges. In B the surface 
of the poultice is covered with a gauze, to prevent 
it sticking to hairs as it dries. 863 
NURSING. 
Syringes and Enemas.—For giving enemas two kinds of syr- 
inge are desirable. The form shown in Fig. 255 is most useful 
when a considerable quan- 
tity of fluid is to be thrown 
iqto the bowel or vagina, 
owing to the fact that the 
nozzle does not have to be 
withdrawn in order to fill 
the syringe, as in the case 
of the one shown in Fig. 
256. The latter is best, 
however, when a small, 
amount of fluid is to be 
employed—as when medi- 
cine is given by the bowel. 
Both should be thoroughly washed after use, and in the case of the 
soft rubber bulb-syringe, soap-water should be used for this pur- 
pose when the enema consists of oily substances. 
I n unscrewing 
the tubes of the for- 
mer, care should be 
taken not to loose 
the valves. The 
leather packing of 
the piston in the 
latter is apt to become dry and loose. This may be remedied by 
partly filling it with warm water and allowing it to stand for a 
time in water or by unscrewing the cap, withdrawing the piston, 
spreading and oiling the packing, and returning it 
carefully to the barrel, as before. Iodine and greasy 
substances cause soft rubber to become brittle. 
In inserting the nozzle of a syringe it should first 
be oiled and then be passed inward and backward 
through the opening of the bowel for an inch and 
a half ; then direct the point slightly forward and 
to the left, or toward the left hip-joint. Whatever 
fluid is used should be about the temperature of 
the blood (99° to 100° Fahr.), unless otherwise or- 
dered, and should be thrown in very slowly and 
gently. If the patient feels a desire to expel it be- 
fore the whole amount ordered has been used, the 
operation may be stopped for a few moments and 
then resumed. 
It is always advisable that the patient should lie upon the left 
Figure 255.—India-rubber bulb-syringe—David- 
son’s pattern. 
Figure 256.—India-rubber (hard) enema syringe. 
Figure 257. 
—A rubber-bag 
syringe. 864 
NUKSING. 
side with the knees drawn up, when an enema is administered; 
and when it is to be retained for some time, this may be aided 
by making firm pressure against the opening of the bowel with a 
warm towel. When an enema of water is to be taken to facili- 
tate a movement of the bowels, and the water-closet is not in the 
house, a convenient syringe is the 
large India-rubber bulb, with a noz- 
zle attached. The bulb can be filled 
and placed in the pocket, and thus 
carried without attracting atten- 
tion. Such a syringe may be used 
as well, on other occasions, but 
should be carefully washed out with 
soap and warm water, and rinsed 
clean when anything besides water 
is used. 
One of the most useful is the 
“ Fountain Syringe.” The reser- 
voir of tin or India-rubber is filled 
and placed on a shelf or hung on a 
conveniently arranged nail or hook, 
and the weight of the column of fluid is sufficient to throw the 
enema into the bowel or vagina. 
Baths.—To give a patient a full bath, slip off the body clothing 
and wrap him in a sheet. If he is to be taken some distance to 
the bath-tub, wrap about him a blanket also. The latter may be 
dropped off as he is placed in the tub, but the sheet may be worn 
while he remains in the bath. If he is weak, a hand may be kept 
under his head as a support during his stay in the bath. On 
rising from the water, wrap the blanket about him and let him 
drop off the sheet into the tub, or on to the floor, and, thus wrapped, 
carry, or take him quickly back to bed. While thus wrapped, 
the skin can be quickly dried by passing the hands and towel 
under the blanket, and the latter can then be withdrawn. Cover 
snugly for a few minutes,, and let him rest before attempting to re- 
place the body-clotliing. 
In giving a bath to sick children, it will often avoid alarming 
them if the bath-tub is filled and taken to the bed-side, covered 
with a large bath-towel or sheet. This is to be held tightly while 
the child is placed on it; both may then be lowered gently into the 
water, and the child’s attention may be taken with a few wooden 
toys that will float about it. 
A foot-bath can be given without disturbing the patient, by 
placing a folded sheet under the legs, and then, drawing the legs 
Figure 258.—Fountain syringe. NURSING. 
805 
up, place the bath on this sheet. While the feet are immersed, a 
blanket can be drawn over the tub and knees to prevent the steam 
from wetting the bed-clothing. 
Hip-bath.—In giving a hip-bath to a weak patient, a tub should 
be used which is large enough to permit the person to sit in it. 
Before rising, the body-clothing should be rolled up about the chest 
and securely pinned, and a blanket be wrapped about the body, so 
as to cover the lower limbs, and open behind. This should be 
pinned at the neck. Then, as the patient rises, let the nurse stand 
behind him, and holding under the arm-pits, support his weight as 
he sits down in the bath. Now, throw another blanket over the 
shoulders and about the tub, and, if need be, sit down behind him 
so as to support his head and shoulders. Roll him up in the 
first blanket as he rises, and dry him off in bed with a towel before 
removing it. 
Vapor-Baths.—For a simple vapor-bath, slip off the body cloth- 
ing and adjust a blanket as directed for a hip-bath. Seat the pa- 
tient in a wooden chair, and envelop him and the chair in a second 
or even a third blanket. Under the chair place a wooden or me- 
tallic dish or tub holding about a gallon of hot water, and into this 
slowly immerse heated bricks or hot flat-irons, so as to make a 
cloud of steam. Do this carefully so as not to scald the patient. 
After the bath has continued for the time directed by the doctor, 
roll the patient again in the first blanket, and allow him to remain 
in it for some time after returning to bed, covering him, also, with 
additional blankets to favor perspiration. 
Moving Patients.—When a sick person is to be moved from one 
bed to another, and is incapable of self-help, the easiest way is for 
four persons to take the lower sheet by its corners gathered to- 
gether, and, having the bedsteads far enough removed from the 
wall to pass between them and the latter, the transfer can be 
made with the greatest ease. When the invalid is not heavy, two 
persons of average strength can thus accomplish the removal by 
rolling the sheet up at the sides into a firm roll, and taking an end 
of a roll in each hand. When beds are of equal height, and can 
be pushed alongside of each other, the patient can readily be 
drawn across from one to the other by filling the gap with a 
blanket, and pulling him over on the bottom sheet. 
In cases of injury of the upper extremities, when the patient 
has to be raised or lowered to or from a sitting posture with care, 
to avoid pain, let a person stand on either side, and pass a hand 
(left hand when standing on the patient’s right, and vice versa) 
between the patient’s back and the pillows, until met half way by 
the hand of the assistant on the opposite side ; then, after hooking 806 
NURSING. 
the ends of the fingers together, the patient can be raised with the 
greatest ease, and without risk of hurting him by uneven pres- 
sure or sudden movements. 
Sweeping.—When a sick room requires sweeping, it avoids dust 
and noise to wrap a dampened towel about the broom, and, laying 
it flat on the floor, push it from side to side. Large bits of litter 
should be picked up. When these methods are tedious or imper- 
fect, a short-handled broom or a bristle-brush and dust-pan should 
be.used, and the dust should be brushed at once into the pan and 
not swept across the floor. The absence of a carpet simplifies 
greatly the labor of keeping a room tidy. 
Screens.—One of the handiest articles in a sick-room is a fold- 
ing screen. It serves to cut off drafts of air; to shield the patient 
from observation when, for any reason the door of the room is 
open; to temper the heat of a fire; to shade the bed from strong 
sunlight, or to enclose a part of the room where the nurse sleeps, 
or where medicines, etc., are kept. One of the simplest and best 
contrivances for this purpose is made by covering an ordinary 
folding clothes-horse with calico, which is attached to it by means 
of tapes. This permits the covering to be removed and washed at 
any time. 
Sick-room Cooking.—When invalids are very sick, no food 
should be prepared in their sight, and no cooking should be done 
•• in the room where they are. Where gas is 
used, a variety of burners are to be had for boil- 
ing water, etc. ; but in their absence an “ Etna- 
lamp/’ such as shown in the figure, will be con- 
venient. The base of the cup is formed by a 
gutter in which alcohol is to be burned. The 
heat will be sufficient to boil water placed in the 
cup. This can easily be made by any tinsmith. 
Night-light.—It is sometimes desirable, in the 
sickness of children and others, to have a small 
amount of light during the night, and little 
kerosene lamps are now made for this purpose. No light is 
superior, however, to that of a gas-jet turned down to a small 
flame and shaded by means of tin or pasteboard from shin- 
ing in the direction of the patient. Next to this, a small glass 
partly filled with sweet oil, in which a little wick is floated by 
means of a cork, is the best. Such a flame serves as a means for 
lighting a candle or taper, when more light is wanted, or for seeing 
a clock or watch-face without risking the awakening of the pa- 
tient by scraping a match. A mistake is often made in keeping a 
sick-room too light during the hours of rest. 
Figure 259. — An 
■“ Etna-Lamp.” NURSING. 
807 
Champagne-tap.—A number of appliances are made, of which 
the adjoining figure illustrates one, whereby effervescent drinks— 
so often used by the sick—can be drawn in small quantities, and 
thus avoid wasting the greater portion of the contents of the bottle. 
Figure 260.—One form of “Champagne-tap ” which serves also as a corkscrew. The cross- 
piece acts as a stop-eock. 
Ice may be preserved, in small lumps, for a number of hours, 
and in such a way as to be available for use by the patient without 
assistance, by taking a glass, or bowl, covering it with a piece of 
clean flannel, and, after pushing the latter down into the glass so 
as to form a pouch, holding it in place by 
means of an India-rubber band or a cord. 
Into this pouch small lumps of ice can be 
put, and the whole must then be covered 
with several layers of flannel. In such a 
pocket, ice will keep, without melting, for 
a long time. When water has accumulated 
in the glass, so as to reach to the pouch, it 
must be poured off. 
To divide a lump of ice, notice the di- 
rection of the grain and then press the point 
of a large-headed shawl-pin steadily in that 
direction at the place where it is desired to separate it. In this way, 
with no noise or waste, and with little labor, a large cake may be 
easily split. To break ice into small fragments, enclose the lump 
to be broken in a coarse towel, and either pound it with a heavy 
object or strike it against a hearth or the marble top of a wash- 
stand. This will quickly mash it into fine pieces and avoid scatter- 
ing it about. 
Figure 261.—A glass ar- 
ranged for holding ice. 868 
NURSING. 
Catheters should always be thoroughly washed after they have 
been used, by letting water run through them. Care should be 
taken that there are no plugs of mucus or blood in the side-open- 
ings near the point. When they are to be used they should first 
be warmed and then greased with a finger dipped in oil, and not 
by dipping the catheter itself in oil, as this allows oil to enter it, 
and renders the urine greasy, so that it cannot afterward be ex- 
amined if desirable to do so. When a catheter is being withdrawn, 
cover the outer opening with the end of a finger. This prevents 
the entrance of air, or the dripping of urine from the lower end, 
and the wetting of the bed. A very convenient arrangement is 
the attachment of small India-rubber tubing to the catheter, so as 
to extend outside the bed-clothing and prevent all risk of wetting 
them or necessity of placing a vessel in the bed. 
Do not attempt to bend the ordinary yellow elastic catheters 
without warming them, and never use a catheter the tip of which 
is at all cracked or broken. It is always well to have a new cath- 
eter for every patient. 
Rubbing.—Among the accomplishments of a good nurse is the 
knowledge of how to rub a patient so as to relieve pain, dissipate 
swelling, increase the circulation of blood in paralyzed or cold 
limbs, loosen stiff joints, and exercise the muscles of the body gen- 
erally. The art of doing this cannot well be conveyed in print, 
but must be learned by practice. A general description of the 
methods is given, however, in Vol. I., in the chapter on Thera- 
peutics. 
Sponges are dangerous things to use about open wounds. For 
operations, where they are indispensable, they should always be 
new, and unless they have already been prepared, they should 
first be pounded to break up the chalky lumps which they often 
contain, and to dislodge the sand; then wash them thoroughly 
under a small stream of water and dry them. For cleaning sores, 
a stream of warm water to which carbolic acid has been added (a 
teaspoonful to two quarts of water), aided by small bunches of 
oakum or cotton-wool, are the best, as the latter can at once be 
destroyed. Sponges are apt to contain blood and matter in their 
interior, even after the most careful washing, and these, by putre- 
fying, convey poisonous matter to a wound when next used. 
Sponges used for the skin should occasionally be washed with a 
solution of ten grains of permanganate of potassium in a quart of 
hot water, rinsed in clean water, and hung by a string to dry in 
out-door air. 
Compresses are pads of cotton, tow, oakum, lint, or folded fab- 
ric, of various shapes, and adapted, in thickness, to the varying NURSING. 
869 
surface of the part to which they are to be applied as a means for 
exerting pressure. 
Laced Stockings.—When it is desirable, as in cases of en- 
larged veins of the leg, to apply pressure for a considerable time, 
elastic bandages, made after careful measurements, are most ser- 
Fig. 263. 
Fig. 262. 
Fig. 264. 
Figure 262.—Laced stocking for supporting enlarged veins of the leg. 
Figure 263.—A “reef-knot” properly tied. 
Figure 264.—The “ granny-knot,” or a square knot improperly tied. 
viceable. Very good results, however, can be had from bandages 
made of flannel in the shape desired, and lacing them at the side 
in the manner shown in the adjoining figure. 
Knots.—Occasionally it is necessary to assist a surgeon in tying 
a blood-vessel, and it will be well to know how to tie a square knot 
properly so that it will not slip. For this purpose the reef-knot 
and not the “ granny-knot ” should be made. In the former it will 
be seen that both ends of the thread pass over and under their re- 
spective loops, whereas in the “granny-knot,” the ends pass over 
and under alternately. 
Nausea, which almost always follows the inhalation of ether 
or chloroform, often continues for a number of hours, and may 
cause repeated vomiting. It may sometimes be controlled by 
swallowing small lumps of ice; by doses of a drop of tincture of 
ipecac in a teaspoonful of water, at intervals of ten or fifteen min- 
utes ; by a dose of twenty to thirty grains of bromide of potassium ; 
by a mustard poultice to the stomach ; or by taking a few mouth- 
fuls of solid food. Iced cream which has not a very decided 
flavor, sometimes controls it nicely. So does boiled corn-starch 
with a little cream. 870 
NURSING. 
Medicine Measures.—These are far better than spoons, owing 
to their greater accuracy. Even when the medicine has to be 
given with a spoon, it is better to measure it with a properly gradu- 
Fig. 365.—Medicine glass. 
Fig. 366.—Medicine glasses fitted to,a morocco case. 
ated glass. For small quantities a minim glass is necessary, while 
a two-ounce glass, graduated for drachms and ounces, will usually 
serve all other purposes. 
When spoons are used it is the custom to estimate that: 
One teaspoonful equals 1 drachm. 
One dessertspoonful equals 2 drachms. 
One tablespoonful equals | ounce. 
Dropping Medicine.—Although it is always desirable to meas- 
ure fluid medicines in a glass made for the purpose, especially in 
the case of such strong ones 
as are given in drops, it may 
sometimes be necessary to 
depend upon a less accurate 
method. A simple dropper 
that answers every purpose 
may be made of a little strip 
of soft, unglazed paper—like 
filter-paper, or even the clean 
edge of a newspaper. This 
may be about one-eighth of 
an inch wide and a couple of inches in length. Bend it to a right 
angle at its centre, and put one end into the neck of the vial. On 
tipping the vial the drops will run steadily from the outer end of 
the strip. 
Pills.—The reason for the difficulty which some persons meet 
Figure 367.—Contrivance for dropping medicine. ISTUKSING. 
871 
with in swallowing pills, lies in the fact that the pill is too small to 
be grasped by the upper part of the throat; by sticking to the side 
of the passage, it excites ineffectual efforts at swallowing, and 
these are followed by retching. All this will be avoided by en- 
closing the pill in some soft material, so as to form a mass like that 
of a morsel of food ; no trouble will then be experienced with it. 
Powders.—Unless they are of such disagreeable taste that they 
require to be mixed with something that will disguise it, powders 
can ordinarily be taken best by pouring them from 
a folded paper into the back of the throat, and then 
rinsing them down with cold water. In the case of 
bulky powders this may be troublesome, unless two 
or more portions be made of them. When the taste 
is disagreeable — as in the case of quinine — they 
may be wrapped in thin tissue-paper, or a wafer of 
rice-flour and milk—such as may be obtained of a 
druggist—or they may be enclosed in capsules of 
the same material, shaped like small watch-crystals, and cemented 
at their edges (also to be had of many druggists), or in jujube-paste 
capsules, like those shown in the adjoining figure. When a wafer 
is employed it may be managed as follows : 
Take a piece about one and one-half inches square and lay it on 
the bowl of a large tablespoon. Dip the spoon carefully into cold 
water so as to fill it, and wet the under side of the wafer only. 
Pour out the water and the wafer will sink into the hollow of the 
spoon. Place the powder to be enclosed into the centre of the 
wafer, and with the aid of a wet knife-blade fold over the sides of 
the wafer so as to enclose it, making gentle pressure with the 
blade on the folded ends so as to cause them to adhere. Fill the 
spoon again with water, and detach the wafer from the bottom, so 
that it will float freely. Insert the spoon well into the mouth and 
tip it up, and the water and wafer-packet will be swallowed with- 
out difficulty. 
When the jujube capsules are used, fill the long part, packing 
the powder with a small stick, if necessary, and put on the short 
part which forms a cover. See that the outside is wiped clean of 
the powder before it is given. These may also be taken with a 
spoonful of cold water. 
Suppositories may be introduced by having the patient lie on 
the side and then make an effort at bearing down. During such 
effort the suppository can readily be pushed into the bowel. Oc- 
casionally the presence of the suppository just within the opening 
of the bowel causes such discomfort that it may be expelled ; it is, 
then, desirable to pass it up a couple of inches. To enable this to 
Figure 268.—Me- 
dicine capsules of ju- 
jube-paste. 872 
NURSING. 
be done without discomfort, an instrument called a suppository- 
syringe is sometimes employed. 
Blisters.—Before applying a blister, the surface of the skin 
should be washed with soap, and rinsed, to free it completely from 
grease. Ordinarily, a blister will “draw” in about three hours ; 
but the length of time varies with different persons, and with the 
part to which it is applied. Lift the edge occasionally, and when 
the skin is seen to have risen and shows little bladders of fluid, 
take off the blister and put on a hot poultice if it is desired to draw 
away much fluid. The large sac of fluid which usually follows 
may then be snipped in various places with scissors, and the fluid 
be allowed to ooze away. The blistered surface should be covered 
with a rag or lint spread with vaseline, cosmoline or sweet oil, 
and care be taken that the skin is not further disturbed unless it 
is desired to have a sore place. 
Hot Stupes are only serviceable when they are applied as hot 
as can be borne. The best mode of doing this is to take a jack- 
(or roller) towel and put a broomstick or cane through each end of 
it. On it lay a flannel cloth folded to the form in which it is to be 
applied. Hold them over a dish and pour on boiling water until 
the flannel is soaked, then, by means of the sticks, twist the towel 
in opposite directions, and this will have the effect of wringing the 
flannel without risking scalded hands. When a roller clothes- 
is to be had, this will answer the same purpose. Put 
the hot flannel on as soon as possible, and cover thoroughly with 
several folds of some dry, woollen material. The effect of the 
stupe may be increased by sprinkling it with a teaspoonful or two 
of turpentine. 
Cold Applications.—When it is not convenient to apply ice to 
produce cold, as in a case of injury where it is necessary to avoid 
inflammation, cold water may be allowed to drip from a small hole 
in a suspended vessel of some sort. The surface on to which it 
falls should be covered with a piece of lint, and India-rubber 
cloth should be arranged so as to conduct the water away from the 
bed. If a very cold water is desirable, ice may be put into it. 
If the dropping of the water is a source of annoyance, a piece 
of lamp-wicking may be attached by one end to the opening, and 
the other laid on the surface to be kept wet. 
Liniments are commonly used either for the relief of pain seated 
within a limited space ; to relieve chronic inflammation, by caus- 
ing an irritation of the skin adjoining it; or to drive away a swell- 
ing. In the first instance aconite or some other benumbing agent 
is employed as a chief ingredient. In the second, the water of am- 
monia, tincture of cantharides or of capsicum, chloroform, oil of NURSING. 
873 
cloves, turpentine, etc., are used ; and in the latter, a greasy sub- 
stance that will prevent the skin becoming sore with the prolonged 
rubbing, is most desirable. 
The skin having been cleaned and dried, some of the liniment 
is to be poured on to it, and the ends of the fingers of one hand 
are to be firmly and slowly rubbed, with circular strokes, upon 
the part to be affected. When swelling is to be removed, the 
rubbing should always be from the extremities toward the body, 
as this helps to drive the blood and fluid out of the tissues. 
Sometimes, in feeble persons, oil is rubbed into the skin in the 
same way, as a nourishment. This should be done before a fire, 
when possible. 
Lotions are solutions of medicinal substances in water, or water 
and spirits, for external application. They are used solely for 
their local effect, as their ingredients are hardly likely to be ab- 
sorbed. Generally they are applied to inflamed surfaces either as 
astringents or to produce cold. Water, if allowed to evaporate, 
will accomplish the latter, but it must be applied with a single fold 
of loose-textured, coarse muslin or linen, which must be kept wet, 
and it may be best to have the water ice-cold. Vinegar and wa- 
ter, or alcohol and water, used with brown paper, accomplishes 
this latter purpose—viz. : cooling—and nothing more. 
Issues are made by inserting beads of wood or similar material 
into an open sore, so as to keep up a discharge of matter. They are 
rarely employed at the present day. 
Moxas.—Little cones of camphor or of nitre, mixed with some 
vegetable powder, placed on the skin and burned for the purpose 
of creating a sore. 
Cautery.—A very decided influence is sometimes required to be 
made upon the nerves of some part of the body, and to do this with 
less delay or pain than attends the use of a blister, a piece of iron 
attached to a handle is warmed to a white heat and applied lightly 
to the surface. The pain that attends the use of a white-hot iron 
is trivial compared to that caused by one which is only red-hot. 
Setons are not now used as often as formerly. They consist 
of a piece of tape, oakum or lint passed through the flesh, and the 
ends tied together outside the wound to prevent their displace- 
ment. Their use is to keep up a constant discharge of matter. 
Drainage-Tubes.—Not uncommonly, when death of a portion of 
a bone has taken place, and it is not expedient to remove it by op- 
eration, it is customary to insert into the sinus or canal which leads 
to it through the flesh, a piece of pure India-rubber tubing, that 
keeps the passage free for the discharge of fragments of dead bone ; 
or to pass a twisted strand of oakum down to the seat of the dis- 874 
NURSING. 
ease for the same purpose. Either of these measures are also em- 
ployed to allow a free discharge of matter from deep cavities 
caused by operations, or by the discharge of an abscess. 
Temperature, and the Use of a Thermometer. 
During health the temperature of the body is about 98.4° of 
Fahrenheit’s scale—that is, a little less than 98£°. This varies 
somewhat during the day, being the highest about nine o’clock in 
the forenoon, and lowest about three hours after midnight. This 
range of temperature, as it is termed, is not much affected by the 
habits of healthy persons, although there are slight modifications 
peculiar to various ages. Food does not ordinarily raise the body- 
heat, although hot drinks may do so temporarily. Hot baths of 
air or water may raise it as much as a degree or two, but it falls 
again at once when they are discontinued. Alcoholic drinks, quite 
contrary to the general belief, lower the temperature of the body. 
Exercise and mental excitement cause a slight temporary rise. 
The sense of touch, as conveyed by the hand, has ceased to be 
considered a reliable guide, since the temperature of the surface 
of the body exposed to the air may undergo considerable changes, 
owing to numerous circumstances, and the palms of the hands 
of a person coming from cool, outside air may convey an im- 
pression that the skin of an invalid is hot, when it is no warmer 
than natural. A dry skin often feels warmer than it really is, and 
a moist skin may convey a sense of coolness when the patient is 
really feverish. Ho physician of intelligence, therefore, places any 
reliance, as a rule, upon his sense of touch for information on this 
matter, but makes use of a thermometer which has been allowed 
to remain for at least five minutes in contact with some covered 
portion of the skin,—as an arm-pit or the fold of a groin—or which 
has been inserted for at least three minutes in the bowel, or four 
minutes in the mouth of a patient. The thermometer employed 
for this purpose differs only from that in ordinary use in having 
no metallic or wooden backing—the graduations being engraved on 
the glass itself; in its greater sensitiveness to impressions, owing 
to the fineness of the tube, and in being made to indicate variations 
only between the temperatures of 90° or 95° to 112° Fahr. These 
are called clinical or fever thermometers. It is now customary to 
use thermometers in which a detached thread of quicksilver re- 
mains in the tube, and which is left stationary when the metal 
recedes into the bulb as the thermometer cools. This is called the 
“index,” and its upper extremity, or that which is furthest from 875 
NURS1XG. 
the bulb, is the one which indicates the height to which the 
column of mercury has risen. 
In “taking the temperature” of a patient this “index” is 
shaken down until its upper end is about opposite the mark 
indicating 96°. An armpit is then wiped dry, and the bulb of 
the thermometer is placed so that when the arm is brought closely 
against the body, the upper end of the glass projects toward 
the front, and the mercury and the greater portion of the tube 
Figure 269.—Clinical thermometer. 
are entirely covered. After it lias remained in this position for 
five to seven minutes, it is to be carefully removed, and the height 
to which the mercury has risen, carefully noted. It is desirable to 
write down at once, on paper, the time when the observation 
was made, and the exact height to which the column of quicksil- 
ver ascended. 
When a thermometer is used in which there is no “ index,” it 
will obviously be necessary to note the position of the mercury 
before the instrument is removed from the armpit. 
When a person is notin bed, and the armpit is inaccessible 
without removing most of the bodv-clothing, the bulb of the ther- 
mometer may be placed under the tongue, on either side, and well 
back toward its root; the lips should then be closed about the 
glass, and it may be left, as before, for about five minutes. With 
infants, it is customary to insert the bulb of the instrument into 
the bowel, since it would often be difficult to make use of either of 
the above named places, owing to the restlessness of the child. 
This may be done with but little disturbance, and, indeed, without 
awakening them when sleeping. 
To read the indication it is necessary to know that it is cus- 
tomary to number only the marks indicating 95°, 100°, 105°, and 
110°. The intermediate degrees have long marks, and each of the 
spaces so created are subdivided by four shorter marks, thus form- 
ing five divisions representing fifths of a degree of Fahrenheit’s 
scale. Opposite the point of normal temperature it is customary 
to place a mark shaped like an arrow-head, for greater conven- 
ience of reference. 
The usefulness of the thermometer in domestic practice con- 
sists largely in the information it affords of the comparative grav- 
ity of an attack of illness. Children are almost always rendered 
more feverish by slight disturbances of health than are adults, but 876 
NURSING. 
among either, a persistence, for any considerable time, of a tem- 
perature of 100° should lead to consultation of a physician. When 
a person appears ill, and the use of a thermometer shows that the 
temperature has risen to 101° or upward, unless it can be accounted 
for by an attack of indigestion, diarrhoea from some cause, or a 
catarrhal cold, etc., there is a probability that some acute disease 
is impending. The same may be said of a corresponding fall of 
the temperature two or three degrees below the normal point (98f°). 
After an ordinary attack of illness, such as ague and fever, if the 
temperature remains higher than natural, although the symptoms 
of the disease have otherwise disappeared and the patient may 
feel comparatively well, recovery is not perfect and suitable pre- 
cautions should continue to be taken. 
Another way in which the thermometer may render service in 
cases of illness, is, in noting for future reference the variations 
which the temperature undergoes at certain hours of the day and 
night. In many diseases these variations are markedly charac- 
teristic, and by their inspection alone, a physician may some- 
times tell, with great certainty, the nature of the malady. The 
“range” of temperature, in a typical case of typhoid, lias been 
illustrated in the chapter on Acute Infectious Diseases (page 25), 
and the diagram there shown is such as is ordinarily employed by 
physicians. It is not necessary, however, that .this mode of re- 
cording it should be followed; all that is essential is to note the 
day of the month, the time of the day, and the exact temperature 
at that time. 
It is rare for the temperature to exceed 106°, or to fall below 96° 
Fahr. 
Other Signs of Disease have been mentioned with sufficient 
fulness in the first volume of this work. These should be studied 
by all nurses, and they should also acquire the ability to count the 
pulse at the wrist, and the number of respirations per minute. 
These should be written down at once, in some such way as the 
following (T. standing for temperature, P. for pulse, and R. for 
respirations): 
T. 
P. 
R. 
April 25th.—7.45 a.m.— 102i° 
96 
28 
12 m.— 102° 
92 
26 — etc. 
Reports.—A nurse can often render great service by acquiring the 
habit of always noting on paper the various occurrences of the sick- 
room at the time when they take place. Following the doctor’s 
visit she should accompany him to another room after he has seen 
the patient, and receive from him explicit instructions regarding NURSING. 
877 
what is to be done or noted during the interval that precedes his 
next visit. These instructions should be written out at the time, 
and should be followed as closely as the circumstances of the case 
will permit. At the next visit of the doctor he should have an op- 
portunity before entering the patient’s room, to see, written out, 
the nurse’s observations. 
Such a “log,” as a sailor would call it, should have a column 
ruled off at the left margin of the paper for noting the time of the 
observations; and the latter should embrace all such matters of 
information as : the amount and character of sleep ; cough; pain; 
fever, as measured by a thermometer; restlessness ; vomiting, or 
movements of the bowels and their character; urine; perspira- 
tion ; food taken (specifying how much); medicine administered ; 
visits of friends or others—in fact, whatever may relate to the case. 
To keep such a memorandum well, so as to include that which 
is really valuable and leave out other things, requires skill and 
practice. It is better, for a beginner, to have the report too full 
than too scanty. 
Operations. 
It is not usual for operations to be made without some previous 
arrangement on the part of the surgeon as to the time, etc. He 
then directs what he would like to have provided. For nearly all 
operations of any importance the following arrangements may, 
however, be useful. If the patient is in bed, select an adjoining 
room for the operation. Have the temperature about 70° Fahr., and 
in front of a window place a table—an ordinary small kitchen table 
may answer if it is long enough, if not, a broad board resting upon 
secure supports. Under the end toward the window, or at the 
side on which the operation is to be made, protect the carpet with 
a square of India-rubber cloth from blood and the slopping of 
water. Fold a blanket and lay it on the table, and over it spread 
another piece of rubber cloth, or a sheet folded two or three times. 
Provide a small, firm pillow for the patient’s head ; a clean, empty 
bucket to receive blood and water from the sponges; an empty 
basin of some kind to use in case the patient vomits ; a wash-bowl 
and pitcher of cold water ; soap ; a bucket or large pitcher of hot 
water ; a plenty of clean towels ; two or three sheets that the opera- 
tor and his assistant (if one is needed) can pin about them to keep 
their clothes clean, and to cover the patient with during the opera- 
tion ; one or two empty buckets for dirty water ; a few ounces of 
brandy, and some spirits of ammonia ; a fan ; ice ; an extra wool- 
len blanket in which to wrap the patient; a piece of strong, brown 
paper with which to make an ether-cone (if needed); pins; a couple 878 
NURSING. 
of needles threaded with strong, white cotton, and a straight-sided 
tin dish to hold water for warming adhesive plasters. The latter 
need not be brought until toward the end of the operation, as the 
water needs to be boiling. A small stand is desirable for holding 
instruments, and so are one or two firm chairs that are not uphol- 
stered. A large sponge may be useful in wiping up any “ muss.” 
A quantity of clean, soft cotton-wadding, and an old sheet that can 
he torn up for bandages, are often desirable. 
It is customary to place a patient under ether before removal 
from the bed to the operating room, and for extra assistants 
to remain out of the room until the anaesthetic has rendered the 
patient unconscious of their presence. They should also retire, 
unless their presence is needed, before consciousness returns. 
In preparing a patient for an operation, it is customary to 
empty the bowel with a dose of some medicine taken the night 
before, followed by an enema of warm soap-water in the morn- 
ing. When an ansesthetic is used, no food whatever should 
be taken for at least four or five hours before, and it is better to 
allow only a very light breakfast of tea or coffee, and bread and 
butter ; anything more than this should he ordered by the doctor. 
It is better not to disturb the patient by loosening bandages or 
other dressings before the operation, as this can be done with 
greater comfort and ease after the anaesthetic has been taken. 
Have the bed properly made while the operation is being per- 
formed, and put a foot-warmer, or a couple of well-corked bottles 
of hot water in the bed, and cover them up, so that it will he 
warmed. Protect the mattress by means of a rubber sheet, and 
lay a folded draw-sheet on the lower sheet, for the patient to lie 
on and to catch discharges. 
Caring for the Dying and Dead. 
Contrary to the general belief, death usually takes place with- 
out consciousness of suffering. Not unfrequently pain, distressful 
want of breath, convulsions, and restlessness cease as the end ap- 
proaches, and although spasmodic movements of the muscles of 
respiration may sometimes occur, they are not usually attended 
with corresponding suffering. Even to the last the effort should 
be made to administer a few drops, if no more, of food or stimu- 
lants, and a little cloth attached firmly to a pencil, or similar 
piece of wood, may be used to clear the invalid’s mouth of mucus 
when strength is so far gone as to prevent him doing it for himself; 
or a soft napkin wrapped about the end of a finger, or twisted into 
a cone, may serve the same purpose. Dryness of the mouth is NURSING. 
879 
often the most distressing symptom, and lemon-j uice with water, 
or a little vinegar with water, may be used to moisten it. Keep 
the limbs warm with hot bottles, raise the head and shoulders 
slightly on pillows if breathing appears difficult, use a fan to sup- 
ply an abundance of fresh air, and, if necessary, open a window. 
Keep the room quiet, and do not allow strangers to be present un- 
less it has been specially requested by members of the family or 
by the invalid. 
The end oftentimes approaches so gradually that it is difficult 
to tell the moment of death. The breathing becomes slower and 
slower. Each breath is attended with a raising of the chest, and, 
it may be, with a deep sigh, and at last they cease entirely. 
A hand placed over the heart will detect pulsations for some 
time after they cease to be felt at the wrist. 
After life has passed away, clear the room of those who are not 
needed to arrange the body, and carry out all articles used about 
the patient that are not wanted, fold a small sheet into the form of 
a diaper, and pin it about the hips, and with a folded napkin or 
handkerchief tied over the head, hold the lower jaw closed. Care- 
fully wash and dry the entire surface, and remove the body from 
the bed to a board, like an ironing-board, covered with a folded 
sheet, or to a table, in the case of an infant. Fasten the feet to- 
gether with a napkin, place the hands in an easy position, and 
cover with a clean sheet. Open a window so as to cool the room, 
and take out all the clothing, bedding, towels, etc., used about 
the patient. 
Unless the weather is very warm, a corpse will keep for two or 
three days without the aid of ice. Undertakers generally insist 
that this precaution is necessary, but quite unjustifiably in most 
cases. In cold weather and in a cold room a corpse will sometimes 
be well preserved for more than a week. An exception to this oc- 
curs when death follows certain forms of blood-poisoning, in which 
decomposition seems almost to have set in before • death. For 
many hours after death the body retains its warmth. Sometimes 
this is excessive, and is due to chemical changes in the tissues. 
In nearly all cases, at a variable period after death, the muscles 
of the body become rigid and the joints stiffened. The rapidity 
with which this rigor mortis takes place varies with the cause of 
death and the state of the body at the time, but its occurrence is 
a pretty sure sign that death is real and not apparent. After de- 
composition has set in it disappears. When this shrinking of the 
muscles occurs, the skin also contracts, and hairs, like those of the 
beard, protrude further from their follicles or sheaths. This has 
given rise to the popular belief that the hair may continue to grow 880 
NURSING. 
long after death has taken place. It is better, for this reason, to 
defer the shaving of the face for a day or two in order that this 
contraction of the skin may be complete. 
When death follows interference with breathing, and the lips, 
ears, and cheeks have acquired a bluish and dusky color, their 
natural hue may be soon restored by keeping the face covered 
with a muslin cloth wet with a solution of an ounce of saltpetre in 
a pint of cold water. DIET AND THE PREPARATION OP 
FOOD FOR THE SICK. 
While properly the word diet includes in its meaning all food 
or victuals, it is, in the more restricted sense, of that only which 
is taken in the prevention and cure of disease, that we have to do 
in this work. 
It was formerly a general practice to treat patients by depriving 
them almost entirely of food, in addition to blood-letting and the 
administration of physic. Happily, this method of treatment has 
been almost wholly discarded, and, as we believe, a much more 
rational one has taken its place. A sick person, as a rule, neither 
eats nor desires to eat as much as when in full health, but it by no 
means follows that because he is sick he must not be fed; for 
proper food is oftentimes more essential than medicines. Even 
those who are seriously ill should not, in this respect, be neglected. 
In such cases, articles of food which are stimulating, or contain 
nourishment in a concentrated form, may be used with the greatest 
possible benefit. 
Among such articles may be enumerated milk, essence of beef, 
and beef-tea. Irritable stomachs will usually retain small quantities 
of these articles, given regularly and at short intervals, when they 
will reject a large quantity of any food that can be offered. Beef- 
tea and the essence of beef, however, are chiefly useful as stimu- 
lants, and contain only a very small amount of nutritive material. 
Milk and gruels are far more nutritious than these, and should not 
be displaced by them. Milk may be given to a patient with safety 
under any circumstances. If there is undue acidity of the stom- 
ach, the digestion of the milk may be aided by the addition of the 
time-honored liquid, lime-water, in the proportion of one table- 
spoonful to four or six of milk. Sometimes it can be taken and 
retained only in very small quantities—for example, a teaspoonful 
every ten or fifteen minutes—but such small doses may save the 
patient’s life. 882 
DIET EOR THE SICK. 
When the stomach absolutely and persistently rejects all forms 
of food, the system can be sustained for a long time by the use of 
nutritious injections consisting of milk, eggs, and other articles. 
Attention has recently been directed to the very remarkable 
value of the blood of animals, when used as a food and given by 
injection into the bowel. To use it in this manner, the blood 
should be stirred with a stick or with a whisp of broom-corn until 
all the fibrin, or clot, is removed, and then strained through a 
coarse towel, or something similar, to get rid of any small clots 
that may remain, and which might choke the nozzle of the injec- 
tion syringe. It should be warmed to a temperature of 100° to 103° 
Fahr. just before it is used and, for an adult, four ounces or a tea- 
cupful is quite sufficient, while less may answer. This may be re- 
peated at intervals of six hours, or even twice in the twenty-four 
hours. A larger quantity is liable to be expelled from the bowel. 
The blood of calves or sheep may be used when beef-blood is not 
to be had. 
Children, especially, are apt to be very thirsty when suffering 
with fevers. Small bits of ice are useful in satisfying them when 
old enough not to swallow them entire, and at the same time will 
prevent their taking too much water.* 
It is very important to see that such children, too young to 
make their wants known, are properly supplied with water. To 
illustrate this point we will relate a case : A child was moderately 
sick with scarlet fever, and one day, without assignable cause, its 
fever greatly increased. The child had a general look of anxiety, 
and frequently threw up its hands as though it wanted something. 
The mother finally thought that the baby wanted water, and when 
a gobletful was brought and put to its lips, the child seized it so 
firmly that it could not be withdrawn until the entire gobletful 
had been swallowed. Within twenty minutes the fever almost 
disappeared, and with a subsequent regular supply of drinking- 
water the case went on to convalescence without any more sudden 
and alarming changes. Water may be given to nursing babies 
without harm. 
Tea is a stimulant, and is very grateful to most sick persons. 
It may be prepared to suit the taste of the patient, unless quite ill. 
The ease with which food is digested is materially affected by 
the manner in which it is prepared. Cooking appears to lessen 
cohesion, and to so change the character of most substances as to 
make them more easy of mastication, and of being afterward di- 
gested. 
* See chapter on Nursing for a contrivance for keeping broken ice in a sick room. 883 
DIET FCK THE SICK. 
The digestibility of meat stands in some proportion to its ten- 
derness, and tenderness and digestibility are said to be much influ- 
enced by circumstances previous to cooking; for instance, flesh, 
whether of fish, fowl, or animal, if cooked immediately after 
death, before it has become stiff, is much more tender and easy of 
digestion than when it has been kept until the stiffening of the 
muscles has taken place. When this rigor mo7'tis, as it is called, 
has occurred, meat, poultry, and game should be allowed to 
hang in a dark and cool place for a number of days, when they 
will again become tender and juicy, and their flavor will be then 
improved by cooking. Fish, however, is never so good as when it 
is the freshest. The flesh of animals which have been driven or 
hunted just prior to being killed is rendered more tender thereby. 
Vegetables, in cooking, become softened, and their structure 
more or less loosened, so as to be readily mashed in the mouth 
and to permit the penetration of the juices of the stomach into 
their substance. Hard water has less of this useful effect than 
soft, and when salt is added to the water in which vegetables are 
boiling to preserve their color, as is often done, the eye is pleased 
at the sacrifice of tenderness. 
The modes of cooking in common use are baking or roasting, 
broiling, stewing, boiling, and frying. 
Baking or roasting.—Strictly speaking, very little roasting is 
done in this country, baking in a close oven almost wholly taking 
its place. This latter process, however, is commonly termed roast- 
ing, and is here specially treated of. In baking, the empyreumatic 
products are mainly retained, and the meat is thus rendered richer 
and stronger than by any other process of cooking. The operation 
being carried on in a confined space, the volatile fatty acids gener- 
ated are prevented from escaping, and thus permeate the cooking 
articles. Meat prepared in this way is not well adapted for deli- 
cate persons, or for those who suffer from indigestion. 
Broiling, properly performed, produces the same effect as roast- 
ing, and while the hardened surface-fibre is greater, on account of 
the relatively larger surface exposed to the fire, the natural juices 
of the meat are in a great measure retained. If the hard and 
scorched outside is carefully cut off, the appetizing juicy interior 
is in the most favorable condition for invalids, and for easy diges- 
tibility. 
Stewing.—In this process the meat is usually cut up into com- 
paratively small pieces and simmered, rather than boiled, in a small 
quantity of water. The juices and other portions which escape 
are not lost, but mingle with the water and form a thick gravy 
which is commonly served with the meat. Stewing, therefore, is 884 
DIET FOR THE SICK. 
a healthful and nutritious way of preparing food. If, however, 
boiling be allowed to occur the meat becomes tough and hard. 
By surrounding with water the vessel which contains the meat 
to be cooked, it may be stewed in its own vapor. For example, 
a chop or other small piece of meat may be placed in an ordinary 
preserve jar, with a piece of cloth tied over the top, and partially 
immersed in water. The water is made to simmer or gently boil, 
and in due time the meat is found perfectly soft and tender, and 
surrounded by a liquor composed of the juice which has escaped 
during the process. Meat thus prepared is in an exceedingly suit- 
able state for the sick and the convalescent. 
Hashing is the same process applied to previously cooked, in- 
stead of to fresh meat. 
Boiling.—If the object to be attained by boiling is to impart to 
the surrounding liquid the goodness of the meat, as in making 
broths, soups, etc., the article used is first cut up into small bits 
and soaked in cold water for a short time. Heat should be gradu- 
ally applied. If for soups, prolonged boiling is necessary in order 
fully to extract the gelatine, which, in fact, forms the basis of all 
soups. Thus treated, the nutritious portions of the meat, as far as 
possible, pass out into the water, and as this gains in strength of 
flavor and nutritive properties, the meat becomes impoverished 
and a hard fibrous residue is formed, insipid and of little value as 
food. When, however, it is desirable that the meat should retain 
its flavor and nutritive properties, it is to be plunged suddenly into 
boiling water and the process of boiling briskly maintained for 
five or ten minutes. This coagulates the albuminous matter upon 
the surface and forms a more or less impermeable external layer 
which serves to retain the juices. After this has been done it 
should gently simmer only, until fully cooked. Boiled in this 
manner, the interior part of the meat remains juicy and tender, 
and is in the highest degree nutritious and digestible. Brisk boil- 
ing throughout renders the fibre of meat tough and strong, and 
proportionably indigestible. 
Fish, boiled in sea-water, or water to which salt has been added, 
is considered more highly flavored, and is more firm than when 
boiled in soft water. Food, when boiled, is more insipid than 
when cooked in other ways. 
Frying is an objectionable way of cooking for persons having 
weak digestion. The meaning of the word frying is somewhat 
different in this country and in Europe. The method of cooking 
in a shallow dish and with a small amount of fat, here called 
frying, is the French saute; while in Europe saying that food 
is fried, means that it has been placed into a vessel containing DIET FOR THE SICK. 
885 
enough boiling fat to entirely cover the article. In the latter case 
the effect of the intense heat of the fat is, in a measure, to seal up 
the surface of the meat, and to both prevent the escape of its 
juices and the entrance of the fat by which it is surrounded. Ar- 
ticles of food prepared by frying become, however, more or less 
penetrated with fatty matter, which causes it to resist, to a greater 
extent than otherwise, the solvent action of the gastric juices. 
It is apt, also, to be impregnated with the products arising from 
the decomposition of the fat or oil used in cooking. These are 
badly tolerated by the stomach, and may give rise to the gastric 
trouble known as heartburn. 
The loss of weight in cooking beef and mutton is about as fol- 
lows : A piece of beef weighing ten pounds, will lose, in boiling, 
two pounds ; in roasting, three pounds. A piece of mutton weigh- 
ing ten pounds will lose two pounds in boiling, and three and a 
half pounds in roasting. This loss is mainly composed of the 
water contained in the substance of the meat, but some of the 
nutritive materials may also escape. 
Rules to be Observed in Feeding the Sick—Appearance 
of Food, etc. 
Those who are in health are more or less attracted, or repelled, 
by the appearance of the food set before them, the manner in 
which it is served, etc., and the sick are often even more sensitive 
in this particular. The plate or bowl in which food is presented 
should be scrupulously clean, and its contents neatly placed. Al- 
ways thoroughly cleanse the cups, dishes and spoons used by sick 
persons, especially such as may have contained milk or anything 
which has a tendency to become sour. 
A quantity of food, enough, and perhaps more than sufficient 
for a well person, will hardly fail to produce aversion and even 
nausea in one who is ill. A small amount, repeated, if desired, is 
more acceptable. Sometimes those who are only moderately sick 
will feel repelled from an otherwise acceptable dish, if the food re- 
quires any exertion to prepare it for eating. It is well, therefore, 
to consult them in advance as to whether they would not like to 
have the meat cut neatly for them, the potato mashed, the milk- 
toast divided into nice little squares, etc. 
Food not taken, or, when a part only has been used, should not 
be left by the patient’s side, or in sight, for several hours. It is 
rarely touched again, and may excite a disinclination to eat at all. 
Remove it after a few minutes, and if a desire is afterward ex- 
pressed to try it, or to eat more, it is best to put it upon a clean 886 
DIET FOR THE SICK. 
plate or bowl, and make it appear as if freshly prepared. If it has 
been warm or hot, see that it is made so again before offering it, 
or make another portion if necessary. It is always unpleasant to 
have food which should be served hot, presented nearly cold, and 
in sickness it is enough to effectually drive away any inclination 
to eat. 
Small quantities.—While it is improper to unduly compel pa- 
tients to take food, it is sometimes necessary that they should 
swallow more than inclination prompts, and in such cases small 
quantities at a time is the rule. Frequently, when a wineglassful 
of beef-tea or milk cannot be taken at once, a tablespoonful every 
half-hour will accomplish the same results, with the added advan- 
tage that with such a quantity a weakened stomach is more likety 
to perform its work properly. 
Appetite should not be expected in sick persons, especially if 
they are fed frequently. Its absence may be considered as evi- 
dence of imperfect digestion. It is the duty of the nurse to dis- 
cover, and properly present that which in each case appears to be 
best adapted to the changed condition of the body and mind. 
Undue force should not be used to make patients eat, under the 
mistaken idea that if they can only get the food down, it will do 
good, for, unless it can be properly digested, it is far more likely to 
injure them than to do them good. Judicious persuasion may be 
employed, but it should not be forgotten that unless food is ac- 
ceptable it may produce such an aversion as to render it abso- 
lutely impossible to swallow. Endeavor to stimulate the appetite 
by making whatever is offered pleasing to the eye and agreeable 
to the senses of smell and taste. Avoid the too frequent error of 
restricting the diet to one or two articles, but give as much variety 
as is consistent w*ith the nature of the disease. 
Food at night.—Do not allow the sick to become exhausted by 
permitting too long intervals to occur between the times of giving 
their food during the night. It is commonly a good rule to give 
something to eat the last thing before they settle down for the 
night; it will help to support them and prevent too great weak- 
ness in the morning. 
Food in the morning.—The early morning is the time when the 
sick are most feeble ; and at that hour they have less desire and 
strength to take food ; something to drink should then be given, 
such as milk, or warm gruel or porridge, which will take the place 
of more solid food, that will be better relished after nine or ten 
o’clock. 
Food and sleep.—While sleep is sometimes of more importance 
than food (and great care should be taken not to awaken the sick DIET FOR THE SICK. 
887 
unnecessarily) it should be remembered that the critically sick 
require food as well as sleep ; and that from lack of it, they some- 
times sink away and die, when, if they had been roused and had 
received food, they might have lived. 
Insensible and delirious persons may be fed by first attracting 
their attention as much as possible, then putting the spoon to their 
lips and pressing down upon it, gently moving it back and forth 
until the lips instinctively separate, as they usually do, and then 
passing the spoon well into the mouth and emptying it slowly. 
Diet for the Critically Sick. 
By critically sick are meant those who are so extremely ill, or 
so prostrated from any cause, that their recovery is doubtful. In 
such cases, one of the highest authorities says : “When life seems 
passing away under their eyes, the friends will often shrink from 
tormenting (as it seems to them) the sick man with food. Let 
them not despair; many a one has recovered after the doctor has 
taken his leave with a sad shake of the head, and without making 
a fresh appointment.” * 
Gently and firmly, with soothing words of loving encourage- 
ment, the very sick should be induced to swallow some supporting 
food to the very end ; its character, in such cases, must be mainly 
stimulating. It is best to give food of this kind in small quanti- 
ties, from a tablespoonful to a 
wineglassful at a time, and at in- 
tervals of half an hour or more, as 
the state of the patient may seem 
to demand. Persons who are very 
weak should never be obliged to 
sit up to take their food. Cups 
with one side drawn out so as to 
form a spout, and partially cov- 
ered, are made, and may be had 
at the drug stores in cities and the larger towns (Fig. 270), as 
may also drinking-tubes, made either of glass bent at an angle to 
facilitate its use (Fig. 271), or partly of glass and partly of rubber 
(Fig. 272) ; the former is best, as it is not easy to keep the rubber 
tube clean. When these cannot be obtained, the tube from a 
baby’s nursing bottle will answer. In choosing glass tubes for 
this purpose, get those which have an inside diameter of about 
figure 270.—Cup with mouth-piece for 
administering food or drink to an invalid. 
* Thos. King Chambers, M.D., in Diet in Health and Disease, p. 235. 888 
DIET FOR THE SICK. 
one-quarter of an inch. When they are smaller, they are apt to 
become clogged, and the patient becomes exhausted with the 
Figure 271.—Glass tube for the same pur- 
pose. 
Figure 272.—A tube of india-rubber and 
glass, having a metal clip for attaching it to the 
edge of a glass or cup, so that an invalid may 
drink without holding the latter. 
effort to draw through them as much as he requires, and thus 
takes less than he otherwise would do. 
Diet for the Sick and Convalescent. 
In administering food to the sick it would be absurd to attempt 
to follow any scientifically prepared rules, or dietary scales; the 
trouble usually is to get them to eat at all. Their tastes and preju- 
dices must he consulted and humored, so far as consistent with 
their condition. Common-sense must be employed in selecting a 
variety of food, and if what is given is relished, and no harm 
seems to come from its use, it will probably do good. 
When patients begin to recover, they are often fastidious and 
hard to please. So far as reasonable, their desires for special kinds 
of food should be gratified, always restricting them at first, how- 
ever, to moderate quantities at a time. During sickness the appe- 
tite is almost or wholly lost, and when it begins to return it should 
be encouraged by longer and more nearly natural intervals be- 
tween times for eating. A greater variety of dishes becomes 
available at one time or another, and should be made use of. 
In selecting from the number of recipes which follow, it must 
be observed, that while any of them may be used in the various DIET EOR THE SICK. 
889 
stages of convalescence, those most suitable for ordinary cases of 
sickness come first in the list, progressing from forms of fluid 
food, which may be used in extreme cases, to those which are 
suitable for the nearly well. 
Concentrated Meat-juice. 
Take half a pound of lean meat, cut it finely, and put it into a preserve-jar, with 
two tablespoonfuls of cold water and a very little salt. Cover the jar with a saucer 
(right side uppermost) and then place it in a saucepan containing a small quantity of 
boiling water. Place the saucepan on a fire, and keep the water boiling for two hours. 
Then remove the jar, and press the meat out of the fluid, which should be set aside 
until it gets cold, when the fat can be skimmed from the surface. If a double sauce- 
pan is among your kitchen utensils, it will answer admirably in preparing this concen- 
trated food. 
Brandy Mixture. 
Take four ounces (about eight tablespoonfuls) of brandy, the same quantity of cinna- 
mon water, the yelks of two eggs, and a heaping tablespoonful of white sugar, or more, 
to suit the taste. Rub the yelks of the eggs and the sugar together, and add the cinna- 
mon water and then the brandy, mixing them well together. To be given in doses of 
from two to four tablespoonfuls as a restorative and stimulant. 
Take a piece of rump or round steak, as large as the palm of the hand and about half 
an inch thick. Heat a frying-pan very hot and lay the beef upon it for a few seconds, 
and then turn it. Do not let it brown, but simply heat it through. Then, with a lemon- 
squeezer, press the juice into a hot cup and season with salt. 
Essence of Beef. 
Beef-Tea. 
Take a pound of beef from which all the fat has been removed. Cut it into very small 
pieces and put it into a preserve-jar with half a pint of cold water. Cover the jar and 
let it stand by the fire for an hour. Then place it in a pot containing enough hot water 
to rise to the same level with the meat and water inside the jar. Put the pot on the 
fire and let it simmer (not boil) at least three hours. As the water in the pot evaporates 
add more. Strain the broth through flannel, and season with pepper and salt to suit the 
taste. If only a very little beef-tea is required at a time, strain what is wanted and set 
the jar back into the pot of hot water, and keep it warm. 
Beef-Tea, Another Method. 
Take one pound of raw beef, minced, for each pint of water. Stir, while cold, and 
let it stand one hour. Then place the vessel in which they are mixed in a pan of water 
and let them simmer for another hour over a slow fire. If allowed to boil it becomes 
gluey, and is not equally nutritious or digestible. Strain the tea through a coarse strainer, 
and flavor at discretion. 
Egg and Milk. 
Take a fresh egg, beat it up with a very little salt, and pour into it a pint of boiling 
milk, being careful to stir it all the time. This is to be taken hot. 890 
DIET FOR TIIE SICK. 
Beat up the yelk of one or more eggs perfectly ; scald a glassful or more, as required, 
of port or white wine, and melt in it a lump or two of sugar. Stir the egg rapidly one way, 
never changing the direction of the spoon, and keep stirring while you pour in the wine 
very gradually. Have another glass or basin ready, and pour the mixture quickly, two 
or three times, from one vessel to the other, which process makes it froth. 
To Mull Wine. 
Put an ounce of fine gum, two ounces of sugar, and a pint of water, into a jar, and 
then set it in a saucepan of hot water, and stir occasionally until the gum is dissolved. 
This is very useful as a night drink for cough, and will allay tickling in the throat. It 
should be kept as hot as possible. 
Gum-Arabic Water. 
Dissolve an ounce of the best gum-Arabic in two pints of cold water, and flavor with 
lemon-peel. 
Another. 
Toast and Water. 
Cut a slice of bread, and toast it to a rich brown color, without burning it. Put it 
into a jug with a thin slice of lemon, or a little nutmeg, and pour on it a quart of boil- 
ing water. When cold, strain it. 
To three-quarters of a pint of warm water add two tablespoonfuls of flaxseed, and 
allow it to stand for one or two hours, then strain, sweeten, and add lemon-juice to 
taste. This is a good drink in case of sore throat. 
Flaxseed and Lemonade. 
Gelatinized Milk. 
Dissolve a quarter of an ounce of gelatin in a quarter of a pint of boiling water; add 
to it a pint of hot milk; then put in two or three drops of essence of lemon or almonds, 
and sweeten to taste. 
Flaxseed Tea. 
Whole flaxseed, one ounce; white sugar, one ounce ; liquorice-root, half an ounce ; 
lemon-juice, four tablespoonfuls. Pour on the materials two pints of boiling water, let 
them stand in a hot place four hours, and then strain off the liquor. 
Do not give this to patients taking medicines containing lead, iron, or copper. 
Barley Water. 
Take two ounces of pearl barley. Wash it with a little cold water, and strain. Then 
pour on it a pint of boiling water, and boil for a quarter of an hour; strain again, and 
throw away the water. Now pour on the barley two quarts of boiling water, and boil 
them down to one quart. Do not strain it, unless at the patient’s request; it may be 
taken hot or cold. It may be sweetened if preferred, and any flavoring may be added. 
A piece of orange-peel may be boiled in the water, or some flavoring essence added after- 
ward. If lemon-juice be added, it forms a capital cooling drink. 
Barley Gruel. 
Take two ounces of pearl barley, wash in clean cold water, then boil it for five min- 
utes in a pint of water. Pour this water away, and put a quart of boiling water to 
the barley; let it boil for three hours, strain, and flavor to suit the taste; if that of 
lemon-peel is desired, cut it very thinly, and soak for ten minutes in enough cold water 891 
DIET FOR THE SICK. 
to cover it; stir the liquid into the barley gruel. Equal quantities of milk and barley 
gruel make a very nourishing drink, especially useful in feverish cases. Barley gruel 
should not be mixed with milk or syrup before required for use, as in a warm atmosphere 
it undergoes changes, and sometimes slightly ferments. 
Oatmeal Water. 
Put a large tablespoonful of coarse oatmeal into a jug, pour over it a pint of cold 
water. Stir it well, allow it to stand until the oatmeal has settled at the bottom of the 
jug, then strain and use the water, either as a remedy for thirst or to make lemonade, 
to which it imparts a slight amount of nourishment. 
Rice Water. 
Wash two ounces of best rice, and boil it fast for half an hour in three pints of 
water. Any flavoring may be added, or a small piece of stick cinnamon or shred lemon- 
peel may be boiled with the rice, and sugar used, according to circumstances. Strain, 
and put the water aside to get cold * 
Beat the white and yelk of one egg together for five minutes, addding a small quan- 
tity of sifted sugar and a cup of warm or cold milk. To this may be added a small quan- 
tity of wine or brandy, and a grated nutmeg. If milk is not desired, beat the egg and 
sugar together, and add a little wine only. 
A Plain Egg-Nogg. 
Best French brandy, four ounces ; cinnamon water, four ounces ; yelks of two eggs ; 
sugar, of each, half an ounce. Rub the sugar and egg-yelks together, then add the rest. 
Egg Nogg of the British Pharmacopoeia. 
White Wine Whey. 
White wine whey is made by adding a wineglassful of sherry to half a pint of boiling 
milk, and straining the mixture through a fine sieve. Sweeten the whey to suit the 
taste. The curds should not be used. 
Procure a piece of rennet (the stomach of the calf) from the butcher, place a small 
portion of it in a cup of hot water, and allow it to remain for four or five hours. Pour 
the liquid into a quart of milk, and let it stand till the curd appears. Then strain and 
use the whey, having sweetened it to suit the taste. 
Rennet Whey. 
Put two ounces of sago into a quart of water, and boil until a mucilage is formed. 
Then take half a teaspoonful of essence of lemon, a teaspoonful of essence of ginger, 
and half a pint of sherry wine ; mix and add this to the sago mucilage, and boil the 
whole for five minutes. 
This is an excellent cordial where acute diseases, not of an inflammatory kind, have 
left the patient in a state of great debility. A large wineglassful may be taken at one 
time, at intervals of four and five hours. 
Sago Posset. 
Take an ounce of fresh suet, cut into small pieces, and tie them loosely in a muslin 
bag ; boil this in a quart of cow’s milk, and sweetened with a quarter of an ounce of 
white sugar. 
This is an excellent article of diet in scrofulous emaciation, and in the later stages of 
pulmonary consumption. 
Artificial Goat’s Milk. 892 
DIET FOR THE SICK. 
Take half an ounce of bruised mustard seeds, and one pint of milk; boil them to- 
gether until the milk is curdled, and strain to separate the whey. A teacupful at a time 
may be taken. 
This whey has been found to be a useful drink in dropsy ; it stimulates the kidneys, 
and consequently augments the urinary secretions. 
Mustard Whey. 
Aromatic Barley Wine. 
Take a quart of barley-water, and boil it down one-third ; add to it, while it is hot, a 
pint of sherry wine, a teaspoonful of essence of cinnamon, and an ounce of sugar. A 
wineglassful, two or three times a day, is a good cordial in convalescence attended with 
much debility. 
Toast and Wine. 
Take a slice of nicely toasted bread; break it into small pieces and put in a bowl; 
pour over it rather more than enough water to soak it; sweeten and flavor with nutmeg 
and wine. 
An old-fashioned dish, rarely well made. Put stale bread into a bowl, the pieces of 
of equal size, the shape of dice, but larger. Boil some milk, and the moment it rises 
pour it over the bread; cover the bowl close with a plate for ten minutes; the bread 
will then be perfectly and equally soaked. Add a little salt, or sugar, to taste. 
Plain Boiled Milk and Bread. 
Flour Caudle or Thick Milk. 
Put a large spoonful of flour into about five spoonfuls of cold water, and mix thor- 
oughly ; heat five spoonfuls of fresh milk, slightly sweeten, and, when boiling, pour it 
gradually over the flour and water ; put it on the fire and boil twenty minutes, stirring 
all the time. Add salt to taste. 
Another mode is as follows : Tie a handful of dry flour tightly in a cloth, and boil 
for an hour, as if it were a dumpling; rub off the outer hard skin, and grate the flour; 
mix in milk as above. Baked flour may be used in a similar way. 
This is good food for infants whose bowels are weak. 
Water Panada. 
Put a pint of cold water and two slices of dry bread into a stewpan and boil for 
three-quarters of an hour, stirring occasionally ; add salt and stir in the yelk of an egg, 
and serve. 
To a teacupful of stale bread-crumbs add boiling water sufficient to cover them, and, 
when soft, mix thoroughly. Put the mixture into a pint of milk, boil, and stir till it 
thickens. Sweeten, add salt, and flavor with lemon, almond, cinnamon, or vanilla, ac- 
cording to taste. 
Milk Panada. 
Use good broth or beef-tea; proceed as for water panada, omitting the egg. 
Broth Panada. 
Meat Panada. 
To a teacupful of bread-crumbs add half a pint of boiling water and boil till it thick- 
ens ; then mix it well with some kind of gravy or beef-extract. DIET FOR THE SICK. 
893 
Take one ounce of Iceland moss, and soak it in half a pint of hot water for a quarter 
of an hour. Strain, and add the moss to a quart of water and boil till it is reduced to 
a pint. Strain again, and boil the water down to a third of a pint. Mix this with half 
a pint of hot milk, sweeten, and flavor to taste. 
Iceland Moss and Milk. 
Milk-Rice. 
Wash a quarter of a pound of rice, boil as directed above, and, having drained it, 
put it into a stewpan with half a pint of fresh milk; stir over the fire until the rice has 
absorbed the milk. 
Richer Milk-Rice. 
Soften, in plenty of hot water, two and a half ounces of best rice ; cool with plenty of 
cold water, and drain. Boil three pints of milk in a two-quart stewpan; mix the rice 
in the milk and stir on the fire till boiling ; add a tablespoonful of sugar and a small 
pinch of salt; boil for an hour ; serve. 
This is improved by adding more sugar, a small quantity of nutmeg, and wine. 
Rice Gruel. 
Take of ground rice two ounces; cinnamon, a quarter of an ounce; water, four pints. 
Boil for forty minutes. This is somewhat astringent and useful in cases of diarrhoea. 
Take of oatmeal a single handful; boiling water a gallon ; mix in a deep vessel. Let 
the oatmeal settle, which it does in half an hour, and pour off the tea. By this process 
hard water is made potable. 
Oatmeal Tea. 
In all cases oatmeal should be thoroughly boiled, and, though so simple, there is no dish 
requiring more care and attention in its preparation than an oatmeal porridge. 
To a pint of boiling water slowly add a teaspoonful of oatmeal and half a teaspoonful 
of salt, stirring constantly with a wooden spoon, and afterward let the porridge boil for 
an hour, stirring occasionally to prevent sticking to the saucepan. When done, pour it 
out and serve with milk or cream. Those who like it may be allowed sugar or syrup. 
Porridge is made lighter by longer boiling, and, for dyspeptic people especially, it 
should be boiled more than an hour, adding a little boiling water should it appear likely 
to thicken. 
Oatmeal Porridge. 
Sago. 
Sago must be soaked before using. An ounce should be placed in a pint of water and 
allowed to stand on the back of the range or stove, or in the oven, for two hours. Then 
boil it till it is entirely soft, and flavor with lemon or a spoonful of wine, and sweeten. 
Egg, Cream, and Sago Broth. 
Take one. ounce of sago and wash it well. Then stew it in half a pint of water till it 
is very soft, gradually evaporating it down to about one-half. Beat together one egg 
and a quarter of a pint of cream, and add this to the sago slowly, stirring well. Lastly, 
stir in, in the same way, one pint of good boiling beef-tea. 894 
DIET FOR THE SICK. 
Arrow-root. 
To one large tablespoonful of arrow-root add sufficient cold water to make a smooth, 
thin paste. Stir this gradually into a pint of boiling water, and flavor as required. 
For “ Milk Gruel” and “ Milk Arrow-root,” milk is substituted for water. 
Sage Tea. 
Take of leaves of green sage, plucked from the stalks and washed clean, half an ounce; 
sugar, one ounce ; outer rind of lemon-peel, finely pared from the white, quarter of an 
ounce. Put them in two pints of boiling water, let them stand near the fire half an 
hour, then strain. 
When the sage is dried, it must be used in rather less quantity than above mentioned. 
Take a pint of milk and one large teaspoonful of flour, corn-starch, or arrow-root; 
thoroughly mix either of the latter with a little cold milk; then add this to the rest 
of the milk when hot, and boil for five minutes, stirring all the time. Sweeten accord- 
ing to taste. The amount of farinaceous matter may be varied at pleasure, and a drop 
or two of essence of lemon, or cinnamon, or a small quantity of grated nutmeg, can be 
added to flavor it. 
Farinaceous Milk. 
Port-wine Jelly. 
Take one ounce of isinglass (Cooper’s or Cox’s shredded gelatine is the best) and one 
ounce of the best gum-Arabic, put them into a pint of port wine, and grate into it the 
whole of a small nutmeg ; allow it to stand at least an hour ; then put it over a slow fire 
until thoroughly dissolved, watching constantly to prevent burning ; add sugar according 
to taste, and strain. Pour into a flat dish, and, when nearly cold, cut into squares. 
This may be made of any other kind of wine or liquor, and forms a jelly stiff enough 
to be carried in the pocket. Give about a cubic inch when a patient feels weak. 
Slippery-Elm Bark Jelly. 
Take of the bark four ounces ; pour on it a quart of cold water; let it stand all 
night; stir it thoroughly and let it settle ; add the rind, thinly sliced, and the strained 
juice of a lemon ; add sugar, simmer gently for a quarter of an hour ; then strain into a 
mould and let it cool. 
Vegetable Soup. 
Take two large peeled potatoes, an onion, and crumb up half a pound of stale bread ; 
put them into a quart of water and boil until reduced to a pint; strain and add a few 
sprigs of parsley and a small quantity of salt, and, if desired, pepper; cover, and allow 
it to get cold. May be warmed for use. When animal food is inadmissible, this is a good 
article of diet. 
Farinaceous Milk Pudding. 
Take a pint of milk and one large tablespoonful of flour, corn-flour, ground rice, or ar- 
row-root, one egg, and one tablespoonful of sugar. Mix the flour with a little cold 
milk. Boil the rest of the milk, and pour it boiling on the paste. Then stir in the egg 
and sugar, which have been previously beaten together, pour into a dish, and bake for 
fifteen minutes. If preferred, the whole may be boiled for five minutes, stirring all the 
time. 895 
DIET FOR THE SICK. 
Rice Cream. 
Bake one ounce of best rice in a pint of milk; when done, remove the skin from the 
top. Dissolve a quarter of an ounce of gelatine, previously soaked in two tablespoonfuls 
of cold milk, in a quarter of a pint of boiling milk or cream; add the yelks of two eggs, 
two ounces of sugar, and a small quantity of the extract of vanilla ; stir over the fire for 
five minutes, mix with the rice, pour it into a mould, and let it remain until set. More 
or less sugar may be used, according to taste; the quantity given will make the cream 
rather sweet. 
Put into half a pint of boiling water the peel of two lemons, very thinly shred, and 
allow it to simmer for a quarter of an hour ; then boil half a pound of sugar in it for 
two minutes, strain it, add three eggs (the whites and yolks beaten together) and the 
juice of the lemons; stir until thick, it will take about twenty minutes. Have ready a 
quarter of an ounce of gelatine, soaked in a spoonful of cold water, and when the cream 
is poured into a basin, put the gelatine, with another spoonful of water, into the stew- 
pan, and stir until dissolved ; when both are nearly cold, mix thoroughly together, and 
put the cream into a mould. It should stand until the next day. This will be useful 
where milk or cream is not allowed, and is nourishing and delicious. 
Lemon Cream. 
Take two large tablespoonfuls of either of these, one pint of milk, sugar and flavor- 
ing to taste. Mix with a little of the milk, boil the rest, and stir in with the paste. 
Boil all together for ten minutes, stirring constantly. Pour into a mould, and allow it 
to cool. 
Arrow-root or Corn-starch Blanc Mange. 
Puddings. 
In making puddings with milk and eggs, the milk must always be boiled, as this pre- 
vents curdling. It is a good plan to boil the sugar with the milk, and then pour them 
on the eggs. Very slow baking is absolutely necessary for all puddings which have cus- 
tard ; if quickly baked, the custard is often mixed with the more solid portion of the 
pudding, and it is also rendered tough and unsuitable for invalids. 
Savory Bread Pudding. 
Pour half a pint of beef-tea, boiling, over a cup of bread-crumbs; beat well together, 
and let it soak for half an hour; then add two eggs beaten with a quarter of a pint of 
boiling milk. Season with pepper and salt, beat together for five minutes, put the pud- 
ding into a buttered dish, and bake for three-quarters of an hour. 
Hasty Pudding. 
Mix two ounces of flour smoothly in a little cold milk, stir it into half a pint of boil- 
ing milk ; add a well-beaten egg; sweeten, and flavor with grated nutmeg, add a pinch 
of salt, and stir over a slow fire until the pudding thickens. Turn it out and serve. 896 
MET FOR TIIE SICK. 
Ground Rice Pudding. 
Mix two tablespoonfuls of ground rice with half a pint of cold milk; pour upon them 
half a pint of boiling milk, in which a heaping tablespoonful of sugar has been dissolved ; 
add flavoring to suit, one egg well beaten, and stir over the fire for ten minutes ; bake 
in a buttered dish for three-quarters of an hour. 
Tapioca Jelly. 
Put two ounces of tapioca into a bowl with half a pint of cold water and the grated 
peel of a lemon. Set the bowl in a saucepan of water, and keep it boiling. When the 
tapioca begins to thicken, stir in another half-pint of water, let it boil gently for an 
hour, stirring occasionally. Sweeten with sifted sugar, and pour into a mould. 
Let it stand until cold, when it will turn out of the mould a stiff jelly. If approved, 
a little sherry or brandy may be added, so much less water being used. This jelly is 
light, nourishing, and very delicate. 
Orange Jelly. 
Take one ounce, or half a package, of Cox’s or Cooper’s gelatine ; squeeze enough 
oranges to make a pint of juice ; soak the gelatine in the juice with half or three-quar- 
ters of a pound of sugar, for an hour; then add one pint of boiling water, stir till dis- 
solved, and strain into a mould. If put on ice it will harden quickly, and is very accept- 
able often when wine jelly would be too stimulating. 
Snow Pudding. 
One two-ounce package of Cox’s or Cooper’s gelatine, dissolved in one quart of boiling 
water. Beat the whites of five eggs to a froth. After the gelatine is cold, stir into it 
alternately two large cups of sugar and a few spoonfuls of the beaten egg, till all is 
thoroughly mixed. Then add the juice of four lemons, beating continuously while mix- 
ing. Beat in all about twenty minutes. Pour into moulds, and, when hardened, serve 
with boiled custard or whipped cream. 
Apple Souffle. 
Bake two or three sour apples, scrape out the pulp, sweeten with powdered sugar, and 
add the white of an egg beaten to a stiff froth. Put it on a flat tin dish and bake in a 
moderately heated oven a quarter of an hour, or until it puffs up. Serve immediately. 
Flavoring may be added to suit the taste. 
Apple Puree. 
Bake good sour apples, remove the pulp with a spoon, and beat it up with a little 
sugar. To a teacup use the yelk of an egg and a penny sponge-cake; mix, and rub 
through a sieve. 
This is nourishing, and useful in some cases where cream or custard is objectionable. 
Take of lean loin of mutton, one pound, exclusive of bone; water, three pints, boil 
gently till very tender, putting in a small quantity of salt, and an onion, if agreeable. 
Pour the broth into a basin, and when it is cold skim off all the fat. 
Mutton Broth. 897 
DIET FOR THE SICK. 
It can be warmed as wanted. If barley or rice is added, as is desirable during con- 
valescence, they must first be boiled separately till quite soft, and then added when the 
broth is heated for use. 
Egg and Corn Flour Broth. 
Take one large teaspoonful of corn flour and half a pint of cold water. Mix the 
com flour smoothly with a small portion of the water, then add the remainder. Heat it 
over the fire, stirring continuously, and remove when it thickens. Mix with it gradu- 
ally one pint of hot beef-tea. When it has become nearly cool enough to swallow, stir 
into it one well-beaten egg. 
The egg may be omitted when it is known to disagree. 
Baked Flour Broth. 
To make the broth, a good teaspoonful of baked flour should be mixed smoothly with 
a small quantity of cold water, then stirred into a quarter of a pint of hot water, and the 
whole should be made to boil; a pint of hot beef-tea or mutton-broth should then be 
added. 
Clam Broth. 
Chop into small pieces a dozen hard clams, and boil them a few minutes in their 
juice. Strain and pour over crackers. 
Mutton Soup. 
Chop three pounds of neck of mutton into small pieces, put them into three pints of 
water, with a large chopped turnip and a pinch of salt. As soon as the water boils, skim 
thoroughly, and allow it to continue to boil gently for three hours; then strain, and let 
the broth cool in order to remove the fat. Boil it again; stir in a teaspoonful of flour 
mixed smooth in a half-pint of milk or cream ; let it thicken ; season to taste, and serve. 
If there is no objection, the flavor may be heightened by using a sprig of thyme, and rather 
more turnip, and a sliced onion. 
Stewed Prunes. 
Wash the fruit, and for every pound allow a half-pound of sugar and one pint of 
water. Boil the sugar and water together for ten minutes, then put in the fruit and let 
it boil gently for two hours, or until perfectly tender, so that it breaks if touched with 
the finger. Drain the syrup from the prunes, and boil it until it becomes thick ; then 
put the prunes back into it, and let them stand until the next day. 
Omelet. 
To be suitable for invalids, omelets should be cooked with as little butter as possible, 
and be very lightly fried. 
Put half an ounce of butter into the omelet pan ; as soon as it is hot, pour in ge.ntly 
two eggs well beaten, with a tablespoonful of milk, a little chopped parsley, pepper and 
salt; let them rest quiet, the fire being gentle, for half a minute, then, with a fork, stir 
in the middle of the pan to prevent the omelet catching there ; in less than a minute it 
will be nearly done. Now hold the pan over the fire and shake gently, until the omelet 
is done ; now fold it over, slide it on to a dish, and serve immediately. 
Vol. IT.—57 898 
DIET FOE THE SICK. 
“ The Invalid’s Mashed Potato.” 
Boil one pound of potatoes, with their jackets on, till they are tender or brittle. 
Peel them and rub them through a fine sieve ; when cool, add a small teacupful of fresh 
milk or cream and a small quantity of salt, beating lightly as you go on, till it is quite 
smooth, and warm it gently for use. 
Orange Cream. 
Take two oranges ; grate the peel, and put it and the juice, with a cup of finely pow- 
dered sugar, into a half-cupful of water. To this add four well-beaten eggs, and beat all 
together for some time. Strain the whole through flannel into a saucepan and set it over 
a gentle fire, stirring it one way until it is scalding hot and thick. Do not let it boil, for 
it will curdle. Serve as custard in jelly-glasses. MATERIA MEDICA. 
This* term indicates the branch of science which relates to the 
nature of the substances used as medicines. Their preparation 
from the crude drugs in such manner as to be most easily used or 
most efficacious is called pharmacy. The number of articles hav- 
ing more or less medicinal value is very great, and, quite natu- 
rally, the number in actual use varies in different countries. Those 
that are native to the country are most commonly employed, in 
the case of such as are of vegetable origin. This, to a certain 
extent, is so in the United States; but while our native drugs are 
some of them very valuable, there are others—like opium, cam- 
phor, Peruvian bark, rhubarb, assafoetida, nux vomica, etc.—which 
are brought from abroad. 
Formerly, animal and vegetable substances were almost exclu- 
sively used as medicines, but drugs of inorganic origin are now 
largely resorted to, while substances of animal origin have become 
very few; cod-liver oil, pepsin, cantharides, musk, and sperma- 
ceti, being almost the only ones now made use of. 
The collection of plants of value as medicines requires con- 
siderable knowledge of their appearance, and of the places where 
they are apt to be found, as well as of the time when they contain 
their properties in most active form. Care is also required in their 
preservation, and, for domestic use, a knowledge as to how to pre- 
pare them. 
It is obvious that only the simplest preparations can be made 
without a knowledge of pharmacy and the possession of the neces- 
sary apparatus. Practically, infusions, or solutions made by soak- 
ing plants in water ; decoctions, or teas made by steeping or boil- 
ing plants in water; and tinctures, made by soaking plants in 
alcohol or spirits, and, occasionally, powders and salves, are the 
onty forms available for domestic manufacture. These, how- 
ever, if made with fresh plants, are often more valuable as re- 
gards their effects, although less convenient and easy of admin- 900 
MATERIA MEDICA. 
istration than the fluid and solid extracts, elixirs, pills, emulsions, 
syrups, and other compounds made by apothecaries. For the latter 
reasons it will usually be better to obtain all medicines of an 
apothecary when it is possible to do so. 
In collecting plants they should be taken when the leaves are 
free from rain or dew; they should, if possible, be collected fresh 
every year, and, when the tops are the parts used, the flowers 
should have blossomed and the seeds should not be developed. 
When the seeds are the portions sought, they should have become 
ripe. Roots should be dug up in the fall, after the tops have 
withered, or in the spring, before the stems have commenced to 
grow. Barks should be peeled off in the spring. 
As soon as possible after plants, roots, seeds, or barks are 
gathered, they should be quickly dried in the shade with a free 
exposure to air, and be then tied up securely in paper and placed 
where they are not exposed to damp air or insects. Roots should 
not be washed, but when the dirt on them has become dry it should 
be brushed off, and in the case of large roots, cutting them up 
into moderate-sized pieces will hasten their drying. 
In administering medicines it is customary, though less so than 
formerly, to combine them with a view to modifying their indi- 
vidual effects, or to avoid the necessity of giving a large number 
of separate doses. The art of doing this, however, requires more 
knowledge of their individual properties and their effects upon 
disease than can be obtained without much study, since the sub- 
stances chosen and their various proportions require to be varied 
more or less in every case. Experience has shown, however, that 
certain combinations are generally applicable in a large number of 
cases, and since it is desirable to save the labor and expense of writ- 
ing and compounding such mixtures or combinations in each case, 
definite and descriptive names have been given to many such com- 
pounds, and, when made according to methods that have generally 
been agreed upon by physicians and apothecaries, they are known 
as “ officinal” or “pharmacopoeial ” preparations, and the works in 
which they are described are called pharmacopoeias. Such formu- 
las or recipes are used only for the sake of convenience, and physi- 
cians are at liberty, of course, to adopt others whenever, in their 
opinion, others will better serve their purpose. Many of the secret 
preparations sold in the shops are nothing more than such as are 
regularly made by apothecaries, but called by other and more fan- 
ciful titles. 
The doses of medicines appropriate for different ages cannot 
be fixed accurately by any rule, since they vary with the nature 
of the disease ; moreover, certain medicines are relatively more MATERIA MEDIC A. 
901 
active or less active in the case of infants? and children than in 
adults. The following table is sometimes used as a general guide 
to the size of doses, but the only real guide is the effect which 
the remedy produces. 
Taking the dose for an adult as unity : 
A patient under 1 year of age would require from A to A- of this dose. 
“ 2 “ i 
- 3 “ * 
“ 4 i 
7 “ i “ 
“ “ 14 “ “ | 
“ 20 “ “ I 
A patient from 20 to 50 years of age would require the full dose. 
Another rule to follow in the case of children under 12 is to 
add their age in years to 12 and divide the product by the age : 
Child’s age 4 
Add 12 
Total, divided by age 4) 16 ( 4 or I = single dose. 
The weights and measures used in this country in preparing 
and dispensing medicines are as follows : 
The grain written gr. 
The scruple. “ 3, equal to 20 gr. (gr. xx.). 
The drachm “ 3, “ 60 “ or 3iij. 
The ounce “ 3, “ 480 “ “ Sxxiv. or 3 viij. 
In other words, 
20 grains make 1 scruple (3i.). 
3 scruples “ 1 drachm ( 3 i.). 
8 drachms “ 1 ounce ( § i.). 
Troy Weights. 
The minim written Tip 
The fluid drachm “ f 3 equal to 60 minims (Titlx.). 
The fluid ounce “ f§ “ 480 “ or 3 viij. 
The pint “ O “ fsxvj. 
The gallon “ cong. “ Oviii. 
Fluid Measure. 
It is not to be expected that all the medicines here referred to 
are desirable to have constantly on hand for domestic use, since 
the need for most of them may arise but seldom, and they can 
then be obtained fresh from an apothecary, as they are wanted. 
Certain articles, however, should be kept in every family, as they 
are likely to be serviceable in emergencies, or may prevent delay 
in obtaining them even when a physician is called in. All such 902 
MATERIA MEDICA. 
medicines should be put into carefully closed bottles, jars, or 
boxes ; they should be distinctly labeled with the name and dose, 
and they should all be kept in some secure place where they may 
not be accessible to children and may be easy of access for those 
who are competent to use them. 
It will be well to make a distinction in the vials which hold 
remedies that are intended only for external use or which are 
more than ordinarily poisonous, so that even in the dark the at- 
tention may be attracted to the care needed in using their con- 
tents. For example, aconite, laudanum, liniments, etc., may be 
kept in square vials, while spirit of Mindererus, lime-water, bitter 
tinctures, castor-oil, the ordinary cough mixtures, diarrhoea reme- 
dies, etc., may be in round ones. A small case provided with 
shelves and a drawer, closed with locked doors, and arranged to 
hang on the wall, will prove to be convenient. 
The following are recommended as calculated to be most often 
serviceable, and pains should be taken to learn their properties 
so that they may be used with intelligence. Others may from 
time to time be added to, or substituted for them as the ordinary 
needs and experience of the family may indicate : 
Laudanum (Tincture of Opium).—Dose for an adult, fifteen to twenty drops. Small 
children are very susceptible to its effects, and it should not be given to them, except 
with the directions of a physician. Discontinue its use when it causes drowsiness. 
Tincture of Nuk Vomica.—Dose for an adult, five to fifteen drops, or even less. 
It is a very valuable remedy in habitual constipation and in the dyspepsia of nervous and 
overworked people. 
Tincture of Belladonna.—Dose for an adult, five to fifteen drops. Especially valua- 
ble in acute sore throat with pain during swallowing, whooping-cough, excessive per- 
spiration or night-sweats, some forms of cough, incontinence of urine, etc. When the 
pupils of the eyes become large, and there is a flushed face and dryness of the throat, 
stop its use for a time. 
Tincture of Aconite.—Dose for an adult, three to six drops. Even less when given 
at short intervals. A drop every fifteen minutes until there is perspiration on the face or a 
decline of fever, will often arrest a cold in its commencement, or cut short an inflamma- 
tion. It is chiefly used to lessen fever, or, applied externally, to relieve neuralgic pain. 
Be careful not to get it on the lips (unless it is very dilute) or into the eyes. 
Compound Soap Liniment.—Useful for sprains, bruises, or soreness of the muscles, 
in which latter case apply it with gentle rubbing. 
Paregoric Elixir (Camphorated Tincture of Opium).—Dose for an adult, two tea- 
spoonfuls. An excellent remedy for diarrhoea, bellyache, and to quiet cough. 
Sweet Spirit of Nitre (Spirit of Nitrous Ether).—In doses for an adult, of two tea- 
spoonfuls, with water, it increases the activity of the kidneys. 
Hoffman’s Anodyne (Compound Spirit of Ether).—Dose for an adult, two teaspoon- 
fuls, with water. Believes spasm, “nervousness,” the pain of menstrual periods, and 
some forms of headache. 
Aromatic Spirit of Ammonia.—A teaspoonful with cold water is serviceable in sick 
headache, or as a stimulant in cases of faintness. The vapor may also be inhaled. MATERIA MEDICA. 
903 
Tincture of Ipecac.—A couple of teaspoonfuls, with warm water, will cause vomit- 
ing. Two drops, with a little cold water, will have a contrary effect, and will often quiet 
nausea. Ten drops, with half to one teaspoonful of paregoric, is a good remedy for sim- 
ple coughs. 
Tincture of Camphor.—A few drops in cold water is useful as a stimulant in head- 
ache. Rubbed on the skin it causes redness. 
Compound Licorice Powder consists largely of senna and sulphur. A teaspoonful 
in a half glass of cold water, taken on going to bed, acts as a mild laxative. 
Sulphate of Cinchonidia, made into six-grain powders, for convenience sake, is use- 
ful in malarial fevers and neuralgia, and while much less expensive than sulphate of 
quinia, is very nearly as efficacious. Half this amount, taken before meals, serves as a 
tonic. 
Bromide of Sodium, in thirty-grain powders. Taken with a wineglassful of water, 
it relieves headache and restlessness, causes sleep, quiets a “nervous” cough, and con- 
trols spasmodic affections, such as hysteria, etc. 
Compound Rhubarb Pills usually contain three grains each; two to four act as a 
cathartic of rather greater power than the compound licorice powder. 
Powdered Chlorate of Potash, dissolved in cold water, is much used as a gargle for 
sore mouths and throats. 
Powdered Alum.—A heaped teaspoonful in a quart of water is serviceable as an in- 
jection for leucorrhcea, or, applied with cloths, to relieve inflammation of the skin. A 
teaspoonful with warm water acts promptly as an emetic when swallowed. 
Powdered Borax is used for similar purposes as the chlorate of potash. 
Bicarbonate of Soda (ordinary baking soda), when made into a paste with cold 
water, is one of the most efficacious applications to burns and scalds. Ten to thirty 
grains, taken with cold water, relieves heart-burn. 
Vaseline, or Cosmoline Cerate, is better than the ordinary kind, owing to the fact 
that it does not become rancid by keeping. 
Adhesive Plaster. 
Lime Water may be added to the list, since it serves, when given with four parts 
of milk, to check nausea or vomiting, especially in babies; and with equal parts of lin- 
seed oil (or even sweet oil) it forms a thick, white mixture, known as Carron liniment, 
which is used on cloths as a dressing for burns. 
It is customary, for convenience sake, to arrange medicines in 
classes according to one or more of their general effects ; but all 
remedies have certain effects peculiar to them, or depending upon 
the quantity given or other circumstances attending their admin- 
istration ; and there are few remedies—even the oldest known— 
about which something more is not being learned almost daily. 
The following will illustrate some of these general classes : 
Astringents are such substances as cause contraction of the 
soft tissues of the body to which they are applied. They accom- 
plish this in several ways, but usually by their local effects. 
When applied too freely they may cause irritation. They are 
chiefly valuable when there is relaxation or swelling of the sur- 
face, attended with an over-fulness of its blood-vessels, as in con- 
gestion of the skin and mucous membrane—such as occurs in sore 
throat or in simple diarrhoea. They are also serviceable in arrest- 904 
MATE III A MEDIC A. 
mg bleeding from small vessels. Astringents may be either vege- 
table or mineral. The former nearly always depend for their ac- 
tivity upon tannin (or tannic acid) or gallic acid which is made from 
it. Nearly all vegetable substances which impart a puckery taste 
contain this first-named acid in one form or another—viz., galls, 
persimmons, oak-bark, hemlock-bark, catechu, kino, log-wood, 
rliatany, blackberry root, pomegranate-root bark, geranium root, 
etc. 
The most important mineral astringents are alum, acetate of 
lead, sulphate of zinc, subcarbonate or subnitrate of bismuth, and 
sulphate of copper. 
Astringents should not be taken into the stomach shortly be- 
fore eating, nor during digestion, and should be used either in 
dilute form or in pills. When applied externally they usually act 
best when in cold water, or mixed with glycerin or some oily or 
fatty substance that is free from rancidity. Astringent eye-washes 
should never be made with lead preparations. 
Tonies are remedies which improve the health generally. They 
aid digestion and other functions of the body, and increase nutri- 
tion and muscular strength. They are slower in their action than 
stimulants, and, unlike the latter, are not followed by reaction. 
Some have a special influence upon certain parts, like bitters upon 
the stomach, iron upon the blood, phosphorus and strychnia upon 
the nervous system. The bitter tonics, when taken shortly before 
a meal, excite the appetite and cause a greater flow of gastric 
juice, but when used in too large doses they may derange the 
digestive organs and cause headache. The simple bitters, which 
have the effect only of improving the appetite and digestion, are 
quassia, gentian, barberry, columbo, boneset, goldthread, cen- 
taury, dogwood, yellow root, etc. 
Certain bitters possess peculiar properties, such as wild-cherry 
bark, in which there is a small amount of hydrocyanic acid that 
acts as a sedative ; Peruvian bark, which contains quinia, cinclio- 
nidia, and other substances that are especially useful in malarial 
diseases. Others have aromatic principles rendering them more 
stimulating than the simple bitters, like chamomile flowers, Vir- 
ginia snake-root, and cascarilla bark. In others the aromatic sub- 
stances are in larger proportion and the bitter principle is less 
abundant or quite absent, as cinnamon, cloves, nutmeg, allspice, 
ginger, cardamom, pepper, etc. These are not unfrequently classed 
as stimulants. 
Among the mineral tonics, preparations of iron increase the 
richness of the blood in red gobules. The mineral acids (especially 
hydrochloric, which aids digestion) produce an improvement in MATERIA MEDICA. 
905 
general nutrition when not too long nor too freely administered. 
Phosphorus and strychnia in proper doses increase the nutrition 
of the nervous system. 
The bitter tonics, with iron, are usually of service after fevers, 
or when the health has suffered from over-work, deprivation of 
air and sunlight, but in any case the aid of hygienic measures is 
essentia] to their favorable action. 
Stimulants commonly increase the force with which the heart 
acts, and are applicable in all cases of loss of heart-power from 
disease or nervous shock. The remedies of this class are am- 
monia, turpentine, and the various alcoholic drinks. Digitalis 
has a special effect in making the heart’s beat stronger and slower 
when it is acting rapidly and feebly. 
Sedatives are the opposite of the foregoing in effect, and when 
given internally lessen, and sometimes (in large doses) arrest the 
heart’s action. To this class belong many of the most deadly 
poisons, such as preparations of antimony, aconite, veratrum, and 
prussic acid. They are employed to subdue inflammation, lessen 
fever, and quiet the heart’s action, and for this purpose are ad- 
ministered in a great variety of inflammatory and febrile diseases. 
Their use requires caution. 
Antispasmodics are remedies which act upon the nervous 
system much as stimulants do upon the heart. They are useful in 
such affections as St. Vitus’ dance, hysteria, colic, etc. Among 
them are musk, camphor, valerian, assafoetida, ether, black 
snake-root, hops, etc. 
Anodynes or Analgetics are medicines which relieve pain. 
Chief among these is opium and its various alkaloids, such as 
morphia, codeia, etc., and hemp. There are a number of remedies 
which, in addition to the power of alleviating pain, have the 
property of causing the pupil to enlarge. These are belladonna, 
hyoscyamus and stramonium, their pain-relieving power is, how- 
ever, much less than that of opium. They are sometimes called 
mydriatics owing to their influence upon the eye. 
Still another section of this class is known as Anaesthetics. 
They are used by inhalation and have the power of causing tem- 
porary unconsciouspess ; these are nitrous oxide or laughing-gas, 
ether, chloroform, and a few others. They are all extremely 
volatile and vary somewhat in their effects. 
There are two classes of remedies which exert their influence 
almost entirely upon the nervous system. Strychnia is the notable 
one of this Excito-motor class as it is called. Under its influence 
the reflex irritability of the spinal cord (see vol. I., pages 77 and 
539) becomes so much increased, that when it is given in over- 906 
MATERIA MEDIC A. 
doses, slight impressions made upon the surface of the body cause 
convulsion or spasm of the muscles. 
Opposed to the excito-motor class of remedies, are the Depresso- 
motor, or those which diminish the susceptibility of the spinal 
cord and brain to external impressions. The bromides of am- 
monium, potassium, or sodium, together with chloral, coniurn, 
lobelia (or Indian tobacco), and nitrite of amyl are examples. 
Lastly, among the remedies which affect the system generally, 
are those known as 
Alteratives.—These are medicines which modify in some 
manner the nutrition of the body, but which show no other evi- 
dence of their effects (unless they are given in too large or long- 
continued doses) than the improvement in health which follows 
their use. Such remedies are often spoken of as “ blood-purifiers.” 
Many of the most powerful medicines belong to this class, such 
as mercury, arsenic, iodine, bromine, chlorate of potash, muriate 
of ammonia, alkalies, cod-liver oil, colchicum, sarsaparilla, dande- 
lion, guaiacum, inezerium, etc. Such remedies are resorted to in 
rheumatism, gout, syphilis, rickets, etc. Under the influence of 
appropriate alteratives, aided by habits of life calculated to im- 
prove the health generally, the diseased portions of the body 
undergo such changes that their particles are replaced by others 
of a more healthy character, and the invalid is gradually restored 
more or less completely to health. The application of these 
remedies in these various diseases has been referred to elsewhere. 
Certain remedies have effects that are mainly local, or which 
are manifested upon special organs. Some of these belong to the 
class of those which affect the system generally, but depend for 
such local action upon the mode of administration. Of these, 
Emetics are medicines which cause vomiting. Sometimes, 
though not ordinarily, this is accomplished without preceding 
nausea. §ome of this class act by the irritation which they 
create—mustard, blue vitriol (sulphate of copper), and sulphate of 
zinc are of this class. They are “mechanical” remedies and do 
not require to be absorbed into the blood to produce their effect. 
Others, like tartar-emetic and apomorpliia, are typical examples 
of the class that operate through the nerves, and require to be first 
absorbed by the blood and carried to the nerve-centres. The first 
need to be taken into the stomach directly; the others may be 
taken in this manner, or they may be injected into the bowel, or 
into a vein, by means of a hypodermic syringe. 
The choice of an emetic depends upon the purpose to be accom- 
plished. When it is simply desired to unload the stomach of 
poisons or undigested substances, ipecac, mustard flour, sulphate 907 
MATERIA MEDICA. 
of copper, turpeth mineral, sulphate of zinc, or powdered alum are 
serviceable. When foreign bodies are to be dislodged from the 
windpipe, the same agents will suffice, and ordinarily they act 
without causing much nausea. When, however, it is desired to 
lessen the force of the heart’s action or reduce inflammation, a 
moderate amount of nausea is desirable, and tartar-emetic may 
be used. 
Cathartics are medicines which cause an evacuation of the 
bowels. They are subdivided according to their activity into laxa- 
tives (aperients or lenitives)—medicines which simply cause the 
bowel to discharge its contents, but do not cause purging; purga- 
tives (or purges)—or such as produce frequent and loose move- 
ments, but which do not act so freely as to cause exhaustion; 
hydragogues—those which cause profuse and watery discharges, 
and which in large doses may have harmful effects ; and drastics, 
which are so irritant in character as to act as poisons when given 
in too large doses. 
To the first class of remedies belong simple enemas of water, or 
soap-water, and those which increase the tone of the muscular coat 
of the bowel—such as nux vomica,—or those which cause slight 
stimulation of the intestine and increase the contraction of its 
muscles, like oat-meal, unbolted flour, figs and dried fruit of all 
kinds, etc. Molasses and brown sugar have a laxative effect, and 
so has milk with some people. Among medicinal substances tama- 
rinds, manna, magnesia, and sulphur, are the chief. 
Purging remedies embrace castor-oil, calomel, blue-mass, rhu- 
barb (has often a constipating effect as a reaction), aloes, senna, 
Epsom salt, Glauber salt, citrate of magnesia, and Rochelle salt, or 
Seidlitz powder. 
Drastic medicines include jalap, colocynth, scammony, may- 
apple root (or its active principle, podophyllum), elaterium, gam- 
boge, and croton-oil. 
Diuretics are substances which cause an increased flow of urine. 
They are not very certain in their action, especially when the skin 
has a tendency to perspire. They are chiefly serviceable to stimu- 
late the kidneys in cases of dropsy, and to render the urine less 
acid by increasing the proportion of water to soluble matters. The 
chief diuretics are squill, digitalis, broom, spirit of nitric ether, 
buchu, bearberry, juniper, wild carrot, fleabane, turpentine, co- 
paiba balsam, cubebs, and certain of the potash salts—such as the 
acetate, citrate, bitartrate (or cream of tartar), and nitrate (nitre or 
saltpetre). 
Diaphoretics increase the activity of the glands of the skin 
and cause perspiration. Hot baths of air, vapor, or water are 908 
MATERIA MEDICA. 
among the best means for accomplishing this. Spirit of Min- 
dererus (solution of acetate of ammonia), sweet spirit of nitre 
(spirit of nitric ether), and alcoholic drinks will cause sweating by 
increasing the flow of blood to the skin, while tartar-emetic, 
ipecac, aconite, and veratrum viride do it by relaxing the blood- 
vessels of the skin. 
Forms in which Medicines are Prepared. 
Infusions are generally made by pouring a pint of boiling water 
upon a definite amount of the drug; the seeds, bark, or roots 
having first been coarsely powdered, or pounded so as to break up 
their woody fibres. After standing, covered, until cool, the fluid 
portion is to be strained off. As a rule infusions will keep for 
only two or three days, and are better when freshly made from 
day to day. The dose is generally one to two wineglassfuls. 
The proportions of the drugs are mentioned belo w. 
Two drachms to the pint: 
Cloves. 
Digitalis leaves. 
Quassia chips, etc. 
Chamomile flowers. 
Calumbo root. 
Red pepper. 
Catechu gum. 
Gentian root. 
A half troy ounce to the pint: 
Hops. 
Flaxseed (whole). 
Rhubarb root. 
Persimmon bark. 
Sage leaves. 
Snake root (Virginia). 
Pink root. 
Valerian leaves. 
Ginger root. 
Mints of all kinds. 
Oak-bark, etc. 
Buchu leaves. 
Cascarilla bark. 
Peruvian bark. 
One troy ounce to the pint: 
Boneset tops. 
Juniper berries. 
Rhatany root. 
Pareira root. 
Tar (tar-water). 
Wild cherry bark. 
Senna leaves, etc. 
Two troy ounces to the pint: Dandelion root. 
, etc. 
Decoctions are nearly all made by adding a troy ounce of the 
drug to a pint of water and boiling it slowly for a half-hour ; 
allow it to cool and then strain off the fluid. Pour through the 
drug, in the strainer, enough water to make a pint of the fluid. 
Tinctures.—These are among the most commonly used forms 
in which medicines are prepared; the advantage being that the 
alcohol used to extract the active elements of the drugs serves to MATE III A MEDICA. 
909 
prevent, in most cases, any subsequent change in their properties. 
Moreover, these solutions are commonly so concentrated that they 
can be combined and administered with greater ease than in the 
case of the foregoing preparations. As a rule it will be better to 
make them of fresh plants, and for this purpose one part (by 
weight) of the plant (having been cut or pounded in the case of 
barks, roots, or seeds) may be placed in two parts of strong alcohol, 
in a stoppered bottle, or other closed vessel, where it is to be 
allowed to remain for a week, stirring or shaking it frequently. 
At the end of this time the fluid should be strained off, and the 
remaining drug be squeezed as dry as possible—a press of some 
kind being desirable for this purpose when it can be had. A clean 
rubber clothes-wringer is not a bad arrangement for accomplish- 
ing this in some cases. If it is desired that the tinctures should 
be clear, they may be filtered through a paper-cone placed in a 
funnel. 
Tinctures made from dried substances are so variable in the 
proportions of their ingredients that they had better be obtained 
in all cases from an apothecary. 
Ointments and Cerates are mixtures of medicinal substances 
with fats or similar bodies. This is generally done by rubbing 
them together cold, or by melting them with a heat just sufficient 
to liquefy them, and stirring them until cool. Cerates are of firmer 
consistence than ointments, usually owing to their containing 
wax. 
Fluid Extracts are of the nature of concentrated tinctures. 
Vinegars are solutions of drugs, made with diluted acetic acid, 
instead of water or spirit. 
Medicated Waters are solutions of essential oils, gases, etc., 
in water. 
Confections are made with sugar, honey, or similar substances 
as a basis. They are occasionally used by themselves as medi- 
cines—as in the case of confection of senna, others are used to in- 
corporate with other substances, as aromatic confection, confec- 
tion of orange-peel, confection of roses, etc. 
Plasters are mixtures of medicinal substances with some adhe- 
sive body—like resin, oil, Burgundy pitch, India rubber, etc., 
which enables them to hold to the skin. Some of them, like 
diachylon and belladonna plasters, are to be had of apothecaries in 
the form of a cylindrical mass which can be spread, with a 
warm knife, on pieces of kid, wash-leather, or cloth as they are 
needed. 
Solid Extracts, or, more properly, semi-solid extracts are among 
the most concentrated of vegetable extracts, and are used for 910 
MATERIA MEDICA. 
the preparation of pills, suppositories, plasters, ointments, etc., 
where fluids would not be admissible. 
. Glycerites are solutions of certain substances in glycerin. 
Their number is limited, and they are chiefly used for making 
gargles for sore mouths and throats, or for application to the skin. 
Among the former are glycerites of borax, of carbolic acid, and 
of tannin. Glycerite of starch is used for making pills, and gly- 
cerite of tar is of service in some skin diseases. 
Liniments are intended for external use only, and, owing to the 
nature of their ingredients, are often poisonous when taken in- 
ternally. When used to relieve pain they contain some anodyne, 
as belladonna, aconite, or opium. When a stimulating effect is 
desired, ammonia, capsicum, chloroform, turpentine, cantliarides, 
camphor, etc., are added. The Carron-liniment is of service as a 
coating for burns. When it is desired to drive away swellings, 
oily substances are used in order to prevent the skin being irri- 
tated by prolonged rubbing. 
Pills are of the most variable and complicated character. They 
are not, as many persons suppose, always intended to affect the 
bowels, but are used to administer substances in concentrated 
form; when their effect is not intended to be rapid; when it is 
desired 'to avoided unpleasant flavors, and as matters of conveni- 
ence, since they enable the dose to be accurately measured and 
can easily be carried in the pocket. To cover their taste or to pro- 
tect their contents from the action of the air, they are often 
covered with a thin, soluble varnish or a coating of sugar, extract 
of licorice, or silver leaf. 
Powders consist either of the drug itself, finely ground, or its 
active principles mixed with sugar of milk or some other substance 
that enables it to be finely divided. Occasionally, as in the case 
of Dover's powder—made with opium, ipecac, and sulphate of pot- 
ash—the substance added (sulphate of potash in this instance) has 
no particular medicinal value, but by its gritty nature it serves to 
grind the woody fibre of the other substances. 
Suppositories are intended for the administration of medicines 
by the bowel. They are most commonly made with the oil or 
‘•butter” of cacao, which is solid at ordinary temperatures, but 
melts with the heat of the body. They should, therefore, be kept 
in a cool place. Gelatin is sometimes used as a basis instead, but 
is apt to become practically insoluble when long kept. 
Syrups are solutions of medicinal substances in water, the 
sugar serving either to improve their flavor or to protect them 
from changes due to exposure to air, as in the case of preserved 
fruits. MATERIA MEDICA. 
911 
Lozenges or Troches are used on account of the facility with 
which doses can be divided and carried ; for the sake of the agree- 
able form in which they can thus be administered, and especially 
for remedies used in diseases of the throat, when, by their gradual 
solution in the mouth, their ingredients are brought for some time 
in contact with the diseased surface. 
Wines are practically weak tinctures made with wine—usually 
sherry. They are especially useful in the preparation of sub- 
stances that are not so soluble in alcohol as in water; but when 
the presence of a small proportion of the latter prevents the drug 
from spoiling with keeping. Their more agreeable flavor is also 
a reason for their use. 
FORMULAS. 
Sal ammoniac, 5 parts; nitrate of potash, 5 parts; water, 16 parts ; or: 
Sal ammoniac, 5 parts; nitrate of potash, 5 parts; Glauber’s salt, 8 parts ; water 16 
parts; or: 
Glauber’s salt, 6 parts; sal ammoniac, 4 parts; nitrate of potash, 2 parts; dilute 
nitric acid, 4 parts. 
Either of the above is said to cause a fall of mercury in the thermometer, from 50° 
to 10°. 
Freezing Mixtures. 
Muriate of ammonia, 24 grains ; alcohol, 72 minims; water, 2 ounces. Or, alcohol, 
bay rum, or cologne, 1 part; water, 8 parts. 
Used with thin muslin or linen as an application to inflamed surfaces. 
Evaporating Lotions. 
Poultices. 
Charcoal.—Soak 2 ounces of bread crumbs in 10 ounces of boiling water for ten 
minutes. Mix them and stir in £ ounce of pulverized wood charcoal and ounce of lin- 
seed meal. Spread on a cloth in the usual way and, just before applying, sprinkle the 
surface with powdered charcoal. 
Mustard.—Enough mustard flour to form a poultice of the desired size should be 
stirred to break up any lumpy masses ; then add enough boiling water to make a paste, 
which should be spread on muslin or paper, and be covered with thin gauze. 
Flaxseed.—See page 861. 
Bread and Milk.—Never make it with milk, but use hot water. Milk becomes quickly 
sour and causes irritation of the surface to which it may be applied. 
Break the soft part of bread into lumps about an inch in size, and put into a hot 
flat dish or basin. Pour on boiling water and cover the whole with a plate. I)o not stir 912 
MATERIA MEDICA. 
it! When the crumb has become soft, strain off any surplus water, turn the poultice into 
a cloth, which should be folded as directed on page 862, and covered with oiled-silk or 
flannel. Keep it as light and porous as possible. 
Slippery Elm.—Having broken up any lumps of powdered slippery elm bark, add 
enough boiling water to make a mass of proper consistence. This poultice has the dis- 
advantage of sticking tightly to hairs, as it becomes dry, and of becoming stiff and irri- 
tating as it loses its moisture ; for these reasons its surface should be oiled (with cosmo- 
line, vaseline, of suet), and it should be well covered with oiled-silk or flannel. 
Okra.—The fruit of the “okra” or gombo, being bruised, makes a very soothing 
mucilaginous cold poultice. 
Carbolized Oil. 
Carbolic acid, 1 part; olive (or cotton-seed) oil, 10 parts. 
Enemas {Clysters). 
Soap.—Castile-soap scraped fine, 1 ounce ; hot water, 2 pints. Mix thoroughly. 
Assafostida.—Tincture of assafoetida, 2 drachms; barley water, f pint. Mix, and 
use for flatulence and “ nervousness.” 
Turpentine.—Spirit of turpentine, 1 ounce ; the yelk of 1 egg. Rub them well to- 
gether as in making a salad-dressing. Then add gradually 1 pint of barley-water or thin 
gruel. 
Chloroform. —Chloroform, 3 parts; cotton-seed oil, 4 parts. Mix them. 
Soap.—Soap, in shavings, 10 parts ; camphor, 5 parts ; oil of rosemary, 1 part; water, 
a sufficient quantity ; alcohol, a sufficient quantity. 
Place the soap in 16 parts of the water and allow it to remain until dissolved. Dis- 
solve the camphor and the oil in 70 parts of alcohol. Mix the two and filter. 
Hartshorn.—Mix 1 part of water of ammonia with 2 parts of cotton-seed oil (or sweet 
oil) by shaking them in the bottle. 
Camphor.—Camphor, 1 part; cotton-seed oil, 4 parts. Allow the camphor to dissolve 
before use. 
Turpentine.—Resin cerate, 2 parts ; oil of turpentine, 1 part. Melt the cerate with 
gentle heat ; add the oil gradually, and stir them until thoroughly mixed. 
Liniments. 
Carron Oil or Liniment. 
Equal parts of lime water and sweet oil. well shaken together, forms a creamy emul- 
sion which is a soothing application for fresh burns. It should be applied on cotton 
batting. 
Tannic acid, 1 part; glycerin, 5 parts. Mix. Useful for application to inflammations 
of the skin and to piles; and, mixed with 3 parts of water, as a gargle for sore throat and 
as a mouth-wash. 
Glycerite of Tannin. 
Barley Water. 
Pearl barley, 1 part; wash with cold water, then boil it with 4 parts of fresh water 
for five minutes and throw away the liquid portion. Put it into 30 parts of cold water, 
boil it down to one-half and strain. 
Lime Water. 
Fresh lime, 1 part, slake it by pouring on 1 part of boiling water, then add 30 parts 
of cold water (pure) and stir it occasionally for a half hour. Allow it to stand for one 913 
MATERIA MEDIC A. 
hour ; gently pour off the water and throw it away. Add again 30 parts of water, stir 
it well, and after'allowing the coarser particles of lime to settle, pour off the mixture 
into a clean bottle and let it stand until clear. Pour off the clear water, as wanted. 
Cough Mixture. 
Acetate of morphia, or sulphate of morphia, 2 grains; wine of antimony, 4 ounce. 
Mix them and add powdered gum tragacanth and powdered sugar, of each 1 drachm. 
Rub them in a mortar with water, 8 ounces. Dose, a tablespoonful (for adults or large 
children only) every three hours. Chiefly of use in the early stage of a catarrhal cough. 
Another Cough Mixture (Brown Mixture). 
Extract of licorice, powdered gum-arabic, and powdered sugar, of each 3 parts ; pare- 
goric, 12 parts; wine of antimony, 6 parts; spirit of nitrous ether, 2 parts; water, 71 
parts. Rub the licorice, sugar, and gum with the water in a mortar (adding the water 
slowly), then add the other ingredients and mix the whole thoroughly. Dose for an 
adult, 2 to 4 teaspoonfuls every 4 to 6 hours; for a child, a teaspoonful. Useful in the 
advanced stage of a cold. 
Rhubarb and Soda Mixture. 
Bicarbonate of soda, 1 drachm ; powdered rhubarb, 4 ounce; spirit of peppermint, 
2 drachms ; water, enough to make 4 fluid ounces. 
Teaspoonful doses for children are serviceable in correcting summer bowel-disturb- 
ances with sour-smelling stools. 
Tincture of opium, 1 fluid ounce; tincture of capsicum, 1 fluid ounce ; spirits of cam- 
phor, 1 fluid ounce ; chloroform, 3 fluid drachms ; alcohol, enough to make 5 fluid ounces. 
Mix. Give 20 to 40 drops with a little hot water after every movement of the bowels. 
Chiefly useful in summer diarrhoea of adults. 
Diarrhoea Mixture (Squibb's). 
Pills of Tannic Acid and Opium. 
Tannic acid, one drachm; opium, five grains; confection of roses, sufficient. Make 
into twenty pills. Take one every 6 hours in chronic diarrhoea and in prolonged bleeding 
from the bowel or womb. Should not be given to children. 
Tartrate of soda and potassa, 2 drachms; bicarbonate of soda, 40 grains. Mix them 
thoroughly and dissolve in 4 glass of water. In another large glass, not quite half full, 
dissolve 35 grains of tartaric acid, and then pour this into the contents of the first glass. 
Drink it while effervescing. 
An agreeable saline and cooling laxative. 
Seidlitz Powder. 
Hair Restorer. 
Cantharadin, 1 grain; acetic ether, 2 drachms ; rectified alcohol, 3 ounces; castor 
oil, 1 ounce; oil of lavender, or of rosemary, 15 drops. To be mixed and rubbed lightly 
on the head when the hair is falling, or even on places already bald. It should be washed 
off if it causes too much irritation. 914 
MATERIA MEDIC A. 
Tooth-powder of Rhatany, etc. 
Extract of rhatany, 1 or 2 drachms; myrrh, 1 drachm; powdered orris root, 6 
drachms; oil of cinnamon, 2 drops; oil of myrrh, 10 drops; balsam of Peru, 10 grains. 
Mix well. Serviceable for tender or sore gums. 
Cold Cream. 
Oil of sweet almonds, 2 ounces; spermaceti, \ ounce; white wax, 1 drachm; rose- 
water, 1 ounce. Melt the ingredients by stirring them in a white porcelain pot placed 
in boiling water. When they are well melted remove the pot from the boiling water, 
add 1 ounce of rose-water and continue the stirring until the whole is cool. 
Dover’s Powder {modified by Dr. Piffard). 
Ipecac, in fine powder, 1 part; opium, dried and in fine powder, 1 part; sugar of 
milk, in moderately coarse powder, 8 parts. Rub them together in a mortar into a fine 
powder. 
Every 10 grains contains 1 grain of opium, which is the dose for an adult. Should 
not be used for children except with a doctor’s directions. 
Tully’s Powder. 
Sulphate of morphia, 1 part; camphor, powdered licorice root, precipitated chalk, 
of each 20 parts; alcohol sufficient. 
Grind the camphor to powder in a mortar with the aid of a few drops of alcohol. 
Rub with this the chalk and licorice root, and when they are well mixed add the mor- 
phia with a small amount of the foregoing, adding the balance slowly until the whole is 
thoroughly mixed. 
This is largely used in place of the “ Dover’s Powder,” owing to tho absence of ipe- 
cac in its composition. 
Powdered rhubarb, 4 drachms; powdered aloes, 3 drachms; powdered myrrh, 2 
drachms; soft soap (apothecary’s), \ drachm; oil of peppermint, 15 minims. Beat up 
into an uniform mass with a small amount of water, and divide into 200 pills, two to 
four of which serve as a laxative of somewhat greater activity than the following. 
Compound Rhubarb Pills. 
Compound Powder of Licorice. 
Senna, in fine powder; licorice root, in fine powder, of each 2 parts; fennel, in fine 
powder; washed sulphur, of each 1 part; sugar, in fine powder, 6 parts. Rub them 
together until thoroughly mixed. A teaspoonful, taken with 4 glass of water, is an ex- 
cellent laxative. 
Compound Tincture of Benzoin (Friar's Balsam). 
Benzoin, in powder, 3 ounces; socotrine aloes, in powder, ounce; storax, 2 ounces ; 
balsam of tolu, 1 ounce; alcohol, enough to make 2 pints. Put them together into a 
bottle and allow them to stand for several days. A good dressing for cuts. GLOSSARY. 
N.B.—See also the Index, and Worcester’s or Webster’s Dictionaries. 
Abnormal, contrary to the natural. 
Achromatic, without color. 
Adjuvants, medicines which aid the action 
of others. 
Adynamic, without power. 
Ague-cake, enlarged spleen. 
Algid, cold. 
Alveoli, teeth-sockets, or little cavities. 
Alvine, relating to the belly—such as alvine 
discharges, or faeces. 
Amenorrhcea, absence of the menstrual 
flow. 
Amorphous, without form, usually applied 
to substauces that are not crystalline. 
Ancemia, without blood. 
Anchylosis, rigidity of joints. 
Angina maligna, malignant sore-throat. 
Anhydrous, without water. 
Anodynes, medicines that relieve pain. 
Anomalous, not according to rule. 
Anthelmintics, remedies that cause expul- 
sion of worms. 
Anti, against. 
Antidote, a remedy which counteracts the 
effects of poisons or diseases. 
Antiperiodics, remedies which relieve peri- 
odical diseases—such as ague. 
Antiscorbutics, articles of food that prevent 
scurvy. 
Aperients, remedies which relax the bowel. 
Aphonia, absence of voice. 
Apnoea, want of breath. 
Aquafortis, nitric acid. 
Aqua regia, a mixture of equal parts of 
nitric and hydrochloric acids. 
Areola, a circle of color such as surrounds 
a nipple or a point of inflammation. 
Arthritic, relating to a joint. 
Articulation, point of union between bones. 
Ascites, dropsy of the belly. 
Asphyxia, suffocation. 
Asthenia, weakness, want of strength. 
Astringent, puckering, contracting. 
Atonic, want of tone. 
Atrophy, emaciation, wasting. 
Auditory, relating to the sense of hearing 
or the ear. 
Bilateral, on both sides. 
Bistouri, a small knife. 
Blennorrhagia, a discharge of mucus. 
Bluestone, sulphate of copper. 
Bolus, a large pill. 
Bougie, an instrument used for dilating nar- 
rowed passages. 
Bursa, a purse, applied to enlarged sheaths 
of sinews. 
Cachexia, a derangement of general health 
depending upon some constitutional dis- 
ease. 
Calculus, a stone. 
Calvarium, the upper portion of the skull. 
Canthus, the angle formed by the union of 
the eyelids. * 
Capillary, hair-like. 
Caries, ulceration of bone. 
Carminatives, medicines that relieve flatu- 
lence and colic. (From carmen—a charm.) 
Carpus, the wrist. 
Catalysis, a form of decomposition pro- 
duced by contact. 
Catamenia, the menses. 
Cautery, destruction by means of heat. 
Cephalalgia, headache. 
Cerebellum, the little brain. 
Cerebral, pertaining to the brain. 
Cerebrum, the upper part of the brain. 916 
GLOSSAKY. 
Cerumen, wax. 
Cervix, neck. 
Chalybeates, medicines containing iron. 
Charpie, ravelled lint. 
Chin-cough, whooping-cough. 
Chlorosis, green-sickness. 
Cholagogues, medicines that increase the 
discharge of bile. 
Chorea, St. Vitus’s dance. 
Chylopoietic, relating to the digestive or- 
gans. 
Chymification, conversion of fatty food into 
chyme, or an emulsion. 
Climacteric, the change or critical period of 
life. 
Clinical, bedside. 
Clonic, applied to intermittent spasms. 
Clyster, an enema. 
Coagulum, clot. 
Collapse, sudden failure of vitality. 
Colliquative, excessive discharge—applied to 
perspiration or movements of the bowel. 
Colloid, jelly-like. 
CoUyrium, an eye-wash. 
Coma, profound unconsciousness. 
Condyle, side-projections of joints. 
Congenital, from birth. 
Congestion, overfulness of blood-vessels. 
Contagion, the communication of disease 
from one person to another. 
Contagious, capable of being communicated 
from one person to another. 
Convalescence, the stage of recovery from 
illness. 
Copperas, sulphate of iron. 
Coryza, catarrh of the cavity of the nose. 
Cranium, the skull. 
Cretinism, a form of idiocy accompanying 
goitre. 
Crisis, a period in disease when a change is 
liable to occur. 
Cuticle, the surface skin. 
Cutis, the true skin. 
Dejections, the stools—faeces. 
Demulcent, softening. 
Diagnosis, the recognition of disease. 
Diaphoretics, medicines which cause per- 
spiration. 
Diathesis, a state of the system peculiar to 
certain diseases. 
Diuresis, increased flow of urine. 
Diuretics, remedies which increase the ac- 
tivity of the kidneys. 
Dorsal, pertaining to the back. 
Dorsum, the back. 
Dysuria, painful urination. 
Ecchymosis, discoloration from a bruise, or 
rupture of blood-vessels. 
Effusion, escape of fluid into unnatural lo- 
calities. 
Emmenagogues, remedies which promote 
the menses. 
Emphysema, distention of tissues with air. 
Empyema, collection of matter. 
Endemic, belonging to a locality. 
Entozoa, internal parasites. 
Ephemera, transient fever. 
Epidemic, when applied to disease, indi- 
cates one depending upon causes that do 
not belong naturally to the locality. 
Epigastrium, the region commonly known 
as the “pit of the stomach.” 
Epistaxis, bleeding from the nose. 
Epithelium, the superficial layer of skin, or 
of mucous or serous membranes. 
Erethism, excitement. 
Escharotics, substances which destroy the 
tissues when applied to them—such as 
the mineral acids, arsenic, etc. 
Etiology, the doctrine of causes. 
Exanthem, an eruption—applied to diseases 
of the skin. 
Excoriated, raw. 
Extra, without (outside of). 
Extravasation, escape of blood or fluid out 
of their proper vessels or cavities into un- 
natural situations. 
Exudation, oozing of fluid—applied also to 
products of inflammation. 
Faces, excrement. 
Fascia, a broad tendinous membrane. 
Fauces, back part of throat. 
Febrile, pertaining to fever. 
Fluor albus, whites, leucorrhoea. 
Follicle, a tube-shaped gland. 
Fomites, matters containing the contagious 
elements of disease. 
Fontanelle, an opening between the adjoin- 
ing bones of the skull of infants. GLOSSARY. 
917 
Foramen, an opening (generally referring 
to bones). 
Fungus, morbid growths of rapid develop- 
ment. 
Galactorrheea, excessive milk-flow. 
Ganglion, an isolated mass of gray nerve- 
substance; also an enlarged tendinous 
sheath. 
Gangrene, mortification or death of soft 
tissues. 
Gastric, relating to the stomach. 
Genu, knee. 
Globus hystericus, hysteric ball—a sensation 
of a ball rising in the throat. 
Glottis, the opening from the throat into 
the air-tubes. 
Semicrania, pain on one side of the head. 
Hepar, liver. 
Hepatic, relating to the liver. 
Hydatid, a small bladder. 
Hydrops, dropsy. 
Hypercesthesia, excessive sensitiveness. 
Hypertrophy, overgrowth. 
Hypnotic, a medicine which produces sleep. 
Hypodermic, beneath the skin. 
Icterus, jaundice. 
Idiopathic, primary; not depending upon 
another disease. 
Idiosyncrasy, individual peculiarity. 
Inanition, want of food. 
Incubation, hatching. 
Infection, communication by contact. 
Infra, below. 
Inguinal, relating to the groin. 
Insomnia, sleeplessness. 
Intermittent, recurring at intervals. 
lntra, within. 
It is, when added to the name of a locality 
or organ, signifies an inflammation of it. 
Julep, an aromatic drink. 
Labia, lips. 
Lac, milk. 
Lactation, suckling. 
Lachrymce, tears. 
Lacteals, lymph-vessels connected with the 
intestine. 
Lamina, a layer. 
Laryngotomy, opening the wind-pipe. 
Lateral, on one side. 
Lesion, hurt, breach of substance, injury. 
Lethargy, unconsciousness. 
Leucorrhcea, whites. 
Lientenc, consisting of undigested food. 
Lithontriptie, medicines supposed to be ca- 
pable of dissolving stone. 
L/ithotomy, operation for stone by cutting. 
Lobe, a distinct division or portion of an 
organ. 
Lochia, discharges which occur after child- 
birth. 
Lumbar, relating to the loins. 
Lymph, fluid contained in the lymphatic 
vessels. 
Malaria, bad air. 
Mamma, a breast. 
Matrix, the uterus. 
Melcena, black-vomit. 
Meninges, membranes covering the brain. 
Menstruum, fluid serving to hold substances 
in admixture or solution. 
Metamorphosis, change of form. 
Metastasis, shifting. 
Metritis, inflammation of the uterus. 
Miasm, poisonous gases. 
Morbilli, measles. 
Moribund, near death. 
Mortification, death of soft tissues. 
Motility, the capacity for movement. 
Muscce volitantes, floating specks. 
Narcotism, the effect of narcotics. 
Naris, a nostril. 
Nates, buttocks. 
Necrosis, death of bone. 
Nephralgia, kidney-pain. 
Nephritic, relating to the kidneys. 
Neuralgia, nerve-ache. 
Neurosis, nerve-disease. 
Node, a lump. 
Normal, natural, regular. 
Nostalgia, home-sickness. 
Nostrum, a secret preparation. 
Nucha, nape of the neck. 
Obstetric, relating to childbirth. 
Occiput, back of the head. 
(Edema, dropsical swelling. 
(Edematous, dropsical. 
Oil of vitriol, crude sulphuric acid. 
Olfactory, relating to smell. 918 
GLOSSARY. 
Omentum, the caul. 
Onychia, a felon. 
Ophthalmic, relating to the eye. 
Ossification, conversion into bone. 
Ovariotomy, removing an ovary. 
Ovum, an egg. 
Panacea, a remedy for all things. 
Paracentesis, puncture. 
Paralysis, loss of power. 
Parietes, walls. 
Paroxysm, period of attack. 
Pathognomonic, distinguishing symptom. 
Pectoral, relating to the chest. 
Pedicle, stalk. 
Pediluvium, a foot-bath. 
Pellicle, a film. 
Petechia, spots like flea-bites. 
Phagcedena, a spreading ulcer. 
Pharynx, back of the mouth. 
Phlebitis, inflammation of veins. 
Phlebotomy, bleeding by opening a vein. 
Phlegmasia dolens, painful swelling, applied 
to an enlargement of the lower extremi- 
ties most frequent after childbirth. 
Phlegmon, a localized inflammation, as a 
boil. 
Phlegmonous, inflammatory. 
Plethora, overfulness, applied usually to 
blood-vessels. 
Pleurodynia, pain in the side. 
Plexus, a net-work. 
Podagra, gout. 
Polypus, a tumor attached to the surface 
from which it originated by a narrower 
portion, termed a pedicle. 
Post-mortem, after death. 
Primce vice, stomach and intestine. 
Process, a bony prominence. 
Prognosis, prediction. 
Prolapsus, falling. 
Prophylactic, preventive. 
Pruritus, itching. 
Pseudo, false. 
Psychology, the study of mind. 
Ptyalism, excessive flow of saliva. 
Puerperal, belonging to childbirth. 
Pulmonary, relating to the lungs. 
Pyrexia, fever. 
Ranula, a tumor below the tongue. 
Regurgitate, to belch up, the opposite of 
swallowing. 
Remittent, of variable intensity. 
Rheum, catarrh. 
Rigor, shivering 
Sanguis, blood. 
Sanies, a watery discharge from sores. 
Sciatica, neuralgia in the hip and thigh. 
Scirrhus, hard. 
Sclerosis, hardening. 
Sedatives, medicines which diminish activ- 
ity. 
Semeiology, relating to symptoms. 
Senile, old. 
Sensoi’ium, seat of consciousness. 
Sequelae, results, effects. 
Serum, the fluid which separates from the 
clot when blood coagulates. 
Sialagogues, medicines which increase the 
flow of saliva. 
Slough, the layer of dead flesh which sep- 
arates from a wound. 
Sopor, sleep. 
Sphincter, a ring-like muscle. 
Sporadic, occasional. 
Sputum, expectorated matter. 
Stertix)', snoring. 
Strangulated, choked. 
Stupor, insensibility. 
Subcutaneous, under the skin. 
Sudorifics, remedies that cause sweating. 
Synchronous, acting together. 
Syncope, fainting, swooning. 
Tabes, wasting. 
Tenesmus, straining at stool. 
Tetanus, rigidity of the muscles. 
Thorax, chest. 
Tic-douloureux, a sudden and severe form 
of neuralgia of the face. 
Traumatic, resulting from injury. 
Trismus, rigidity of the muscles of the jaw. 
Velum, a curtain. 
Venter, the belly. 
Ventral, belonging to the belly. 
Vesication, blistering. 
Virus, poison. 
Viscus, an internal organ. 
Viscera, the plural of viscus. 
Vomica, a cavity, applied to the lungs. INDEX. 
ABBOTT, F., on the mouth and teeth, ii. 639 
Abdomen, arteries of the, i. 53 
changes of form due to pregnancy, i. 401 
muscles of the, i. 35 
nerves of the, i. 85 
Abdominal bandage, i. 439 
Abortion, i. 438 
causes of, i. 434 
symptoms of, i. 434 
treatment of, i. 435 
“ Absences ” of mind, i. 569 
Abscess, ii. 814 
at roots of teeth, ii. 652 
of liver, ii. 700 
of rectum, ii. 717 
Absorbents, the, i. 73 
Acarus hominis, ii. 187 
Access-pipe, form of, i. 179 
Accident, definition of, i. 587 
Accidents, what to do in case of, i. 587 
Acephalic, definition of, i. 543 
Acetic acid as a disinfectant, ii. 161 
Accommodation of vision, ii. 225 
Acetabulum, the, i. 24 
Achorion Sehonleinii, ii. 185 
Acidity of gastric juice, ii. 666 
Acids, effects on the teeth of. ii. 658 
as aids to digestion, ii. 666 
Acne, ii. 155, 171 
Acne rosacea, ii. 172 
Aconite, description of, i. 785 
dose of, ii. 902 
poisoning by, i. 784 
Acromion process, i. 21 
Acupuncture, i. 358 
Acute infectious diseases, ii. 3 
reasons for non-recurrence, ii. 10 
specific character of, ii. 11 
Adam’s apple, i. 69 
Adductor magnus muscle, i. 34 
muscles of the thigh, i. 45 
AEsthesiometer, description of, i. 330 
Afterbirth, i. 395 
Afterpains, i. 421 
Ague-and-fever, ii. 52 
as a cause of convulsions, i. 567 
Aiken, climate of, i. 238 
Air, affinity for moisture, i. 148 
Air-cells, i. 72 
collapse of, ii. 457 
Air, common impurities of, i. 154 
constituents of, i. 146 
function of, i. 142 
hygienic relations of, i. 142 
Air, impurities of, i. 156 
impure, as a cause of disease, i. 157 
of nurseries, i. 157 
physical properties of, i. 142 
purification of, i. 158 
Aix-la-Chapelle mineral water, i. 377 
Aix-les-Bains mineral water, i. 377 
Albany mineral water, i. 875 
Albumen in urine, test for, ii. 483 
Albumin, nutritive value of, i. 103 
Albuminoids, digestion of, ii. 98 
Alcohol as a cause of eye disease, ii. 285 
its value as food, i. 136 
Alcoholic beverages, uses and effects of, i. 
137 
as a cause of liver-disease, ii. 698 
Alcoholism, ii. 290 
Algid intermittent, ii. 56 
Alimentary canal, anatomy of the, i. 87 
Alkaline waters, i. 378 
Alopecia areata, ii. 180, 195 
Alteratives, definition of, i. 860, ii. 906 
Alum waters (Va.), i. 877 
Amenorrhoea, ii. 549 
American ivy, poisoning by, i. 804 
Ammonia, as an element of air, i. 153 
as an impurity of the air, i. 156 
Amnion, fluid of the, i. 397 
Amyelie, definition of, i. 546 
Anasarca, ii. 829 
Anaemia, ii. 820 
as a cause of death, i. 302 
definition of, i. 296 
of the brain, ii. 583 
of the spinal cord, ii. 584 
Anaesthesia, definition of, i. 319 
modes of producing, i. 361 
Anaesthetics, ii. 905 
definition of, i. 361 
use during confinement, i. 411 
Analgesia, definition of, i. 319 
Analgetics, ii. 905 
Anastomosing arteries of the knee, i. 54 
Anatomy and physiology, i. 3 
Aneuria, definition of, i. 302 
Aneurism, ii. 806 
of heart, ii. 748 
rupture of, i. 776 
Andrews, J. B., on insanity, ii. 611 
Angina pectoris, ii. 736, 746 
ankle-bones, i. 25 
dislocations of, i. 749 
Anilin colors, poisonous, i. 784 
Anodynes, ii. 364, 905 920 
INDEX. 
Anosmia, ii. 372 
Anteflexion of the uterus, ii. 563 
Anteversion of the uterus, ii. 562 
Anterior brachial muscle, i. 39, 40 
chamber of eye, ii. 228 
tibial muscle, i. 47 
Antidotes, nature of, i. 773 
Antiferments, i. 365 
Antiphlogistics, i. 363 
Antiseptics, i. 365 
Antispasmodics, i. 571, ii 905 
Anus, ii. 97 
absence of, ii. 707 
diseases of, ii. 705 
fissure of, ii. 710 
fistula of, ii. 715 
neuralgia of, ii. 724 
wounds of, ii. 724 
Aorta and its branches, i. 49, 53 
Aperients, ii. 907 
Aphasic, i. 545 
Aphonia, ii. 403 
Aponeurosis, i. 32 
Apollinaris mineral water, i. 374 
Apoplexy, i. 767, ii. 593 
congestive, ii. 582 
in childhood, i. 557 
Apparatus, definition of an, i. 3 
Appetite, loss of, ii. 668 
unnatural, ii. 668 
Apnoea, i. 302 
Aquapuncture, i. 358 
Aqueous humor, ii. 228 
Arachnoid, i. 77, 79 
Areola, ii. 121 
Arkansas Hot Springs, i. 380 
Arm, arteries of the, i. 51 
bones of the, i. 20 
bone, upper dislocations of, i. 717 
fracture of, i. 656 
movements of, how accomplished, i. 42 
muscles of the, i. 40 
sling, how to make, i. 634 
veins of the, i. 58 
Arnica-poisoning, ii. 162 
Arrow-root, ii. 894 
Arsenical colors, poisonous, i. 782 
Arsenic in syrups, i. 811 
Arterial system, the, i. 48 
Arteries, arrangement of, i. 48 
diseases of, ii. 749 
Articular arteries of the ankle, i. 55 
Articulation, definition of, i. 28 
Artificial feeding, i. 467 
Arum triphyllum, poisoning by, i. 793 
Arytenoid cartilage, i. 69 
Ascites, i. 292, ii. 828 
Asheville, climate of, i. 238 
Asthenopia, ii. 294 
Aspirator, i. 328 
Asphyxia, i. 302 
Asthenia, i. 302 
Asthma, ii. 416 
in children, ii. 456 
Astigmatism, ii. 302 
Astragulus, the, i. 27 
Astringents, ii. 903 
Asylums for the insane, ii. 631 
Atelectasis, i. 457 
Atlas, the, i. 16 
Atmosphere, effects upon invalids, of variation 
of, i. 145 
weight of, i. 143 
Atmosphere, variations in density of, i. 145 
Atmospheric conditions influencing vision, ii. 
244 
Atomizer for applying medicines, ii. 357 
Atrophy, i. 290 
Aura, definition of, ii. 603 
Auditory canal, ii. 307 
Auricle, ii. 307 
Auricles of the heart, i. 61 
Auscultation, i. 322 
Autumnal catarrh, «ii. 45 
Axillary artery, i. 50, 51 
Axis, the, i. 16 
BABY-wagons, when to use, i. 454 
Back, muscles of the, i. 34 
nerves of the, i. 84 
Bacteria, ii.7 
in diphtheria, ii. 64 
Bagnieres de Luchon, mineral water, L 377 
Bahamas, climate of the, L 234 
Baking, ii. 883 
Baldness, ii. 195 
Ball, A. B., on the kidneys in health and dis- 
ease, ii. 463 
Ballston mineral waters, i. 874 
Bandages and their application, ii. 855 
for fracture, application of, ii. 641 
Banting, dietary table of Mr., i. 109, 348 
“ Barber’s-itch,” ii. 172,181 
Bareges mineral water, i. 377 
Barley-gruel, ii. 890 
Barley, nutritive value of, i. 127 
Barn-yard, arrangement for management of 
slop-water and sewage in, i. 187 
Barley water, ii. 890 
wine, aromatic, ii. 892 
Barometer, explanation of the, i. 145 
Bartlett’s splint for fractured collar-bone, i. 
652 
Basedow’s disease, ii. 747 
Basilic vein, i. 58 
Bath-Alum (Va.) mineral water, i. 378 
Bathing during pregnancy, i. 404 
newly-born infants, i. 415 
Baths, i. 352 
for infants, i. 448 
Bauer’s splint for fractured leg, i. 693 
Baunscheidtismus, i. 358 
Beans, nutritive value of, ii. 127 
Beard, protrusion after death, ii. 879 
ringworm of the, ii. 181 
Beaver-poison, poisoning by, i. 792 
Bed-bug bites, i. 616 
Bed for confinement cases, i. 411 
for sick persons, ii. 844 
Bedford-Alum (Va.) mineral water, i. 378 
Bedford (Pa.) mineral water, i. 378 
Bed-sores, how to prevent, ii. 645 
Beef-essence, ii. 889 
Beef-tea, formulas for, ii. 889 
Beef, nutritive value of, i. 119 
Bee-stings, i. 615 
Beer-yeast, ii. 7 
Belladonna, poisoning by, i. 798 
Belly-ache, ii. 672 
Belly-band, infants’, i. 416 
Belly, inflammation and tumors of, ii. 690 
swelling of, ii. 673 
Bermuda, climate of, i. 234 
Bethesda (Wis.) mineral water, i. 379 
Beverages, i. 130 INDEX. 
921 
Biceps muscle of the arm, i. 36, 39, 40 
of the thigh, i. 24, 46 
Bile, i. 94 
chemical composition of, i. 105 
Biliary colic, ii. 697 
Bilious fever, ii. 53 
typhoid, ii. 40 
Biliousness,” ii. 676, 694 
Binder after confinement, i. 412 
use of, during pregnancy, i. 402 
Biology, ii. 6 
Bismuth for intestinal catarrh, i. 511 
Bites of domestic animals, i. 627 
Biting finger-nails, to prevent, ii. 200 
Bitter-sweet, poisoning by, i. 800 
Black death, the, ii. 28 
Black-eye, i. 611 
Black fly, bites of the, i. 618 
“ Black vomit,” ii. 35 
Bladder, action of, in infants, i. 456 
catarrh of, ii. 519 
diseases, vise of mineral water, i. 384 
disorders of, during pregnancy, i. 433 
emptying with catheter, ii. 511 
how to wash out the, ii. 512 
inflammation of (in cystitis), ii. 516 
irritable, ii. 515 
location of the, i. 53 
stone in the, ii. 521 
structure and diseases, ii. 514 
tumors of, ii. 523 
Bladon mineral water, i. 374 
Bleb, definition of, ii. 149 
Bleeding, i. 590 
from the bowel, i. 593 
lungs, ii. 426 
mouth, i. 693 
stomach, ii. 670 
wounds, i. 592 
into the brain, i. 543 
spinal cord, i. 548 
kinds of, i. 591 
to stop, i. 592 
Blindness, feigned, ii. 303 
hysterical, ii. 304 
Blind spot in the eye, ii. 227 
Blisters, i. 359, ii. 872 
Bloating of stomach, remedies for, ii. 685 
Blood-blister, nature of a, i. 609 
Blood, causes of the flow of, i. 67 
chemical composition of, i. 105 
coagulation of, i. 68 
color of, i. 67 
constituents of, i. 67 
corpuscles of the, i. 67 
course of the, i. 66 
enemas of, ii. 882 
in the veins, flow of, i. 56 
rapidity of the flow of, i. 67 
Blood-shot eye, i. 609 
Blood-vessels, elasticity of the, i. 67 
poisoning by the, i. 775 
Blood, vomiting of, ii. 670 
Bloodletting as a remedy, i. 363 
Bloody flux, ii. 688 / 
Bloody urine, intermittent, ii. 493 
il Blossoms,” ii. 171 
Blue-disease, ii. 745 
Blue-gum, growth of, as a preventive of mala- 
rial fevers, ii. 57 
Blue-rocket, poisoning by, i. 784 
Boiling, ii. 884 
Boils, ii. 166 
Bone, chemical composition of, i. 6, 12, 105 
cancellated i. 12 
structure of, i. 5, 12, 13 
Bones, number of, i. 13 
Borland mineral water, i. 376 
Bostock’s catarrh, ii. 45 
Bosvvorth, F. H., on the nose and its diseases, 
ii. 347 
Bothryocephalus, i. 516, 519 
Bottle-feeding, i. 467 
-taps, ii. 867 
Bournemouth, climate of, i. 232 
Bovine virus, ii. 123 
Bowel, action of, in infants, i. 456 
inflammation of, ii. 686 
ulceration of, ii. 693 
Brachial artery, i. 50 
Brain, absence of, i. 542 
anaemia of, ii. 583 
anatomy of the, i. 79, 534 
arrest of growth of the, i. 544 
chemical composition of, i. 105 
congestion of, ii., 581 
congestion of, in infancy, i. 555 
fever, i. 550 
functions of the, i. 80 
hardening of the, i. 559 
inflammation of the, i. 551 
in idiots, i. 80 
size of the, i. 79 
Brachial plexus of nerves, i. 84 
Brandy mixtures, ii. 889 
Brazil, exemption from epidemics of typhoid, 
ii. 17 
Break-bone fever, ii. 44 
Breast-bcne, i. 18 
fracture of, i. 668 
Breast-feeding, rules for, i. 459 
Breast-milk, i. 457 
Breast-pumps, i. 425 
Breasts, care of the, i. 423 
during pregnancy, i. 402 
changes due to pregnancy, i. 400 
“ gathered ” or inflamed, i. 426 
support for the, i. 424 
Breath, bad, causes of, i. 311 
Breathing through the mouth, causes of, ii. 353 
Bright’s disease, ii. 481 
improper food as a cause of, ii. 109 
Broiling, ii. 883 
Bromine as a disinfectant, i. 161 
Bronchial catarrh, ii. 407 
tubes, an atomy of the, i. 70 
Bronchitis, ii. 407 
capillary, causes and symptoms, ii. 409 
chronic, ii. 411 
use of mineral waters in, i. 383 
membranous, ii. 410 
of children, ii. 456 
Bronchocele, definition of, i. 298 
Bruises, i. 754 
of eyelids, ii. 259 
Brunner’s glands, i. 92 
Bubo, ii. 129 
Buck, A. H., on the ear, ii. 307 
Buckwheat, nutritive value of, i. 125 
Building-sites, healthfulness of, i. 261 
Bunions, ii. 212 
Butter, composition and nature of, i. 116 
Buttercup, poisoning by, ii. 787 
Buttermilk-cure, ii. 346 . 922 
INDEX. 
Caecum, the, i. 95 
Cachexia, definition of, i. 297 
Caffeine, i. 132 
Calcanean artery, i. 55 
Calcaneum, the, i. 26 
Calcic waters, i. 379 
Calcification of arteries, ii. 750 
Calculi, ii. 488 
Calculus, salivary, ii. 653 
Calculus, use of mineral waters in, i. 384 
Calico-bush, poisoning by, i. 805 
California, climate of, i. 241 
Calistoga mineral water, i. 377 
Callus, ii. 173 
Capillaries, diagram of the, i. 66 
Camphor, use in ears improper, ii. 321 
Canaliculi, description of, i. 5 
Cancellated structure of bone, i. 6 
Cancer, ii. 802 
of the breast, ii. 799 
of the kidneys, ii. 489 
of the lip, ii. 802 
of the lungs, ii. 429 
of the nose, ii. 368 
of the penis, ii. 501 
of the prostate, ii. 508 
of the tongue, ii. 801 
of the rectum, ii. 721 
of the stomach, ii. 693 
Cancerous degeneration of warts, ii. 203 
Canites, ii. 196 
Capsules, medicine, ii. 871 
Carbolic acid as a disinfectant, i. 161 
wash, i. 422 
Carbonic acid, accumulation of, i. 152 
as an element of air, i. 150 
function of vegetable life in relation to, i. 
151 
normal proportions in air, i. 153 
physical properties of, i. 151 
removal from wells, etc., i. 152 
sources of, i. 157 
symptoms of poisoning by, i. 153 
Carbonic oxide as an impurity of air, i. 154 
poisonous effects of, i. 154 
sources of, i. 154 
Carbuncle, malignant, i. 613 
Carminatives, definition of, i. 360 
Carolina pink, poisoning by, i. 802 
Carotid arteries, i. 50 
Carpus, the, i. 23 
Carr’s forearm splint, i. 665 
Carrying infants, i. 453 
Cartilage, chemical composition of, i. 105 
description of, i. 5 
varieties of, i. 28 
Casein, nutritive value of, i. 103 
Castle, F. A., on diseases of the organs of di- 
gestion, ii. 663 
on diseases of the general system, etc., ii. 
819 
Castor-oil beans, poisoning by, i. 786 
Catalepsy, ii. 608 
Cataract, treatment of, ii. 282 
varieties of, ii. 280 
Catarrh, bronchial, ii. 407 
definition of, ii. 353 
intestinal, symptoms of, i. 505 
Cat-bites, i. 628 
Cathartics, nature of, i. 363, ii. 907 
Catheters, forms of, ii. 511 
how to oil, ii. 868 
Cauda equina, i. 77 
Caudle, ii. 892 
Cauterization, nature of, i. 359 
Ceiestin mineral spring, i. 337 
Cellars, ventilation of, i. 185 
Cells, epithelial, i. 6 
Cementum of the teeth, ii. 643 
Centipede-bites, i. 621 
Cephalic vein, i. 58 
Cerates, ii. 909 
Cerebellum, i. 79, 80 
Cerebral arteries, i. 511 
Cerebro-spinal meningitis, i. 551 
epidemic, ii. 61 
Cerebro-spinal system, i. 74 
Cerebrum, i. 79 
Cesspools, construction and location of, i. 182 
influence of gases from, on the air of houses, 
i. 185, 186 
odorless method for removal of contents, i. 
183 
Chafing of the skin of the newly-born, i. 420 
Chagres fever, ii. 54 
Chalk-stones, ii. 827 
Chalybeate waters, i. 377 
Chamomile tea, i. 422 
Chancre, ii. 13L 
Chancroid, ii. 129 
phagedenic, ii. 129 
“ Change of life, ” ii. 540 
Charcoal, as a disinfectant, i. 158 
Charleston mineral water, i. 375 
i Cheese, adulteration of, i. 117 
composition of, i. 117 
! poisonous, i. 815 
Chest, air-capacity of the, i. 73 
bones of the. i. 18 
Chewing of food, importance of thorough, ii. 
666 
Chicken-pox, ii. 72 
Chickering, J. W., on deaf-mutism, ii. 325 
; Chigoe, the, i. 617 
[ Chilblain, ii, 160, 214 
Chills and fever, ii. 52 
Chittenango mineral water, i. 376 
| Chlorine as a disinfectant, i. 161 
Chlorosis, i. 298, ii. 820 
use of mineral waters in, i. 381 
Chocolate, composition of, i. 134 
Choking, i. 757 
I Cholasmia, definition of, i. 299 
| Cholera, causes and nature of, ii. 80 
causes which prevent, ii. 86 
disinfection during a case of, ii. 90 
| Choleraic intermittent, ii. 56 
' Cholera infantum, i. 503 
brain symptoms in, i. 557 
Cholera-poison, nature of, ii. 81 
origin of, ii. 79 
! prevention of, ii. 87 
mode of propagation of, ii. 84 
j “ Cholera stuff,” ii. 81 
: Cholesteraemia, definition of, i. 299 
i Cholesterine. i. 95 
; Chomel mineral spring, i. 373 
Chorea, i. 572 
epidemic, i. 573 
Chordee, ii. 504 
Choroid, ii. 224 
diseases of the, ii. 285 
Cicatrix, definition of, i. 606, ii. 149 
Cicuta maculata, poisoning by, i. 792 
Cigarettes for relief of hay-asthma, ii. 49 
Ciliary body, ii. 224 923 
INDEX. 
Ciliary processes, ii. 225 
Circumflex arteries, i. 54 
Cirrhosis of the liver, ii. 698 
Cisterns as sources of water-supply, i. 191 
Clavicle, the, i. 20 
Cleft spine, i. 546 
Cleft palate, ii. 812 
Clergyman’s sore throat, ii. 392 
Clifton mineral water, i. 376 
Climacteric, ii. 540 
Climate, advantage from change of, i. 233 
as a remedy in consumption, ii. 455 
causes which influence, i. 225 
directions for changing, i. 234 
influence on disease, i. 232 
mountain, hygienic value of, i. 231 
mountain, peculiarities of, i. 231 
of America, changeable character of, i. 227 
of England, cause of mildness of, i. 226 
of Europe, i. 227 
of Japan, cause of the mildness of, i. 226 
of New England, i. 235 
of North America, i. 227 
of various countries, i. 225 
Climates, European, i. 235 
disadvantages of foreign, i. 241 
irritant, i. 235 
relaxing, i. 235 
tonic, i. 235 
varieties of, i. 235 
Clothing of infants, i. 445 
Clove-hitch, i. 729 
Clubbed-feet, ii. 216 
Clubbed-hands, ii. 204 
Cochlea, ii. 310 
Cocoa, nutritive value of, i. 133 
the fruit of, i. 134 
Coeliac axis, i. 54 
Coffee, adulterations of, i. 133 
effects of, i. 132 
leaves, use of, as a beverage, i. 135 
nutritive, value of, i. 132 
preparations of, i. 132 
Cohen, J. S., on the throat, ii. 377 
Cold applications, ii. 872 
Cold, a common, ii. 354, 407 
Cold hands and feet, ii. 205 
“ Cold in the eye,” treatment of, ii. 264 
Cold in the head, ii. 354 
prevention of, ii. 355 
treatment, ii. 306 
Cold-sore, ii. 167 
Cold water as an application for eyes, ii. 243 
Colic, ii. 688 
biliary, ii. 697 
Collar-bone, i. 20 
fracture of, i. 651 
Colon, the, i. 96 
Colorado, climate of, i. 234, 235, 240, 241 
Color-blindness, ii. 303 
Color, nature of, ii. 238 
Colored fabrics, poisonous, i. 782 
Colostrum, i. 457, 496 
Columbia mineral water, i. 376 
Columnse camese, i. 63 
Coma, definition of, i. 302 
Comedo, ii. 155 
Communicating arteries of the knee, i. 55 
Complemental air, i. 73 
Compressed-air bath, i. 355 
Compresses, ii. 868 
Conception, definition, i. 389 
Condiments, uses of, i. 129 
Condyles of the thigh-bone, i. 24 
Confectionery, poisonous, i. 808 
Confections, ii. 909 
Confinement, management during, i. 411 
Congestion, i. 288 
Congestion of the brain, ii. 581 
in childhood, i. 555 
Congestive chill, ii. 56 
Conium maculatum, poisoning by, i. 791 
Conjunctiva, ii. 228, 281 
inflammation of the, ii. 268 
Conjunctivitis, ii. 263 
Constipation, ii. 675 
after confinement, i. 422 
in infants, i. 417, 482, 513 
in typhus fever, to relieve, ii. 32 
of pregnancy, i. 429 
treatment of, ii. 677 
use of mineral waters, i. 384 
Consumption, catarrhal, ii. 444 
damp soil as a cause of, i. 167 
fibrous, ii. 445 
in children, ii. 458 
treatment of, ii. 452 
tubercular, ii. 445 
value of a mild climate in, i. 237 
varieties of, ii. 444 
Contagion, parasitic nature of, ii. 8 
Contrexville mineral water, i. 379 
Conversation-tubes, ii. 322 
Convolutions of the brain, i. 79 
Convulsions, i. 756 
cause of frequency in infants, i. 538 
in infants, i. 566 
treatment during, i. 567 
Cooling, i. 276 
Cooking, importance of proper, i. 189 
sick-room, ii. 866 
Cooper’s W ell mineral water, i. 377 
Copper cooking-vessels, i. 808 
in preserved foods and drinks, i. 807 
Coraco-brachial muscle, i. 36 
Corium, ii. 8, 143 
Cornea, ii. 223 
conical, ii. 276 
inflammation of, ii. 272, 274 
spots on the, ii. 273 
ulcers on the, ii. 272 
Corns, ii. 210, 174 
Corn-starch, nutritive value of, i. 126 
Coronary arteries, i. 50 
sinus, i. 61 
Coronoid process, i. 21, 36 
Corpora striata, the, i. 81 
Corpuscle, connective-tissue, i. 5 
bone, i. 5 
Corpuscles of the blood, i. 67 
Corti’s organ, ii. 311 
Coryza, ii. 354 
Cosmetics, poisonous, i. 78 
Costiveness, ii. 675 
as a symptom, i. 315 
Cough, as a symptom of disease, i. 310 
Cough mixtures, ii. 911 
Cough-mixture for influenza, ii. 59 
for measles, ii. 73 
Counter-irritation, i. 358 
Cowhage as a remedy for tape-worm, i. 525 
Cowl-muscle, i. 33 
Cow-pox, ii. 119 
Crab Orchard mineral water, i. 378 
Cramps of cholera, ii. 83 
Cranial nerves, i. 82 924 
INDEX. 
Crazy-bone, i. 21 
Crazy-weed, poisoning by, i. 786 
Creamometer, the, i. 115 
Cretinism, i. 298, ii. 576 
Crick in the back, ii. 825 
Cricoid cartilage, i. 69 
Crosby, A. B. and A. H., on accidents and 
emergencies, i. 587 
Crosby, A. H., on hydrophobia and rabies, ii. 
95 
Cross-eyes, ii. 290 
treatment of, ii. 292 
Croup, ii. 397 
as a cause of convulsions, i. 567 
false, i. 564, ii. 402 
Crureus muscle, i. 44 
Cry of an infant, the, i. 483 
Crystalline lens, ii. 228 
Cuboid, the, i. 27 
Cuneiform bones, the, i. 27 
“Cures,” description of various, i. 345 
Cusset-Vichy mineral water, i. 373 
Cuticle, the, ii. 143 
Cynanosis, ii. 745 
Cysticercus, i. 121,517 
Cystitis, ii, 354, 516 
Daltonism, ii. 303 
Damp soil as a cause of disease, i. 167 
Dandruff, ii. 154 
“ Dandy-fever,” ii. 44 
Darnel-seeds, poisoning by, i. 787 
Dead animals, danger in handling, i. 612 
Dead, laying out the, ii. 878 
Deaf-mute institutions, ii. 342 
Deaf-mutes, Bell’s method of instruction, ii. 340 
education of, ii. 331 
French method of instruction, ii. 333 
German method of instruction, ii. 335 
Deaf-mutism, ii. 325 
Deafness, ii. 312 
as a symptom, i. 320, ii. 312 
caused by acute diseases, ii. 313 
certain trades, ii. 322 
from injuries of the head, ii. 313 
Death, causes of, i. 302 
in hanging, cause of, i. 81 
of the foetus, i. 437 
Decidua, i. 395 
Decoctions, ii. 908 
Degeneration, i. 29 
Delirium tremens, ii. 290 
Deltoid muscle, i. 34, 36, 39, 40 
Delusions, definition of, ii. 613 
Dementia, ii. 624 
infantile, ii. 573, 577 
Dengue fever, ii. 44 
Dentine, ii. 643 
Dentition, i. 491 
Denver, climate of, i. 240 
Depression, i. 295 
Depresso-motors, ii. 906 
Dew, cause of, i. 149 
Diabetes, ii. 476 
insipid, ii. 480 
use of mineral waters in, i. 382 
Diagnosis, definition of, i. 306 
Diapers, soiled, as a cause of soreness, i. 416 
Diaphoretics, ii. 364, 907 
Diaphragm, the, i. 37, 38, 53 
Diarrhoea, ii. 674 
as a cause of convulsions, i. 566 
Diarrhoea, as a symptom, i. 315 
during pregnancy, i. 429 
in infancy, i. 417, 501 
inflammatory, i. 503 
of cholera, ii. 82 
of typhoid fever, ii. 22 
remedies for infantile, i. 511 
treatment of, ii. 675 
Diastole, definition of, i. 65 
Diet, diabetic, ii. 478 
essentials of a perfect, i. 110 
for invalids, ii. 881 
Dietetic treatment, definition of, i. 344 
Difficulty of breathing during pregnancy, i. 430 
Digestion, duration of stomach, i. 91 
peculiarities in infants, i. 477 
physiology of, i. 90 
Digestive apparatus, the, i. 87 
Digitalis, poisoning by, i. 790 
Diphtheria, i. 390 
catarrhal, ii. 65 
causes of, ii. 63 
croupous, ii. 65 
epidemic, ii. 63 
false membrane of, ii. 66 
how conveyed, ii. 64 
prevalent in damp localities, i. 169 
Discharges after confinement, i. 422 
during pregnancy, i. 432 
Disease, causes of, i. 287, 303 
definition of, i. 287 
signs of, i. 306 
Diseases, cachectic, examples of, i. 301 
classification of, i. 301 
contagious, examples of, i. 301 
course of, i. 302 
infectious, i. 301, ii. 3 
inflammatory, examples of, i. 301 
unclassified, examples of, i. 301 
Disinfectants, i. 159, 365 
Disinfection, ii. 13, 90 
Dislocations, general character of, i. 705 
general treatment of, i. 708 
how to detect, i. 707 
Distant vision, cultivation of, ii. 245 
Diuretics, i. 365, ii. 907 
Dog-bites, i. 627 
Dorsalis pedis artery, i. 55, 56 
Dorsal nerves, i. 84 
Doses, rules for the regulation of, i. 333, ii. 900 
Dover’s powder, use of, for infants, i. 510 
Dragon-root, poisoning by, L 793 
Drainage, i. 167 
area of, i. 192 
effect on health of English towns, i. 167 
proper meaning of the word, i. 167 
Drastics, ii. 907 
Dress during confinement, i. 411 
during pregnancy, i. 402 
Drinking, effects upon vision, ii. 250 
Drooping eye-lids, ii. 257 
Dropsy, i. 291, ii. 828 
causes of, i. 292 
of the belly, i. 699 
when a symptom of Bright’s disease, ii. 
483 
Drowning, i. 757 
Drum-membrane of the ear, ii. 308 
false, ii. 322 
puncturing, ii. 321 
Dulcamara, poisoning by, i. 800 
Dumb-bell exercise, i. 250 
Dumb, definition of, ii. 325 925 
INDEX. 
Dunglison. R. J., on the modes of employing 
remedies, i. 333 
Duodenum, the, i. 91 
Dupuytren’s splint for fractured leg, i. 693 
Dura mater, i. 76, 79 
Dying, care of the, ii. 878 
Dynamometer, description of, i. 339 
Dysentery, ii. 688 
causes of, ii. 689 
chronic, use of mineral waters in, i. 383 
epidemic, ii. 60 
symptoms of, i. 315 
Dysmenorrhoea, ii. 553 
Dyspepsia, ii. 665 
causes of, ii. 666, 681 
symptoms of, ii. 665, 679 
uses of mineral waters in, i. 383 
definition of, ii. 48 
Earache, ii. 313 
treatment, ii. 314 
Ear, anatomy of the, ii. 307 
bones of the, ii. 310 
canals and cavities of the, ii. 310 
care of the, ii. 330 
discharge from the, ii. 316 
diseases of the, ii. 313 
effect of acute diseases upon the, ii. 330 
how to apply leeches to the, ii. 314 
how to syringe the, ii. 319 
inflammation caused by bathing, ii. 3.31 
inflammation from snuffing up water, ii. 331 
inflammation of middle, ii. 313 
insects and other foreign bodies in, ii. 318 
middle, ii. 308 
outer, ii. 307 
ringing in the, ii. 318 
scraping with ear-spoon harmful, ii. 331 
wearing wool or cotton in the, ii. 330 
trumpets, ii. 333 
Ear-wax, ii. 307 
as a cause of deafness, ii. 313 
how to remove, ii. 318 
Earth-bath, i. 354 
Eating, erroneous proverbs respecting, i. 140 
importance of a proper mode of, i. 139, ii. 666 
Eaton Rapids mineral water, i. 379 
Ecchymosis, definition of, ii. 38 
Echinococcus, ii. 490 
Echolalia, ii. 576 
Eclecticism, i. 343 
Ecstacy, ii. 608 
Ectozoa, definition of, ii. 187 
Ectropion, ii. 357 
Eczema, ii. 168 
Effusion, i. 389, 291 
Egg and milk, ii. 889 
cream, and sago broth, ii. 893 
-nog, ii. 891 
Egg3, composition of, i. 118 
digestibility of, i. 118 
effect of cooking on, i. 118 
Elbow, dislocations of, i. 723 
fracture of point of, i. 661 
fracture of upper arm. near, i. 660 
Electricity, uses of. i. 367 
Electro-puncture, i. 358 
Elephantiasis, ii. 751 
Elevation, its effects on climate, i. 230 
Ely, E. T., on the anatomy and physiology of 
the eye, ii. 221 
Embolism, ii. 593, 732, 743 
Embryo, development of the, i. 394 
Emetics, uses of, i. 364, ii. 906 
Emphysema, i. 292 
of the lungs, ii. 420 
Empyema, ii. 433 
Ems mineral water, i. 374 
Enamel of the teeth, ii. 642 
Enamelled cooking-vessels, i. 807 
Endocarditis, ii. 731 
ulcerative, ii. 732 
Enlarged veins during pregnancy, i. 430 
Enteralgia, definition of. i. 497 
Enteric fever, definition of, ii. 15 
Entropion, ii. 257 
Epidemic diseases, definition of, ii. 3 
Epidemics, destructive nature of, ii. 12 
supposed causes of, ii. 5 
Epidermis, the, ii. 143 
Epiglottis, i. 70, ii. 377 
function of the, i. 89 
Epilepsy, ii. 603 
in childhood, i. 568 
Epithelium, ciliated, i. 7 
columnar, i. 7 
description of, i. 6 
pavement, i. 7, 64 
pigment, i. 9 
spheroidal, i. 7 
Epistaxis, ii. 370 
Ergot, poisoning by, i. 788 
Eruptive diseases, distinguishing signs of, ii. 78 
Erysipelas, i. 647, ii. 165 
Erythema, ii. 158 
Escharotics, definition of, i. 359 
Esotoxaemia, definition of, i. 305 
Essential oils as sources of ozone, i. 160 
Estill mineral water, i. 378 
Ethmoid bone, i. 18 
Eustachian tube, ii. 308 
Evaporating-pans in furnaces, need for, i. 149 
Exanthem, definition of. ii. 158 
Excessive flow of milk, i. 465 
Excitants, definition of, i. 360 
Excito-motors, ii. 905 
Excoriation, definition of, ii. 149 
Excrement as a conveyer of disease, ii. 16 
Exercise during pregnancy, i. 403 
effects of varieties of, i. 246 
for invalids, i. 256 
for wet-nurses, i. 467 
hygienic value of, i. 245 
mental, i. 257 
proper times for, i. 255 
Exhaustion, i. 295 
Exotoxsemia, definition of, i. 305 
Expectant treatment, definition of, i. 344 
Extension apparatus for fractured thigh, i. 676 
of fractures, definition, i. 644 
Extensor muscles of the fingers, i. 40 
of the thigh, i. 44 
of the toes, i. 47 
External canthus, ii. 230 
oblique muscle, i. 34 
Extracts, fluid, ii. 909 
solid, ii. 909 
Eyeball, the, ii. 222 
hardness of, ii. 287 
muscles of, ii. 229 
paralysis of muscles of, ii. 293 
Eyebrows, the, ii. 234 
Eye, catarrh of the, ii. 263 
“cold,” in the, ii. 263 
foreign bodies inside of, ii. 288 926 
INDEX. 
Eye, foreign bodies on the, ii. 270 
growths upon the, ii. 269 
injuries of the, ii. 288 
purulent inflammation of the, ii. 265, 266 
Eyelashes, ii. 232 
displaced, ii. 257 
Eyelids, the, ii. 230 
adhesion to eyeball of, ii. 270 
bruises of, ii. 259 
displacements of, ii. 257 
how to clean the, ii. 255 
how to turn over the, ii. 268 
inability to close the, ii. 258 
inflammation of, ii. 254 
spasm of, ii. 259 
tumors of the, 236 
twitching of, ii. 259 
wounds of, ii. 260 
Eyes, ages at which they should be used for cer- 
tain purposes, ii. 251 
artificial, ii. 290 
care of the, ii. 241 
constant movement of the, ii. 293 
diseases of the, ii. 244 
duration of continuous use of, ii. 251 
inflamed, care of, ii. 252 
movements of the, ii. 239 
of children, care of, ii. 241 
sympathetic inflammation of the, ii. 289 
symptoms connected with the, i. 320 
tired, ii. 241 
ulcers on the front of the, ii. 272 
Eye-stones, ii. 271 
FACE, muscles of the, i. 32 
paralysis of the, i. 563 
Face-pimples, ii. 171 
Fachingen mineral water, i. 374 
Facial artery, i. 50 
Faecal matter, unnatural appearance of, ii. 
678 
Faeces, impaction of, ii. 722 
Fainting, i. 589 
during pregnancy, i. 430 
Falling of the bowel, ii. 719 
Falling-sickness, ii. 603 
Fallopian tube, i. 390 
False-pregnancy, i. 436 
Faradization, i. 367 
Farcy, ii. 113 
Far-sight, ii. 295 
Fascia, definition of a, i. 5 
of the sole of the foot, i 48 
of the thigh, i. 44 
Fasting as a cause of disease, i. 109 
Fats, digestion of, i. 93, ii. 667 
nutritive value of, i. 106 
sources of vegetable, i. 110 
Fat-tissue, functions of, i. 108 
Fatty degeneration of heart, ii. 741 
Fatty liver, ii. 701 
Favus, ii. 184 
Feeble infants, care of, i. 470 
Feeding the sick, rules for, ii. 881 
Feet, care of the, ii. 205 
diseases of the, ii. 210 
hot and cold, ii. 215 
sweating of the, ii. 156 215 
Felon, ii. 201 
Female genital organs, anatomy of, ii. 533 
Femoral artery, i. 54 
Femur, the, i. 24 
Fever, as a symptom or inflammation of the 
brain, i. 552 
cot, ii. 846 
definition of, i. 294 
“ food ” Barker’s, i. 646 
in typhoid, course of the, ii. 24 
Fever-sore, ii. 167, 816 
Fibrin, i. 68 
nutritive value of, i. 103 
Fibula, the, i. 25 
Field-anemone, poisoning by, i. 804 
Filaria sanguinis hominis, ii. 493 
Finger, dislocations of, i. 729 
Finger-nails, care of the, ii. 200 
Fingers, deformed, ii. 204 
fractures of, i. 667 
supernumerary, ii. 204 
Fire-places, i. 274 
Fish-hooks, to extract, i. 604 
Fish, nutritive value of, i. 123 
salted, poisonous, i. 815 
Fish-skin disease, ii. 175 
Fissures (skin), definition of, ii. 149 
Fistula in ano, ii. 715 
Fits, ii. 603 
Fixed air, i. 142 
Flat-foot, ii. 218 
Flatulence, causes of, ii. 667, 673 
treatment of, ii. 674 
Flavoring extracts, injurious, i. 812 
Flax-seed tea, ii. 890 
Flesh, chemical composition of, i. 105 
Flesh-fly, bites of the, i. 612 
Flexor muscles of the fingers, i. 40 
of the toes, i. 47 
' Floating bodies before the eyes, ii. 250, 287 
i Flooding, i. 437 
! Florida, climate of, i. 239 
i Flour caudle, ii. 892 
I ergot in, i. 788 
poisonous, i. 801 
I Flowers as air purifiers, i. 161, ii. 844 
j Fluid extracts, ii. 909 
| Flushing-tank for slop-water, i. 184 
! Foetus, growth of the, i. 397 
j Follicles of the intestine, i. 92 
of the stomach, i. 90 
| Food after confinement, i. 413 
animal, nature of, i. Ill 
artificial, for infants, i. 499 
chapter on, i. 101 
deficiency of. as a cause of disease, ii. 664 
effects of improper, i. 104 
effects of unsound, i. 140 
for young children, i. 469 
for children liable to brain diseases, i. 554 
for newly-born infant, i. 416 
for nursing-women, i. 463 
for wet-nurses, i 466 
general remarks on, i. 138 
hydro-carbonaceous, i. 102 
importance of having a variety of, i. 139 
influence of climate upon the demand for, 
i. 138 
nitrogenous, definition of, i. 102 
poisonous, i. 808 
proper for use during pregnancy, i. 403 
properties of different, i. 101 
upon the temperament, effect of varieties 
of, i. 138 
Foods, nutritive value of various, i. 102 
respiratory, i. 106 
suitable for different ages, ii. 664 927 
INDEX. 
Foods, vegetable, varieties of, i. 124 
Fool’s parsley, poisoning by, i. 789 
Foot, arteries of the, i. 56 
bones of the, i. 26 
dislocations of bones of, i. 753 
fractures of the bones of, i. 700 
muscles of the, i. 48 
structure of the, i. :.7, ii. 206 
Forearm-bones, fracture of, i. 663 
muscles of the, i. 40 
Foreign bodies in the eye, ii. 270 
in the nose, ii 369 
in the rectum, ii. 723 
Forests, influence on climate, i. 228 
Foreskin, diseases of, ii. 498 
Formulas, ii. 911 
Foster, F. P., on vaccination, ii. 119 
Foundations, proper construction of, i. 170, 
263 
Foul-breath, ii. 671 
Fovea centralis, ii. 228 
Foveolation, definition of, ii. 121 
Fox-bites, i. 629 
Fox-glove, poisoning by, i. 790 
Fracture apparatus, i. 644 
Fracture-beds, i. 683 
Fracture-box, i. 691 
Fractured limbs, how to handle, i. 674 
non-union of bones after, i. 682 
of bones of nose, ii. 372 
probable results of, i. 638 
varieties of, i. 635 
Fractures, bad union of, i. 685 
compound treatment of, i. 644 
dressings for, i. 641 
general nature of, i. 635 
general principles of treatment, i. 639 
“green-stick” definition of, i. 635 
how to detect, i. 636 
incomplete, i. 635 
Freckles, i. 9, ii. 175 
French Lick mineral water, i. 376 
Fresh air for infants, i. 453 
Friedrichshall mineral water, i. 378 
Fright, as a cause of St. Vitus’s dance, i. 
573 
Frontal bone, i. 17 
Frosted feet, ii. 215 
Fruits, nutritive values of, i. 128 
Frying, ii. 884 
Funny-bone, i. 21 
Furnaces, i. 274 
Furuncles, ii. 166 
Furunculosis, definition of, ii. 167 
GALL bladder, the, i. 94 
Gall-stone, ii. 697 
use of mineral waters in, i. 384 
Galvanism, uses of, i. 367 
Galvanized-iron pipe, i. 806 
Game, nutritive value of, i. 123 
Ganglia, definition of, i. 533 
Gangreen, i. 292 
of the lungs, ii. 428 
of the mouth, i. 489 
Garden nightshade, poisoning by, i. 800 
Garget, poisoning by, i. 802 
Gargles, disinfecting, ii. 77 
for diphtheritic sore throat, ii. 67 
Gaseous air-purifiers, i. 160 
Gases, diffusive power of, i. 63, 151 
in the intestine, i. 97 
Gases which render air impure, i. 156 
Gastein hot springs, i. 381 
Gastralgia, i. 497, ii. 686 
Gastric artery, i. 54 
Gastric juice, i. 90, ii. 666 
Gastric remittent fever, ii. 53 
Gastritis, ii. 681 
Gelatin, nutritive value of, i. 103 
Gelsemium sempervirens, poisoning by, i. 
794 
Gemeli muscles, i. 42 
Genito-urinary organs, female, ii. 583 
male, ii. 497 
Georgia, climate of, i. 234 
German-measles, ii. 73 
Giddiness, ii. 586 
| Gin-drinker’s liver, ii. 698 
Gland, definition of a, i. 8 
thymus, i. 98 
thyroid, i, 98 
Glanders, ii. 113, 378 
mode of inoculation with, i. 613 
symptoms in man, ii. 114 
Glands, lymphatic, i. 73 
of the intestine, i. 92 
of the stomach, i. 90 
salivary, i. 88, 90 
solitary, i. 92 
without ducts, i. 98 
Glaucoma, ii. 287 
Gleet, see stricture of urethra, ii. 505 
Glisson’s capsule, i. 94 
Glossary, ii. 915 
Glottis, i. 70 
spasm of, i. 571 
Gluten flour, ii. 479 
Gluten, nutritive value of, i. 103 
Gluteus muscles, i. 34, 42 
Glycogenic matter, i. 95 
Goat’s flesh, nutritive value of, i. 121 
milk, artificial, ii. 891 
Goitre, i. 298 
Goggles, objection to wearing, ii. 244 
Gonorrhoea, see urethritis, ii. 503 
“Goose-flesh,” cause of, ii. 145 
Gout, ii. 826 
Gracilis muscle, i. 34, 45 
Grand Grille mineral spring, i. 337 
Granular lids, ii. 268 
Granulations, definition of, i. 606 
Grape-cure, i. 848 
Gravel, ii. 488, 520 
symptoms of, i. 316 
use of mineral waters in, i. 384 
Graves’s disease, ii. 747 
Gray matter of spinal cord, i. 77 
of the nervous system, i. 75 
Greenbriar mineral water, i 376 
Green colors, poisonous, i. 782 
sickness, definition of, i. 298 
Green tumor of the eye, ii. 287 
Grindelia robnsta as an antidote for ivy poison- 
ing, i. 777 
Ground-air, i. 185 
Growth, influence of nervous system upon, i. 
542 
Gullet, the, i. 89 
Gum-arabic water, ii. 
Gum-boil, ii. 652 
Gums, bleeding of the, ii. 657 
cutting the, i. 495 
Gymnastics, i. 247 
medical i. 356 928 
INDEX. 
TTADDEN, A., on the castration of dogs as a 
-CL preventive of rabies, ii. 96 
Hair, care of the, ii. 193 
diseases of the, ii. 194 
effect of cutting upon, ii. 194 
excessive growth of, ii. 194 
gray, ii. 196 
loss of, ii. 195 
loss of color of, ii. 196 
restoratives, poisonous, i. 781 
structure of, ii. 192 
Hair-dyes, danger from use of, ii. 196 
, poisonous, i. 781 
Hallucinations, definition of, ii. 614 
Hamilton, A. McL., on idiocy, and nervous 
diseases of adult life. ii. 573 
Hamilton’s arm splint, i. 658 
forearm splint, i. 664 
sling for compound fractures, i. 692 
splint for fractured knee-cap, i. 687 
Hamstring muscles, i. 46 
Hand, arteries of the, i. 82 
bones of the, i. 23 
fracture of bones of, i. 666 
Hands, paralysis of, from lead poisoning, i. 780 
sweating of, ii. 156 
muscles of the, i. 41 
diseases and deformities of, ii. 200 
care of the, ii. 199 
Hanging, i. 757 
cause of death in, i. 81 
Hang-nail. ii. 201 
Hare-lip, ii. 809 
Harrodsburg mineral water, i. 378 
Habtsiiokne, Henry, on Disease, its Nature, 
Causes and Manifestations, i. 287 
Hashing, ii. 884 
Hautenve mineral water, i. 373 
Haversian canals, i. 5 
Hawley’s food, i. 499. 
Hay asthma, ii. 45 
Hay fever, cause and distribution of, ii. 45 
persons liable to. ii. 47 
regions exempt from, ii. 47 
various forms of, ii. 48 
Head, bones of the, i. 16 
Head-covering for infants, i. 453 
infants, shape after labor, i. 41S 
injuries of the, i. 701, 766 
muscles of the, i. 32 
nerves of the, i. 81, 82 
veins of the, i. 57 
Headache, ii. 5S4 
as a symptom of brain disease, i. 55S 
in childhood, i. 540 
in inflammation of the brain, i. 552 
Health-resorts, directions for choosing, i. 386 
of Europe, advantages of, i. 237 
of the United States, principal, i. 238 
Hearing, mechanism of, ii. 311 
Heart, action of the, i. 64 
aneurism of the, ii. 748 
blood-vessels of the, i. 60 
dilatation of the, ii. 739 
fatty degeneration of the, ii. 74 
force of the, i. 65 
frequency of its action, i. 65 
inflammations of the, ii. 729, 733 
location of the, i. 61 
muscle of the, i. 64 
neuralgia of the, ii. 746 
murmurs, causes of, ii. 736 
overgrowth of the, ii. 737 
Heart, overstretching of, ii. 739 
rupture of the, ii. 748 
sounds of the, i. 65 
structure of the, i. 62 
valves, disease of the, ii. 733 
with its principal vessels, i. 49 
Heart-burn, ii. G67. (172 
remedies for, ii. 685 
Heart-pang, ii. 746 
Heat-stroke, ii. 830 
Heating, i. 265 
by hot water and steam, i. 275 
Heat-rash, ii. 161 
Heel-bone, i. 27 
Hellebore, poisoning by, i. 790 
white, poisoning by, i. 814 
Hemiplegia, ii. 593 
spastica, definition of, i. 574 
Hemispheres of the brain, i. 79 
Hemlock, poisoning by, i. 791 
Hemoptysis, ii. 426 
Hemorrhage, definition, i. 590 
into the brain in infancy, i. 557 
varieties of. i. 309, 591 
uterine, ii. 556 
Hemorrhagic diathesis, i. 69 
intermittent, ii. 56 
Hemorrhoidal plexus, i. 59 
Hemorrhoids, ii. 709 
during pregnancy, i. 429 
remedies for, i. 442 
Henbane, poisoning by, i. 793 
Hepatic artery, i. 54 
vein, i. 61 
Hernia, t. 762 
Herpes, ii. 167 
progenitalis. ii. 500 
zoster, ii. 601 
Hiccough, ii. 671 
causes of, i. 311 
Hiedra-poisoning, i. 776 
Hip-bones, i. 23 
fracture of, i. 669 
Hip, dislocations of, i. 729, 733 
general remarks on. i. 742 
muscles of the, i. 42 
Hives, ii. 159, 397 
Hob-nail liver, ii. 698 
Hodgen, J. T., on accidents and emergencies, 
i. 754 
Hog-bites, i. 628 
Homoeopathy, i. 34L 
Horse-bites, i. 628 
Hot bath, i. 352 
Hot water as an application for sore eyes, ii. 253 
House-building, the hygiene of, i. 261 
House-sewers, construction of, i. 179 
Humerus, the, i. 21 
dislocations of, i. 717 
fractures of, i. 656 
Humor, a, ii. 150 
Hunger-cure, i. 347 
Hunyadi Janos mineral water, i. 378 
Hyaloid body, ii. 228 
Hydatids of the kidney, ii. 490 
Hydragogues, ii. 907 
Hydrocele, ii. 528 
Hydrocephaloid disease, i. 507 
Hydrocephalus, i. 292, 551 
spurious, i. 503, 507, 556 
Hydropathy, i. 349 
Hydrophobia, ii. 95 
and rabies, distinction betweeu, ii. 97 INDEX. 
929 
Hydrophobia, prevalence of, ii. 96 
symptoms of. ii. Iu5 
treatment of. ii. 107 
Hydrothorax. i. 292 
of children liable to brain diseases, i. 554 
of females, ii. 541 
of pregnancy, i. 402 
Hygrometer, description of the, i. 149 
Hyoid bone, i. 18 
Hyoscyamus niger, poisoning by, i. 793 
Hyperoesthesia, definition of, ii. 61 
Hypodermic use of medicine, i. 388 
Hypermetropia, ii. 295 
Hyperopia, ii. 295, ii. 298- 
Hypertrophy, i. 290 
Hysteria, i. 574 
in children, i. 574 
TCE-HOUSES, i. 279 
-L Iceland moss and milk, ii. 893 
Ice, modes of preserving, i. 279 
Ice-mills, i. 281 
Icthyosis, i. 175 
Idaho hot springs, i. 380 
Idiocy, ii. 573 
causes of, i. 544 
theroid, ii. 576 
unusual forms of, ii. 576 
Idiopathic, definition of, ii. 729 
Idiots, education of, ii. 578 
Ileo-typhus, definition of, ii. 15 
Ileum, the, i. 91 
Iliac arteries, i. 54 
muscle, i. 36 
muscles, i. 42 
Ilium, the, i. 23 
Illusions, definition of, ii. 614 
Imbecility, ii. 567, 573 
Immature infants, appearance of, i. 414 
Innominate artery, i. 50 
Incubation-stage of acute infections diseases, 
ii. 9 
Index, ii. 919 
thermometer, ii. 875 
Indian-club exercise, i. 250 
Indian corn, nutritive value of, i. 126 
poke, poisoning by, l. 79 > 
tobacco, poisoning by, i. 795 
turnip, poisoning by, i. 793 
Indigestion, causes of, ii. 663 
chronic, symptoms in infancy, i. 497 
of infants, i. 495 
Infant feeding, rules for, i. 497 
newly born, care of the, i. 413 
Infection, chemical theory of, ii. 6 
nature of, ii. 4 
Inflammation, i. 289 
of bowel, ii. 686 
of the belly, ii. 691 
of the brain, i. 551 
results of, i. 290 
Influenza, ii. 58, 373 
Infra-spinatus muscle, i. 34, i. 40 
Infusions, ii. 908 
“ Infusion ” of medicines, definition of, i. 340 
Inguinal canal, the, i. 36 
Insane neurosis, ii. 573 
Insanity, causes of, ii. 614 
classification of, ii. 618 
early symptoms of, ii. 626 
nature of, ii. 611 
treatment of, ii. 628 
Insect-bites, treatment of, i. 618 
Insecticides, poisoning by, i. 818 
Insertion of muscles, i. 31 
Insomnia, delinition, ii. 588 
Instruments used in diagnosis, i. 325 
Intemperance as a cause of idiocy, ii. 577 
Internal canthus, ii. 230 
Intussusception, i. 527 
Intercostal muscles, i. 36, 37 
Inter-lobular veins, i. 94 
Intermarriage as a cause of disease, ii 517 
Intermittent fever, ii. 52 
treatment of, ii. 56 
Interosseous artery of the leg, i. 55 
Intestinal coats, the, i. 92 
digestion, ii. 608 
juice, i. 92 
obstruction, treatment of, i. 529 
Intestine, anatomy of the small, i. 91 
obstruction of the, i. 527 
the large, i. 95 
Intra-lobular veins, i. 94 
Inward fits, i. 564 
Inward spasms, i. 507 
Iodine as a disinfectant, i. 161 
Iridectomy, ii. 288 
Iris, ii. 225 
cause of different colors of, ii. 226 
defects of, ii. 280 
inflammation of, ii. 276 
Iritis, ii. 277 
Iron preparations, effects on the teeth of, ii. 658 
Irregular sight, ii. 302 
Irritation, i. 288 
Ischium, i. 23 
Isle of Pines, climate of, i. 233 
Isothermal lines, i. 226 
Itch, ii. 187 
Itching, ii. 178 
during pregnancy, i. 432 
of the anus, ii. 708 
of the bowel, worms as a cause of, i. 523 
of the genitals, ii. 547 
Ivy-poisoning, ii. 162 
TACK-IN-THE-PULPIT, poisoning by, i. 793 
It. Jackson, A. Reeves, on the diseases pecu- 
liar to women, ii. 533 
Jacksonville, climate of, i. 234 
Jacobi, Mary Putnam, on the nervous dis- 
eases of infancy and childhood, i. 538 
Jamestown weed, poisoning by, i. 802 
Janes, Dr. Edward H., on food, i. 100 
on air in its hygienic relations, i. 142 
Jasmine, poisoning by, i. 794 
Jaundice, ii. 695 
of the newly-born, i. 419 
Jaw-bones, fracture of, i. 649 
Jaw, dislocation of, i. 711 
lower, ii. 641 
upper, ii. 640 
Jeger’s test-type, ii. 248 
Jelly, port wine, ii. 894 
slippery elm bark, ii. 894 
Jejunum, the, i. 91 
Jigger-bites, i. 617 
Joints, arrangement of, i. 29 
description of the. i. 2S 
functions of various, i. 30 
injuries of the, i. 705 
varieties of. i. 28, 705 
Joint-water, i. 23 930 
INDEX. 
Jordan (Va.) mineral water, i. 378 
Jugular veins, i. 57 
Ketchup, poisonous, i. 797 
Kentucky mineral waters, i. 376 
Keratitis, ii. 272, 274 
Keyes, E. L., on the male genito-urinary 
organs, ii. 497 
Kidney, cancer of the, ii. 489 
chronic inflammation of the, ii. 484 
congestion of the, ii. 481 
diseases of the, ii. 476 
disease as a cause of convulsions, i. 567 
granular, ii. 485 
hydatids of the. ii. 490 
inflammation of pelvis of the, ii. 489 
movable, ii. 492 
parasites of the, ii. 490 
Kidneys, situation in the abdomen of the, i. 53 
structure of the, ii. 463 
stone in the. ii. 488 
waxy, ii. 486 
Kissingen mineral water, i. 378 
Kneecap, dislocations of, i. 743 
fractures of the, i. 686 
Knee, cartilages, dislocation of, i. 746 
dislocations of, i. 747 
fractures just above the, i. 685 
Kneepan, i. 25 
Koumiss or Kumyss, i. 346 
Kousso as a remedy for tape-worm, i. 526 
LABIAL arteries, i. 50 
Labor, definition of i. 405 
management of, i. 408 
premature, i. 436 
the various stages of, i. 406 
Labyrinth of the ear, ii. 310 
Lachrymal apparatus, ii. 232. 
canals, ii. 233 
caruncle, ii. 232 
fistula, ii. 201 
glands, ii. 232 
sac, ii. 233 
Lacteals, i. 73 
Lactometer, the, i. 114 
L icunae. description of. i. 5 
Lambkill, poisoning by, i. 805 
Lamb, nutritive value of, i. 121 
Laparotomy, i. 530 
Large belly, i. 439 
Laryngitis, acute, ii. 394 
chronic, ii. 395 
definition of, ii. 354 
Laryngoscope, description of, i. 326 
mode of using, ii. 382 
Larynx, i. 69, ii. 377, 380 
inflammation of, ii. 394 
spasm of, ii. 402 
Latissimus dorsi muscle, i. 33, 34, 36 
Latrine, Jenning’s, i. 178 
Laudanum, use in ears improper, ii. 321 
dose of, ii. 902 
Laurel, poisoning by, i. 805 
Laxatives, ii. 907 
Lead in drinking water, i. 806 
in flour, i. 808 
in preserved foods and drinks, i. 807 
pipe, substitutes for, i. 806 
poisoning, i. 780 
Leather cloth, poisonous, i. 784 
Ledoyen’s disinfecting fluid, i. 159 
Leg, arteries of the, i. 54 
bones of the, i. 25 
dislocations of the, i. 749 
fractures of the bones of the, i. 689 
loss of power in spinal disease, i. 562 
muscles of the, i. 47 
veins of the, i. 59 
Liebig’s theory of animal heat, i. 107 
food, i. 499 
Lemonade, flaxseed, ii. 890 
; Lenatives, ii. 907 
Leucocythemia ii. 752 
Leucocytis, description of, i. 67 
Leucorrhoea ii 546, 554 
Leukaemia, i. 296, ii. 752 
Levis’s instrument for dislocated finger, i. 127 
Lice, ii. 190 
Lieberkuehn’s follicles, i 92 
Ligaments, definition of. i. 2S 
Ligamentum nuchae, i. 33 
Light, arrangement of, for perfect sight, ii. 242 
Lightning-stroke, i. 768 
Limbs, stiffness of. in infancy, i. 545 
wasting of, in paralysis, i. 560 
Lime as a disinfectant, i. 159 . 
-juice as a preventive of scurvy, ii. 820 
Liniments, ii. 910 
how to apply, ii. 872 
Lingual artery, i. 50 
Liquor sanguinis, i. 68 
Litmus paper, i. 510 
Liver, chemical composition of, i. 105 
complaint, ii. 694 
complaints, use of mineral waters in. i. 384 
congestion of, ii. 700 
contracted, ii. 698 
diseases of the, ii. 694 
enlargement of the, ii. 698 
fatty, ii. 701 
gin-drinker’s, or hob-nail, ii. 698 
spots, ii. 176 
the, i. 93 
Lobelia, poisoning by, i. 795 
Lobules of the lungs, i. 72 
Lockjaw, punctured wounds as causes of, i. 603 
Locomotor ataxia, ii. 597 
Long supinator muscle, i. 40 
; Loomis, A. L., on diseases of the respiratory 
organs, ii. 407 
j Loss of smell, ii. 372 
I Louisville mineral water, i. 376 
j Lower extremity, bones of the, L 23 
muscles of the, i. 42 
nerves of the, i. 85 
veins of the, i. 58 
Lozenges, ii. 911 
Lucifer disease, i. 779 
Lumbago, ii. 600, 825 
Lumbar arteries, i. 53 
region, nerves of the, i. 8 > 
Lung, dropsy of, in children, ii. 456 
fever (pneumonia), ii. 435 
inflammation of. in children, 458 
Lungs, anatomy of the, i. 71 
apoplexy of the, ii. 425 
bleeding from the, ii. 426 
cancer of the, ii. 429 
congestion of the, ii. 424 
in children, ii. 456 
in infants, i. 507 
dropsy of the, ii. 423 
emphysema of the, ii. 420 931 
INDEX. 
Lungs, inflammation of, ii. 435 
gangrene of the, ii. 428 
poisoning by the, i. 775 
Lung-tissue, chemical composition of, i. 105 
Lying-in room, rules for the, i. 409 
Lymph, i. 74 
Lymphatics, diseases of. ii. 750 
Lymphatic system,-i. 73 
MACULA lutea, ii.'227 
Maculae, definition of, ii. 149 
Madeira, climate of, i. 236 
Magnetism, uses of, i. 367 
Malar bones, i. 18 
Malarial cachexia, ii. 55 
Malarial fevers, circumstances that favor, ii. 50 
how spread, ii. 51 
irregular forms of, ii. 54 
nature of, ii. 50 
persons liable to, ii. 51 
prevention of, ii. 57 
where most prevalent, ii. 50 
Malarial intoxication, ii. 55 
Maleolar arteries, i. 55 
Maleolus, i. 25 
Malformations of the rectum, ii. 707 
Malignant carbuncle, i. 613 
pustule, i. 613 
sore throat, ii. 75 
Malt extract, use of, ii. 668 
Mammary arteries, i. 51 
Mandrake, poisoning by, i. 795 
Mange, ii. 182 
Mania, ii. 620 
Marriage after syphilis, ii. 138, 
of females, proper age for, i. 392 
Marsh’s test for arsenic, i. 783 
Massage, i. 256 
definition of, i. 361 
Masseter muscle, i. 32 
Mastoid cells, ii. 309 
Masturbation (see diseases of the testicle and 
cord), ii. 523 
Matches, poisoning by, i. 814 
poisonous nature of, i, 779 
Mate, or Paraguay tea, i. 135 
Materia medica, i. 332, ii. 899 
Mattresses, ii. 845 
Maxillary arteries, i. 51 
bones, i. 18 
May-apple, poisoning by, i. 795 
McClellan, Ely. on epidemic cholera, ii. 79 
Measles, cause and symptoms of, ii. 72 
complications of, ii. 73 
effect of, upon the ears, ii. 320 
how conveyed, ii. 11 
malignant, ii. 74 
prevention of, ii. 74 
rash of, ii. 73 
treatment of, ii. 73 
Measly pork, i. 121 
Measures, fluid, ii. 901 
Meat, amount consumed as food, i. 118 
effect of cooking on, 119 
Meat-juice, ii. 
Meats, smoked, poisonous, i. 815 
suitable for invalids, ii. 
Meconium, i. 496 
Medicine-dropper, ii. 870 
Medicines, circumstances which modify the 
action of, i. 332 
forms of, ii. 908 
Medicines, list of household, ii. 902 
inodes of administering, ii. 338 
teeth injured by certain, ii, 057 
Median nerve, 
veins, i. 58 
Medulla oblongata, i. 79, 81, 533 
Meibomian glands, ii. 232 
Meinberg mineral water, i. 377 
Melancholia, ii. 622 
Melasma, ii. 176 
“ Mellin’s ” food. i. 499 
Membrana tympani, ii. 308 
Membrane, mucous, i. 8 
serous, i. 8 
synovial, i. 8 
Meningitis, i. 550 
Menorrhagia, ii. 556 
Menstruation, ii. 391, 538 
arrest of, ii. 549 
delayed, ii. 543 
painful, ii. 552 
use of mineral waters, i. 385 
too profuse, ii. 556 
vicarious, ii. 551 
Menstrual derangements, ii. 545 
Mental activity, safe amount for children, i. 541 
derangement as a symptom, i. 320 
habits during pregnancy, i..404 
Mesenteric arteries, i. 54 
Mesentery, the, i. 91, 98 
Mesdames (Vichy) spring, i. 373 
Metatarsus, the, i. 26 
Metrorrhagia, ii. 556, 558, 560 
Mercurials, uses of, i. 364 
Mercurial vapor bath, i. 355 
Mercury, effect on the teeth, ii. 657 
use in syphilis, ii. 135 
Microcephalic, definition of, i. 544, ii. 574 
Micrococcus, in diphtheria, ii. 64 
Middle Park mineral water, i. 377 
Millbank Prison, water supply of, i. 189 
Milfoil, poisoning by, i. 786 
Milia, ii. 156 
Miliary fever, causes and history, ii. 41 
rash, definition of, ii. 43 
Milk, adulteration of, i. 113 
and egg, ii. 889 
as a conveyer of typhoid fever, ii. 20 
as a means of transporting disease, i. 114 
causes that change the character of, i. 496 
composition of, i. Ill 
condensed, as food for infants, i. 499 
value of. i. 114 
cow’s, as infant food, i 498 
differences in. i. 113 
effect of diseases on, i. 496 
effect of menstruation on, i. 496 
effect of mental emotions on. i. 496 
effect of pregnancy on, i. 496 
examination of, i. 116 
excessive flow of. i. 465 
farinaceous, ii. 894 
food-value of. i. Ill 
gelatinized, ii. 890 
human, characteristics of, i. 496 
influence of feeding on cow’s, i. 114 
microscopical appearances of. i. 112 
N. Y. Health Board standard for, i. 115 
of animals as infant’s food. i. 467 
precautions needed in the use of, i. 113 
scanty, i. 426 
specific gravity of, i. 114 
Milk-crust, i. 450, ii. 169 932 
INDEX. 
Milk-cure, i. 345 
Milk-feeding of infants, i. 457 
Milk fever, cause of, i. 423 
Mind, disturbance of, in typhus fever, ii. 31 
Mineral springs, i. 371 
Mineral waters, classification of, i. 373 
composition of, i. 372 
rules for drinkiDg, i. 386 
Minne.'ota, climate of, i. 235, 241 
Miscarriage, i. 433 
“Mistral,” the, i. 235 
Mitral valve, i. 63 
Mixed nursing, directions for, i. 417 
Moist hands and feet, ii. 205 
Moles, ii. 176 
Monads, ii. 10 
Monkshood, poisoning by, i. 784 
Morbid growths, i. 293 
Morning sickness, i. 399 
remedies for, i. 428 
Mortification, i. 289, 292 
Mosquito bites, i. 616 
Moth, ii. 176 
Mother’s marks, ii. 177 
Mouth, anatomy of the, i. 187 
gangrene of the, i. 489 
inflammation of, in infants, i. 187. 485 
symptoms connected with the, L 312 
ulceration of, in infants, i. 486 
washes, ii. 656 
“Mountain sickness,” i. 231 
Movement cure, i. 356 
Mucous coat of the intestine, i. 92 
patches, ii. 133 
Mud bath, i. 354 
Mumps, symptoms of, ii. 115 
treatment of, ii. 116 
Muscies, i. 30 
action of. i. 31 
involuntary, i. 30 
of the abdomen, action of, i. 37 
of the eyeball, ii. 229 
of the eyeball, paralysis of, ii. 293 
of the eyelids, ii. 232 
of the skin, ii. 145 
of respiration, i. 37 
of the wrist and hand, i. 39 
striped, i. 30 
structure of, i. 30 
symptoms connected with the, i. 317 
voluntary, i. 30 
Musculo-spiral nerve, i. 84 
Mushquash root, poisoning by, i. 792 
Mushroom, edible, i. 129 
poisoning, i. 796 
Mushrooms, nutritive value of, L 128 
Mustard whey, ii. 892 
Mute, definition of, ii. 325 
Mutton, “ braxy,” i. 120 
broth, ii. 896 
soup, ii. 897 
nutritive value of, i. 120 
Mycelium, ii. 178 
Mydriasis, ii. 279 
Myocarditis, ii. 733 
Myopia, ii. 295, 300 
Myosis, ii. 279 
ii. 177 
’ Nails, ringworm of the, ii. 182 
Nasal bone, i. 18 
catarrh, acute, ii. 354 
Nasal catarrh, chronic, ii. 358 
“ dry,” ii. 359 
cavities, ii. 347 
ulceration of, ii. 365 
douche, ii. 360 
duct, ii. 233 
septum, deviation of, ii. 369 
perforation of, ii. 369 
syringe, ii. 361 
Nassau, climate of, L 239 
Nausea, ii. 669 
as a symptom, i. 312 
Nauseants, uses of, i. 364 
Navel-cord, i. 396 
division of the, i. 414 
how to dress the, i. 415 
rupture at the, i. 419 
soreness of the, ii. 419 
Near-sight, ii. 295 
Needles, to extract from wounds, L 604 
Nerve cells, i. 76 
fibres, i. 74 
force, i. 78, 540 
functions of, i. 538 
ganglions, i. 86 
terminations of, i. 75 
tissue, mode of development of, i. 537 
Nerves, kinds of, i. 533 
mixed, i. 78 
motor, i. 77 
of the head, i. 82 
of the spine, i. 84 
pneumogastric, i. 83 
roots of the. i. 84 
sensory, i. 78 
sympathetic, i. 86 
Nervines, definition of, i. 360 
Nervous diseases, causes in children, i. 536 
fever, definition of. ii. 14 
frequency of, i. 535 
functional, i. 563 
non-congenital, i. 549 
organic, i. 549 
of adults, ii. 581 
symptoms of, i. 549 
system, i. 74 
anatomy of the. i. 533 
congenital, i. 542 
inhibitory action of, i 539 
symptoms connected with the, i. 318 
“ Nestle’s lacteous farina,” L 499 
Nettle poisoning, i. 778 
rash, ii. 159 
Neundorf mineral water, i. 377 
Neuralgia, ii. 598 
cervico-brachial, ii. 600 
during pregnancy, i. 431 
intercostal, ii. 600 
occipital, ii. 600 
of the anus, ii. 724 
of the heart, ii. 746 
of the urethra, ii. 503 
spinal, ii. 600 
use of warm baths in, i. 382 
Nichols, Dr. A. H.. on climate, i 225 
Night-blindness, ii 285 
worms as a cause of, i. 522 
Night-lights, ii. 866 
Nightshade, poisoning by, i. 798 
Night-terrors, i. 577 
Nightwalking, i. 581 
Ninth day,” i. 427 
Nipple, changes due to pregnancy, i. 400 INDEX. 
933 
Nipples for nursing-bottles, i. 468 
sore, i. 425 
Nitrate of lead as a disinfectant, i. 159 
Nitrogen, function as an element of air, i. 147 
Nitrous acid as a disinfectant, i. 161 
mode of producing, i. 162 
Nodes, syphilitic, ii. 134 
Nodules (skin) definition of, ii. 149 
North Carolina warm springs, i. 380 
Nosebleed, i. 591, ii. 370 
as an early symptom of typhoid fever, ii. 22 
Nose, catarrh of the, ii. 354 
deformities of the, ii. 374 
diseases of the, ii. 353 
foreign bodies in the, ii. 369 
fracture of the, i. 648. ii. 372 
function during speech, ii. 352 
in respiration, ii. 353 
restoration of the, ii. 373 
the, ii. 347 
Nostrils, function in respiration, ii. 378 
Nucleolus, definition of a, i. 76 
Nucleus, definition of a. i. 76 
Nursery temperature of the, i. 247 
Nurses, changing, i. 467 
Nursing, ii. 839 
effects on the mother of, i. 417 
maternal, i. 459 
mixed, i. 461 
mothers, rules for, i. 463 
of infants liable to brain disease, i. 554 
Nutritive equivalents of foods, i. 103 
Nutrition, physiology of, i. 105 
Nystagmus, ii. 293 
OATMEAL, nutritive value of, i. 126 
porridge, ii. 893 
tea, ii. 893 
water,' ii. 891 
Obesity, causes of, i. 108 
Oblique muscles of the abdomen, i. 35, 36 
Obstetrics, definition, i. 389 
Obturator muscles, i. 42 
Occipital arteries, i. 50 
bone, i. 16 
Occipito frontalis muscle, i. 32 
(Edema, i. 292 
(Esophagus, the, i. 89 
Officinal remedies, ii. 900 
Oiling the skins of infants, ii. 449 
Oil, carbolized, ii. 912 
of bitter almonds, poisonous, i. 812 
Ointments, ii. 909 
Oleander, poisoning by, i. 801 
Olecranon, the, i. 21 
Oleomargarine, i. 116 
Olfactory bulbs, ii. 351 
Omeiet, ii. 897 
Omentum, the, i. 98 
Omo-hyoid muscle, i. 36 
Onychia, ii. 201 
of the toes, ii. 213 
Operations, arrangements for, ii. 877 
Opium, administration to infants, i. 510 
dose of tincture, for adults, ii. 902 
Ophthalmic arteries, i. 51 
Ophthalmoscope, i. 386, ii. 283 
Optic axis, ii. 222 
disk, ii. 229 
foramen, the, ii. 221 
lobes, the, i. 8l 
nerves, ii. 229 
Optic nerves, diseases of, ii. 285 
papilla, ii. 227 
thalamus, the, i. 81 
Ora serrata, ii. 226 
Oratava, climate of, i. 236 
Orbicularis oris muscle, i. 32 
palpebrarum muscle, i. 32 
Orbits, the, ii. 221 
Orchitis, ii. 528 
Organ, definition of an, i. 3 
Organic matter an element of air, i. 152, ii. 9 
Origins of muscles, i. 31 
Os calcis, the, i. 27 
Ossification, centres of, i. 6 
of arteries, ii. 750 
Ovarian tumors, ii. 568 
Ovary, i. 389 
Ovulation, i. 390 
Ovum, the, i. 389 
changes due to conception, i. 394 
Oxalate of lime in urine, ii. 474 
Oxygen, a.s a constituent of the air, i. 146 
effect of a deficient supply of, i. 147 
its necessity to life, i. 146 
mode by which it reaches the tissues of the 
body, i. 147 
Ozone as a disinfectant, i. 160 
as an element of air, i. 154 
effects of an excess of, i. 154 
importance of, in the atmosphere, i. 230 
sources of armospheric, i. 154 
where most common, L 154 
Ozena, ii. 363 
PACINIAN corpuscles, i. 75 
Pail-closet, Rochdale, i. 180 
Pain as a symptom, i. 318, ii. 546 
in the belly, ii. 672 
in the bowels of infants, i. 481 
in the eyeball, importance as a symptom, 
ii. 247 
Paints, poisonous, i. 780 
Palatal bones, i. 18 
fissures of, ii. 812 
Palate, paralysis of the, i. 564 
fissures of, ii. 812 
relaxation of, i. 392 
uses of the soft, i. 89 
Palpitation, i. 308, ii. 735, 747 
Palsy, ii. 593, 596 
wasting, ii. 606 
shaking, ii. 607 
■Panada, ii. 892 
Pancreatic juice, i. 93 
Pancreatine, i. 93 
Pancreas, the. i. 90, 92 
Pandemic diseases, ii. 3 
Papillae of the skin, ii. 144 
Paralysis, ii. 593 
facial, ii. 598 
following diphtheria, ii. 66 
from lead poisoning, i. 780 
from pressure, ii. 597 
infantile, i. 559 
of eyelids, ii 257 
of infants, sudden, i. 560 
of the insane, ii. 624 
spinal, ii. 596 
use of warm baths in, i. 382 
Paraphymosis, ii. 500 
Paraplegia, ii. 596 934 
INDEX. 
Parasites, skin, ii. 178 
Paregoric, use for infants, i. 510 
Paresis, ii. 624 
Parietal bones, i. 17 
Paris green, poisoning by, i. 813 
Paroquet mineral water, i. 376 
Parotid glands, the, i. 88 
Parotitis, ii. 115 
Parvin, T., on obstetrics; or, the art of mid- 
wifery, i. 389 
Paso Robles mineral water, i. 877 
hot springs, i. 380 
Patella, the, i. 25 
Peas, cheese made from, i. 127 
nutritive value of, i. 127 
poisonous i. 809 
Pectineus muscle, i. 45 
Pector.dis major muscle, i. 36 
minor muscle, i. 36 
Pectoral muscles, i. 88 
Pelvis, the, i. 24 
the female, i. 390 
Penis, cancer of, ii. 501 
wounds of, ii. 501 
Pepsin, ii. 666 
Percussion, definition of, i. 321 
Pericarditis, ii. 729 
Pericardium, the, i. 64 ,» 
Periphlebitis, ii. 752 
Periosteum, definition of, i. 5 
Peritoneum, the. i. 98 
Peritonitis, ii. 691 
in typhoid fever, ii. 26 
Permanganate of potash as a disinfectant, i. 159 
wash, i. 422 
Pernicious fever, ii. 55 
Perineal muscles, i. 47 
Perspiration, offensive, ii. 157 
Pertussis, ii. 833 
Petechise, definition of, ii. 62 
Petit mal, ii. 603 
Peyer’s patches, i. 92 
Pfeiffer, Carl, on the hygiene of house build- 
ing, i. 261 
Phagedenic, definition of, ii. 129 
Phalanges, the. i. 26 
Pharynx, ii. 378 
Pharmacopoeial remedies, ii. 900 
Pharmacy, ii. 899 
Pharyngitis, acute, ii. 386 
chronic, ii. 392 
Phimosis, ii. 498 
Phlogiston, i. 142 
Phosphate of lime, nutritive value of, i. 104 
Phosphates, urinary, ii. 473 
Phosphorus poisoning, i. 779 
Phrenic arteries, i. 53 
Phthisis pulmonalis, ii. 444 
Physical diagnosis, description of, i. 320 
Physiology, chapter on, i. 3 
Pia mater, i. 77, 79 
Pickles, poisonous, i. 808 
Piffard, on chancroid and syphilis, ii. 120 
Pigeon breast, i. 388 
Pigment of retina, ii. 22S 
skin, ii. 146 
Pimples, ii. 155 
supposed influence of some foods in causing, 
ii. 151 
PlNKHAM, Dr. J. W., on drainage, sewerage, 
and water supply, i. 167 
Pink-root as a remedy for worms, i. 524 
Piles, ii. 709 
Piles during pregnancy, L 429, 442 
location of, i. 60 
Pills, ii. 910 
Placenta, i. 394 
Plague, filth-origin of the, i. 172 
the, ii. 37 
Plantar arteries, i. 55 
fascia, i. 48 
Plants, rules for gathering, ii. 900 
Plasma, definition of, i. 68 
Plaster, adhesive, i. 599 
to apply, i. 600 
Plaster-of-Paris dressings, i. 643 
splint for leg, i. 694 
Plasters, ii. 909 
Platysma rnyoides muscle, L 32, 36 
Plethora, definition of, i. 297 
Pleura, arrangement of the, i 71 
Pleurisy, ii. 430 
acute, ii- 431 
chronic, ii. 433 
in children, ii. 458 
Pleurodynia, ii. 600 
Pleximeter, description of, i. 321 
Plexus of nerves, definition of, i. 85, 86 
Plica similunaris, ii. 331 
Plombieres hot springs, i. 381 
Pneumogastric nerve, i. 83 
Pneumonia, ii. 435 
catarrhal, ii. 441 
croupous or lobar, ii. 437 
. interstitial, ii. 443 
varieties of, ii. 436 
Pneumo-hydrothorax, ii. 435 
Podophyllum peltatum, poisoning by, i. 795 
Poison dogwood, poisoning by, i. 776 
Poison ivy, poisoning by, i. 776, ii. 163 
Poison oak, poisoning by, i. 776 
Poison sumach, poisoning by, i. 776 
Poisoned wounds, treatment of, i. 613 
Poisoning, what to do in a case of, i. 817 
Poisonous cooking vessels, i. 807 
foods, i. 807 
plants, i. 776 
plants liable to be eaten, i. 784 • 
Poisons, definition of, i. 771 
their effects and antidotes, i. 771 
Poke, poisoning by, i. 802 
Polypus, nasal, ii. 367 
of rectum, ii. 718 
of the uterus, ii. 563 
Pomegranate, bark of the root as a tape-worm 
remedy, i. 526 
Pons Varoiii, the, i. 80 
Popliteal artery, i. 54 
Pork, a bad application for wounds, i. 605 
as a source of tape-worm, i. 517 
liability to be diseased, i. 121 
nutritive value of, i. 121 
precautions to be taken in cooking, i. 122 
Portal vein, i. 60 
Position of child during labor, i. 506 
Posterior chamber of the eye, ii. 228 
tibial artery, i. 55, 56 
tibial muscle, i. 47 
Potato apples, poisoning bv, i. 800 
Potatoes as preventives of scurvy, ii. 820 
poisonous, i. 800 
mashed, i. 898 
Potassium salts, nutritive value of, i. 105 
Poultices, formulas for, ii. 911 
how to make, ii. 861 
improper for use on eyes, ii. 252 INDEX. 
935 
Poultry, nutritive value of, i. 123 
Poupart’s ligament, i. 35, 36 
Powders, ii. 910 
administration of, ii. 871 
Pregnancy, definition of, i. 389 
diseases peculiar to, i. 428 
duration of, i. 389 
hygiene of, i. 402 
signs of, i. 398 
termination of, i. 404 
Prepuce, ii. 498 
Presbyopia, ii. 295, 296 
Prescott, A. B., on poisons, i. 771 
Presentation during labor, definition of, i. 405 
Privet, poisoning by, i. 801 
Privy, an improved form of, i. ISO 
Privies, dry-earth system of, i. 181 
objections to, i. 179 
odorless method for emptying, i 183 
Procidentia, of bowel, ii. 719 
Prodromes, definition of, ii. 30 
Profunda artery, i. 54 
Prolapsus, ii. 560 
of bowel, ii. 719 
Promenades for infants, i. 453 
Pronator muscles of the arm, i. 40 
Prostate, ii. 506 
enlarged, ii. 508 
inflammation of the, ii. 597 
tubercle and cancer of the, ii. 508 
Prostration, i. 295 
Protomycites, definition of, ii. 33 
Protoplasm, i. 4 
Proud flesh, definition of, i. 606 
Proximate principles composing the body, i. 105 
Prunes, stewed, ii. 895 
Pruritus, ii. 178 
Psoas muscles, i. 36, 42 
Pseudencephalic. definition of, i. 543 
Psoriasis, ii. 170 
Pterygium, ii. 269 
Ptosis, ii. 257 
Puberty, i. 392, ii. 538 
hygiene of, ii. 542 
Pubis, the, i. 23 
Pudding, farinaceous milk, ii. 894 
Pudic artery, i. 55 
Pullna mineral water, i. 37S 
Pulmonary artery, i. 56 
emphysema, ii. 420 
veins, i. 61 
Pulp of the teeth, ii. 643 
Pulsatilla, poisoning by, i. 804 
Pulse at the wrist, location of, i. 52 
in inflammation of the brain, i. 552 
in typus fever, ii. 30 
nature of the, i. 307 
Pumpkin-seed as a tapeworm remedy, i. 526 
Punkey-bites, i. 618 •" 
Pupil, ii. 225 
contraction of. ii. 279 
excessive enlargement of, ii. 279 
Purgatives, ii. 907 
Purgative waters, L 378 
Purples, the, ii. 173 
Purpura, ii. 173 
Pus-poisoning, i 645 
Pustule, malignant, i. 613 
Pustules, definition of, ii. 149 
Pyaemia, i. 293, 300, 645 
Pyloric extremity of the stomach, i. 90 
Pyriformis muscles, i. 42 
Pyrmont mineral water, i. 377 
Pyrosis, ii. 672 
Pythogenetic fever, ii. 15 
QUADRATUS FEMORIS muscle, i. 42 
Quarantine in yellow fever, ii. 36 
necessity for, ii. 13 
Quartan fever, ii. 53 
“ Queen’s chair,” to make a, i. 633 
Quickening, i. 394, 400 
Quicksilver as a remedy in intestinal obstruc- 
tion, i. 528 
Quinine, effects upon ears of, ii. 322 
effects upon the eyes of, ii. 286 
in malarial fevers, use of, ii. 57 
popular fallacies regarding effects of, ii 58 
Quinsy, i. 389 
Quotidian fever, definition of, ii. 53 
Rabies, ii. 95 
in man, symptoms of, ii. 105 
in the wolf, ii. 103 
mode of communication, ii. 102 
symptoms of, ii. 98, 110 
when most prevalent, ii. 97 
Radial artery, i. 52 
nerve, i. 84 
veins, i. 58 
Radius, the, i. 21 
Rainfall, causes which influence, i. 226 
in Egypt, i. 229 
Ranunculus, poisoning by, i. 187 
Rawley Spring mineral water, i. 377 
Reading by invalids to be avoided, ii. 245 
in bed, harmful effects of, ii. 245 
music liable to hurt the eyes, ii. 246 
on railroads harmful to the eyes, ii. 245 
Rectum, i. 97, ii. 705 
abscess of the, ii. 717 
cancer of the, ii. 721 
diseases of the, ii. 705 
foreign bodies in the, ii. 723 
polypus of the, ii. 718 
stricture of the, ii. 713 
ulcer of the, ii. 712 
veins of the, i. 59 
Rectus muscle, of the abdomen, i. 35, 36 
muscle of the thigh, i. 36 
Red eyes, salted water as a wash for, ii. 243 
Red gum, i. 48 
Red Sulphur mineral water, i. 376 
Reflex action, explanation of, i. 538 
movements, definition of, i. 77 
Regurgitation, definition of, ii. 734 
Relapsing fever, ii. 39 
Relaxed bowel, ii. 723 
Remittent fever, ii. 53 
complications in, ii. 54 
Renal veins, i. 60 
Rennet whey, ii. 891 
Reserve air, i. 73 
Residual air, i. 72 
Resolution, i. 289 
Respiration, artificial, for stillborn infants, i, 
414 
physiology of, i. 72 
sounds connected with, i. 322 
symptoms connected with, i. 309 
Respirators, ii. 380 
Respiratory organs, i. 69 
diseases of the, ii. 407 
in children, diseases of the, ii. 456 936 
INDEX. 
Rest during pregnancy, i. 404 
essential in childhood, i. 540 
Reports, nurse’s, ii. 876 
Retina, ii. 226 
central artery of the, ii. 229 
central vein of the, ii. 229 
diseases of the, ii. 284 
Retroflexion of the uterus, ii. 563 
Retroversion of the uterus, ii. 561 
Revaccination, course of, ii. 121 
Rheumatism, ii. 821 
acute, ii 822 
as a cause of St. Vitus’s dance, i. 571 
chronic, ii. 823 
deforming, ii. 825 
syphilitic, ii. 134 
use of mineral waters in, i. 381 
Rhus-poisoning, i. 776 
Ribs, i. 20 
fractures of, i. 668 
Rice-eating, effects of, i. 127 
milk, ii. 893 
nutritive value of, i. 126 
water, ii. 89 L 
“ Rice-water ” stools of cholera, ii. 82 
Rickets as a cause of convulsions, i. 566 
as a cause of fabe-croup, i. 565 
congestion of the brain from, i. 555 
definition of, i. 298 
paralysis from, i. 562 
Ridges, food, i. 499 
Riding, i. 251 
Rigor mortis, ii. 879 
Ringworm, ii. 179 
of the beard, ii. 181 
of the nails, ii. 182 
Rochdale privy, i. 180 
Roasting, h. 883 
Robinson. B., on the care of infants in health, 
i. 445 
Rockbridge mineral water, i. 378 
Rooms, dark, improper for diseased ej'es, ii. 
252 
disinfection of, i. 161 
Roosa, D. B. St. J., on the care and diseases 
of the eyes, ii. 241 
Rotheln, or “ German measles,” ii. 73 
Rowing-exercise, i. 252 
Rubbing, ii. 868 
Rubefacients, i. 859 
Rubeola, ii. 72 
Run-around, ii. 201 
Rupture, i. 762 
at the navel, i. 419 
flatulence as a cause of, ii. 673 
Russian bath, i. 353 
Rye, nutritive value of, i. 125 
SACCHAROMYCES cerevisise, ii. 7 
Sacral arteries, i. 53 
nerves, i. 85 
Sage-tea, ii. 6 
Sago, ii. 898 
posset, ii. 891 
Saline waters, i. 874 
Saliva, i. 88 
uses of, ii. 660 
Salivation during pregnancy, i. 429 
murcurial, ii. 657 
Salt, common, nutritive value of, 104 
Salt pork a bad application for wounds, i. 605 
Saltrheum, ii. 168 , 
Salt-sulphur mineral water, i. 376 
Salt, value of, as a condiment, i. 129 
Sand bath, i. 354 
Santa Barbara mineral water, i. 377 
Saute, ii. 884 
Sanitaria, period when most resorted to, i. 236 
Santonin as a remedy for worms, i. 524 
Saratoga mineral waters, i. 374 
Sarcoptes, ii. 187 
Sartorius muscle, i. 44 
Sausage-meat as a source of tapeworm, i. 517 
Sausages, poisonous, i. 815 
Scab, definition of, ii. 149 
Scabbing of wounds, i. 607 
Scabies, ii. 187 
Scald-head. ii. 169. 183 
Scalp, disease of. ii. 183 
Scaphoid, the, i. 27 
Scapula, the, i. 20 
Scar, nature of a, i. 606 
Scarf-skin, the, ii. 143 
Scarlatina (see scarlet fever), ii. 74 
as a cause of convulsions, i. 567 
malignant, ii. 75 
Scarlet fever, causes and symptoms, ii. 74 
effect upon the ears of, ii. 320 
how conveyed, ii. 11 
prevention of, ii. 77 
rash of, ii. 75 
results of, ii. 76 
Scavengers, comparative healthfillness of, ii. 16 
Schlangenbad warm springs, i. 3~>1 
School-desks, proper form of. ii. '.'43 
School-rooms, proper lighting of, ii. 243 
Schooley’s Mountain mineral water, i. 297 
Schooling, excessive, as a cause of brain-disease, 
i. 553 
Schwalbach mineral water, i. 377 
, Sciatica, ii. 600 
Sclerosis, definition of, i. 559 
Sclerotic, ii. 223 
, Scoke, poisoning by, i. 802 
Scorbutus, i. £98, ii. 819 
Scorpion-bites, i. 620 
s Screaming at night, i. 577 
Screens, ii. 866 
Scrofula, definition of, i. 297 
use of mineral waters in, i. 382 
Scurvy, definition of i. 298, ii. 819 
Seasickness, ii. 831 
Seat bone, the, i. 23 
Sebaceous glands, ii. 145 
disorders of, ii. 152 
Seborrhoea, definition of, ii. 154 
Sedatives, i. 364, ii. 905 
Self-abuse (see diseases of the testicle and 
cord), ii. 523 
Selters mineral water, i. 874 
Semilunar ganglion, the, i. 86 
Semimembranous muscle, i. 46 
Semitendinosus muscle, i. 34, 46 
Septicaemia, definition of, i. 300 
Septic diseases, definition, ii. 3 
Seratus magnus muscle, i. 40 
muscles, i. 64 
Serous membranes, i. 64 
Serum, definition of, i. 68 
Sewage, nature of, i. 171 
Sewers as sources of disease, ii. 17 
Sewerage, general considerations, i. 171 
proper definition of, i. 167 
Sewer gas, means of protection against, i. 174 
J source of, i. 174 INDEX, 
937 
Sewer traps, construction of, i. 175 
Sharon mineral water, i. 376 
Shell-fish, nutritive value of, i. 123 
Shin bone, i. 25 
Shingles, ii. 167, 601 
Shining skin, cause of, ii. 152 
Shock, i. 587 
Shoemaker, J. V., on exercise, i. 245 
Shoes, improper, ii. 208 
Meyer’s, ii. 207 
proper, ii. 207 
Shortness of breath, ii. 735 
Short-sight, nature of, ii. 300 
Short supinator muscle, i. 40 
Shoulder-blade, i. 20 
dislocations of, i. 716 
fracture of, i. 655 
Shoulder, fracture of the point of, i. 655 
muscles of the, i. 40 
Shrady, Geo. F., on general surgery, ii. 791 
Sight, loss of, ii. 247 
Sight-purple of the retina, ii. 324 
Sigmoid flexure of the colon, i. 96, ii. 7C5 
Sinus, ii. 816 
S muses of the skull, i. 57 
Size of infants at birth, i. 397 
Skeleton, the human, i. 10, 11 
Skin, care of the, ii. 147 
color of the, ii. 146 
dryness of the, ii. 153 
eruptions of secondary syphilis, ii. 133 
excessive growth of the, ii. 173 
greasiness of the, ii. 152 
inflammations of the, ii. 157 
in typhoid fever, eruption on the, ii. 23 
poisoning by the, i. 774 
shedding of, after scarlatina, ii. 75 
structure of the, ii. 143 
symptoms connected with the, i. 313 
diseases, causes of, ii. 150 
classification of, ii. 150 
use of mineral waters in, i. 3S5 
Skin-worms, ii. 155 
Skunk bites, i. 629 
Sleep during confinement, i. 411 
of infants, i. 450 
Sleeplessness, ii. 588 
Slop-water, disposal of, i. 183 
filter for, i. 183 
Small-pox, cause and symptoms of, ii. 69 
character of the eruption of, ii. 70 
when most contagious, ii. 11 
Smell, sense of, ii. 351 
Smith, J. Lewis, on the diseases of the diges- 
tive organs in infancy and childhood, i, 
477 
Smoked glasses, when useful, ii. 244 
Smoky air harmful to the eyes, ii. 244 
Smothering, i. 757 
Snake-bites, i. 622 
poisoning by, i. 778 
treatment of, i. 624 
Snake-stones, i. 624 
Snellen’s test-type, ii. 249 
Snoring, cause of, ii. 359 
Snow-light bad for delicate eyes, ii. 244 
Soap-and-sugar, bad for wounds, i. 605 
Soap, choice and use of, ii. 148 
Soda, use as a mouth-wash, ii. 659 
Soil-dampness as a cause of sickness, i. 227 
Soil, character of, as influencing climate, i. 
Soil-pipes, arrangement of, i. 176 
Soil, sandy, healthful nature of, i. 228 
Soil-water, i. 170, 191 
Solar plexus, the, i. 86 
Somnambulism, i. 581 
Sore buttocks, causes of, i. 506 
Sore eyes, consequences of. ii. 267 
proper care of, ii. 252 
Sore throat, use of mineral waters in, i. S83 
in syphilis, ii. 133 
of scarlatina, ii. 75 
Soup, mutton, ii. 897 
vegetable, ii. 894 
Sour-stomach. ii. 672 
South Carolina, climate of, L 234 
Sparring exercise, i. 254 
Spasm, as a symptom, i. 317 
Spectacles, the use of, ii. 294 
invention of, ii. 295 
Specifics, definition of, i. 344 
Speech, absence of power of, i. 545 
Spermatazoa, i. 392 
Sphenoid bone, i. 17 
Sphj’gmograph, description of, i. 327 
Spigelia, as a remedy for worms, i. 524 
poisoning by, i. 802 
Spider-bites, i. 615 
Spinal anaemia, ii. 584 
cord, absence of the, i. 546 
anatomy of the. i. 76, 534 
bleeding into the, i. 548 
diagram of a portion of the, i. 78 
diseases of, in childhood, i. 559 
function of the, i. 77 
hardening of the, i. 562 
inflammation of the, i. 559 
irritation, ii. 584 
nerves, i. 78, 84 
Spine, i. 13 
cleft, i. 546 
dislocations of the, i. 714 
fissure of the, i. 546 
Spirometer, description of, i. 329 
Spleen, i. 9S 
Splenic arteries, i. 54 
Splint bone, i. 25 
Splinters, to extract, i. 604 
Splints, various kinds of, i. 642 
Split-lip, ii. 809 
Sponges, care of, ii. 868 
Sporadic, definition of, ii. 63 
Spores, ii. 178 
Spots on theej'e, ii. 273 
Spotted cowbane, poisoning by, i. 792 
Spotted fever, i. 551, ii. 23, 61 
Sprains, i. 7(55 
Sprue, i. 488 
Spurred rye, poisoning by, i. 788 
Squint, ii. 290 
St. Anthony’s fire, ii. 165 
Starch, digestion of, i. 93, ii. 667 
grains, illustrations of, i. 124 
indigestion of, ii 667 
Starches, nutritive value of, i. 106 
Staphyloma, ii. 275 
St. Augustine, climate of, i. 234 
Stenon’s duct, i. 8S 
Sterility, i. 440 
Sterno-cleido-mastoid muscle, i. 32, 36 
Sterno-hyoid muscle, i. 36 
Sternum, the, i. 18 
Stethoscope, description of, i. 322 
Stewing, ii. 883 
Stiff joints, use of mineral waters for, i. 385 
Stillbirth, l. 427 938 
INDEX. 
Stillborn infants, management of, i. 414 
revival of. i. 760 
Stimulants, i. 369, 905 
administration of, to infants, i. 513 
Stings and bites of insects, i. 615 
poisoning by, i. 778 
Stink-nose, ii. 363 
Stockings, ii. 207 
Stomach, i. 89 
cancer of the, ii. 693 
digestion, process of, ii. 666 
inflammation of the, ii. 681 
movements of the, ii. 666 
neuralgia of the, ii. 686 
pits of the, i. 90 
poisoning by the, i. 774 
ulceration of the, ii. 673 
Stone-bruise, ii. 215* 
Stone in the bladder, ii 521. 
in the kidney, ii. 488 
Stoves, i. 273 
coal, precautions in the use of, i. 155 
Strabismus, ii. 290 
Stramonium, poisoning by, i. 802 
Strangling, i. 757 
Stranguary, definition of, i. 315 
“ Strawberry tongue,” ii. 75 
Stretcher, how to make a, i. 631 
Stricture, cause of urethral, ii. 504, 505 
of gullet, ii. 681 
of rectum, ii. 713 
Stupes, ii. 872 
St. Vitus’s dance, i. 572 
as a symptom of tumors of the brain, i. 558 
epidemic, i. 573 
worms as a cause of, i. 522 
Styes, ii. 255 
Subclavian arteries, i. 51 
Sublingual gland, the, i. 88 
Submaxillary gland, the, i. 88 
Subscapular artery, i. 50 
Subscapularis muscle, L 40 
Sudor Anglicus, ii. 42 
Surf-bathing, i. 253 
Sugar, digestion of, i. 93 
liver, i. 95 
nutritive value of, i. 106 
source of supply, i. 106 
Sugars, poisonous chemicals in, i. 810 
Sulphuretted hydrogen as an atmospheric im- 
purity', i. 156 
Sulphurous acid as a disinfectant, i. 161 
mode of producing, i. 162 
Sulphur waters, i. 375 
Summer catarrh, ii 45 
excursions for infants, i. 455 
Sunflowers, as preventives of malarial fevers, 
ii. 50 t 
Sunlight, hygienic value of, i. 282 
Sunstroke, ii. 830 
when most liable to occur, i. 148 
Suppurants, definition of, i. 359 
Suppuration, i. 289 
Supra-renal capsules, the, i. 98 
Supra spinatus muscle, i. 34, 40 
Suppository soap, i. 514 
Suppositories, ii. 910 
administration of, ii. 871 
Suture, sagittal, i. 17 
Swallowing, difficulty of, ii. 681 
foreign bodies, i. 762 
mechanism of, i. 89 
Swamp hellebore, poisoning by,.i. 790 
Sweat-glands, ii. 144 
disorders of, ii. 156 
Sweating in intermittent fever, ii. 52 
of hands and feet, ii. 156 
sickness, ii. 42 
Swedish movement exercise, i. 257 
Sweeping, ii. 866 
Sweetbread, the, i. 90. 62 
Sweetflag as a preventive of malarial fevers. 
50, 57 
Sweet Springs (Ya.) mineral water, i. 379 
Swelling of limbs during pregnancy, i. 430 
Swimming exercise, i. 253 
Swooning, i. 589 
Sycosis, ii, 172, 181 
Sympathetic system of nerves, i. 74, 86 
Symptoms, how to record, ii. 876 
Syncope, definition of, i. 589 
Synovial fluid, i. 28 
membranes, i. 28 
Syphilis, ii. 131 
definition of, i. 298 
hereditary, ii. 134 
influence upon question of marriage, 
138 
origin and nature of, ii. 131 
secondary, ii. 133 
tertiary, ii. 134 
use of mineral waters in, i. 381 
Syphilitic inflammation of the eye, ii. 274 
Syringes, ii. 357, 863 
Syrups, ii. 910 
poisonous chemicals in. i. 810 
System, definition of a, i. 3 
“ Systems ” of treatment, L 340 
Systole, definition of, i. 65 
H'lABES dorsalis, ii. 597 
1- Tactile corpuscles, i. 75 
Taenia (tape worm) i. 516 
echinococcus, ii. 490 
Talipes, ii. 216 
calcaneus, ii. 216 
equinus, ii. 216 
valgus, ii. 216 
varus, ii. 216 
Tan, ii. 175 
Tapeworm of the dog, ii. 491 
origin of the, ii 121 
treatment of, i. 525 
Tarsal artery, i. 55 
Tarsus, the. i. 26 
Tartar on the teeth, ii 653 
Tea as a drink in sickness, ii. 882 
effects of, i. 131 
mode of preparing, i. 131 
nutritive value of. i. 130 
varieties of, i. 131 
Tear-apparatus, ii. 232 
diseases of, ii. 260 
Tears, ii 233 
Teeth, action of medicines on the, ii. 657 
artificial, ii. 654 
care of the, ii 656 
decay of the. ii. 650 
order of appearance of the, ii. 645 
peculiarities of the, ii. 659 
permanent, ii. 642 
primary or milk, ii. 644 
shedding, ii. 647 
uses of the, ii. 643 
wisdom, ii. 649 INDEX. 
939 
Teething, i. 491 
peculiarities of, ii. 659 
Temperament, varieties of, i. 805 
Temperature, causes of variation in, i. 225 
effect of illness upon, ii. 876 
how to ascertain, ii. 875 
in intermittent fever, ii. 52 
in typhoid fever, ii. 24 
in typhus fever, ii. 80 
of the body, ii. 874 
Temporal artery, i. 51 
bone, i. 17 
Tendinous cords of the heart, i. 63 
Teneriffe, climate of, i. 236 
Tenesmus, definition of, ii. 60 
Teres muscles, i. 84, 36, 40 
Tertian fever, definition of, ii. 53 
Test-letters, ii. 247 
Testicle and cord, diseases of the, ii. 523 
inflammation of the, ii. 528 
swollen, ii. 527 
following mumps, ii. 116 
tumors of the, ii. 529 
Tetanie, i. 570 
Tetanus of the new-born, i. 548 
Texas, climate of, i. 240 
Theme, i. 130 
found in Mate', i. 186 
Theobromine, i. 133 
Therapeutics, definition of, L 332 
Thermal waters, i. 380 
Thermometer, clinical, description of, L 825, 
ii. 874 
Thumb, dislocations of the, i. 726 
Thomasville, climate of, i. 239 
Throat, ii. 377 
care of the, ii. 378 
causes of disease of the, ii. 379 
sore, i. 386 
chronic, i. 892 
swelling of, in diphtheria, ii. 65 
Thrombosis, ii. 742 
Thrush, i. 488 
Thomsonianism, i. 333 
Thoracic arteries, i. 50 
duct, i. 73 
Thorax, cavity of the, i. 71 
Thorn apple, poisoning by, i. 802 
Thorns, to extract, i. 604 
Thigh, arteries of the, i. 54 
bone, i. 24 
fractures at middle portion of, i. 674 
fractures at the neck of, i. 670 
movements of the, how accomplished, i. 44 
muscles of the, i. 44 
Thymus gland, i. 98 
Thyroid artery, i. 50, 51 
cartilage, i. 69 
gland, i. 50, 98 
Tibia, i. 25 
Tibial nerve, i. 55 
Tick-bites, i. 617 
Tic-douloureux, ii. 600 
Tidal air, i. 73 
Tinea circinata, ii. 179 
favosa, ii. 184 
sycosis, ii. 179 
tonsurans, ii. 179 
versicolor, ii. 186 
Tissue, adipose, i. 5 
cellular, i. 4 
connective, i. 4 
definition of, i. 3 
Tissue, fibrous, i. 4 
Tissues, description of the various, i. 4 
Toast-water, ii. 891) 
Tobacco amaurosis, ii. 2S6 
as a cause of eye disease, ii. 285 
effects of use, upon vision, ii. 250 
Toe-nails, ingrowing, ii. 213 
Toes, cracks in the, ii. 216 
dislocations of bones of the, i. 753 
Toeplitz hot springs, i. 3S 
Tongue, anatomy of the, i. 88 
enlargement of, ii. 751 
in scarlet fever, appearance of, ii 75 
in typhus fever, appearance of, ii. 31 
symptoms connected with the, i. 311 
Tonics, ii. 904 
Tonsils, ii. 378 
enlarged, ii. 387 
inflammation of the, i. 389 
Tooth-ache, ii. 652 
during pregnancy, i. 431 
Tooth-powders, ii. 656, 914 
Torricelli’s experiment, i. 143 
Torula cerevisise, ii. 7 
Toxaemia, definition of, i. 299 
Trachea, anatomy of the, i. 70 
Tracheotomy, value of, ii. 68 
Transfusion, definition of, i. 340 
Transportation of the sick and wounded, i. 630 
Transversalis muscle of the abdomen, i. 35 
Trapezius muscle, i. 32, 33, 34, 36 
Traumatic, definition of, ii. 729 
Tree planting, influence on rain-fall, i. 229 
Trephining (or trepanning), nature of operation, 
i. 704 
Triceps muscle of the arm, i. 36, 39, 40 
Trichina disease, mistaken for typhoid fever, ii. 
20 
spiralis, i. 122 
Trichocephalus, i. 520 
Tricophyton tonsurans, ii. 180 
Tricuspid valve, i. 63 
Triplets, frequency of, i. 398 
Trochanters, the, i. 24 
of the thigh bone, i. 34 
Troches, ii. 911 
Tropical fever, ii. 54 
Truffle, dietetic value of, i. 129 
Trunk, muscles of the, i. 33 
Trusses for ruptured navel, L 419 
importance of, i. 763 
Tuber-annulare, the, i. 80 
Tubercle of the prostate, ii. 508 
Tubercles (skin), definition of, ii. 149 
Tubercula quadrigemina, the, i. 81 
Tuberculosis, definition of, i. 297 
Tumors, i. 293, ii. 791 
bony, ii. 796 
cartilaginous, ii. 795 
cystic, ii. 797 
fatty, ii. 792 
fibrous, 792 
fibrous, of the uterus, ii. 564 
fibro-cystic, ii. 565 
fibrous, of the nose, ii. 368 
horny, ii. 795 
of the bladder, ii. 523 
of the brain, i. 55S 
of the nasal cavity, ii. 367 
ovarian, ii. 568 
vascular, ii. 794 
Turbinated bones, i. 18 
Turkish bath, i. 353 940 
INDEX. 
“ Tusks,” ii. 648 
Twins, i. 437 
frequency of, i. 39S 
Twitching of muscles, i. 572 
Type suitable for the eyes, ii. 242 
Typhlitis, ii. 692 
Typhoid fever, ii. 14 
ages most liable to, ii. 14 
epidemic at Croydon, ii. 15 
at Halle, ii. 16 
at Kloten, ii: 20 
at North Boston, ii. 17 
eruption of, ii. 23 
frequency of, ii. 14 
influence of filth in causing, i. 172 
liability of wash-women to, ii. 19 
mode of conveyance of, ii. 18 
nature of, ii. 15 
not contagious, ii. 19 
probabilities of, ii. 26 
symptoms of, ii. 21 
treatment of, ii. 26 
when most common, ii. 14 
poison, difficulty of destroying, ii. 20 
experiments with, ii. 19 
Typho-malarial fever, ii. 54 
Typhus abdominalis, ii. 22 
Typhus fever, ii. 14 
cause of, ii. 28 
convalescence from, ii. 31 
persons most liable to, ii. 29 
prevention of, ii. 32 
symptoms of, ii. 30 
treatment of, ii. 31 
Typhus exanbhematicus, ii. 22 
ULCERS, ii. 149. 176 
of the anus, ii. 710 
of the eye, ii. 272 
of the rectum, ii. 712, 725 
Ulceration of nasal cavity, ii. 365 
of the stomach and bowel, ii. 693 
of the uterus, ii. 566 
Ulna, the, i. 21 
Ulnar artery, i. 52 
nerve, i. 84 
veins, i. 58 
Umbilical cord, i. 396 
Under-feeding as a cause of ill-health, ii. 664 
Upper Blue Lick mineral water, i. 376 
Upper extremities, bones of the, i. 20 
muscles of the, i. 38 
nerves of the. i. 84 
veins of the, i. 58 
Urate of soda, ii. 827 
Urates, ii. 471 
Urea, excretion of, ii. 470 
Ureters, i. 53, ii. 465 
Urethra, ii. 501 
deformities of the, ii. 502 
inflammation of the, ii. 503 
neuralgia of the, ii. 503 
neuralgia of the deep, ii. 507 
stricture of the, ii. 505 
Urethritis, ii. 503 
Uric acid, ii. 472 
Urinal, soft rubber, ii. 514 
Urinary organs, symptoms connected with the, 
i. 315 
Urination, disturbances of, ii. 548 
Urine, bloody, ii. 475 
chylous, or milky, ii. 493 
Urine, color of, ii. 466 
composition of, ii. 466, 470 
dark colored, ii. 475 
density of, ii. 409 
gelatinous, ii. 498 
normal quantity of, ii. 469 
odor of, ii. 467 
painful passage of, by infants, i. 420 
pus or matter in, ii. 475 
reaction of, ii. 468 
retention of, i. 316, ii. 520 
sediment in, ii. 471 
suppression of, symptoms of, i. 316 
temperature of, ii. 470 
test for sugar in, ii. 477 
Uriniferous tubes, ii. 465 
Urticaria, ii. 159 
Uterus and appendages, i. 391 
Uterus, displacements of, ii. 560 
during pregnancy, i. 433 
growth during pregnancy of the, i. 397 
involution of, definition of, i. 4:i7 
laceration of the, ii. 566 
• ulceration of the, ii. 566 
Uveal tract, ii. 224 
Uvula, elongated, i. 392 
VACCINATION, complications of, ii. 125 
proper age for, ii. 123 
proper place for, ii. 123 
how to perform, ii. 123 
Vaccine disease, stages of the, ii. 121 
lymph, preservation of, ii. 122 
Valves of the heart, i. 62 
of the intestine, i. 92 
of the veins, i. 56 
Valvulae conniventes, the, i. 92 
Valvular disease, ii. 733 
Van de Wakkeii, E., on acute infections dis- 
eases, ii. 28 
Vapor bath, i. 353, ii. 865 
Varicella, ii. 72 
Varicocele, ii. 526 
Varicose veins, ii. 752 
Variola (see smali-pox), ii. 69 
Varioloid, ii. 70 
Vas deferens, location of the, i 53 
Vasti muscles, i. 44 
Veal, nutritive value of, i. 120 
Vegetable diet as a cause of disease, i. 124 
Vegetables, nutritive value of various, i. 123 
Veins, capacity of the, i. 67 
diseases of the, ii. 751 
of the liver, i. 94 
rupture of, i. 766 
Velocipede-riding, i. 251 
Vena cava, the, i. 60 
Venous system, description of the, i. 56 
Ventricles of the heart, i. 61 
Ventilating flues, i. 267, 269 
Ventilation, i. 162, 265 
methods for, i. 163 
Ventilators, i. 268 
Vesicles, definition of, ii. 149 
Veratrum viride, poisoning by, i. 790 
Vermin-killers, poisoning by. i. 813 
Vermiform appendix, the, i. 96 
Vertebra, definition and description of a, i. 13 
Vertebral artery, i. 50, 51 
bones, the names and number of, i. 13 
Vibrios, ii. 7 
Vichy mineral water, i. 373 INDEX. 
941 
Villi of the intestine, i. 92 
Vinegars, ii. 909 
Vinegar, value of, as a condiment, i. ISO 
Virginia creeper, poisoning by, i. 804 
Virginia hot springs, i. 380 
Virginia warm springs, i. 380 
Virus, definition of, i. 300 
of vaccination, ii. 122 
Vision, blurred, nature of, ii. 246 
distant, cultivation of, ii. 245 
effects of habits of life upon, ii. 250 
phenomena of, ii. 834 
stereoscopic, causes of, ii. 240 
Visual impressions, duration of, ii. 288 
*• Vital air,” i. 142 
heat, source of, i. 107 
Vitreous humor, ii. 228 
diseases of, ii. 286 
Vocal cords, i. 69 
false, i. 70 
during production of sound, ii. 383 
Voice, ii. 380 
care of the, ii. 384 
loss of the, ii. 403 
registers of the, ii. 884 
Vomer, the, i. 18 
Vomiting, ii. 669 
as a symptom, i. 312 
in young children, i. 479 
of scarlet fever, ii. 74 
by newly-born infants, i. 418 
WAKEFIELD earth-closet, i. 181 
Wakefulness, ii. 588 
Wake-robin, poisoning by, i. 793 
Walking-exercise, i. 251 
time when infants should commence, i. 
454 
Wall papers, poisonous, i. 782. 
Walton, Geo. E., on mineral springs, i 371 
Warts, ii. 174, 203 
in the nose, ii. 367 
on the prepuce, ii. 500 
Warm bath, i. 352 
springs (N. C.) mineral water, i. 377 
Wash basins, precautions necessary with, i. 
174 
Wasp-stings, i. 615 
Waste and repair of tissues, i. 101 
Water as a drink in sickness, ii. 882 
beds, ii. 845 
brash, ii. 672 
carriage of typhoid fever, i. 190 
closets, construction of, i. 174 
Jenning’s, i. 178 
common impurities of, i. 188 
coolers, i. 277 
cure, i. 348 
drinking, mineral salts in, i. 188 
hemlock, poisoning by, i. 792 
in the brain, i. 543 
medicated, ii. 909 
nutritive value of, i. 103 
on the brain, i. 551 
poisonous nature of organic matter in, i. 
188 
supply, its effect upon health, i. 189 
sources of, i. 188 * 
Watery vapor, amount which the air will hold, 
i. 148 
as an element of air. i. 148 
effect of an excess of, i. 148 
Watery vapor, principal source of, i. 150 
Waxy-liver, ii. 701 
Weakness as a symptom, i. 817 
in typhus fever, ii. 80 
Weak-sight, ii. 294 
Weals, definition of, ii. 149 
Weaning, i. 402 
choice of time for, i. 497 
Weeping-eye, ii. 260 
Wells as sources of water-supply, i. 191 
contamination of, i. 191 
Weight of infants at birth, i. 397 
Weights, troy, ii. 901. 
West Indies, climate of, i. 234 
West’s mixture for diarrhoea, i. 512 
Wetnurses, changing, i. 508 
choice of, i. 465 
Wetnursing, i. 465 
Wheat, composition of, i. 124 
Whey-cure, i. 347 
White of the eye, diseases of, ii. 276 
White gum, i. 484 
White, J. C., on the skin and hair, ii. 143 
Whites, the, ii. 546, 554 
worms as a cause of, i. 523 . 
Whitlow, ii. 201 
Whittakek, J. T., on acute infectious diseases, 
ii. 3 
Whooping-cough, ii. 833 
as a cause of convulsions, i. 567 
Wire beds, ii. 844 
Wildungen mineral water, i. 379 
Wind, causes of the, i. 145 
harmful to delicate eyes, ii. 244 
hygienic value of, i. 282 
velocity of, i. 163 
Winds of Texas, i. 235 
Wines, ii. 911 
j Wine, to mull, ii. 890 
wney, ii. 891 
! Winter resorts, advantages of, 235 
Wolfsbane, poisoning by, i. 784 
Worm, thread, remedies for, i. 526 
whip. i. 520 
| Worms, i. 515 
liability to be confounded with brain dis- 
ease. i. 253 
lumbricoid or round, i. 515 
pin, i. 516 
symptoms caused by, i. 521 
tape, i. 516 
thread, i. 516 
treatment of, i. 523 
Wounds, i. 597 
bruised or contused, i. 605, 609 
dissecting, i. 612 
modes of dressing, i. 602 
of anus, ii. 724 
of eyelids, ii. 260 
of penis, ii. 501 
of the limbs, head and trunk, to stop bleed- 
ing from, i. 595 
old, use of mineral waters for, i. 885 
poisoned, i. 611 
primary or dry union of, i. 605 
punctured, i. 602 
to sew. i. 602 
torn or lacerated, i. 605, 607 
Wrist, bones of the, i. 23 
dislocations of the, i. 726 
fracture of arm near the, i. 664 
Writer’s cramp, ii. 605 
Wry-neck, mechanism of, i. 33 942 
INDEX. 
ii. 175 
YALE, LEROY M., on anatomy and physi- 
ology, i. 3 
on the hands and feet, ii. 199 
Yarrow, poisoning by, i. 786 
Yeast-plant, ii. 7 
poultice, ii. 911 
Yellow fever, blindness in, ii. 286 
cause of, ii. 83 
germs, ii. 34 
nature of the poison of, ii. 11. 
occupations which favor, ii. 34 
prevention of, ii. 35 
Yeilow fever, races and persons most liable to, 
ii. 33 
symptoms of, ii. 34 
treatment of, ii. 36 
where mostly prevalent, ii. 33 
Yellow jessamine, poisoning by, i. 794 
Yellow spot of the eye, ii. 227 
Yellow sulphur mineral water, i. 876 
Yew, poisoning by, i. 804 
ZINC-LINED pipe, i. 8C6 
Zonula of Zinn, ii. 228 
Zygoma, the, i. 17 
Zymotic, definition of, i. 800 
diseases, i. 300, ii. 3