COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDAHD HX6407561 3 R A776 P99 1 907 A manual ol personal I RECAP Hygiene Pyle M- LL^ Columliia ®nibers(itp ^'^''^ m ti)t Citp of i^etu g^orfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Robert- Gr-OJVenoR- / Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/manualofpersonaOOpyle A MANUAL OF Personal Hygiene Proper Living upon a Physiologic Basis BY AMERICAN AUTHORS EDITED BY WALTER L. PYLE, A.M., M.D. Member of the American Ophthalmological Society ; Fellow of the American Academy of Medicine; Fellow of the College of Physicians of Philadelphia ; Assistant Surgeon to the Wills Eye Hospital, Philadelphia, etc. CONTRIBUTORS D. H. BERGEY, M.D. "WALTER L. PYLE, M.D. J. "W. COURTNEY, M.D. B. ALEXANDER RANDALL, M.D. GEORGE HOWARD FOX, M.D. G. N. STEWART, M.D. (Edin.) E. FLETCHER INGALS, M.D, CHARLES G. STOCKTON, M.D. THIRD EDITION, REVISED AND ENLARGED PHILADELPHIA AND LONDON W. B. SAUNDERS COMPANY 1907 Set up, electrotyped, printed, and copyrighted May, 1900. Reprinted and recopyrighted April, igoi. Revised, reprinted, and recopyrighted August, 1904. Reprinted August, 1905. Revised, reprinted, and recopyrighted January, 1907 Copyright, 1907, by W. B. Saunders Company ELECTROTYPED BY PRESS OF WESTCOTT & THOMSON, PHILA. W. B. SAUNDERS COMPANY PREFACE, The object of tlii.s nianual is to .set forth plainly the best means of developing and maintaining physical and mental vigor. Throughout the book there is concise but adequate discussion of the anatomy and physiology of the parts under consideration, upon which is based the subjoined advice. In other words, there is an exposition of proper living upon a physiologic basis. Purely technical phraseology has been avoided, as far as compatible with the scientific value of the text, and numerous explanatory diagrams and illustrations have been introduced. Although each special chapter is com- plete in itself, there has been purposive repetition of remarks upon subjects of such general interest as eating, drinking, breathing, bathing, sleep, exercise, etc., in order that the}^ may be discussed more thoroughly from several standpoints. WALTER L. PYLE. PREFACE TO THE THIRD EDITION. In response to a growing demand, the work has been thoroughl}'' revised and numerous additions have been made, including an illustrated System of Home-G5'mnastics, a chap- ter on Domestic Hj'giene, and an Appendix, containing the simpler methods of Hydrotherapy, Thermotherap^^ and Me- chanotherap3^ and a section on First Aid in Medical and Surgical Accidents and Emergencies. A concise Glossars* of the purel}- medical words unavoidably used in the text has been especially prepared for the convenience of non-medical readers. WALTER L. PYLE. 1806 Chestnut St., Philadelphia. INTRODUCTION.' Strange as it may seem, the one subject which every fair-minded person admits should be taught thoroughly — namely, how to keep healthy — has been largely neglected. .With all the recent agitation for educational reform, there remains, in a measure, the same indifference to the proper teaching of the care of the body, regarding which Herbert Spencer lectured the pedagogic world over forty years ago. Mr. Spencer proved that knowledge may have in- trinsic value, and that the value of some knowledge must be greater than that of others. In our brief lives it is most necessary to distinguish and give precedence to the useful, real, and effective over the non-useful, conventional, and ornamental ; or, to use a Baconian phrase, "we must determine the relative value of knowledges." All knowledge passes into action, and that knowledge that leads men to better physical lives is a communal as well as an individual gain. Mr. Spencer says that, in the order of their importance, the leading kinds of activity which con- stitute human life are : I. Those activities which directly minister to self- preservation. ' A considerable portion of this introductoiy chapter is from an ad- dress by the editor in oj^ening the Sj'mposium of the American Academy of Medicine, on the " Teaching of Hygiene in the Public Schools," in Washington, D. C, May ii, 1903. VI INTR OD UCTl ON. 2. Those activities wliicli, by securing the neces- saries of life, indirectly minister to self-preservation. 3. Those activities which have for their end the rearing and disciplining of offspring. 4. Those activities which are involved in the main- tenance of proper social and political relations. 5. Those miscellaneous activities which make up the leisure part of life, devoted to the gratification of the taste and feelings. In other words, a rational order of subordination is : Education which prepares for a direct self-preser- vation ; that which prepares for an indirect self-pres- ervation ; that which prepares for parenthood ; that which prepares for citizenship ; and that which pre- pares for miscellaneous refinements. It is stated with great emphasis that without doubt the actions and precautions which from moment to moment secure self-preservation are of primary im- portance ; and that, "as vigorous health and its accompanying high spirits are larger elements of happiness than any other things whatsoever, the teaching how to maintain them is a teaching that should yield in moment to no other whatever." Fortunately, knowledge subserving direct self-pres- ervation is largely provided for by nature. The com- mon animal instincts give warning against gross dan- gers. The inquisitive, timid, restless infant is chiefly concerned in hourly acquisition of the primitive facul- ties of coordination, estimation of distance, size, con- sistence, and weight, the avoidance of things likely to cause pain, the assimilation of food, etc. Through- out childhood and youth there is a further elaboration of these primal requisites. But more than this is JNl'NODUVJ'ION. Vll necessary, for besides the ineclianical dangers, there are the evils following breaches of physiologic laws. Unfortnnately, so profonnd is the innate ignorance of these laws of life that it is often not even known that our sensations are our natural and most trnstworlhy guides. The less evident but no less real dangers arising from the complexities of modern social life and the attendant evil habits are continually present, despite all innate instincts of waruing. The per- nicious influence of improper food and bad air, the abuse of stimulants "and narcotics, the modern dissi- pations and vices, etc., can be modified only by proper and timely education. It has been said that "health is man's birthright ; that it is as natural to be well as to be born," and that from ignorance and transgressions of physiologic and hygienic laws arise most disease and tendency to disease. Yet to-day, so tardy has been the recog- nition of the importance of instruction in the funda- mental principles of applied physiology as a means to complete living, that a thoroughly well person after middle life is the exception in every com- munity. On every side we find chronic complaint, physical weakness, weariness, and overwhelming gloom, which might have been prevented by proper timely instruction. A striking example of the sacrifice of health from avoidable and preventable suffering is the great num- ber of physical and moral wrecks, the victims of the very prevalent habit of worry. So close are the rela- tions of the mind an i the body that one of the most prolific sources of suffering is continuous worry, and one of the surest wavs to restore health that is threatened VUl , INl'KODUCTION. is to keep the mind cheerful and hopeful. Excessive ambition, misdirected energy, longing for the unattain- able, regret for the unalterable, anticipation of future happenings, lack of a sense of perspective, fretting over non-essentials, indecision, reopening of trouble- some questions already settled, avarice, selfishness, excessive emotions, uncontrolled passions, and the actual cultivation of the melancholic state, are some of the important causes of mental anguish and sub- sequent physical suffering that are not commonly associated with the baneful breaches of hygienic laws to be demonstrated by teachers of practical physiology. With those who are physically or men- tally defective we have the patience to reason and to make allowance for, but little sympathy or guidance is offered to the practically normal person who is gradually becoming the slave of a cultivated habit of worry, letting the minor trials and troubles of a day shut out much of the sunshine and happiness of life. The spiritual sin of worry and its utter futility should be made plain, but its association with chronic ill- health needs more discussion in both schools and churches. Observance of such teaching would do much to lessen the great American army of neu- rasthenics. Besides the individual suffering from preventable illness, time and money are ruthlessly wasted, com- mercial and artistic instincts are curtailed, good parenthood and citizenship are rendered impossible, appreciation of amusement is dulled, and, besides being immensely deteriorated, life is markedly short- ened. "Is it not clear," asks Mr. Spencer, "that the physical sins — partly our forefathers' and partly JN'l'R on UCTION. IX onr own — which produce this ill-licaltli deduct more from complete Hvini'» '•*' Fig. 5. — Deformity caused by thumb-sucking (Darby). whatever cause arising, habitual breathing through the mouth leads to the accumulation of organic mat- ter about the teeth and thus favors the destruction of dentin'. Certain families through several genera- tions have soft or feeble teeth, apparently because of some congenital disturbance in the nutrition of the parts. It is commonly believed that in such individ- uals much more care is required to prevent the devel- opment of caries. These poorly developed teeth are sometimes seen in scorbutic or rachitic children, and Fig. 6. — Teeth in congenital syphihs. in those suffering from congenital syphilis; but the con- dition is also present in those wdio in other respects ap- pear to enjoy good health. In congenital syphilis the secondary teeth are affected in a characteristic way 20 THE DIGESTIVE APPARATUS. (Fig. 6). The incisors are peg-shaped, notched, and sometimes placed at such an angle that their cutting edges are found to meet. Many cases of irregular eruption of the teeth are improperly attributed to syphilis, and the same may be said of the notching that occurs along the teeth of many fairly healthy children — irregularities not identical with the peculi- arities pointed out by Jonathan Hutchinson. Causes of Decay. — It is commonly believed that in the matter of resistance and external irritation the teeth of certain individuals are naturally faulty. Even when the teeth receive reasonably intelligent care the development of caries is a constant source of anxiety; on the other hand, in certain families, and particularly in certain races, the teeth are naturally strong and are often retained until old age — even when they receive no further care than that which comes from vigorous use in the mastication of coarse and resisting foods. A like difference may be noted in the integument of people, and may be explained by assuming that this depends upon some peculiarity in nutrition. The form of diet has been thought by some to be a factor in caries of the teeth. It has been noticed that the teeth that are least called upon for mastication are often the most delicate. Strong and resisting teeth seem to come naturally to those who live upon coarse foods. Apparently the innerva- tion and blood-supply is better in healthy individuals who use their teeth somewhat severely. While common observation teaches that the devel- opment of caries depends in part upon the suscepti- bility of the teeth of certain individuals, this fact has been denied, and apparently with some reason. CAUSES OF DECAY OF 'J HE TEETH. 21 Black, of Indiana, subjected a large number of ex- tracted teeth to a great variety of tests, including their exposure for varying periods to the action of chemicals and to the attacks of bacteria. When these teeth were subsequently examined by the most careful methods, there was seen to be practically no difference in the resistance that they had shown. Strong and feeble teeth were affected alike, and it may be inferred that poor teeth do not differ materially from those that are usually regarded as strong in their resistance to the influences that produce decay. The old opinion that the teeth are injuriously affected through the action of certain acids found in the stomach is also disappearing. Miller, who found more than one hundred varieties of micro-organisms that grew in the mouth or about the teeth, believes that caries is the result of lactic acid produced by the growth of certain of these bacteria. It is now generally accepted that the bacteria are in some way responsible for dental caries; but there is a growing doubt as to lactic or other acids playing any special part in this process. Hopkins, of Harvard, has taken up the question, and has shown that in these micro- organisms, of which he has found about fifty varieties commonly present in diseased teeth, about one-fifth of the number were producers of lactic acid, but the strongest proportion of acid that he was able to pro- duce by the growth of these bacteria was o. 5 per cent. He subsequently found that if teeth, good and poor alike, were subjected to a solution of lactic acid in the strength 'of 0.5 per cent, for a period of four months, no carious action whatever could be dis- covered. The observer emphasizes a fact, previously 22 THE DIGESTIVE APPARATUS. known, that some of the organisms that are appar- ently destructive give rise to secretions alkaline rather than acid in reaction. It has been commonly observed that some mouths in which caries is conspicuous show a free secretion of saliva and a constant alkaline reaction. Much has yet to be learned about the mat- ter; but it may be assumed that to bacteria we must attribute dental decay; that the question of natural resistance of the teeth plays but a subordinate part; and that the character of the diet, so long as it is suf- ficiently nutritious, has not been shown to have any influence whatever. When fragments of food, to- gether with the secretions of the mouth, find lodge- ment between and around the teeth there is afforded an opportunity for the growth and development of bacteria. Some idea of the number of these organ- isms may be inferred from what has been said. It is believed that micro-organisms are concerned in the formation of the discolored tartar so disfiguring to the teeth and injurious to the gums. But teeth are at- tacked and cavities are formed without the develop- ment of tartar; all that seems necessary is for the or- ganism to find a lodgement in some protected place where they are removed from the action of the tooth- brush and other toilet articles commonly used to dis- lodge them. Catarrhal irritation about the margin of the gums leads to their recession and exposure of the teeth where they are unprotected by enamel. This catarrhal condition is due in large part to the action of bacteria, but the condition is much favored by the continual irritation from tobacco and acrid foods, also by the presence of tartar and by carelessness in the use of tooth-brushes, tooth-picks, and the like. PRF.SlikVATJON OF ■Jill': 'J/:1:J'JI. 23 A disease of iiiiich iiiiportaiiee that occasionally af- fects the giiuis is known as pyorrhcea alveolaris, commonly called Rii^^gs' disease. This was at one time believed to depend upon a constitutional condi- tion, and in some way to be associated with the so- called uric-acid diathesis. This view never seemed logical, and is overthrown by recent study. Un- doubtedly, as in the case of other infections, perfect systemic health is the best safeguard against infec- tion, but that good general health can prevent the development of bacteria is untenable. Younger, of Chicago, regards the disease as essentially of bacterial nature, and views injury to the gums, and especially the perforation of the peridental membrane, as the first step in its process. Such injuries are usually produced by the forcible introduction between the gum and tooth of hard foreign bodies, like seeds of berries, bits of bone, and bristles from the tooth-brush. Preservation of Teeth. — From what has been said it may be concluded that, so far as we understand the matter, the preservation of the teeth resolves itself into a few simple principles; namely, the prevention of overcrowding, the avoidance of chemical or me- chanical injury to the teeth and gums, the careful and frequent cleansing of all the exposed surfaces of the teeth, and the use of such harmless antiseptics as will prevent the long continuance of pathogenic bacteria in the mouth. The most easily available means of protection lies in the proper cleansing of the teeth. For this purpose the frequent use of the tooth-brush is indispensable. The ordinary bristle brush has been opposed on the ground that it is too hard and is liable to injure the gums, particularh' when stray bristles 24 THE DIGESTIVE APPARATUS. are thrust into the soft parts around the teeth. Brushes of badger's hair, of felt, and of various other substitutes, have been recommended. Most of these contrivances, however, are lacking in the essential resistance and elasticity so important in the thorough dislodgement of foreign matter. The bristle brush in which the bristles are not too closely placed together, thus admitting of their passage between the teeth, is the most practical instrument. Great care should be taken not to allow the bristles to spread, and the brush should be discarded before it is soft or ragged from long use. The brush should not be too broad, and the handle should be bent in the direction of the tuft on the brush so as to admit more easily the reaching of the various curved surfaces of the teeth. The brushing should be practised after each meal and before going to bed, and once daily should be ac- companied by the use of a tooth-powder sufficiently coarse to produce some grinding and polishing effect. A powder that is too soft or too fine is of little avail. Powdered chalk and orris root are common bases for tooth-powder. Some harmless antiseptic, such as borax, oil of wintergreen, or tincture of myrrh, should be incorporated with the powder to help destroy any colonies of bacteria that may be reached. Twice each week all the exposed surfaces of the teeth should be carefully gone over, and, with the assistance of the tooth-powder, carefully rubbed with a narrow chisel- like piece of a w^ood that is hard and fine-grained in texture, such as orange-wood, so as to smooth away all the roughness and inequalities. This puts a smooth polish on the teeth and renders their subse- quent cleansing by means of the tooth-brush a com- IMPORTANCE OF THE TEETH JN DIGESTION. 25 paratively simple matter. If this rule were applied in the care of children's teeth, the work of the dentists would be greatly restricted. Of equal importance is the daily use of soft, silk twine, known as dental floss. It should be drawn between the teeth firmly but carefully, so as to remove foreign matter that can- not be reached in other ways. It is important not to cut or irritate the gums nor to loosen their attachments to the teeth. A little experience enables one to ac- complish the work deftly and quickly. In the neglect of this practice the teeth can hardly be said to have been cleaned. In addition to these methods, the mouth and teeth should be carefully rinsed every night with some innocuous antiseptic solution. Some of the most harmless antiseptics are powerful germi- cides, and should be employed to the exclusion of others that may do injury to the general health of the individual as well as to the teeth. Tincture of orris, rose-water, and alcohol in equal parts, flavored with a drop of oil of bitter almond, make a very agreeable mouth-wash, and it may be rendered more actively antiseptic by the addition of 0.5 per cent, of formalin. The importance of the teeth in digestion is not sufficiently recognized. Many cases of chronic indi- gestion arise from imperfect mastication due to faulty dentition. In all such cases it is of primary impor- tance to have decayed teeth filled, or if there are many missing teeth they should be replaced by artificial ones. Otherwise medication and dietary regulation may be of little avail. 26 ' THE DIGESTIVE APPARATUS. HYGIENE OF THE GASTRO=INTESTINAL TRACT. The Appetite. — When there is bodily inactivity or mental indolence, as compared with habitual physical or mental exertion, the problems of nutrition must differ widely. The long struggle of the human race to find at all seasons sufficient nourishment to satisfy the demands of life doubtless led to the building up of physiologic laws which made it possible for the or- ganism to undergo periods of starvation, to be fol- lowed by periods of repletion. Thi^ history of feast and famine must have left to its survivors an appe- tite that urged its possessor to feats requiring the greatest energy of body and mind ; conversely great activity and great expenditure of energy should lead normally to an appetite correspondingly large. In reviewing the history of organized life, it will be found that appetite has been the great ruling principle that has enabled the living cell to cope successfully with the destructive agents that surrounded it. A good appetite still reminds one of the most necessary factors in our survival, and we instinctively feel that its disappearance or its unnatural perversion is a seri- ous warning of degeneracy or decay. This splendid instinct so necessary for our existence has now more than ever to meet with sudden modifications resulting from the complexity of modern life. While pri- marily responsible for the discovery of innumerable aliments, the very abundance in this generation, both in quantity and variety, is embarrassing, and we find the results of unnecessary and artificial stimulation in the unnatural desires for food. The lack of at- tention as to the appropriateness of food subjects not only the digestive apparatus, but all the cells of the THE EFFECT OF THE MIND ON NUTRITION. 2/ individual organism to distress and not infrequently to disease. In this matter the problem to be solved is, first, how to train the appetite into natural and wholesouie paths; and, second, how to live so that by means of proper physical, mental, and moral activity there may be successfully oxidized the kind and quantity of nutriment required in normal life, and successfully discharged the waste products that re- sult from the oxidation. It is unsafe to trust the individual to the guidance of the appetite alone, for the reason that this instinct was built up for a condition of existence very different from that which enables the people of this country to indulge them- selves to-day. Nevertheless, the appetite is a more reliable guide than speculation, and more trustworthy than a certain narrow scientific view which would select foods along the lines of nutritive values ascer- tained by chemical experiments. Not that there should be neglect of knowledge as to the calories of energy that may be developed by one substance as compared with another, or the omission of some things that may be learned by rational deduction; but it should never be forgotten that in instinct there is a guide that has been accumulating experience for un- known ages, and that if life in other respects is normal this appetite is likely to lead very nearly in the right direction. The Effect of the Mind on Nutrition. — These gen- eralities include many specific facts that will bear amplification. In the consideration of the efiect of the mental and moral state upon the problems of nutrition there is much food for thought. It is no idle phrase to say that a contented mind, a willing 28 ' THE DIGESTIVE APPARATUS. disposition, and a joyous nature give rise to good digestion. It is a truth of such importance that no physician can wholly succeed in relieving derange- ments of digestion unless he takes this matter into consideration ; in other words, remorse, worry, over- responsibility, petulance, envy, jealousy, and other undesirable mental states give rise to such disturb- ances, both in primary nutrition and cellular met- abolism, that good health is not to be obtained. This explains the fact that a change of scene, a long vaca- tion, and new associations will sometimes improve the digestion and restore health generally when care- ful dieting and other measures have failed to bring relief. Unenviable mental characteristics may be- come prominent partly as the result of brain irritation that arises in many unsuspected ways. Such dis- turbance of the nervous system deranges the appetite, the digestion, and nutrition in general, as well as the mentality. The Effect of Eye-strain on Nutrition. — One of the most important of these sources of irritation is the continual use of the eyes in all manner of fine work, often in imperfect or wrongly directed light. In the modern system of education, in which children from the kindergarten upward are required to use the eyes closely upon small objects, in association with the concentration of the mind, this evil is found in an ag- gravated form. As this sacrifice of the ocular ap- paratus seems demanded by the requirements of edu- cation and culture, the nervous system has to undergo the strain as best it may. It has long been recog- nized that there result headache and various expres- sions of nervousness, but that the appetite and THE EFFECT OF EYE-STRAIN ON NUTRITION. 29 digestion are also made to suffer are facts that are too little recognized. Whoever carefully looks into this matter will find really that nutrition first shows the result of nerve-strain, no matter from what source arising ; and, as a rule, some peculiarity of the primary digestion gives the earliest intimation of the trouble. For instance, there may develop a distaste for certain substances in the dietary ; the appetite may become capricious or perverted. Again, a dis- turbance in motion will arise, and the stomach may contract in a spasmodic, tremulous, or irregular way, while the individual is conscious of disagreeable and sometimes alarming sensations, accompanied with eructations of gas or fluid from the stomach. Or the gastric juice may be secreted irregularly, and in many instances a long chain of dyspeptic symptoms appear without any real disease of the stomach, but merely a disturbance of the nervous system occasioned by improper habits of life. In a certain sense the stom- ach is acting in the role of monitor ; but if we are sufficiently wise it may often be regarded as that of the kind mentor. This most common experience may be avoided sometimes by removing the strain to the nervous system, and again by strengthening it by exercise, bathing, recreation, and more hours for sleep and repose. Eye-strain may be lessened or ob- viated by the wearing of spectacles that are made ac- curately and adjusted precisely; or by attending to the direction in which light enters the room, or perhaps by prohibiting the use of books printed with small or illegible type. Observance of these precautions may render it unnecessary for the individual to give special attention to his diet ; but it is the usual cus- 30 THE DIGESTIVE APPARATUS. torn at first for the stomach to be considered the source of trouble. As the disagreeable digestive ex- periences are attributed to the stomach, the fault is commonly supposed to lie in the character of the food, and wiseacres take the responsibility of advis- ing the withdrawal of sugar, fats, or meats, and the abundant taking of oatmeal, grits, and beef-tea, a dietary most likely to undermine resisting power and in the end do infinite harm. For similar relief re- sort is sometimes had to a milk diet or to abstinence from food, because it is found that the stomach is more comfortable when it has little to do. But this erroneous course will ultimately fail ; it is wiser, when possible, to remove the cause of the difficulty. When it is impracticable to remove the source of worry it becomes necessary to modify the diet, and it is a compromise of this sort that unfortunately we must sometimes make. Regulation of Meals. — When required to adapt the diet to a tired nervous system and an irritable stomach it must be so managed that the most hearty meal should be taken at a time when it is possible for the individual to enjoy the greatest physical and mental composure, and there should not be demanded too much of the digestive organs when it is known that unusual taxation of the nervous system has been experienced. It is not generally wise in such cases to take a hearty breakfast before functional activity is sufficiently aroused ; nor is it well to allow the chief meal at midday, when the energy is likely to be taxed by work or study. It is better to wait until late in the afternoon, when, after a little rest, the chief meal should be taken — and taken slowly, com- REGULATION OF MEALS. 3 I posedly, and cheerrully. T'ollowin*,^ tliis tlierc slioiikl be spent a few hours in quiet enjoyment before ; THE DIGESTIVE APPARATUS. pressed on the other by equally potent factors that cannot be excluded; for instance, by constantly occur- ring emotional stales as well as by recreation, exertion, and fatigue. The latter group will be considered as merely physiologic influences, and therefore not open to criticism; but this conclusion is not altogether true. Certain mental states result in interference with digestion to such an extent that the appetite may be lost, nausea induced, the gastric secretion interrupted, and the movements of the stomach and intestine depressed, or irregular and spasmodic movements induced which lead to the upward dis- charge of gas from the stomach and perhaps regurgi- tation or vomiting of the undigested food; or there may be developed such severe contraction of the gas- tric muscles that pain is induced. The same causes very frequently induce gastric distress and occasional neuralgia. On the other hand, in tempting displays, agreeable zests, and appetizing odors, we have in- stances of stimulants that as often lead to excess in eating as they do to increased activity in digestion. A curious phenomenon is the overdistention of the stomach and intestine with gas which apparently does not arise from fermentation, but appears to be abnor- mally secreted in the stomach and bowels. Under such conditions a gentle stimulant will enable the diges- tive organs to regain their equilibrium, after which a small amount of fluid food might be easily managed. These are the cases for a cup of tea or coffee, or a pos- set of aromatic herbs, and those who have no moral scruples against its use may be quickly relieved by a thimbleful of brandy. Eating after Bathing. — A similar state of depres- EATING AFTER EXERCISE. 43 sion of the digestive organs may result from a too pro- longed bath ; and the popular opinion that it is un- safe to eat after bathing is based upon the fact that functional energy is for the time being apparently diminished, and in some people digestion is thereby interrupted. This fact does not apply to all alike, but it is true with sufficient frequency to give rise to the popular belief. Eating after Exercise, — Physical exertion is more likely to disturb digestion than bathing. Its effect upon the digestion is similar to that produced by mental fatigue. Singularly enough, this fact has not been universally recognized ; and it is common for people who are physically exhausted from tennis- playing, bicycling, and other violent exercises to in- dulge themselves in a hearty repast without having previously rested. Most people understand that it is imsafe to undergo vigorous exercise directly after a meal ; but they do not realize the mistake of eating heartily when too tired. These truths apply more to those who are untrained and unaccustomed to physical strain ; but athletes have discovered that it is not wise to eat heartily when about to engage in great exertion. Flint found that during a period in which the pedestrian Weston walked a total of 317 miles in 5 days, he consumed on an average about 83 grammes of proteids daily. Yet in the diet of an ordinary farmer or mechanic in this country- about 100 grammes of proteids are taken during 24 hours. Of course, other forms of food besides proteids are taken, and much energy is derived from the combus- tion of the fats and carbohydrates. As a rule, a well-trained man who is carrying on for a prolonged 44 THE DIGESTIVE APPARATUS. period unusual physical effort is able to eat and di- gest more food than the ordinary man. The dispro- portion between the nutriment taken and the energy expended may be approximately ascertained by noting the change in the weight of the body. A. P. Bryant states that Sandow's daily diet contains 244 grammes of proteids, which supplied 4460 calories of energy. Under great strain more proteid is required than under conditions of normal exercises ; but when the strain is to be short and severe it is wise to re- trench at the table lest there should succeed re- bellion in the stomach. Influence of Carriage and Dress on Diges- tion. — Abnormal condi- tions of the liver are for the most part secondary to disorders of the stom- ach and intestines, and in cases in which there is de- rangement of the prima vise it is usually safe to conclude that the liver is also out of condition. One of the most com- mon causes of sluggish- ness in hepatic circula- tion and secretion, as well as of the disturb- ances of the intestines and other portions of the digestive apparatus, may be attributed to faulty car- FlG. 7. — Showing constriction of the abdomen and, necessarily, the displacement of the abdominal vis- cera, produced by an improper corset. CARRIAGE AND DRESS INEI.UENCING DIGEST/ON. 45 riage of the body and relaxation of the abdominal muscles, lessening of the abdominal type of respira- tion, and consequently the loss of diaphragmatic mo- tion. All of these conditions are very much aggra- vated, and some of them are directly induced, by the improper dress almost universally adopted by women, and to some extent by children. In illustration may be instanced a woman who is said to dress loosely. With her corset removed she is found to measure twenty-seven inches around the waist, but as ordi- narily dressed she measures twenty-one inches around the waist outside the garments (Fig. 7). For the correct performance of function on the part of the stomach, liver, and intestines it is neces- sary that free and properly related movements of these organs should take place. Such movements are impossible in the large majority of women. The defects are so common, and the deformities of the body necessarily associated with them begin so early in life, that they are largely overlooked, and are argued to be natural and beautiful by the mass of womankind. A certain amount of intra-abdominal pressure is necessary if the viscera of that region are to be held in their proper places and proper relations. This is possible only when the body is erect in sit- ting and standing, when the chest is kept habitually raised to its normal position, and when the abdom- inal muscles are strong, and are not allowed to relax, pouch out, and thus favor the descent of the organs (Fig. 8). This position should be urged during child- hood, and mothers should be instructed in the proper method of dressing their children so that the chest may haye the freest motion without meeting with 46 THE DIGESTIVE APPARATUS. opposition from the clothing. All garments should be suspended from the shoulders, to prevent the down- ward displacement of the stomach, intestines, kid- neys, liver, etc. Practically all women stand in an Fig. 8. — Showing the shape of the abdomen in a well-developed woman standing in the correct posture. Fig. 9. — Showing the shape of the abdomen and the contours of the body in a well-developed case of enteroptosis. improper attitude, a fact of which they are appar- ently ignorant. Others would not remain ignorant of the fact but for the concealment attending women's dress. That this is no exaggeration, every physician who has given the subject careful study CARRIAGE AND DRESS INFLUENCrNG DIGESTION. 47 will readily agree ; but the fact that more than 50 per cent, of all civilized women, in all classes of life, have developed the condition known as enteroptosis (Fig. 9), which means that the stomach, intestines, very often the kidneys, and sometimes the liver, are dragged downward and remain permanently out of their proper position, is not generally known. Such, however, is the case ; and this condition more than any other cause is responsible for the constipation, backache, debility, biliousness, early loss of com- plexion, headache, and that long list of ailments of which so many women in all civilized coun- tries are victims. Those who have vigorous con- stitutions, strong nervous systems, and who keep the body in a healthy tone hy leading out-of-door lives and avoid the common habits of worry and petu- lance, may live with moderate comfort even though suffering from the enteroptosis made necessary and permanent by the methods of dress. But the greater proportion of women lack these sturdy qualities, and therefore suffer more or less from the symptoms described. Furthermore, this downward dragging of the abdominal organs leads to displacements and derangements of the pelvic organs, and the genito-urinary diseases so common in women are a natural result. In young children the intestines have not yet assumed that position which is normal in adult life, and in some this lack of development makes a constant difficulty in evacuation of the bowels. By a slow process, and in the absence of interference, these matters in time right themselves; but not infrequently the child is so handicapped through the want of out-of-door sports, adequate 48 THE DIGESTIVE APPARATUS. physical training, and proper methods of dress that the large intestine never assumes its proper place. Constipation and Diarrliea. — Downward dis- placement of the bowels not only leads to consti- pation, but it also favors a catarrhal state of the intes- tinal lining, leads to intestinal indigestion, and occa- sionally produces diarrhea, and sometimes pain and the discharge of mucus with the feces. There are other reasons aside from displacement that com- monly give rise to constipation and other unhealthy conditions of the intestines, important among which are diet and habit. Influence of Diet. — It has been said that the cel- lulose of fruits and vegetables exercises a wholesome influence upon the intestinal mucous membrane, in- creasing the bulk of the contents and stimulating the activity of the secretions of the intestinal glands and the contraction of the intestinal muscles. Formerly, when the use of coarser foods was more common than at present, when flour and meal were less carefully bolted, constipation is said to have been less common. For these reasons it is often advised that those who suffer from constipation should confine themselves to coarse and bulky foods. It is true that such a diet is beneficial to one class of people, but it is harmful to another. When it happens that the mucous membrane of the intestine is less than nor- mally irritable, when the unstriped muscle-tissue is so quiescent that it fails to contract from the stimulus offered by soft and semifluid contents, it is found that both the secretion and motion of the part are so dimin- ished that there is slowing of the intestinal stream, and an evacuation does not occur until there is a con- CONSTIPATION AND DIARRHEA. 49 siderable accumulation in the colon. Under such conditions the bowel is usually successful in empty- ing itself unassisted, but only irregularly and after improper delay. Such stagnation of the intestinal stream is injurious to the intestine and to the organ- ism. To the former, because of the undisturbed har- boring of micro-organisms, the dulling of the normal irritability of the motor and secretory nerves, and the weakening of the intestinal muscle ; to the latter, because of the absorption from the intestine of certain toxic substances that are much more likely to be formed when the intestine is inactive. These toxic substances, finding their way, first, to the liver and then to the general circulation, develop those symp- toms that are commonly recognized under the name of biliousness. This term has come to have a broad meaning, which, indeed, is necessary, as the expres- sions of this form of auto-intoxication are varied. It will be understood how a coarse diet may be very ser- viceable in relieving the condition described above. But there is another and nearly as large a class in which the mucous membrane and muscle of the intestine are too irritable. This results sometimes from a low grade of inflammation affecting the superficial lining of the intestine, and sometimes to over-impressionability of the nerves of the part. Under such circumstances a bland, unstimulating diet results in intestinal contents that excite the irritable bowel to proper activity; but if the food is coarser and contains much vegetable fibers or husks of grain it causes so much mechanical irritation that the intestine contracts spasmodically and prevents the normal onward movement of the feces. These influences may so disturb the part that 4 50 THE DIGESTIVE APPARATUS. over-secretion and over-motion result, and a diarrhea follows, usually to be succeeded by constipation, and it in turn by diarrhea. The physical condition ac- companying either one of these states may not be so unlike those accompanying the other ; and whatever course of living most tends to regularity is equally useful in the prevention of diarrhea and constipation. It so happens that there is no one diet that is suitable to all cases of constipation. For the ordinary indi- vidual it is a mistake to restrict the diet to over- . refined and highly nutritious foods; nor should the other extreme be followed. A correct blending of coarse and fine foods, with the proper proportion- ment of meats, vegetables, fruits, fats, starches, and sugars, is the diet most likely to agree with the intes- tine as well as the stomach. The influence of habit is equally important in evacuating the bowels as it is in tjie matter of eating. The habit of having a regular daily movement after the morning meal should be cultivated. Irregularity in defecation, usually the result of postponement be- cause of inconvenience, is one of the most successful means of inducing constipation, hemorrhoids, and other unnatural states of the intestine. Few realize that the digestive apparatus is under a sensitive nervous control, and does not tolerate unphysiologic treatment without most appreciable resentment. While infrequency in defecation is evidently harmful, over-frequency is also to be condemned. For the colon to contract naturally and successfully it should have a certain amount of contents of a sufficient con- sistency. Such conditions stimulate a regular and progressive contraction of the bowels and a successful THE /N/'VA/KNCE OF I/.lB/y 5 I result. Ill children the amount of effort put forth, the time required for defecation, and the form, quantity, and character of the evacuation should be carefully observed. Tlie dejections are normally more frequent in the young than in the adult. Yet even in children the habit of going to stool several times during the day should be discouraged. There is a certain rhythm necessary in most physiologic processes, and this is so true of the digestive tract that disregard of the impulse for physiologic defecation is to establish irreg- ularity and. usually suffering. HYGIENE OF THE SKIN AND ITS APPENDAGES. By GEORGE HOWARD FOX, M. D., OF NEW YORK, Clinical Assistant, Dermatological Department, College of Physicians and Surgeons. ANATOMY AND PHYSIOLOGY. The skin is composed of two layers, a superficial thin layer, called the epidermis or cuticle, and a deep layer, known as the derma cutis or true skin. The epidermis is readily separable from the derma, and is the portion of skin that is raised by the fluid of an ordinary blister. Its chief function is to give protection to the underlying true skin and to prevent it from drying and losing its natural softness and pliability. The epidermis has little or no sensibility, and in this respect differs from the true skin, which is remarkably sensitive from the presence of many deli- cate nerve-endings. The deeper layer of the epider- mis consists of cells which are polygonal in shape and moist in character, and is called the mucous layer or rete mucosum. The superficial cells are dry and flattened, and constitute the horny layer of the epidermis. There is a constant production of new cells in the epidermis taking the place of other cells, which are pushed toward the surface and finally shed by the skin. This process of shedding the superficial dry scales is constantly taking place, and is aided by the rubbing of the clothing against the skin and by the friction employed in bathing. This desquamation 52 77//'; EPIDERMIS. 53 takes place in the form of iiiinute scales. Only npon the scalp do they tend to become visible to the eye and appear as flakes, forminesides being an organ of excretion, the skin, by means of its pores or perspiratory glands, performs the important function of regulation of the body-temperature. Fig. II. — Vertical section of skin : si^^, sebaceous glands ; c/, epidermis ; A, hair ; d, derma. When the body is at rest or only slightly in motion perspiration is constantly taking place in the form of a vapor, and is spoken of as being insensible. When, however, considerable exercise is taken the pores be- come more active and produce a visible amount of perspiration, which is termed sensible. The condition of the atmosphere greatly influences the activity of the glands. If the air is saturated with moisture, the 56 THE SKIN AND ITS APPENDAGES. perspiration does not readily evaporate, but remains upon the body. If the air is dry, and especially in motion, the perspiration readily evaporates and be- comes insensible. When the surrounding air is much warmer than the body the vessels of the skin dilate, free per- spiration takes place, and by its evaporation the body becomes cooled. If the air is already full of moisture, evaporation of the perspiration becomes very difficult, and we suffer more from heat than if the air were dry. This phenomenon of finding hot weather most uncomfortable when humidity is pres- ent is known to all through disagreeable experience. It is for the same reason that a much higher tempera- ture can be born in the Turkish bath where the air is dry than in the hot vapor or Russian bath. When the air is cooler than the body the blood-ves- sels contract and retain the warmth of the body by lessening the amount of blood in the skin to be cooled. Considering the purposes subserved by the perspiratory glands, it is highly important to remove the dry scales of the epidermis which constantly accumulate and interfere with their free action. While this is par- tially accomplished by the friction of the clothing, nothing will take the place of systematic bathing if we desire to keep the skin in a perfectly healthy con- dition. While the perspiratory glands give out moisture, it is not probable that they absorb any appreciable amount of water from without, as experiments attempting to show an increase of weight after long- continued immersion in water have proved incon- clusive. The same is true of salt in solution, and THE OIL-PKODUCING OR SEBACEOUS GLANDS. 5/ the eflficacy of sea-bathing in giving and maintaining health and vigor is due to causes other than tlie absorption of salt. The oil-producing or sebaceous glands are found in all parts of the skin, with the exception of the palms and soles, and are especially abundant on the face. Under the microscope they appear like small sacs situated more superficially than the perspi- ratory glands, and opening in most cases into the ■■Mr* Fig. 12. — Transverse section of skin from scalp, showing hairs cut transversely : cp, epidermis ; A, hairs ; sbgl, sebaceous glands. little pits for the hairs known as the hair-follicles. They secrete a greasy substance, for the purpose of lubricating the skin and keeping it in a soft and pliable condition. The special oil-glands of the eye- lids prevent adhesion of the lids, while those in the scalp form a natural hair oil or pomatum. The oil- glands prevent injurious friction of opposing sur- faces, and the oily secretion in general tends to pro- tect the body from moisture, as it does in the case of feathered creatures. 58 THE SKIN AND ITS APPENDAGES. Although the hair and nails appear to be entirely different in structure from the skin, they are merely modifications of its horny layer. The hair consists of a shaft which appears above the surface of the skin, and a root which is placed in Hair-shaft- Epidermis Derma Sebaceous gland Medullary substance of hair-shaft - Cortical sztbstance of hair-shaft Inner root-sheath Outer root-sheath Hair-bulb Hair-papilla Fig. 13. — Section through hair and follicle. a socket or inversion of the skin, called the hair-follicle. At the bottom of the follicle the hair and the various layers of the skin are found to be THE HAIR. 59 continuous. The substance of the hair consists of three different layers, and has been compared to the trunk of a tree. The main portion of the hair, tlie fibrous portion, is comparable to the dense wood of the tree, and consists of flattened and elongated cells. It constitutes the main bulk of the hair. The central portion, or pith, consists of cells nearly spherical in shape. The outermost layer of the hair consists of flat cells which overlap one another like tiles on a roof, and to this fact is due the rough feeling when a hair is pulled between the fingers from the point toward the root. The property of " felting" is also due to this peculiar saw-like surface of hair. By the same arrangement a loose hair may at times work its way into a wound. The color of hair depends upon the presence of pigment in the pith and fibrous layer, and upon the presence of minute bubbles of air. The greater part of the body is covered with fine, downy hairs, whose roots extend but a short distance in the skin, while the roots of the large stiff hairs extend into the fat beneath the skin. The hair serves various useful purposes, besides being a very great adornment to the human body. It protects the head against the sun's rays and against violence, and affords a very considerable amount of warmth. The eyelashes protect the eyes against the entrance of foreign matters, and the stiff hairs of the ear and nose prevent intrusion of insects and foreign bodies. The moustache is supposed to act as a filter of the air that is breathed, while the beard is said to serve the purpose of protecting the throat from cold. 6o THE SKIN AND ITS APPENDAGES. The nail consists of modified horny tissue lying upon the nail-bed, which is a portion of the true skin. The nail itself corresponds to the: epidermis in this region. The sides and root of the nail are embedded in folds of skin, while its end is free. Near the root of the nail is seen a semilunar area, which is more opaque than the rest of the nail, due to a scarcity of blood-vessels in this situation. The nail itself has no color and is bloodless. Its apparent color is due entirely to the vascularity of the nail-bed beneath, which shines through the translucent substance. The growth of the nail takes place at its root by constant formation of new cells pushing the nail forward. If, however, an obstacle to its forward growth is offered by a tight-fitting shoe sooner or later the nails will begin to grow into the flesh, and the painful condition of ingrowing nail will be the result. The discussion of the hygiene of the skin naturally involves a number of important subjects, prominent among which are food, exercise, bathing and clothing. As food and exercise are treated else- where in this work, it need only be mentioned here that the maintenance of the skin in a healthful condition depends largely upon a judicious dietary and systematic exercise, while the attention of the reader is particularly invited to the subjects of regular bath- ing and proper clothing. BATHING. While discussing the physiology of the skin it was shown how the superficial scales of the epidermis tend to collect, and with the sebaceous matter and BATJUNC. 6 1 dirt to form a pellicle which interferes witli the proper functions of the perspiratory glands. Bathing re- moves this pellicle and is an important factor in maintaining a healthy skin. In addition it has a very beneficial effect upon the general health, as the skin is intimately connected with the internal organs by means of the nervous system. Classification of Baths. — Baths are often spoken of as local or general, according as the ablution is confined to a portion or the whole of the body. Again, they may be classified according to tempera- ture as follows : hot, over 98° F ; warm, between 90° and 98° F. ; tepid, between 80° and 90° F. ; cool, be- tween 65° and 80° F. ; and cold, below 65° F. These are merely arbitrary, but convenient distinctions. For practical purposes it will be sufficient to describe the cold, the warm, and the tepid bath. The cold bath is intended to act as a stimulant and give strength, as opposed to the warm bath, which has a soothing action, or, technically speaking, is sedative. The proper time to take a cold bath is before breakfast and as soon after ris- ing as convenient. A simple and by no means in- effective way of taking the morning bath is with the sponge, for the conveniences of a shower bath or tub are not always at hand. Every one, however, may possess a sponge and a bowl of cold water, and will derive health' and enjoyment from their daily use. Considering the fact that cold baths are so bene- ficial and pleasant, as those who take them regularly will affirm, it seems strange that in this country at least such a small number of persons indulge in them. Many say that they cannot take the cold bath, 62 THE SKIN AND ITS APPENDAGES. as it gives them too great a shock, or is too weak- ening, or is not followed by a proper reaction. On the contrary, however, most persons can take .a cold bath every morning if they will only make up their minds to do so and go about it properly. It would not, of course, be advisable for one advanced in years, when the blood-vessels are naturally weak, to risk apo- plexy by plunging into a cold bath without being properly trained to it by gradual stages. The physiologic action of the cold bath is to con- tract the cutaneous vessels and to drive the blood to the internal organs, causing a pallor of the skin. The respiration is greatly increased in depth, quick- ened at first and then slowed. The frequency of the pulse is lessened and the temperature somewhat lowered. The nervous system and especially the mental faculties are immediately and very power- fully stimulated. Upon emerging from the bath, if the reaction takes place, the tiny arteries dilate and cause the skin' to be flushed, the pulse and respira- tion soon become normal, and the bather experiences very quickly a sensation of warmth and general well- being. This reaction is the test of prime importance as to whether or not the bath is well borne. With practised bathers it will take place very speedily, and a delightful feeling of warmth will very soon be the reward of having for a moment braved the cold water. After leaving the bath, in order to aid the reaction the bather should rub the body from head to foot with a rough towel till the skin fairly glows, and when entirely dry the clothing may be put on without delay. While most persons are able to take cold baths, THE WARM BATH. 63 tliey should become accustoinetl to llieni gradually. Not only will well persons maintain their health and strength, but many in poor health, and especially those of a nervous temperament, will derive much good from the daily cold bath. The best time to be- gin systematic cold bathing is in the warmer months, and by the time winter arrives they can be kept up with very little trouble or discomfort. If the bather has not the conveniences of a tub, or fears such a decided change as a tub bath, it is well to begin with a cold sponge bath. The sponge should be saturated with cold water and squeezed over the arms, then over the chest and back, and finally over the legs, after which a vigorous rubbing should be taken. The tempera- ture of the water can be raised somewhat at first, and gradually lowered as the bather becomes more ac- customed to the cold water. The temperature of the water should not be so extremely low, however, as to interfere with a thorough and speedy reaction. A very beneficial way of taking the morning cold bath is by means of the shower, which is stimulating through the impact of the water against the skin as well as through its temperature. Nothing quite equals the full tub bath, however, if the bather will begin with water only moderately cold, or will first become ac- customed to the sponge bath, and then change to tub baths. One of the most benefical results of cold baths is the almost universal immunity to catching cold, as every one who takes a cold bath daily will declare. The Warm Bath. — The cold and the warm baths are almost directly opposite in their physiologic action and purposes. The warm bath dilates the 64 THE SKIN AND ITS APPENDAGES. tiny arteries, as is shown by redness of the skin, and causes profuse perspiration. The pulse and respira- tion are increased in frequency and the temperature is raised. The warm bath has an extremely soothing effect on the nervous system, and for this reason is best taken at night before retiring. The perspira- tion which is likely to continue after a warm bath is disagreeable to some, and may be prevented by spong- ing the body with cold water at the end of the bath. After an unusual amount of physical labor, when the muscles are sore and aching, nothing is more wel- come or soothing than a warm bath. The blood is withdrawn from the muscles, lessening chemic change, and pain and soreness vanish speedily. In addition to removing muscular soreness and pain, the warm bath is relaxing and tends to relieve spasmodic conditions or cramps. For those who suffer from difficulty in getting to sleep, a warm bath just before retiring will often invite a refreshing slumber. While the warm bath is to be highly recommended as a means of relieving weariness after prolonged physical exertion, under no circumstances should a cold bath be taken at this time. The hot bath (above 98° F.) should not be taken except upon the advice of a physician. The tepid bath has no decided physiologic effect and is generally employed for cleansing purposes. It may be taken any time during the day, though pref- erably in the afternoon or just before bedtime. The proper time to bathe is just before a meal or about three hours after. In order to digest food properly the stomach needs an abundant supply of blood to form its necessary juices and ferments, and SOAP. 65 if the blood is diverted from the stomach to the sur- face of the body by means of a bath the digestion will necessarily suffer. Soap. — As water alone cannot dissolve the grease upon the skin, the use of soap is essential in order to effect a thorough cleansing. Soap is a combination of a fat with an alkali in greater or less excess. The latter combines with the fat of the skin, rendering it soluble and freely miscible with water. Potash is the alkali used to form soft soap, while a hard soap is produced by combining the fat with soda. A soap is said to be neutral when the alkali nearly balances or is in very slight excess of the fat, and in this class are included most of our ordinary toilet soaps. A good soap should be made of pure and fresh fat, should not contain too much alkali, which tends to irritate and roughen the skin, and the percentage of water should not be so high as to cause unnecessary waste. Adul- teration with foreign substances, such as silica, which is added to increase the bulk, should be avoided. The harm actually done by impure soaps is very small in proportion to the amount of fear and appre- hension expressed concerning their use. No one stops to ask just what special make of bread is pure, but continues to eat whatever bread appears to be wholesome and palatable ; and similarly any toilet soap upon the market may be used with impunity by the majority of people. A soap that will form a large amount of lather is not on that account valu- able, for cocoanut oil is often added to produce this result. The expense of a soap is a better test of its value, as a good soap cannot be made very cheaply. The various soaps that are claimed to have soothing 5 dd THE SKIN AND ITS APPENDAGES. properties are not to be recommended on that account, as the most that is desired of a soap is that it shall be simply pure and non-irritating. Medicated soaps are of little use, although great hopes were expressed as to their usefulness when first introduced. No special therapeutic value can reside in a substance like soap which is intended to come in contact with the skin for such a short space of time. Tar soap has attained a considerable popularity, espe- cially for use in shampooing the head. For this pur- pose it is generally pleasant and effective, but with the exception of a strong odor it cannot be said to possess any very unusual quality- Sea-bathing. — There are numerous causes that tend to make sea-bathing beneficial to the health, as well as a pleasure to the majority of people. ^ The very fact that a bath in the ocean is enjoyable will increase its beneficial effect, and, indeed, any exercise or recreation will be of greater benefit if undertaken cheerfully and not considered as a tiresome matter of duty. The fine, pure air of the seashore constitutes one of the important advantages to be derived from sea-bathing. Breezes from the ocean are always fresh and free from micro-organisms, and constitute an invigorating tonic for healthy as well as for many sickly persons. The shock of the cold bath is always lessened by the exercise taken, especially if the bather can swim. The motion of the waves acts as a sort of massage to the body and adds invigoration to the bath. It is rather doubtful whether any special virtue resides in the large amount of salt and greater density of sea water. It has been remarked that very little if THE rUKKISII OR HOT- AIR liAJV/. 6y any salt can be absorbed through the skin, and this alleged advantage of sea-bathing is probably mostly in the mind of the bather. Many persons abuse the privilege of bathing in the ocean by remaining in the water until their fingers and lips are blue and teeth are chattering. All are not alike in their ability to bear cold water, and convalescents or persons with serious organic disease should bathe only under medi- cal supervision. No one should remain in the bath until thoroughly chilled. Ten to twenty minutes should constitute the range of duration. No one should attempt to plunge into the water suddenly when overheated, and if there is any con- siderable perspiration it is well to sponge oflf the body with cold or cool water before beginning the bath. The morning is the most appropriate time to take the daily bath in the ocean, as its general purpose is to be invigorating, and it is also most conveniently taken when the water is at high tide. After bathing in the salt water many find it agreeable to take a brief shower or sponge bath of fresh water. When the bath-house is provided with an inner courtyard it is healthful and advisable for the bather to lounge about in the sun for a while and allow the air as well as sunlight to come in contact with the skin, and then to don the clothing leisurely. The word " bath " does not always refer to an ablu- tion with water, but in a broader sense means surround- ing the body with any medium whose quality or tem- perature is unusual. Thus we speak of the hot-air bath, the hot-vapor bath, the compressed-air bath, etc. The Turkish or hot-air bath serves several useful purposes, and is well borne by the average healthy 68 THE SKIN AND ITS APPENDAGES. person. Its systematic use may at times be advan- tageous, although it is for many an expensive luxury and not accessible outside of cities. In taking a Turkish bath, the bather, after removing his clothing, enters the warm room where the temperature is only a little above that of the body. Here he remains for a short time till a gentle perspiration appears upon the skin. He next enters the hot room, where the temperature ranges from 120° to 140° F., and some- times a still hotter room is provided where the tem- perature may exceed 170° F. Upon entering the hot room the inexperienced bather often feels a sensa- tion of nausea or suffocation; but, as a rule, in a well- ventilated bath these uncomfortable feelings will van- ish with the appearance of a free perspiration. A practised bather will suffer no inconvenience in the hot room, and will perspire much more freely and much more quickly than the beginner. By drinking a glass of water before or during the bath the produc- tion of perspiration is greatly aided. After leaving the hot room the bather is shown to a moderately cool room and reclines while the attendant lathers him from head to foot and scrubs and massages him vigor- ously. This removes all the dried epithelial scales, and as a means of cleansing the skin it may be said that the Turkish bath is without an equal. The soap is' removed by a douche, beginning with warm and ending with cold water. The bather may then take a plunge in a tank of cold water if this is afforded by the establishment, or immediately repair to a cool room and recline for a half hour or more wrapped in a blanket. For persons who are exhausted from great exertion and whose muscles and joints are sore hA 77/- /Vv' UIUTUS. 69 and stiff the Turkisli Imtli is most rcfrcsliing. Many sufferers from rheumatism will derive relief from a systematic course of such baths. The Turkish bath is often successfully resorted to for breaking up a cold. The Russian bath differs from the Turkish bath in substituting hot vapor for the hot air of the latter. Perspiration cannot take place as readily in the Rus- sian bath as has been explained, and for producing a copious perspiration the Russian bath is inferior to the Turkish. It is employed in some cases of chronic rheumatism, and is especially beneficial for dry forms of bronchitis. Bath-pruritus. — A recent writer speaks of a dis- agreeable and annoying result occasionally produced by bathing, which he calls "bath-pruritus." He de- scribes it as a sensation of burning, or more often itch- ing, chiefly confined to the lower extremities, which appears very shortly after an ablution. Its duration varies from a few minutes to a half hour. It may follow bathing in salt or in fresh water. The itching seems to be aggravated by too long continuance or extremes of temperature of the bath; by the use of soap that is too strong or is allowed to remain upon the skin. Indulgence in scratching seems to increase the pruritus. The writer further states that the affec- tion is likely to occur in persons with a naturally irritable skin and a tendency to urticaria or hives. This statement suggests sufficient cause for the majority of cases of this so-called bath-pruritus. In- deed most persons who suffer from itching after a bath must look for the cause in a natural irritability of the skin rather than in the bath itself. yO THE SKIN AND ITS APPENDAGES. The treatment, which is not always satisfactory, is based upon general principles. Any digestive or nervous disturbances are to be corrected, and a re- stricted diet and plenty of exercise are to be advised. The intestinal action should be rendered free by lax- ative food or medicine. The bath should not be of too long duration, and for cleansing the skin a good toilet soap should be employed. After the bath it is well to dry the skin gently without friction, and then to apply freely some dusting-powder, such as equal parts of starch and zinc oxid. Care of the Complexion. — From the exposure to which the face is naturally subjected it should receive no less than two daily ablutions. Cold water should be used for washing the face, as it has a stimulant action on the blood-vessels and improves the circula- tion in the skin. It also improves the tone of the elastic fibers of the skin and tends to delay the appear- ance of wrinkles. Furthermore, the general sensa- tion of bathing the face with cold water is most refreshing. If the water is so cold as to be disagree- able, its temperature may be raised slightly ; but it is not advisable to use hot or warm water regularly for washing the face. Using hot water upon the face and then undergoing exposure to cold air or wind, especially in winter, has a decided tendency to pro- duce chapping and roughening of the skin. It is a question as to whether the use of soap is advisable for the daily cleansing of the face. For the perfectly healthy skin soap is not absolutely essen- tial, and its too frequent use may prove injurious. For persons, however, with a very oily skin, or for those residing in cities where the air is laden with TOILET LOTIONS. 7 I soot from the use of soft coal, the daily use of soap may be necessary. If the complexion is sallow and there is a tendency to pimples and blotches, nothing will serve better to stimulate the circulation and to improve the complexion than vigorous i)inching of the face by the fingers. Questions are frequently asked regarding the advis- ability of using various toilet creams and lotions on the face, and about the use of the various complexion or face powders. If the skin is unnaturally dry, there can be no harm in the application of a little grease to the face, while the employment of powder is largely a matter of taste. In hot weather the application of a small quantity of rice powder to the face will often be grateful, and can do no harm to the complexion. The preparations known as cold creams are mixt- ures of some solid fat as wax or spermaceti, with an oil such as castor or almond oil, to which some fragrant substances are added. They can be used on the face with perfect freedom and without danger of injury. The toilet or face creams are mucilaginous preparations containing tragacanth and other ingre- dients, and are pleasant applications for a fissured or chapped skin. Toilet lotions serve a similar purpose, and are gen- erally transparent preparations containing ghcerin and other substances. For removing summer freckles and tan the follow- ing lotion may be employed : R. — Siilphocarbolate of soda, 50 grains Glj'cerin, 2 ounces Rose-water, I ounce ; Alcohol, I ounce. 72 THE SKIN AND ITS APPENDAGES. For an obstinate case of freckles the following may be recommended : R. — Bichlorid of mercury, 6 grains ; Alcohol, I ounce ; Glycerin, 2 ounces Oil of lavender, lo drops. Face powders are generally composed of one or more of the following substances : Talcum, starch, bismuth, chalk, zinc oxid, and magnesia, and, as a rule, are entirely harmless. Lead has at times been employed as an ingredient of face powders, and if the powder contains this substance it is objectionable from the possibility of a poisonous effect. CLOTHING. The materials most frequently used for clothing are derived partly from the animal and partly from the vegetable kingdom. From the former are obtained silk, wool, furs, and leather, while from the latter are derived cotton, linen, and rubber. In discussing the value of these different substances as materials for clothing, two important physical properties to be considered are their power of conducting heat and capacity for absorbing moisture. The heat-conducting power which a garment possesses does not depend to any great extent on the fabric itself, but chiefly on the manner in which that fabric is woven. Dry air is a very poor conductor of heat, and any garment which is loosely woven and is capable of holding considerable air in its meshes will be a poor conductor, and will consequently feel warm. Wool, for the reason that it is naturally woven into cloth that is loose in texture and porous, is a most CLOTHING. 73 valuable clothing material for use in cold weather. If numerous thicknesses of woollen clothing will not suffice to withstand severe cold, then furs may be supplemented. Cotton is naturally woven into cloth whose texture is compact and not porous, and is, therefore, not so valuable as wool for use in cold weather. When, however, specially manufactured so that its texture closely resembles that of woollen cloth, it may be a fair substitute for wool. The capacity for absorbing moisture is possessed by wool to a very high degree, silk being next to wool in this respect. Linen is only moderately, and cotton very slightly, hygroscopic. A woollen gar- ment has the property of absorbing a great deal of moisture without feeling wet. Evaporation of moist- ure proceeds slowly from woollen clothing, while cotton clothing, especially underwear, speedily becomes saturated with moisture and evaporation is liable to take place suddenly, with resulting chilling of the body. In speaking of flannel, some philosopher has made the paradoxical remark that no matter how cold and wet it may be it is always warm and dry. As flannel underclothing is so hygroscopic and does not allow the moisture it absorbs to evaporate too rapidly, it is the most valuable material for under- clothing for use in temperate and changeable climates. For cold weather, heavy woollen underwear cannot be surpassed for warmth and comfort. By manufactur- ing cotton into cloth with large meshes or air-con- taining spaces a very fair substitute for flannel underwear has been obtained. While probably not superior to flannel for underclothing, this material is valuable for persons who find wool next to the skin 74 THE SKIN AND ITS APPENDAGES. uncomfortable. Many, however, who think at first that they cannot bear wool next to the skin will, after awhile, tolerate its presence. Another substi- tute for woollen underwear is found in merino, which consists of a mixture of wool and other materials. Woollen underclothing has the disadvantages of shrinking readily when washed and of absorbing odors readily. The former fault can be somewhat overcome, however, by buying goods which have been shrunken and by having them washed in tepid water, with little soap and no violent friction. On account of this tendency to shrink, old flannel under- clothing is not the equal of new, for after repeated washing the fabric becomes " felted," less porous and of a closer texture, and consequently not so warm. Clothing for Cold Weather. — It is a mistake to try to endure cold w'eather without wearing sufii- ciently warm clothing. Whenever a feeling of cold or chilliness is experienced it is highly proper to put on an extra garment without delay, and it is folly to w^ait till the body is chilled before taking the trouble to make a change of clothing. The habit of wearing thin clothing all the year round and of going without an overcoat through the winter to dis- play a vigorous constitution is not advisable. It is true that some persons seem to keep well from such a course, and while the heat-producing power may be equal to the extra demand, it is at the expense of the nervous energy of the individual. Children and old people, whose power of producing heat is lim- ited, should be proportionately warmly clad, and the practice of dressing children with the legs exposed is as cruel as it is unhvo-ienic. CLOTHING J'OK WARM WEATHER. 75 Clothing fbr Warm Weather. — For use in tropical climates flannel underwear is found to be too warm, and cotton, silk, and linen are more serviceable ma- terials. The Chinese plan of wearing a net next to the skin, and over it a thin silken garment, is ad- mirable, the silk readily absorbing the perspiration, while the net prevents the silken garment adhering to the skin. Silk underclothing is always agreeably soft and fresh, but it is expensive and is likely to shrink considerably in washing. Much of the under- clothing said to be pure silk is probably of mixed composition. Thin linen for tropical wear is said to be very acceptable and always has a feeling of fresh- ness, but it is more expensive than cotton, which is for practical purposes the most available material to be employed. Cotton cloth is strong, durable, cheap, does not shrink readily, and absorbs odors very slightly. As a protection against excessive heat the color of clothing is of considerable importance. By placing pieces of cloth of light and dark shades upon snow it is found that the snow melts more readily under the dark than under the light cloth. From this we infer that light colors, such as yellow or white, which ab- sorb fewest of the heat rays of the sun, are the more suitable colors for tropical clothing. The presence of cheap aniline dyes in underclothing and stockings will occasionally cause considerable irritation to the skin, though much less frequently than is generally supposed. By observing cleanliness and discarding the offending garment relief will very promptly be afforded. Underclothing should be washed frequently, de- 76 THE SKIN AND ITS APPENDAGES. pending on the amount of perspiration of the wearer. It should be aired very thoroughly over night, and the same set should never be worn both day and night. Damp underclothes offer a most excellent soil for the growth of micro-organisms, and favor the development of certain parasitic skin-diseases which flourish only under conditions of warmth and moist- ure. Rubber or mackintosh clothing is very useful as a protection against wind as well as rain, and is suit- able for persons whose occupation requires consider- able exposure but not much exercise, as, for instance, coachmen or seamen. For active occupations it is to be condemned. Being impermeable to air, the per- spiration cannot evaporate as readily as it does when woollen garments are worn. There has lately been introduced a form of waterproof cloth that differs from rubber in being entirely permeable to air. Overcoats made of this material will shed rain per- fectly, and, unlike a mackintosh, will feel perfectly comfortable when exercise is taken. As this mate- rial allows free evaporation of the perspiration it forms the ideal waterproof garment. Shoes. — There is hardly an article of clothing upon which our comfort depends to so large an extent as upon the covering of the feet. It seems superfluous to say that shoes should fit the feet perfectly, yet owing to the demands of fashion this does not always seem to be the chief consideration in purchasing shoes. If expense need not be considered, boots or shoes should be made to order. By standing in the stockings a tracing is made about the foot and from this the proper last is constructed. In a well-made pair of SHOES. 77 Fig. 14. — Normal feet (Whitman). FiG. 15. — Proper soles for normal feet (Whitman). shoes the inner sides should be nearly parallel and not diverge greatly when the wearer stands with feet Fig. 16. — Deformed feet (Whitman). Fig. 17. — Shoemakers' soles (Whitman). together. The outer side of the shoe should have a gentle curve inward, and the toe should in no case be 78 THE SKIN AND ITS APPENDAGES. pointed. In Fig. 14 is shown an impression made by the normal foot. To provide a sensible form of shoe for a foot of this shape it does not seem rational to have the toe narrow and pointed; nor, on the other hand, perfectly square as is seen in some of the so- called common-sense shoes. The sole of a properly constructed shoe should have the shape shown in Fig. 15. In Fig. 16 is given an illustration of a foot that has become deformed and made to fit a shoe whose shape is improper and unhygienic (Fig. 17). It is most essential to comfort that a shoe should be sufficiently long. A good rule to follow is to wear shoes that are at least three-quarters of an inch longer than the foot. By observing these common- sense ideas many troublesome conditions, such as corns, bunions, and others more serious, may be pre- vented. The soles of the shoe should be of the extension type if intended for hard walking, as the projecting Fig. 18.— The rocker sole (Whitman). Fig. 19.— The flat sole (Whit- man). part affords considerable protection against loose stones. If the sole is flat, a much better support is given the foot than in the usual sole that turns up from the ground (see Figs. 18 and 19). The leather should be moderately thick for protection, and at the same time pliable. SOCKS AND STOCKINGS— GARTERS. 79 The heels should always be broad and low. The high heels so frequently worn by women for the purpose of increasing their height and lessening the apparent size of the foot are harmful. They tend to produce weakness of the arch of the foot through atrophy of the plantar ligaments. lyow shoes are a hygienic form of footwear, since they allow excel- lent ventilation of the foot, and are especially desir- able for use during the warmer months. Patent leather shoes are not advisable for con- tinued wear, since, being impermeable to air, they do not allow proper evaporation of the perspiration from the feet. However uncomfortable rubber shoes may feel, they are probably the means of preventing many colds ; they should never be worn unnecessa- rily. For those who have to do considerable walking in wet weather and cannot conveniently wear rub- bers, hobnails are a great protection to the soles of the shoes, and also add to the firmness of the step. Socks and stockings should often be changed, the frequency depending on the amount of perspira- tion of the wearer's foot. In the case of those who suffer from excessive perspiration of the feet, at times of a bad odor, the socks or stockings should be changed daily. The feet should be washed and dried without friction, and over the feet and in the fresh socks may be dusted the following powder — salicylic acid, i part ; starch, 4 parts. Garters. — Unfortunately, ill-fitting shoes are not the only portions of the human attire that bring about evil consequences and are to be condemned. Any article of clothing which unnaturally constricts a portion of the body is harmful and unhygienic. The 8o THE SKIN AND ITS APPENDAGES. circular elastic garter acts as a constant tourniquet about the leg and interferes with the circulation of blood in the veins. These will tend to dilate after awhile and become tortuous, giving rise to the con- dition known as varicose veins. The dilated veins generally prove to be sources of considerable annoy- ance, and at times of danger. Instead of using circu- lar garters, the proper plan is to suspend the stockings from some part of the underclothing. Corsets. — The subject of improper clothing could not well be passed by without adding a few words to the volume of protest already entered against the wearing of tight corsets. The practice of compressing the body unnaturally by means of various kinds of stays seems to continue in spite of the hostility of practically all physicians. Constrict- ing the waist too tightly causes a change in position and interferes with the functions of many of the in- ternal organs (see page 44). It prevents the proper muscular development of women, as no tightly-laced woman can indulge in any vigorous exercise. Corsets greatly interfere with the fullest attainment of health and vigor. When tightly laced they lessen the amount of air that can be taken into the lungs. As a result the blood is imperfectly aerated, deteriorates in quality, and the wearer suffers from anemia. The entire list of injuries attributed to wearing tight corsets is a formidable one, and should cause every woman to think before continuing the prac- tice. Most women say that they would have a feel- ing of utter collapse if the stays were to be laid aside. This is due to the imperfect development of muscles that are not called into play when stays are BED- Cf. O TJIING. 8 I worn, but whicli should be strenj^tliened by exercise in order to perform their natural functions. A certain writer has expressed opinions about stays that have given great consolation to women who wear them. She says that women breathe naturally with the chest, especially the upper portion, and employ abdominal breathing very slightly, so that tight lacing which does not interfere with chest breathing is hygienic and proper. Opposed to this view, some experimenter has found that Indian girls who have never constricted the waist by stays breathe with the diaphragm as naturally as do men, and con- clude that the insufficient method of breathing with the chest, common in women, is itself due to the habit of wearing stays. As a matter of fact, no skilled singing teacher would ever consent to allow his pupils to sing when handicapped by a tightly- laced waist, but would insist upon their breathing to their utmost capacity. This • can only be accom- plished when both chest and abdomen are free and unhampered. Bed-clothing should not be unnecessarily heavy. A light covering, such as an eiderdown quilt, will afford more warmth than a blanket of greater weight, owing to its capacity for retaining more air in its meshes. Similarly two coverings will be warmer than one which is equal to both in thickness, on account of the layer of air contained between them. Bed-clothing should be aired thorough!}' every morn- ing, the windows of the sleeping-room being opened for this purpose. 82 THE SKIN AND ITS APPENDAGES. CARE OF THE HAIR. A fine head of liair is a possession universally prized, and one which is frequently neglected by its owner as often through ignorance as through care- lessness. In the preservation of the hair some per- sons have a great natural advantage over others. If there is an inherited tendency to baldness, as shown by a thin and poorly nourished scalp, there will be greater difficulty in preserving the hair than other- wise. The scalp is comparable to the soil. Neither hair nor plants will grow luxuriantly if the quality is poor. A scalp which is favorable to the growth of hair is thick and pliable, and moves freely over the bones of the skull beneath. If the scalp is very thin, the blood-vessels contained will be few in number. If it is drawn tightly over the skull, it will tend to con- strict the blood-vessels, lessen the supply of blood to the scalp, and cause atrophy of the roots of the hair from pressure. The two principal causes which bring about a premature thinning of the hair are a deficient circulation of the blood in the scalp and the constant presence of dandruff. Dandruff is a collection of epithelial scales mixed with dried sebaceous matter, and is the forerunner of premature baldness in a large percentage of cases. It will be present to a greater or less degree in many scalps unless it is constantly guarded against. It is highly important to keep the scalp perfectly clean and free from dandruff, and to attain this end daily brushing of the hair and frequent shampooing are necessary. CARE OF '11 /E HAfR. 83 Hair-brushes. — Theliair slionld be brushed morn- ing and night for several minutes until there is a feeling of warmth in the scalp and all ])articles of dandruff are removed. For an adult the brush should be a stiff one, with the little tufts of bristles widely separated to facilitate cleaning. For children and for those with very sensitive scalps, softer brushes must be used. Brushes should never be so stiff nor the brushing so vigorous as to produce any soreness of the scalp. Brushes should be frequently washed in water containing a little ammonia, and then dried in the sun with the bristles down. Combs are chiefly useful for disentangling snarls and dressing the hair, and may be employed daily with the brush. The teeth of the comb should be wide apart, have blunt ends, and be free from any irregularities which might tear the hair. In no case should the old-fashioned fine-toothed comb be used, as this pulls out the strong hairs, especially if the growth is luxuriant, and the fine points may produce disease of the scalp from irritation. Many persons are morbidly afraid that any consid- erable amount of brushing and combing will cause a serious loss of hair. Its effect, however, is just the opposite and increases the growth of hair by stimu- lating the circulation in the scalp and by removing dandruff. Brushing removes many loose hairs which are ready to fall, but their place will soon be taken by new and more vigorous ones. The groom knows by experience that the only way to keep the coat of his horse thick and glossy and in a healthy condition is to constantly iise the currycomb and brush, and that he is not likely to use either too much. 84 THE SKIN AND ITS APPENDAGES. Shampooing. — Many persons wlio are favored by nature with a luxuriant growth of hair and who per- haps consider themselves immune to baldness, will grudgingly give any time to the care of the hair and consider shampooing especially distasteful. To keep the hair clean and free from dandruff, shampooing at intervals is very necessary. There are many popular fallacies concerning ques- tions of physiology and hygiene, and some ideas about shampooing of the scalp are no exception to the rule. Shampooing, like brushing, also removes some loose hairs, but by cleansing and stimulating the scalp it forms a most important means of preserving a good head of hair or aiding to restore it after a tem- porary falling. The frequency of shampooing of the scalp depends on the rapidity with which dandruff accumulates, and to some extent on occupation of the individual. For some persons, washing the scalp once a month will be found sufficient to keep it in a hygienic condition. Others, and especially those whose business requires much travelling or exposure to dust and dirt, may find it necessary to wash the head once a fortnight, or even once a week. There is never any danger of shampooing the healthy scalp too frequently, notwithstanding the opposite state- ment so frequently made by some hairdressers, whose chief stock in trade is some ' ' tonic ' ' of alleged miraculous virtue. When the hair has begun to fall out prematurely, due to long neglect or following an illness, it is well to begin shampooing the head twice or even three times a week, and to gradually lessen the intervals to once in three or four weeks. Not only are some afraid that the shampoo will SHAMPOOING. 85 cause considerable loss of hair through the friclioii employed, but they fear that all the oil in the scalp will be removed and great damage done to the hair by the dryness resulting. Immediately after washing the scalp, especially if alcohol be used in addition to the soap, the scalp will certainly feel dry, but it will soon become more oily than usual due to improve- ment in circulation and consequent stimulation of the oil-glands. This will be the result in the majority of cases, and very few persons will suffer from dryness of the scalp if they practice shampooing with suffi- cient frequency. Some persons actually say that after the shampoo the scalp becomes too oily. When the scalp fails to respond to the mechanical stimulus of shampooing by producing an insufficient amount of sebaceous matter, then it is well to rub into the scalp some form of grease or oil. Nothing answers the purpose better than pure vaseline, although some barbers prefer to use olive oil. This can be con- veniently applied by a medicine-dropper, after making numerous parts in the hair. The use of soap on the hair agitates many persons who, though employing the best soap in cleaning the skin, consider that shampooing is a dangerous procedure unless the soap used is recommended by physicians. Any good toilet soap upon the market will answer the purpose, and more harm is done by refraining from the use of the shampoo than by using an inferior quality of soap on the hair. The addition of alcohol to shampooing liquids, as in the tincture of green soap will greatly assist the thor- ough cleansing of the scalp. The addition of an egg to the shampoo is thought by mau}^ to make it more 86 THE SKIN AND ITS APPENDAGES. pleasant and effective. As the egg has no cleansing effect its use is largely a matter of taste. There is no more reason for its employment upon the scalp than for its use in the daily washing of the hands and face. A very satisfactory shampoo liquid is found in the linamentum saponis mollis of the Pharmacopeia, which consists of 50 parts of soft soap, 2 parts of oil of lavender, and 33 parts of alcohol. In the operation of shampooingany ordinary good toilet soap may be selected. A lather is then formed and rubbed vigorously into the scalp with the finger tips or a stiff brush, a nail brush being very conve- nient for the purpose. The lather is best removed by a warm-water douche, always ending the process with cold water to lessen the danger of contracting a cold. The hair is then to be dried as thoroughly as possible with towels, and to complete the drying it is well to remain for a while in the sun or near an open fire or radiator. Head-gear. — While many persons naturally possess a thin head of hair and a poor circulation, they are handicapped still further by various causes that tend to lesson the circulation in the scalp. One of these causes is the wearing of hats. The hats worn by men at the present time, especially the Derby and silk hat, allow very little ventilation, prevent the access of sunlight as well as air, and do not permit the proper evaporation of the perspiration. The tight-fitting brim also constricts the blood-vessels and hinders the circulation. Women's hats have no tight brim, allow free ventilation, and, unless very heavy, are seldom objectionable in this respect. The interesting and MASSAGE OF Till': SCAIJ\ 8/ oft-repeated argiiinents against the wearing of hats may here be cited. Savages who go bareheaded do not suffer from baldness, and tlic same immunity to early falling of the hair is said to be the gocxl for- tune of the lads of the "Blue-Coat vSchool " in London. These boys never wear any hats, however stormy the weather may be nor how low the ther- mometer may descend. As the hats of the present day seem to be necessary evils, the only practical advice that may be given is that they should not be worn unnecessarily, especially when the head is perspiring, and that they should not be jammed on the head with such firmness as to interfere with the circulation of the scalp. The fact that women are more free from baldness than men may be due in a slight degree to their wearing a more hygienic form of head-gear, but undoubtedly the chief cause lies in their possession of a thick scalp and an underlying cushion of fat, which is naturally better adapted to support a good growth of hair. Some physicians think that the amount of brain- work done may be a factor in bringing on premature baldness, but this has not been definitely proven. The answer to the question as to what can be done to improve the circulation of the scalp and the growth of the hair is, briefly — mechanical stimula- tion. This may be practised through shampooing, massage, and the local application of electricity. Shampooing has been considered, and its thorough and frequent practice cannot be too strongh' urged. Massage of the Scalp. — Vigorous daily massage, if continued for a considerable time, will tend to im- prove the circulation and to increase the growth of 88 THE SKIN AND ITS APPENDAGES. hair. If the scalp is pale and thin, it is well to com- bine a few minutes of massage by the finger-tips with the daily morning and night brushing. A variety of motions may be practised, such as moving the fingers over all parts of scalp, and then placing them firmly on the scalp and moving the scalp itself over the bones beneath. Electricity acts merely as a local stimulant to the circulation, and is best used in the form of galvan- ism, A wire-brush electrode is attached to the negative pole of the galvanic battery, and applied to the scalp through the hair until the former becomes well reddened. Cutting the Hair. — Many persons entertain the false idea that cutting the hair increases its thick- ness. While it may aid to some extent the rapidity of growth, cutting certainly does not increase the number of hairs. To keep the hair short in chil- dren up to the age of eight or nine years is generally deemed sensible and hygienic. Its good effect is mostly due to the easier access of air and sunlight to the scalp and to the greater ease with which the head can be kept clean, although some think that if the hair of a growing child is kept short there will be less of a tax upon its strength and vitality. The opinion seems to be pretty general that shaving with a sharp razor will produce a thicker and firmer growth of hair, although one recent writer on hy- giene claims that .shaving actually has a depilatory effect. In the process of shaving, the roots of the hairs are stimulated to a slight degree, and a coarser and thicker growth upon the face of a young man doubtless results in due time ; but time rather than HAIR RESTOKKKS OR IJAJR TONJCS—J'OMADES. 89 shaving is responsible for the change. The experiment occasionally tried by enthusiasts of shaving the head in the hope of obtaining abetter growth of hair is never productive of any brilliant result, and may be con- sidered as absurd and useless. In dressing- the hair it is important to make no violent traction upon the roots, as this has a ten- dency to loosen and cause a falling of the hair. There should be no twists or knots which produce feel- ings of discomfort for such are certain to prove in- jurious. There is no great objection to curling- the hair if it is not done with too much vigor. Curl papers, if not put on so tightly as to pull on the roots of the hair, are not likely to do harm. Curling irons, however, are often overheated and make the hair un- naturally dry and brittle. A very absurd idea that pervades the mind of the average " tonsorial artist" is that singeing the hair will tend to preserv-e it and to stimulate its growth. There is no truth in the barber's assertion that the hair is a hollow tube which will allow the escape of oil, and that if the ends can only be sealed by singe- ing much benefit will result. Hair restorers or hair tonics are fully as useless as singeing. These preparations, which are wadely advertised, fail utterly to accomplish the purpose for which they are employed. Shampooing, brushing, massage of the scalp, and attention to the general health, and not the use of a hair tonic, are the only means of preserving a good head of hair and aiding its restoration after falling. Pomades are mentioned only to say that their use in general is considered unnecessary, while to most 90 THE SKIN AND ITS APPENDAGES. people they seem uncleanly and disagreeable. A generation ago some oily dressing for the hair was universally used, largely because it was the fashion. Bear's grease was often used as an ingre- dient of the pomade, in hopes that some hair-restor- ing properties might be possessed by the fat of an animal as naturally hairy as the bear. Many young men indulge in the habit of fre- quently wetting the hair in order to make it set smoothly. In addition to producing a doubtful esthetic effect, this practice is harmful by tending to cause decomposition of the roots of the hair. As has been stated, there is no harm in washing the hair frequently if it is subsequently dried with towels. Removal of Superfluous Hair. — The use of de- pilatory pastes or substances to remove superfluous hairs is not recommended, except upon the advice of a physician. These pastes will often remove a downy growth of hair, but cannot remove large stiff hairs without doing too much damage to the skin to warrant their employment. For removing large hairs, the only satisfactory method is the slow but sure one by electrolysis. By this method an experienced operator can remove any number of large hairs per- manently without leaving any scars or causing much pain. Gray Hair. — An eminent dermatologist has re- marked that the only sensible thing to do for gray hair is to admire it. While gray hair undoubtedly improves the looks of some people and is welcomed by them, it is to others a source of considerable an- noyance. In the rare cases of sudden blanching of the hair, such as sometimes follows profound mental CARE OF THE BEARD. 9 1 disturbance, a return of the former color is a possi- bility, but even this could not probably be aided by any efforts of the physician. Nothing can really be done to prevent the hair turning gray. Dyeing the hair is an exhibition of poor taste, and is really only excusable in the case of young persons whose hair has turned gray at an unusually early age. Many of the dyes for coloring the hair black contain lead, and on this account should be avoided, as cases of lead-poisoning from the use of hair-dyes undoubtedly have occurred. Before the application of any hair-dye the head should be thoroughly shampooed and then dried. The dye is most conveniently applied to the hair by a tooth-brush, avoiding contact as far as possible with the scalp. Leonard recommends the following harmless hair- d)^e for producing a black color. B. — Bismuth citrate, i ounce ; Rose water, 2 ounces ; Distilled water, • 2 ounces ; Alcohol, Yz ounce ; Ammonia water, a few drops. To be applied in the morning. R. — Sodium hyposulphite, ij^ ounces ; Distilled water, 4 ounces. To be applied at night. To obtain a brown color a mixture of pyrogallic acid and rose water may be used Care of the Beard. — An equal amount of care should be bestowed upon the cleanliness of the beard and mustache, as is shown in the case of the scalp. 92 THE SKIN AND ITS APPENDAGES. The frequent ablutions of the face during the day should include both beard and mustache. To give softness and lustre to the mustache, preparations known as brilliantines may be employed without danger of a harmful effect. A suitable formula for such a preparation consists of glycerin, castor oil, and alcohol in the proportions of one, two, and three re- spectively, to which a proper amount of perfume may be added. In regard to shaving, it may be said that it is always a good plan for a man to practise shaving himself and so avoid any possible danger of infection from the barber-shop. In these establishments a number of diseases may be contracted, notably ringworm. This affection, so obstinate when attacking the hairy por- tions of the body, is usually acquired from the use of a damp towel, less often from the shaving-brush, the "clipper," or the hands of the barber. The razor is not at all likely to be the cause of infection. The damp towel offers a most excellent medium for the growth of the ringworm parasite, as this fungus, like ordinary mould, requires moisture for its development. If a barber-shop is to be patronized regularly, the customer should have a private cup, shaving-brush, and razor. If, in addition, the towels to be used are perfectly clean and dry, and the barber washes his hands thoroughly after shaving each customer, there will be still less danger of contracting ringworm and other infectious diseases. Care of the Nails. — The proper care of the nails depends upon the observance of a very few and sim- ple rules. The portion of skin overhanging the root of the nail tends to encroach too far over the lunula, CAI^E OF THE NAILS. 93 and is likely to become torn and ragged, giving rise to so-called " hangnails." These offer little open- ings throngh which infections matter may enter and do a good deal of damage, and it is possible for blood- poisoning to result from infection through one of these apparently insignificant lacerations. The epidermis overhanging the root of the nail should be pressed back once or twice a week with some convenient in- strument. For cleaning the nails, nothing but soap, warm water, and the nail-brush should be employed. The penknife should not be used in place of the nail- cleaner, as it scratches the under surface of the nail and makes a place for the lodgement of dirt. The surface of the nail should never be scraped. A word of advice may be given in regard to cut- ting tine nails, for it seems that the proper method is not universally known. The finger-nails are most conveniently cut in a curved direction, or they may be filed if this slower method is preferred, A pair of curved scissors is very convenient for cutting the finger-nails, but should not be used for the toe-nails, as these are always to be cut straight across. If, in addition to the proper selection of shoes, this last pre- caution is observed, a great deal of trouble and dis- comfort may be avoided. For removing stains from the nails a solution of acetic acid and rose water, one part of the former to sixteen parts of the latter, may be employed. Oxalic acid is perhaps more efficient for accomplishing this purpose, but its use is not desirable, owing to its poisonous qualities. HYGIENE OF THE VOCAL AND RESPIRATORY APPARATUS. By E. FLETCHER INGALS, M. D., OF CHICAGO, Professor of Laryngology and Diseases of the Chest in the Rush Medical College ; Professor of Laryngology and Rhinology in the Chicago Polyclinic. THE NOSE. The nose is described as consisting of an outer, or facial, and an inner portion ; the latter lying within the skull. The outer nose has a bony framework in its upper portion, consisting of the nasal bones and nasal proc- esses of the upper jaw. The lower half of the outer nose is made of flexible cartilages, supported in the center by the septum, or dividing wall of the nostrils (Figs. 20, 21). The external nose has muscles of great importance in facial expression, and capable of dilating the nostrils during inspiration. The inner nose consists of two lofty air-passages, extending back into the skull as far as the posterior end of the hard palate, or roof of the mouth. Here the nostrils end in a roomy chamber called the naso- pharynx. The inner wall of each nasal passage, or naris, as it is called, is formed by the division of the nostrils, or septum (Fig. 21). This is composed in its back 94 THE NOSE. 95 and upper parts of two bones, the vomer, or plough- share, below, and a thin plate of bone above, called upper lateral, cartilage Lower lateral. cartiUii^e Sesamoid bones Cell tissue Fig. 20. — Lateral cartilages of tlie nose. the perpendicular plate of the ethmoid bone. These two bones join behind to form a solid wall, but spread- Horizontal plate of ctJtinoid Fc i/>endic!ila r /•late of ethmoid Palatal I.oii'cr lateral cartilage Siif-erior maxillary Fig. 21.— Cartilage and bones of the septum of the nose. ing in front include, like a V, the front or cartilagi- nous part of the septum, which fortunately is very flex- 96 VOCAL AND RESPIRATORY APPARATUS. ible ; because if it were of bone, fractures of this part of the nose would occur very frequently. The outer wall of the nose is made of a compli- cated bony framework, supporting three ledges or shell-like projections into the nasal cavities, called the turbinated bodies. These bodies consist of thin bone covered with mucous membrane, containing a sponge-like network of blood-vessels, forming what is called erectile tissue. There are three turbinated bodies in each nostril, called the lower, the middle, and , 4 Fig. 22. — Anterior nares, show ins; white deposit of inspired magnesium- powder upon the septum and middle turbinals only. the upper. The lower and the middle extend the whole length of the nasal cavity; the upper along the posterior half only. Underneath the lower turbinate we have the opening of the tube, or duct, conducting the tears from the eye to the nose ; under the middle turbinated body we have the opening to a thin- walled cavity, which hollows out the upper jaw, and is called the antrum of Highmore. This cavity lies immediately external to the nostril. Accessory Sinuses. — There are other bony cavities connecting with the nose in this location, two in the forehead, or frontal bone, and a large number of cells in a very thin bone at the top of the nose, called the 77//', MUCOUS MKMJiRANE. 97 etliuioid bone. These cliainbeis in tlie bones of tlie skull all contain air. The roof of the nose is formed by the nasal bones in front ; behind this by a plate of thin bone separ- ating the nasal cavity from the brain. This plate of bone contains many sieve-like holes, which give pas- sage to the filaments of the nerve of smell, and is called the cribiform plate of the ethmoid bone. A hollow bone back of this completes the roof of the nose ; it is called the body of the sphenoid bone. The floor of the nasal cavity is formed by the hard palate, a thick, massive plate of bone forming also the roof of the mouth. The mucous membrane of the nose is very sensi- tive, having many nerves of sensation from the fifth pair of nerves besides the special nerves of smell, which are found only along the space between middle turbinated body and the septum, in the so-called olfactory region. A single layer of minute, microscopic epithelial cells covers the surface of the nasal mucous mem- brane, like pavement blocks, each cell having hair- like processes on its free surface, called cilise. Nu- merous little tubes, called mucous glands, keep the mucous membrane lubricated with mucus. The best known of the functions of the nose is the sense of smell ; but the other functions are more important to the health of the individual. The many folds and narrow passages of the nasal surface warm the air as it passes over them, at the same time sup- plying it with moisture to the extent of two-thirds saturation. The moist mucous membrane of the nose also catches almost all of the dust that escapes 7 98 VOCAL AND RESPIRATORY APPARATUS. the many hairs, or vibrissse, as they are called, which are placed at the entrance to the nostrils. Whatever dust lodges on the mucous surface is pushed toward the outer orifice by the minute ciliae, which are in constant outward motion. With the dust, of course, any microbes entering the nose are also expelled. In addition to this mechanic expulsion, however, the nose probably possesses the power of destroying the bacteria by means of its mucus, which is germicidal, so that only a very short distance within the nostrils the mucous membrane is found compara- tively free from microbes. Obstruction in the Nasal Passages. — To keep the nose and the air-passages below it in a healthy state the nostrils must be open for the passage of air. The commonest cause of stopping up of the nose in chil- dren is enlargement by adenoid growth of a structure called the pharyngeal or Luschka's tonsil, or the third tonsil. This is placed behind the posterior open- ings of the nose, and when enlarged enough, may en- tirely obstruct breathing through it. Practically all mouth-breathing children have this form of obstruc- tion, the external nasal passages being open. If this form of nasal blocking is allowed to persist, it has a very deleterious effect on the development of the inner nose, which from lack of use is retarded in its growth. In such cases the nasal passages at the beginning of adult life are as small as those of a child, while the upper jaw is narrow, producing an ugly protrusion of the front teeth and a characteristic stupid expression. In adults, nasal obstructions are often due to deformities of the septum, which is either much bent to one side or thickened in such a way as to close MO [77 'II- BREA I I/ING. 99 up one nostril permanently. (3ther frequent causes of stoppages of the nose of a lasting character are mucous growths called polyps. The most common source of nasal occlusion in grown persons is swell- ing of the nasal mucous membrane. Mouth -breathing, with its attendant evils, is the result of these obstructions to the free passage of air through the nose. Mouth-breathing .allows the en- trance of dust and microbes directly to the lower air- passages, larynx, trachea, and lungs ; whereas in breathing through the nose most of these particles are lodged on the nasal mucous membrane and returned to the outer world in the ways mentioned. The bronchi and trachea have ciliated epithelium as well as the nose, and although this epithelium, by means of its waving, hair-like processes, is capable of expel- ling many of the minute foreign bodies that enter the lungs, still some reach the air-cells even under ordi- nary conditions when breathing is carried on with the mouth "closed, while mouth-breathing adds enor- mously to their number. In this way the microbes of tuberculosis, pneumonia, bronchitis, influenza, etc. penetrate the lungs more readily than in nose-breath- ing. This is especially true of the rapid and forced breathing accompanying violent exertion. Through the open mouth diphtheria germs reach the larynx or tonsils directly. Closure of one nostril, common in adults, com- pels the sufferer to try heroically to breathe through the other nostril, with consequent rarefaction of the air in the free nasal passage and the pharynx, thus by suction overfilling the blood-vessels and pre- disposing to catarrhal diseases. In singers the effect lOO VOCAL AND RESPIRATORY APPARATUS. of nasal stoppage is to place undue strain on the voice by trying to overcome the lack of resonance due to the obstructed nose. It is well known to long-distance runners that the breath gives out very soon if mouth-breathing is used, while breathing through the nose is soon fol- lowed by what is called "second wind," during which respiration becomes easy again. Second wind is partly due to a dilatation of the blood-vessels, mak- ing the blood-pressure lower and the heart's action easier. It is also in part due to the fact that in breathing through the comparatively narrow nasal orifice the air enters the thorax with more difficulty than through the mouth; this increases the negative pressure within the chest, causes the respirations to be long and deep, and so gives the thorax an oppor- tunity to pump blood as well as air into its cavity, thus aiding the heart in its work. So deep breathing through the nose during exertion tends to lessen the heart-strain of cycling, running, boxing, or other sports and exercises. The foregoing statements sufficiently prove how indispensable to healthy respiratory organs is an un- obstructed nose. Causes of Nasal Disease. — A healthy nose needs no care by means of sprays, nasal douches, and the like. In fact, the care of the nasal passages involves chiefly a knowledge of the causes predisposing to nasal disease, and as far as possible the avoidance of these causes. There are, however, classes of nasal affections, such as malignant growths, bony tumors, etc., which are not preventable, but much can be done to limit the occurrence of the ordinary catarrhal TO AVOID CATCHING COLD. 10 1 affections of the nose which lead np to other morbid conditions, such as polypi or suppuration of the air- chambers about the nose called the sinuses. First among the causes of catarrhal nasal affections is exposure to cold, especially of those portions of the body ordinarily protected by clothing. This occurs especially during high winds or chilly and damp weather, as a result of wetting of the garments, and from insufficient covering at night. It is pro- longed exposure in moderately low temperatures that is dangerous, rather than a short subjection of the body to a sudden cold shock. A cold douche or plunge is followed by vigorous contraction of the smooth muscle-fibers of the skin, driving the blood from the surface, while in prolonged exposure to slight cold there is no such reaction of the skin and a a large amount of blood is cooled slowly. This is es- pecially true of those who have made themselves non- resistant and "soft" by excessive clothing or con- tinued indoor life. Contraction of the muscles and vessels of the skin does not take place as readily in such persons as in hardy ones used to exposure and outdoor existence. Cold as a cause, of catarrhal nasal affections does not seem operative in very pure air, as is the experience in Arctic exploring expeditions, so that the congestion of the mucous membrane caused by cold appears to need in addition microbic infection to produce the common "colds in the head." To avoid catching cold it is needful to make the body resistant to the influence of cold. The cold shower-bath is of great value for this purpose. It may be used every morning or evening for from one to two minutes. The water should be cold I02 VOCAL AND RESPIRATORY APPARATUS. enough to produce a decided reaction with the ap- pearance of ' ' goose-flesh' ' pimples on the skin. As the body-temperature and vigor are lowest in the morning, the evening shower is preferable for delicate people. Over-heated rooms and too much clothing are to be avoided. It is well to see that the sleeping- room does not cool down slowly over night, but that it is properly cooled at bedtime. As is true of most other ailments, the avoidance of nasal catarrh involves also the keeping of the body in its best physical condition, when the nasal pas- sages will resist irritants that in depreciated health they cannot withstand. This is especially so of the inhalation of irritants, such as dust or germs, which of themselves are not likely to cause nasal catarrh in healthy persons. Although the healthy nose can dispose of dust and microbes so well, as soon as its mucous membrane is swollen and inflamed in consequence of catarrhal states it becomes liable to germ infection, so that in the last stages of acute catarrh of the nose, and in many cases of the same affection of a chronic order, we have a purulent secretion on account of pus-pro- ducing germs present in the nose. The bacilli of diphtheria, tuberculosis, influenza and glanders, staphylococci and streptococci, and the contagion of measles and of scarlet fever are all liable to infect the nose, especially when the soil is prepared by a nasal catarrh. It is possible to avoid dust-inhalation up to only a certain limit; but the amount of dust in households should be reduced to at least a minimum. The greatest dust-catcher is carpet, but curtains and THE DRY AIR OF IIKATKI) HOUSES. I03 drapery hold large amounts. It is in sweeping and dusting these articles that dust is distributed over the rooms and remains in the air for hours. It is known that the air of rooms contains many more microbes than that of the city streets. Those who have dusty occupations are often told to use a respir- ator, but these contrivances are generally so dis- figuring that few can be induced to wear them, so that in this class there will be many victims of unhealthy respiratory conditions as long as employers do not supply pure air to their establishments. The dry air of heated houses in winter is unfav- orable to healthy conditions in the nose. The se- cretions become scanty, and the mucous membrane becomes dry, preventing the elimination of dust iii the normal manner. The mucus forms adherent crusts which are liable to crack and be torn off, in- juring the epithelial coating of the underlying mem- brane, and so opening the way to germ infection. This is especially the case if a slight catarrhal condi- tion already exists. Erysipelas is sometimes caused in this way, the microbe of this disease entering the fissures and denuded places about the nostrils. It should be regarded almost as important to supply moisture to the air of a house in winter as to supply heat, and until architects appreciate this fact, most persons will suffer rather than use such troublesome preventive measures as hanging moist cloths in front of the radiators, etc. An atomizer containing a saturated solution of boric acid is a useful article in the care of the nose when the evil conditions — dust-breathing and dry heated air — exist. Its daily employment will relieve 104 VOCAL AND RESPIRATORY APPARATUS. the dry irritated condition of the mucous membrane, and act as a preventive of nasal catarrhs by removing the excess of dust. Picking of the nose is a very unhygienic habit. Most of the nose-bleeding in children is due to the finger-nail injuries of the mucous membrane of the septum, causing small crusting ulcers. Removal of these crusts is likely to be followed by nose-bleed. The hair-follicles at the nasal entrance are also liable to be infected by the finger, and boils result. All conditions which favor drying of nasal secretions foster the habit of nose-picking in children. A few drops of vaselin brushed into the nostrils of chil- dren will do much to prevent crusting, as all oils dis- solve crusts. Abscess and suppuration of tlie antrum of Highmore, the air-cavity in the upper jaw, is often due to decay of teeth whose roots project into the antrum. Care of the teeth is necessary to prevent this form of disease. THE NASOPHARYNX. The space back of the nose is called the naso- pharynx. Its roof is formed by the base of the skull, its back wall by the vertebrae of the neck, its front by the posterior ends of the nostrils, its lateral walls by the Eustachian tubes, which project into the naso- pharynx and supply the ear with air. A deep re- cess, called the fossa of Rosenmliller, lies back of the Eustachian tube and completes the lateral wall. The floor is formed by the soft palate, behind which there is an open space leading into the pharynx. This is closed when the soft palate is made tense and ele- TJIJ'. NASOPJIARYNX. 105 vated. In children the greater part of tlie roof of the nasopharynx is covered by what is called tlie third, or I^nschka's tonsil. The evil effects of en- largement of this tissne by adenoid growth have al- ready been referred to as far as stoppage of respira- tion is concerned, bnt another important danger of this condition is pressure on the Eustachian tubes interfering with the ventilation of the middle ear — a common cause of deafness in children (see page 157). Ji/ptrict •WM/Wfl/ Fig. 23. — Pharyngeal tube-mouth, as seen by posterior rhinoscopy. Habitual stopping up of the nose in children is therefore always to be taken seriously, as chronic deaf- ness may result from neglect of this condition. The best treatment of enlargement of the third tonsil is its removal by operation. As it is a condition oc- curring in the hardiest and healthiest children, there seems to be no means to avoid its occurrence. In adults enlargement of the third tonsil usually disap- pears by atro])h5^, but not until the nasopharynx becomes the seat of frequent catarrhal attacks. The catarrhal states of the nasopharynx are due I06 VOCAL AND RESPIRATORY APPARATUS. to the same causes as those of the nose, and their pre- vention requires the measures already described. Catarrhal conditions of the nasopharynx should not be neglected, as they endanger the hearing by the possible involvement of the Hustachain tubes and middle ear. Deafness is also favored by nasal ob- struction, as in such condition the act of swallowing causes a partial vacuum to form in the nasopharynx which sucks the air from the middle ear, drawing in its little chain of bones and stopping their vibratory motions. THE OROPHARYNX. Anatomy and Physiology. — Below the naso- pharynx and continuous with it is the oropharynx, or part of the pharynx connecting with the mouth. It is directly visible through the mouth, while the naso- pharynx is only visible by means of the laryngeal mirror and reflected light. The oropharynx is con- tinuous with the cavity of the mouth, but is separated from it by the isthmus of the fauces, a narrowing caused by muscles which are continuous with the soft palate, and form what are called the anterior and the posterior pillars of the fauces. Between these lie the tonsils, also called faucial tonsils. The posterior wall of the oropharynx is continuous with that of the nasopharynx, and lies in front of the vertebrae of the neck. Its anterior wall is formed by the back of the tongue. The oropharynx is used for both respiration and swallowing. It is a part of the throat that is very resistant to disease, while the tonsils in front of it are, perhaps, more liable to infections than any other part of the body. THE TONSILS. IO7 The tonsils are often enlarged as the resnlt of chronic hypertrophy, and are then an obstruction to respira- tion and cause injury to the voice. Many tonsils that do not enlarge are subject to constantly recurring in- flammation, due to repeated microbic invasion. An enlarged tonsil is especially likely to be the seat of diphtheritic infection, making it a constant menace to its possessor. The evil effects of enlarged tonsils on breathing and hearing are not nearly so marked as those of the enlarged pharyngeal tonsil. Neverthe- less, the tonsils are often removed, as they are visible and easy of access, while the worse offender, the third tonsil, is left behind. In many persons the tonsils are frequently infected with pus microbes, causing repeated abscesses around them. Children suffer- ing from enlarged tonsils often show a marked gain in weight and health after their removal, and in adults continually recurring infection necessitates treatment and often removal of the tonsils before proper hygiene of the throat can be practised. The Tongue, — The back of the tongue is often covered with masses of thickened, decomposing epi- thelium, which may extend forward to the tip and cause visible "coating of the tongue." It is this epithelium at the back of the tongue which is the cause of most cases of bad breath where there is no actual disease to account for it. Scraping off these masses from the back of the tongue, as far back as one can reach with the ring of one handle of a pair of scissors, removes this bad smelling material. Most persons do not know that the base of the tongue is often the site from which bad breath arises, and attribute it to catarrh. The cause of coatiuQ- of the io8 VOCAL AND RESPIRATORY APPARATUS. tongue, whether of gastric origin or due to some throat disorder, is, of course, a subject for medical treatment. The laryngopharynx is the lowest division of the pharynx, and is situated behind the larynx. Below this it becomes the esophagus. It is not much subject to disease of a preventible order, but is a place of frequent lodgement of foreign bodies, fish- bones, and the like. THE LARYNX. The larynx is placed in front of the lowest part of the pharynx, and is composed of a number of carti- lages. The largest of these, the thyroid, forms the greater part of the front of the larynx, and has somewhat the shape of a shield. Below and behind it is the cricoid cartilage, with which the thyroid articulates, being freely movable upon it. The cricoid cartilage has the shape of a signet ring, with the broad part of the ring behind. On the top of this broad por- tion rest two small, very mov- able cartilages, of pyramidal shape, the arytenoid carti- lages. To the front end of these are attached the strong, band-like structures of white, fibrous material, called the vocal cords, the instruments of sound for the voice. Fig. 24. — Lateral view of lar- ynx in its relation to the hyoid bone and trachea. TIIF. VOCAI. CORDS. 109 The vocal cords are strctclicd between the aryte- noid cartilages behind and the thyroid cartilage in front. They are attached in front and laterally to the thyroid cartilage, posteriorly to the arytenoid carti- lages. The larynx has many muscles of small size. Some Image 0/ ^ epiglottis linage of vocal _ cords Fig. 25. — Schematic view of the tongue-base, epiglottis, arytenoids and ary-epiglottic folds, ventricular bands, and vocal cords, with the larj'ngo- scopic reflection. of these move the cricoid backward from the thyroid cartilage in such a way that the vocal cords are made tense ; others move the arytenoid cartilages so that they bring the vocal cords together, and others move these cartilages apart, so that the space between the no VOCAL AND RESPIRATORY APPARATUS. vocal cords, or glottis, as it is called, opens for breath- ing. If these last muscles are paralyzed the vocal cords come together and cannot open, so that there is danger of suffocation. There is a muscle seated in the vocal cord that regulates its tension and makes the wonderfully fine adjustments of the voice possible. It is called the musculus vocalis, or th3^ro-aryte- noideus. For a more detailed description of the laryngeal muscles the reader is referred to works on anatomy. In looking into a larynx with the laryngoscopic mirror (Fig. 25) the most conspicuous structures we see are the vocal cords, two white glistening bands ex- tending forward and back. They stand wide apart at their posterior ends during quiet breathing, leaving a triangular opening, which permits a view down the trachea, or windpipe. When a sound is made the vocal cords can be seen to come together and touch Fig. 26, — The laryngoscopic image in deep inspiration and in phonation. each other with their inner borders. In front of and above the cords we see the epiglottis, a leaf-shaped structure which curls above the larynx, and is designed to cover it during swallowing of food or liquids. At the posterior ends of the vocal "cords we see two FUNCTIONS OF THE LARYNX. Ill rouiidisli bodies, which move out and in with the cords. These are the arytenoid cartilages. Functions of the Larynx. — During inspiration tlie vocal cords may be seen to move automatically apart, coming slightly together again during expiration. The larynx has, therefore, as its first function that of respiratory opening for the passage of air to the lungs, for which purpose it is needful that the vocal cords should be held apart by the proper muscles. Another function of the larynx is to guard the lower air-passages from the entrance of foreign bodies. Bven a small object entering the larynx causes at once a spasm of the vocal cords, that brings them together so tightly that nothing can pass them. This spasm may be lasting enough to cause symptoms of suffocation with blueness of the face ; even death may occur before the spasm relaxes. The most important function of the larynx is the production of voice-sounds. For this purpose three things are necessary : The bellows, supplied by the lungs ; the vibrating membranes, the vocal cords ; and the pipe, or trumpet, beyond them, supplied by the cavities of the nose, pharynx, and mouth. For the production of sound the vocal cords must be brought together and made tense by the laryngeal muscles. The higher the tone of the sound to be produced the more tense are the vocal cords, and the higher the larj'ux is raised in the pharynx, thus diminishing the length of the pipe, or tube, attached to the larynx, which has been likened to the part of a trumpet beyond the vibrating reed. For low tones the larynx is lowered or descends ; thus the trumpet is lengthened. This raising and loweriusf of the 112 VOCAL AND RESPIRATORY APPARATUS. larynx facilitates the production of liigli or low tones, but is not absolutely necessary, for by muscu- lar effort the changes of pitch can be produced with- out change of the position of the larynx. This mus- cular effort, however, is a severe strain for the voice, and it will be referred to under the hygiene of the singing voice. The up and down motions of the lar- ynx can be tested by anyone who feels of the organ during the production of low or high notes. The Production of Voice-Sounds. — While the pitch of the voice is mainly, therefore, furnished by the vocal cords, its timbre, or quality, depends chiefly on the pharyngeal, nasal, and mouth-passages. It is possible to permit the air to pass through the mouth only, when a sound is made, the soft palate shutting off the nose from the mouth ; or the air may be al- lowed to go only through the nose, or through both nose and mouth together. Endless slight modifica- tions of these conditions are possible, so that the vol- untary changes in the quality of the voice by altera- tion of the position of the soft palate, lips, tongue, or pharyngeal muscles are innumerable. So much do the shape, size, and position of the air-passages attached above to the larynx affect the quality of the sound produced that there are no two voices exactly alike, and individuals can be recog- nized by their voices alone. For convenience we will call the oral, pharyngeal, and nasal passages above the larynx the attached tube. If the larynx is detached from this, as it is at times in cases of cut-throat, it makes a feeble sound only. This shows that the attached tube not only gives quality to the voice-sounds, but intensity as CARE OF THE VOICE. 113 well, acting in this way similarly to a speaking- trnnipet. The respiratory function of the larynx is interfered with only by actual disease severe enough to so narrow the air-passages as to cause shortness of breath. The Care of the Voice. — A pleasing speech and voice are almost equal to personal appearance in im- portance to the individual in his relations to others. A great number of complex movements are needed to produce proper speech, and these are ac- quired slowly and with difficulty. In fact, a center for these delicate coordinated movements has to be developed in the brain as the child grows. Speech is largely the result of imitation, and if the voices a child hears are harsh or coarse so will its own be- come. The best way therefore to teach a child dis- tinct and refined speech is to let it hear such only. However, this is not always all that is sufficient. Enlarged tonsils and, still more, adenoid vegetations block the way of the sound-waves to the nasal cav- ities after they leave the larynx. This deprives the voice of both intensity and resonance, and compels the child to adjust its laryngeal muscles and those of articulation to the strain thus thrown upon them. This interferes with the acquirement of the delicate coordination of the muscles needed for distinct speech, and such children usually have an imperfect utterance. The number of people that are allowed to grow up handicapped by hast}^, slurred, harsh, disagreeable speech and voice is great. Parents do not seem to appreciate the advantage to their children in after- life that a refined, melodious voice will be. Proper singing is one of the best modes of cultivat- 114 VOCAL AND RESPIRATORY APPARATUS. ing a pleasant speaking voice, even if the singer has no chance of anything more than a place in a chorus. It is a delight to hear a good singer speak, and often we can tell that a person is a singer simply from the speech. Improper singing is not only a- distress to others, but soon ruins at least the singing voice. Children should be encouraged to sing. It paves the way to singing in adult life, and as they are not self-conscious and not afflicted with improper " methods" they do not strain their laryngeal muscles, especially as the tunes they sing are within easy reach of their voices. This presupposes, of course, that there are no obstructions to the passage of sound- vibrations in the upper air-passages, such as enlarge- ment of either the faucial or the pharyngeal tonsils. Of course, children with hoarseness due to laryngeal ailments cannot sing. Those with an imperfect ear for music may be improved vastly by persistent efforts to sing true. When a child's voice is changing, singing should be prohibited until the adult type of voice has been fully developed. This is true of girls as well as boys. Singing is an excellent form of re- spiratory gymnastics, and tends to develop a full, well- formed chest. In this way it acts as a preventive of lung-diseases. Loss of the adult singing voice means loss of occu- pation to professional singers, and to amateurs the loss of a valued social quality. All singers know what uncertain possessions their voices are. Many voices deteriorate early, or, giving good promise at first, do not stand the training and lose their tone; and this is not without reason. One of the first causes of voice-deterioration is iMPRorjiR JMF/rnoj) jn singing. 115 imperfect general health. Feeble persons, with weak mnscles and imperfect nntrition, cannot develop a good voice, nor can those maintain it whose health has failed. Being non-resistant to disease because of low general vitality, the part put upon the greatest strain, the larynx, is subject to repeated catarrhs and to early fatigue in singing. This strain of the mus- cles of the larynx soon results in loss of the singing voice. A second prolific cause of loss of the singing voice is persistence in singing during attacks of acute laryngitis, a persistence often rewarded with the chronic form of the disease. There is thickening of the mucous membrane, interfering with the action of the laryngeal muscles, hindering approximation of the cords, and causing the muscles to be used too energetically in order to overcome the abnormal re- sistance, so that their delicately fine adjustment be- comes quite disordered. In such cases the singer's notes become untrue in pitch. During attacks of laryngitis the voice should have as nearly perfect rest as possible. Neither should a singer use his voice during an attack of cold in the head, as the abnormal obstruction to the sound-waves caused by the swollen mucous membrane of the nose disturbs the adjust- ment of the laryngeal muscles. The commonest cause of voice-injury is improper method in singing. A singer with proper control of his voice adjusts the vocal cords and the at- tached tube so perfectly by exact muscular action that not only is no power wasted, no muscle made tense that is not necessarily so, but also the proper position is attained at once, so that the moment the Il6 VOCAL AND RESPIRATORY APPARATUS. bellows (lungs) force air through the larynx, the exact pitch and loudness desired are attained and held. In other words, the voice-muscles of a good singer are as perfectly under his control as are the muscles used in keeping the balance of an expert in bicycling. As with other muscles, those of the larynx subjected to excessive action tend to become strong and slow, while delicate adjustments are lost. In other words, they become, as gymnasts say, mus- cle-bound. All improper modes of singing include needless strain of the voice-muscles, and so interfere with their exact adjustment and cause them to con- tract too forcibly, so stiffening their action. One of the worst faults is a rigid position of the larynx, its up and down motion being inhibited, producing a "throat voice." This involves tense contraction of many muscles that should be relaxed, and thus compels them to work under great disad- vantage. One can hardly believe that this imperfect method of singing with suspension of the normal up and down motions of the larynx is a part of a "method" taught by certain vocal instructors. A disagreeable tremolo is one of the bad effects of singing forte under these conditions, and an annoy- ing forced or pressed sound of the voice also re- sults. Another of the evil effects of this strained way of singing is chronic laryngitis with thickening and excrescences of the vocal cords. This is true of any other improper and strained mode of using the voice, though the resistance of the larynx to abuse varies. A voice which is used out of its nor- mal register, especially if there is a constant strain- ing after high notes, is one that will not last long. EXCESSIVE USE OF THE VOICE. WJ Singing-teachers commit great errors in yielding to the ambitions of pupils, or in not being careful enough in determining the normal voice in question, allowing altos to attempt to be sopranos, and baritones to try to become tenors, etc. Excessive use of the voice threatens its integrity, as do attempts to sing difficult music before the voice has been sufficiently trained. The action of the laryngeal muscles differs from that of many others in that they are continually and with great exactness adjusting the position and tension of the cords, and holding them in certain positions. This renders them especially liable to injuries after prolonged fatiguing contractions. In order to sing well and long, careful practice is needed until little by little the muscles learn their exact adjustments. By im- proper use of the voice it may become irretrievably damaged and even actual disease of the larynx may result. No one should sing until the larynx becomes fatigued, but an attempt should be made by easy stages to strengthen the voice-muscles until they acquire more endurance. Many persons in speaking or singing are likely to begin the vocal sound sforzando with sudden em- phasis. As this implies bringing the vocal cords together with spasmodic force, such practice not only produces a disagreeable vocal sound, but irri- tates the free borders of the vocal cords, rendering them liable to the occurrence of small prominences, called singers' nodes, wdiicli interfere greatly wdth the clearness of the voice. This spasmodic action of the vocal cords is called the "coup de glotte. " Some strong, robust people wntli good natural Il8 VOCAL AND RESPIRATORY APPARATUS. voices attempt by sheer muscular effort to overcome their defective vocal education. As these individuals have not learned to co-ordinate their laryngeal mus- cles for proper united action, the result is a dis- agreeable tremolo. Persons with weak physique and imperfect development should strengthen them- selves by calisthenics and breathing-exercises before beginning to sing. Attention to the general nutri- tion of the body is also needed. Those who have lost much weight or have not fully recovered from ex- hausting ailments should not sing. Here it is that the modern method of forced feeding, having the patient limit his daily amount of food not by his ap- petite, but by his digestive powers, is of great value. There is no doubt that a great many of the thin in- dividuals of the community suffer from self-imposed starvation, as their appetites from nervous causes fail and their sense of hunger is lost, while their di- gestive powers are unimpaired. If these were made use of to their limit, they w^ould bring a return of weight and strength. Constricting garments, espe- cially corsets, should not be worn, as they interfere with the chest-expansion, the sustaining of tones, and the regulation of the air-current supplied by the res- piratory muscles. The manner of using the vocal organs in practis- ing singing is, of course, a matter best left to sing- ing-teachers; but as these are not all competent, an attempt has been made to furnish some knowledge as a guide to those who desire to sing, knowledge which it is hoped will help them to tell whether or not they are in good hands when they begin to take singing-lessons. THE CHEST AND LUNGS. I 10 THE CHEST AND LUNGS. The hygiene of the respiratory organs within the chest inchides a consideration of the thorax, the re- spiratory muscles, and the hnigs. The thorax, or chest-cavity, is formed 1)\ the at- tachments of the ribs, their costal cartilages, and the sternum, to the spinal column. The latter is the fixed base to which the other movable parts of the chest Circuvi/crcncc of apex of thorax. Manubrium sterni Costal ca rtilages Gladiolus Ensifonn carti- lage of xiphoid ajff>endix Seventh rib'-\ Eleventh rib Eleventh rib Circumference of base. Fig. 27. — Thorax, anterior view. are fastened. The part of the spinal column to which the thorax is affixed includes the twelve dorsal vertebrae. Twelve ribs on each side of the body are joined to it, their heads forming joints with the bodies of the vertebrae, while their necks rest on the strong 126 VOCAL AND RESPIRATORY APPARATUS. vertebral transverse processes, moving upon them and being attached to them by another joint at the tip of the transverse process. The ribs end in front in the costal cartilages, which are really elastic prolonga- tions of the ribs. The costal cartilages of the first seven ribs join the breast-bone directly; those of the next three ribs are joined to the costal cartilages above; while those of the last two ribs are unattached and form what are called the floating ribs. The breast-bone, or sternum, closes the thorax in front and moves with the ribs, forming with them a movable cage enclosing the lungs. The muscles of the thorax are the intercostals that fill the space between the ribs and complete the chest- walls; the diaphragm, which closes the cavity of the chest below, separating it from the abdomen; and the auxiliary respiratory muscles, or muscles of forced breathing, which, however, are not in use during quiet breathing. These auxiliary muscles are the scaleni, arising from the neck vertebrae and in- serted into the upper two ribs; the sterno-cleido-mas- toid muscles, arising from the skull and attached to the clavicle; the pectoralis minor, arising from, the scapula and inserted into the third and fourth ribs; and the serratus posticus superior muscle, arising from the spinal column and attached to the ribs. The muscles that are used for forced expiration are the abdominal muscles, the serratus posticus inferior, attached to the spine below and reaching up to the ribs, and the quadratus lumborum muscle, which takes its fixed point from the pelvis and pulls the ribs downward. The only muscles in use during quiet breathing are TIIK LUNGS. 121 the intercostal muscles, the diaphra<:^in, and the leva- tores costaruni longus et brevus muscles. These are all muscles of inspiration. Ordinary expiration re- quires no muscular effort at all, as the weight of the thorax and the elasticity of the lungs give sufficient power to contract the thorax and expel the air, the Right co7ijmon, carotid artery Subclavian arteries Innominate artery Arch of aorta' ■ Right lung Superior vena cava Right auricle Larynx Coronary artery Fig. 28. — Relation of lungs to other thoracic organs. ribs dropping back into the expiratory position after being lifted by the inspiratory muscles. The lungs are composed of an immense number of little air-cells, or alveoli, which connect with the outer air by means of the bronchial tubes. These begin as tubes of microscopic size, which unite to larger and larger ones until they enter the windpipe, or trachea, by means of a large bronchus, or air-tube, for 122 VOCAL AND RESPIRATORY APPARATUS. each lung. The larger bronchial tubes are stiffened with rings of cartilage, and the smaller ones down to a caliber of one millimeter with cartilaginous plates. The smallest bronchial tubes have only circular mus- cle-fibers instead of cartilage. The air-cells, or alve- oli, are coated with thin pavement-epithelium and have the greater part of their walls composed of a dense network of capillary blood-vessels. The function of the air-cells is to allow the red blood- eel Is to absorb oxygen from the air and give off the carbon dioxid which they hold partly in chemical combination and which is partly also contained in the fluid blood. The lung is therefore a gland designed to take in and excrete the gaseous constituents of the blood. The red blood-cells do not simply absorb the oxygen of the air, but take it into loose chemical combination with their pigment of hemoglobin. This in turn delivers the oxygen to the tissues of the body. The blood passing through the capillaries of the air-cells comes from the pul- monary artery and right ventricle of the heart, and is venous blood while in this vessel. It leaves the capil- laries lining the air-cells to enter the pulmonary veins as arterial blood, or blood which has taken up oxygen. The lungs have a further blood-supply for their own nutrition, as that which passes through the capillaries of the pulmonary artery is not utilized by the lung itself, but is utilized merely for the pur- pose of oxidation. The arteries supplying the lungs with nutrient blood are called the bronchial arteries, and are branches of the aorta. The walls of the alveoli of the bronchial tubes and of the interstitial tissue between the lobules, or THE MECHANISM OE RESPIRA'J'ION. I 23 clusters of air-cells, at the end of a bronchiole, or minute bronchus, are all composed largely of what are called elastic fibers. This gives to the lung its rubber-like power of elastic retraction after expansion. The lungs are not attached directly to the chest- wall, but are covered by a smooth glistening mem- brane called the pleura. A similar membrane lines the inside of the chest-wall, and though the lungs lie in contact with this wall they are not attached to it, as* the layer of the pleura covering the lung, while in touch with that lining the chest-wall, nevertheless glides smoothly upon it during the respiratory motions. If the chest-wall is perforated, the lung collapses by reason of its own elastic retractility, air meanwhile rushing into what is called the pleural cavity between the two layers of the pleura. In health, of course, there is no cavity, as these layers lie against each other. The lungs are kept expanded by the suction of the chest-wall, and in health never entirely collapse. The inspiratory muscles lift the ribs upward and outward, thus increasing the capacity of the chest in its circumference, while the diaphragm descends, increasing the capacity vertically. This causes an increase of the negative pressure in the chest; and as in health air cannot enter the pleural cavity, the lung must follow the pulling force of the expanding thorax and fill with the air that rushes into the trachea. Ordinary expiration takes place, as stated, by means of the retractile power of the lung and the weight of the chest- walls, no muscular effort being needed. It is obvious that when expanding the lung must not only suck in air into its air-cells, but also must draw blood into its capillary vessels. The narrower 124 VOCAL AND RESPIRATORY APPARATUS. the orifice tlirougli wliich the air passes the more power is left to suck in blood, so that nose-breathing is an aid to the circulation of blood in the lung, while mouth-breathing is not. The thorax loses mobility and expanding power in later life, and in the aged becomes stiff and rigid. The motion of the ribs in their sockets becomes limited, while the elastic costal cartilages, which are twisted or undergo torsion during each inspiration, normally become too stiff to yield in this way to the inspiratory pull. Age therefore dis- qualifies for violent exertion, as this rigidity of the thorax gives the respiratory muscles more work to do, and breathlessness comes sooner during exertion in age than in youth. By continuing gymnastics and respiratory exercises through life the greater part of the mobility of the thorax can be maintained till a very advanced age. This is an argument against the theory that after youth is passed, gymnastics are of no use. Deformities of tine Thorax. — The highest effi- ciency of the lungs as organs of blood-oxygenation demands a well-formed thorax; yet it is precisely the thorax that of all parts of the skeleton is most often deformed, a fact which accounts in part for the fre- quency of lung-diseases. The chest is simply an air-pump, and if its capacity is diminished by being bent out of shape it can obvi- ously suck in less air than is necessary. This is also the case if its movements are restricted. In the extreme chest-deformity of hunchbacks, in which in parts of the chest there is no movement at all, we find portions of the lung entirely unex- panded, forming simply a fleshy rriass. This exam- DEFONMI'J-JKS OF 7I/J': 77/0 RAX. I 25 pie of great defoniiity shows how in a less degree the comiiiouer deformities of the chest hinder the proper expansion of the Inngs, especially within the parts most deformed. The most freqnent chest-deformity is scoliosis, or lateral curvature of the spine, with twisting of the whole spinal colnmn to one or the other side, usually the right. In this form of deformity the shoulder is lower on one side than on the other, and the relatives and teachers of the* child or youth so deformed tell him to lift his shoulder and stand "straight," imagining that the deformity is in the shoulders. Scoliosis contracts the side of the thorax toward which the spine is twisted. There is ordi- narily another spinal deformity associated with scoli- osis, called kyphosis, or bending of the spinal column forward, producing a thorax rounded behind and flattened in front — the typical, flat-chested, round- shouldered person which is so often the product of our schools (see page 238). Even the laity know from sad experience that this form of chest predisposes to consumption. The effect of the kypho-scoliotic thorax is deficient expansion, especially of the apex of one lung, render- ing it very liable to tubercular infection. This de- formity originates chiefly in school, on account of fatigue of the muscles which maintain the spinal column in the erect position. As they relax from weariness due to long sitting at the desk the column of vertebras bends forward and rotates toward one or the other side. When this is often repeated and kept up for hours at a time from compression the growing bones become permanently misshapen, and deformity 126 ' VOCAL AND RESPIRATORY APPARATUS. results which lasts through life. Kyphosis, however, may exist without scoliosis. The prevention of spinal deformities requires, in the first place, seats that will permit a child to rest his spine in the proper position of erectness. The plane of the book's surface should be placed, if necessary, by special desk-attachments almost parallel to the plane of the child's face, so that he can read while sitting erect without bending over his desk. The possible factor of astigmatism at oblique axis in the early development of spinal curvature should not be over- looked. Interruptions of study by calisthenic exercises de- signed to give vigor to those muscles that counteract the evil, deforming effects of prolonged sitting should occur every half-hour, and be continued for five min- utes at a time. The muscles that hold the spine erect and give it lateral support are the ones to be especially strengthened in this way. Deformity inva- riably results whenever muscular support is removed from any part of the skeletou, as the ligaments which unite the bones stretch under strain, for they are sim- ply li miters of excessive motion, not supports of the skeleton like the muscles. The spinal muscles are quite independent of those that move the shoulders. It is useless to tell round-shouldered persons to draw their shoulders back; this will not straighten their backs. The shoulders and shoulder-girdle, composed of the clavicles and scapulas, are only secondarily dis- placed by the spinal deformity, and have little to do with an erect carriage. The spinal muscles, chiefly the erector spinae, are the ones to be exercised while the shoulders are being held loosely and in a state of relaxation. ''SIIOULDEK-BRACESr 12/ "Shoulder-braces" are absolutely worthless con- trivances, which not only do not take the place of the spinal muscles in holding the spine erect, but make their wearer stiflf and ungainly in his motions. After growth is attained much can be done at least to partly overcome those spinal deformities the correction of which has been neglected during growth. Develop- ment of the spinal muscles is also indicated, but will not accomplish as much as in the growing period. In overcoming the deformity of scoliosis rotary mo- tions of the spine in a direction opposite to its natural faulty twist are indicated. Symmetric chests without actual deformity may be narrow and of limited capacity, with deficient expan- sion. The tendency to this form of chest should be counteracted in growing years by special attention to respiratory gymnastics and light exercises, such as sparring, running, etc. In adults, though the bony frame of the chest is unchangeable and the number of air-cells in the lungs is unalterable, breathing-ex- ercises will cause the limited excursions of the ribs in their joints to increase, adding thus to the amount of air exhaled and inhaled, and making the chest larger in full inspiration, when air-cells heretofore only half expanded become fully so. The chest becomes more roomy because of the greater motility of its parts, not because there is any increase in their size. The fact is so universally appreciated that the flat and narrow chest with wide intercostal spaces pre- disposes to consumption of the lungs that it is called the " phthisical thorax." Pulmonary tuberculosis is found much less often in persons with well-formed chests, as all parts of the lungs are equally expanded 128 VOCAL AND RESPIRATORY APPARATUS. and kept healthy by use; while in the flat, narrow chest the upper parts of the lungs, or apices, get little expansion, and experience shows that these portions are especially liable to tubercular infection. The purity of the air inhaled is next to a well- formed chest in importance to the health of the lungs. Nature tries to make the air dust- free before it reaches the finer bronchial tubes and alveoli, but in spite of the many safeguards some dust penetrates the air- cells. In addition to the upper air-passages, which arrest most of the dust, the bronchial tubes, branching angularly, catch nearly all that remains before it enters the finer bronchioles and air- cells. The dust so caught is moved into the outer world again by the ciliated epithelium of the bronchi. Excessive amounts of dust irritate the larynx and trachea, and cause coughing-fits which expel the noxious particles. Only when the secretions are excessive is coughing needful to keep the lungs clear ; otherwise a balance is maintained between the supply of mucus to the bronchi and the amount needed. The dust which reaches the air-cells is taken up by the leukocytes, or white blood-cells, as they are called, and carried by the lymphatic channels to the bronchial lymph-glands, where the dust is deposited. Microbes entering the air-cells are carried off in the same way, and are liable to excite inflammation and abscess of the bronchial glands. This occurs so rarely, though, and these glands are so very tolerant of large amounts of dust, that they may be regarded as a very perfect safeguard to the lungs. Coal-dust and vegetable-dust are the least harmful to the lungs. The dust of metals and minerals, if PREVENTION OE I'UBERCULOSIS. I 29 inhaled long enough, is one of the chief causes of fibroid phthisis. The methods of avoiding dust- breathing have been considered sufficiently in that portion of this chapter referring to nasal hygiene. Virulent microbes are being constantly inhaled; but only under conditions of impaired resistance due to lowered vitality or local disease in the lung are they liable to attack the individual. The diplococcus of pneumonia, for instance, which is present in the mouths of many people and is often inhaled, is likely to cause pneumonia if the person who has inhaled it has had a severe chilling. The influenza bacillus is a germ that seems cap- able of causing disease in almost all persons; but the infection varies greatly in severity, the aged especially being liable to the grave pneumonic forms of influ- enza. The bacillus of tuberculosis, which we doubtless often inhale into our lungs, in those of lowered vitality may cause pulmonary tuberculosis, called also consumption of the lungs or phthisis. Again, there may be a special predisposition to tubercular disease in some individnals which makes them par- ticularly liable to be attacked by the microbe even when in good health. This predisposition to infec- tion by the bacillus of tuberculosis may be noticed in certain varieties of animals, the ruminants, as a rule, being more liable to tuberculosis. A damp soil favors the development of tuberculosis. Prevention of Tuberculosis. — It is impossible to avoid inhaling the germs of disease into the lungs at some time, but the danger of infection may be dimin- ished by care on the part of those already infected. 130 VOCAL AND RESPIRATORY APPARATUS. It is known that the sputum, or expectoration, of tubercular patients should always be deposited in fluid and not allowed to dry. If the sputum dries on the floor or in handkerchiefs, it is likely to be pulver- ized and float about as dust. Thus inhaled, it is a means of spreading tuberculosis. The sputum, there- fore, should be caught in a vessel containing fluid which dissolves the tough mucus, the best being a solution of lye. A stronger disinfectant, such as 5 per cent, aqueous solution of carbolic acid, may also be used. In spite of care, sputum may lodge on the edge of the vessel, so that this should be protected from flies, as they may carry the bacilli about and in- fect food or light on wounds. Patients who go out of doors should carry cloths to cough into, or a paper- bag which can be burnt with the cloths. Of course, most patients will deposit their sputum on the street, not heeding the danger in which they place the pub- lic. Fortunately, sunlight and the open air soon ren- der harmless bacilli deposited out of doors. Patients in the last stages of the disease, too weak to use a sputum-cup, should have a large pan into which they can drop the cloths they use to catch their sputum. These cloths are, of course, to be burned. It is es- pecially by these patients who are near death that the bacilli are spread, as precautions are little observed by either patient or attendants at this time. The patients should be taught to take these pre- cautions for their own sake, as they are likely to infect healthy parts of their lungs or the larynx by inhaling bacilli derived from their sputum. A room in which a tubercular patiefit has lived should be re- peatedly and thoroughly disinfected with formalin, MAINTENANCE OF BODILY HEALTH. 131 wliicli is best made in large generators, which con- vert a half gallon of wood alcohol into formalin vapor in a short time, so insuring concentration. At the same time the air of the room should be made very moist by hanging up a number of wet sheets. Lately it has been claimed that in coughing and even in speaking tubercular patients eject into the air minute particles of saliva containing bacilli. During coughing this probably occurs to a slight de- gree at times; but, on the whole, this source of tuber- cular infection is very unusual and does not justify compelling consumptives to wear cloth masks to catch bacilli, as has been suggested. During coughing, however, a cloth should always be held in front of the mouth. The sputum of patients with influenza, pneumonia, or bronchitis should be disposed of in the same man- ner as that of tubercular patients, as the discharges from the lungs in these diseases also contain patho- genic germs. The freedom of the lungs from disease more than most organs depends on the maintenance of a high standard of bodily health. The lungs especially become vulnerable to the causes of local disease on account of poor nourishment of their tissues due to low vitality. Children of the poorer class, often ill-fed and living in badly ventilated rooms, are more liable to pulmonary and bronchial affections than those liv- ing under better circumstances. Natural immunity plays a great role in preventing tubercular disease in many whose ill-health would otherwise render them liable to consumption; but those who have even a strong hereditary predis- 132 VOCAL AND RESPIRATORY APPARATUS. position to the disease can usually avoid it by keeping up a robust state of health. On the other hand,' many have their natural immunity destroyed by certain de- pressing causes, especially by alcoholism and dia- betes. Habitual drinkers bring upon themselves a disposition to tuberculosis even while their appear- ance remains robust and their weight normal. Ex- cessive use of alcohol seems to neutralize natural im- munity to the disease. The vital depression which comes on with advancing age, however, is accom- panied by a tendency to the formation of fibrous tis- sue, which toughens the lungs and renders them less liable to consumption. When the disease occurs in elderly people it is likely to assume a slow and rela- tively benign type. Physical training of a tubercularly inclined youth should receive as much care as his mental develop- ment. Every observer sees children well developed mentally who are in greatest need of physical devel- opment for their feeble, light-boned, flat-chested bodies; bodies that must serve them through life, a perpetual hindrance to success and effort, and which are the cause of premature aging and invalidism. It is only during the growing years from twelve to twenty-four that physical training is of avail, and it is strange that parents appreciate so little this pro- moter of the health and beauty of their children. Though we meet with some remarkable minds in feeble bodies, ordinarily these minds are of the receptive order, which take in facts readily but do not possess the power to elaborate or apply them. The functions of the heart and lungs are inti- mately connected, and it is necessary to mention their EXERCISES. 133 relations in consicleriiio; this subject. Proper develop- ineiit of the muscles of the Iwdy implies not only a strongly developed set of respiratory muscles, but also a strong and enduring heart. The function of respiration is a great aid to the heart in maintaining the circulation, each inspiration and expiration forc- ing blood as well as air into and out of the chest. A well-developed thorax, with wide respiratory excur- sions, is therefore a great aid to the heart in its work. Exercises requiring increased breathing should be performed with deep inspiration and expiration through the nose. The expiration should be watched especially, as the tendency is to keep the lungs full of air without emptying them properly, so that many athletes suffer from acute emphysema, or dilatation of the lungs. All exercises causing slow powerful contractions of many muscles, as lifting great weights, wrestling, part of the work done on the horizontal or parallel bars, tend to develop powerful, large, but slowly-acting muscles, and throw a strain on the heart, because respiration during these acts is either suspended or limited while the thorax is held rigid. The chief cause of acute heart-strain or dilatation of the heart is sudden, severe muscular effort. These exercises are to be avoided or at- tempted in moderation, and only by the robust. They are certainly of little use to those who wish to develop the thorax, as the respiratory excursions are too limited during them. Another class of exercises tending to one-sided mus- cular development and physical strain are those re- quiring prolonged muscular efforts, such as long- 134 VOCAL AND RESPIRATORY APPARATUS. distance cycling, rowing, or running. In moderation these are all of benefit, but tbe tendency to overdo them is great. Of the three, running is by far the best, as the thorax is not held rigidly as a base for the attached muscles, but is free and unrestrained in its motions. Running, when properly performed, is one of the best of all exerci.ses. In riding the bicycle it is highly important that the breathing should be deep, full, and through the nose. It is especially in this form of exercise that heart-strain is likely to occur, largely because the thorax is held rigidly and the breathing is shallow. A heart which has once been strained and dilated by imprudent exertion may apparently regain its vigor, but it is usually liable to a recurrence of the affection on moderate exertion, and so remains a weak organ. The best exercises for developing an enduring and robust body are general calisthenics, the so-called " army setting-up drill." Sparring, vaulting, hand- ball, and all work of this light, quick class are to be commended. Swimming also is a fine respiratory and free-motion exercise. In fact, all those exercises furnishing unrestrained and easy motions are prefer- able to feats of strength or endurance. No exercise should be continued until it becomes a physical strain. Although the two may be easily combined, sport is not physical culture, for the latter is not to be pursued for amusement only, but as a serious duty to one's self and others. ' No one should neglect his bodily vigor. The Influence of Climate on Consumption. — Those with very strong tubercular tendencies had better seek a proper climate for their permanent home CLIMATIC TKl'lATMENI' OF TUBERCULOSIS. 1 35 early rather than postpone tlie change of residence until the appearance of the disease. Considering the fact that whole families die of consumption, one after the other, this preventive measure seems fully justi- fied. A move from the large city to the neighboring suburbs is often of benefit. The chief requisite of a good climate is the op- portunity it offers to live out of doors as much as pos- sible. Certain climates are often looked upon as specific cures for consumption ; but the disease origi- nates de novo in any climate, and its course is in- fluenced favorably by proper hygienic measures in all climates. We must not overestimate the effect of the special region in which the patient is placed, though high and dry localities undoubtedly have a favorable influence on the course of the disease. Adjuvants to Climatic Treatment. — In addition to avoiding as much as possible the chance of infec- tion with the bacillus of tuberculosis, persons pre- disposed to consumption should give the greatest care to their bodily nutrition and keep their weight up to the normal standard by judicious feeding with plain fare — meats, and especially bread and butter. They should avoid gastric pleasures that give but little nourishment to the organism and only contrib- ute to disorder digestion. Reference is especially made to alcoholic drinks and coffee, to excess of sweets, fruits, pies, and the like, and to drinking of large amounts of ice water, causing atony and di- latation of the stomach. Chronic nicotin-poisoning, fast eating, taking fifteen minutes to a meal instead of forty, violent exercise causing heart-strain, all are factors that lower vitalitv and which should be 136 VOCAL AND RESPIRATORY APPARATUS. avoided by those predisposed to consumption. A hygienic life and a dry soil are far greater safeguards against the disease than the false sense of security fur- nished by a certain climate. Keeping up the body- weight, maintaining the muscles hard and firm, and the heart strong by exercise, and good food are safe- guards, and all but those greatly predisposed to con- sumption may feel reasonably sure of escaping it if they do not neglect them. Division of climates may be conveniently made by levels. Tine sea-level, the lowest, furnishes a high at- mospheric pressure which necessitates only moderate lung-expansion during exercise. The air is germ- free and dust-free when the wind is on-shore. The appetite, nervous system, and tissue-change are stim- ulated. However, high winds prevail, and experience shows that this is not a good climate for consump- tives. The low levels, up to 1200 feet, lack the tonic properties of the higher levels or the sea-level. The temperature-changes from night to day are moderate. On the whole, these climates are not suitable for consumptives, nor for those who are relaxed or run down and need stimulation. The moderate levels, 1200 to 3000 feet, are excel- lent for delicate people who need stimulation of their nervous system and appetite, but who would find it hard to endure the great changes in temperature and the difficulty of exertion connected with life in the higher altitudes, which require a strong heart and well-developed respiratory muscles. Moderate levels are therefore better for older persons with more or THE IIWJIER LEVELS. I 37 less rigid chest-walls. The air in these regions is rela- tively pure. The higher levels, above 3000 feet, give the effect of low air-pressure; the air is rarefied and much colder at night than in the daytime. Differences in temperature are sudden and extreme. The air is usually dry and germ-free. The amount of blood passing through the vessels of the skin and lungs is increased; the rarefied air makes freer respiratory movements of the chest needful. More water and heat are lost from the body, causing greater tissue-change. Such climates are suitable for the more robust, with good digestion, in whom the losses due to rapid tissue-changes can be readily replaced. On the whole, the high altitudes are the best for a person predisposed to consumption, provided he is not deli- cate and nervous, or that age has not made his arteries rigid and his thorax non-expansile, and that his heart is sound. In making a change of climate one should always consider whether the conditions in a strange place will be as good as those at home. Many consump- tives would have fared better at home than in a more suitable climate than their home can offer if con- nected with this new climate there are a lack of nur- sing and badly cooked food at some boarding-house or hotel. For those who seek new climates to avoid acquiring consumption it is of first importance that in their new surroundings they be well fed and have healthy, airy rooms and suitable occupations. It would be a poor move for a man living a healthy out-of-door life in Illinois to assume an unhealthy indoor occupation in Colorado. 138 VOCAL AND RESPIRATORY APPARATUS.- It is likely that the greater expansion of the lungs with air and the better blood-supply due to deeper respiration have much to do with the good effects of the higher altitudes on the slower and milder types of consumption. This influence is liable to be posi- tively unfavorable in rapidly advancing cases with fever, when both body and lungs need rest. In such cases the treatment by perfect rest in the open air in the recumbent position, with feeding up to the full limits of the digestive powers, is the best treatment, and accomplishes more than a change of climate. THE HYGIENE OF THE EAR. By B. ALEX. RANDALL, M.D., OK PHILADELPHIA, Professor of Diseases of the Ear in the University of Pennsylvania, and in the Philadelphia Polyclinic. The hygiene of the organ of hearing — as of each organ of the body — depends largely upon its anatomy and physiology. The essential part of the organ — the. nervous apparatus by which the sound-waves are received and conveyed to the perceptive centers — is so deeply placed as to be out of the reach of most direct influences except those which affect the whole body; but the accessory or conducting apparatus is open to many injuries and affections which may be warded off by hygienic rules such as may be considered strictly aural. These rules are more often negative — the forbidding of common but pernicious interferences — and may be summed up in a brief "let alone," as will appear in the detailed consideration of the sub- ject. Ivcaving the internal or percipient portions of the ear for later consideration, we are primarily concerned with the external and middle portions, and can be free from some usual misconceptions with regard to these only by studying them in some detail. THE EXTERNAL EAR. The Auricle. — The external ear is a moulding in and out of the skin-surface, and is governed by most 139 I40 THE EAR. of the rules pertaining to the general cutaneous sys- tem. It comprises the projecting auricle and the de- pressed canal, an irregular tube which penetrates more than an inch nearly directly in-ward. Apart from its liability to injury, frost-bite, and skin-affections, the auricle is unimportant, and its total loss does not ap- preciably affect the hearing and merely causes an un- sightly deformity. Its imdeveloped conditions are often accompanied by absence or incompetence of more valuable deeper structures, to which any defect Fossa of helix Afithelix Concha Antitra^us- —Helix Fossa of anthelix Tragus If Lobule Fig. 29. — External ear. of hearing is really ascribable. The auricle might be passed with mere reference to the need of slow thaw- ing after frost-bite but for the need of a few words as to the barbarism of wearing earrings. Fortunately, fashion is rather setting her face against them ; but this is little felt as yet in the lower walks of life, where the tradition that piercing the ears is helpful to sore eyes also is strong. This latter superstition is the basis for the not uncommon wearing of earrings among sailors. This is wholly specious unless, as with the seton of the older surgeon, a strongly coun- BLOOD-CVSr, OR " J/KA/A /OA/A:' 141 ter-irritatint^ sore is produced, but this is an obso- lete measure wholly superseded by more ratioual surgery. Too often the piercing of the ears has been entrusted to Some ignoraut peddler of earrings, and a single group of children will furnish many cases of abscess, more or less severe, resulting from his use of Fig. 30. — Abscess of the lobule after piercing for earrings. an infected needle. Severe blood-poisoning may not be usual, but some deformity is likely to result. Es- pecially in the colored race, a fibrous enlargement, or " keloid," may arise without decided septic infection, may grow even to the size of the fist, and recur in spite of skilful removal by operation. Such results are often ascribed to the earrings being too heavy or composed of base metal ; and the rings rather than the primary piercing are blamed for the consequences that follow. Of decided interest also is the blood-cyst, or " hematoma," of the auricle, most commonly due to injury in sparring, foot-ball, etc., but occurring also 142 THE EAR. without known cause, especially in the insane. Some have even held that the formation of such a blood- cyst may be prophetic of mental trouble not yet ap- parent. Often painless and stubborn, they may leave much deformity, since the cartilage of the ear depends for its nutrition upon the fibrous tissue which covers it, and this is lifted away from its place by the effused fluid being poured out between them: softening and shrinkage are therefore likely to follow the tardy cure. The hygiene of the auditory canal or meatus is more special. Here we have a skin-lined pocket more than an inch in depth, with the drum-head at its bottom and its walls supplied at the outer part with hairs and glands. The narrowness and curvings of the canal serve to keep out foreign bodies— even dust being arrested by the hairs, which act like a sieve, and by the wax-covered walls. The ear-wax, or cerumen, is a thin yellowish fluid formed by glands strictly like the sweat-glands of other skin-surfaces. It thickens into a yellow paste as it dries and unites with the little flakes of dead skin, and it tends to dry and fall outward. As the glands are only in the outer two-thirds of the canal, no wax forms on or near the drum-head, and when found in this vicinity it has been pressed there by meddlesome interference. All skin-surfaces are constantly shedding the dry dead cells of the outer layer; but this should' be more imperceptible on the fine skin of the ear-canal than elsewhere. Yet the finest scales might interfere with the delicate func- tion of the drum-head; so by a remarkable provis- ion of nature its cells grow so much faster at the THE EAR-WAX, OR CERUMEN. 143 center as virtually to overflow the rest of the surface, pushing the other cells before them over the edge on to the adjacent wall, and even some distance along this before they are thrown off. Thus the drum-head keeps itself clean, and may be said even to sweep the neighboring canal-walls of the effete material loosened from their surfaces. Then the wax begins to gum into scales this dandruff-like material, and with the help of the stiff little hairs, which tend to get caught Fig. 31. — Metal cast of the external ear, showing the curves of the canal. Fig. 32. — Cast of the canal in profile. under it, it is worked toward the external opening. The movements of the jaw act upon the outer part of the canal, as is easily felt by a finger thrust into the ear, and furnish power enough to move large flakes of wax outward, or even to eject them upon the shoulder. Thus a healthy ear should never show much more than enough wax to render sticky the hairs within it, and the owner should be unconscious of any wax coming away. Wax does not collect in a healthy ear. No appli- 144 ^-^^ ^^^• ance is called for to remove it, and all such are to be condemned. Yet the penetration of water in bath- ing or other unnatural conditions may serve to agglu- tinate the wax into masses that do not come away naturally, and collections may take place, especially in ears not healthy. This may indicate lessened rather than increased wax-formation, although the accumulation may seem astonishingly great when brought to light. Often it is in those who take the most (misguided) pains to keep their ears clean with scoops or mops that we find the largest and hardest masses. In hospital clinics, coal-heavers and others employed in dusty work constitute a large number of the ear-cases showing this condition. Efforts to remove collections of ear-wax are likely to be dangerous and futile, and should be en- trusted only to. the skilled hand; although the ease and safety with which the expert syringes them away may make his fee seem too easily earned. Only those who see how much harm is frequently done by the in- experienced can realize that the value of such service lies as much in what is avoided as in the good work done. Collecting gradually for months until only a small slit alongside the mass admits the sound-waves to the ear, the entrance of a little moisture or even of damp air may swell the wax enough to close sud- denly all passage-way and cause sudden deafness, with perhaps dizziness, nausea, cough, or other curious and at times most distant extraordinary symptoms. These may pass away as the w^ax dries and shrinks, only to return under similar circumstances of com- pleteness of closure. Pain is not usually a part of the trouble unless the mass has been displaced FOREIGN BODIES IN THE EAR. 1 45 (Sind pressed down upon tlie druiii-liead, alUioiigli even then it may be moulded to a perfect cast of the tympanic membrane-surface without ^^cnuine pain, which must therefore usually be taken as an indica- tion of inflammatory involvement calling all the more urgently for prompt and gentle removal. Tradition is responsible for the habit of dropping oil or other fluids into the ear as a preliminary " to soften the wax;" but this rather tends to swell the mass and increase pressure without any compensating advantage in facilitating its removal, while it is utterly reprehensible as a supposed substitute. Care- ful, vigorous syringing with hot water (105°-! 15° F.) is the proper procedure for removing the wax; no better solvent than hot water is obtainable. Yet syringing, like most manipulations of the ear, may cause dizziness, or even fainting; and should be dis- continued and the patient laid flat on the back at the first symptoms of such an occurrence. Ear- scoops or mops are permissible only in the hands of a skilled aurist, and he will use them but little. An ear that has been syringed and freed from obstruc- tive material should generally be dried as thoroughly as possible and protected from air for the rest of the day by a flake of cotton. On the other hand, any habit of wearing cotton is to be condemned as use- less, uncleanly, and prone to interfere with the proper exit of wax. Often a forgotten plug is the basis of a wax collection obstructing the canal. Foreign Bodies in the Ear. — The months or years that such masses may remain unnoticed, or at least without irritation, in the ear exemplifies the slight harm that may arise from insects, pebbles, or other 10 146 THE EAR. objects entering the canal. A living insect must be smothered with oil, vapor of chloroform (which can be poured like a fluid from a drop in the bowl of a spoon), or even water, lest its movements cause un- bearable distress; but any dead, inactive object is generally devoid of irritating effect. Children rarely introduce beads or such objects deeper than the soft portion of the canal, from which they will easily fall out if the head be inclined to the side and the canal straightened by pulling the auricle outward and backward. But great danger to life as well as to hearing may be caused by injudicious and panicky efforts to extract these intruders. Most of the cases that come to the physician have been seriously com- plicated by meddling; and if he makes good use of syringing without obtaining an early success and advises delay, another and more active operator is likely to be sought. Too often some form of forceps is introduced into the canal in hope of with- drawing the foreign body, and it is pressed deeper and wedged in the bony canal or actually driven through the drum-head into the tympanic cavity. At times, like damage is done when no foreign body is present — the wrong ear being worked at or the object having already fallen out unnoticed. No examina- tion or operation should be undertaken without good illumination; and it sometimes suffices to let the light fall in past the examiner's brow while the canal is straightened by pulling the ear upward, backward, and outward, in order to give a good view. It should be clearly and positively borne in mind that foreign bodies seldom cause serious harm, even if remaining for years, unless they furnish an excuse for harmful SLIGHT ITCHING AND IRRITATION OF CANAL. 1 47 interference, and we may look for few of tlie bad results that have been disgracefully frequent in the past. Rotary rubbing in front of the ear while it is turned downward will permit many a small body to fall out promptly. Any other measures besides this and careful syringing should be entrusted only to the expert; for when the foreign body is really wedged fast, it is at times a safer and simpler measure to remove it by cutting the soft parts loose and turning them out of the way, than to probe blindly in a narrow, swollen canal in which terrible damage may easily be done unseen. Slight itching and Irritation of the canal are very common, and may occur with or without distinct eczema, perhaps of gouty origin. They are important as giving occasion to the thrusting of objects into the ear to scratch it, or to the dropping in of oil or other fluids. Such measures are likely to aggravate the con- dition; and any break of the surface is easily infected, and causes a boil or perhaps a long series of such ab- scesses. These may be terribly painful and exhaust- ing, but are rarely serious to life or hearing; yet they are easily confounded with the serious conditions of pus in the middle ear and may cause needless alarm. Douching with pure water as hot as can be borne may assuage and perhaps quickly terminate those already present; but skilful care is needed to cut short the rather probable series of such boils, as gland after gland becomes affected. Deep extension of the in- flammation may involve the periosteum covering the bony wall, and not only may the swelling press for- ward the auricle and simulate an abscess of the mas- toid, but the nutrition of the bone may be injured 148 THE EAR. and its decay ensue, possibly with penetration of the process into the deep structures. Such an infection, although "only a boil," is not to be lightly re- garded. Whether the presence of invisible germs is the cause or only a consequence of such affections, long experience has shown the high value of remedies in- imical to such life; and we note at times as the result of improper conditions a growth of mould inside the ear. The diffused inflammation, with its heat and moisture, is probably first present to furnish a favor- able site for such growths; but they certainly tend to keep up such a condition by their presence. The precise aspergillus or penicillium present is rather a botanical than a hygienic matter; although the occupa- tion and surroundings of patients doubtless have in- fluence in making them liable to such implanting of one or another form. The growths do not occur in healthy ears, and will disappear as soon as dryness and more normal conditions have been secured. Drop- ping of oil or other fluids into the ear may not have been so distinctly responsible for such growths as some claim, but it is surely not the best way to com- bat such conditions when present. Overgrowth of the bony wall of the canal is a curious condition — fortunately rare — and one or more of the bony knobs may encroach on the passage- way. These may be broad-based and ill-defined, or form tumors with narrow, stalk-like attachments; hence their division into hyperostoses and exostoses respectively. Often there is a discharge from the mid- dle ear, which affords by its irritation of the surface some explanation of the growth and greatly enhances THE DRUM-MEMBRANE. 149 its seriousness. There is little likelihood that such a bony mass will close the canal so that sound-waves cannot enter; but it may readily interfere with due exit of discharge and lead to the most serious consequences. In many of the cases the cause is quite doubtful, but the fact that it is far more common in the upper-class Englishmen than in any other peo- PlG. 33. — The drum-membrane and ossicles from within, showing attach- ment of malleus-handle to drum-head, the insertion of the tensor tendon below the chorda, the axis of rotation through the gracilis process and the posterior ligament of the incus, and the tooth of its articulation with the malleus head. pie (unless the semi-amphibious Sandwich Islanders) points to bathing as a rather likely factor in its production. The Drum-membrane. — At the bottom of the external canal is stretched a thin, tense membrane — the tympanic membrane, or the drum-head (Fig. 33) — 150 THE EAR. which separates the external from the middle ear. It is very oblique in position; its lower margin is farther from the outside than its upper, and the forward is deeper than the back part — so it could be called quite accurately the lower rather than the outer wall of the drum-cavity. The outer layer of the drum-head is continuous with the skin-lining of the canal and really belongs to it clinically; but in most respects it is considered with the middle ear, which it bounds. Its function is largely protective, although it also serves as a receiver for sound-waves and aids in con- veying them to the internal ear through the chain of little ear-bones (ossicles) connected with it; but an opening in it, or even its total loss, may hardly im- pair the hearing to a recognizable degree. lyow tones will perhaps be heard less distinctly, but high tones rather better for its absence. The old impression that hearing depends upon the drum-head is ex- ploded; yet its removal, even when it has become an obstacle to hearing, has not often proved a judicious measure. The eyelids are not essential to perfect sight, yet they are very important to its safety ; just so the drum-head shuts out many hurtful influences and helps to maintain a moist, pliable condition of the important parts within it. The handle of the tiny hammer-bone (malleus) is encased in the upper part of the drum-head and reaches down to its middle. The membrane is kept stretched tightly inward, and the shallow funnel shape thus given adapts it to respond to a very wide range of vibrations. The slight thickening due to age causes it to vibrate less per- fectly and to impede the penetration of high-pitched 'V/ A' '/ ■//'/( •/./ /, /'.// R PR UMSr 1 5 I sound-waves; and disease-changes may act similarly and mncli worse at any period of life. The drum-head may be torn by the penetration of twigs, hair-pins, toothpicks, etc., stuck into the ear; or it may be split by explosions or a severe box on the ear. DeafnevSS may be extreme after such accidents, but it is the result of the concussion of the recipient apparatus beyond the drum-head, and it may persist after prompt and perfect healing of any rents. Most patients with discharge from the ear have an opening in the drum-head, yet may have practi- cally unaffected hearing, and such "holes in the drum" are by no means the death-warrant of the function whether the perforation closes or not. Loss or change. of the drum-head may give occasion for the employment of an "artificial ear-drum;" but, as a rule, only for its effect in tightening relaxed por- tions of the conducting-apparatus. Such an appa- ratus has its parallel in the bridge of a violin rather than in the head of a drum. Most of the much lauded patent "ear-drums" are inferior to a little pellet of cotton, which is so placed that its press- ure will tune up the mechanism without too much irritation. However, all artificial ear-drums gener- ally irritate, and after short use are advantageously discarded with retention of any gain in hearing. Most of the advertisements in conflict with this state- ment are false and misleading. As the proportion is small of cases of deafness in which such laxness of tissue is at fault, the field of usefulness of artificial ear-drums is very narrow; and, like anv other foreign body thrust in the ear, they may cause much irritation or damasfe even in cases needino- them. 152 THE EAR. Injuries to the Drum-membrane. — Some of the less sharp but rather more persistent earaches are of merely mechanical origin and due to preponderance of atmospheric pressure on the outside of the drum- head when there is lowered pressure within. They are comparable to that due to diving into deep water or entering the compressed air of a caisson. In the latter case swallowing, or yawning, or Valsalva infla- tion equalizes the pressure (as can hardly be done by the diver), and precautions of this sort must be care- fully taken in the air-lock on both entering and leav- ing the caisson. The healthy ear-drum can bear a pressure on either surface of some fifteen pounds to the square inch, but more than this will probably rupture it, while much less may give severe pain and cause inflammation. When weakened by disease, small pressure may rupture the membrane, and not only explosions, but a box or other tap on the ear may have such a result. So too even the slight suc- tion of a kiss on the ear has been credited with rupt- uring the drum-head, and to almost all persons such a demonstration is very painful. It is also possible that inflation by the Valsalva or Politzer method may burst the drum-head from within; and violent cough- ing, as in whooping-cough, often causes breaking of small blood-vessels or even tearing of the tympanic membrane. Such shocks as are experienced in violent falls may rupture the drum-head. This is frequent in fractures of the base of the skull, and the flow of blood from the ear is often taken as proving a serious and probably fatal injury; yet the tear may be inde- pendent of fracture, and may be from the wall of the canal without severe injury to the bone. In rare DISEASE OE 'J7/E DRUM MEMBRANE. [53 cases a fall upon the chin may drive the lower jaw back into the ear-canal and canse any of the previous symptoms. Non-interference and mere protection should be the rule in all such injuries. vSyrin(,nng and instillations are usually uncalled for, and are likely to do harm, and the expert aurist intervenes only for clear cause. 'Such a rupture of the drum- head will usually heal after a time, even though it shows no early promise of such repair, and the aurist has at command means to secure this when it would otherwise be doubtful. Disease of the Drum-membrane. — Most of the ruptures of the drum-head are due to the outbreak of fluid from within ; and while some of these are mere pressings aside of the fibers, which close again without scar, others take place only after so much ulcerative destruction that a considerable perforation is made or the whole membrane may be destroyed. Healing after -the loss of tissue entails new scar-tissue, which is generally recognizable by its thinness and is likely to stretch and sag out of the plane of the rest of the drum-head. As has been said, it was formerly thought that the drum-head was very essential to hearing, and that perforations in it never healed, but entailed permanent defect or loss of hearing. On the con- trary, we now know that it may be destroyed by disease or removed by the surgeon with little im- pairment of the hearing, and that large openings may close nicely even after they have been present for years. The cutting away of the entire drum-membrane is followed by its renewal in many cases, and without its destruction w^e sometimes find a membrane not unlike the drum-head formed 154 THE EAR. across the canal external to the real membrane. The protective function of the membrane is very impor- tant, and we usually desire its repair in every case even although it may prove rather an impediment than an aid to hearing. Many operations have been done to remove it wholly or in part when its changes make it an obstacle to the access of sound-waves; but these have generally failed because of its regrowth, or when successful in securing a permanent opening they have been followed in a year or two by a loss of all the gain in hearing and generally of what was before possessed. Such operations have, therefore, been generally abandoned. When the drum-head is open the cavity within is likely to become too dry for the best hearing, while it is constantly liable to irritation from the entrance of water or dust, with lighting-up of severe inflammation. All of these inflammations have danger, for extension may easily take place to adjacent important structures, and fatal meningitis, brain-abscess, or general blood-poisoning may ensue. One of the curious and pernicious conditions fre- quently met is a tendency to grafting of skin-flakes from the outside of the drum-head upon the succulent lining of the middle-ear cavities. Here their ex- traordinary power of growth is increased by unusual food-supply, and the cavity becomes lined with skin, which sheds rapidly, layer upon layer, imtil onion- like masses of cholesteatoma are formed. These may provoke suppuration as an effort of nature to soften and break them down, and by pressure they cause absorption or destruction of the bony surroundings, opening a way for escape — outward, perhaps, but too often inward upon the brain. Many, if not most, TIIK MJJ)])LK EAR. I55 cases of persistent or recurrent ear-discharges are complicated and pro])ably caused by such cholestea- tomatous collections. THE MIDDLE EAR. The middle ear, which lies beyond the drum-head, is the seat of two-thirds of all aural troubles, and as some of its affections are of the utmost danger to life as well as to hearing, its health is proportionally still more important. It is by no means so limited in ex- tent as often considered, for the drum-head forms the lower, outer wall of only one portion of the drum- cavity; while the Eustachian tube, extending forward an inch or more to connect it with the upper part of the throat, and the air-cells, which extend back- ward into the mastoid region (and may also penetrate every portion of the temporal bone), are equally por- tions of the middle ear. It is a part of the upper air- passages, very complex, and not easily affected throughout by their diseases, but as likely to be in- volved as any of the accessory cavities of the nose; while the intricacy of the field or the extreme delicacy of some portions makes persistence of the trouble very probable. Hence it has been calculated that at least one-third of all our adult population are notably deaf in one or both ears. The census informs us that no less than 700 per million are dumb as the result of deafness, but these represent only a small group who lost their hearing before they had fully acquired speech. The middle ear is an intricate air-space developed outward from that portion of the air-passages where nose and throat meet. At this point is the trumpet- 156 THE EAR. mouth of the Eustachian tube (Fig. 34) — above the soft palate, but in close relation to the tonsil-masses on each side of the back of the mouth and to the more important tonsil in the vault above the palate. On account of the influence of nasal disease on the ear much of the real hygiene of the ear is considered in the preceding chapter. The whole middle ear is lined with mucous membrane absolutely continuous with that in the nose and throat, and, like it, having its effete cells melt down into sticky mucus instead of Jtoofof Tp/npanum- .„ ., . . , x'iswa™,/ .EustachSanlSiie ■ of Bona Meatus \ I i ^^S-k \ •> . I , \.-